Case 3: Velopharyngeal dysfunction following multidisciplinary head and neck surgery Plastic Surgery/ENT CASE SUMMARY A male in his early-90s in very good health for his age, was admitted to hospital with an invasive tumour involving his right alveolus, maxillary sinus, nasal floor and nasolabial skin. The patient had been a heavy smoker many years before. The tumour was 3cm in diameter with indistinct margins and alveolar ulceration. Assessment in the head and neck multidisciplinary clinic determined 2 possible options: treatment with wide local excision and microvascular reconstruction followed by adjuvant radiotherapy, or palliative radiotherapy. A positron emission tomography (PET) scan demonstrated probable bilateral cervical lymph node metastases, so a bilateral supraomohyoid neck dissection was added to the treatment plan. This was considered to be the only curative treatment option. Surgery was performed by a team of surgeons from Plastic and Reconstructive and ENT. The operation took 14 hours and involved the recommended excision and neck dissection. Reconstruction was achieved with a composite myocutaneous fibula flap from the right leg, with the donor site grafted. The flap had no subsequent intrinsic problems. The pathology report indicated a large (≥3cm) poorly differentiated squamous cell carcinoma invading bone and skin and extending to at least 4 margins. Review at the clinic recommended adjuvant radiotherapy to the right maxilla, after dental clearance. (This treatment never eventuated.) Following an initial period of confusion and disorientation, the patient recovered remarkably well, other than 2 major problems related to velopharyngeal dysfunction, these being: repeated aspiration of sputum, oral secretions and gastric regurgitation resulting in aspiration pneumonia and eventually bronchiectasis; and severe oesophageal dysphagia with inability to initiate a swallow. Despite focused attention from all allied services, the patient experienced continued aspiration and dysphagia. Video-fluoroscopy showed a dysfunctional velopharynx and no ability to swallow or expectorate. Eventually a percutaneous endoscopic gastrostomy (PEG) was inserted for feeding purposes, but metabolic equilibrium was difficult to achieve, complicated by the onset of type 2 diabetes. Repeated metabolic problems and aspiration occurred despite the frequent efforts of attending staff.
VOLUME 20 | AUGUST 2021
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