ENT Palliative Care

Question 1

What are the benefits of palliative care?

Answer 1

Offers support system to help patients live as actively as possible until death, enhances quality of life, may positively influence the course of illness

Question 2

What ENT patients are referred for palliative care?

Answer 2

Patients with head and neck cancers, patients with cancers elsewhere causing significant cervical lymphadenopathy, patients with ENT problems who have significant other health problems that may need palliation

Question 3

What are the red flags for head and neck cancer?

Answer 3

Greater than 3 weeks of sore throat, hoarseness, stridor, difficulty swallowing, lump in neck or unilateral ear pain

Question 4

What are the majority of head and neck cancers?

Answer 4

Squamous

Question 5

What are some risk factors for head and neck cancer?

Answer 5

Increased incidence with age, alcohol, tobacco, deprivation

Question 6

What virus is head and neck cancer associated with?

Answer 6

HPV = younger patients, small, tumour but big nodes, HPV sexual transmission, better prognosis

Question 7

When may a patient receive palliative care?

Answer 7

At time of diagnosis, during treatment (including curative), following treatment (disease-free/recurrent), metastatic disease/poor prognosis at diagnosis, when dying

Question 8

What are some functions of the head and neck?

Answer 8

Speech, taste, smell, swallowing and nutrition, airways and breathing, communication, appearance, quality of life

Question 9

What are some treatments for head and neck cancer?

Answer 9

Surgery, chemotherapy, radiotherapy, nutritional support, symptom management

Question 10

How is palliative care delivered?

Answer 10

Support patient and family, symptom management, work with ENT and oncology

Question 11

What is a symptom?

Answer 11

Any sensation or change in bodily function experienced by a patient in association with a disease = management must be tailored to each patient

Question 12

How effective is the WHO analgesic ladder?

Answer 12

Manages 70-80% of cancer patients

Question 13

What are the steps on the WHO analgesic ladder?

Answer 13

Step 1 = non-opioid +/- adjuvant
Step 2 = opioid for mild/moderate pain +/- non-opioid +/- adjuvant
Step 3 = opioid for moderate/severe pain +/- non-opioid +/- adjuvant

Question 14

What are adjuvant analgesics?

Answer 14

Painkillers whose primary indication is for something other than pain (i.e anticonvulsants, antidepressants)

Question 15

What are the routes for administering analgesia?

Answer 15

Oral, via feeding tube, subcutaneous, IV, transdermal, topical

Question 16

How may patients die of head and neck cancer?

Answer 16

Infection (pneumonia), issues related to hydration/nutrition, frailty and medical comorbidities, emergency situations (e.g bleed)

Question 17

What causes stridor?

Answer 17

Large airway obstruction (trachea/main bronchus) = sound on inspiration, signifies airway compromise

Question 18

What is the management of stridor?

Answer 18

Oxygen, steroids, heliox, decide on level of intervention (actively treat/palliate)

Question 19

What are some interventions that may be involved in treating stridor?

Answer 19

Tracheostomy by ENT, stenting by respiratory doctors, radiotherapy by oncology

Question 20

How would palliative care manage a patient with stridor?

Answer 20

Active sedation, work with nurse, explain situation to relatives

Question 21

What may cause a major haemorrhage in a patient with head and neck cancer?

Answer 21

Erosion of major artery, carotid “blow out”

Question 22

When would palliation of a patient with a major haemorrhage be considered?

Answer 22

If effective treatment of preventative measures have been ruled out, if resuscitation wouldn’t work

Question 23

How does palliative care manage a patient with a massive haemorrhage?

Answer 23

Large doses of midazolam IM or IV, joint management with nurse present, someone stay with patient at all times (don’t leave them alone to get drugs)

Question 24

How should sedation be used in palliative care?

Answer 24

Judiciously and proportionately = normally time to discuss and titrate dose

Question 25

When may large doses of sedation be used?

Answer 25

In an emergency with the aim of rapid sedation