Malignant Fungating Wounds of the Head and Neck: Management and Antibiotic Stewardship

Abstract

Objective Malignant fungating wounds (MFWs) are unfortunate and underreported manifestations of some advanced head and neck cancers. The management of MFWs is complex and challenging. MFWs are often mistaken for infectious processes/abscesses and treated indiscriminately with oral or intravenous antibiotics. Our aim is to promote awareness of MFWs and provide education on their management. We summarize their cost-effective and evidence-based therapies and highlight antibiotic stewardship with respect to their management. Data Sources A literature review was performed of PubMed, Cochrane Review, SCOPUS, Embase, and Google Scholar databases regarding topical and systemic treatments for MFWs. Review Methods Full-text articles were identified with the following terms: fungating, ulcerative, wound, tumor, malignancy, antibiotics, topical, dressings, radiotherapy, head, neck, scalp, face, lip, and ear. Treatment recommendations were extrapolated, categorically summarized, and retrospectively assigned with an evidence level based on the GRADE system (Grading of Recommendations, Assessment, Development, and Evaluation). Conclusions In the absence of systemic signs and symptoms of infections, MFWs should not be treated as conventional infections or abscesses, with prophylactic oral or intravenous antibiotics. Topical treatments such as ointments and wound dressings are the mainstay in terms of managing the unsightly appearance and fetid odor from these entities. Implications for Practice MFWs are most often not amenable to definitive/curative surgical or nonsurgical therapy, but consultation with a head and neck oncologic specialist will help to determine if the underlying malignancy requires surgery, radiation therapy, or palliative treatment.

Caring for Patients With Malignant Fungating Wounds

“…50 Considered collectively, findings from these studies indicate that malodor may be alleviated by several topical or systemic therapies including metronidazole, ionic silver, polyhexamethylene biguanide, green tea, manuka honey, nanocrystalline silver nanoparticles, and charcoal. 51 However, we found no significant differences between these interventions and no standard or consensus concerning the best dosage and route of these therapies. 13,19,20,52 We found several articles that evaluated systemic or topical agents for relief of pain in patients with MFW.…”

“…However, the small sample size in the study rendered it difficult to reflect the genuine effectiveness of systematic antibiotics in relieving symptoms of MFWs 9. A recent literature review suggested that prophylactic systemic antibiotics should be avoided for treating patients with MFWs 51…”

Managing a malignant wound in palliative care

“…The use of systemic antibiotics should be limited to managing acute infection 44 . Bacterial colonisation of necrotic tissue leads to chronic infection which is best managed with an appropriate dressing regimen.…”

Topical therapy for pain management in malignant fungating wounds: A scoping review

“…Over time, these wounds evolve and deteriorate, becoming more extensive and invasive (Hoshi et al, 2019; Tilley et al, 2020; Young, 2017). Approximately 4%–15% of cancer patients develop this type of injury (Firmino et al, 2020) that predominately involve breasts (62% to 66%), head and neck (24%), and the chest due to the proximity of the compromised tissue to the skin (EONS, 2015; Firmino et al, 2020; Neves Duarte Lisboa, 2016; O’Neill et al, 2022). According to the Haisfield‐Wolfe and Baxendale‐Cox staging system, people with MFWs in their advanced stages are beleaguered by debilitating symptoms, including odour, exudate, itching, bleeding and pain (Haisfield‐Wolde & Baxendale‐Cox, 1999).…”

“…Over time, these wounds evolve and deteriorate, becoming more extensive and invasive (Hoshi et al, 2019;Tilley et al, 2020;Young, 2017). Approximately 4%-15% of cancer patients develop this type of injury (Firmino et al, 2020) that predominately involve breasts (62% to 66%), head and neck (24%), and the chest due to the proximity of the compromised tissue to the skin (EONS, 2015;Firmino et al, 2020;Neves Duarte Lisboa, 2016;O'Neill et al, 2022).…”