Your Guide To Head & Neck Surgery Singapore General Hospital Outram Road Singapore 169608 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any way, from or by any means electronic or mechanical, including photocopying, microfilming, recording or otherwise, without the prior written permission from SGH. Tel: 222 3322 Fax: 222 1720 http://www.sgh.com.sg 90500-1/7 (Sep 2001)
Your Guide To Head & Neck Surgery C O N T E N T S Foreword 2 Introduction 3 Head & Neck Cancer 4 Head & Neck Surgery and Reconstruction 5 Preparation before Surgery 6 Day of Surgery 8 After Surgery 10 Medical and Nursing Care in the 11 Inpatient Care Units Discharge Instructions 15 You are advised to follow any specific written or oral instructions given to you by your doctor or healthcare worker. Please seek clarification if you are in doubt. This booklet is produced by the SGH Department of Plastic Surgery, and contains general information and advice regarding your condition. It is designed to provide you with a guide on how to safeguard your health. However, it is not intended to contain exhaustive instructions. In specific cases, you may receive different or additional instructions from your doctor.
Foreword Introduction Dear patient, Welcome to the Singapore General Hospital. This booklet is specially prepared for you and your family to give you some information regarding your impending surgery. We hope that the information will help you understand what happens before, during and after your surgery. We will guide you through the steps you will be taking on your path to recovery. Please accept our best wishes, and we hope that you would have a pleasant stay with us. Welcome to the Singapore General Hospital. Our doctors, nurses and other members of the healthcare team will guide you towards a speedy recovery. If you have any questions, concerns or comments, please feel free to discuss with us. Your Personal Particulars Name: NRIC: Date of Birth / Age: Sex: Ward Admitted: Doctor-in-charge: A/Prof Tay Boon Keng Chairman, Division of Surgery Singapore General Hospital Please call Tel: if you have any questions or need any clarifications. 2 3
Head & Neck Cancer Cancers in the head and neck region commonly involve the oral cavity, tongue, lip, face, scalp, parotid or larynx. What are the causes? Predisposing factors include: smoking alcoholic consumption dental caries tobacco chewing ill-fitting dentures iron deficiency betel nut chewing syphilis How does a patient know that he has the disease? The earliest symptom/sign is tissue changes in the mouth Raised growth, swelling or lump Changes in color with the presence of red, brown or black spots, redness with white or rough patches Bleeding from the nose or mouth A sore that does not heal Burning or numbness in the tongue, lip or mouth Painful, sensitive or loose teeth Difficulty in swallowing or talking What is Head & Neck Surgery and Reconstruction? A multidisciplinary approach is required in the management of head and neck cancer. It usually involves the following: Wide resection to remove all the cancer Reconstructive surgery to restore form and function Post-operative adjuvant radiotherapy or chemotherapy may be necessary Post-surgery rehabilitation for speech, swallowing and breathing For oral cancers, the operation involves firstly removing all the disease tissue which may include a portion of the tongue, mouth or jaw bone. It is frequently necessary to perform a neck dissection to remove the adjacent lymph nodes in the neck. The reconstruction of the jaw or oral cavity may require the transfer of skin from the forearm or bone and skin from the leg using microsurgical techniques. 4 5
Preparation Before Surgery You will be admitted to hospital either a day before the surgery, or on the day of the surgery. If you have additional medical problems, admission may even be earlier to allow for stabilisation. Get a Good Night s Rest Have a good night s sleep before your operation. Do let your doctor or nurse know if you require some medication to help you to sleep. Personal Items & Valuables We advise that you leave all your valuables and personal items at home, and to keep not more than ten dollars with you during your stay in the hospital. Dental Clearance Arrangement will be made for you to see the dental surgeon for a dental clearance examination before going for the surgery, if indicated. No Smoking We strongly discourage smoking one week prior to surgery and especially on the night before the surgery. Smoking makes it difficult for you to clear your secretions after surgery, and may impede your recovery. Bowel and Skin Preparation A laxative may be given to help clear your bowels on the night before the surgery. The surgeon may make markings on the skin where tissue may be taken for grafting. Please do not remove these markings when bathing and washing. No Food Consumption You should not consume any food, not even water, after midnight. This is to prevent any vomiting and subsequent breathing of the vomitus into the lung during surgery, which could be life-threatening. 6 7
Day of Surgery Before you go for your operation It is advisable for you to take a good shower, brush your teeth and rinse your mouth. You should refrain from drinking anything on the morning of your surgery. However, if you have to take medication for your medical problem, the nurse will advise you to take it with sips of water. Shortly before the estimated time of your operation, the nurse will inform you to do the following: Empty your bladder Remove any dentures, spectacles and contact lenses, make-up, nail polish, hairpiece, jewellery and prosthesis Change into a gown Please inform your nurse if you have any personal items requiring safekeeping. Family Room Your family members could either return to the ward or wait in the waiting area just outside the operating theatre. Please advise them not to wait along the corridor. In the Operating Theatre Once you have arrived at the operating theatre, the nurse there will verify your identity and also the type of surgery you are scheduled for. After verification, you will be transferred to another trolley and wheeled into the induction room to meet the anaesthetist and the surgeon. The anaesthetist will give you an injection to put you in a deep sleep, so that you will not feel any pain. The operation is usually done under general anaesthesia. A tube is usually inserted into the bladder when you are asleep to help in passing urine and this will be kept in place for the next few days after surgery. Pre-medication You may be given medication in the form of tablets or an injection to help you relax. This medication will make you sleepy, or cause dryness in your mouth. You should not attempt to get out of bed after taking the medication. Our nurse or health attendant will transfer you to the operating theatre on a trolley. 8 9
After Surgery Recovery Room After your operation, you will be taken directly to the recovery room. Your blood pressure, breathing and heart rate will be checked frequently. Please inform the nurse if you are feeling nauseous or experiencing any pain, so that medication could be given to relieve your discomfort. You may also be put on Patient-Controlled Analgesia (PCA) to help you control you pain. Your anaesthetist would explain to you before the surgery on the use of the patient demand button. When you are awake and your blood pressure and pulse have stabilised, you may be transferred to the Intensive Care or High Dependency Care Unit. Medical and Nursing Care in the Inpatient Care Units Nursing Care In the ICU, you will see some equipment by your bedside. These are used to monitor your heart, respiratory rate, blood pressure and the oxygen saturation. A team of doctors and nurses will take care of you and also answer any questions you may have. You may be nursed in the ICU for about one to two days. The length of stay may vary depending on the rate of your recovery. Please inform your family members that the visiting hours for ICU is similar to the general wards - 12 noon to 2 pm and 5 pm to 8.30 pm. However, the number of visitors will be restricted to two visiting you at the bedside. When your condition has stabilised, you will be moved to the High Dependency area of the general ward. Relief of Post-Surgery Discomfort You will experience some pain at the site of your surgery. Medication will be given to you to relieve any pain or discomfort. The medication may be administered through any one of the following methods: Injections Patient Controlled Pumps Epidural - where medication is released through a fine catheter inserted into your back Tablets 10 11
Tracheostomy A tracheostomy (small opening in the trachea at the front of the neck) is usually performed as part of the operation to facilitate excision of cancerous tissues and reconstruction of jaw or oral cavity. A tracheostomy tube is inserted to maintain a clear airway and to facilitate suction of secretion. This tube will be removed when the wound has healed in one to two weeks. Wound and Skin Care The dressing over your wound will be removed 24 hours after the surgery and the wound must be kept clean and dry. Drainage tubes will be inserted near the operation site to prevent any accumulation of fluid or blood in the wound. These tubes will gradually be removed when the amount of fluid has decreased. Diet You will not be allowed to eat or drink through your mouth for at least a week or two to allow the wound to heal. An intravenous drip will be inserted into your hand or arm for one or two days to provide you with adequate fluid and medication to keep you comfortable. Feeds will be given through a nasogastric tube that is inserted via the nose into your stomach on the second or third day after surgery, to ensure that you have adequate nutrition. If you experience any difficulty in swallowing, the Speech Therapist will assist you to regain your swallowing ability. Initially, you will only be able to drink and consume soft food. Elimination Need A urinary catheter may be inserted into your bladder during the operation, to assist you in passing urine and also to monitor your urine output. You may experience an urge to urinate with the tube in position, even though your bladder is empty. The catheter will be removed once you are well enough to attend to your own toilet needs. You may have to pass motion using a bedpan in bed if you have not started ambulation. Please inform the nurse if you require any assistance. Deep Breathing It is not easy to breathe deeply and cough after surgery, due to the discomfort that may result from your incision. The Physiotherapist will assist and teach you to perform deep breathing and coughing exercises. This is to help you cough out any secretions that may have collected in your airways during surgery, to prevent any chest infection from developing. Speech You will not be able to speak immediately after the operation because of the tracheostomy and surgery. You may wish to communicate by sign language or through writing. Pen and paper will be provided. You speech may also be impaired as the surgery involves the oral cavity, tongue or jaw. The Speech Therapist will help you to overcome the problem during your recovery period. 12 13
Activity While lying in bed, you will need to turn on your sides and move your legs at least once every two hours. Such activity helps to stimulate circulation and speed up your recovery. The level of activity will be increased slowly and by the fifth day, you may be allowed to sit on a chair by the side of the bed. The Physiotherapist will assist you to resume walking in preparation for your discharge from the hospital. Length of Stay The average length of stay for patients undergoing head and neck surgery is usually between five to fourteen days. However, the length of stay may vary with each individual. Discharge Instructions The following discharge instructions will help you to take care of yourself during your recuperation at home. Activity You should: sit up during the day and sleep in a propped up position using two to three pillows. avoid putting any pressure on the operated site. Diet Consume a soft diet for four weeks. Medication Take your medications as prescribed by your doctor. Wound Care Keep the steristrip dressing on the neck wound dry and intact. Apply olive oil to the exposed donor area three times a day. Clean the tracheostomy with cooled boiled water, then apply dry dressing daily until the wound is healed. Oral Care You should: practise good oral hygiene. rinse your mouth with gargle after each feed and meal. 14 15
When to consult the doctor Seek medical consultation with your surgeon at the SGH Specialist Outpatient Clinic, if any of the following conditions occurs: an increased pain, bleeding or discharge from the wound you have a fever of 38 C and above you notice an adverse change in the colour of the flap to a pale, reddish or bluish colour you notice a separation of flap you experience difficulty in swallowing any other abnormal and/or prolonged symptoms which cause concern Follow Up Appointment Report to the Doctor on the appointment date and time. 16