- You ring me to ask advice, and my advice is "Take a history, do an examination, think about it for 15 minutes and ring me back". Give me the night time speil that will convince me he has a typical presentation of a head and neck malignancy (ISBAR please, 10 lines max)
Some of the really infuriating things about calls at night:
Having an inadequate history and examination presented. The history and examination are the "tools of the trade", they are the starting point, in much the same way that turning on the car and putting it in gear is the starting point for driving, or selecting a club and teeing up the ball is the sart of a golf round. But its only a start, the substance follows from there, but as you often hear from football commentators, games are won when the fundamentals are done well. So an incomplete 'scatter-gun' history and poorly undertaken or highly selective examination can add days to the patient's admission, hasten their disability or just kill them. Learn to do these two things well. When you see your boss establish the diagnosis from a shorter history and examination than yours, ask them what was deficient in your thinking, what were the clues, and why did they do that unusual examination. This will demonstrate thought processes, observation processing, history selection and plain intuition, so that you have some hope of learning it.
Your H&P (history and physical) have a special place in the deliberations of consultants. Your H&P should point to a particular diagnosis that you think is present, and when we listen to your H&P we are comparing your history and examination items with that diagnosis to see if they retain credibility. This is why your presentation of these findings requires thought and preparation. You are arguing a case - like a lawyer. You take the facts and order them to build a case for a particular disease being present. As time goes on this become easier and more automatic, and conducted in fewer and fewer words. When we consultants speak we speak in short hand, but each terms carries with it a mountain of learning and understanding.
Another irritant in the middle of the night is when the resident wants to build suspense. Suspense is lost on us at 4 am. Only sleep matters. So you should learn to start with the conclusion, and then add a little detail. Ask yourself, does the social history really matter at 4 am? If the patient presents in acute pain, how long do you want to spend on the previous ineffective pain relief? Or their anti-hypertensives? If you think you are making a rare diagnosis, you can BRIEFLY apologise for your inability to find something more uncommon, but keep to the story!
At this time of night you want me to say "OK, that's a good plan, do it!", not to hold your hand and walk you through what you should be able to do without help. So you will want to tell me some things.
1. why is he here in the early morning?
2. why can't you assess him, make some arrangements to bring him back tomorrow for investigations, WITHOUT calling me?
3. have you worked out what you expect me to do?
So even if you examine him and find a mobile, hard mass and an ulcerating lesion in the ipsilateral tonsil, and think "OMG, that's my first cancer diagnosis and it's really obvious", you should think carefully about whether you will disturb me at 4 am to share this joy of discovery with me. My view will be somewhat jaundiced by the darkness outside and the weary feeling in my bones, and an appreciation that once awake my sleep for the rest of the night has gone.
Following all this, the description of the routine H&N cancer diagnosis is easy! Smoker, drinker, commonly male, mass in the neck points to one of three primaries - tonsil (easy to examine, so make sure you do it!), nasopharynx (not easy to examine but the ED has a nasopharyngoscope and some there might be skilled in its use) and piriform fossa (easier than the NPC because you can see it with a mirror, but indirect laryngoscopy is quite a skill too, but don't be afraid to acquire it!). The mass is usually hard; mobile when small, fixed when large usually to sternomastoid muscle; non-tender initially but with nerve involvement can be both tender and painful; may be single or multiple. The site of the mass can betray the primary site. The parotid nodes are very high on the neck and are more commonly involved from skin cancers. The submandibular nodes are just under the mid jaw and can be involved by skin cancer or primary salivary tumours. Nodes in the mid and lower neck indicate the sites listed above. An anterior midline node below the thyroid cartilage (Adam's apple) is called the Delphian node, but you can look up that if you are interested).
- Discuss the curative management of head & neck malignancy
The essence of curative management of H&N cancer is achieving locoregional control while supporting the patient through the morbidity of these attempts. In terms of roles the following words apply:
| Surgery: |
primary |
salvage after primary radiotherapy |
. |
| Radiotherapy: |
primary |
adjuvant after surgery |
palliative |
| Chemotherapy: |
. |
neoadjuvant before …
concurrent with …
adjuvant after … |
palliative |
The decision about which to apply depends on two questions:
1. what can the patient cope with?
Elderly patients will find it difficult to cope with concurrent radiotherapy and even mild chemotherapy such as weekly cisplatin at low dose. The patient who gets angina with a haircut, probably shouldn't be aggressively treated also. The mucositis associated with radiotherapy will result in mortality in 2-10% of patients.
2. what sequence of treatment will leave the patient with the least morbidity?
In this case, it often follows that the preservation of an organ, e.g., the larynx, will be better than its removal, so long as one condition is satisfied. That is, that the combination Radiotherapy + Surgical Salvage has the same survival as Surgery + Adjuvant Radiotherapy. Either treatment has a large bevy of side effects.
