Anaesthesia for oral cancer: introduction to special series

There are over 500,000 new cases of head and neck malignancy diagnosed every year worldwide (1), of which oral cancer constitutes a significant proportion. Whilst non-surgical treatments (chemotherapy, radiotherapy, brachytherapy, and immunotherapy) are well established and continue to evolve, their unpleasant side-effects and associated long-term morbidity have meant that surgery still remains the principal treatment modality. Like many other surgical specialties, oromaxillofacial and head & neck surgical techniques have developed to reduce surgery-related morbidity, with an increasing number of minimally invasive approaches being introduced. Nevertheless, open major cancer resection, neck dissection and free flap reconstruction, with tracheostomy and percutaneous gastrostomy formation, remains a commonly performed surgical procedure in these patients. Thus, anaesthesia for oral cancer surgery can range from the perioperative management of patients undergoing minor diagnostic tissue biopsies to those undergoing major cancer resection, as well as newer techniques such as transoral robotic surgery.

Despite this range of different procedures, the principles of patient management remain the same—meticulous airway assessment (including review of imaging and nasendoscopy), a well-planned and communicated airway management strategy, preparation for failure, and prioritization of oxygenation at all times. This special case series describes the epidemiology and aetiology of oral cancer, cancer staging and the range of indications for surgery, the role of preoperative evaluation, risk prediction and optimisation/prehabilitation, the essentials of airway assessment, the array of airway management and oxygenation techniques available, the fundamentals of intraoperative and postoperative/critical care, and procedure-specific guidance, covering the specialist areas of oral cancer emergencies, free flap reconstruction and transoral surgery.

Patients with oral cancer (regardless of the stage of disease, and respective phase of their treatment pathway) should be viewed as high risk, even when undergoing relatively minor surgery, due to the impact of the primary pathology, radiotherapy and/or previous surgery on the airway, affecting reliability of standard airway manoeuvres and airway management techniques (both primary and rescue), as well as cardiorespiratory comorbidities common to this population. Indeed, patients undergoing head and neck surgical procedures accounted for 39% of all airway complications reported in the UK Fourth National Audit Project (NAP4) (2). The contribution of human factors in airway management was also highlighted in NAP4, and its importance is now well recognised, meriting its own article in this series, as well as dedicated guidelines [soon to be published by the Difficult Airway Society (DAS)]. Additionally, a multidisciplinary approach is consistently reinforced throughout this series as it is fundamental to ensuring patient safety and optimum outcome.

Therefore, the main purposes of this series are: (I) to provide a comprehensive and detailed overview of all aspects of anaesthesia for patients with oral cancer; (II) to provide a reference resource on anaesthesia for oral cancer for anaesthetists of all grades (specialists and trainees), nurses, intensive care physicians, surgeons and allied health professionals; and (III) to provide a guide that highlights important safety aspects involved in the anaesthesia management of oral cancer, particularly useful to those less experienced in managing these complex patients.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial Office, Journal of Oral and Maxillofacial Anesthesia, for the series “Anaesthesia for Oral Cancer”. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://joma.amegroups.com/article/view/10.21037/joma-22-29/coif). The series “Anaesthesia for Oral Cancer” was commissioned by the editorial office without any funding or sponsorship. PAW serves as the unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from June 2022 to May 2024 and served as unpaid Guest Editor of the series. MGI serves as the unpaid editorial board member of Journal of Oral and Maxillofacial Anesthesia from July 2021 to June 2023 and served as unpaid Guest Editor of the series. MGI declares the license for Textbook: Taking on TIVA Cambridge University Press and attended the meeting AAGBI Belfast September 2022. The authors have no other conflicts of interest to declare.

Ethical Statement:The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Stenson KM. Epidemiology and risk factors in head and neck cancer. UpToDate 2021. Available online: https://www.uptodate.com/contents/epidemiology-and-risk-factors-for-head-and-neck-cancer
2. Patel A, Pearce A, Pracy P. Chapter 18 Head and neck pathology. In: Cook T, Woodall N, Frerk C. editors. Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society. Major complications of airway management in the United Kingdom. Report and Findings. London: Royal College of Anaesthetists, 2011:143-54.