Surgery

[CCRN]

Okay you guys, I need opinions from anyone who's had head and neck surgery.

Would you believe I'm going to have to have surgery AGAIN in less than a year after valve surgery? I'm telling you it just keeps getting better and better.

I noticed a less than small grape size node-like thingy last spring right under my earlobe. I was in the midst of psychological panic over aortic stensosis/bicuspid valve at the time so it really wasn't the top thing on my mind but I did point it out to my surgeon and he wasn't "concerned". Everybody else told me to stop obcessing and get over myself.

Fast forward to last week. It's still there. I had mentioned it to two of my personal Docs and a couple I work with and got a 50/50 check it out/it's okay response. I decided to side with my paranoia and went to see a Head and neck Doc. He called a pathologist to jab a needle in my neck 4011 times and the next day I was told the "good news": I have a pleomorphic adenoma or "mixed tumor" on my left partid gland. It is benign right now but such "aliens" do have a tendency to turn cancerous so the thing must come out. What is it with my body that things want to blow up? First it was my aorta and now it's this ditsel on my neck. It also makes me nervous because I work in CT surgery and used to do ENT/head and neck. Makes one wonder if you really can get the diseases in which you work.

Anyway, the head and neck guy started with the regular song and dance of "you'll have to go off the coumadin" and I told him absolutely not unless I am bridged with heparin or lovenox and if he didn't agree I would take my business elsewhere. I believe this intrigued him as he admitted he had never had a patient who could not stop their anticoagulation. I did get support troups in the form of his partner the ear Doc with whom I used to work who refered me to him. He informed him he had had a couple of patients like me and it was doable. I believe the guy is deep into research about it at this time.

I would like this guy to operate on me as he has excellent credentials for the procedure I need. I am very impressed that he outright diagnosed me prior to the Path report and my friend, the other ENT guy highly recommends him.

I've been researching through this forum but basically have only found treatment with uterine ablations, colonoscopy, and dermatologic procedures. I've also searched the net as well as Al's bridging outline. There seems to be conflicting opinions between Heparin and Lovenox. I've had great success with lovenox the few times my INR has been subtherapeutic and hope I can go that route. I guess what I'd like to know is if anyone has had parotid or submandibular gland surgery after valve replacement with mechanical valve and how your anti coagulant therapy was adjusted. I can't be the only one who's faced this can I?

 

[Karlynn]

My husband had surgery last fall for a tumor on his parotid gland. But I'm the one on Coumadin, so I didn't have to stop it for his procedure. He was quite bandaged up after, and there was a drainage tube. But not a lot of bloody drainage as I recall. Sorry I can't give you any info on your bridging questions.

 

[Guest]

CC, you probably are the only one.

I'd stick with the doc you like -- he is willing to learn. None of can know everything. Can he consult with your cardiologist. I know that the cardios that I work with like to be consulted and are more than willing to help manage things through the uncertain time. We have 9 cardiologists in the building that my office is in. I would put my life in the hands of anyone of them -- probably will some day.

 

[DrAllan]

I am a retired, Harvard trained, otolaryngologist. I have probably performed about 250-300 parotidectomies in my career with no significant complications. The major risk from the surgery is damage to the facial nerve resulting in paralysis. In the hands of a careful surgeon WITH the use of a facial nerve monitor (not just a stimulator) being monitored by a certified technician at all times in the operating room (the surgeon is too busy to watch the monitor patterns) and the audible warning may occur too late, this risk to the nerve is significantly reduced. If your surgeon balks at this go elsewhere.

As with all surgery the question of bleeding and visibility is crucial. There are two phases to the operation, first elevating the skin flap, which tends to be somewhat bloody. One technique to reduce this is to inject 1:100,000 adrenaline (without zylocaine) under the flap at the start of the case. I stopped doing this because I didn’t appreciate the additional skin swelling.

The second and most crucial part is the actual dissection of the gland off of the facial nerve. There are several techniques for keeping the field dry, all of which have particular advantages and disadvantages. The crudest is spreading, clamping and tying. Others use types of cautery under direct vision of the gland elevated off of the underlying nerve. The cautery techniques may be mono-polar, bi-polar, or the “Shaw’ scalpel. This device, which was my favorites, is about 20-30 years old, and no longer popular after the development of the harmonic scalpel, which is inappropriate for parotid surgery. If your surgeon has not used any particular technique, this is not the time to try learning something new.

I hope that this info gives you a starting point to discuss with your surgeon. Most of us, not taking Coumadin, only think of the bleeding at the surgery and are ignorant of the risk of stroke from stopping therapy. Thus two questions for your surgeon. One, would he be willing to take the risk of a stroke himself as the patient? Two, if he was doing a carotid bypass, or carotid resection for H&N cancer invading the carotid, would he have any trouble using heparin during the operation?

Best to you

 

[warrenr]

low or high bleed risk

low or high bleed risk

Keep it simple. The best place to start is having the physician determine if it is a low or high bleed risk procedure and go from there.

 

[CCRN]

Wow!

Wow!

I am a retired, Harvard trained, otolaryngologist. I have probably performed about 250-300 parotidectomies in my career with no significant complications. The major risk from the surgery is damage to the facial nerve resulting in paralysis. In the hands of a careful surgeon WITH the use of a facial nerve monitor (not just a stimulator) being monitored by a certified technician at all times in the operating room (the surgeon is too busy to watch the monitor patterns) and the audible warning may occur too late, this risk to the nerve is significantly reduced. If your surgeon balks at this go elsewhere.

As with all surgery the question of bleeding and visibility is crucial. There are two phases to the operation, first elevating the skin flap, which tends to be somewhat bloody. One technique to reduce this is to inject 1:100,000 adrenaline (without zylocaine) under the flap at the start of the case. I stopped doing this because I didn?t appreciate the additional skin swelling.

The second and most crucial part is the actual dissection of the gland off of the facial nerve. There are several techniques for keeping the field dry, all of which have particular advantages and disadvantages. The crudest is spreading, clamping and tying. Others use types of cautery under direct vision of the gland elevated off of the underlying nerve. The cautery techniques may be mono-polar, bi-polar, or the ?Shaw? scalpel. This device, which was my favorites, is about 20-30 years old, and no longer popular after the development of the harmonic scalpel, which is inappropriate for parotid surgery. If your surgeon has not used any particular technique, this is not the time to try learning something new.

I hope that this info gives you a starting point to discuss with your surgeon. Most of us, not taking Coumadin, only think of the bleeding at the surgery and are ignorant of the risk of stroke from stopping therapy. Thus two questions for your surgeon. One, would he be willing to take the risk of a stroke himself as the patient? Two, if he was doing a carotid bypass, or carotid resection for H&N cancer invading the carotid, would he have any trouble using heparin during the operation?

Best to you

WOW!

An answer from a real live Otolaryngologist! I love you guys. I used to cover the service at Vanderbilt Hospital so I fully am aware of the facial nerve thing. My surgeon pretty much specializes in that sort of thing and has already reviewed with me the intraoperative nerve monitoring using the latest technology. His response scared me at first but his actions since have encouraged me. I believe he's a good guy. He's already contacted my cardiologist and the plan is to admit me the day before the procedure for bridging on heparin. My INR will be checked three days before the surgical date prior to stopping the coumadin and again two days later upon hospital admittance so I'm pretty much satisfied so far. I was pretty impressed that he nailed the diagnosis upon physical exam and immediately ordered a needle biopsy. Thank you so much for your response. Words cannot express the relief you have given.