Head and Neck Cancer

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Head and Neck Cancer

• Isabel Quinn
• Clinical Nurse Specialist in Head and Neck
• July 2009

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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)

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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

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• Mouth pharyngeal cancers ? 20 last 30 years,
  particularly lt 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)

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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)

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Risk Factors

• Smoking
• Alcohol consumption
• Deprivation

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Treatments

• Surgery resection /- reconstruction. Eg
  laryngectomy, neck dissection, free forearm flap
  grafts
• Radiotherapy /- chemotherapy
• Combined modality

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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

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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

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Neck Dissection

• To clear neck of metastatic disease
• Lymph nodes /- other structures
• Associated morbidity

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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)

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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

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Effects for patients

• Cumulative effects worse when treatment
  finished
• Pain skin reactions / oral mucositis
• Difficulty swallowing nutritional needs
• Dry mouth
• Fatigue
• Osteonecrosis

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3 days post treatment 17 days post
treatment
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Chemotherapy

• Used as dual modality treatment with
  radiotherapy.
• Enhances effects of radiotherapy
• Significantly enhances side effects
• Palliative
• Performance status

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Tracheostomy and Laryngectomy
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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.

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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

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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.

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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.

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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.

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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.

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Altered body image

• Encourage continued self care of tube / self
  suctioning if possible.
• Encourage patient (carers) to look at / touch
  tube.
• Remain professional, dont show displeasure /
  disgust.

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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.

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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

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Maintain humidification

• Bib / cravat /scarf
• Heat and moisture exchangers
• Nebulisers
• Steam inhalations
• Humidified oxygen therapy

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Indications for Laryngectomy

• As curative surgical treatment of carcinoma of
  larynx.
• To overcome an incompetent larynx
• e.g. after radiotherapy, radio necrosis.

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Post Laryngectomy

• Communication issues.
• Risk to airway.
• Maintain humidification.
• Altered body image.
• Usual cancer issues

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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.

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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

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Maintain humidification

• Bib / cravat /scarf
• Heat and moisture exchangers
• Nebulisers
• Steam inhalations
• Humidified oxygen therapy

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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

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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.

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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.

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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)

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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.

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• Note tenacity, colour and quantity of secretions.
  Infected - ? specimen for cs.
• 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.

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Suction Technique

• Dos
• Insert and withdraw catheter gently
• Use low suction pressure lt120mmHg
• Use multi hole suction catheter.
• Use vacuum breaker.
• Involve physiotherapists.

• Don'ts
• Do not perform suction routinely - only when
  necessary.
• Do not instil saline prior to suctioning.
• Do not apply suction for more than 15 seconds.
• Do not apply suction when inserting catheter.

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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.

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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.

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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.

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Suction catheter sizing
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• Thank you
• Any questions