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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis
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Enferm Clin. 2017;xxx(xx):xxx---xxx
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NURSING CARE
Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis夽 Olga González-Antolín Servicio de Digestivo y Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain Received 28 October 2016; accepted 9 February 2017
KEYWORDS Osteoradionecrosis; Fistula; Debridement
PALABRAS CLAVE Osteorradionecrosis; Fístula; Desbridamiento
Abstract Radionecrosis is a late, and difficult to treat, complication of radiotherapy performed on head and neck tumours, and it is difficult to treat. This process causes significant damage, not only in the skin, but also in muscular, nervous, vascular, and bone structures. This, in turn, leads to airway and digestive tract involvement, as well as a functional loss and a cosmetic defect that usually requires reconstructive surgery. Therefore, this process is associated with a significant loss in the quality of life of patients and involves a long hospital stay for treatment, as well as the necessary support measures. This article describes the local treatment of pharyngocutaneous fistula secondary to radiation therapy of squamous cell carcinoma of the right oropharynx. The lesion appeared two months after completing this treatment and required surgical reconstruction with a myocutaneous flap to repair the tissue defect. In this context, an alginate wound dressing with silver was used, combined with a medium grip polyurethane foam with a silicone border. Within one month, there was autolytic debridement of all the necrotic tissue and the appearance of granulation tissue. At the same time, the infection was controlled, and a better management of the exudate was obtained, which provided a suitable surgical bed for the reconstruction. © 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
Tratamiento local de un faringostoma secundario a osteorradionecrosis Resumen La osteorradionecrosis es una complicación tardía y de difícil manejo que se produce como consecuencia de los tratamientos con radioterapia realizados en los tumores de cabeza y cuello. Ocasiona importantes da˜ nos, no solo en la piel sino también en estructuras
夽 Please cite this article as: González-Antolín O. Tratamiento local de un faringostoma secundario a osteorradionecrosis. Enferm Clin. 2017. http://dx.doi.org/10.1016/j.enfcli.2017.02.005 E-mail address: [email protected]
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O. González-Antolín musculares, nerviosas, vasculares y óseas produciendo una afectación de las vías aérea y digestiva que condicionan una pérdida funcional y un defecto estético que suele precisar de cirugía reconstructiva para su reparación. Este proceso lleva asociado una importante pérdida en la calidad de vida del paciente y conlleva largos ingresos hospitalarios por los tratamientos y medidas de soporte necesarios. En este artículo se describe el tratamiento local de un faringostoma secundario al tratamiento con radioterapia de un carcinoma epidermoide de orofaringe derecha. La lesión apareció a los dos meses tras finalizar la radioterapia, y precisó reconstrucción quirúrgica con un colgajo miocutáneo para reparar el defecto tisular. En este contexto, se ha utilizado un apósito de alginato con plata asociado a una espuma de poliuretano de adherencia media con reborde de silicona, consiguiendo en el plazo de un mes el desbridamiento autolítico de todo el tejido necrótico y la aparición de tejido de granulación, a la vez que se controló la infección y se consiguió un mejor manejo del exudado, proporcionando así un lecho quirúrgico adecuado para la reconstrucción. © 2017 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Osteoradionecrosis and chondronecrosis are amongst the complications that can appear after radiotherapy in the treatment of head and neck tumours, they are characterised by their late onset and difficulty in treatment. These complications originate essentially because radiation affects all cells in the field of treatment, especially the endothelium of small and medium-sized blood vessels, causing their obliteration, atrophy and fibrosis, resulting in tissue hypoxia, hypocellularity and hypovascularity and consequent necrosis. The incidence of osteoradionecrosis in patients with head and neck tumours is from 3% to 14%.1 The jawbone is the most-affected bone, since it is most frequently exposed to radiation. The hyoid bone, clavicles, temporal bone, and base of skull can also be affected, the latter in the treatment of nasopharyngeal cancers.1 Adverse reactions to radiotherapy depend on the volume and surface that is being irradiated, the total number of doses and their fractionation, and the age and condition of the patient. These effects can be divided into three phases: 1. The acute effects that occur during treatment. 2. The delayed early effects that appear between a few weeks and up to 2---3 months after completing treatment, which are usually reversible. 3. The delayed late effects that appear after between 3 months and 12 years following radiotherapy. These are generally irreversible and result in a worsened quality of life of the patient, causing permanent disabilities of varying intensity.2 These effects involve the cutaneous mucosa and can range in severity from a simple erythema to tissue necrosis, processes of hyperpigmentation, alopecia and mucositis are common. Fibrosis of the cervico-facial muscles can also occur and its consequent impact on chewing and swallowing and cervical mobility. Likewise, involvement of the salivary
glands is also common with consequent xerostomia, which in turn increases the risk of dental caries and can encourage mucosal candidiasis. Complications secondary to radiotherapy, bearing in mind that these are tumours usually originate in the oral cavity, pharynx and/or larynx, and sometimes even with previous surgical sequelae, often cause these patients swallowing difficulties. In fact up to 50% of head and neck cancer patients suffer some degree of malnutrition, which is severe in a third of these patients.3 Osteoradionecrosis is one of the most feared lesions that can occur after exposure to radiation. This complication results in ischaemic bone necrosis which causes pain and loss of bone structure which can occur spontaneously or, more usually, after trauma (generally teeth extractions). In patients with head and neck tumours who have undergone radiotherapy, the jawbone is most affected as it is poorly vascularised and very dense; therefore it is very sensitive to the effects of radiation. In 95% of cases soft tissue necrosis and bone exposure are also associated. These radio induced lesions are the most common indication for hyperbaric oxygen treatment, to reduce hypoxia and oedema, and to improve the host’s response to infection and ischaemia.4,5 Reconstruction of the defect after removing all devitalised hard and soft tissue can only be achieved with healthy vascularised tissue. At this point, muscle and myocutaneous flaps, using pectoralis major, sternocleidomastoid, deltoid or trapezius muscle enables volumes of tissue to be moved with excellent vascularisation, and they are particularly indicated for reconstructing defects that reach deep structures. Free flaps are also an alternative in the treatment of these head and neck defects, but are more complex to create.6 In this article we present a case that required local treatment of a pharyngostomy secondary to radiotherapy treatment of an epidermoid carcinoma of the right oropharynx, the lesion having appeared two months after completion of treatment. The lesion required surgical
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis reconstruction with a myocutaneuos flap (pectoralis major muscle) to repair the tissue defect. Lesion bed preparation is essential prior to surgical reconstruction. Because the lesion was located in the neck, the principal problem in debridement of the necrotic tissue lay in the proximity of the damaged tissue to the carotid artery and jugular vein, where surgical debridement with a scalpel would carry a high risk of bleeding and also be painful. Enzyme debridement by collagenase ointments is not indicated either for these types of lesions due to the risk of aspiration through the airway or digestive tract because these are exposed. For these reasons, an aginate dressing with silver was chosen because it combined the properties required for local treatment of the lesion such as autolytic debridement of the necrotic tissue, promotion of granulation, control of infection and management of exudate. The references report that pharyngocutaneous fistula is the most common postoperative complication after total laryngectomy.7 Reports agree that there are numerous risk factors for this complication to appear, such as radiotherapy treatment and tracheotomy prior to laryngectomy, the tumour site, diabetes mellitus and, in the postoperative period, haemoglobin levels below 10 g/dl and/or prealbumin levels below 17 mg/dl.7,8 As well as surgical reconstruction with myocutaneous and free flaps, negative pressure treatment is another treatment option for pharyngocutaneous fistulas, but its application has numerous limitations (uncontrolled infection of the fistula, the presence of necrotic tissue requiring debridement, non-revascularised arterial disease or exposure of vessels and organs with a high risk of bleeding).9 The literature only refers to the use of alginate dressings in treating pharyngocutaneous fistulas for managing salivary exudate.9 However, there are references to the use of silver alginate dressings in the treatment of venous leg ulcers.10
Case description A 62-year-old female patient who was transferred to our unit on 12 January 2016, referred by the radiotherapy department where she had been admitted 17 days previously with a diagnosis of right laterocervical abscess. Her history included: • Smoking and alcohol intake of 60---80 g/day. • Epidermoid carcinoma of the right tonsil (T2N2M0) in 1999 treated with chemotherapy and radiotherapy. • Infiltrating ductal carcinoma of the right breast diagnosed in December 2008, treated by tumorectomy plus chemotherapy and tamoxifen until June 2015. • Diagnosis of second epidermoid carcinoma of the right oropharynx (soft palate T2N0M0) in August 2015 for which she received radiotherapy at a dose of 2 Gy per day, 5 days a week over 6 weeks. She tolerated the treatment well and had no adverse effects of note. Two weeks prior to admission, the patient had started a picture of poorly controlled pain, the presence of a mass in her right laterocervical region progressively growing and
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Figure 1 Day 1. Pharyngostomy due to radionecrosis. Exposure of the sternocleidomastoid muscle, visualisation of the pharynx, including the nasogastric tube.
subsequently abscessing, developing into a right laterocervical necrosis with gradual destruction of the tissue planes of the skin, muscle (sternocleidomastoid) and right lateral pharyngeal wall. A large pharyngostoma had opened from the lower edge of the jawbone to the height of the hypopharynx. Initial culture of a sample of exudate from the lesion isolated Staphylococcus aureus and Klebsiella pneumoniae, intravenous antibiotic treatment was started with amoxicillin/clavulanic acid and metronidazole. This antibiotic guideline was changed two weeks after the patient’s admission after a further antibiogram that indicated intravenous cloxacillin. On the third day of admission, the nasogastric tube was replaced with a percutaneous gastrostomy by endoscopic approach. The most relevant finding from imaging studies (cervicothoracic CT and CT angiography), apart from the major necrosis and loss of tissue, was the complete obliteration of the common carotid artery and its main branches. On initial assessment of the lesion, the patient presented a large pharyngostomy through which could be seen the nasogastric tube, base of tongue, larynx, hyoid bone and lower edge of the horizontal branch of the jawbone with edges that were erythematous, inflamed, painful to touch, with abundant necrotic tissue adhering strongly to the underlying structures and the presence of abundant necrotic, purulent and malodorous material (Fig. 1). Up until that moment, local treatment of the lesion had comprised dry dressings with nitrofurantoin ointmentimpregnated gauze covered by a polyurethane foam dressing that required changing twice or even three times a day due to abundant purulent drainage. For this reason a dressing strategy was implemented with the following objectives: 1. To remove necrotic tissue in the least traumatic way possible, due to the anatomical area of the lesion and cause the patient the least discomfort possible. 2. To control of local infection. 3. To manage the exudate. 4. To schedule dressings every 48 h. 5. To prepare the surgical bed for subsequent reconstruction. A dressing regimen was established with these objectives in mind using a combination of silver alginate dressings
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Figure 2 Day 15. Sternocleidomastoid muscle coming away from its point of insertion.
Figure 3 Day 15. The necrosed sternocleidomastoid muscle is cut with a pair of scissors; the hyoid bone is left completely exposed. The base of the tongue, the left lateral wall of the pharynx (from which a drop of saliva is falling) and the entrance to the larynx can be seen.
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(Biatain alginate AG ) for local treatment of infection, associated with an activated carbon dressing to reduce the odour and a polyurethane foam dressing with a silicone edge ® (Biatain Silicone ) to manage the exudate and to maintain the damp environment required by the dressing. A spray ® barrier dressing was applied (Cavilon ) to protect against maceration of the skin around the lesion. Gradually a reduction in the amount of purulent exudate and odour was noticed, performing the dressings every 48 h. Fifteen days after starting the dressing regimen with Biatain ® Alginate AG , the sternocleidomastoid muscle, which was completely necrosed, was debrided (Figs. 2 and 3). The dressing regimen was subsequently changed, the activated carbon dressing was removed as there was no longer any odour, and in its place a low adherence ® polyurethane foam dressing (Biatain Soft Hold ) was placed to retain the exudate and because it was adaptable enough to cover the lesion. A further dressing of polyurethane foam ® with silicone edge (Biatain Silicone ) was placed on top of this dressing as a secondary dressing to ensure that the lesion was properly covered, because if only one polyurethane foam dressing had been placed, when the lower part of the dressing became saturated and due to the action of gravity it would become loose and leave the lesion uncovered. By using this double dressing we prevented this problem with
Figure 4 Day 22. Exposed hyoid bone. The lesion bed shows disperse sloughy tissue and abundant granulation tissue.
Figure 5 Day 22. Insertion of the silver alginate dressing ® (Biatain Alginate AG ) in the bed of the lesion after cleaning with saline.
the added advantage of keeping the dressing damp without needing to change it, at least within two days. Two weeks after implementing this dressing regimen and as a side effect of fentanyl patches, the patient developed a paralytic ileus with profuse vomiting that flowed through the pharyngostomy, therefore parenteral nutrition was commenced to combat nutritional decline. Likewise, it was necessary to change the antibiotic treatment, since the result from a culture taken after the bouts of vomiting was positive for Enterococcus faecalis and Escherichia coli (E. coli), and I.V. ceftazidime and metronidazole were prescribed. The lesion was less exudative but continued to drain purulent content (Figs. 4 and 5). Once enteral feeding was resumed through the nasogastric tube, and a month after starting treatment, a significant improvement in healing was observed. The purulent exudate abated, hardly any sloughy tissue remained, and abundant granulation tissue appeared that was well vascularised at the edges of the wound, partially covering the hyoid bone. The dressings were then scheduled every 72 h (Fig. 6). The result of a further culture showed the presence of a multiresistant Pseudomonas aeruginosa in addition to the earlier E. coli and E. faecalis, and therefore the patient had to be isolated and the antibiotic treatment changed again (ceftazidime and teicoplanin IV). Despite this setback, the appearance of the lesion continued to improve, with slight progress of the granulation tissue and filling of the cavity from the edges inwards, and the fistula reduced considerably in size (Fig. 7).
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis Table 1
Focussed assessment: list of altered needs.
Need
Assessment
Breathing
Difficulty in eliminating secretions due to the orocervical communication caused by the pharyngostomy. Difficulty in intake and swallowing solid or semi-liquid foods secondary to the pharyngoscomy with the consequent risk of malnutrition. Possible alterations in bowel habit secondary to diet and analgesic treatment (opiates and derivatives). Usual sleep patterns might be altered due to many causes (fear of not being able to breathe properly due to the difficulty in eliminating secretions, pain, discomfort, hospital routines that make sleep difficult. . .). There might be alterations in self-perception (the patient sees herself as inferior to others because of the deformity caused by the lesion), in her pattern of interaction with family and those closest to her and in adapting to change (especially communication difficulties and the change in body image). The patient has difficulties in communicating due to the pharyngostomy; phonation and correctly articulating words are made difficult. It is important to be aware of her level of knowledge of her state of health and whether or not she finds it difficult to learn new things, which will help independent management of the treatment guidelines.
Eating and drinking
Figure 6 Day 27. It can be seen that the hyoid bone is completely covered by granulation tissue. Measurements: 7 cm long × 5 cm wide × 7 cm deep.
Elimination
Need for rest and sleep
Avoiding danger
Figure 7 Day 47. Good progress, the hyoid bone is not exposed. Measurements: 6 cm long × 5 cm wide × 5.5 cm deep. Visualisation of the larynx.
A month and a half after the dressings had been started, when the cultures returned negative and given the lesion’s good progress, antibiotic treatment was discontinued (66 days of I.V. treatment) and the patient was taken out of isolation. A cervico-thoracic PET was performed showing no signs of pathological uptake and surgical reconstruction was scheduled two weeks later. In this latter stage, care comprised removing mucous crusts adhering to the bed of the lesion, helped by dampening and applying Vaseline locally, it was then only necessary to cover the lesion with polyurethane foam dressings (Fig. 8). Surgical treatment comprised closure of the pharyngostomy by a pedicled flap of the right pectoralis major muscle, as well as a tracheotomy. In the immediate postoperative period (third day), the flap was found to be warm to the touch, with no accumulation of blood and with capillary refill of at least 3 seconds. In the distal area there was a purplish area (venous congestion) which only affected the epidermis (Fig. 9).
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Communicating
Need to learn
The care plan from the NANDA nursing diagnoses and potential complications (bifocal perspective) with the corresponding criteria from NOC outcomes and NIC interventions are shown on Table 2.11---13
Nursing assessment Discussion A nursing assessment was made according to Virginia Henderson’s model which showed that the needs for breathing, eating and drinking, eliminating waste, rest and sleep, communication and avoiding dangers were altered. (Table 1).
The treatment of a lesion caused by radionecrosis involves various aspects from nutrition, control of infection by targeted antibiotic treatment to appropriate wound care, all of which have a significant impact on outcome. Preparation
Care plan according to NANDA-NOC-NIC taxonomies.
NANDA nursing diagnosis
NOC outcomes
NIC interventions
00126 Deficient knowledge: therapy regimen Related to: Lack of exposure. Manifested by: Verbalisation of the problem
1813 Knowledge: therapy regimen Indicators: 1. Prescribed diet 2. Prescribed medication 3. Prescribed activity
5614. Teaching: prescribed diet Activity: 1. Teach the patient about the prescribed diet
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Table 2
5616. Teaching: prescribed medication Activity: 1. Teach the patient about administration of medication
1918. Prevention of aspiration Indicator: 1. Kept in upright position 30 minutes after feed. 2. Avoid risk factors
3200. Precautions to prevent aspiration Activities: 1. Keep the head of the bed elevated for 30---45 min after feed. 2. Assess the presence of dysphagia, as necessary. 3. Keep aspiration equipment at hand. 1570. Management of vomiting Activities: 1. Position the patient appropriately to prevent aspiration. 2. Ensure that effective antiemetics have been given to prevent vomiting. 3. Assess colour, consistency, presence of blood, duration and volume
00118. Disturbed body image Related to: The cervical lesion Manifested by: Not touching or looking at a body part
1200. Body image Indicators: 1. Adjustment to body changes due to surgery. 2. Attitude towards not touching the affected body part
00153. Risk for situational low self-esteem Related to: Disturbed body image
1205. Self-esteem Indicators: 1. Acceptance of own limitations. 2. Acceptance of constructive criticism. 3. Maintenance of personal care/hygiene
5220. Body image enhancement Activities: 1. Observe whether the patient can look at the part of her body that has changed. 2. Help the patient to identify actions that will enhance her appearance 5395. Self-efficacy enhancement Activities: 1. Identify obstacles to a change in behaviour. 2. Provide an environment for support in knowledge and to learn the skills necessary to perform the health behaviour. 3. Provide positive reinforcement and emotional support during the learning process
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00039. Risk for aspiration Related to: The presence of an enteral tube
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5612. Teaching: prescribed exercise Activity: 1. Teach the patient about the prescribed activity
Interventions/NIC
1. Airway obstruction
3160. Airway suctioning Activities: 1. Establish the need for tracheal/oral suctioning. 3140. Airway management Activities: 1. Administer air or humidified oxygen. 2. Position the patient so as to relieve dyspnoea. 3. Teach how to cough effectively 1400. Pain management Activities: 1. Perform a thorough pain assessment (location, onset, duration, frequency...). 2. Monitor the patient’s satisfaction level with pain control 6540. Infection control Activities: 1. Teach the patient/family about the signs and symptoms of infection and when they should be reported to carers. 2. Ensure aseptic handling of IV lines. 3. Ensure appropriate wound care technique. 4. Put universal precautions into practice. 5. Apply Zero Tolerance Protocol. 3440. Incision site care Activities: 1. Inspect the incision site for reddening, inflammation and or signs and symptoms of infection. 2. Clean the area around the incision with an antiseptic from the cleanest to the least clean area applying an appropriate bandage or dressing 3. Teach the patient how to care for the incision while 4020. Bleeding reduction Activities: 1. Teach the patient/family about the signs of bleeding and appropriate measures to be taken (report to nursing staff). 2. Establish the amount and nature of blood loss. 3. Maintain a permeable I.V. line. 4. Teach the patient about restrictions in activities, as appropriate. 5. Place the patient in the semi-Fowler position. 6. Apply manual pressure on the area of bleeding or potential bleeding
2. Pain
3. Infection
4. Bleeding
4140. Fluid resuscitation Activities: 1. Obtain samples for crossmatching. 2. Administer I.V. fluids as prescribed. 3. Administer blood products as prescribed. 4. Monitor haemodynamic response
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Potential complications
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis
Table 2
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Table 2
(Continued) Interventions/NIC
5. Insomnia
1850. Sleep enhancement Activities: 1. Adapt the patient’s environment to enhance sleep. 2. Check the patient’s sleep hygiene. 3. Administer prescribed medication according to route and assess therapeutic and adverse effects 1160. Nutritional monitoring Activities: 1. Weigh the patient at regular intervals and monitor progress. 2. Monitor calories and food intake. 1100. Nutrition management Activities: 1. Teach the patient about dietary requirements according to their condition. 2. Monitor tendencies for weight gain or weight loss 0450. Constipation/Impaction Management Activities: 1. Monitor the appearance of signs and symptoms of constipation. 2. Identify possible causative, contributory factors (medication, diet. . .). 3. Encourage increased fluid intake. 4. Instruct the patient/family about a fibre-rich diet
6. Malnutrition
7. Constipation
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Potential complications
Source: Heather Herdman11 , Johnson et al.12 and Bulechek et al.13
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patient because the objectives of removing the necrotic tissue in the least traumatic manner possible and achieving an exudate and infection-free surgical bed were met. Since this is a lesion located in the neck, and due to the vascular structures in the area, there is the added problem that cutting debridement with a scalpel carries a high risk of bleeding, therefore the autolytic debridement provided by alginate is an advantage. Furthermore, it enabled dressings to be scheduled so as to cause the patient the least discomfort possible, preventing cross contamination or infections as far as was possible and enabling continuity of care. Figure 8 Day 84. Good progress, with granulation tissue at the left lateral and lower edges. No signs of infection. Only mucous present in the bed of the lesion. Exposure of the right edge of the jawbone. Visualisation of the larynx and the uvula at the back. Measurements: 5.5 cm long × 5 cm wide × 5.5 cm deep.
Conflict of interests The author has no conflict of interest to declare.
Acknowledgements I want to express my sincere gratitude to the patient in this case, who gave her consent for this study of her case and to publish the photographs that show the progress of her lesion. I also want to thank all my colleagues from the 6th floor of Pabellón 2 Noviembre and the ENT department of the University Hospital Marqués de Valdecilla for their excellent work and collaboration, and José Luis Cobo Sánchez, Research, Development and Innovation Support Unit nurse, for his advice.
References
Figure 9 Day 93. 3rd postoperative day. Reconstruction of the defect with right pectoralis major muscle and tracheotomy. Superficial haematoma only affecting the epidermis.
of the lesion bed to the best possible condition, with no signs of infection, free from necrotic tissue and with granulation tissue increases the possibilities for successful surgical reconstruction when this is necessary.
Conclusions The choice of a silver alginate dressing for local treatment of this type of lesion was very useful and beneficial for the
1. Zurita-Jiménez MS. Radionecrosis de hueso y cartílago en el tratamiento de tumores de cabeza y cuello. Radiobiología [revista en Internet]. 2004;4:82---3. Available from: http://www-rayos.medicina.uma.es/rmf/radiobiologia/revista/ radiobiología.htm [accessed 28.02.16]. 2. Chiesa-Estomba CM, Araujo-da Costa AS, Rivera-Schmitz T, Martínez-Cueto P, Pérez-Carro A, Araujo-Nores J. Complicaciones post radioterapia en el área otorrinolaringológica. Rev Soc Otorrinolaringol Castilla León Cantab La Rioja. 2013;4:128---34. 3. Martín-Villares C, San Román-Carbajo J, Fernández-Pello ME, Tapia-Risue˜ no M, Domínguez-Calvo J. El estado nutricional en pacientes con cáncer de cabeza cuello: implicaciones pronósticas. Nutr Hosp. 2003;18:91---4. 4. Herrera-Herrera A, Díaz-Caballero A, Herrera-Barrios F, FangMercado LC. Osteorradionecrosis como secuela de la radioterapia. Av Odontoestomatol. 2012;28:175---80. 5. Torres-León JM, Domínguez-Alegría AR, Navarro-Télle M, Brinquis-Crespo MA, Espigares-Correa A, Pérez-Mochales JF. Patologías tratadas con oxigenoterapia hiperbárica en el Hospital Central de la Defensa. Sanid Mil. 2015;71:77---83. 6. Benito-Duque P, Elena-Sorando E, De Juan-Huelves A, CanoRosas M. Colgajo deltopectoral bilateral para el tratamiento de úlceras por radionecrosis en el cuello. Caso clínico. Cir Plas Iberolatinoam. 2006;32:219---23. 7. Kilic C, Tuncel Ü, Cömert E. Phayngocutaneous fistulae after total laryngectomy: analysis of the risk factors and treatment approaches. B-ENT. 2015;11:95---100. 8. Liang JW, Li ZD, Li SC, Fang FQ, Zhao YJ, Li YG. Pharyngocutaneous fistula after total laringectomy: a systematic review and meta-analysis of risk factors. Auris Nasus Larynx. 1973;2015:1---7.
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10 9. Loaec E, Y-Vaillant P, Bonne L, Marianowski R. Negative-pressure wound therapy for the treatment of pharyngocutaneous fistula. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131:351---5. 10. Leaper D, Münter C, Meaume S, Scalise A, Mompó NB, Jakobsen BP, et al. The use of biatain ag in hard-to-heal venous leg ulcers: meta-analysis of randomised controlled trials. PLoS ONE. 2013;8:e67083. 11. Heather Herdman T. Diagnósticos enfermeros definiciones y clasificación 2009---2011 --- Nanda Internacional. 8.a ed Barcelona: Elsevier; 2010.
O. González-Antolín 12. Johnson M, Maas M, Moorhead S. Clasificación de Resultados de Enfermería (CRE). Nursing outcomes classification (NOC). 2.a ed Madrid: Harcourt; 2001. 13. Bulechek G, Butcher H, McCloskey-Dochterman J. Clasificación de Intervenciones de Enfermería (NIC). 5.a ed Barcelona: Elsevier; 2008.
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NURSING CARE
Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis夽 Olga González-Antolín Servicio de Digestivo y Otorrinolaringología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, Spain Received 28 October 2016; accepted 9 February 2017
KEYWORDS Osteoradionecrosis; Fistula; Debridement
PALABRAS CLAVE Osteorradionecrosis; Fístula; Desbridamiento
Abstract Radionecrosis is a late, and difficult to treat, complication of radiotherapy performed on head and neck tumours, and it is difficult to treat. This process causes significant damage, not only in the skin, but also in muscular, nervous, vascular, and bone structures. This, in turn, leads to airway and digestive tract involvement, as well as a functional loss and a cosmetic defect that usually requires reconstructive surgery. Therefore, this process is associated with a significant loss in the quality of life of patients and involves a long hospital stay for treatment, as well as the necessary support measures. This article describes the local treatment of pharyngocutaneous fistula secondary to radiation therapy of squamous cell carcinoma of the right oropharynx. The lesion appeared two months after completing this treatment and required surgical reconstruction with a myocutaneous flap to repair the tissue defect. In this context, an alginate wound dressing with silver was used, combined with a medium grip polyurethane foam with a silicone border. Within one month, there was autolytic debridement of all the necrotic tissue and the appearance of granulation tissue. At the same time, the infection was controlled, and a better management of the exudate was obtained, which provided a suitable surgical bed for the reconstruction. © 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
Tratamiento local de un faringostoma secundario a osteorradionecrosis Resumen La osteorradionecrosis es una complicación tardía y de difícil manejo que se produce como consecuencia de los tratamientos con radioterapia realizados en los tumores de cabeza y cuello. Ocasiona importantes da˜ nos, no solo en la piel sino también en estructuras
夽 Please cite this article as: González-Antolín O. Tratamiento local de un faringostoma secundario a osteorradionecrosis. Enferm Clin. 2017. http://dx.doi.org/10.1016/j.enfcli.2017.02.005 E-mail address: [email protected]
2445-1479/© 2017 Elsevier Espa˜ na, S.L.U. All rights reserved.
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O. González-Antolín musculares, nerviosas, vasculares y óseas produciendo una afectación de las vías aérea y digestiva que condicionan una pérdida funcional y un defecto estético que suele precisar de cirugía reconstructiva para su reparación. Este proceso lleva asociado una importante pérdida en la calidad de vida del paciente y conlleva largos ingresos hospitalarios por los tratamientos y medidas de soporte necesarios. En este artículo se describe el tratamiento local de un faringostoma secundario al tratamiento con radioterapia de un carcinoma epidermoide de orofaringe derecha. La lesión apareció a los dos meses tras finalizar la radioterapia, y precisó reconstrucción quirúrgica con un colgajo miocutáneo para reparar el defecto tisular. En este contexto, se ha utilizado un apósito de alginato con plata asociado a una espuma de poliuretano de adherencia media con reborde de silicona, consiguiendo en el plazo de un mes el desbridamiento autolítico de todo el tejido necrótico y la aparición de tejido de granulación, a la vez que se controló la infección y se consiguió un mejor manejo del exudado, proporcionando así un lecho quirúrgico adecuado para la reconstrucción. © 2017 Elsevier Espa˜ na, S.L.U. Todos los derechos reservados.
Introduction Osteoradionecrosis and chondronecrosis are amongst the complications that can appear after radiotherapy in the treatment of head and neck tumours, they are characterised by their late onset and difficulty in treatment. These complications originate essentially because radiation affects all cells in the field of treatment, especially the endothelium of small and medium-sized blood vessels, causing their obliteration, atrophy and fibrosis, resulting in tissue hypoxia, hypocellularity and hypovascularity and consequent necrosis. The incidence of osteoradionecrosis in patients with head and neck tumours is from 3% to 14%.1 The jawbone is the most-affected bone, since it is most frequently exposed to radiation. The hyoid bone, clavicles, temporal bone, and base of skull can also be affected, the latter in the treatment of nasopharyngeal cancers.1 Adverse reactions to radiotherapy depend on the volume and surface that is being irradiated, the total number of doses and their fractionation, and the age and condition of the patient. These effects can be divided into three phases: 1. The acute effects that occur during treatment. 2. The delayed early effects that appear between a few weeks and up to 2---3 months after completing treatment, which are usually reversible. 3. The delayed late effects that appear after between 3 months and 12 years following radiotherapy. These are generally irreversible and result in a worsened quality of life of the patient, causing permanent disabilities of varying intensity.2 These effects involve the cutaneous mucosa and can range in severity from a simple erythema to tissue necrosis, processes of hyperpigmentation, alopecia and mucositis are common. Fibrosis of the cervico-facial muscles can also occur and its consequent impact on chewing and swallowing and cervical mobility. Likewise, involvement of the salivary
glands is also common with consequent xerostomia, which in turn increases the risk of dental caries and can encourage mucosal candidiasis. Complications secondary to radiotherapy, bearing in mind that these are tumours usually originate in the oral cavity, pharynx and/or larynx, and sometimes even with previous surgical sequelae, often cause these patients swallowing difficulties. In fact up to 50% of head and neck cancer patients suffer some degree of malnutrition, which is severe in a third of these patients.3 Osteoradionecrosis is one of the most feared lesions that can occur after exposure to radiation. This complication results in ischaemic bone necrosis which causes pain and loss of bone structure which can occur spontaneously or, more usually, after trauma (generally teeth extractions). In patients with head and neck tumours who have undergone radiotherapy, the jawbone is most affected as it is poorly vascularised and very dense; therefore it is very sensitive to the effects of radiation. In 95% of cases soft tissue necrosis and bone exposure are also associated. These radio induced lesions are the most common indication for hyperbaric oxygen treatment, to reduce hypoxia and oedema, and to improve the host’s response to infection and ischaemia.4,5 Reconstruction of the defect after removing all devitalised hard and soft tissue can only be achieved with healthy vascularised tissue. At this point, muscle and myocutaneous flaps, using pectoralis major, sternocleidomastoid, deltoid or trapezius muscle enables volumes of tissue to be moved with excellent vascularisation, and they are particularly indicated for reconstructing defects that reach deep structures. Free flaps are also an alternative in the treatment of these head and neck defects, but are more complex to create.6 In this article we present a case that required local treatment of a pharyngostomy secondary to radiotherapy treatment of an epidermoid carcinoma of the right oropharynx, the lesion having appeared two months after completion of treatment. The lesion required surgical
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis reconstruction with a myocutaneuos flap (pectoralis major muscle) to repair the tissue defect. Lesion bed preparation is essential prior to surgical reconstruction. Because the lesion was located in the neck, the principal problem in debridement of the necrotic tissue lay in the proximity of the damaged tissue to the carotid artery and jugular vein, where surgical debridement with a scalpel would carry a high risk of bleeding and also be painful. Enzyme debridement by collagenase ointments is not indicated either for these types of lesions due to the risk of aspiration through the airway or digestive tract because these are exposed. For these reasons, an aginate dressing with silver was chosen because it combined the properties required for local treatment of the lesion such as autolytic debridement of the necrotic tissue, promotion of granulation, control of infection and management of exudate. The references report that pharyngocutaneous fistula is the most common postoperative complication after total laryngectomy.7 Reports agree that there are numerous risk factors for this complication to appear, such as radiotherapy treatment and tracheotomy prior to laryngectomy, the tumour site, diabetes mellitus and, in the postoperative period, haemoglobin levels below 10 g/dl and/or prealbumin levels below 17 mg/dl.7,8 As well as surgical reconstruction with myocutaneous and free flaps, negative pressure treatment is another treatment option for pharyngocutaneous fistulas, but its application has numerous limitations (uncontrolled infection of the fistula, the presence of necrotic tissue requiring debridement, non-revascularised arterial disease or exposure of vessels and organs with a high risk of bleeding).9 The literature only refers to the use of alginate dressings in treating pharyngocutaneous fistulas for managing salivary exudate.9 However, there are references to the use of silver alginate dressings in the treatment of venous leg ulcers.10
Case description A 62-year-old female patient who was transferred to our unit on 12 January 2016, referred by the radiotherapy department where she had been admitted 17 days previously with a diagnosis of right laterocervical abscess. Her history included: • Smoking and alcohol intake of 60---80 g/day. • Epidermoid carcinoma of the right tonsil (T2N2M0) in 1999 treated with chemotherapy and radiotherapy. • Infiltrating ductal carcinoma of the right breast diagnosed in December 2008, treated by tumorectomy plus chemotherapy and tamoxifen until June 2015. • Diagnosis of second epidermoid carcinoma of the right oropharynx (soft palate T2N0M0) in August 2015 for which she received radiotherapy at a dose of 2 Gy per day, 5 days a week over 6 weeks. She tolerated the treatment well and had no adverse effects of note. Two weeks prior to admission, the patient had started a picture of poorly controlled pain, the presence of a mass in her right laterocervical region progressively growing and
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Figure 1 Day 1. Pharyngostomy due to radionecrosis. Exposure of the sternocleidomastoid muscle, visualisation of the pharynx, including the nasogastric tube.
subsequently abscessing, developing into a right laterocervical necrosis with gradual destruction of the tissue planes of the skin, muscle (sternocleidomastoid) and right lateral pharyngeal wall. A large pharyngostoma had opened from the lower edge of the jawbone to the height of the hypopharynx. Initial culture of a sample of exudate from the lesion isolated Staphylococcus aureus and Klebsiella pneumoniae, intravenous antibiotic treatment was started with amoxicillin/clavulanic acid and metronidazole. This antibiotic guideline was changed two weeks after the patient’s admission after a further antibiogram that indicated intravenous cloxacillin. On the third day of admission, the nasogastric tube was replaced with a percutaneous gastrostomy by endoscopic approach. The most relevant finding from imaging studies (cervicothoracic CT and CT angiography), apart from the major necrosis and loss of tissue, was the complete obliteration of the common carotid artery and its main branches. On initial assessment of the lesion, the patient presented a large pharyngostomy through which could be seen the nasogastric tube, base of tongue, larynx, hyoid bone and lower edge of the horizontal branch of the jawbone with edges that were erythematous, inflamed, painful to touch, with abundant necrotic tissue adhering strongly to the underlying structures and the presence of abundant necrotic, purulent and malodorous material (Fig. 1). Up until that moment, local treatment of the lesion had comprised dry dressings with nitrofurantoin ointmentimpregnated gauze covered by a polyurethane foam dressing that required changing twice or even three times a day due to abundant purulent drainage. For this reason a dressing strategy was implemented with the following objectives: 1. To remove necrotic tissue in the least traumatic way possible, due to the anatomical area of the lesion and cause the patient the least discomfort possible. 2. To control of local infection. 3. To manage the exudate. 4. To schedule dressings every 48 h. 5. To prepare the surgical bed for subsequent reconstruction. A dressing regimen was established with these objectives in mind using a combination of silver alginate dressings
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Figure 2 Day 15. Sternocleidomastoid muscle coming away from its point of insertion.
Figure 3 Day 15. The necrosed sternocleidomastoid muscle is cut with a pair of scissors; the hyoid bone is left completely exposed. The base of the tongue, the left lateral wall of the pharynx (from which a drop of saliva is falling) and the entrance to the larynx can be seen.
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(Biatain alginate AG ) for local treatment of infection, associated with an activated carbon dressing to reduce the odour and a polyurethane foam dressing with a silicone edge ® (Biatain Silicone ) to manage the exudate and to maintain the damp environment required by the dressing. A spray ® barrier dressing was applied (Cavilon ) to protect against maceration of the skin around the lesion. Gradually a reduction in the amount of purulent exudate and odour was noticed, performing the dressings every 48 h. Fifteen days after starting the dressing regimen with Biatain ® Alginate AG , the sternocleidomastoid muscle, which was completely necrosed, was debrided (Figs. 2 and 3). The dressing regimen was subsequently changed, the activated carbon dressing was removed as there was no longer any odour, and in its place a low adherence ® polyurethane foam dressing (Biatain Soft Hold ) was placed to retain the exudate and because it was adaptable enough to cover the lesion. A further dressing of polyurethane foam ® with silicone edge (Biatain Silicone ) was placed on top of this dressing as a secondary dressing to ensure that the lesion was properly covered, because if only one polyurethane foam dressing had been placed, when the lower part of the dressing became saturated and due to the action of gravity it would become loose and leave the lesion uncovered. By using this double dressing we prevented this problem with
Figure 4 Day 22. Exposed hyoid bone. The lesion bed shows disperse sloughy tissue and abundant granulation tissue.
Figure 5 Day 22. Insertion of the silver alginate dressing ® (Biatain Alginate AG ) in the bed of the lesion after cleaning with saline.
the added advantage of keeping the dressing damp without needing to change it, at least within two days. Two weeks after implementing this dressing regimen and as a side effect of fentanyl patches, the patient developed a paralytic ileus with profuse vomiting that flowed through the pharyngostomy, therefore parenteral nutrition was commenced to combat nutritional decline. Likewise, it was necessary to change the antibiotic treatment, since the result from a culture taken after the bouts of vomiting was positive for Enterococcus faecalis and Escherichia coli (E. coli), and I.V. ceftazidime and metronidazole were prescribed. The lesion was less exudative but continued to drain purulent content (Figs. 4 and 5). Once enteral feeding was resumed through the nasogastric tube, and a month after starting treatment, a significant improvement in healing was observed. The purulent exudate abated, hardly any sloughy tissue remained, and abundant granulation tissue appeared that was well vascularised at the edges of the wound, partially covering the hyoid bone. The dressings were then scheduled every 72 h (Fig. 6). The result of a further culture showed the presence of a multiresistant Pseudomonas aeruginosa in addition to the earlier E. coli and E. faecalis, and therefore the patient had to be isolated and the antibiotic treatment changed again (ceftazidime and teicoplanin IV). Despite this setback, the appearance of the lesion continued to improve, with slight progress of the granulation tissue and filling of the cavity from the edges inwards, and the fistula reduced considerably in size (Fig. 7).
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis Table 1
Focussed assessment: list of altered needs.
Need
Assessment
Breathing
Difficulty in eliminating secretions due to the orocervical communication caused by the pharyngostomy. Difficulty in intake and swallowing solid or semi-liquid foods secondary to the pharyngoscomy with the consequent risk of malnutrition. Possible alterations in bowel habit secondary to diet and analgesic treatment (opiates and derivatives). Usual sleep patterns might be altered due to many causes (fear of not being able to breathe properly due to the difficulty in eliminating secretions, pain, discomfort, hospital routines that make sleep difficult. . .). There might be alterations in self-perception (the patient sees herself as inferior to others because of the deformity caused by the lesion), in her pattern of interaction with family and those closest to her and in adapting to change (especially communication difficulties and the change in body image). The patient has difficulties in communicating due to the pharyngostomy; phonation and correctly articulating words are made difficult. It is important to be aware of her level of knowledge of her state of health and whether or not she finds it difficult to learn new things, which will help independent management of the treatment guidelines.
Eating and drinking
Figure 6 Day 27. It can be seen that the hyoid bone is completely covered by granulation tissue. Measurements: 7 cm long × 5 cm wide × 7 cm deep.
Elimination
Need for rest and sleep
Avoiding danger
Figure 7 Day 47. Good progress, the hyoid bone is not exposed. Measurements: 6 cm long × 5 cm wide × 5.5 cm deep. Visualisation of the larynx.
A month and a half after the dressings had been started, when the cultures returned negative and given the lesion’s good progress, antibiotic treatment was discontinued (66 days of I.V. treatment) and the patient was taken out of isolation. A cervico-thoracic PET was performed showing no signs of pathological uptake and surgical reconstruction was scheduled two weeks later. In this latter stage, care comprised removing mucous crusts adhering to the bed of the lesion, helped by dampening and applying Vaseline locally, it was then only necessary to cover the lesion with polyurethane foam dressings (Fig. 8). Surgical treatment comprised closure of the pharyngostomy by a pedicled flap of the right pectoralis major muscle, as well as a tracheotomy. In the immediate postoperative period (third day), the flap was found to be warm to the touch, with no accumulation of blood and with capillary refill of at least 3 seconds. In the distal area there was a purplish area (venous congestion) which only affected the epidermis (Fig. 9).
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Communicating
Need to learn
The care plan from the NANDA nursing diagnoses and potential complications (bifocal perspective) with the corresponding criteria from NOC outcomes and NIC interventions are shown on Table 2.11---13
Nursing assessment Discussion A nursing assessment was made according to Virginia Henderson’s model which showed that the needs for breathing, eating and drinking, eliminating waste, rest and sleep, communication and avoiding dangers were altered. (Table 1).
The treatment of a lesion caused by radionecrosis involves various aspects from nutrition, control of infection by targeted antibiotic treatment to appropriate wound care, all of which have a significant impact on outcome. Preparation
Care plan according to NANDA-NOC-NIC taxonomies.
NANDA nursing diagnosis
NOC outcomes
NIC interventions
00126 Deficient knowledge: therapy regimen Related to: Lack of exposure. Manifested by: Verbalisation of the problem
1813 Knowledge: therapy regimen Indicators: 1. Prescribed diet 2. Prescribed medication 3. Prescribed activity
5614. Teaching: prescribed diet Activity: 1. Teach the patient about the prescribed diet
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Table 2
5616. Teaching: prescribed medication Activity: 1. Teach the patient about administration of medication
1918. Prevention of aspiration Indicator: 1. Kept in upright position 30 minutes after feed. 2. Avoid risk factors
3200. Precautions to prevent aspiration Activities: 1. Keep the head of the bed elevated for 30---45 min after feed. 2. Assess the presence of dysphagia, as necessary. 3. Keep aspiration equipment at hand. 1570. Management of vomiting Activities: 1. Position the patient appropriately to prevent aspiration. 2. Ensure that effective antiemetics have been given to prevent vomiting. 3. Assess colour, consistency, presence of blood, duration and volume
00118. Disturbed body image Related to: The cervical lesion Manifested by: Not touching or looking at a body part
1200. Body image Indicators: 1. Adjustment to body changes due to surgery. 2. Attitude towards not touching the affected body part
00153. Risk for situational low self-esteem Related to: Disturbed body image
1205. Self-esteem Indicators: 1. Acceptance of own limitations. 2. Acceptance of constructive criticism. 3. Maintenance of personal care/hygiene
5220. Body image enhancement Activities: 1. Observe whether the patient can look at the part of her body that has changed. 2. Help the patient to identify actions that will enhance her appearance 5395. Self-efficacy enhancement Activities: 1. Identify obstacles to a change in behaviour. 2. Provide an environment for support in knowledge and to learn the skills necessary to perform the health behaviour. 3. Provide positive reinforcement and emotional support during the learning process
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00039. Risk for aspiration Related to: The presence of an enteral tube
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5612. Teaching: prescribed exercise Activity: 1. Teach the patient about the prescribed activity
Interventions/NIC
1. Airway obstruction
3160. Airway suctioning Activities: 1. Establish the need for tracheal/oral suctioning. 3140. Airway management Activities: 1. Administer air or humidified oxygen. 2. Position the patient so as to relieve dyspnoea. 3. Teach how to cough effectively 1400. Pain management Activities: 1. Perform a thorough pain assessment (location, onset, duration, frequency...). 2. Monitor the patient’s satisfaction level with pain control 6540. Infection control Activities: 1. Teach the patient/family about the signs and symptoms of infection and when they should be reported to carers. 2. Ensure aseptic handling of IV lines. 3. Ensure appropriate wound care technique. 4. Put universal precautions into practice. 5. Apply Zero Tolerance Protocol. 3440. Incision site care Activities: 1. Inspect the incision site for reddening, inflammation and or signs and symptoms of infection. 2. Clean the area around the incision with an antiseptic from the cleanest to the least clean area applying an appropriate bandage or dressing 3. Teach the patient how to care for the incision while 4020. Bleeding reduction Activities: 1. Teach the patient/family about the signs of bleeding and appropriate measures to be taken (report to nursing staff). 2. Establish the amount and nature of blood loss. 3. Maintain a permeable I.V. line. 4. Teach the patient about restrictions in activities, as appropriate. 5. Place the patient in the semi-Fowler position. 6. Apply manual pressure on the area of bleeding or potential bleeding
2. Pain
3. Infection
4. Bleeding
4140. Fluid resuscitation Activities: 1. Obtain samples for crossmatching. 2. Administer I.V. fluids as prescribed. 3. Administer blood products as prescribed. 4. Monitor haemodynamic response
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Potential complications
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Local treatment of a pharyngocutaneous fistula secondary to osteoradionecrosis
Table 2
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(Continued) Interventions/NIC
5. Insomnia
1850. Sleep enhancement Activities: 1. Adapt the patient’s environment to enhance sleep. 2. Check the patient’s sleep hygiene. 3. Administer prescribed medication according to route and assess therapeutic and adverse effects 1160. Nutritional monitoring Activities: 1. Weigh the patient at regular intervals and monitor progress. 2. Monitor calories and food intake. 1100. Nutrition management Activities: 1. Teach the patient about dietary requirements according to their condition. 2. Monitor tendencies for weight gain or weight loss 0450. Constipation/Impaction Management Activities: 1. Monitor the appearance of signs and symptoms of constipation. 2. Identify possible causative, contributory factors (medication, diet. . .). 3. Encourage increased fluid intake. 4. Instruct the patient/family about a fibre-rich diet
6. Malnutrition
7. Constipation
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Source: Heather Herdman11 , Johnson et al.12 and Bulechek et al.13
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patient because the objectives of removing the necrotic tissue in the least traumatic manner possible and achieving an exudate and infection-free surgical bed were met. Since this is a lesion located in the neck, and due to the vascular structures in the area, there is the added problem that cutting debridement with a scalpel carries a high risk of bleeding, therefore the autolytic debridement provided by alginate is an advantage. Furthermore, it enabled dressings to be scheduled so as to cause the patient the least discomfort possible, preventing cross contamination or infections as far as was possible and enabling continuity of care. Figure 8 Day 84. Good progress, with granulation tissue at the left lateral and lower edges. No signs of infection. Only mucous present in the bed of the lesion. Exposure of the right edge of the jawbone. Visualisation of the larynx and the uvula at the back. Measurements: 5.5 cm long × 5 cm wide × 5.5 cm deep.
Conflict of interests The author has no conflict of interest to declare.
Acknowledgements I want to express my sincere gratitude to the patient in this case, who gave her consent for this study of her case and to publish the photographs that show the progress of her lesion. I also want to thank all my colleagues from the 6th floor of Pabellón 2 Noviembre and the ENT department of the University Hospital Marqués de Valdecilla for their excellent work and collaboration, and José Luis Cobo Sánchez, Research, Development and Innovation Support Unit nurse, for his advice.
References
Figure 9 Day 93. 3rd postoperative day. Reconstruction of the defect with right pectoralis major muscle and tracheotomy. Superficial haematoma only affecting the epidermis.
of the lesion bed to the best possible condition, with no signs of infection, free from necrotic tissue and with granulation tissue increases the possibilities for successful surgical reconstruction when this is necessary.
Conclusions The choice of a silver alginate dressing for local treatment of this type of lesion was very useful and beneficial for the
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10 9. Loaec E, Y-Vaillant P, Bonne L, Marianowski R. Negative-pressure wound therapy for the treatment of pharyngocutaneous fistula. Eur Ann Otorhinolaryngol Head Neck Dis. 2014;131:351---5. 10. Leaper D, Münter C, Meaume S, Scalise A, Mompó NB, Jakobsen BP, et al. The use of biatain ag in hard-to-heal venous leg ulcers: meta-analysis of randomised controlled trials. PLoS ONE. 2013;8:e67083. 11. Heather Herdman T. Diagnósticos enfermeros definiciones y clasificación 2009---2011 --- Nanda Internacional. 8.a ed Barcelona: Elsevier; 2010.
O. González-Antolín 12. Johnson M, Maas M, Moorhead S. Clasificación de Resultados de Enfermería (CRE). Nursing outcomes classification (NOC). 2.a ed Madrid: Harcourt; 2001. 13. Bulechek G, Butcher H, McCloskey-Dochterman J. Clasificación de Intervenciones de Enfermería (NIC). 5.a ed Barcelona: Elsevier; 2008.