Incidence of sepsis

Although deaths from sepsis due to odontogenic infection are very rare, they have been reported. The incidence of sepsis is on the increase, possibly due to:

·        A growing elderly population

·        An increased use of invasive surgery

·        An increased incidence of bacterial resistance

·        An increased number of immunocompromised patients

Causes of sepsis

·        A localised infection which progresses into an uncontrolled systemic response is usually the cause of sepsis. Progression to acute physiological deterioration with the risk of multiple organ failure and death can be swift.

·        In normal circumstances, the body's immune system will prevent or fight infection (bacteria, viruses, fungi). However, the immune system can sometimes go into overdrive, resulting in vital organs and other tissues being targeted. This can result from any injury or infection in the body.

·        Although a wide variety of different microorganisms (for example, Streptococcus, E. coli, MRSA or Clostridium difficile) can cause sepsis, it is usually caused by common bacteria that don't normally make patients ill.

·        Any infection can lead to sepsis though pneumonia (commonly referred to as chest sepsis) is the cause in half of the cases.

·        Sources of sepsis infection (approximate percentages)

1.       Pneumonia: 50%

2.       Urinary tract: 20%

3.       Abdomen: 15%

4.       Skin, soft tissue, bone and joint: 10%

5.       Endocarditis: 1%

6.       Device-related infection: 1%

7.       Meningitis: 1%

8.       Others: 2%.

Risk factors for developing sepsis

The National Institute for Health and Care Excellence (NICE)has highlighted the following risk factors for sepsis:

·        Children under one year of age and people >75 years old

·        Frailty

·        Impaired immune systems because of illness or drugs, including patients:

·        On chemotherapy for cancer

·        Taking long-term steroids

·        Taking immunosuppressant drugs to treat non-malignant disorders such as rheumatoid arthritis

·        With an impaired immune function; for example, diabetics, previous splenectomy and sickle cell disease

·        Recent surgery, or other invasive procedures, in the past six weeks

·        Breach of skin integrity; for example, cuts, burns, blisters or skin infections

·        Intravenous drug users

·        Existing indwelling venous line or urinary catheter

·        Pregnancy and within six weeks following birth, termination of pregnancy or miscarriage.

General Principles and Outline of Management

1.   All patients with suspected carcinoma of head and neck should be evaluated by a head and neck surgical oncologist and should record the following:

A.   History

·       Disease related information

·       Detailed history of habits and addictions

·       Medical and Family history, including any prior malignancy

·       Comorbidity

B.   Clinical Examination

·       Performance and Nutrition status assessment

·       Histological diagnosis – FNAC/Biopsy/ Slide review

·       Imaging for extent of disease and assessment of operability

·       Clinical staging and documentation of the subsite(s) involvement

C.   Investigations

·       X-Ray

·       Chest CT Scan / MRI for extent of disease

·       EUA / Endoscopy for mapping of disease

·       USG for N0 neck in select cases

·       Ba swallow + PC film

·       PET - CT whenever indicated.

Treatment decisions for all patients should be made in a multidisciplinary joint clinic with the goal for maximizing survival and preservation of form and function.

General guidelines for selecting a treatment modality:

·       Stage I / II disease - Single modality (Surgery or Radiotherapy)

·       Stage III & IV disease - Combined modality

1.      Surgery + Radiotherapy ± chemotherapy

2.      Chemotherapy + radiotherapy

Selection of modality depends on the subsite of cancer.

·       When different modalities are available, the modality that gives maximum chance of cure should be used.

·       When different modalities have similar results, a modality that gives better quality of life, with organ / function preservation is preferred.

Surgery is preferred over radiotherapy as a single modality in

1.   Sites where surgery is not morbid (cosmetically and functionally)

2.   Lesions involving or close to bone - to prevent radionecrosis.

3.   Young patients – possibility of a subsequent second primary

4.   Presence of sub mucous fibrosis (SMF).

Radiotherapy is preferred over surgery as a single modality, were

1.   Severe impairment of function / cosmesis with surgery, e.g. base tongue, glottis.

2.      Surgery is technically difficult with high morbidity and poor results e.g. nasopharyngeal carcinoma.

3.   Patient refuses surgery

4.   High risk of surgery

For patients undergoing planned surgery,

·       A plan should be developed for a tumour free resection margin and appropriate reconstruction for restoration of form and function

·       No modification of this plan should be done based on response to any prior chemotherapy

·       Modify plan for wider resection, if there is disease progression while waiting.

· 

Assessment of resectability

A. Tumour involvement of the following structures are considered technically unresectable:

·       Erosion of pterygoid plates, sphenoid bone, widening of foramen ovale

·       Extension to superior nasopharynx or deep extension into Eustachian tube or lateral nasopharyngeal wall

·       Encasement of internal carotid artery, defined radiologically as tumor surrounding the carotids > 270 degrees.

·       Involvement of mediastinal structures

·       Involvement of prevertebral fascia or cervical vertebrae

Principles of resection

1.   En bloc resection of primary tumor whenever feasible

2.   In continuity neck dissection when direct extension of primary into neck

3.   Third dimension (the base) should be taken carefully into account before excision

4.   Adequate margin: 1.5 – 2 cm

5.   Clear margin: > 0.5 cm

6.   Close margin < 0.5 cm

7.   Frozen section confirmation for margins may be done if the facility is available

8.     Contralateral neck should be addressed when the probability of bilateral / contralateral metastases is high. Eg. Tumours crossing the midline / midline tumours.

Reconstruction options:

1.      Mucosal defects:

·       Small defect –Primary closure/local flap / SSG / leave raw according to the site involved

·         Large defect –Try to replace tissue loss with similar kind of tissue

2.      Soft tissue loss: (Pedicled Flaps Eg. PMMC) or Free tissue transfer

·         Skeletal defects +/- Soft tissue and Skin loss

Ø    Anterior or Midline:

Ø      Free fibula / Deep Circumflex Illiac Artery (+/- Skin paddle

Ø      Regional osteo myocutaneous flaps

Ø      Plate

Ø    Posterior Segment

Ø  PMMC

Ø  Free Fibula

·       Skin defects can be covered with

·       Local flaps /forehead flap

·       Deltopectoral flap / PMMC Free flaps Indications for postoperative radiotherapy 1.Primary:

Ø  Large primary – T3/T4

Ø  Deep infiltrative tumour

Ø  High grade tumour

Ø  Lymphovascular and perineural invasion

2.  Lymph nodes:

Ø  Bulky nodal disease N2/N3

Ø  Extra nodal extension

Ø  Multiple level involvement

Ø  Multiple nodes

3.  Chemo-radiotherapy

Ø  Positive or close margin after curative resection

Ø  Nodes with perinodal extension

4.  Role of Brachytherapy (BRT)

Ø  Accessible lesions

Ø  Small (preferable < 3 cm) tumours

Ø  Lesions away from bone

Ø  N0 nodal status

Ø  Superficial lesions

Dose for radical radiotherapy

Tumours suitable for brachytherapy

Ø  T1-2 N0:- Radical BRT: 60-70Gy low dose rate 192Iridium or equivalent doses with fractionated high dose rate.

Ø  T1-3 N0-1- External RT: 56 -60Gy/28-30#/6wks Boost BRT: Low dose rate 192Iridium: 15-20 Gy or High Dose rate: 14Gy in 4 fractions over 2 days (4-3- 3-4 Gy)

Tumours not suitable for brachytherapy

Ø  T1-4 N0-2 -Concomitant chemoradiation: 66-70Gy/33-35#/ 6-7 wks + Sconcomitant Cisplatin, 30mg/m2 for 6-7 wks or 3 weekly Cisplatinum, 100mg

/m2 x 3 cycles

Or

Ø  External RT: 66-70GY/33-35#/6-7weeks (reducing fields)

Doses and Volumes in adjuvant setting

Ø  Primary and involved nodal disease: 56-60 Gy/ 28-30#/6 weeks, using reducing fields.

Ø  Site of residual disease, positive cut margins: 4-10 Gy Boost

Ø  Uninvolved nodal stations: 45 -50 Gy

Dose of chemotherapy in the adjuvant setting in combination with radiotherapy: 30mg/m2 weekly with hydration and antiemetic prophylaxis

Rehabilitation

Ø  Abstinence from tobacco/alcohol

Ø  Oral hygiene

Ø  Shoulder physiotherapy in all cases of neck dissections

Ø  Bite guide prosthesis following mandibulectomy

Ø  Jaw stretching exercises to prevent post-operative trismus

Ø  Swallowing and speech rehabilitation

Follow up :

Ø  Every 2-3 months in first 2 years

Ø  Six monthly for next 3 years

Ø  Annually thereafter

Ø  On every follow up thorough head and neck examination for loco-regional control, second primary tumour and late sequelae of treatment. Investigation only if indicated by symptoms and positive clinical findings.

Ø  Serum T3, T4 & TSH annually for all patients ssreceiving RT.