Nutritional Concerns in ENT Practice.ppt
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Transcript of 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.