Post-Op Ground Round: Q&A

Q1. What does the surgical abbreviation list stand for?

Q2. What is the likely primary diagnosis?

Q3. What is the purpose of each surgical component?

• WLE: Resect the primary tumor with clear margins
• Marginal mandibulectomy: Remove the cortex of the mandible when tumor abuts but does not deeply invade the medullary canal (preserves mandibular continuity; preferred over segmental mandibulectomy)
• MRND: Cervical lymphadenectomy for regional nodal clearance; preserves one or more of: sternocleidomastoid (SCM), internal jugular vein (IJV), or spinal accessory nerve (SAN) - unlike radical neck dissection which removes all three
• PMMC flap: Pedicled myocutaneous flap based on the pectoral branch of thoracoacromial artery; provides bulk and skin cover for the oral defect
• Tracheostomy: Airway protection from post-operative edema, especially after intraoral reconstruction

Q4. What are the prerequisites/criteria before decannulation on POD 12?

1. Level of consciousness - Patient must be alert and able to protect his airway
2. Respiratory status - No ongoing ventilatory requirement; adequate spontaneous ventilation
3. Ability to cough - Adequate cough reflex to clear secretions
4. Ability to swallow - To reduce aspiration risk
5. Airway patency above the stoma - Fiberoptic endoscopy to confirm adequate patency of glottis and subglottis
6. Wound status - Afebrile, no active infection (this patient satisfies this criterion)
7. Cuff deflation tolerance - Patient should tolerate cuff-deflated tube prior to decannulation
8. No anticipated further procedures requiring general anaesthesia/intubation in the near term

POD 12 is an appropriate time for decannulation - standard practice in head and neck surgery units is to attempt decannulation between days 3-5 in simple cases, but after major reconstructive oral cavity surgery with PMMC, oedema may keep the airway precarious longer, making POD 10-14 more appropriate.

• Cummings Otolaryngology Head and Neck Surgery

Q5. What is the step-by-step decannulation protocol?

1. Cuff deflation - ensure patient tolerates this without distress (POD 1 in simple cases; delayed here given reconstruction)
2. Downsizing - progressively reduce tube size (optional, depending on unit protocol)
3. Speaking valve trial - Passy-Muir valve with deflated cuff to assess upper airway patency
4. Tube capping/plugging - occlude tube for 24-48 hours; patient must maintain adequate SpO₂ and ventilation
5. Fiberoptic laryngoscopy - confirm glottis/subglottis is clear; check for granuloma, tracheomalacia
6. Remove tracheostomy tube
7. Occlusive dressing - cover stoma; usually closes spontaneously within days
8. Monitor for respiratory distress for 24-48 hours after removal

Q6. What are the complications of MRND relevant in the post-op period?

Q7. What are the complications of PMMC flap?

• Wound dehiscence
• Seroma / haematoma
• Chest wall deformity (usually tolerated)

• Partial or total flap necrosis (bulky pedicle may compromise vascularity at the distal tip)
• Fistula formation (orocutaneous/orocervical) - more common if post-op radiotherapy
• Infection
• Flap bulkiness (affects swallowing and articulation)
• Hair-bearing skin in the oral cavity (skin paddle contains chest hair in males)

Q8. What is marginal vs. segmental mandibulectomy and when is each chosen?

Q9. What are likely ground round viva questions about this case?

• PMMC is a reliable, pedicled flap with no requirement for microvascular anastomosis
• Suitable for moderate-to-large defects where the recipient vessels may be compromised (previous neck dissection) or in elderly/comorbid patients
• Faster operation; no monitoring required post-op
• However, RFFF provides a thinner, more pliable skin paddle better suited for floor-of-mouth reconstruction - PMMC is bulky and may impair speech/swallow

• Post-operative airway oedema from intraoral reconstruction (especially with PMMC) can compromise the pharyngeal airway
• Elective tracheostomy is standard in cases with floor-of-mouth reconstruction, bilateral neck dissection, or anticipated prolonged intubation

• By POD 10-14, post-operative edema has resolved significantly
• Flap viability is established
• Oral feeding has typically commenced (soft/liquid diet)
• Indicates satisfactory progress

• Flexible nasopharyngoscopy / fibreoptic laryngoscopy
• ABG or pulse oximetry baseline
• Chest X-ray (if respiratory concern)
• Cuff deflation test / capping test pass

Q10. What post-decannulation care is needed?

• Occlusive dressing over stoma; change daily
• Monitor SpO₂ and respiratory rate for 24-48 hours
• Speech and language therapy assessment for dysphagia/dysphonia
• Nutritional assessment - likely nasogastric tube or oral liquid diet continuing
• Wound care for neck and chest donor site
• Plan for adjuvant radiotherapy staging/discussion (depending on final histopathology - margins, nodes, perineural invasion, lymphovascular invasion, extracapsular spread)