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Head and Neck Cancer

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  1. Head and Neck Cancer Isabel Quinn Clinical Nurse Specialist in Head and Neck July 2009

  2. 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)

  3. 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

  4. 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)

  5. 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)

  6. Risk Factors • Smoking • Alcohol consumption • Deprivation

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

  8. 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

  9. 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

  10. Neck Dissection • To clear neck of metastatic disease • Lymph nodes +/- other structures • Associated morbidity

  11. 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)

  12. 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

  13. Effects for patients • Cumulative effects – worse when treatment finished • Pain – skin reactions / oral mucositis • Difficulty swallowing – nutritional needs • Dry mouth • Fatigue • Osteonecrosis

  14. 3 days post treatment 17 days post treatment

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

  16. Tracheostomy and Laryngectomy

  17. 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.

  18. 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

  19. 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.

  20. 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.

  21. 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.

  22. 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.

  23. 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.

  24. 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.

  25. 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

  26. Maintain humidification • Bib / cravat /scarf • Heat and moisture exchangers • Nebulisers • Steam inhalations • Humidified oxygen therapy

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

  28. Post Laryngectomy • Communication issues. • Risk to airway. • Maintain humidification. • Altered body image. • Usual ‘cancer’ issues

  29. 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.

  30. 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

  31. Maintain humidification • Bib / cravat /scarf • Heat and moisture exchangers • Nebulisers • Steam inhalations • Humidified oxygen therapy

  32. 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

  33. 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.

  34. 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.

  35. 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)

  36. 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.

  37. 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.

  38. Do’s Insert and withdraw catheter gently Use low suction pressure <120mmHg 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. Suction Technique

  39. 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.

  40. 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.

  41. 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.

  42. Suction catheter sizing