nutritional concerns in ent practice.ppt

8/13/2019 Nutritional Concerns in ENT Practice.ppt

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Nutritional Concerns in

ENT Practice

Samir SomaENT Registrar

Baragwanath Hospital2008/04/23


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Head and Neck Cancer and its

Management is a violation of the

physiology of swallowing

and speaking


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Oral Preparatory Phase of

Swallowing

Fine Motor Tongue Control

Intact Sensation of Oral Mucosa

Facial Tone Soft Palate Mobility

Mobility of the Mandible Relative to

the Maxilla


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Pharyngeal Phase of Swallowing

Endolaryngeal Muscles

Contraction of the Suprahyoidmuscles


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GI Motility online(May 2006) | doi:10.1038/gimo2

Figure 1Diagrammatic illustration of motor events of swallowing reflex.


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Nutrient Deficiencies present a

dynamic challenge in every facet of

Head and Neck cancer

Management


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The Problem

57% of patients are malnourished atpresentation

Deficient intake Pre-morbidlifestyle

Cancer Patho-physiology & itsmanifestation

Digestive tract obstruction

Nutrient Losses


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Significant Impact on Morbidity,

Mortality and Quality of life

Pre-treatment weight loss is anindependent risk factor of survival

Depressed immune system facilitatesunimpeded tumour growth

Higher incidence of treatmentcomplications


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Larynx Cancer

Most common cancer in an ENT ward

Mostly presents in the 3rdand 4thstage

Treatment goal is cure of cancer

Secondary objective is the

reconstruction of voice and ability toswallow without aspiration

Total Laryngectomy


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Feeding Post-Laryngectomy

Early at day 3 oral

Delayed at day 10 with confirmationof a closed hypopharynx

Temporary trans Tracheo-oesophageal fistula enteric feeding


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Oral Cavity Tumours

2ndmost common cancer in the ENTward

Advanced stage locally aggressive

with nodal metastasis in 30 % Functional impairment is dependant

on the location and degree of

resection, soft tissue and mandiblereconstruction and development ofsustainable swallowing


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Limitted peroral resection withSkin grafting


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Schematic for a composite resectionwith segmental mandibulectomy

Marginal Mandibulectomy forcancer of the lateral floor of the mouth


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Figure 2. Reconstruction of a partial glossectomy defectwith a free forearm flap. (A) Early postoperative result (9th day).

(B) Late postoperative result, showing good tongue function.


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Other Resections


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Peritonsillar Abscess

Incidence: estimated 30/100 000 Diagnosis is usually by physical exam

but other modalities have been used such as USand CT.

Widely accepted that Staphylococcus aureusisthe most common organism causing the infectionand origin is usually from the superior pole of thetonsil (from minor salivary gland - AKA: Webergland).

Clinical presentation:

Dysphagia, odynophagia

Muffled voice

Trismus

Inability to swallow with drooling.


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Peritonsillar Abscess

Initial treatment centers around needleaspiration vs. incision and drainage. I&D has slightly higher success rate than needle

asp, but more painful with NNT (number neededto treat) of 48 after aspiration.

Hydration possible admission for IVFL if patientis unable to tolerate PO

Antibiotics Clindamycin (For infants/children:25-40mg/kg IV/IM divided q6-8 or 10-30 mg/kg

PO daily divided q6-8). Steroids (Dexamethasone 0.5 mg/kg)


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The gut works so we should use it


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Enteral nutrition

Nasogastric feeding tube

Gastrostomy feeding tube

Open, endoscopic, flouroscopic, pushvs. pull

Jejunostomy feeding tube

Open, endoscopic, flouroscopic


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Nasogastric Feeding Tubes

Appropriate for patients who are unable toingest sufficient calories despitesupplementation and who will need enteralnutrition for less than 30 days

May bolus feed, but less aspiration withcontinuous

Need replacement when narrow lumen

clogs (about every 10-15 days) Patient tolerance/pressure necrosis

Reflux, depressed cough reflex, GIdysfunction


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Gastrostomy or Jejunostomy

Appropriate for patients who will needlonger-term enteral feeds (at least 2weeks)

Fewer complications than NGT feeding(aspiration, dumping syndrome, tubeobstruction, nasal damage)

Can be easily maintained and used in

outpatient setting, less cosmetic impact Ideal for bolus feeds (Gastrostomy)

Complications: leak, infection,dysfunction, pain


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NGT vs. Gastrostomy

Gibson, et al studied NGT vs. Gastrostomyone day before surgery for patients withStage III/IV SCCA of larynx, tongue, OC,

tonsil Gastrostomy group had significantly

shorter hospital stay (60+% reduction fortonsil and laryngeal cancers)

Saunders, et al showed patients toleratedgastrostomy long-term with high patientsatisfaction and no nutritional

rehospitalization


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Impact of Nutritional Support

Bertrand, et al, and Van Bokhorst-de Vander Schuer et al showed that patients whowere given 7-10 days of preoperative

enteral nutrition had a 10% reductioninmorbidity and improved quality of life

Scolapio, et al showed that PEG placementbefore XRT resulted in prevention of

weight loss, treatment interruption, andhospitalization for hydration.

nutritional concerns in ent practice.ppt

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