Head and Neck Issues in Cirrhotic Patients


Immediate complications

Early complications

Late complication

Desaturation

Bleeding

Airway stenosis

Stroke

Mucous plug

Granulation tissue

Pneumothorax

Infection/Tracheitis

Tracheoinnominate fistula

Severe blood loss

Accidental decannulation

Tracheoesophageal fistula
  
Tracheomalacia
  
Aspiration



Intraoperative complications are lowest when performed by an experienced surgeon. Nonotolaryngologists are 9.1 times more likely to have an intraoperative complications compared to otolaryngologist, specifically in prolonged desaturation and mortality [9]. Preoperative optimizations to reduce the rate of intraoperative complications include minimizing ventilator setting, weaning vasopressors, and correction of coagulopathy. The most common early complication is bleeding which occurs in approximately 2.6% of cases. Percutaneous tracheotomy has a significantly higher rate of postoperative bleeding compared to an open method with a rate of 6.6% compared to 1.9% [9]. The use of security sutures to anchor the tracheostomy tube has been shown to decrease rates of early complications, specifically bleeding and accidental decannulation [9]. Placement of anchoring sutures is highly encouraged. Late complications are directly related to injury during placement of the tube, abnormal healing at site of injured tracheal mucosa, or prolonged need for inflated cuff [10]. The development of high-volume low-pressure tracheostomy tube cuffs has led to a ten-fold reduction in cuff site stenosis [10]. Insertion of appropriately sized tracheostomy tube and avoidance of overinflation of the cuff can assist in avoiding tracheal mucosal injury. Given that, it is the belief of this author that tracheostomies in critical ill patients such as those with end-stage liver failure should be performed in the operating room by an experienced otolaryngologist to minimize complications.

Appropriate decannulation is critical in avoiding long-term consequences of tracheostomy. Decannulation can be considered once the indication for tracheostomy tube placement has resolved. A consensus statement was published by the American Academy of Otolaryngologist in 2012, based on the Delphi survey outlining 77 statements to reduce variations in practice in management of tracheostomy [11]. A list of prerequisites for decannulation has been provided in Table 23.2. The decannulation process should be performed in the following manner: (1) Remove the tracheostomy tube; (2) Clean the site; (3) Cover the site with a dry gauze dressing; (4) Instruct the patient to apply pressure over the dressing with fingers when talking or coughing; (5) Change dressing daily and as needed if moist with secretions until the site has healed; and (6) Monitor for decannulation failure.


Table 23.2
Prerequisites for decannulation in adult patients




















Answer the following to determine readiness of patient for decannulation of tracheostomy tube:

Have the indications for the tracheostomy placement resolved or significantly improved?

Is the patient tolerating a decannulation cap on an appropriately sized uncuffed tracheostomy tube without stridor?

Does fiberoptic laryngoscopy confirm airway patency to the level of the glottis and immediate subglottis?

Does the patient have an adequate level of consciousness and laryngopharyngeal function to protect the lower airway from aspiration?

Does the patient have an effective cough while the tracheostomy tube is capped?

Have all procedures that require general endotracheal anesthesia been completed?



Head and Neck Cancer


Head and neck cancer is a major health issue with an incidence of over 60,000 new cases in the United States each year. These include cutaneous malignancies, malignancies of the aerodigestive tract, and salivary gland cancers.

The two greatest risk factors for developing head and neck cancer include alcohol and tobacco use. Other risk factors include human papillomavirus infection, betel quid use, radiation exposure, and poor oral health. Many of these are also risk factors for developing liver cirrhosis. In patients who have undergone liver transplant, there is a 3.7 times greater overall incidence of de novo head and neck tumors compared to the general population ranging from 3% to 26% [12].


Cutaneous Malignancies


The majority of head and neck malignancy in transplant patients are skin cancers of the head and neck. In patients who have undergone transplantation, around 80% of patient will develop a cutaneous malignancy in patients who live in areas of high sun exposure [13]. The most common types of cutaneous malignancy are basal cell cancer (BCC) and squamous cell cancer (SCC) with BCC outnumbering SCC by a factor of 4:1. Less common lesions include malignant melanoma and Merkel cell carcinoma. There is a fivefold increase in developing melanoma in post-transplant patient when compared to the general population. In patients with a pretransplantation history of melanoma, there is a 20% recurrence rate after transplantation and a waiting period of at least 5 years before considering transplantation is recommended [14]. Merkel cell carcinoma or neuroendocrine carcinoma is a rare entity with 55 cases reported in transplant population [15]. Merkel cell carcinoma has a much more aggressive clinical course with higher incidence of lymphatic involvement and spread. Risk factors for development of skin cancer include increase age at time of transplant, duration of immunosuppression, smoking, and prior infection by human papilloma virus [16].

Treatment of skin cancer is primarily with surgical excision and treatment of the neck lymphatics. Reduction of immunosuppression may improve prognosis, as well as conversion to a non-potentiating immunosuppressive agent such as rapamycin or everolimus. Education of skin exposure protection from the sun is mandatory. Close clinical follow-up is necessary and early intervention remains critical to preventing metastatic disease and death.

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Jun 27, 2017 | Posted by in GASTROENTEROLOGY | Comments Off on Head and Neck Issues in Cirrhotic Patients

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