4.2 - Dysphagia in Head + Neck Cancers

Question 1

What are the Risk Factors for head and neck cancers?

7

Answer 1

Tobacco

Alcohol

HPV in oropharyngeal cancers

Epstein-Barr virus in nasopharyngeal cancers

Poor oral hygiene

Poor nutrition especially Vitamin A and B deficiency

GERD in pharyngeal cancers

Question 2

In TNM Cancer Classification, what do the numbers 0-4 mean?

Answer 2

The extent of spreading.

0=more localized, 4=diffuse

Question 3

In TNM Cancer Classification, what does the letter “T” mean?

Answer 3

Tumor

Question 4

In TNM Cancer Classification, what does the letter “N” mean?

Answer 4

Lymph Node

Question 5

In TNM Cancer Classification, what does the letter “M” mean?

Answer 5

Metastasis

Question 6

What is M1 basically equivalent to?

Answer 6

T4

Question 7

What was the trend in cancer treatment prior to 1990?

Answer 7

Surgery usually followed by XRT.

XRT = Radiation therapy

Question 8

What is the goal in current cancer treatment?

Answer 8

Organ preservation

Question 9

What is the current trend in cancer treatment?

3

Answer 9

Using chemoradiation therapy to try to shrink the tumor.

Surgical removal of the tumor

Radiation therapy to address remaining cancer cells

Question 10

What are the three general guidelines to head and neck cancer assessment?

Answer 10

Preoperative conference

Preoperative clinical swallow evaluation

Preoperative videofluoroscopic swallow evaluation

Question 11

What is the goal of a Preoperative Conference for patients with head and neck cancer?

Answer 11

To discuss outcome options.

Question 12

What is performed in a Preoperative Conference for patients with head and neck cancer?

(2)

Answer 12

Discussion of what the patient should expect

PEG placed pre, peri or post op?
PEG = Percutaneous Endoscopic Gastrostomy

Question 13

Why do we hold a Preoperative Clinical Swallow Evaluation for patients with head and neck cancer?

Answer 13

Patients are probably already experiencing changes in swallowing.

Question 14

What is performed in a Preoperative Clinical Swallow Evaluation for patients with head and neck cancer?

(2)

Answer 14

Clinical swallow

Objective swallow

Question 15

What is a Clinical swallow?

3

Answer 15

Done on first visit

Non-instrumental exam

Patient questions and trial swallows

Question 16

What is an Objective swallow?

Answer 16

Evaluation using objective measurements

Question 17

How is a Preoperative Videofluoroscopic Swallow Evaluation performed for patients with head and neck cancer?

Answer 17

With or without postural or compensatory techniques.

Question 18

What is done in Surgical Removal of cancer?

2

Answer 18

Removal of cancerous structures.

Primary tumor surgery

Question 19

What are the risks of Surgical Removal of cancer?

5

Answer 19

Decreased movement.

Scar tissue formation.

Wound dehiscence.

Decreased sensation at suture/graft site.

Presence of tracheotomy.

Question 20

What is Dehiscence?

Answer 20

Wound ruptures along a surgical incision.

Question 21

What kinds of surgeries are seen in head and neck cancer?

8

Answer 21

Mandibulectomy/Mandibulotomy (Lower jaw)

Matxillectomy (Upper jaw)

Laser

Laryngectomy

Tracheostomy

Gastrotomy

Neck dissection

Reconstruction

Question 22

What is used in Post Radiation Therapy?

Answer 22

Use of X Ray beams

Question 23

How does Post Radiation Therapy change the patient’s Anatomy?

(2)

Answer 23

Changes the nature of the tissues by reducing blood supply

This damages small nerve endings in the region

Question 24

What are the major negative effects of Post Radiation Therapy?

(6)

Answer 24

Nausea

Fibrosis (hardening of muscle tissue)

Irritation to skin

Damages the salivary glands causing xerostomia (dry mouth)

Peripheral neuropathies

Necrosis (death) of tissue

Question 25

What are the major negative effects of Chemotherapy? | 6

Answer 25

Nausea (poor tolerance to food) Loss of appetite Infections of oral cavity Occasional mucositis (inflammation, very painful) Hair loss Xerostomia (dry mouth)

Question 26

What are the major negative effects of Chemoradiation Therapy in regards to swallowing? (4)

Answer 26

Reduced strength and coordination of the anterior tongue. Reduced posterior movement of the base of tongue (to the posterior pharyngeal wall) Reduced laryngeal elevation Reduced airway closure.

Question 27

What are the cancers of the Oral Cavity? | 4

Answer 27

Lip Floor of the Mouth Tongue Retro-Molar Trigone

Question 28

In what population does Lip Cancer most often occur?

Answer 28

Men- 55 to 65 years old.

Question 29

What are the primary risk factors for Lip Cancer? | 3

Answer 29

Alcohol Tobacco Poor oral and dental hygiene

Question 30

How does Lip Cancer usually present initially? What happens in more advanced stages?

Answer 30

Non-healing ulcers Pain in advanced stages.`

Question 31

How is Lip Cancer usually treated in the initial stage?

Answer 31

Radiation

Question 32

How is Lip Cancer usually treated in Carcinoma In-Situ?

Answer 32

Lesions of the lip may also be surgically removed

Question 33

What does "Carcinoma In-Situ" mean?

Answer 33

Within a particular structure/area

Question 34

What kind of Dysphagia is seen in patients with Lip Cancer? | 2

Answer 34

Mostly oral stage deficits – Labial seal, oral bolus control. May affect other structures because of radiation effects.

Question 35

Where are cancers of the Floor of the Mouth seen? | 2

Answer 35

Anterior surface on either side of the midline. They can spread to bone and tongue

Question 36

Approximately ___% of Floor of the Mouth Cancers involve the sub-maxillary nodes.

Answer 36

30%

Question 37

What kind of Dysphagia is seen in patients who have Cancer in the Floor of the Mouth? (3)

Answer 37

Mostly oral stage deficits – Oral bolus control. Can affect other physiological processes – hyoid excursion and UES opening. May affect other structures because of radiation effects.

Question 38

``` If Tongue Cancer affects the anterior section (initial 2/3rds), we say it affects the _______. ``` ``` If Tongue Cancer affects the posterior section (latter 1/3rd), we say it affects the _______. ```

Answer 38

Oral Cavity Oropharynx

Question 39

What happens if the lesions in Tongue Cancer are at the base and posterior 1/3 of the tongue? (2)

Answer 39

It can invade the tonsils It is usually advanced.

Question 40

How do we treat Tongue Cancer? | 2

Answer 40

Radiation Glossectomy

Question 41

What sort of Dysphagia is seen in Tongue Cancer?

Answer 41

Mostly oral stage deficits.

Question 42

What sort of Dysphagia is seen in Partial Glossectomies? | 2

Answer 42

Bolus prep Holding bolus.

Question 43

What sort of Dysphagia is seen in Total Glossectomies?

Answer 43

Posterior propulsion of bolus.

Question 44

What sort of Dysphagia is seen in Removal of Base of the Tongue? (2)

Answer 44

Pharyngeal stripping affected Could affect hyoid excursion as well.

Question 45

What can also create Dysphagia in patients with Tongue Cancer? What might also be affected?

Answer 45

Effects of radiation. In cases of velar resection – Velopharyngeal Closure (VPC) is affected as well.

Question 46

What is the Retro-Molar Trigone?

Answer 46

Triangular space behind the last molar tooth

Question 47

How common is Cancer in the Retro-Molar Trigone?

Answer 47

Rare

Question 48

What are symptoms of Cancer in the Retro-Molar Trigone? | 3

Answer 48

Tongue pain Ear canal pain Truisms (spasm of jaw muscle)

Question 49

How is Cancer in the Retro-Molar Trigone treated?

Answer 49

Radiation therapy

Question 50

What sort of Dysphagia is seen in Cancer in the Retro-Molar Trigone? (3)

Answer 50

Poor mastication Poor oral control Poor posterior propulsion of bolus into the oropharynx.

Question 51

What creates the Dysphagia seen in Cancer in the Retro-Molar Trigone?

Answer 51

Side effects of surgery or radiation.

Question 52

What are the cancers of the Pharynx? | 3

Answer 52

Oropharynx Nasopharynx Hypopharynx/Laryngopharynx

Question 53

What structures are affected in Cancer of the Oropharynx? | 5

Answer 53

Base of the tongue Tonsils Soft palate Uvula Lateral-posterior pharyngeal walls

Question 54

What structures are affected in Cancer of the Nasopharynx? | 4

Answer 54

Postero-superior pharyngeal wall Lateral pharyngeal wall, Eustachian tube orifice Adenoids

Question 55

What structures are affected in Cancer of the Hypopharynx/Laryngopharynx? (3)

Answer 55

Pyriform sinuses Post-cricoid Lower posterior pharyngeal walls.

Question 56

What are common surgeries used for Pharyngeal Cancer? | 3

Answer 56

Palatal resection Pharyngeal resection. Laryngo-pharyngectomy (if laryngeal involvement)

Question 57

What sort of Dysphagia is is seen in Pharyngeal Cancers? | 6

Answer 57

Pharyngeal stripping Velopharyngeal Closure (VPC) Base of the Tonge to Posterior Pharyngeal Wall (BOT to PPW) retraction UES opening Hyoid excursion may be affected. Poor mastication due to Truisms (jaw muscle spasms)

Question 58

What are the Cancers of the Larynx? | 3

Answer 58

Supraglottis Glottis Subglottis

Question 59

What is the Supraglottis?

Answer 59

The area above the vocal folds.

Question 60

What is the Glottis?

Answer 60

The area around the vocal folds.   

Question 61

What is the Subglottis?

Answer 61

The area below the vocal folds.

Question 62

What is the main cause of Laryngeal Cancer?

Answer 62

Smoking

Question 63

Are Glottic Cancers life threatening? | 2

Answer 63

No Removal of larynx will cause loss of voice but life is saved

Question 64

Supraglottic lesions are usually ______. These lesions usually spread superiorly to the ______.

Answer 64

Large Epiglottis

Question 65

Lymph nodes are usually involved in ___% - ___% of patients with Glottic Cancer.

Answer 65

40%-50%

Question 66

What is the major risk of Subglottic Cancers? How are they usually treated?

Answer 66

Airway obstruction. Total laryngectomy in most cases.

Question 67

What sort of Dysphagia is seen in Laryngeal Cancers?

Answer 67

Laryngeal penetration/Aspiration

Question 68

What usually causes the dysphagia in patients with Laryngeal Cancers? (3)

Answer 68

Changes due to radiation. TEP (tracheoesophageal puncture) and tracheostomy influences. Can influence physiological abnormality of hyoid excursion + UES opening.

Question 69

What is a Hemilaryngectomy?

Answer 69

A surgical procedure that removes part of the front of the larynx

Question 70

What are the risks of Hemilaryngectomy? | 2

Answer 70

Airway protection compromised Unilateral weakness in the pharyngeal areas.

Question 71

What is a Supraglottic Laryngectomy?

Answer 71

Only the portion of your larynx above the vocal cords is removed

Question 72

What are the risks of Supraglottic Laryngectomy? | 2

Answer 72

Pharyngeal propulsion impaired Airway compromise.

Question 73

What is a Total Laryngectomy?

Answer 73

The entire larynx is removed

Question 74

What are the risks of Total Laryngectomy? | 2

Answer 74

Airway compromise Pressure issues for bolus flow.

Question 75

What is always affected in Oral, Laryngeal, + Pharyngeal Cancers?

Answer 75

Anatomy

Question 76

What Oral, Laryngeal, + Pharyngeal Cancers treatments and intervention will significantly affect swallowing? (3)

Answer 76

Radiation Chemo Surgery

Question 77

What is commonly seen in Oral, Laryngeal, + Pharyngeal Cancers?

Answer 77

Aspiration

Question 78

What physiological components are affected in Oral, Laryngeal, + Pharyngeal Cancers?

Answer 78

Based on the site of the tumor.