People with whom you will be working 










285
Chapter12
People withwhom you
will be working
Other surgeons 286
Dental specialists 288
Members of the multidisciplinary head and neck team 290

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285 Chapter12People withwhom you will be workingOther surgeons 286Dental specialists 288Members of the multidisciplinary head and neck team 290 286CHAPTER12 People withwhom you will be working 286Other surgeonsENT surgeons• ENT surgeons are probably our closest colleagues and you will often nd that we share wards, junior doctors, clinics, and also patients.• There are many occasions in OMFS when you will work with ENT surgeons and you will usually nd the relationship mutually benecial.• ENT (Head and Neck) surgeons are members of the head and neckMDT.• You may be asked to see ENT cases with head and neck abscesses on the ward to give an opinion, often to see whether the abscess has a dental origin. The arrangement is, of course, reciprocal.• ENT surgeons are occasionally asked to employ their endoscopic sinus skills to help with retrieval of tooth roots or implants from the sinuses, or even to reduce orbital oor fractures or to decompressRBH.• Some TMJ patients rst present to the ENT with earache.Plastic surgeons• Plastic surgeons are also usually members of the head and neckMDT.• In most OMFS units the OMFS surgeons do their own reconstruction, including microvascular free aps. However, ENT surgeons often call upon plastic surgeons to work with them as the reconstructive team, and OMFS surgeons do so occasionally.• You may nd that the ED will have some arrangement with the local plastic and OMFS teams regarding the management of facial lacerations, and you should be aware what thisis.Ophthalmic surgeons• You will often call upon the help of the ophthalmic team mainly for the management of trauma patients with periorbital and zygomatic complex fractures. These patients may or may not have globe injuries (see E p. 86).• Ophthalmic surgeons are also often involved in the management of periorbital cancer resections and also problems such as entropion, ectropion, and dacrorhinosinusitis.• Asub- specialty is oculoplastic surgery. Oculoplastic surgeons are highly skilled at managing eyelid problems such as BCC, SCC, and other pathology in and around the lids. It is usually sensible to seek an opinion in such cases or transfer the patient to theircare. OTHER SURGEONS287 288CHAPTER12 People withwhom you will be working 288Dental specialistsGeneral practice dentists• Otherwise known as dental surgeons or general dental practitioners (GDPs).• Most of the referrals to OMFS units are fromGDPs.• By far the most frequent referral a GDP makes to a district general hospital is to the OMFS department.• You may also nd that a GDP calls you to make an emergency referral about something you may not consider an emergency— a common example is a failed extraction.• While you have to full your priorities with your experiences as a hospital doctor, you should try to be aware that the GDP does not have the hospital resources that you have to hand. Until you have worked in the community setting you may not appreciate how dicult it is to deal with complications outside of a hospital. Therefore you should try to show some empathy and help as best you can— they may also be friendly with the consultant and give you either positive or negative feedback!Periodontists• Periodontists deal with the tissues supporting the teeth, i.e. the gingivae, periodontal ligament, cementum, and alveolarbone.• In practice this means that they deal with periodontal pocketing and dental implantology (numerous people deal with dental implants).• They are encountered mainly either in the primary care setting (not NHS) or in dental hospitals.Endodontists• Endodontists deal with root canal treatment and apical surgery.• Developments in root canal therapy have radically reduced the numbers of patients who require an apicectomy and this is an improvement in patientcare.• Endodontists also provide apical surgery under magnication, which gives much better results.• However, like periodontists, they are not generally available on the NHS outside dental hospitals.Orthodontists• Orthodontists are the dental specialist you are most likely to encounter in a district general hospital. This is because of their role in children’s dentalcare.• Hospital- based orthodontists usually deal with children with severely crowded teeth and are also part of the cleft palateteam.• Hospital- based orthodontists are a part of the orthognathic team (see E pp. 168–9).• Community- based orthodontists usually provide a mixture of private and NHS practice in accordance with NHS guidelines on what the NHS will payfor. DENTAL SPECIALISTS289 Paediatric dentists• Paediatric dentists are not generally available on the high street but are available in community centres, teaching hospitals, dental schools, and some specialist units. They are part of the cleft palateteam.Oral surgeons• Oral surgeons are employed almost exclusively in dental schools and are involved in surgery of the structures which support the teeth and oral tissues. However, times are changing, and there is a move to employ oral surgeons in the district general hospital setting aswell.• They are also involved in dental implants and bone grafting to thejaws.• There are many sta grade and associate specialists (collectively termed SAS) in OMFS units who are on the specialist GDC list for oral surgery. These practitioners are not the same as consultant oral surgeons who have completed specialist training just like other consultants.• Some consultant oral surgeons may have been appointed based on previous experience/ training (grandfathering). There are now several training schemes and a Specialty Advisory Committee (SAC) in oral surgery.Restorative dentist• Restorative dentists are not usually available outside dental schools or private care, except as part of the head and neckMDT.• In the MDT, they provide an opinion about which teeth need to be extracted prior to radiotherapy elds which may involve the jaws. They can also advise and help with dentures, dental implants, and dental obturators (for maxillectomy patients).• In dental schools and private practice, their work is mainly concerned with crown and bridge work, inlays, and veneers.Prosthodontists• Prosthodontists are experts on xed or removable falseteeth.• In private practice this means removable false teeth or dentures and bridges, with or without dental implants. They may also be part of the head and neck MDT instead of a restorative dentist.Oral medicine• Oral medicine specialists are predominantly found in teaching hospitals and are incredibly helpful for complex oral medicine problems but are also a source of referral to OMF of oral cancers. 290CHAPTER12 People withwhom you will be working 290Members ofthe multidisciplinary head and neckteamGeneralpoints• This list is not intended to be exhaustive and there is some variation betweenunits.• There will be no repetition of plastic surgeons, ENT surgeons, or restorative dentists and prosthodontists as these are noted in the previoustopic.The histopathologist• The head and neck histopathologist may be a dental pathologist who may or may not also have a medical degree, but more commonly is a medically qualied histopathologist. Either way, they are highly skilled experts on oral pathology and without them OMFS is very much more dicult.• They are key to the success of head and neckMDTs.• If your district general hospital does not have a dedicated oral or head and neck histopathologist, you may nd that some of the unusual pathologies that you see, especially rare salivary gland lesions, will be forwarded to oral pathologists.• When a diagnosis of lymphoma has been made, the case is often reviewed by a designated lymphoma expert/ panel who may not be the same person as the head and neck pathologist.The clinical oncologist• Head and neck clinical oncologists are often the ‘bridge’ within the MDT that unites the ENT and OMF surgeons.• They oversee chemo- and radiotherapy. As non- surgeons, they often have a dierent perspective and their input is invaluable.The radiologist• Head and neck radiologists are responsible to the MDT for reporting on the stagingscans.• They also work alongside the oncologists to plan radiotherapy.• They will be available in the one- stop neck lump clinic where they provide ultrasound expertise.• Interventional radiologists will oversee investigations such as angiography, and CT or MR angiography.Speech and language therapist(SALT)• The SALT should see all the head and neck cancer patients prior to treatment (surgical or medical) and will be called upon to help with post- treatment rehabilitation.• They are particularly useful for assessing both speech and swallowing function after surgery. They will see patients with the radiologist and discuss barium swallows. They also have input in patients with aspiration following treatment and in assessing whether patients can eat/ drink safely.• Many are often actively involved in research. MEMBERS OFTHE MULTIDISCIPLINARY HEAD AND NECKTEAM 291 The dietician• The dietician should see all head and neck cancer patients preoperatively.• Often they will liaise with the PEG, RIG, or even the total parenteral nutrition service.• Postoperatively they oversee the patient’s nutrition through oral, PEG, nasogastric, or parenteral routes.• They will provide help if your patient has special needs such as those with chyle leaks who need medium- chain triglyceridediets.The clinical nurse specialist• Clinical nurse specialists are key workers for head and neck cancer patients. They liaise with the other specialists and feed back to the consultantteam.• They provide emotional and practical support, and as such are highly skilled in a wide range of medical and psychological disciplines.The researchnurse• Research nurses are highly prized members ofMDTs.• They are involved in patient recruitment and day- to- day management of patients in trials and data collection.Palliative care consultant• Palliative care consultants are increasingly involved inMDTs.• It is widely acknowledged that a signicant number of cases discussed at the MDT meeting are not at a stage where curative treatment is an option, and many of these patients benet from palliative care specialists.• Quality of death or dying is rarely considered, but is very important for those patients with end- stage disease.11 Ethunandan M, Homan G, Morey PJ, etal. (2005). Quality of dying in head and neck cancer patients:a retrospective analysis of potential indicators of care. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 100:147– 52. 292

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