Negative pressure therapy in the orofacial region in oncological patients – two case reports

Introduction

Negative pressure therapy (also known as vacuum therapy) is a non-invasive method used for the treatment of non-healing wounds through the application of subatmospheric pressure combined with the removal of excessive exudate [1]. The negative pressure causes macro- and microdeformations of the wound and facilitates the removal of excess fluids, which, in combination, causes the change of the wound environment. Macrodeformation is a term used to describe the reduction of the wound surface arising as a result of the forces acting on the wound surface through the foam (or other suitable material) which shrinks due to the applied suction [2]. Macrodeformation is in­fluenced by the size of the wound and the type of the contact material, especially its specific density or texture. The ideal value supporting the formation of the granulation tissue is 125 mmHg [3]. The term microdeformation describes the reaction of the tissues on the microscopic level where the mechanical cell deformation triggers signalling cascades initiating cell migration and proliferation, which contributes towards wound healing [4]. The tension induced by the vacuum affects the cell cytoskeleton and the differentiation of fibroblasts (preferentially to myofibroblasts) and, in effect, production of collagen and other components of the extracellular matrix [3]. Removal of the liquids from the wound leads to the reduction of swelling and of capillary compression, thus improving tissue perfusion. At the same time, drainage of the exudate removes inflammatory cytokines, leukocytes and, possibly, bacteria (although there has been no clear evidence on reducing the bacterial contamination of the wound so far) [2]. Increased infiltration of the wound floor by neutrophils when applying negative pressure therapy has been reported [3].

The negative pressure system consists of a vacuum pump, fluid receptacle, drainage tubing, occlusive dressing responsible for maintaining the va­cuum, and the contact dressing itself, usually made of a polyurethane or polyvinyl alcohol foam, sometimes antiseptic gauze. The dressing is applied under aseptic condition, the wound must be thoroughly cleaned and its vicinity must be prepared in a way ensuring that the occlusive dressing does not fail. From the foam or another contact material, a suitable shape is cut out; the size must be sufficient to cover the entire wound floor. Then, the occlusive dressing is applied (at least 5 cm around the wound), containing a hole in the middle through which a suction tube is inserted and the joint is sealed. The tubing is connected to the vacuum pump through the receptacle; after turning on the pump, the foam contracts [5].

The most common applications for vacuum therapy include treatment of dehisced wounds, skin-loss injuries, burns, ulceration, or, sometimes, covering dermo-epidermal grafts. Contraindications of the application of vacuum therapy can be divided into absolute and relative. Absolute contraindications include the presence of a tumour or necrotic tissue on the wound floor and active bleeding. Relative contraindications include untreated osteomyelitis, the presence of the neurovascular bundle or a parenchymatic/hollow organ on the wound floor, conditions with a high risk of bleeding and patient’s non-compliance [3].

Although negative pressure therapy has been used in the treatment of wounds in the orofacial region relatively rarely so far, it can be used in certain conditions, such as in the treatment of inflammations in the vicinity of the jaws. It could also significantly contribute towards healing acceleration and towards the improvement of the quality of life of patients with extensive defects of the soft tissues in the orofacial region [6].

In this paper, we would like to present two cases of oncological patients in whom negative pressure therapy was successfully used.

Case reports

Patient 1

A 65-year-old male with spinocellular carcinoma T3N2bM0 (T – primary tumor, N – regional lymph nodes, M – metastasis) in the retromolar region of the right lower jaw was admitted to our department for planned surgery in October 2019. His comorbidities included lower extremity arterial disease, hypertension, the homozygous form of the Leiden mutation and history of gastroduodenal ulceration. The patient smokes approx. 15 cigarettes a day, alcohol consumption is occasional only.

After admission, percutaneous endoscopic gastrostomy (PEG) was performed. The following day, he underwent a radical neck dissection of lymph nodes from level I–IV, tooth extraction from both the upper and lower jaws and tumour excision with mandibular resection with the interruption of mandibular continuity. Histological examination revealed intact resection margins without marks of angioinvasion or perineural spread. The surgery itself was without complications, with blood loss < 750 mL, under an antibiotic cover. After the surgery, the patient was observed at an Intensive Care Unit (ICU) and the following day transferred to our Department of Oral and Maxillofacial Surgery in a stabilized condition. The wounds were treated with Betadine solution and sterile dressing was changed daily; in the mouth, 3% hydrogen peroxide was used. Antibiotic therapy continued. The patient rinsed the mouth 3-times a day with 0.12% chlorhexidine and was advised to perform meticulous dental hygiene. The nutrition was ori­ginally administered only via PEG, later also orally; everything was consulted with a nutritional therapist.

On Day 7 after the surgery, a small dehiscence developed in the mouth and serous liquid started to leak submandibularly between stitches. On the next day, the dehiscence was intraorally re-sutured and a compression dressing was applied externally. However, as the wound dehiscence reappeared again and the exu­dation continued, swabs were taken for bacteriological examination. Based on the results of cultivation and consultation with the antibiotic centre, Augmentin was replaced with a combination of metronidazole and ciprofloxacin. Despite this change in antibiotic therapy, the wound dehiscence continued, which resulted in the deve­lopment of an orostoma. Hence, on Day 24 after the surgery, a wound revision under general anesthesia from the origi­nal cutaneous side was performed. The margins of the orostoma were excised and the mesial mandibular stump protru­ding into the wound was resected. The defect was then covered with a flap from the anterior belly of the digastric and sternocleidomastoid muscles and soft tissues were sutured in layers. The tissue samples for both bacteriological and histological examinations were taken.

On Day 3 after the second surgery, the wound began to disintegrate again, forming a dehiscence of approx. 3.5 cm with a mucous exudate; the wound, however, did not communicate to the oral cavity any more (Fig. 1). Following another consultation with the antibio­tic centre, another medication change was made. The wound was externally bathed with Actimaris solution followed by the application of Actimaris gel; 3% hydrogen peroxide and 0.12% chlorhexidine were used for rinsing and bathing the wound from the side of the oral cavity. The wound floor began slowly to granulate. At that time, we decided to apply vacuum therapy with a 2-day interval of dressing change. As our department does not possess a suitable va­c­uum pump, a Redon drain was used for achieving negative pressure (Fig. 2).

After 10 days of negative pressure therapy, the wound was significantly smaller and the patient was discharged from the hospital with instructions to continue local treatment with Actimaris solution and gel (Fig. 3). Within one month, the wound fully healed. After this healing, the patient underwent adjuvant cancer therapy. The follow-up in November 2020 (i.e., approx. 1 year after the primary surgery) did not reveal any clinical signs of recurrence of the tumour.

Patient 2

A 57-year-old male patient was treated at the ENT Department with a quadruple malignancy in the region of the oral ca­vity and oropharynx. In October 2017, he underwent excision of the spinocellular carcinoma from the oral floor and tonsillolingual sulcus (left-sided) with a ra­dical neck dissection on the same side followed by adjuvant radiotherapy that was completed in February 2018. The personal history included hypertension, post-radiation hypothyreosis, chronic obstructive pulmonary disease and neuro­pathy of lower extremities. The patient does not drink alcohol and smokes 3 cigarettes a day. He was admitted to the Department of Maxillofacial Surgery due to a left-sided osteoradionecrosis of the lower jaw for elective necrectomy and lower jaw resection with interruption of mandibular continuity.

Under general anaesthesia and anti­biotic cover, the excision of the left-sided submandibular extraoral fistula, extraction of teeth 21–12 and, subsequently, left-sided mandibular resection with continuity interruption in the extent of −34567. The bone stumps were cleaned to the macroscopically healthy bone and fixed to the surrounding tissue. The soft tissues were hermetically sutured in layers. Samples for histopathological and bacteriological examinations were collected during the surgery. The surgery was without complications. A nasogastric tube was introduced after the surgery and the patient was (repeatedly over the next few weeks) examined by a nutritional therapist.

Since Day 1 after the surgery, the patient kept rinsing his mouth with 0.12% solution of chlorhexidine 3-times a day, the wounds were locally disinfected during everyday dressing changes and ATB treatment (Augmentin) continued. Despite this, an intraoral dehiscence appeared on Day 3, followed by a leak of serosanguinolent fluid. After consulting the antibiotics centre, ciprofloxacin was added into the medication on Day 4. On Day 5, however, even extraoral wound disintegration occurred; 2 days later, the dehiscence size was 4 × 2 cm and communicated to the oral cavity. A swab for further bacteriological examination was taken, the frequency of dressing changes with debridement was increased to twice a day.

Following another consultation with the ATB centre, vancomycin was added into the therapy; 5 days later, however, it had to be discontinued due to increasing creatinine levels. On Day 20, the patient was transferred to the ICU as a result of acute renal failure; at about the same time, the wound in the oral ca­vity began to close. During his stay at ICU, the external application of Hyiodine gel was combined with intraoral Actimaris gel application.

After overall stabilization of the patient, he was transferred back to the standard ward. At that point, the dehiscence of approx. 4 × 2 cm persisted but it did not communicate with the oral ca­vity any more (Fig. 4). This facilitated the application of the vacuum system, again in a modification with a Redon drain (Fig. 5). The dressings were changed every 2 days for a period of 8 days, after which the wound length decreased to approx. 2 cm only (Fig. 6). The patient was subsequently transferred to a hospital nearer to his place of living (his lab results were still not normal enough for his discharge to a home care). The va­c­uum therapy was discontinued at the local hospital; the wound was, however, treated with standard means. After his discharge from the hospital, the patient was followed-up on an outpatient basis. The insufficient home wound care resulted in prolonged healing but eventually, the wound healed with a scar. Approx. 5 months later, another spinocellular carcinoma developed on the lateral and ventral side of the tongue ­(T1-2N0M0), which was surgically removed with histologically confirmed carcinoma-free resection margins. At present, the patient is in a home care.

Discussion

Wound healing is a complicated process consisting of a complex interaction of various inflammatory cells, chemokines, cytokines, molecules, and nutrients. These processes comprise four stages of wound healing, namely hemostasis, inflammation, proliferation and remodeling. Disruption of this cascade leads to the development of chronic non-healing wounds [7].

Such wounds are often infected, a permanent inflammatory infiltrate is present, re-epitelization is disrupted and the wound fills with granulation tissue. This tissue is of poor quality, with low fibroblast infiltration and increased levels of matrix metallopro­teinases (MMP) and cytokines [8]. MMPs are enzymes involved in the degradation of the extracellular matrix during wound healing. The presence of pro-inflammatory cytokines, such as interleukin-1-alfa (IL-1α), epidermal growth factor (EGF), platelet derived growth factor (PDGF) and tumor necrosis factor-alpha (TNF-α) increases the MMP production. TNF-α (cachectin), predominantly produced by macrophages, plays an important role in wound healing. Excessive synthesis of TNF-α (and, therefore, of MMP) can cause healing disturbances leading to the development of a chronic wound or other inflammatory diseases [9].

Many factors, both internal and external, play a role in wound healing. Among others, this includes factors affecting blood supply, immune functions, metabolic diseases, drug use or previous tissue damage (e.g. by radiotherapy). Stable pressure, temperature and humidity are also important factors [7].

As wound healing is an energetically demanding process, the role of nutrition must not be underestimated. In malnourished patients, increased nutrition supply or use of food supplements with high energy and protein values are needed [10].

As already mentioned, vacuum the­rapy reduces the wound size and can also positively influence the amount and the quality of granulation tissue. It is instrumental in reducing the extent of edema and amount of pro-inflammatory mediators (including MMP) through draining the exudate, which is another mechanism of how this technique can positively affect the wound environment and, in effect, contribute to better healing.

In the field of maxillofacial surgery, negative pressure therapy is relatively rarely used, in particular, because of the difficulty of achieving sufficient sealing of the wound caused by the complex anatomy of the head and neck, as well as by the fact that wounds usually heal re­latively well in this area [11].

Conclusion

The options for the use of negative pressure therapy in the orofacial region are limited and, moreover, debatable in oncological patients. Our expe­rience, however, indicates a very positive influen­ce of such therapy on the healing of chronic wounds, despite the fact that our experience is based on the use of an improvised vacuum therapy solution (in the Czech Republic, negative pressure therapy systems Vivano®Tec, PICO® or AVELLE® are available on the market).

A complex approach towards the patients with chronic wounds in the area of head and neck is necessary and suitable nutrition should not be underestimated as such patients often suffer from malignant tumours or extensive inflammatory processes and their organisms are often exhausted by both the disease itself and its therapy. Healing is often proble­matic in such patients, often nega­tively in­fluenced by radiotherapy and hence, even a notable reduction of the wound can be considered as success in these cases.

Grant support: This paper was supported by the grant AZV/009830/2019 of the Ministry of Health of the Czech Republic and the Institutional Support RVO-FNOs/2018 and SGS14/LF OU/2017-2018.

Disclosure: This manuscript has not been published and is not under consideration for publication else­where. We have no conflicts of interest to disclose. All procedures performed in this study involving human participants were in accordance with ethical standards of the institutional and/or national research committee and with the Helsinki declaration and its later amendments or comparable ethical standards.

Roles of authors: Julia Belobradová: review of literature, patient treatment, manuscript writing. Oldřich Res: final manuscript approval, patient treatment. Jiří Stránský: final manuscript approval, patient treatment. Zuzana Čermáková Zděblová: final manuscript approval, patient treatment. Tomáš Blažek: final manuscript approval, patient treatment. Pavel Hurník: final manuscript approval, patient treatment. Jan Štembírek: manuscript writing, final manuscript approval, patient treatment.

Jan Štembírek, MD et MD, PhD

Department of Oral and Maxillofacial Surgery

University Hospital Ostrava

17. listopadu 1790/5, 708 52 Ostrava

Czech Republic

e-mail: jan.stembirek@fno.cz

Submitted: 20. 11. 2020

Accepted: 06. 02. 2021