Part 3: Care of Site Specific Side Effects: II. H&N

mnemonic for HN side effects

x-rays- xerostomia

treat- taste alterations

many- mucositis/ stomatitis

painful- pharyngitis/ esophagitis

tumors- trismus

even-eye effects

odd-otalgia

ones- other

Side effects of H&N

term. xerostomia

dryness of the mucous membranes

What are the 3 sets of salivary glands?

1. parotids

2. sublingual

3. submandibular

When does xerostomia occur?

• peaks at 2 weeks

• Can linger for a LONG TIME

If xerostomia is temporary, how long may it take to go away?

months to years

Salivary function may not come back as good as it was prior to tx

Medical interventions for xerostomia

1. Salagen (injection) BEST

2. Artificial saliva

3. Ethiol

Hints to minimize xerostomia:

In general, what are you trying to do?

Stimulate whatever salivary function is left

Hints to minimize xerostomia:

1. Sugar Free Sour candy

2. humidifiers

3. force fluids (3L/day)

4. Avoid:

   1. tobacco

   2. alcohol

   3. spices/salt

   4. Citrus fruits (vitamin C)

   5. Hard, course foods (pop corn, chips)

   6. most mouthwashes

What type of mouthwashes can patients with xerostomia use

Alcohol-free mouth wash: Biotene (available OTC)

True or False: Xerostomia patients may require dental care/ Why or why not?

True. Because Saliva has an anti-bacteriostatic substance that helps prevent tooth decay

True or False: If the patient is experiencing xerostomia, they should seek dental care immediately even before consulting the radiation oncologist

False. The patient needs to consult the radiation oncologist before dental care begins

True or False: It is ok to treat patient with “suspect” teeth.

False, All suspect teeth should be removed prior to treatmentHow

How many days prior to tx should suspect teeth be removed ? Wny?

10-14 days

Cuz RTT inhibits healing process

Other general hints on dental care:

1. establish a careful & extensive mouth-care routine

2. rinse with warm salt water

3. brush with soft bristled toothbrush after every meal

General Mouth Care instruction

1. Brush after each meal & at bed time w/ soft bristled toothbrush & non-abrasive toothpaste

2. Massage gums after brushing for 1 min to stimulate blood flow

3. Floss regularly with direction from physician

4. Apply fluoride txs as prescribed by the dentist

5. Avoid most commercial mouthwashes

6. Rinse mouth with ½ glass water + 1 tsp baking soda 4x/day

7. Apply lip & oral mucosa moisturizers

8. Avoid smoking/ alcohol

9. Examine mouth daily. Check for…

   1. mouth soreness

   2. bleeding gums

   3. white patches or dots on tongue, mouth, lining of cheek

   4. fever blisters/ cold sores

   5. unable to wear dentures (pain)

2. Taste Alterations

2. Taste Alterations

What is the importance of saliva in taste.

No saliva causes mouth blindness: everything tastes the same

Causes of taste alterations (3)

1. destruction of taste buds

2. decreased saliva

3. CA can release substances resembling amino acids that stimulates bitter taste sensations

Food that generally tastes bad to cancer patients:

Good with protein in it, cuz it has amino acids

1. eggs

2. fish

3. poultry

4. pork

If patient complains that everything has a but of a metallic taste, one could suspect:

possible liver metastases

Interventions (what to do if foods don’t taste very good)

1. avoid foods the patient doesn’t like

2. experiment with (moderate) different spices

3. -"package" the meal

4. plenty of liquids to assist in swallowing

3. Mucositis/ Stomatitis

term. Mucositis

def. inflammation of the mucous membranes

term. Stomatitis

def. inflammation of the oral mucosa

(Mucositis/ Stomatitis) is associated with RTT, while (Mucositis/ Stomatitis) is associated with chemo

Mucositis

Stomatitis

Mucositis can happen at ___ Gy

30-40 Gy

Why does RTT cause mucositis?

the epithelial lining of the oral cavity has a rapid cell turnover, making the region highly vulnerable to the effects of RTT

How often is the epithelial lining of the oral cavity replaced?

Every 7 days

When can mucositis occur?

2 weeks into tx

ends 2 weeks after tx

Infection secondary to mucositis

2 types:

1. fungal

2. bacterial

f

fungal infection secondary to mucositis is also known as

1. candidiasis

2. tongue thrush

What causes fungal infections secondary to mucositis

An over-proliferation of the candida albicans microorganisms that naturally occur in the mouth

Appearance of fungal infections secondary to mucositis

white, powdery patches on the tongue / in mouth

Treatment of fungal infections

diflucan -new and effective

Appearance of bacterial infections secondary to mucositis

exudative (oozing); a pus-like serum

Treatment of bacterial infections secondary to mucositis

antibiotics

Possible side effect of treating bacterial infections secondary to mucositis with antibiotics

yeast infection

Suggestions for mucositis

1. rinse mouth regularly w/ hydrogen peroxide/ saline (or water) (mild mouthwashes can be added)

2. Use petroleum jelly or lip balm to keep lips moist & prevent added oral discomfort

3. force fluids

4. Avoid floss/ water-piks

5. Brush with cotton-tip applicator (if toothbrush hurts)

6. Each cold/ frozen foods

7. Avoid citrus fruits

Medical Interventions for mucositis

1. analgesics (pain relief)

2. The Mixture

3. Bromptons Cocktail

The Mixture aka

1. Miracle Mouthwash

2. Magic Mouthwash

The Mixture consists of:

3 Equal Parts:

1. Xylocaine Viscous

2. Benalyn or Benedryl

3. Antacid

How does The Mixture work

1. Relieves pain

2. Relieves inflammation

3. Promotes proper pH (to promote healing)

4. Promotes easier eating (swallowing)

PIPE

True or False: Bromptons Cocktail is available in the US

False. Only available in england

Brompton’s cocktail ingredients

1. cocaine/heroine

2. morphine

3. antiemetic (fyi: antinausea)

4. thorazine (tranq)

_____ is the most common affective response to cancer, followed by ____

anxiety

depression

FYI: affective = emotion

4. pharyngitis/esophagitis

4.pharyngitis/ esophagitisW

pharyngitis aka

sore throatW

What causes pharyngitis/ esophagitis

1. mucositis

2. drainage

3. dryness

When does pharyngitis/ esophagitis occur?

2 weeks into tx

fades 2 weeks after tx

term. dysphagia

def. difficulty swallowing

esophagitis shows up as

pain in the substernal area that is severe and constant

esophagitis closely mimics the symptoms of

myocardial infarction

esophagitis can happen at ___ Gy

20 Gy

Interventions for esophagitis

Medical

1. The Mixture

2. Carafate

3. analgesics

4. Avoid hydrogen peroxide (may irritate mouth/ esophagus ulcers)

lifestyle

1. Nutritional counseling

Carafate aka

Sucralfate

What is Carafate?

A prescription for coating mucosa & relieve discomfort

5. Trismus aka

Lock jaw

6. Effects to the eye: 2 types

1. ocular lens:

2. lacrimal glands:

Ocular lens:

1. RTT can cause:

2. Tolerance dose

1. opacities (cataracts)

   1. 1000 cGy

Lacrimal glands:

1. aka

2. tolerance dose

1. tear ducts

   1. 30 Gy (3000cGy)

7. Otalgia aka

ear pain

Otalgia can happen if:

middle ear (Eustachian tube) is in the tx area

Intervention for otalgia

anesthetic ear drops

skin care for external ear

Other side effects to the H/N area include:

1. atrophy of the skin

2. Roosters Crowell

3. tracheostomy/ laryngectomy

term. Rooster’s Crowell

def. atrophy in adipose tissues (as a result of oblique incidence)

FYI: "When treating H&N with lateral fields that extend under the jaw and chin, due to the skin being thin in that area, it receives a higher dose, often leading to fibrosis and thickening resembling a rooster’s comb

What’s this?

Tracheostomy/ laryngectomy patients may require saline suction

What side effect can happen to laryngectomy/ tracheotomy patients?

1. stomatitis during tx

in (tracheostomy/laryngectomy) vocal cords are still intact

tracheostomy

laryngectomy side effect

permanent loss of voice (larynx is removed)

4 options for speaking with laryngectomy patients

1. esophageal speech

2. transesophageal puncture (TEP)

3. reconstructive surgery (not super effective)

4. Artificial larynx (electrolarynx device)

fyi:

esophageal speech aka

burp talk

Transesophageal puncture (TEP)

connects trachea to esophagus with a plastic valve

(enhanced burp talk)

artificial larynx (electrolarynx device)

chest tube/ chest drain

a flexible tube that is inserted through the side of the chest into the pleural space

Used to remove air (pneumothorax) or fluid (pleural effusion, blood, chyle), or pus (empyema) from the interthoracic space

chest tube or chest drain:

Chest tube:

The free end of the tube is usually attached to:

1. an underwater seal, above the level of the chest

2. an underwater seal, below the level of the chest

3. an air filled bag, above the level of the chest

4. an air filled bag, below the level of the chest

2

Chest tube:

The free end of the tube is usually attached to an underwater seal, below the level of the chest.

Why is it attached below the level of the chest? Select all that apply.

1. Allows air to escape from the pleural space

2. Allows pus to escape from the pleural space

3. Allows fluid to escape the pleural space

4. Prevents anything returning to the chest

1,3,4

Chest tubes are inserted under:

1. General anesthesia

2. local anesthesia

3. Analgesics

2

True or false: A small incision is made in the chest through the skin and muscle, and a tube is placed though this passage

True

True or false: if necessary paitens may be given additional analgesics for the procedure

True

True or False: To prevent the tube from falling, it is stapled in place

False, it is sutured in place

How long does the chest tube stay for?

as long as there is air or fluid to be removed

def. accumulation of AIR in the pleural space

term. pneumothorax

def. accumulation of FLUID in the pleural space

term. pleural effusion

Contraindications to chest tube placement include:

1. Chest pain

2. Refractory coagulopathy

3. Coughing

4. Wheezing

5. lack of cooperation by the patient

6. Diaphragmatic hernia

2,5,6

Major complications of chest tube

1. hemorrhage

2. fibrosis

3. necrosis

4. expansion pulmonary edema

5. blistering

6. infection

1, 4,6

Minor complications of chest tube

1. Depression

2. anxiety

3. SOB

4. Irritation

5. Dyspnea

6. cough

2,3,5,6