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Cancers of the Head and Neck

Raquel Branom, DNP, RN, ACNS-BC

ObjectivesAt the end of this course, the participant will be able to:

Describe the normal anatomy and physiology of the head and neckDefine the most common cancers in head and neck patientsFormulate evidence based care plan for the post-operative head and neck patient

OverviewHead and neck cancers include cancers of the larynx (voice box), throat, lips, mouth, nose, and salivary glands.Most types of head and neck cancer begin in squamous cells that line the moist surfaces inside the head and neck (for example, the mouth, nose, and throat).Tobacco use, heavy alcohol use, and infection with the human papillomavirus (HPV) increase the risk of many types of head and neck cancer.

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OverviewMore than 90% of head and neck malignancies are squamous cell carcinomasTends to spread within the mucosaInvolve the lymph nodesDisfigurementPatients leave the hospital with radical changes in body functions, lifestyle, body imagePermanent or temporary alternation in communication, sound reception, taste, smell

Incidence and MortalityCancers of the head and neck account for 3% of all malignant cancersIncidence decreasing over last 30 yearsCancer of larynx decreasing each year since 1988Mortality rate still higher in African Americans

EtiologyAlcohol and tobacco

15X greater than non-smokers

InfectionsHuman papillomavirus-16 (HPV)Isolated in 36% of oral cavity cancers

Inflammatory cause

Genetic factors

• Mixing cured tobacco with betel nuts

– 2.8 times higher – 10 times if combined with

smoking• Dental factors• Endocrine disturbances• Radiation• Occupational exposures

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Cancers of the Head and Neck

TNM Classification for Glottic Cancer

T1: Tumor limited to vocal cords

T2: Tumor extends to supraglottis with impaired vocal cord mobility

T3: Tumor limited to the larynx, minor thyroid cartilage erosion

T4: Tumor invades thyroid cartilage and tissues beyond Larynx

Staging for Regional MetastasisNX: Regional lymph nodes cannot be assessedN0: No regional lymph node metastasis

N1: Metastasis in single ipsilateral lymph nodeN2: Metastasis to single lymph node 3-6 cm

N3: Metastasis in lymph node larger than 6 cmM1: Distant metastasis

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Test Your KnowledgeWhich of the following are risk factors for head and neck cancer?

Helicobacter pylori infection and history of herpes zosterHuman papillomavirus (HPV) infection, alcohol use, and all forms of tobacco usePetroleum cleaning solvents, asphalt paving, and painting suppliesGluten allergies and dairy allergies

Clinical FeaturesUnfortunately patients are most often identified only after development of symptoms at advanced stages of diseaseDiscomfort is the most common symptomExamination includes high risk sites

Lower lipAnterior floor of mouthLateral border of the tongueCervical and submandibular lymph nodes

Symptoms and Warning Signs

Any sore in the mouth or throat that does not healNeck or jaw pain that radiates to the earAbnormal growth in the mouthChange in mole or new skin lesion

• A lump in the neck that doesn’t go away

• Chronic cough or hoarseness

• Sore throat that does not improve

• Coughing up blood• Unilateral nasal

obstruction or bleeding

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Treatment• Whether to treat or not depends on

• Age

• Health status

• Advanced stage

• Local disease

• Chemotherapy

• Radiation therapy

• Surgery

• Combined therapies

• Full assessment will lead to one of the following

• Patient is potentially curable• Primary tumor is curable but

patient develops another illness• Patient is incurable but should

be treated• Patient is incurable and should

not be treated

Patient ProfileGenerally over 45 yearsYears of tobacco useYears of alcohol usePoor prognosis related to patients poor overall healthTumors developing in immunocompromised patients do not respond to any treatment modality

Test your KnowledgeThose diagnosed with head and neck cancer are at an increased risk for developing other primary tumors because of

The immunosuppressive side effects of treatment for head and neck cancerThe prolonged exposure of the mucosal surface to carcinogensHPV 16Repeated exposure to petrolatum products

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Cancer of the Mouth

Examination of the Mouth

Cancer of the LipAge: 60 or olderSex: Male to female ratio is 80:1Covered with non-keratinized stratified squamous epithelium

TransparentAppears red

Crusted oozingNon tenderIndurated ulceration of <1 cm

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Cancer of the Buccal Mucosa Lump or non-healing ulcerWhite or red patches

LeukoplakiaBleedingPain or numbnessMetastasis by the submandibular lymph nodes on the lower deep cervical chain

Cancer of the Floor of the Mouth

Signs and SymptomsPainful or painless lesionRestricted tongue movementSlurred speechExcessive salivationLoosening or exfoliation of teeth

The floor is close to the skin and appears as a palpable lump in the submandibular areaLymphatic drainage through submandibular lymph nodes to upper deep cervical chains

Cancer of the TongueMiddle aged to elderly85% occurs on lateral borderPainless indurated mass or ulcerLesion may be infiltrated –small on the outside, but palpation shows deep invasionRisk factors

SmokingAlcoholSpicy foodSharp teethGlossitis

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Treatment for Lip and Oral Cancer

Early stage cancers (stage I and stage II)

Highly curableSurgery or radiationTreatment determined by functional and cosmetic results

Advanced stage cancer (stage III and stage IV)

Surgery and radiationConsider for clinical trials

• Survival– Advanced cancers have

increased chance of developing a second primary tumor of the aero digestive tract

Cancer of the Neck and Throat

Neck structuresHyoid bone

Cricoid cartilage

Tracheal rings

Thyroid isthmus

Lateral lobes of thyroid curves posteriorly around sides of trachea and esophagus

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Regions of the Pharynx

Cancer of the Nasopharynx• Often subtle initial

symptomsSlowly enlarging neck massOtalgia – ear acheHearing lossNasal obstruction

• Predisposing factors– Chinese ancestry

– Epstein-Barr virus exposure

– Heavy alcohol intake• Not linked to tobacco or

alcohol Older age and male

Cancer of the OropharynxUncommonAge 50-70Males more than femalesSoft palate and oropharyngeal mucosaRisk factors

SmokingHPV infection

Symptoms: DysphagiaPain and radiating to ear

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Cancer of the HypopharynxUncommonAge 50-60Tends to be aggressive

High rate of distant spread>50% of patients have positive cervical nodes

SymptomsSore throatEar pain“lump in throat”Marked weight loss

Generally poor prognosis

Prognosis and Treatment OptionsChronic pulmonary and hepatic diseases related to excessive tobacco and alcohol usePoor prognosis related to

Presentation at late stageMultisite involvementExcessive regional lymphatic networkRestricted surgical options for complete resection

Surgery followed by radiotherapyTreatment failures occur within first 2 years after definitive surgery

Cancer of the Larynx (Voice Box)MalesAge 60 and aboveSmoking and alcohol25% of patients diagnosed with laryngeal cancers have another cancer

Mouth, esophagus, lung15% will later develop cancer in one of these areasHighest risk for recurrence in first 2-3 years

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Cancer of the LarynxSymptoms

Hoarseness of voiceLump in the neckSore throat or ear acheDifficulty breathingPain and difficulty in swellingPain is a late sign

Prognosis and Treatment OptionsSmall cancers without spread to lymph nodes have very good cure rates 75%-95%Treatment goal is to preserve the larynxRadiotherapySurgery

Complete or total laryngectomyRadical neck dissection

Total LaryngectomyInvolves removal of epiglottis, thyroid cartilage, vocal cords, hyoid bone, cricoid cartilage and 2-3 tracheal rings

Indicated in bilateral and extensive lesions of the vocal cords

Patient will have a permanent laryngeostome or “neck stoma or hole”

Voice is not preserved

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Total Laryngectomy Trach Care

AssessmentAirwayStoma

Trach assessmentCuffed vs uncuffedSutures vs trach tiesInner cannula: disposable vs reusableAir humidity

Test Your KnowledgeMr. R. is a 73 year old chicken farmer. He is in for pre-op work up for scheduled radical neck dissection. Mrs. R reports they do not understand why Mr. R. needs to have his neck operated on when he only had the lump under his tongue. He has had many tests, which have “only found a few spots on his bones”. You know that:

Test Your KnowledgeHis disease has likely spread to the lymphatics and the bone

The surgery on his neck will allow placement for a tracheostomy tube

The neck surgery is needed for placement of a PEG feeding tube

The disease has spread to the lymph nodes; the surgery will stop this spread

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General Nursing ConceptsAirway assessmentFlap and graft assessments

Neck dressingIncisionDoppler checks for circulationGraft donor dressing

Neuro status Changes from baselineTics, tremors

Radical Neck Dissection

General Nursing ConceptsTrach Management

Suction Stoma careOxygenHumidification

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General Nursing ConceptsManaging complications

Airway obstructionmucous plug

Suctioning

Maintaining humidityInfection

Incisional careFlap and skin graft donor sites

Circulation

Flap viabilityDoppler checks