1. Isabel Quinn Clinical Nurse Specialist in Head and Neck July 2009
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: per 100,000 Thames & Oxford 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

10. 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

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

18. 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)

19. 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

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

22. 3 days post treatment 17 days post treatment

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

24. Tracheostomy and Laryngectomy

25. 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.

26. 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

27. 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.

28. 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.

29. 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.

30. 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.

31. 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.

32. 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.

33. 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

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

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

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

37. Unable to speak conventionally
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.

38. 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

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

40. 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

41. 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.

42. 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.

43. Equipment required
Functional suction apparatus - suction pressure 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)

44. 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.

45. Note tenacity, colour and quantity of secretions. Infected -
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.

46. Suction Technique 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.

47. 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.

48. 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.

49. 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.

50. Suction catheter sizing
Trache tube internal diameter (on box and flange)
Recommended suction
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

51. Thank you
Any questions