4.2 - Dysphagia in Head + Neck Cancers Flashcards
What are the Risk Factors for head and neck cancers?
7
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
In TNM Cancer Classification, what do the numbers 0-4 mean?
The extent of spreading.
0=more localized, 4=diffuse
In TNM Cancer Classification, what does the letter “T” mean?
Tumor
In TNM Cancer Classification, what does the letter “N” mean?
Lymph Node
In TNM Cancer Classification, what does the letter “M” mean?
Metastasis
What is M1 basically equivalent to?
T4
What was the trend in cancer treatment prior to 1990?
Surgery usually followed by XRT.
XRT = Radiation therapy
What is the goal in current cancer treatment?
Organ preservation
What is the current trend in cancer treatment?
3
Using chemoradiation therapy to try to shrink the tumor.
Surgical removal of the tumor
Radiation therapy to address remaining cancer cells
What are the three general guidelines to head and neck cancer assessment?
Preoperative conference
Preoperative clinical swallow evaluation
Preoperative videofluoroscopic swallow evaluation
What is the goal of a Preoperative Conference for patients with head and neck cancer?
To discuss outcome options.
What is performed in a Preoperative Conference for patients with head and neck cancer?
(2)
Discussion of what the patient should expect
PEG placed pre, peri or post op?
PEG = Percutaneous Endoscopic Gastrostomy
Why do we hold a Preoperative Clinical Swallow Evaluation for patients with head and neck cancer?
Patients are probably already experiencing changes in swallowing.
What is performed in a Preoperative Clinical Swallow Evaluation for patients with head and neck cancer?
(2)
Clinical swallow
Objective swallow
What is a Clinical swallow?
3
Done on first visit
Non-instrumental exam
Patient questions and trial swallows
What is an Objective swallow?
Evaluation using objective measurements
How is a Preoperative Videofluoroscopic Swallow Evaluation performed for patients with head and neck cancer?
With or without postural or compensatory techniques.
What is done in Surgical Removal of cancer?
2
Removal of cancerous structures.
Primary tumor surgery
What are the risks of Surgical Removal of cancer?
5
Decreased movement.
Scar tissue formation.
Wound dehiscence.
Decreased sensation at suture/graft site.
Presence of tracheotomy.
What is Dehiscence?
Wound ruptures along a surgical incision.
What kinds of surgeries are seen in head and neck cancer?
8
Mandibulectomy/Mandibulotomy (Lower jaw)
Matxillectomy (Upper jaw)
Laser
Laryngectomy
Tracheostomy
Gastrotomy
Neck dissection
Reconstruction
What is used in Post Radiation Therapy?
Use of X Ray beams
How does Post Radiation Therapy change the patient’s Anatomy?
(2)
Changes the nature of the tissues by reducing blood supply
This damages small nerve endings in the region
What are the major negative effects of Post Radiation Therapy?
(6)
Nausea
Fibrosis (hardening of muscle tissue)
Irritation to skin
Damages the salivary glands causing xerostomia (dry mouth)
Peripheral neuropathies
Necrosis (death) of tissue
What are the major negative effects of Chemotherapy?
6
Nausea (poor tolerance to food)
Loss of appetite
Infections of oral cavity
Occasional mucositis (inflammation, very painful)
Hair loss
Xerostomia (dry mouth)
What are the major negative effects of Chemoradiation Therapy in regards to swallowing?
(4)
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.
What are the cancers of the Oral Cavity?
4
Lip
Floor of the Mouth
Tongue
Retro-Molar Trigone
In what population does Lip Cancer most often occur?
Men- 55 to 65 years old.
What are the primary risk factors for Lip Cancer?
3
Alcohol
Tobacco
Poor oral and dental hygiene
How does Lip Cancer usually present initially?
What happens in more advanced stages?
Non-healing ulcers
Pain in advanced stages.`
How is Lip Cancer usually treated in the initial stage?
Radiation
How is Lip Cancer usually treated in Carcinoma In-Situ?
Lesions of the lip may also be surgically removed
What does “Carcinoma In-Situ” mean?
Within a particular structure/area
What kind of Dysphagia is seen in patients with Lip Cancer?
2
Mostly oral stage deficits – Labial seal, oral bolus control.
May affect other structures because of radiation effects.
Where are cancers of the Floor of the Mouth seen?
2
Anterior surface on either side of the midline.
They can spread to bone and tongue
Approximately ___% of Floor of the Mouth Cancers involve the sub-maxillary nodes.
30%
What kind of Dysphagia is seen in patients who have Cancer in the Floor of the Mouth?
(3)
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.
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 \_\_\_\_\_\_\_.
Oral Cavity
Oropharynx
What happens if the lesions in Tongue Cancer are at the base and posterior 1/3 of the tongue?
(2)
It can invade the tonsils
It is usually advanced.
How do we treat Tongue Cancer?
2
Radiation
Glossectomy
What sort of Dysphagia is seen in Tongue Cancer?
Mostly oral stage deficits.
What sort of Dysphagia is seen in Partial Glossectomies?
2
Bolus prep
Holding bolus.
What sort of Dysphagia is seen in Total Glossectomies?
Posterior propulsion of bolus.
What sort of Dysphagia is seen in Removal of Base of the Tongue?
(2)
Pharyngeal stripping affected
Could affect hyoid excursion as well.
What can also create Dysphagia in patients with Tongue Cancer?
What might also be affected?
Effects of radiation.
In cases of velar resection – Velopharyngeal Closure (VPC) is affected as well.
What is the Retro-Molar Trigone?
Triangular space behind the last molar tooth
How common is Cancer in the Retro-Molar Trigone?
Rare
What are symptoms of Cancer in the Retro-Molar Trigone?
3
Tongue pain
Ear canal pain
Truisms (spasm of jaw muscle)
How is Cancer in the Retro-Molar Trigone treated?
Radiation therapy
What sort of Dysphagia is seen in Cancer in the Retro-Molar Trigone?
(3)
Poor mastication
Poor oral control
Poor posterior propulsion of bolus into the oropharynx.
What creates the Dysphagia seen in Cancer in the Retro-Molar Trigone?
Side effects of surgery or radiation.
What are the cancers of the Pharynx?
3
Oropharynx
Nasopharynx
Hypopharynx/Laryngopharynx
What structures are affected in Cancer of the Oropharynx?
5
Base of the tongue
Tonsils
Soft palate
Uvula
Lateral-posterior pharyngeal walls
What structures are affected in Cancer of the Nasopharynx?
4
Postero-superior pharyngeal wall
Lateral pharyngeal wall,
Eustachian tube orifice
Adenoids
What structures are affected in Cancer of the Hypopharynx/Laryngopharynx?
(3)
Pyriform sinuses
Post-cricoid
Lower posterior pharyngeal walls.
What are common surgeries used for Pharyngeal Cancer?
3
Palatal resection
Pharyngeal resection.
Laryngo-pharyngectomy (if laryngeal involvement)
What sort of Dysphagia is is seen in Pharyngeal Cancers?
6
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)
What are the Cancers of the Larynx?
3
Supraglottis
Glottis
Subglottis
What is the Supraglottis?
The area above the vocal folds.
What is the Glottis?
The area around the vocal folds.
What is the Subglottis?
The area below the vocal folds.
What is the main cause of Laryngeal Cancer?
Smoking
Are Glottic Cancers life threatening?
2
No
Removal of larynx will cause loss of voice but life is saved
Supraglottic lesions are usually ______. These lesions usually spread superiorly to the ______.
Large
Epiglottis
Lymph nodes are usually involved in ___% - ___% of patients with Glottic Cancer.
40%-50%
What is the major risk of Subglottic Cancers?
How are they usually treated?
Airway obstruction.
Total laryngectomy in most cases.
What sort of Dysphagia is seen in Laryngeal Cancers?
Laryngeal penetration/Aspiration
What usually causes the dysphagia in patients with Laryngeal Cancers?
(3)
Changes due to radiation.
TEP (tracheoesophageal puncture) and tracheostomy influences.
Can influence physiological abnormality of hyoid excursion + UES opening.
What is a Hemilaryngectomy?
A surgical procedure that removes part of the front of the larynx
What are the risks of Hemilaryngectomy?
2
Airway protection compromised
Unilateral weakness in the pharyngeal areas.
What is a Supraglottic Laryngectomy?
Only the portion of your larynx above the vocal cords is removed
What are the risks of Supraglottic Laryngectomy?
2
Pharyngeal propulsion impaired
Airway compromise.
What is a Total Laryngectomy?
The entire larynx is removed
What are the risks of Total Laryngectomy?
2
Airway compromise
Pressure issues for bolus flow.
What is always affected in Oral, Laryngeal, + Pharyngeal Cancers?
Anatomy
What Oral, Laryngeal, + Pharyngeal Cancers treatments and intervention will significantly affect swallowing?
(3)
Radiation
Chemo
Surgery
What is commonly seen in Oral, Laryngeal, + Pharyngeal Cancers?
Aspiration
What physiological components are affected in Oral, Laryngeal, + Pharyngeal Cancers?
Based on the site of the tumor.
