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A. J. Rickart and G. Merrick
ning from Mauritania to Ethiopia, the incidence
is highest in West Africa [3]. In spite of this, there
is a consensus that noma is prevalent in marginalized communities internationally but is chronically under-reported.
Risk factors can broadly be held under the
umbrella of poverty. However, specic factors
identied from affected populations highlight
viral co-infection, poor oral hygiene, the low coverage of immunizations, malnutrition, poor sanitation and lack of access to clean water alongside
an increasing incidence in those affected by the
HIV and AIDS pandemic [2, 5, 6].
What turns the preceding oral ulceration or
necrotizing ulcerative gingivitis into noma is as yet
undened, though it is probably due to a combined
pathological oral ora in the presence of a child
with limited physiological resources and impaired
immunity secondary to poor nutrition and concurrent disease. Fusobacterium necrophorum and
Prevotella intermedia are purported microbiological isolates, although an unfavourable shift in oral
microbiota is more likely than a singular causative
organism [7–9]. Sub-Saharan Africa, in keeping
with the rest of the world, sees faltering growth
most frequently noted before the third year of life,
with some infants predisposed following intrauterine growth restriction [10]. As a result, it is
unlikely to be a coincidence that the average age of
onset of noma is analogous with the timing of the
linear phase of growth retardation and often affects
those most profoundly stunted [10].
Facing Africa: Our Experience
inEthiopia
Treatment for the acute phase of the disease
includes addressing the underlying malnutrition,
provision of oral antibiotics and good oral
hygiene. However, timely access to care alongside accurate diagnosis and management is missing from local settings. Regardless, vertical
programs to address noma will always be less
effective when compared to wider efforts addressing the root cause of the disease: poverty [12].
For those who survive, predicted to be numbering 770,000 people worldwide, the functional, psychological and aesthetic sequalae are
signicant [2]. In an effort to determine the
global burden of the disease, it was calculated
that there are between 1 and ten million disability-adjusted life years lost due to noma, which is
analogous to other neglected tropical diseases
[12]. A retrospective review of patients treated
by FA for deformity and functional impairment
secondary to noma between 2015 and 2019 provided insight into each patient’s quality of life
[13]. It is clear that it is not just the aesthetic and
functional side of disease that reconstructive
surgery aims to address but mental wellbeing
and a feeling of belonging being of upmost
importance.
Defects secondary to noma frequently cause
trismus, nasal stulae, loss of teeth and incompetent lips, which makes eating, drinking and talking a signicant challenge. Several studies have
also reported that the physical appearance carries
a stigma, which can lead to social isolation, bullying and an inability to integrate into society, be
this through work, education or nding a partner
[14].
Facing Africa (FA), described in detail previously in Chap. 34, is an NGO that has focused on
the rehabilitation of patients suffering from the
late complications of noma in Ethiopia since
2007. With an estimated incidence in Eastern
Ethiopia between 1.6 and 13.4 per 100,000 children aged 0–9years, the need to provide resources
and care to those at the Eastern edge of the ‘noma
belt’ is clear [11].
Pattern ofDisease
Classication of the defects of noma patients
treated by FA enables us to describe the pattern of
disease [13]. Montandon’s classication of noma
defects has been adopted by the WHO, and the
distribution of our cases is demonstrated in
Fig.37.2 [4, 15]. The distribution of defects seen
by our group is similar to that described in a
37 How to Approach Noma and Facial Infections, Trauma and Tumours Through Charity Missions…
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obtaining long-term follow-up, a validated,
noma-specic tool for recording patient-reported
outcome measures is a potential focus for future
Type 2
21%
Type 1
29%
collaborative work [20].
Summary
463
Type 4
37%
Type 3
21%
Fig. 37.2 Pattern of disease distribution, as classied by
Montandon, of cases seen by Facing Africa between May
2015 and May 2019 [13]
series by Pittet etal. [16] Most commonly, they
are laterally based, with the majority being classied as Type I or IV.These cases can be surgically challenging to manage, often with
signicant ankylosis, and the required scar
excision leaving an even larger defect than initially appears.
Over time, treatment has evolved considerably
as initial management predominantly focused on
local or pedicled delto-pectoral, latissiumus dorsi
or supraclavicular island aps [17]. It still
remains true that local aps are generally used
where possible, conferring excellent tissue
match, reliability and reduced morbidity.
Certainly, FA has also found the submental island
ap particularly useful in the reconstruction of
noma. In spite of this, large pedicled aps are
now generally discarded in favour of free tissue
transfer, which has been shown to be safe and
reliable even in resource-poor, developing countries [18, 19]. Although there are challenges in
For nearly 25 years, extreme poverty has been
steadily declining. However, as the disruption of
the COVID-19 pandemic is compounded by conict and climate change, global poverty is currently increasing. Previous progress in health,
education and living standards are at risk of
becoming undone, and consumption distributions
show that the poorest are becoming even poorer.
It is this small subset where noma is most prevalent, and the inequality is not easily overcome.
Noma will continue to affect those with the
least, representing a preventable loss of life and
devastating those who survive. A commitment to
the United Nation’s Sustainable Development
Goals, with particular relevance to addressing poverty and hunger alongside improvements in immunization coverage, water, sanitation and hygiene,
would go a long way to eradicating noma.
In the interim, there has been a drive to include
noma in the WHO list of neglected tropical diseases (NTDs). This diverse list of 20 diseases, all
borne out of poverty, includes analogous conditions such as leprosy and buruli ulcers. This
would provide the benets of being swept along
with the WHO NTD 2021–2030 road map, facilitating integrated approaches, multisectoral coordination and improved access to funding and
research. It seems that the ‘noma paradox’ holds
true in that by the time a country has developed
the resources to manage the disease effectively,
the associated economic developments have
caused it to disappear [19, 21]. Until progress is
made, the need to help those devastated by noma
will continue, and our approach to the surgical
management of these complex patients will be
the focus of this chapter.
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A. J. Rickart and G. Merrick
Ethical Approval Consent for publications of photographs was kindly provided by the patients or their
guardians.
References
1. Ashok N, Tarakji B, Darwish S, Rodrigues JC,
Altamimi MA.A review on Noma: a recent update.
Global J Health Sci. 2016;8(4):53.
2. Enwonwu C, Falkler W Jr, Idigbe E.Oro-facial gangrene (Noma/cancrum oris): pathogenetic mechanisms. Crit Rev Oral Biol Med. 2000;11(2):159–71.
3. World Health Organization, Regional Ofce for
Africa. Evaluation of the WHO Africa Regional
Programme on Noma Control (2013–2017). Available
from: https://www.afro.who.int/publications/
evaluation- who- africa- regional- programme- nomacontrol- 2013- 2017. Accessed 30 Mar 2022
4. World Health Organization, Regional Ofce of Arica.
Information brochure for early detection and management of noma. Available from: https://www.afro.
who.int/publications/information- brochure- earlydetection- and- management- noma. Accessed 30 Mar
2022
5. Galli A, Brugger C, Fürst T, Monnier N, Winkler MS,
Steinmann P. Prevalence, incidence, and reported
global distribution of Noma: a systematic literature
review. Lancet Infect Dis. 2022;22:e221.
6. Chidzonga MM, Mahomva L. Noma (Cancrum
oris) in human immunodeciency virus infection
and acquired immunodeciency syndrome (HIV
and AIDS): clinical experience in Zimbabwe. J Oral
Maxillofac Surg. 2008;66(3):475–85.
7. Farley E, Mehta U, Srour ML, Lenglet A. Noma
(Cancrum oris): a scoping literature review of a
neglected disease (1843 to 2021). PLoS Negl Trop
Dis. 2021;15(12):e0009844.
8. Falkler W, Enwonwu C, Ewell A, Idigbe E.Isolation
of fusobacteria from the oral cavities of malnourished
Nigerian children living in agricultural and herding
villages. Oral Dis. 2000;6(2):103–5.
9. Marck KW.Noma: a neglected enigma. Lancet Glob
Health. 2013;1(2):e58–9.
10. De Onis M, Blössner M. The World Health
Organization global database on child growth and
malnutrition: methodology and applications. Int J
Epidemiol. 2003;32(4):518–26.
11. Lafferty N.Changing the face of Africa. In: Estimating
the burden of noma in rural Ethiopia and identifying
options for prevention and improvement in its diagnosis and management Liverpool School of Tropical
Medicine; 2012.
12. Srour ML, Baratti-Mayer D. Why is Noma a
neglected-neglected tropical disease? PLoS Negl Trop
Dis. 2020;14(8):e0008435.
13. Rickart AJ, Rodgers W, Mizen K, et al. Facing
Africa: describing Noma in Ethiopia. Am J Trop Med
Hygiene. 2020;103(2):613.
14. Wali IM, Regmi K. People living with facial disgurement after having had Noma disease: a systematic review of the literature. J Health Psychol.
2017;22(10):1243–55.
15. Montandon D, Lehmann C, Chami N. The surgical treatment of Noma. Plast Reconstr Surg.
1991;87(1):76–86.
16. Pittet B, Jaquinet A, Montandon D.Clinical experience in the treatment of Noma sequelae. J Craniofac
Surg. 2001;12(3):273–83.
17. Rüegg E, Baratti-Mayer D, Jaquinet A, Montandon
D, Pittet-Cuénod B. The surgical management of
extra-articular ankylosis in Noma patients. Int J Oral
Maxillofac Surg. 2018;47(12):1527–33.
18. Giessler GA, Schmidt AB.Noma: experiences with
a microvascular approach under west African conditions. Plast Reconstr Surg. 2003;112(4):947–54.
19. Rodgers W, Lloyd T, Mizen K, etal. Microvascular
reconstruction of facial defects in settings where
resources are limited. Br J Oral Maxillofac Surg.
2016;54(1):51–6.
20. Speiser S, Langridge B, Birkl MM, Kubiena H,
Rodgers W.Update on Noma: systematic review on
classication, outcomes and follow-up of patients
undergoing reconstructive surgery after Noma disease. BMJ Open. 2021;11(8):e046303.
21. Marck KW. A history of noma, the “Face of
Poverty”. Plastic and Reconstructive Surgery.
2003;111(5):1702–1707.
How to Approach Noma and Facial
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Infections, Trauma, and Tumours
Through Charity Missions: The
Management of Trismus and
Ankylosis in Noma
WillRodgers andDavidDunaway
38
Introduction
Trismus is dened as a restriction in the range of
motion of the jaws from any cause. Trismus may
cause difculties in feeding, speech and maintaining oral health and may compromise protection of the upper airway. The differential
diagnosis for trismus is large, in this chapter, we
will focus on trismus as a sequela of noma.
Trismus is common in noma, and it is estimated
that up to half of all noma patients have a degree
of trismus. Trismus forms part of the NOITULP
noma classication (see Table38.1) ranging from
normal mouth opening to absolute trismus or
ankylosis [1]. Ankylosis is dened as a fusion of
the mandible to the skull base and may be articular (involving the temporomandibular joint) or
extra-articular.
Trismus occurs as a late sequela of noma and
is dependent on the site and severity of the acute
phase of the disease and subsequent scar formation and tissue contraction. The pathogenesis of
trismus in noma is often multifactorial and may
result from:
W. Rodgers (*)
Craniofacial Unit, Great Ormond Street Hospital for
Children NHS Foundation Trust, London, UK
D. Dunaway
Great Ormond Street Hospital for Children NHS
Foundation Trust, London University Hospital,
London, UK
Table 38.1 NOITULP noma classication
Degree of trismus Mouth opening
T-0
T-1 >20–40mm
T-2 >0–20mm
T-3 Ankylosis
• Extra-articular ankylosis.
– Fibrous extra-articular ankylosis.
– Bony extra-articular ankylosis.
• Intra-articular ankylosis.
• Myostatic contracture.
Myostatic contracture, where the muscles are
not directly affected by the disease but contract
due to a lack of full passive range of motion, is
secondary to scarring and wound contracture
inlocal tissues, leading to a reduced soft tissue
envelope which is insufcient to allow full opening. Where the muscles of mastication are
involved in the acute phase, the resulting myositis commonly leads to brotic extra-articular
ankylosis. As a rule of thumb, when scarring is
seen distal to the anterior border of the masseter,
at the level of the rst molar tooth, trismus is
likely. Where there is prolonged brous ankylosis, or in cases where the acute phase of noma
involved the bone, a bony extra-articular ankylosis may be seen. If the temporomandibular joint
is affected in the acute phase, a true intra- articular
ankylosis arises. In any prolonged trismus, it is
common to nd hypertrophy of the coronoid pro-
≥40mm
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_38
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W. Rodgers and D. Dunaway
cess, which mechanically obstructs normal
mouth opening both on the ipsilateral and contralateral sides [2].
In this chapter, we report our experience of 49
cases of trismus secondary to noma infections.
Assessment
Assessment of trismus in people with noma
should include an assessment of the functional
effects caused by limitation of mouth opening.
Difculty with feeding may lead to malnutrition
and a low BMI.Speech may be affected, and it is
likely that there will be poor oral health due to
obstructed access to the oral cavity. Although
patients may be severely affected by the condition, there is a signicant subgroup that manages
to function effectively even with severe trismus.
Clinical examination should document the
range of movement at both TMJs. The surrounding soft tissue should be assessed and any obvious extracapsular restrictions noted.
A careful intraoral and full dental exam should
be performed. Extensive intraoral scarring is
often found. Caries and periodontal disease are
common, and frequently multiple teeth will
require extraction.
Patients with trismus are often underweight
and may require pre-surgical optimisation prior
to intervention. In our experience, patients often
present several weeks prior to possible intervention, whereupon they receive nutritional assistance and anthelmintics as required.
Radiological assessment is essential for accurate diagnosis and treatment planning. An orthopantomogram aids in dental assessment and can
give an indication of the site of bony ankylosis.
Computed tomography is ideal for radiographic
assessment in those with severe trismus (T-2) and
ankylosis (T-3) for adequate pre- surgical planning
(see Fig.38.1). Contrast enhancement may be of
use if there is concern with regard to the relation
of bony ankylosis to vasculature.
Anaesthetic assessment is essential prior to
surgery. An anaesthetist experienced in the
a
b
ced
Fig. 38.1 Patient with complete ankylosis (NOITULP
stage T3) as a late sequela to noma showing signicant
post-infection scarring. Note the ‘anarchie dentaire’. (a)
frontal view, (b) lateral view, (c) CT lateral view showing
bony ankylosis from mandible to zygoma (e) showing lingual surface of mandible with bony ankylosis from pterygoid plates to mandible
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467
management of difcult airways is a key member of the noma surgical team. Typically
severely affected patients require an awake
breoptic intubation. Tracheostomy is occasionally necessary, and it is important to have a
well-prepared theatre team experienced in airway emergencies.
Management
Our experience of 49 noma patients treated over
2 missions in 2011 and 2012 found 16 to have
trismus of grade T2 or higher. Of the 16, 8 were
male and 8 female. Patients were aged between 6
and 40years with a mean age of 17. Mean BMI
was 16 compared to the mean BMI for all patients
seen during the missions of 17.3. Over the 2 missions, 12 patients had procedures to improve trismus, of whom 5 had true ankylosis requiring
ankylosis release with bilateral coronoidectomies. Post-operative in-hospital stay ranged from
1 to 7days with a mean stay of 4 days. Of the
nine patients who were treated for trismus release
in the rst mission, three required further procedures for trismus release on the following
mission.
Patients with mild trismus and opening of
≥20 mm usually function normally and consideration should be given to the merit of
release of trismus, which may paradoxically
worsen function due to post-operative scarring in settings where close follow-up is
unavailable. Those with trismus of grade
T-2/3 (opening of <20mm) often benefit from
treatment.
The key to the management of trismus is postoperative physiotherapy, therefore intervention
should only be considered in those who are able
to tolerate this, careful judgement is necessary to
avoid an unnecessary procedure.
Surgical Management
In those unable to tolerate signicant intervention or the required post-operative physiotherapy,
dental extractions of affected teeth alone may
provide a sufcient aperture to increase oral
intake and improve nutrition.
Denitive surgical management is directed at
the cause of the trismus. In noma, trismus is often
multifactorial [3].
Fibrous Extra-Articular Ankylosis
Noma causes extensive soft tissue necrosis, and
healing is usually accompanied by extensive
brosis and wound contracture. Post-noma brosis is a particularly difcult condition to treat and
has a great tendency to recur after treatment.
Limited areas of brosis can be treated by
brous band release followed up with intralesional steroid injections to discourage re-brosis
of the area. This treatment should be accompanied by regular physiotherapy.
It is usually necessary to excise areas of brosis in order to mobilise the temporomandibular
joint. Excision of brotic areas should be accompanied by soft tissue reconstruction with local or
distant aps.
Extra- andIntra-Articular Bony
Ankylosis
Treatment requires release of the bony bridges,
which extend between the mandible and skull
base. In noma, bony bridges often exist at sites
quite distant from the temporomandibular joint.
It’s not uncommon for the coronoid process or
body of the mandible to be fused to the skull base
or maxilla.
If there is a signicant risk of recurrence of
ankylosis. Surgical techniques to reduce the risk
of ankylosis include:
Gap arthroplasty with or without interpositional
ap or graft.
Costochondral graft.
Distraction osteogenesis.
TMJ replacement.
The additional complexities of temporomandibular joint replacement and distraction osteogenesis along with their associated complications
and follow up requirements make these treatments inadvisable where long-term regular local
specialist follow-up is unavailable.
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W. Rodgers and D. Dunaway
Coronoid Process Hyperplasia
Hyperplasia of the coronoid process of the mandible frequently occurs in trismus associated with
noma. The elongated coronoid process may
impinge on the medial surface of the zygomatic
arch and act as a further cause of trismus. The
treatment of this condition is coronoidectomy.
Coronoidectomy has a lower relapse rate than
simple coronoidectomy.
For those with severe trismus, examination
under anaesthesia is indicated, followed by a
stepwise approach to releasing the ankylosis.
Our preference is to measure the mouth opening
on- table following intubation; we then proceed
to the release of intraoral scarring and relevant
dental extractions followed by re-assessment of
mouth opening. If adequate opening is not
achieved, then ipsilateral coronoidectomy via
an intraoral approach combined with release of
the masseter is undertaken. Contralateral coronoidectomy and release is often required if adequate mouth opening is not achieved.
In those cases of true ankylosis (T-3), an extraoral Al-Kayat approach may be required to
release the mandible from brous and bony
bridges to the facial skeleton and skull base.
Following release, it may be appropriate to insert
an interpositional dermal fat graft, temporoparietal ap or vascularised tissue graft (Fig.38.2) to
reduce the risk of re-ankylosis.
In noma, patients will frequently require soft
tissue reconstruction concurrently, and it may be
possible to design the reconstruction to provide
an interpositional graft.
Procedure: Coronoidectomy
The coronoid process can usually be removed via
a transoral approach though an extra-oral
approach as described below may be used.
Following local anaesthetic inltration, a vestibular incision is made in the free gingiva extending up the external oblique ridge. A subperiosteal
dissection should expose the ramus to the sigmoid notch laterally. The attaching bres of the
temporalis muscle to the coronoid should be
sharply dissected to facilitate access, and care
should be taken medially with subperiosteal dissection to avoid injury to the inferior alveolar
neurovascular bundle. When the coronoid is adequately dissected, an osteotomy is made from
anterior to posterior in the Frankfurt plane at the
level of the sigmoid notch. Prior to completing
the osteotomy, it is recommended to gain control
of the coronoid with Kocher’s forceps to avoid
displacement of the coronoid fragment superiorly
when the osteotomy is completed. Releasing
temporalis muscle attachment to the coronoid
allows delivery.
Procedure: Ankylosis Release
An extraoral Al-Kayat approach is extended temporally to ensure adequate access with exposure
of the temporalis fascia, temporalis muscle,
zygomatic arch and the full extent of the ankylosis. Noma causes signicant brosis to local tissues, and tissue planes may not be readily
distinguishable. To protect the temporal branch
a
Fig. 38.2 Patient following ankylosis release with bilateral coronoidectomy, dental extractions and radial forearm free
tissue transfer. (a) Frontal view showing improved mouth opening; (b) lateral views
b
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469
of the facial nerve, it is therefore advisable to
incise the temporalis fascia to the temporalis
muscle above the zygomatic arch generously at a
45° angle continuous with a periosteal incision at
the base of the zygoma with subperiosteal dissection continued anteriorly and inferiorly over the
ankylotic mass until the unaffected ramus is identied. Stripping the masseter muscle from the
zygomatic arch facilitates access. Excision of the
entire ankylotic portion, including medial extent,
is crucial to reduce recurrence, leaving a gap of at
least 15mm and ensuring a full range of passive
opening. In noma, it may be the case that the temporomandibular joint is preserved though there is
bony ankylosis more anteriorly. Function of the
joint in this case will need to be assessed on table
following ankylosis release. A coronoidectomy
may also be performed through the same access,
and an interpositional ap or graft can then be
placed [4].
Post-Operative Management
Relapse following trismus release is common.
Regular physiotherapy is key to maintaining adequate mouth opening and can be achieved with
stacked wooden spatulas or bespoke devices.
Physiotherapy should start as soon as possible
post-operatively and may require analgesia initially. Seven exercises seven times per day, ideally supervised, for at least 3months followed by
ongoing three times daily exercise is a typical
routine to maintain mouth opening. Maintaining
compliance with these arduous and uncomfortable physiotherapy regimes is difcult. In spite of
good physiotherapy, our experience is that at
least a third of patients suffer relapse to a degree
such that further intervention is warranted.
Careful patient selection and education is therefore essential prior to any trismus or ankylosis
release.
Complications
Complications related to trismus and ankylosis
release include:
• Infection. Antibiotic prophylaxis should be
given according to local protocols.
• Haemorrhage. The maxillary artery may be
abnormally situated and close to the site of
bony ankylosis. The abnormal anatomy combined with challenging access increases the
risk of signicant haemorrhage. If available,
pre-operative CT angiography will help dene
the anatomy.
• Facial nerve injury. The position of the facial
nerve may be distorted by scar contracture,
and the dense brous tissue can make the
nerve difcult to identify.
• Injury to the parotid gland or its duct may
result in a sialocoele or parotid stula.
• Injury to the external auditory meatus can
result in canal stenosis and hearing
impairment.
Conclusion
Trismus and ankylosis release in noma is challenging with a high risk of recurrence. Long-term
follow-up and physiotherapy are essential, and
further surgical intervention is often required.
Patient motivation and support with arduous postoperative physiotherapy regimes can be challenging. The chance of success is greatest at the rst
operation, and complication rates are higher for
subsequent interventions. In situations where
close follow-up is not possible, operative trismus
release may not achieve long-term success, and
alternative strategies to ensure adequate nutrition
and oral health should be considered [5].
References
1. Speiser S, Langridge B, Rodgers, et al. Update
on Noma: systematic review on classication,
outcomes and follow-up of patients undergoing
reconstructive surgery after Noma disease. BMJ
Open. 2021;11:e046303. https://doi.org/10.1136/
bmjopen- 2020- 046303.
2. Kaban LB, Bouchard C, Troulis MJ. A protocol for Management of Temporomandibular Joint
Ankylosis. Children. 2009;67(9):1966–78. https://doi.
org/10.1016/j.joms.2009.03.071.
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W. Rodgers and D. Dunaway
3. Rüegg EM, Baratti-Mayer D, Jaquinet A, Montandon
D, Pittet-Cuénod B. The surgical management of
extra-articular ankylosis in Noma patients. Int J
Oral Maxillofac Surg. 2018;47:1527. https://doi.
org/10.1016/j.ijom.2018.07.012.
4. Rodgers W, Lloyd T, Dunaway D, etal. Microvascular
reconstruction of facial defects in settings where
resources are limited. BJOMS. 2016;10:11.115.
https://doi.org/10.1016/j.bjoms.2016.11.115.
5. Bos KE, Marck KW.The surgical treatment of Noma.
Uitgeverij Belvédère/Medidact; 2006.
How toApproach Noma andFacial
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Infections, Trauma, andTumours
Through Charity Missions:
Anaesthesia Considerations in
Noma
PeterLee andPatrickSeigne
39
Abbreviations
FOB Fibre-optic intubation
HIV Human immunodeciency virus
Pre-Operative Status
Most patients are young and healthy, but it is
critically important that a full pre-operative evaluation is carried out looking for any evidence of
cardiac, respiratory or other medical conditions
that might be optimised before embarking on
such major surgery inlocations where the management of post-operative complications may be
challenging. Conditions such as tuberculosis and
infection with human immunodeciency virus
(HIV) are not uncommon in this patient population. In a minority of the severe cases, patients
may have absolute trismus due to extraarticular
ankylosis bridging the gap between the mandible
and the maxilla. Apart from the obvious airway
issues this causes for intubation, it may have led
to poor nutritional intake and poor dental hygiene
P. Lee (*)
Bon Secours Hospital, Cork, Ireland
e-mail: plee@bonsecours.ie
P. Seigne
Department of Anaesthesiology and Intensive Care
Medicine, Cork University Hospital, University
College Cork, Cork, Ireland
with their attendant sequelae. Dental review plus
admission for nutritional supplementation a
month in advance of planned major surgery has
proved benecial in improving post-operative
recovery. Pre-operative assessment is best carried
out in multidisciplinary clinics consisting of
maxillofacial surgeons, plastic surgeons, dentists,
operating theatre nurses, ward nurses, wound
care specialists, local doctors and translators. The
experience of all involved health professionals is
vital at this stage to allow a balanced assessment
of risk and potential benet to each patient. Our
practise is to have the patients and all healthcare
workers in the same room together at the time to
facilitate open and immediate communication
and dialogue between the patient and the team.
Careful note taking and medical record maintenance are also critically important– the conduct
of airway management and anaesthesia provision
during previous surgery is very useful in the planning process, many of these patients having had
multiple surgical procedures for this condition.
The availability of laboratory testing is somewhat
limited in resource-poor situations such as this,
but a full blood count and HIV test are useful
in all but the most minor of procedures.
Electrocardiography and cardiac echo are useful
in select cases. Pre-operative radiography of the
upper airway is useful for both surgical planning
and airway assessment. Chest radiography is
indicated in patients with unexplained respiratory
symptoms or a history of tuberculosis.
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. A. Hardy, B. R. Hochman (eds.), Global Surgery, https://doi.org/10.1007/978-3-031-28127-3_39
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