Head and neck cancer Flashcards
What are most type of cancer cells?
squamous cells
What are the risk factors for H&N cancer?
- tobacco
- alcohol
- HPV 16
- weed
- betel nut chewing (south asia)
- poor oral hygiene/ ill fitting dentures
- epstein-barr virus infection
- environmental or occupational inhalants
- prolonged sunlight exposure
- pre-cancerous lesions
- radiation exposure
- ancestry/ethnicity
- diet (intake of preserved/salted foods during childhood)
- mate (a tea like beverage in SA)
- GERD
- weak immune system
What is the TNM system? (what does it stand for)
It’s a staging cancer to determine where it is and the severity:
T: size and extent of the tumour
N: whether cancer cells have spread to nearby lymph nodes and to what extent
M: whether distant metastasis has occured
What are the 4 possible treatments of H&N cancer?
- surgery
- radiation therapy
- chemotherapy/immunotherapy
- research protocols
What are the 2 tests for swallowing function?
- MBS/VFSS
2. FEES
What are the 2 things that dysphagia can be associated with?
penetration and aspiration (could be silent aspiration)
What does H&N cancer cause dysphagia?
- disruption of normal anatomy
- nerve involvement (infiltration of the cranial nerves resulting in reduced sensation and motor function
- tumour induced pain
What are the symptoms of dysphagia in H&N cancer patients?
- odynophagia/otalgia
- sensation of food/something caught in throat
- trismus
- coughing/choking/gagging when eating
- drooling/hypersalivation
- inability to wear dentures
- difficulty chewing/moving food in mouth
- inability to control food, liquids or saliva
- presence of food residue in oral cavity
- nasal regurgitation of liquids/food
- need to take time to eat/slow pace
- need to cut food up into small particle sizes
- need to drink more with meals to clear food residue
What are the interventions prior to treatment? (give 6 recommendations)
- may need to be NPO
- may need EN
- may be able to continue oral diet
- may need modifications to facilitate intake/reduce risk of aspiration
Recommendations:
- high protein, high energy diet with ONS
- small frequent meals
- modify food textures/liquid consistencies
- avoid problematic foods (dry, fibrous, etc)
- increase moisture content of foods
- introduce compensatory techniques
What are some examples of compensatory techniques?
- short straw and long spoons
- take time to eat/cut foods in small pieces
- place food in mouth in a way to bypass the tumour
- chin tuck, down posture, turn head to affected side
- effortful swallow, supraglottic swallow
What is decannulation?
the removal of tracheostomy and closure of opening
What is a TEP and TEP prothesis?
TEP: a fistula between the trachea and esophagus for voice restauration
TEP prothesis: a valve into TEP to keep food out of the trachea but still allows for speech as air can pass by
What is the stoma vent?
a tube to keep the stoma open
What are the 2 indications for tracheostomy?
- to bypass an upper airway obstruction due to:
- tumour obstructing air passage into lungs
- soft tissue edema due to radiation
- bilateral vocal cord paralysis in the closed - Prophylactic insertion at time of OR because expect extensive edema of upper respiratory tract and to ensure adequate pulmonary secretions
What are the impacts of tracheostomy on swallowing?
- increased saliva production
- decreased mobility of tongue
- reduced elevation of larynx
- disordered abductor and adductor laryngeal reflexes
- desensitization of the oropharynx and larynx as a result of airflow diversion through the tracheostomy tube
- altered cough mechanism
- reduced subglottic air pressure
- increased incidence of aspiration
- restoring transglottic airflow and subglottic air pressure will improve swallowing function and reduce/eliminate aspiration
- possible methods of occluding tube
What is the passy-muir speaking valve?
it is a one-way valve which attaches to the outside opening of a tracheostomy tube and allows air to pass into the trachea but not out through it
- exhaled air is directed upwards
- allows for restoration of normal physiology
- *DO NOT USE ON A TOTAL LARYNGECTOMY PATIENT
What are the impacts of a total laryngectomy on swallowing?
- respiration and deglutition are completely separated -> no risk of aspiration/choking, but food may still get stuck in the newly reconstructed pharynx (neopharynx)
- aspiration may occur in TEP without prosthesis because there is just a fistula
- interactions of muscular contraction and pressure generation involved are dramatically altered
- oral tongue must work more to compensate
Which surgeries don’t need extended NPO?
parotidectomy thyroidectomy neck dissections - salivary gland transfers TORS for diagnostic purposes small lip or oral cavity resections ear or minor sinus surgery
In what cases is EN initiated post-op?
- to bypass extensive soft tissue swelling of upper respiratory tract/temporary tracheostomy
- to protect surgical anastomosis
- due to presence of brachytherapy catheters
What are the post-op nutrient recommendations?
E: MSJ x AF: 1.2-1.3 x SF: 1.3
Pro: 1.3g/kg
Fluids: 1500ml for first 20kg + 15ml for each additional kg
What are the 9 factors affecting swallowing post-op?
- sites of the surgical resection
- extent of resection
- nature and extent of reconstructive surgery
- presence of tracheostomy
- post-op brachytherapy: results in edema of tongue
- post-op surgeries or radiation therapy to H&N region
- overall health prior and post-op
- cognitive and emotional state of patient
- pain
What are the 3 benefits of MBS post-op?
- to better assess changes in anatomy and physiology of swallow, especially the pharyngeal phase
- evidence of penetration/aspiration
- to assess benefits of compensatory strategies
What are the acute side effects of radiation therapy?
- xerostomia
- total alterations
- changes in smell
- changes in appetite
- nausea/vomiting
- reflux
- increased secretions/thick viscous saliva
- infections
- trismus
- mucositis/ulcerations
- odynophagia
- dysphagia
Long term effects of XRT?
- xerostomia
- tasta alterations
- dental cavities/poor oral health
- osteoradionecrosis and soft tissue necrosis
- lymphedema
- thyroid problems
- radiation myelopathy
- vision changes/blindness
- fibrosis
- dysphagia
What are the goals for the patient post-op? (related to nutritional intervention)
- promote weight gain or maintain weight
- optimize nutrition and hydration status
- symptom management
- promote oral nutrition to favour swallow preservation
- modify textures and consistencies to facilitate intake and swallow and to prevent aspiration
What are the nutritional interventions at the start of treatment?
- conduct nutritional assessment and swallow evaluation
- avoid alcohol and caffeine, spicy and irritating foods
- increase fluid intake
- discuss oral care guidelines and pain control
What are the nutritional interventions during treatment?
- need to monitor patients on a weekly basis
- provide counselling based on the specific symptoms experienced
- initiate oral nutrition support
- may need EN to support ONS
- patient may no longer be able to consume oral nutrition requiring full EN. If no PEG, NGT will be needed
What are the nutritional interventions post-treatment?
- follow ups to assess adequacy of intake/monitor weight and provide counselling for transition back to oral diet or progression of diet
- patients will continue to have sensitivity to acidic and spicy foods as well as alcohol for a period of time
- if patient was NPO, usually start with pureed foods and liquids
- patient may be able to discontinue PEG but will require ONS
- decision to remove PEG depends on ability to meet nutritional requirements with oral intake and medical status
