1. SG: Case Study Lindsay Dvorak Joel Fruchtnicht Katie Kampen
Victoria Souhlas
Stephanie Spann

2. Background Information
72 y/o Male
history of tobacco chewing and smoking
Pt was admitted to the hospital in Meerut India, on December 15, 2000

3. Symptoms Pt reported: Progressive hoarseness loss of appetite
weight loss
difficulty in swallowing solid foods in the last 6 months
pain in the right ear and pain in the right side of the neck below the mandible in the last 4 months
pt was unable to swallow solid foods 15 days prior to admission
As soon as he ate solid food, he immediately vomited out with a coughing reflex (blood stained)

4. Upon admission.. pt presented with:
Significant difficulty in swallowing solid foods
hoarseness of voice
complaint of pain in the right ear and right side of neck below the mandible
A physical examination revealed enlarged cervical lymph nodes on right side of neck

5. Signs and Symptoms Head and Neck Cancer seen in SG
Change in voice (hoarse)
Difficulty swallowing; dysphagia
Enlarged cervical lymph nodes
Ear pain
Weight loss and loss of appetite
Vomiting with traces of blood
Other signs to check for include:
lump in the neck
a broadening of the larynx
tenderness in the neck
dyspnea- difficulty breathing
hoarseness is one of the first cancer symptom for cancer in the larynx

6. Referral
After examination in the hospital a referral was made to the ENT for Laryngoscopic examination

7. Anatomical Signs
Pharyngoscopy and laryngoscopy are often used to check for signs of head and neck cancer
A physician (ENT) will perform the procedure to determine presence and to what extent of cancer is present
Severity and type identified by the Tumor Classification System

8. Tumor Classification System
T- Tumor Size - T1 (smallest)- T4 (largest)
M- Presence or absence of Metastesis outside the region
N- Nodal Status- # of nodes thought to be involved with the tumor
Larynx is divided into 3 areas:
Supraglottis
Glottis
Subglottic
The extent of effects will depend on the site and size of the tumor

9. Suspected Anatomy of SG
Cancer is one of the diseases that may affect the anatomy and structures of the oral cavity, pharynx and larynx
If a malignant lesion affects one or both vocal folds directly, hoarseness will result due to invasion of the tumor on the structures
The magnitude will depend on the extent and site of the carcinoma

10. Observable Physiological Signs
Laryngoscopic examination may reveal anything from a small, well- defined tumor to a large and diffuse tumor involving any part of the larynx or vocal folds
As the severity of the lesion increases it becomes more invasive which negatively affect vibratory vocal fold behavior
Lesion can cause the vocal folds to become stiff which would affect the mucosal wave and amplitude of vibration

11. Measurable Physiological Signs
With large tumors, airflows are generally increased due to large leakage flows because the tumors can prevent vocal fold closure
Mean airflow rates can increase
Subglottal air pressures may be increased because of the increased stiffness of the vocal folds

12. Here’s why...
Cancerous lesions invade the tissue and destroy normally behaving cells
Invasion of the tumor into the various levels of the lamina propria and muscle results in greater stiffness of the tissue resulting in reduced horizontal excursion of the affected fold and often of the contralateral fold and restricted or absent mucosal wave
prevents vocal fold closure
A variety of benign and malignant tumors may be found in the laryngeal or neck region
Such tumors may obstruct the airway directly or may occupy space and place pressure on the trachea or larynx

13. Dysphagia
Depending on site and lesion, the obstruction of a tumor could result in oropharyngeal dysphagia
If the tumor is located near the vocal folds, it can impede on airway closure resulting in pharyngeal dysphagia

14. Respiratory System
The respiratory system would need to be assessed due to:
Increased risk for respiratory dysfunction and anatomical changes due to history of smoking and complaints of voice disorder
Enlarged lymph nodes can also be indicative of an Upper Respiratory infection or cancer affecting the lungs and/or respiratory system

15. Effects of Smoking Tobacco on Respiratory System
Irritation of the trachea and larynx
reduced lung function and breathlessness due to swelling and narrowing of lung airways
impairment of lungs’ clearing system resulting in lung irritation and damage
increased risk of lung infection and symptoms such as coughing and wheezing
permanent damage to air sacs of the lungs
can cause cancer of the lungs, esophagus, larynx, mouth, throat and more

16. Lymphadenopathy Enlarged Lymph nodes
Lymph nodes filter the lymphatic fluids on its way to central venous circulation, removing cells and other materials
Pathogenic microorganisms carried in the lymphatic fluid can directly infect the lymph nodes
Because lymph nodes participate in the bodys’ immune response, a large number of infectious and inflammatory disorders and cancers are potential causes
Leading causes of enlarged lymph nodes include:
Idiopathetic, self limited (no known cause)
Upper Respiratory Infection
Cancer (lung, gastrointestional, retropertineal)
May be able to see enlarged nodes, pt may report feeling a lump in the neck region, or slp/RN/MD may find lump upon palpation

18. Lymphatic Drainage System
How much of normal tissue resected in a head and neck cancer patient is determined by the site of malignancy
The lymphatic drainage system is a series of vessels that drain fluid from cells
Depending on the way the system drains, it could determine the way in which the tumor spreads
For example, because of the way the lymphatic system drains in the supraglottic larynx, a tumor in that area will not spread downward to the TVF and/or subglottic larynx unless the tumor is at the base of the epiglottis
So it is important to note where and to what extent a tumor has spread to in order to see what changes can be expected anatomically
“Evaluation and Treatment of Swallowing Disorders” Jeri Logemann

20. Following ENT consult...
-MBSS to assess anatomy and physiology of swallowing
-Assess respiratory patterns
-Assess voice production