Dysphagia & Head and Neck Cancer Flashcards
Head and neck cancer is the ____ leading cancer worldwide, and 8th by mortality
6th
Individuals ____ are at higher risk
40-60 years
____ are 2-4 x more likely than women to develop dx
Men
What are most types of head & neck cancer?
Squamous cell cancers
When originating from the salivary glands, what may the tumor be?
Mucoepidermoid, acinic cell, adenocarcinoma, adenoid cystic
What is key for survival?
Early detection and treatment
Most treatment failures occur when?
Within the first 2 years following definitive treatments
Risk factors of H and N cancer?
- Tobacco
- > 2 alcoholic drinks/dat
- HPV infections
- Marijuana use
- Betel nut chewing, betel quid, Paan (southeast asia)
What has a synergistic effect in increasing risk?
-When both tobacco and alcohol are combined
Other risk factors for H and N cancer? (1/2)
- Poor oral hygiene, ill-fitting dentures
- Epstein-Barr virus
- Asbestos, wood dust,paint fumes
- Pre-cancerous lesions
What is the epstein-barr virus especially a risk factor for?
-Nasopharyngeal and salivary gland cancers
Other risk factors for H and N cancers? (2/2)
- Ethnic origin
- Intake of preserved/salted foods during childhood
- Mate
- GERD and reflux
- Weakened immune system and autoimmune disorders
Which ethnicities are at an increased risk for nasopharyngeal cancer?
-Chinese, Middle East, Mediterranean basin
T staging of TNM?
-Size and extend of the tumour
N staging of TNM?
-Whether the cancer cells have spread to nearby (regional) lymph nodes and to what extend
M staging of TNM?
Whether distant metastasis has occured
What are the treatment modalities avaiable?
- Surgery
- Radiation therapy
- Chemotherapy
- Immunotherapy
- Research protocols
- –> May have single types of treatment or may have a combination of treatments
- ->The order in which treatments s are given may vary
- -> Treatments may be curative or palliative
What is included in the oral cavity?
- Lip
- Floor of mouth
- Hard palate
- Oral tongue
- Alveolar ridge and retromolar trigone
What is included in the oropharynx?
- Base of tongue
- Soft palate
- Tonsillar pillar and fossa
What does the pharynx consist of?
- Nasopharynx
- Oropharynx
- Hypo-pharynx
What is included in the larynx?
- Supra-glottis
- Glottis
- Subglottis
Which cancers are seen in the sub-mental and submandibular nodes (I)?
- Lip
- Anterior of tongue
- Floor of mouth
- Gingiva
- Buccal Mucosa
Which cancers are seen in the upper jugulodigastric group? (II)
-Oral cavity, pharynx, arynx
Which cancers are seen in the middle jugular nodes?
-Nasopharyx, oropharynx, oral cavity, hypopharynx, larynx
Which cancers are seen in the inferior jugular nodes?
-Hypopharynx, subglottic larynx, esophagus
What are three types of swallow evaluation techniques?
- Bedside/clinic evaluation which include a detailed pt interview
- MBS
- FEED
What is another name for MBS?
-Video-fluoroscopic swallowing study (VFSS)
What is FEES?
An instrumental assessment which involves passing a flexible fiberoptic endoscope transnasally to obtain a superior view of the pharynx and larynx
What are the 5 phases of nutritional intervention?
-Pre-treatment
-Immediate post-op
-Rehab post-op
=During radiation, chemo, or immunotherapy
-Post-therapy treatments
What is the most common symptom at time of diagnosis?
Dysphagia
When is dysphagia especially the most common symptom at time of diagnosis?
When the cancer is located in the oral cavity, oropharynx, hypo-pharynx
What may dysphagia be associated with?
Penetration and aspiration –> may be silent aspiration
How should we intervene with dysphagia initially?
- detailed patient issue and bedside evaluation
- Then, MBS or FEES may be needed to better evaluate detailed aetiology of dysphagia
What is the aetiology of dysphagia with H and N cancer
- Due to disrupted normal anatomy
- Nerve involvement
- Tumor induced pain
Discuss disrupted normal anatomy
- Replacement of normal structure by tumour/ulcerations, soft-tissue tethering and restricting normal movements and muscle weakness
- Mechanical obstruction due to mass effect/size of tumour
Discuss nerve involvement
-Infiltration of the cranial nerves which results in the reduced sensation and motor function
What is the vagus (laryngeal) nerve responsive for? What happens if there is cancer infiltration?
- Responsible for the motion of the intrinsic laryngeal musculature, which produces vocal cord adduction during the passage of the food bolus
- Injury will result in ipsilateral vocal cord paralysis and possibly aspiration
What are the symptoms of dysphagia? (1/2)
- Odynophagia/otalgia
- Sensation of food/something caught in throat (globus)
- Trismus
- Coughing, choking, gagging when eating/drinking
- Drooling/hypersalivation
- Inability to wear dentures
- Difficulty chewing and moving food in mouth
What are the symptoms of dysphagia (2/2)
- Inability to control foods, liquids or saliva in the oral cavity
- Presence of food residue in the oral cavity
- Nasal regurgitation of liquids and food
Nutritional intervention in dysphagia?
- Need to take time to eat/slow down the pace
- Need to cut-up food into small particle sizes and take small sips of fluid
- Need to drink more with meals to clear food residue
What does dysphagia result in?
Anorexia/Early Satiety –> Decreased food intake –> Weight loss –> Malnourished state and weakness
Assessing H and N cancer requires a nutritional assessment and swallow evaluation what are the nutritional implications?
- May need to recommend patient to remain NP and to implement EN
- May need EN to supplement oral intake
- May be able to continue with oral diet, or may need to modify diet
Interventions to improve nutritional status prior to H and N cancer intervention especially in the context of dysphagia?
- Implementation of high protein, high-energy diet including commercial or homemade nutritional supplements
- Adjusting meal pattern to SMFQM which included protein
- Modification of food textures and liquid consistencies
- Avoiding problematic foods
- Increasing moisture content of foods consumed
What compensatory techniques could be integrated prior to intervention for the H and N cancer?
- Placement of food in the oral cavity to bypass the tumour or ulcer
- Use of shortened straws, syringes an long-handled spoons
- May need to implement postural strategies
- May need swallowing maneuvers
which postural position may facilitate intake in the context of dysphagia?
Chin tuck/down posture, head turned to the affected side, and head tilt to the non-effected side
Which swallowing maneuvers may be helpful in the context of dysphasia?
- Effortful swallow
- Supraglottic swallow (hold breath before swallowing, and cough before breathing again)
- Mendesohn
- -> These are usually done by the speech therapist
Tracheostomy?
An opening made by an incision in the trachea – may be temporary or permanent
Tracheotomy?
Procedure to create the openin
Tracheostomy tube?
Curved hollow tube inserted into the trachea through the opening to allow for the passage of air and the removal of secretions
Decannulation?
Removal of tracheostomy
Total laryngectomy?
-Operation to completely remove the larynx, therefore creating a permanent opening as a tracheostomy/stoma
Tracheoesophageal puncture/ (TEP)
A small opening/fistula created between the trachea and esophagus for voice restoration
TEP Prosthesis?
A valve inserted into the TEP to keep food out of the trachea, but to allow for air into the esophagus to permit tracheo-esophageal speech
Laryngectomy tube?
A tube (similar to tracheotomy tube) designed to maintain patency of tracheostomy following a total laryngectomy to prevent stenosis (narrowing of esophagus)
Stoma vent
Soft, flexible tube designed to maintain the tracheostoma
Neopharynx?
A surgically reconstructed pharynx
TORS?
Trans-oral robotic surgery
What are the two indications for tracheostomy in H and N cancer?
1) To bypass an airway obstruction
2) Prophylactic insertion at time OR because we expect extensive edema of the upper respiratory tract and to ensure adequate elimination of secretions
Why may obstructions occur in the airway in H and N cancer?
- Tumour obstructing the passage of air to the lungs
- Soft tissue edema due to radiation therapy or infection
- Bilateral vocal cord paralysis in the closed (adducted) position, where no air is entering the trachea)
What is the nutritional impact of tracheostomy?
It has an impact on swallowing
Tracheostomy impact on swallowing?
- Increased saliva and secretion production
- Decreased mobility of tongue
- Reduced elevation/anterior rotation of the larynx
- Disordered abdutor and adductor laryngeal reflexes
- Desensitization of the oropharynx and larynx as a result of airflow diversion through the tube
- Altered cough mechanism
- Reduced subglottic air pressure
- Increased incidence of aspiration
What will improve swallowing and reduce/eliminate aspiration?
-Restoring transglottic airflow and subglottic
How can we restore the transglottic and subglottic airflow to improve swallowing function and reduce/eliminate aspiration?
- Occlude the trach tube via:
1) Digital/finger occlusion
2) One way tracheostomy speaking valve (Passy Muir valve)
3) Capping/plugging the tracheostomy
4) Decannulation
What is the Passy-Muir speaking valve?
A one-way valve which attached to the outside opening of a trach tube which allow air to pass INTO the trachea, but not out of it
In a PM speaking valve, where is exhaled air diverted?
Upwards, past the trach tube, volcal cords, mouth and nose
What does the PM speaking valve allow for?
- The restoration of normal physiology
- Allows for vocal cords to move into a closed position
- Allows for improved sensation in the oropharynx
- Restoration of subglottic pressure
(T/F) The PM valve is commonly used for a total laryngectomy patient
F
Cannot be used on a total laryngectomy patient
What is removed after a total laryngectomy?
Both the pharynx and the larynx
- A stoma is created at the trachea
- There is no way to breathe though the mouth
When may aspiration take place?
With a TEP, as there is a fistula between the esophagus and the trachea
What is the impact of total laryngectomy on swallowing?
-Respiration and deglutition are completely separated, therefore there is no risk of aspiration choking
(T/F) Food will not get stuck in the neopharynx after total laryngectomy
F
May get “stuck” due to the impact of reconstruction or edema
–> May feel as though they are choking, but the food is just a bit stuck
When there is a TEP without a prosthesis or catheter, is there a risk of aspiration?
Yes, as there is a fistula created between the trachea and the esophagus
When there is a TEP with a prothesis, the there risk of aspiration?
Not as much, but ensure there is no leaking around/through the prosthesis and into the stoma because it is a direct access to the trachea and the lungs
Ultimately, what is the impact of total laryngectomy on the swallow?
- Interaction of muscular contraction and pressure involves the pharyngeal phase of the swallow will be dramatically altered
- -> The oral longes and tongue base must work more to compensate and the swallow becomes more effortful
- –> Gravity helps in moving the food
Which surgeries immediately post-op do NOT require NPO stats? (PENTTS)
- Parotidectomy
- Thyroidectomy
- Neck dissections (alone) or salivary gland transfers (in preparation for radiotherapy)
- TORS for diagnostic purposes
- Small lip or oral cavity resections
- Ear or minor sinus surgery
- ->However, patients may need modified textures due to pain or edema due to difficult with mastication
When may EN support be initiated immediately pot-op?
- To bypass extensive soft-tissue swelling of upper respiratory tract/temporary tracheostomy
- To protect a surgical anastomosis
- Due to presence of brachytherapy catheters
When a feeding tube is inserted, why is it important that patient does not regurgitate?
To prevent aspiration and to protect the surgical anastomosis
What do energy and protein requirements depend on?
-Extent of surgery, presence of complication, presence of malnutrition prior to OR
Estimated Energy requirements immediately post-op?
- MFSJ
- AF of 1.2-1-3
- SF of at least 1.3
Estimated protein requirements immediately post-op?
At least 1.3 g/kg
Estimated fluid requirements immediately post-op?
1500 ml for first 20 kg + 15 ml for each additional kg
-Account for extra losses due to drooling of saliva, increased secretions, fistula
In the post–operative phase, how should PO feeds be introduced?
-After initial swallow evaluation, which is dependant on surgical procedure and individual recovery
In major operations, when has the swelling decreased enough to start oral feeds?
- Usually 7-10 days
- In brachytherapy, not until after treatments are complete
- If previous XT, may be delayed past 14 days
Which factors should be considered when transitioning to oral nutrition in the post-op phase?
- Adequate wound healing
- Reduction in soft-tissue edema
- Presence of complications (infection, fistula)
- Closure of temporary tracheostomy
What affects the swallow post-op?
- Sites of the surgical resection
- Extent of the resection
- Nature and extent of reconstructive surgery
What should be considered in the extent of the resection?
- Partial or total
- Whether the resection extends into another part of anatomy
- If there is loss of nerve function
What should be considered in the nature and extent of reconstructive surgery?
What types of flap was utilized: Could be a primary closure, local flap, a myocutaneous flap or a free flap or a metal plate used
What is the issue with flaps? (1/2)
- Many flaps are non-sensate, which interfered with normal sensation and hence no motor function, therefore resulting in the loss of propulsive force
- Lack of peristaltic action to move the bolus
What is the issue with the flap? (2/2)
Tissue flaps may be large and bulky, thereby obstructing function and bolus passage
How may the tongue be altered post-op?
-may be tethered to the cheek, instead of the floor of the mouth
When may a gastric pull-up be performed?
When the stomach is required for reconstruction in a total laryngopharyngoesophagectomy
What may brachytherapy result in?
Edema of tongue, difficulties in swallowing
What may previous surgeries or radiation to the H and N region result in?
- May have already compromised swallowing
- Radiation therapy can aggravate
- Xerostomia may occur
Which types of patients may have more difficulties after surgery? What should be considered?
- patients with respiratory problems as they have more difficulty due to competition between respiration, deglutition and periods of apnea
- We should consider whether the patient can clinically tolerate any aspiration or not
What else should be considered about the patient post-operatively?
- the cognitive and emotional state of the patient: if they can learn compensatory techniques, if they are depressed
- If they are in pain
How can we intervene to better asses changes in anatomy and physiology of the swallow, specially in the pharyngeal phase? (1/2)
-In the posterior movement of the food bolus: whether there is premature leakage of food into the pharynx - ability to generate adequate pressure to propel bolus through the pharynx
How can we intervene to better asses changes in anatomy and physiology of the swallow, specially in the pharyngeal phase? (2/2)
- Presence of residue in the valleculae or pyriform sinuse
- Presence of impaired functioning and relaxation of the cricopharygeus muscle
Key nutritional interventions post-op?
1) Patient may need to remain NPO or EN
2) May start with small sips of water, or pureed foods to promote swallow rehabilitation
3) EN may be discontinued and introduction to oral diet with modified textures and consistencies
4) Introduction of SMFQM with high HEHP and oNS
How should food be modified when first introduced?
- Avoid adhesive, grainy, spicy foods and mixed consistencies
- Favour cohesive foods
Why does swallow function improve in time?
- Reduction of edema or brachytherapy
- Reduction in the bulkiness of the flap
- Complete closure of the tracheostomy site
- Less pain
- Improved movement due to exercises
- Better utilization of compensatory techniques
- Less fatigability
- Repair of nerve damage
Monitoring and re-evaluation?
- Adequacy of intake
- Observations at mealtimes; proper positioning, signs and symptoms
- Use of compensatory techniques
- Patient fatigue
- Progression of the diet
What do the severity of the acute side effects of radiation depend on?
- Sites
- Volume of tissue radiated
- Total does of radiation and number of treatments
- If concurrent chemotherapy or immunotherapy is given
- Whether the area was previously radiated
When will the acute side effects of radiation therapy occur?
- Most will start having side effects within 2-4 weeks of starting treatment
- Will continue acutely for 2-4 weeks post-treatment completion
- May take 4-8 weeks to see significant improvements
What are the acute side effects of radiation therapy? (1/2)
- Xerostemia
- Taste alterations(hypogeusia, dysgeusia)
- Changes in smell, appetite
- Nausea and vomiting
- Reflux
- Increased secretions, thick viscous saliva
- Infections: mostly candidiasis and thrush
Acute side effects of radiation therapy? (2/2)?
- Trismus
- Mucositis/ulcerations
- Odynophagia
- Dysphagia
- Fatigue
When is the mandible in the field of radiation? What will occur?
When it is the oral cavity or the oropharynx
–> Will be taken for dental evaluation.
When are dental treatments or extractions to take place?
Prior to starting treatments, but not applicable if the patient is edentulous or is lacking teeth
Nutrition support if extensive mucositis and odynophagia are expected?
Prophylactic PEG is recommended, and will be inserted prior to starting treatments if patient accepts
What are the possible long-term impacts of XRT?
-Xerostemia –> may result in salivary gland transfer
-Permanent taste alteration
-Dental cavities and poor oral health
-Osteoradionecrosis and soft-tissue necrosis
-Lymphedema
-Thyroid problems and hypothyroidism
-Radiation
myelopathy
-Vision changes and blindness
-Fibrosis, Dysphagia
What are the effects of fibrosis? (long-term side effect of fibrosis)
- Reduced range of motion of neck
- Trismus
- Reduced epiglottic deflection
- Reduced peristaltic movement of pharyngeal muscles
- Reduced pressure to stimulate the opening of the the UES
- Stenosis
What are the goals of nutritional management?
- Promote weight gain, stabilize weight
- Maintain or optimize nutritional status/hydration status
- Symptom management
- Promote oral nutrition to favour swallow preservation
- modify textures and consistencies to facilitate intake and swallow to prevent aspiration
If PEG, what aee the nutritional goals?
-Introduce EN as needed to meet energy and protein and fluid requirements
Nutritional interventions at the start of tx?
- Conduct swallow assessment
- Avoid alcohol, caffeine, spicy and irritating foods, temperature extremes
- Increase fluid intake, especially water
- Consider food safety to avoid infections
- Oral care guidelines
Nutritional intervention during Tx?
- Monitor on weekly basis
- Counsel on specific symptoms experienced
- Initiate ONS
- May require supplemental EN
During Tx, what should we suspect as odynophagia increases and secretions become more copious?
- Dysphagia will increase and so does the risk of aspiration
- Patient may no longer be able to consume oral nutrition, requiring full EN, if no pEG, NGT will be needed
- BUT challenge to develop feeding schedule based on requirements, tolerance and treatment/appointment schedules
If during tx, and the patient is not aspirating, how should we proceed?
-Continue with PO intake of well tolerated fluid/food items for swallow preservations; small amounts throughout the day
What percent weight loss will impact healing post-treatment and increase morbidity?
10%
Nutritional intervention post Tx?
- If patient NPO, start with pureed foods and liquids.
- Pay d/c PEG but will require ONS to meet requirements
What does the decision to remove a PEG depend on?
-Ability to meet nutritional requirements with oral intake, medical status
