question

Head and neck cancers are usually

answer

squamous cell carcinomas and are *slow growing*

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Untreated cancer of the head and neck is

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fatal and will lead to death within 2 years of diagnosis

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The cancer begins when the __________ is chronically irritated and becomes _____ and _____.

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Mucosa Tougher and Thicker (squamous cell metaplasia)

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Genes controlling cell growth are damaged, allowing excessive growth of abnormal cells, which eventually become

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malignant

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Leukoplakia

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White patchy lesions

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Erythroplakia

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Red velvety patches

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Head and neck cancer first spreads to the

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Nearby structures -lymph nodes -muscle -bone

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Later spread of head and neck cancer is

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systemic, to distant sites -usually the lungs or liver

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Carcinoma in situ is an

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earlier stage of the cancer - well differentiated - prognosis is good

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Most head and neck cancers arise from the _____ _____ and _____.

answer

Mucus membrane Skin *they can also start from salivary glands, the thyroid, or other structures*

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What are the two most important risk factors for head and neck cancer?

answer

Alcohol and Tobacco use *especially in combination*

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Additional risk factors for head and neck cancers.....

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Voice abuse Chronic laryngitis Exposure to chemicals and dust Poor oral hygiene Additional risk factors *long term GERD and HPV*

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Head and Neck Cancer Assessment findings

answer

Patient may have difficulty speaking because of *hoarseness, shortness of breath, tumor bulk and pain* - Pace the interview to avoid tiring the patient

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Head and Neck Cancer History - What to ask?

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tobacco and alcohol use? hx of acute or chronic laryngitis or pharyngitis? oral sores and lumps in the neck? chronic lung disease? *Use matter of fact approach during the interview to make the patient more comfortable*

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What is the earliest form of laryngeal cancer?

answer

Vocal chord lesions

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People with laryngeal cancer may have ________ hoarseness.

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Painless because of tumor size and inability for vocal cords to come together for normal speech

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A person with a hx of hoarseness, mouth sores, or a lump in the neck for 3-4 weeks should be evaluated for

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Laryngeal cancer

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Diagnostics - Labs

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CBC Bleeding times (could be impaired from liver damage -alcohol abuse) Urinalysis - Kidney function BMP - kidney function, electrolytes, nutrition CMP - Liver function Protein/Albumin - Nutrition status

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Diagnostics - imaging

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X-Ray - cancer spread, tumor invasion, other tumors CT - Evaluate tumors exact location MRI - differentiates normal from diseased tissue Bone Scans/SPECT/PET - help locate additional tumor sites

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Other DX assessments - *Panendoscopy*

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Laryngoscopy, Nasopharyngoscopy, Esophagoscopy, and Bronchoscopy all performed at one time under *general anesthesia* - to define the extent of the tumor

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Tumor Mapping Biopsies

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To identify tumor location Biopsy tissues are taken at the time of panendoscopy to confirm the dx and determine the tumor type, cell features and location

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Tumor Staging is done by the

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TNM method Tumor, Node, Metastasis

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Without treatment, head and neck cancers grow to the point of

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airway obstruction

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Airway obstruction can occur as a result of

answer

treatment

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Preventing Respiratory Obstruction What position should the patient use for best air exchange?

answer

Fowlers or Semi-Fowlers

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Radiation for treatmet of *small cancers in specific locations* has a cure rate of at least

answer

80%

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Standard radiation treatment is usually (course of treatment)

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1-2x/day for 6 weeks

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Radiation therapy would be performed (before/after) surgery....

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After Radiation therapy slows tissue healing, so it would be performed after surgery

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Most patients have what symptoms for several weeks after radiation therapy?

answer

Hoarseness Dysphagia Skin problems Dry Mouth

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Hoarseness following radiation - teaching

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-Reassure that the voice will improve within 4-6 weeks -Teach voice rest and alternative means of communicating until the effects of radiation have passed

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Sore Throat and Difficulty Swallowing after radiation - TEACHING

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Gargling with saline or sucking ice to decrease discomfort Mouthwashes and throat sprays containing a local anesthetic (lidocaine or diphenhydramine) Analgesic drugs *mouthwash should NOT contain alcohol*

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The skin at the site of irradiation becomes red and tender and may peel during therapy - *Teach* the patient

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-Avoid exposing this area to sun, heat, cold, and abrasive treatments (shaving) -Wear protective clothing made of soft cotton -Wash the area with *mild* soap (Dove) -Follow oncology's department policy regarding the use of skin care products

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*Xerostomia* - Radiation can cause dry mouth if the salivary glands are in the irradiation path - This can cause the following problems

answer

Increased risk for dental caries Increased risk for oral infections Halitosis Taste changes

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Xerostomia - *Teach*

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Flouride gel trays and treatments at night - reduce tooth deterioration Heavy fluid intake - particularly water Humidifying the air Artificial Saliva (Salivart) Moisturizing gels or sprays *Saliva Stimulants* - Salagen and cevimeline

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Chemoradiaton

answer

Chemotherapy and radiation are sometimes used at the same time *oral cavity effects of radiation are intensified with concurrent radiation*

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Most chemotherapy regimens for Head and Neck cancer include what drug?

answer

Cisplatin

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Because if the intensified oral cavity side effects that occur from chemoradiation, some patients request

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Breaks in the treatment regimen

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Chemoradiation - breaks in the treatment regimen should be

answer

Avoided - a process called *No SToPS* Breaks *do* affect the outcome of the treatment

question

What intervention is implemented before chemoradiation to improve adherence to the treatment?

answer

Intense patient education before, and support during treatment

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Biotherapy *Epidermal Growth Factor Receptor Blockers* (EGFR)

answer

*Cetuximab* For patients whose cancers overexpress the receptor *This drug blocks epidermal growth factor receptors in normal tissues as well as in the tumor - Severe Skin Reactions are common*

question

Surgical Procedures for Head and Neck Cancers

answer

Laryngectomy (total and partial) Tracheotomy Oropharyngeal Cancer Resections

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Surgical Procedures for Laryngeal Cancer

answer

Cord Stripping Removal of a vocal cord *cordectomy* Partial laryngectomy Total laryngectomy *Nodal Neck dissection* if cancer is in the lymph nodes

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Preoperative Care - *TEACHING*

answer

Teach about the tumor Explain self management of the airway ---> Suctioning, pain control methods, critical care environment (ventilators and critical care routines) Teach nutritional support - may include feeding tubes Help patient *learn new methods of communicating* - and to practice the use of the selected form of communication before surgery

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What two surgical procedures will provide partial preservation of the patients voice?

answer

Hemilaryngectomy (vertical or horizontal) Supraglottic laryngectomy

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Voice conservation procedures are used *only if*

answer

they do not risk incomplete removal of the tumor

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Total Laryngectomy

answer

The upper airway is separated from the throat and the esophagus, the trachea is brought out through the skin in the neck and sutured in place creating a stoma.

question

Neck Dissection includes removal of what?

answer

Lymph nodes Sternocleidomastoid muscle Jugular Vein 11th Cranial nerve (Spinal Accessory Nerve)

question

What can occur as a result of neck dissection - particularly the removal of cranial nerve 11?

answer

Shoulder drop *Physical therapy can help the patient ease the shoulder drop by using other muscle groups*

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What surgical procedures will for Laryngeal cancer will leave the patients voice *Normal/hoarse*?

answer

Laser Surgery Transoral cordectomy Supraglottic partial laryngectomy

question

What surgical procedures will for Laryngeal cancer will leave the patients voice *Normal*?

answer

Laryngofissure

question

What surgical procedures will for Laryngeal cancer will leave the patients voice *Hoarse*?

answer

Hemilaryngectomy Vertical Laryngectomy

question

What surgical procedures will for Laryngeal cancer will leave the patients with *no natural voice*?

answer

Total laryngectomy

question

What are the *first priorities* after head and neck surgery?

answer

Airway maintenance and ventilation

question

Complications after surgery include:

answer

Airway obstruction Hemorrhage Wound breakdown Tumor recurrence

question

Immediately after surgery, most patients need

answer

Ventilatory assistance

question

During weaning from a ventilator after surgery the patient usually uses a

answer

tracheostomy collar (over the artificial airway or open stoma)

question

Oxygen and humidity are used with ventilation after surgery to

answer

-help move mucus secretions -humidity helps remove crusts and prevents obstruction of tube with secretions

question

Secretions after head and neck surgery may remain blood tinged for

answer

1 to 2 days *report any increase in bleeding to the surgeon*

question

A Laryngectomy tube is similar to a _________ tube but is ______ and _______ with a larger lumen. It is used for patients who have undergone a _______ ____________.

answer

Tracheostomy shorter and wider Total Laryngectomy

question

The purpose of a laryngectomy tube is

answer

to prevent scar tissue shrinkage of the skin-tracheal border

question

The laryngectomy tube can be changed how often?

answer

Daily or as needed

question

Laryngectomy button

answer

similar to tube --- softer, has a single lumen and is very short comfortable for the patient easily removed for cleaning available in various sizes and lengths for a custom fit

question

Airway maintenance - *teaching*

answer

instruct the patient how to cough and deep breath to clear secretions Oral secretions can be suctioned by the *alert* patient using a yankauer or tonsillar suction or soft red latex catheter *teach the patient to suction AWAY from the side of the surgery to prevent wound opening* - may provide a mirror

question

Tissue "flaps" may be used after surgery to

answer

close the wound and improve appearance They are skin, subcutaneous tissue and sometimes muscle taken from other body areas that may be used for reconstruction after head and neck resection.

question

Wound, Flap, Reconstructive Tissue Care

answer

*The first 24 hours after surgery are critical* Evaluate all grafts and flaps *hourly for the first 72 hours* Monitor capillary refill, color, drainage and Doppler activity of the major feeding vessel Position the patient so that the side of the head and neck with the flaps is *not dependent* *Report changes to the surgeon immediately!*

question

Hemorrhage is a possible complication after any surgery but it is

answer

uncommon after laryngectomy

question

Postop - neck drain

answer

to collect blood and drainage for about 72 hrs after surgery drain also helps maintain position of skin flaps obstruction or equipment malfunction may cause buildup of blood or serum under the flaps = impaired blood flow = flap failure and tissue loss A sudden stoppage of drainage may indicate a clot obstructing the drain - may need to "milk" the drain Monitor drainage - record amount and character

question

Hemorrhage may occur in patients with head and neck cancer post op because many of these patients have a history of

answer

alcohol abuse = liver damage = poor clotting

question

Postoperative Head and Neck Cancer Wound Breakdown

answer

A common complication caused by *poor nutrition, *long smoking history, alcohol use, wound contamination and previous radiation therapy*

question

Managing wound breakdown

answer

with packing and local care as prescribed to keep the wound clean and to *stimulate the growth of healthy granulation tissue*

question

Postop Head and Neck Cancer Wound Care - *Carotid Artery*

answer

The carotid artery may be exposed after surgery - split thickness skin grafts often are placed over the artery for protection. As the wound heals granulation tissue covers the artery and *prevents rupture* -if granulation is slow and the carotid artery is at risk, another surgical flap may be made to cover and close the wound

question

Postop Head and Neck Cancer It is also possible for the carotid artery to have a small ______ with continuous _______ of ______ ____ ______ . Usually, this leads to a complete ____________.

answer

leak oozing bright red blood rupture

question

Postop Head and Neck Cancer *Pain Management*

answer

*Morphine* by PCA for 1-2 days after surgery Liquid Opioid Analgesics *only after the patient can tolerate oral intake* After discharge - *Liquid NSAIDS* - can be used alone with opioid analgesics

question

Postop Head and Neck Cancer *Pain Management* - Amitriptyline

answer

Or other tricyclic antidepressants may be used for the lancinating pain of *nerve-root involvement*

question

Can a patient aspirate after having a total laryngectomy?

answer

NO The airway and the esophagus have been completely separated

question

Postop Head and Neck Cancer Nutrition

answer

NG, Gastrostomy, or jejunostomy tube is place during surgery for nutritional support while the head and neck heal ~remains in place for 7-10 days ~before removing the tube *assess the patients ability to swallow if nutrition is to be given by mouth*

question

Postop Head and Neck Cancer Nutrition - Swallowing

answer

may be uncomfortable at first - analgesics may be needed

question

Postop Head and Neck Cancer Speech and Language Rehabilitation - voice and speech differences will depend on

answer

the type of surgical resection performed (Table 31-2)

question

What is a laryngectomee?

answer

A person who has had a laryngectomy

question

For voice rehabilitation to be successful for a patient who has had a laryngectomy, they will need

answer

encouragement and support from the SLP, hospital team, and family while relearning to speak. *Having a laryngectomee visit the patient and family is often beneficial*

question

What are common means of communication after having a laryngectomy?

answer

Esophageal speech Using a mechanical device Use of a tracheoesophageal puncture

question

Esophageal speech is produced by

answer

"burping" the air swallowed or injected into the esophageal pharynx and shaping the words in the mouth

question

With esophageal speech, the voice produced is (what does it sound like?)

answer

Monotone Cannot be raised Carries no pitch

question

Patients who do not have adequate hearing and use esophageal speech may need

answer

A hearing aid they need to use their mouth to shape the words as they hear them

question

A side effect some patients have from swallowing air during esophageal speech is

answer

Intestinal bloating *Treatment* - Antacids

question

One benefit of using esophageal speech is that it strengthens the

answer

respiratory and abdominal muscles, which aids in clearing secretions and in breathing

question

Electrolarynges are

answer

~mechanical devices used by the patient who cannot attain esophageal speech ~placed on side of the neck or the cheek ~air inside mouth or throat is vibrated - patient moves lips/tongue as usual

question

The Cooper Rand

answer

An external voice device that consists of a tube that is placed in the patients mouth and vibrates during speech. Robot-like unnatural sound is produced

question

Transesophageal Puncture

answer

If esophageal speech is ineffective and if the patient meets *strict criteria* ~small surgical puncture created between the trachea and the esophagus using special catheter ~after the puncture heals --> silicone prosthesis inserted in place of the catheter ~patient covers stoma, or uses a valve that they open and close which diverts air from the lungs through the trachea, into the esophagus and out of the mouth ~ Lip and tongue movement produce speech

question

Two types of prosthesis used in a transesophageal puncture are

answer

Blom-singer prosthesis Panje Voice button

question

The patient who has had surgery for head and neck cancer is at increased risk for aspiration because of

answer

Surgical changes in the upper respiratory tract Altered swallowing mechanisms The presence of an NG tube

question

Prevent NG tube aspiration with the use of routine reflux precautions such as

answer

elevate the head of bed strictly adhere to tube feeding regimen *check residual volume before each bolus feeding and every 4-6 hrs on continuous feed*

question

Swallowing can be a _______ problem for a patient who has a _________ _____/

answer

Major Tracheostomy tube *sometimes the tube fixes the larynx in place, resulting in difficulty swallowing* Additionally - an inflated tracheostomy tube cuff can balloon backward and interfere with the passage of food.

question

A patient who has had a *partial vertical* or *supraglottic laryngectomy* MUST be observed for aspiration. *Teaching* alternate methods of swallowing such as the ______________ method is critical.

answer

"Supraglottic" method of swallowing

question

Reducing anxiety in the patient with head and neck cancer

answer

~Explore the reason for the anxiety (fear of the unknown, fear of pain, fear of airway compromise) ~Before the patient is scheduled for surgery - provide information - may be able to decrease fears about the disease process and surgical interventions ~ *Lorazepam* is preferred over other antianxiety drugs because of its shorter duration and decreased respiratory side effects

question

Supporting self concept in the patient with head and neck cancer

answer

~Help them set realistic goals ~Teach alternative communication methods ~Teach the family to ease the patient into a normal social environment ~Positive reinforcement, encouragement, acceptance and caring behaviors

question

After surgery the patient may feel socially isolated because of changes in their voice and/or facial appearance. What things can be done to help with this?

answer

~Loose fitting, high collar shirts or sweaters, scarves, and jewelry can be worn to cover a laryngectomy stoma, tracheostomy tube. ~Cosmetics may aid in covering disfigurement

question

Home care management for the patient after a laryngectomy include assessing the home for what particular things?

answer

~General cleanliness of the home ~Possible changes to allow for one-floor living ~Increasing humidity - either add on to a forced air furnace or using a room humidifier ~*If using room humidifier be sure to stress meticulous cleaning to prevent spread of mold or other sources of infection*

question

Teaching for self management - *Stoma Care*

answer

~Use a shower shield (prevent water from entering airway) ~Electric shavers - cover stoma while shaving to prevent hair from falling into it ~Stoma guard during the day ~Increase humidity in the home and stay well hydrated (prevents secretions from thickening) ~ Normal saline instillations if prescribed

question

Teaching for self management -*Communication*

answer

~Have the patient continue the method of communication that began in the hospital ~Instruct them to wear a *MedicAlert* bracelet and carry a special identification card --> instructs the reader about providing an emergency airway or resuscitating someone who has a stoma

question

Psychosocial Preparation - post laryngectomy

answer

~Schedule a visit from a person who has adjusted to the same changes ~Stress the importance of returning to as normal a lifestyle as possible ~Teach that they may need to be prepared for increased mucus secretions during laughing and crying and they should keep a handkerchief or gauze on hand to cover the stoma.

question

Health Care Resources for patient with laryngectomy

answer

American Cancer Society - can provide dressing materials and nutritional supplements to patients in need Local Laryngectomee clubs- support, information, friendships Visiting Nurse Agency - to help locate available resources when having trouble with paying for health care services.

NUR 212 – Unit 4 – Head and Neck Cancer – Flashcards

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