N u t r i t i o n an d

P e r i o p e r a t i v e C a re f o r t h e
Patient with Head and Neck
Cancer
Amarbir Gill, MD, Donald Gregory Farwell, MD,
Michael G. Moore, MD*

KEYWORDS
 Head and neck cancer  Malnutrition  Supplementation  Perioperative recovery
 Antibiotic prophylaxis  Anticoagulation

KEY POINTS
 Optimal recovery after major head and neck cancer surgery requires contributions from members
of a multidisciplinary team. Preoperative counseling can facilitate preparation for surgery and
recovery.
 Head and neck surgical wounds are often contaminated with flora from the upper aerodigestive
tract. Appropriate perioperative antibiotic administration is needed to decrease the rate of wound
infections.
 Perioperative pain management after major head and neck surgery is best accomplished through a
multimodal approach that combines narcotic and nonnarcotic agents.
 Patients undergoing major head and neck cancer surgery are at increased risk for developing post-
operative VTE and may require the use of sequential compression devices and/or systemic
anticoagulants.
 Preoperative conditioning, incentive spirometry, early mobilization, intermittent positive pressure
breathing, and deep breathing exercises can reduce the risk of pneumonia.

INTRODUCTION often battle pain and anxiety that can further pre-
dispose them to adverse outcomes. Herein, we
The recovery from major head and neck ablative summarize the current evidence-based best prac-
and reconstructive surgery is one of the more tices for the perioperative care of patients under-
complex and challenging journeys patients and going major head and neck surgery with the
their families have to endure. The treatment will hopes of providing guidance that will improve
often have a significant impact on their ability to outcomes.
speak, swallow, and breathe. Because of the na-
ture of their underlying malignancy, as well as the
PREOPERATIVE EDUCATION
surgery associated with its removal, many individ-
uals are at particularly high risk for perioperative
oralmaxsurgery.theclinics.com

Recovery after major head and neck surgery can

complications, such as malnutrition, wound infec- be overwhelming for patients and families. Ad-
tions, VTE, and pneumonia. In addition, patients juncts such as tracheostomy and gastrostomy

Disclosure: The authors have nothing to disclose.

Department of Otolaryngology–Head and Neck Surgery, UC Davis School of Medicine, Sacramento, CA, USA
* Corresponding author. 2521 Stockton Boulevard, Suite 7200, Sacramento, CA 95817.
E-mail address: [email protected]

Oral Maxillofacial Surg Clin N Am 30 (2018) 411–420

https://doi.org/10.1016/j.coms.2018.06.003
1042-3699/18/Ó 2018 Elsevier Inc. All rights reserved.
412 Gill et al

tubes, as well as wound care and drain manage- factors that can in turn reduce morbidity and avoid
ment, require significant patient education and interruptions in treatment. Although there are
effort to optimize outcomes and avoid complica- numerous tools that have been proposed for
tions. Patients can benefit from preoperative edu- screening patients for clinically significant malnu-
cation as a means to ease concerns and provide a trition, percent body weight loss and the validated
smooth transition into the recovery period. Such Patient-Generated Subjective Global Assessment
teaching sessions have been shown to benefit pa- (PG-SGA) survey have demonstrated the most
tients in understanding the risks of operations, relevance.11–14
such as parotidectomy and thyroidectomy,1 with The most straightforward and widely accepted
shorter intervals between the education and criteria for identifying severe malnutrition is the
surgery providing the most benefit.2 Effective ap- loss of 10% of body weight over a 6-month period
proaches include: or 5% of body weight over the past month.
This is also the method endorsed by the National
1. Patient education brochures,3 Comprehensive Cancer Network.15,16 As a
2. Preoperative visits with a social worker,4 screening tool, when compared with well-
3. Counseling sessions with a speech language nourished patients, this degree of weight loss
pathologist (for patients preparing for total lar- has been shown independently to predispose indi-
yngectomy),5 and viduals to major surgical complications,12–14 a
4. The use of multimedia and/or computer-based lower quality of life,9,17 and increased mortal-
educational modules.6,7 ity.18,19 Van Bokhorst-de van der Schueren and
Preoperative education is beneficial to patients colleagues13 demonstrated that, after taking into
undergoing major head and neck cancer surgery, account weight loss greater than 10% as a
and should be offered, when possible. prognosticator of malnutrition and surgical compli-
cations, additional measurements, including
percent ideal body weight, nutritional index, and
NUTRITION serum albumin were not predictive of major com-
Head and neck cancer and its associated therapy plications. Gianotti and colleagues14 similarly
can significantly predispose patients to the devel- demonstrated that unlike weight loss of greater
opment of malnutrition. Etiologies of malnutrition than 10%, albumin, total lymphocyte count, total
can include difficulty or pain with swallowing, iron-binding capacity, and serum cholinesterase
loss of appetite/poor dietary habits, alterations in showed a nonsignificant improvement in predic-
taste and saliva production, depression, and tive ability of postoperative infection. In addition
poor social support. In fact, malnutrition has to weight loss, the PG-SGA has also shown appli-
been shown to occur in up to 50% of this popula- cation as a validated tool for the assessment of
tion8 and can have a significant negative impact on malnutrition in the population of patients with can-
patient quality of life9 and survival.10 cer (Fig. 1).11,12
For patients undergoing therapy for head and The PG-SGA survey categorizes the patient
neck cancer, the identification and treatment of into 1 of 3 nutritional categories, with the most
significant malnutrition is critical to improving out- severely malnourished category being predictive
comes. The optimization of perioperative nutrition of surgical complications. Indeed, Ravasco and
has been shown to reduce the risk of wound infec- colleagues12 compared the PG-SGA with percent
tion and refeeding syndrome, and decrease body weight loss and body mass index in an
duration of stay in patients undergoing surgical attempt to identify the best prognosticator of
management of head and neck cancer.11 A recent malnutrition. The authors demonstrated that
publication examined the impact of the Enhanced weight loss was the best single prognosticator,
Recovery After Surgery, emphasizing the impor- but sensitivity and positive predictive value could
tance of nutrition on perioperative outcomes.10 be improved by combining weight loss with the
As a part of this effort, it is important to have close PG-SGA.
communication between all members of the multi-
disciplinary team, including surgeons and dietary/ Summary
nutritional experts. Percent body weight loss greater than 5% over the
last month or greater than 10% over the last
6 months can adequately identify patients at great-
Patient Assessment and Screening for
est risk of postoperative complications from
Malnutrition
severe malnourishment. The addition of the PG-
The evaluation of a patient’s nutritional and func- SGA may be able to identify a larger number of
tional status allows for identification of modifiable such patients.
 Nutrition and Perioperative Care 413

Fig. 1. Patient-Generated Subjective Global Assessment survey. This tool can be used in the pretreatment assess-
ment of patients for clinically significant malnutrition. (From Ottery FD. Definition of standardized nutritional
assessment and interventional pathways in oncology. Nutrition 1996;12:S17; with permission.)

Perioperative Nutrition and Hydration aggressive preoperative hydration and carbohy-

Management drate loading has been shown to be safe with no
increase in aspiration rates when compared with
Although prior dogma dictated the avoidance
more prolonged fasting.20–22 Indeed, several
of oral intake of food and liquids starting at
studies have demonstrated that preoperative
midnight the night before surgery, more
414 Gill et al

carbohydrate loading can improve perioperative of greater than 10% body weight over last
outcomes. Presumably, this strategy works by 6 months, PG-SGA grade C, serum albumin of
minimizing catabolism and insulin resistance, less than 30 g/L, and inadequate intake (ie,
thus providing better glucose control and mainte- <60% of caloric needs). Indeed, data demonstrate
nance of lean body mass.21 However, although that the strongest evidence for supplementation is
the safety of this approach has been confirmed,22 for patients with a greater than 10% weight loss in
appropriately controlled high-quality studies are the last 6 months.13,14 These authors also recom-
needed to evaluate the efficacy of carbohydrate mend initiation of nutritional therapy if the patient is
loading on duration of stay and perioperative unable to eat for more than 7 days. In these high-
outcomes. risk patients, both Talwar and colleagues23 and
The following are the currently accepted guide- Weimann and colleagues24 recommend 10 to
lines for preoperative hydration and carbohydrate 14 days of preoperative supplementation. Findlay
loading.20–22 and colleagues25 advocate for energy intake goal
of 125 kJ/kg/d with close monitoring of postoper-
 Intake of solids are recommended up until ative weight.
6 hours before general anesthesia, except in
high-risk patients.
 All except high-risk patients should continue Immune-Enhancing Nutrition
to consume clear liquids up to 2 hours before Several prospective cohort studies have sug-
surgery. gested the superiority of immunonutrition (enteral
 Between 2 and 4 hours before surgery, pa- feeds supplemented by a combination of arginine,
tients should consume a carbohydrate-rich omega 3, and RNA) over standard enteral nutrition;
(>50 g) clear liquid beverage. however, the quality of data is not sufficient to
make definitive conclusions.26,27 Riso and col-
Early Resumption of Postoperative Nutrition leagues26 examined 44 patients with head and
For patients undergoing major ablative and/or neck cancer and demonstrated a significant
reconstructive surgery of the upper aerodigestive decrease in postoperative complications and
tract, special considerations must be made for duration of stay among the cohort placed on
the postoperative initiation of nutrition. Such indi- immunonutrition compared with the patients
viduals may be at increased risk for wound break- consuming standard enteral feeds. Several ran-
down owing to intraoral or pharyngeal repairs. domized clinical trials (RCTs) were also performed
Moreover, they often are prone to aspiration owing comparing immunonutrition to standard enteral
to alterations in their anatomy, sensation, swallow- feeds in patients undergoing surgery for gastroin-
ing physiology, and/or mentation in the immediate testinal cancer. Braga and associates27 and Daly
postoperative period. However, it has been and colleagues28 demonstrated a significant
demonstrated that early reinitiation of nutrition decrease in duration of hospitalization and post-
(ie, within 24 hours) after major surgery for cancer operative complications among the immunonutri-
improves patient outcomes.10 This goal can be tion cohort when successfully fed patients were
accomplished via the resumption of oral intake analyzed. Conversely, the RCT performed by
(when there is a safe swallow and minimal to no Schilling and colleagues29 included 41 patients
violation of the upper aerodigestive tract), enteral and failed to identify any significant difference in
tube feeds (via nasogastric or gastrostomy tube postoperative infections between the cohort
in individuals who have had major surgery of the receiving immunonutrition versus standard enteral
oral cavity and/or pharynx and/or who are deemed therapy versus total parenteral nutrition.
high risk for aspiration), or parenteral nutrition (only Additionally, a review of 10 RCTs by Stableforth
to be used in circumstances where enteral feeding and colleagues30 compared immunonutrition with
is not possible or safe). standard enteral therapy in patients undergoing
surgery for head and neck cancer. Their analysis
revealed no significant difference in complications
Perioperative Nutrition in Malnourished
between the 2 groups. Nevertheless, the authors
Patients
did demonstrate a 3.5-day decrease in duration
Nutritional supplementation is recommended for hospital stay among the patients who received
patients found to have severe malnutrition on their immunonutrition. The authors were unable to
preoperative screening. In their 2016 guidelines, demonstrate the etiology of this observation and
Talwar and colleagues23 recommend periopera- recommended additional, better powered RCTs.
tive nutritional support for patients with a body Finally, when implemented, immune-enhancing
mass index of less than 18.5 kg/m2, weight loss feeds should be used for 5 to 7 days
 Nutrition and Perioperative Care 415

preoperatively and at least 7 to 10 days  Compared with a nasogastric tube, gastro-

postoperatively.24,25 stomy tubes may lead to longer feeding tube
dependence, greater dysphagia, and an
Summary increased need for pharyngoesophageal
The identification and management of severe dilation.31,33
malnutrition can significantly improve both short-  Longer gastrostomy tube dependence may
and long-term patient outcomes. Moreover, lead to weakening and atrophy of pharyngeal
although immune-enhancing nutrition has shown muscles and worse recovery of swallowing
some benefit after cancer surgery, further study is function.31,33
needed to compare it with standard enteral nutri-
tion and define its use in malnourished patients. Unfortunately, there is sparse literature looking
at the benefit of feeding tube placement in avoid-
ing malnutrition in patients undergoing major
Indications for Feeding Tube Placement in
head and neck surgery. Placement in patients
Patients with Head and Neck Cancer
before head and neck chemoradiation therapy
As discussed, patients with advanced head and yielded an improvement of quality of life over
neck cancer frequently suffer from weight loss those who received a reactive gastrostomy
and malnutrition. It is well-recognized that tube.31,34
continued oral intake is critical in these patients.
Prophylactic feeding tube placement is not recom- Summary
mended in patients without dysphagia at the initial Although the routine placement of a prophylactic
assessment, because continued swallowing dete- gastrostomy tube is not recommended in patients
rioration may develop from nonuse. Patients with undergoing surgery for head and neck cancer, it
preexisting dysphagia and those likely to develop should be considered in certain high-risk
dysphagia during their cancer therapy should be individuals.
assessed and longitudinally followed by a qualified
speech language pathologist with a goal of VENOUS THROMBOEMBOLISM PREVENTION
continued oral intake. There are patients, however, Patients undergoing surgery for head and neck
who are particularly high risk for severe dysphagia cancer are at significant risk for the development
and/or malnutrition, where feeding tube placement of VTE. Studies have estimated that the general
should be considered.15 surgery population not receiving anticoagulation
The decision between prophylactic and reactive have a rate of DVT formation of between 15%
feeding tube placement is of considerable impor- and 30%,35 which increases to 40% to 80% in
tance to practitioners and patients.31 Prophylactic those over 40 years of age with active cancer.36
feeding tubes are placed in individuals before the Patients with head and neck cancer are at signifi-
development of severe dysphagia with the goal cant risk of VTE because they often are frequent
of avoiding any treatment interruption that may smokers, advanced in age, undergo prolonged
develop when a swallowing difficulty progresses surgeries, and often have significant periods of
during therapy. Reactive feeding tubes are placed relative immobility postoperatively. An appropriate
when a patient develops progressive dysphagia/ strategy is to perform a preoperative VTE risk
malnutrition during or after treatment. assessment using previously validated tools such
Advantages of prophylactic feeding tube as the Caprini Score. This system allows patients
placement: to ultimately be grouped into the following risk cat-
 Placement does not require extra hospitaliza- egories: very low, low, moderate, and high risk.
tion over reactive feeding tubes and patients Based on this classification, anticoagulation rec-
may experience less weight loss. ommendations range from early mobilization to
 Potential to avoid treatment interruptions use of sequential compression devices to sequen-
owing to progressive dysphagia, dehydration tial compression devices and heparin or weight-
and/or malnutrition. based low-molecular-weight heparin given
subcutaneously.
Disadvantages of prophylactic feeding tube Complicating the decision for appropriate peri-
placement: operative anticoagulation is the fact that such pa-
 When placed, gastrostomy tubes typically tients often have large wounds and other high-risk
remain on average for 4 to 9 months.31,32 bleeding sites, such as pharyngeal incisions and/
 Patients with gastrostomy tubes have been or tracheostomies. For each individual patient, it
shown to have higher rates of perioperative is necessary to weigh the risk of VTE and bleeding
wound/surgical complications.31 complications.
416 Gill et al

Summary antibiotics, which have been shown to decrease

wound complications across multiple RCTs.10,41 A
All patients undergoing major head and neck can-
perioperative regimen should consist of a single
cer surgery should have their risk for VTE assessed
dose of antibiotics within an hour before the
and consideration should be made for prophylaxis
initiation of surgery and should be extended for an
using sequential compression devices, with or
additional 24 hours postoperatively.10,41–45 Studies
without pharmacologic therapy.
have not shown a significant decrease in infection
rates with a longer course of prophylactic antibi-
EARLY POSTOPERATIVE MOBILIZATION AND otics or with topical decontamination or topical an-
PULMONARY PHYSICAL THERAPY tibiotics in patients with head and neck
One of the most critical aspects of the periopera- cancer.10,41–47 Multiple studies have shown strong
tive recovery after major head and neck surgery evidence that perioperative antibiotics should
is encouragement of early postoperative mobiliza- cover gram-positives and anaerobes in this patient
tion as well as the implementation of an aggressive population; however, data on gram-negative
regimen for pulmonary physical therapy. Without coverage is more controversial.48,49 Nevertheless,
such care, patients are at significant risk for the the head and neck literature most often recom-
development of VTE, pneumonia, and pressure ul- mends prophylactic coverage of gram-positive,
cers, leading to significant morbidity and potential gram-negative, and anaerobic bacteria.44 Impor-
mortality. tantly, several studies have demonstrated
With regard to postoperative physical activity, it increased rate of surgical site infection with the
has been shown that early mobilization decreases use of clindamycin.50,51
the risk of pneumonia in patients undergoing free The American Health System Pharmacist recom-
flap reconstruction of the oral cavity.37 In other mends use of cefazolin/cefuroxime plus flagyl, or
fields of surgical oncology, early mobilization pro- ampicillin-sulbactam, in clean-contaminated onco-
tocols have also been found to decrease medical logic surgery in patients without a beta-lactam al-
complications and length of stay.38,39 The recent lergy.52 In those patients with a beta-lactam
Enhanced Recovery After Surgery protocol after allergy, the American Health System Pharmacist
head and neck free flap surgery review advocates states that clindamycin may be used; however,
mobilization within the first 24 hours postopera- these data demonstrate concern that clindamycin
tively, when deemed safe by the surgical team.10 use may actually increase the risk of surgical site
In addition to early mobilization, further measures infections. Moreover, prior chemoradiation, clean-
should be taken to minimize the risk of perioperative contaminated surgeries, immunosuppression,
pneumonia. Tools such as incentive spirometry, intraoperative blood loss, tracheotomy, prolonged
intermittent positive pressure breathing, and deep operative time, and oral cavity cancer resections
breathing exercises have shown usefulness in indi- have been established as risk factors for surgical
viduals after abdominal procedures.40 Although site infections.53–56 Although many such factors
there is a paucity of literature directly evaluating the are not modifiable, this information may be useful
head and neck surgical population, it is likely that in patient counseling and risk assessment.
such regimens would be applicable to this group.
Summary
Summary For head and neck surgery procedures that are
classified as clean, no perioperative antibiotics are
Early mobilization within the first 24 hours, when recommended. For clean-contaminated surgeries,
safe, and aggressive pulmonary therapy are rec- 24 hours of perioperative antibiotics with gram-
ommended after major head and neck surgery. positive, gram-negative, and anaerobe coverage
should be used. These antibiotics should be initi-
Perioperative Antibiotic Prophylaxis ated within 1 hour before surgical incision. Addi-
The appropriate use of perioperative antibiotics in- tional patient and disease factors may impact
volves an understanding of the risks of periopera- infection risk and should be considered when deter-
tive infection and the potential for development of mining the antibiotic regimen for a particular patient.
resistant infections or antibiotic-related complica-
tions (ie, allergic reactions or antibiotic induced in- PAIN MANAGEMENT
fections, such as colitis). The head and neck
literature demonstrates no role for perioperative an- Patients undergoing major head and neck oncologic
tibiotics in wounds classified as clean.41 Clean surgery suffer from significant pain related to their
contaminated procedures (ie, transmucosal pro- surgical wounds. Adequately addressing this
cedures), however, benefit from perioperative discomfort is critical to allow for appropriate
 Nutrition and Perioperative Care 417

resumption of activity. Various combinations of acet- with the use of gabapentin compared with con-
aminophen, nonsteroidal antiinflammatory drugs, trols.68 More research, including RCTs, is
opioids, gabapentin, and local anesthesia have needed to validate the therapeutic effects of
been discussed in the literature. Acetaminophen gabapentin in patients with head and neck
has been shown to be an effective nonopioid anal- cancer.
gesic agent for control of postoperative pain.57 Data on the efficacy of local neuromuscular
Although the intravenous route may demonstrate blockades in head and neck patients are
more reliable plasma levels,58 intravenous adminis- very limited. A single study examining the effect
tration has shown no advantage in pain control of mandibular nerve block in patients undergoing
over oral administration59 and is considerably more oropharyngeal surgeries demonstrated improved
expensive. analgesia.69 A few studies have shown a signifi-
There are good data demonstrating advantages cant effect on postoperative analgesia when
of cyclooxygenase-2 inhibitors, such as celecoxib, bilateral superior cervical plexus anesthetic
on postoperative pain control across various sur- nerve blocks are performed for patients undergo-
geries, most commonly orthopedic and plastic sur- ing thyroidectomy with or without parathyroidec-
gery.10,60–63 However, data have shown that both tomy,70 with a decrease in the duration of
nonsteroidal antiinflammatory drugs and stay.71 However, a large metaanalysis of RCTs
cyclooxygenase-2 inhibitors can increase risk of analyzing these same blocks in patients undergo-
myocardial infarction, heart failure, and hyperten- ing thyroid surgery concluded that, although anal-
sion, which may be more pronounced in patients gesia can be obtained, the results were not
with preoperative risk factors, female gender, longer clinically significant.72 Thus, additional research
use of medication, and advanced age.60,61 Cele- is necessary to further identify potential benefit
coxib is the preferred agent in these situations, of local neuromuscular blocks on postoperative
because it is the least likely to cause these adverse analgesia in the patient population with head
effects compared with other nonsteroidal antiin- and neck cancer.
flammatory drugs and cyclooxygenase-2 inhibi- A multimodal approach to achieve post-
tors.60,61 Wax and colleagues64 demonstrated a operative pain control is recommended. The com-
lack of adverse effects of celecoxib on wound heal- bination of opioid and nonopioid medications can
ing and free flap survival in a rat model. An additional optimize analgesia while minimizing sedation and
advantage of celecoxib is that the mechanism of ac- allowing for early mobilization.
tion does not inhibit platelet function and thus theo-
retically does not increase postoperative bleeding SUMMARY
complications.65 However, case reports have docu-
mented an association between use of celecoxib Perioperative management of patients undergo-
and bleeding after surgery.66 ing significant ablative and/or reconstructive sur-
Gabapentin is a nonnarcotic medication that gery of the head and neck is complex. Successful
aims at addressing neuropathic pain. A single care requires an organized and multidisciplinary
dose of the drug before tongue carcinoma resec- approach to optimize the patient’s recovery. Pre-
tion and free flap reconstruction, when operatively, patients should be assessed for their
compared with controls, has been shown to surgical candidacy and educated on the risks and
significantly reduce postoperative pain scores, benefits and the functional and physiologic
morphine requirement, or analgesia-related changes that may result from the procedure.
nausea and vomiting.67 Moreover, Doleman and Those patients who elect to pursue treatment
colleagues68 performed a large metaanalysis of should be screened for clinically significant
133 RCTs comparing perioperative gabapentin malnutrition and managed appropriately. Around
(doses ranging from 200 to 1200 mg) with con- the time of surgery, adequate antibiotic and VTE
trols and demonstrated a significant decrease prophylaxis should be provided based on the na-
in postoperative pain scores and opioid require- ture of the surgery and patient-specific risks. In
ments in the first 24 hours. Their metaanalysis the perioperative period, a multimodal approach
also demonstrated that nausea, vomiting, and to analgesia should be implemented, with
itching were decreased in this patient population aggressive resumption of postoperative activity
and sedation was increased.68 Most trials did not and nutrition to minimize the potential for compli-
examine the long-term use of gabapentin on pain cations. Although the treatment for each patient
scores, but 8 trials did show improvement in should be individualized, these evidence-based
chronic pain scores at 3 months postopera- principles can serve as a guide to help both clini-
tively.68 Patient satisfaction scores and preoper- cians and caregivers support those under their
ative anxiety were also significantly improved care.
418 Gill et al

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