80yo F with haemoptysis and new diagnosis throat cancer 

Background:     

• 5 previous neck dissections for head and neck SCC
  • Radiotherapy to neck
• Frail – lives with husband and daughter
  • Independent ADL’s

Issues: 

• New primary laryngeal lesion with local progression
  • ED presentation with haemoptysis requiring embolization
  • Ongoing haemoptysis
  • Hoarse voice, stridor in clinic
  • Chemotherapy commenced but ceased due to MSSA bacteraemia. 
• Infective endocarditis from MSSA bacteraemia

Discussion

Appropriate to proceed to Surgery?

• Palliative procedure in setting of ongoing haemoptysis and risk of airway obstruction 
• Surgery may be futile – patient has advanced disease and is high-risk for perioperative morbidity and mortality 
• NSQIP – increased risk across all variables but particularly functional decline and requirement for post-operative discharge to nursing facility
• Mini-Cog:
  • Unable to complete clock drawing – numbers abnormally placed
  • Indicates cognitive impairment even if word recall is normal 
  • Uncertain as to interpretation of abnormality of specific clock drawings
• Patient and family surprised at possibility of cognitive/ functional decline – wanted time to consider whether she wished to proceed

Non-surgical/less invasive options?

• Surgeons came from theatre to have MDT discussion in periop clinic. Surgeon did not think offering tracheostomy was beneficial alternative over laryngectomy.
• Discussed with oncology who were surprised surgery was offered 

• Following day after clinic represented to ED with worsening haemoptysis and dyspnoea – told staff in ED she has decided not to proceed with OT

Plan:

• Follow up with patient to link in with palliative care team