he authors are to be commended for providing an overview of several important, though often overlooked, management issues in head and neck cancer. In their overview of nutrition, they correctly state that the nutritional status of head and neck cancer patients is frequently compromised even before cancer diagnosis and treatment. Documented reasons for this include poor oral hygiene, ill-fitting dentures, and a high incidence of alcoholism. Consequently, it is imperative that patients pretreatment nutritional status be determined so that necessary dietary modifications can be made prior to therapy. As the authors emphasize, nutritional reassessment and intervention should continue during and after treatment.
Impact of Psychosocial Factors on Nutrition
The situation of head and neck cancer patients is unique in that the structures involved in nutritional intake are often severely compromised by both the disease and its therapy. In addition to these anatomic considerations, other factors, not mentioned by the authors, may play a role in the nutritional status of head and neck cancer patients.
These patients are frequently depressed, and anxiety has been reported to be prevalent not only before surgery but also in the postoperative period at home, increasing as patients try to resume normal activities, such as movement and eating. Fatigue, which can adversely affect nutritional status, can be a major problem for head and neck cancer patients and their caregivers as well. Not surprisingly, head and neck cancer patients perceptions about their quality of life can be directly related to normalcy of diet and eating in public. Caregivers for this patient group are often older women, who express concern that their own fatigue interferes with management of the patient at home. These considerations suggest that a psychologist and/or psychiatrist should be consulted in matters related to nutritional status.
Radiation and Trismus
Trismus and masticatory pain are frequent complaints among the head and neck cancer patients seen in our pain clinic. We have found that active myofascial trigger points are common in the masticatory muscles (eg masseter, temporalis, and medial pterygoid muscles) among patients undergoing radiation therapy. Active trigger points are also frequently identified in the sternocleidomastoid, splenius capitis, and trapezius muscles.
Our experience is that injection of the trigger points with a local anesthetic that does not contain a vasoconstrictor (eg, 0.25% bupivacaine(Drug information on bupivacaine) or 3% mepivacaine(Drug information on mepivacaine)) not only provides symptomatic relief but also reduces the risk of post-radiation trismus. Trigger point injection, typically administered on a weekly basis, coupled with frequent home application of moist heat over the affected muscles, has a progressive, beneficial effect. This regimen is also appropriate for the post-radiation patient who is not seen until after trismus has become established.
In either situation, these techniques should enhance the effect of jaw exercises and provide encouragement to the patient, whose mouth opening typically improves dramatically, if transiently, immediately after trigger point injections. Electromyographic biofeedback and muscle relaxation training havealso helped many of our patients with trismus.
Pain and Dysesthesias as Promoters of Malnutrition
Pain and dysesthesias associated with head and neck tumors and antitumor therapy often severely compromise the ability and/or willingness of patients to obtain adequate nutrition. Effective and monitored pain control is essential in head and neck cancer patients. The first therapeutic intervention should be the prescription of analgesic and coanalgesic (adjuvant) medications (eg, anticonvulsants, antidepressants, and steroids).
The enteral feeding route is preferred, whether accomplished orally, by transcutaneous gastrostomy, or via a nasogastric tube, to provide minimal inter- ference with daily activities. Liquid formulations are useful, especially in patients with dysphagia.
Conventional analgesic and adjuvant medications may fail to adequately relieve dynamic pain evoked by swallowing, talking, and chewing. In these situations, nerve blocks, including neurolytic blocks, may be necessary to relieve pain that is interfering with normal head and neck movements. Although these techniques do not yield permanent relief, they can be quite effective for patients with a limited life expectancy, or for those whose pain is intractable. Reduction of pain, whether dynamic or not, is a crucial step in insuring proper nutrition.
Role of Preemptive Education
One point made by Minasian and Dwyer is worthy of emphasis. A dental consultation prior to radiation therapy will preemptively minimize not only radiation-induced side effects but also the fear and resentment of patients who have been inadequately prepared for the challenges of therapy and its sequelae. My experience in a pain clinic leads me to the conclusion that oncologists, surgeons, radiation therapists, dentists, and others involved in head and neck cancer therapy all need to appreciate the value of explaining to patients what to expect and when to expect it. At our facility, we have found that this approach reduces anxiety and depression, while enhancing patient compliance with the corrective measures that ultimately improve quality of life.