What are the priorities when taking rounds of a head and neck oral cancer surgery patient?

Essential Priorities for Head and Neck Oral Cancer Surgery Rounds

When rounding on head and neck oral cancer surgery patients, your primary focus must be on airway patency, wound integrity, flap viability, drain output characteristics, and early detection of complications that threaten mortality—specifically airway compromise, bleeding, and infection.

Critical Airway Assessment

• Examine for signs of airway obstruction including stridor, increased work of breathing, oxygen desaturation, or inability to handle secretions, as upper airway obstruction represents the most immediate life-threatening complication 1, 2
• In patients with tracheostomy, assess capping trials, adequacy of pulmonary toilet, and readiness for decannulation 3
• Monitor for progressive oropharyngeal or laryngeal edema, particularly in the first 24-48 hours post-operatively, which may necessitate delayed extubation or emergency tracheostomy 4
• Evaluate ability to protect the airway and handle oral secretions, especially in patients who underwent extensive oral cavity resection 1

Wound and Flap Evaluation

• Assess flap color, temperature, capillary refill, and turgor to detect early vascular compromise—free flap failure typically occurs within the first 72 hours and requires immediate surgical exploration 5
• Examine for wound dehiscence, particularly anterior intra-oral incisions, as this represents a serious complication requiring close monitoring due to risk of spreading infection 3
• Document any purulent drainage with specific attention to volume (e.g., 30-50cc), color, and consistency, as persistent thick purulent drainage indicates ongoing infection requiring continued inpatient management 3
• Check for exposed critical structures including bone, vessels, or neural structures, as delayed reconstruction leaving these exposed increases infection risk unacceptably 6

Drain Management

• Record drain output volume, color, and character for each drain separately—sudden increases may indicate bleeding or seroma formation 3
• Monitor for chyle leak in patients who underwent neck dissection, characterized by milky white drainage that increases with oral intake
• Assess drain placement and patency, ensuring drains are not kinked or displaced, as inadequate drainage predisposes to hematoma or seroma formation

Infection Surveillance

• Check for fever, tachycardia, and leukocytosis as indicators of surgical site infection requiring antibiotic adjustment 3
• Examine wound margins for erythema, warmth, and fluctuance suggesting abscess formation
• In patients on antibiotics (e.g., Ampicillin/Sulbactam), assess therapeutic response and monitor for clinical resolution before considering discharge 3
• Head and neck cancer patients are at higher risk for wound complications due to prior radiation therapy, compromised tissue vascularity, and proximity to oral flora 3

Functional Assessment

• Evaluate swallowing function and aspiration risk through bedside swallow assessment before advancing diet, as dysphagia affects both nutrition and aspiration pneumonia risk 3
• Assess pain control adequacy using validated pain scales, as inadequate analgesia impairs mobilization and pulmonary toilet
• Monitor nutritional intake whether oral, enteral (NG/PEG), or parenteral, documenting caloric intake and weight trends
• Check speech and communication ability, particularly in patients with tongue resection or extensive oral cavity surgery 3

Mobility and Complications Prevention

• Ensure early mobilization to prevent venous thromboembolism, pneumonia, and deconditioning
• Verify DVT prophylaxis is appropriately prescribed and administered
• Assess for signs of deep vein thrombosis including unilateral leg swelling, pain, or Homan's sign

Discharge Planning Considerations

• Patients should be afebrile for 24 hours after stopping IV antibiotics before discharge is considered 3
• Drainage should have significantly decreased or resolved prior to drain removal and discharge 3
• Ensure patient can safely perform activities of daily living and has adequate support at home 3
• Verify follow-up arrangements are in place, including wound checks, pathology review, and adjuvant therapy planning

Common Pitfalls to Avoid

• Do not dismiss subtle airway changes—progressive edema can rapidly evolve to complete obstruction, particularly in the first 48 hours 4
• Do not attribute all fever to expected post-operative inflammation—persistent fever beyond 48 hours warrants investigation for infection or other complications 3
• Do not remove drains prematurely—drain output should be <30cc/24 hours and non-purulent before removal
• Do not delay intervention for flap compromise—salvage rates decrease dramatically after 6 hours of ischemia 5