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Head and Neck Cancer - SJ Hospice

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					Head and Neck Cancer

               Isabel Quinn
Clinical Nurse Specialist in Head and Neck
                 July 2009
        Head and Neck Cancers
• Over 30 specific tumour sites
• Includes cancers of
                  mouth, throat, nose, ear,
                  larynx, tongue, floor of mouth
                  salivary glands, thyroid.
• Each site relatively uncommon, 3 most
  common – mouth, larynx and pharynx.
• Generally arise from surface layers upper aero
  digestive tract (squamous epithelium)
                 Incidence
• 8,000 cases and 2,700 deaths per year in
  England &Wales
• 6th most common cancer worldwide
• Marked regional variations:
  8 per 100,000 Thames & Oxford.
  13-15 per 100,000 Wales & North West.
• UHMB cases:
  125 on database
  73 new since July 08
• Mouth & pharyngeal cancers  20% last 30
  years, particularly < 65 yrs
• Laryngeal cancer  very slightly.
• Incidence and mortality higher in
  disadvantaged social groups.
• Survival rates much the same as 30 years
  ago.                 (Nice 2004)
                    Prognosis
• Early cancers T1, T2 single modality treatment. (78-
  91% survival at 5yrs)
• Advanced cancers T3, T4 multi-modality treatment
  (42-67% survival at 5yrs)
• But nodal disease ↓ survival all cancers (46% at 5
  yrs)                      (Feber 2000)

• 29-35% present at T4
• 48 -51% present with nodal disease.
                              (LSCC Network)
                Risk Factors

• Smoking

• Alcohol consumption

• Deprivation
               Treatments
• Surgery – resection +/- reconstruction. Eg
  laryngectomy, neck dissection, free
  forearm flap grafts

• Radiotherapy +/- chemotherapy

• Combined modality
              Laryngectomy

• Larynx removed, trachea brought out onto
  neck as end stoma.
• Permanent
• Different from tracheostomy
• Often no tubes
• Speech rehabilitation
• Airway / secretion management
• Humidification issues
      Free forearm flap grafts
• To repair defect of tumour excision of
  tongue / mouth / pharynx.
• Tissue transferred from forearm – micro-
  vascular techniques.
• Flap failure
• Issues of speaking and swallowing
• Extensive rehab
           Neck Dissection

• To clear neck of metastatic disease

• Lymph nodes +/- other structures

• Associated morbidity
          Effects for patients
• Pain (neuropathic) often difficult to resolve
• Facial / mouth weakness (disfigurement /
  poor tongue control – swallowing issues)
• Inabilty to raise arm above head
• Inability to use shoulder effectively (lifting
  etc)
              Radiotherapy
• For T1 or T2 tumours may be first line
  treatment.
• May have post op dependant upon
  histology.
• Palliative – short course to control local
  symptoms.
• 4 – 6 weeks Monday to Friday
• Planning
         Effects for patients
• Cumulative effects – worse when treatment
  finished
• Pain – skin reactions / oral mucositis
• Difficulty swallowing – nutritional needs
• Dry mouth
• Fatigue
• Osteonecrosis
3 days post treatment   17 days post treatment
            Chemotherapy
• Used as dual modality treatment with
  radiotherapy.
• Enhances effects of radiotherapy
• Significantly enhances side effects
• Palliative
• Performance status
Tracheostomy and Laryngectomy
                 Definitions
• Tracheostomy - artificial opening into trachea
  which is kept open with a tracheostomy tube (can
  be temporary or permanent.) Connection between
  mouth, throat and lungs remains.

• Laryngectomy – Larynx has been removed and
  trachea is then brought out to form a stoma at the
  front of the neck (this is permanent.) There is now
  NO connection between mouth throat and lungs -
  neck breather. Often there will be no tube to keep
  stoma open.
    Tracheostomy – Nursing Aims
• Maintain patent airway
• Prevent aspiration and chest infections
• Maintain adequate humidification
• Prevent tracheal trauma
• Develop alternative communication
  strategies
• Help adjust to altered body image
• Educate patient / carers
        Maintain patent airway
• Tube obstruction 3rd most common cause of death
  in patients with tracheostomies. (El Kilany 1980)
• Feel with hand for good flow of air on expiration.
• Check O2 sats.
• Remove, clean and replace inner tube as required,
  but a good rule of thumb is at start of each shift
  and then prn.
• Encourage patient to cough and self expectorate.
• Suction as required.
      Prevent aspiration and chest
               infections
• Check swallow / cough reflex - cuffed tube if
  necessary. SALT assessment
• Suction to mouth, pharynx prior to deflating cuff.
• Encourage self expectoration of secretions,
  involve physio if required.
• One use equipment / closed humidification units.
• Sterile suction technique.
• Rigorous stoma care - clean tapes / dressings
  daily, and as required.
  Maintain adequate humidification
• HUMIDIFICATION AT ALL TIMES.
  Bibs, Swedish nose.
• Diminished warming, moistening effects,
  leading to drying and crusting and potential
  blocking of tube.
• If oxygen required it MUST be humidified.
• Nebulise saline or steam inhalation if
  secretions are very thick and difficult to
  expectorate. N.b note fluid intake.
Develop alternative communication
             strategies
• Speaking valve attachments and speaking
  tubes. (n.b. not to be used at night and
  unable to use with cuffed tubes unless
  fenestrated.)
• Call bell, pen and pad, picture boards,
  magic slate, Magnadoodle etc.
• Coping strategies - extra time and patience
  required to ‘listen.’
• Educate and encourage visitors / carers.
         Altered body image
• Encourage continued self care of tube / self
  suctioning if possible.
• Encourage patient (carers) to look at / touch
  tube.
• Remain professional, don’t show
  displeasure / disgust.
        Prevent tracheal trauma
•   Staff awareness, training and competency.
•   Selection of appropriate tubes.
•   Correct suctioning techniques.
•   Cuff pressure.
•   Use of fenestrated tubes (suctioning).
•   Change whole tube regularly as per
    manufacturers instructions.
             Risk to airway
• Showering / bathing / swimming – use of
  aids.
• Inhalation dust / foreign bodies etc – use of
  bib / scarf.
• Emergency situations – neck breathers.
• Encourage expectoration of secretions.
• Suction if required
        Maintain humidification
•   Bib / cravat /scarf
•   Heat and moisture exchangers
•   Nebulisers
•   Steam inhalations
•   Humidified oxygen therapy
  Indications for Laryngectomy
• As curative surgical treatment of carcinoma
  of larynx.
• To overcome an incompetent larynx
  e.g. after radiotherapy, radio – necrosis.
           Post Laryngectomy
•   Communication issues.
•   Risk to airway.
•   Maintain humidification.
•   Altered body image.
•   Usual ‘cancer’ issues
         Communication issues
        Unable to speak conventionally
•   Suitability for surgical voice restoration –
    speaking valves.
•   Care of valves.
•   Electronic speaking aids.
•   Oesophageal speech.
•   Pad and paper
•   Involvement with SALT.
             Risk to airway
• Showering / bathing / swimming – use of
  aids.
• Inhalation dust / foreign bodies etc – use of
  bib / scarf.
• Emergency situations – neck breathers.
• Encourage expectoration of secretions.
• Suction if required
        Maintain humidification
•   Bib / cravat /scarf
•   Heat and moisture exchangers
•   Nebulisers
•   Steam inhalations
•   Humidified oxygen therapy
         Valve and stoma care
• Cleaning at least once a day, remove crusting
  from around stoma (forceps)
• Regular tube cleaning (if worn) – observe size
  of stoma
• Use of valve brush / pipette / cotton buds
• Check valve position.
• Valve replacement ?
              Coughing when drinking
              Observe test drink
              Loss of ‘voice’
              Candida
       Indications for tracheal
             suctioning
• Each patient should be individually assessed
  for the need and frequency of suction -
  amount and consistency of secretions.
• Patients ability to cough and clear own
  secretions.
• Respiratory rate.
• Oxygen saturation.
• Presence of infection.
     Suction catheter selection
• Use appropriate size - no more than half
  internal diameter of trachy tube. (see chart)
• Too large - tracheal damage, hypoxia.
• Too small - inadequate clearing of
  secretions requiring repeated attempts
  which may cause tracheal damage.
• Multi - eyed catheters.
          Equipment required
• Functional suction apparatus - suction pressure
  100 - 120 mmHg recommended for adults.
• Sterile bowl with water for flushing tube.
• Protective eye wear, mask and plastic apron.
• Appropriately sized suction catheters.
• Sterile plastic gloves.
• Yellow disposal bag.
• Inner tube if fenestrated tube in situ.
• Vacuum breaker (finger tip control)
           Nursing Intervention

• Explain procedure to patient.
• Prepare equipment.
• Observe patient throughout (hypoxia, bronchospasm
  or vagal stimulation - bradycardia.)
• Switch on suction, connect vacuum breaker and
  catheter.
• Gently introduce catheter just beyond end of trachy
  tube, apply suction and smoothly withdraw catheter.
  Do not suction for more than 15 secs at a time, or
  whilst introducing catheter.
• Note tenacity, colour and quantity of
  secretions. Infected - ? specimen for c&s.
• Remove glove and catheter and dispose.
• Assess patient - is further suction required.
  Repeat with new catheter and glove if
  necessary.
• Flush suction tubing. Switch off suction.
• Make patient comfortable.
• Document procedure.
              Suction Technique
            Do’s                           Don'ts
•   Insert and withdraw         •   Do not perform suction
    catheter gently                 routinely - only when
•   Use low suction pressure        necessary.
    <120mmHg                    •   Do not instil saline prior
•   Use multi hole suction          to suctioning.
    catheter.                   •   Do not apply suction for
•   Use vacuum breaker.             more than 15 seconds.
•   Involve physiotherapists.   •   Do not apply suction when
                                    inserting catheter.
    Changing tapes / dressings
• The tapes and dressings will need to be
  changed at least every 24 hours to enable
  assessment of the tracheostomy site.
• Change more frequently if soiled to
  maintain dry skin and reduce risk of
  infection.
• Adjust and fasten tapes if they become
  loose.
• Use keyhole tracheostomy dressings.
                  Care of tubes
• Most tracheostomy tubes have inner tubes which
  must be cleaned to prevent blockage.
• Frequency of cleaning varies widely - assess
  individually, but a good rule of thumb is to check the
  inner tube at the beginning of each shift.
• No evidence for the best solution for cleaning inner
  tube - sterile or tap water.
• Mouth care sponges, tracheostomy tube swabs /
  cotton buds for plastic tubes.
           Care of tubes (cont)
• Silver inner tubes can be cleaned gently with
  brushes and under running water.
• Do not leave tubes soaking, dry thoroughly and
  replace or store spares in a covered container.
• Do not leave patient without an inner tube, other
  than for cleaning and weaning. Absence of an
  inner tube results in a build up of secretions and
  could lead to blocking of airway.
         Suction catheter sizing
Trache tube internal         Recommended suction
diameter (on box and flange) catheter size
          4.0 – 5.0                    5Fg


          5.5 – 6.0                    8Fg


          6.5 – 7.0                   10Fg


          7.5 – 8.0                   12Fg


          8.5 – 9.0                   14Fg
 Thank you
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