Head & Neck Cancer quiz 1 – Flashcards

hoarseness lesion in the supraglottis

-kills the tissue -maximum gray is about 70, more than this will cause necrosis

-Medicine given to the patient orally or with an IV -the meds stop the cells from replicating but also hurt healthy cells (hair, digestive) since chemo goes to the stomach whereas radiation goes directly to the tumor -targets fast growing cancer cells and damages healthy cells, interferes with cell replication, functioning, DNA replication, mitosis, and instigates apoptosis (cell suicide)

-Subset of circulatory system -A network of tissues and organs that primarily consists of lymph vessels, lymph nodes and lymph. The tonsils, adenoids, spleen and thymus are all part of the lymphatic system -There are 600-700 lymph nodes in the human body that filter lymph before it returns to the circulatory system

Layers: Squamous epethelium, basement membrane zone, superficial, intermediate, and deep lamina propria, TA (vocalis) muscle -Supraglottis- hyoid bone, quadrangular membrane, thyroid cartilage -Glottis- TA muscle Subglottis- conus elasticus, criocoid cartilage

-malignant neoplasm -broad group of diseases involving unregulated cell growth -Uncontrollable cell division and growth -over 200 different known cancers that affect humans

-Laryngeal -Hypopharyngeal -Nasal and Paranasal Sinus -Nasopharyngeal -Oral and Oropharyngeal -Salivary gland cancer -Sarcoma -Thryoid and Parathyroid cancer

-DNA (5-10% traced to genetic defects) -Tobacco -Diet -Infections -Exposure to toxins (chemicals, radiation) -Lifestyle

-Approx 50,000 people diagnosed with H&N cancer in the US every year (5% of cancers in men, 2% of cancers in women) -Most common type is Squamous Cell Cancer (SCCA)- 90% -squamous cells are flat, scale-like cells typically found in lining of nose and mouth -HPV is a virus that affects the squamous cells

-Oral- ulcer/sore that does not heal, pain, dysphagia -Supraglottic- dysphagia, odynophagia (painful swallowing), neck mass -Glottic- hoarseness

-Patient report -Physical exam -Endoscopy -Biopsies -Imaging tests (CT scan, MRI, Chest x-ray) -Staging -Tumor Board Presentation

Tumor- the size of the primary tumor and which, if any of the tissues in the oral cavity or oropharynx the cancer has spread (the bigger this #, the worse the cancer) Node- the number of lymph nodes affected Metastasis- indicates whether the cancer has spread to other areas of the body (most commonly lungs, liver, bones) 0= absent, 1= present

refers to carcinoma in situ which describes early cancer which has not yet invaded surrounding cells

-Tumor factors- site, size, depth of invasion, degree of spread, location and proximity to critical structures, previous TX, reconstruction requirements -Patient factors- comorbidities, preference -Faculty/Physician factors- resources and expertise

-Radiation Therapy -Chemotherapy -Chemoradiation therapy -Surgery -Rehabilitation therapy (Most patients require more than one)

-gamma beams, beta beams, photon beams, and electron beams -Impacts molecular, cellular and visceral level which applies to both normal and malignant tissue -There is a max amount of radiation that tissue can tolerate before necrosis sets in (tissue death) -External Beam Therapy -Internal radiation therapy (brachytherapy) is delivered from radiation sources placed inside or on the body

-measures in a unit called gray -Gray is the measure of the amount of radiation energy absorbed by 1 kilogram of human tissue -Different doses of radiation are needed to kill different types of cancer cells, Different types of XRT are prescribed depending on factors like: -the type of cancer -the size of the cancer -the cancer's location in the body -How close the cancer is to normal tissues that are sensitive to radiation -How far in to the body the radiation needs to travel -The patient's general health and medical history -Whether the pt will have other types of cancer tx -Other factors such as the patient's age and other medical conditions

-Mucositis: irritation of mucosa (like having canker sores all over your mouth) -Xerostomia: dry mouth (the glands that produce saliva have been damaged) -Dysphagia: swallowing difficulty -Fibrosis: excessive connective tissue/ collagen -Trismus: reduced mouth opening -Osteoradionecrosis: death of bone -Dental deterioration: cavities, biofilm, nerve death

-Apoptosis: natural, programmed cell death -Necrosis: premature cell and tissue death, caused by an external force

-Antitumor antibiotics, antimicrobial agents, alkylating agents, antimetabolic agents Administration can be: -Preop/PreXRT (neoadjuvant)- prior to main tx -Postop/Post XRT (adjuvant) -Concomitant Chemoradiation therapy (same time as XRT)

Parts of body with fast dividing cells are more likely to be damaged: hair follicles, digestive system, blood cells -nausea, vomiting, constipation, diarrhea, hair loss, stomasitis, pharyngitis, fatigue, decreased white blood cell count (makes you more susceptible to infection) -reduced salivary flow -mucositis -candidiasis (thrush) -edema -lymphedema -pain -sensory loss -Fibrosis- excessive tissue causing reduced tongue range and jaw range/opening, reduced tongue base movement, pharyngeal contraction, laryngeal elevation, reduced airway closure -Reduced appetite -Changes in voice -Stricture- esophageal narrowing or blockage

-Glossectomy: removal of tongue -Laryngectomy: removal of larynx -Pharyngectomy: removal/reconstruction of pharynx -Thyroidectomy: removal of thyroid -Lumpectomy: removal of lump/lymph node in neck -Neck dissection: removal of lymph nodes -Mandibularectomy: removal/reconstruction of mandible

-5-year survival rate for SCCA in H&N cancer without HPV: 55% with HPV: 85% -survival is dependent on where and when the cancer is found, epidemiology, treatment protocols, and luck

-chewing -swallowing (dysphagia) -articulation -breathing -voicing (dysphonia) -pain -difficulty opening mouth (trismus)

-Difficulty getting past cancer diagnosis -Anxiety -Depression -Social withdrawal -Difficulty accepting anatomical and functional changes -Difficulty dealing with toxicities -Frustration when expectations don't match up with reality

-Medical condition of the patient -Clinical protocol -Ability/ motivation of patient to follow through -Time, insurance -Ethical issues -Support systems -Staff competence

-Pain management -Counseling -Speech and Swallowing intervention -Physical therapy -Nutritional therapy -Troubleshooting Complications -Interdisciplinary Approach is Key

-for patients who are not "curable" -trying to relieve pain and prevent suffering -can involve chemo and/or XRT -medications to treat side effects

Trigeminal - mastication

Facial -Facial movement, taste to anterior 2/3 of tongue, salivation -paresis/paralysis, loss of taste, dry mouth

Glossopharyngeal -taste (post 1/3rd of the tongue), salivation, innervation of the pharynx, contributes to pharyngeal plexus -diminished taste, dry mouth, delay

Movement of velum, pharynx, and larynx sensation in pharynx, larynx, and esophagus Taste in epiglottis Contributes to pharyngeal plexus -Dysphagia and vocal changes, sensory changes, reduced airway closure- aspiration

Spinal Accessory Movement of head and shoulders Innervation of the pharynx -Head turning, shoulder shruggin

Hypoglossal Movement of intrinsic and extrinsic muscles of tongue -Atrophy, deviation on protrusion, fasciculations

oral cavity- bolus control, drinking from a straw, nasal cavity lesion- nasal regurgitation pharynx- reduced ability to contract, may cause pharyngeal residue larynx- loss of ability to close the larynx- aspiration

tumor location- oral cavity, nasal cavity, pharynx, larynx, multiple locations trach- changes a closed system to an open system (changes the pressure)- this can effect tx immediate effects of tx- thicker saliva (salivary glands can be affected), muscle atrophy from disuse from having a g-tube (the patients recieving chemo may have a g-tube due to nausea/ feel poorly, have mouth sores, the tumor may be painful, reduced appetite, etc.) -changes to nerves -chronic or long-term effects of tx

-more structures taken or resected -primary vs. flap closure -more complex surgery -post-op cancer tx

-simple resection- when one structure is resected -composite resection- when more than one structure or parts of more than one structure are included in the resection *Most important thing with cancer surgery is removing all cancer, regardless of effect on functioning- rehab and reconstruction are secondary

-What was removed and how -nodal involvement/ neck dissection -structures and nerves involved -how was the defect constructed

-there's no point to keep an organ if it's not going to function -If someone has a transplant, they have to be on an immunosuppressant drug for the rest of their life- not good for a cancer patient who already has a poor immune system

Oral/Oropharyngeal -lips -tongue- partial (less than half), hemiglossectomy (half), total glossectomy (all oral tongue) -Anterior oral cavity -Posterior oral cavity/ pharyngeal cavity resections Hypopharynx/ Larynx

-aka dry mouth -very common, affects about 80% of patients with H&N cancer -may be from medication, changes salivary glands -there are medications to stimulate saliva but they have bad side effects and many patients say they don't work well -biotene is a mouth-cleansing product that most patients like -taking frequent sips of water helps

-reduced vascularization (damage to small blood vessels in radiated area) -causes stiffening or hardening of muscles -process can continue for many years after RT has been completed (5-7 years later- prevention is key) -"woody-neck" syndrome

-If radiation field will include oral cavity, a predental assessment is necessary before treatment begins -RT can reduce salivary flow resulting in an increase in caries (cavities) -poor oral hygiene with dental disease can quickly worsen due to reduced salivary flow -any infected teeth should be removed prior to RT -extractions after a full course of RT places patient at risk of osteoradionecrosis of the mandible

-Counsleing about potential changes in swallowing before and after tx- important to repeat, they are hearing a LOT of info -Swallowing eval- diet recommendations, important to keep patient on an oral diet, if they become dependent on a g-tube they will lose their ability to swallow -Use clinical judgement to decide if the patient can follow your safety guidelines for swallowing -preventative tx- actively working muscles before atrophy can begin

Carroll et al (2008)- pilot study, 18 patients (9 got pre-tx exercise and 9 got post-tx) (exercises included -They found that it improved BOT to PPW approximation and preserved epiglottic inversion -only re-evaluated at 3 months post CRT -All patients had prophylactic g-tube- this is being done away with- we want to reduce the number of patients that have g-tube and keep them swallowing Kotz et al (2012)- 26 patients, 13 pre-tx, 13 post-tx, only 9 of 13 in tx group were able to adhere to exercises citing CRT-assoicated oral pain, throat discomfort, and overall fatigue Carnaby-Mann- 58 patients, 3 groups: pharyngocise, sham tx, usual care, 68% compliance rate in phayrngocise group- better but still not great, shows that this is not effective if the patients can't perform the exercise -less structural deterioration of genioglossus, hyoglossus, and mylohyoid on MRI in the pharyngocise group and better ability to maintain oral feeding, functional swallowing ability, mouth opening, salivation, taste and smell Shinn et al (2013)- 109 patients, looked at the patients who adhered to the exercises vs. those that did not adhere to them- they found that out of 98 patients- only 13% were fully adherent (most common reasons: general lack of understanding about importance of swallowing exercises, CRT side effects (pain, fatigue, nausea) interfering, forgetting Duarte et al (2013) 85 patients- psuedogargle and masako, effortful swallow- for BOT retraction- significant differences in maintaining or improving diet and incidence of esophageal stenosis Effortful, Masako and Mendelsohn were found to be the most helpful

-Jaw ROM -Tongue ROM, strength and control -BOT retraction -Hyolaryngeal elevation -Airway closure

-Postures -Manuevers -Altered volumes, textures -Modify consistency First try different postures and maneuvers, then volume or consistency

-Chin tuck -Head rotation (L/R) -Head tilt (L/R) -Head back -L/R lean -Side lying

-Effortful swallow -Mendelsohn maneuver -Hard breath hold (bearing down but not the cough like it SGS) -Supraglottic swallow maneuver -Super supraglottic swallow maneuver (holding breath AND bearing down) Others -Modified volumes -Bolus placement (if part of their tongue is gone, you can place the bolus on their strong side) -Liquid wash -Liquid assist- adding liquid to the bolus then swallowing it all together -Double or multiple swallows -Increased sensory input (sour, sweet, carbonation) -Sequential swallows (it may be better for the patient to take a few large drinks than tiny sips where they aspirate on every sip) -Cough

-Liquids- thin, nectar-thick, honey-thick, spoon or pudding-think -Solids- regular, advanced/soft, mechanically altered/ mechanical soft, puree -Pills- whole, split, crushed, liquid

-Lip strength -Lip range (more for aesthetics) -Oral tongue control -Oral tongue strength -Jaw ROM

-BOT retraction/ pharyngeal contraction -Hyolaryngeal elevation -Airway closure -UES opening

anteriorly: base of tongue posteriorly: pharyngeal wall laterally: tonsillar fossae cranially: soft palate the majority of patients with HPV and cancer have oropharynx cancer (the lymph nodes change in the oropharynx as opposed to the oral cavity)

-the upper part of the throat (pharynx) that lies behind the nose -box-like chamber with 1.5 inches on each edge Factors involved in nasopharyngeal cancer: -Epstein Barr Virus (HHV-4) Herpes family: infectious mononucleosis, Hodgkin's lymphoma, nasopharyngeal carcinoma -diet -tobacco -genetics (more common in southern china)

-squamous cell carcinoma (SCCa HPV+ and SSCa HPV-) -Undifferentiated carcinoma -Sarcoma -Salivary gland cancer -Malignant melanoma -Lymphoma -Metastases

-Nasopharyngeal carcinoma (NPC) Nasopharyngeal cancers tend to get noticed later, after the cancer has gone into the lymph system and has caused a mass in the neck 3 types: Keratinizing= it looks a lot like the normal cells in that order non-keritanizing- not as clear Undifferentiated carcinoma- no resemblance to normal cells

a cancer that starts in epithelial cells- the lining of the internal and external surfaces of the body

-Human Papilloma Virus -Infects epithelial cells of skin and mucosa -Transfer of virus happens when contact btw epithelial cells occurs -Leading cause of oropharyngeal Cancer -Over 200 strains -9 strains are high risk -HPV16 -up to 80% of Americans will have HPV infections in their lifetime and 99% will clear these infections without consequence

-1 yr survival: 83% -5 yr survival: 62% -10 year survival: 51% -survival dependent on size, location, and if they have HPV (HPV patients respond better to tx) -HPV+ SCCa: 85-90% 5 year survival rate -Nasopharyngeal cancer- 5 year survival rate is 53%

-Surgery- best option for if the cancer hasn't spread -Photodynamic therapy -Composite resection with primary reconstruction (something is removed and replaced with an implant in the same surgery) -Brachytherapy and External Beam XRT (comes from the outside) -Chemo radiation

-Surgery- secondary to chemoXRT -Radiation therapy- proton Tx is the most advanced XRT available- it destroys the cancer cells but not the healthy tissue surrounding -Chemotherapy- most commonly used with XRT for treatment -Targeted therapy- man-made version of an immune system protein that targets the epidermal growth factor receptor (EGFR) -Immunotherapy- cytotoxic T-cell based immunotherapy

-Medical history -Extent of surgery -5-7 days post-surgery for clinical swallow and communication eval -14 days if flap reconstruction was involved

-can be helpful for both speech and swallowing -3 general types: palatal lift, palatal obturator, palatal augmentation prosthesis -customized by the maxillofacial prosthodontist -introduced 4-6 weeks after completion of tx -speech and swallow exercises should be completed with the prosthesis in place