As the economics of health care increasingly dictate the parameters of patient care delivery, the role of rehabilitation has taken on new meaning with regard to positive patient outcomes. This is particularly true for the head and neck cancer patient coping with devastating physical and functional changes. With treatment advances leading to increased survival, health-care providers must therefore focus on restoring function and assisting the patient to achieve an acceptable quality of life. For the head and neck cancer patient with multiple rehabilitation needs, this can best be accomplished through a comprehensive, coordinated approach, utilizing interdisciplinary clinical and community resources aimed at facilitating the rehabilitation process and ultimately achieving individualized rehabilitation goals. [ONCOLOGY 12(1):81-89, 1998]
Although head and neck cancer accounts for only 5% of all malignancies, the resulting disfigurement and functional changes heighten the impact of this disease. Patients diagnosed with a head and neck malignancy face extensive and radical treatment approaches, including surgical intervention, radiation therapy, and chemotherapy, all of which can severely affect the patient’s quality of life in terms of speech, swallowing, and cosmetic appearance. Health-care providers must therefore focus not only on eradicating the disease process but also on restoring function and maintaining the psychosocial well-being of the patient and significant others. Realistically, cancer care is incomplete unless rehabilitation is addressed. That is, if we only treat the cancer and do not rehabilitate the patient, then we have failed to provide complete care.
Rehabilitation can be defined as an active, changing process focused on assisting patients to achieve optimal physical functioning after treatment, within the limits imposed by the disease entity. Rehabilitation involves ongoing follow-up and continues until patients have achieved their goals or have reached their rehabilitation potential.
The etiology of most head and neck cancers is related to the use of tobacco in all forms: cigars, cigarettes, pipes, and smokeless tobacco products. When tobacco is used in combination with alcohol consumption, a synergistic effect occurs on the tissues of the upper aerodigestive tract and a malignancy may develop within the oral cavity, pharynx, larynx, or esophagus.
Histologically, most head and neck cancers are squamous cell in nature.
Head and neck tumors are diagnosed through history, presentation of risk factors, head and neck examination, and family history. Diagnostic evaluation includes computed tomography (CT) and magnetic resonance imaging (MRI) to assess tumor extension and identify nodal involvement. A panendoscopy with biopsy allows for thorough examination and tissue diagnosis to document the nature of the tumor.
The tumor is staged using the TNM system of the American Joint Committee for Cancer. This system categorizes primary tumor size (T), degree of nodal involvement (N), and evidence of metastasis (M). Tumor staging is inherent to treatment planning since therapeutic options are determined by tumor location, histology, and staging. Conventional treatment modalities are surgery and radiation therapy, used either alone or in combination. Chemotherapy is reserved for patients with persistent disease or as part of an investigational protocol.
Patients who need radiation therapy are referred to a dentist for a pretreatment dental evaluation and prophylactic dental care because of the potential results of xerostomia, dental caries, and osteoradionecrosis. Dental extractions must be accomplished before radiation is initiated and the patient should be placed on an oral hygiene protocol, including the daily use of fluoride trays.
Ideally, the process of rehabilitation begins when the cancer is diagnosed and a definitive treatment plan has been established. If surgical intervention is to be the primary treatment modality, the patient and significant others should be scheduled for preoperative teaching with a nurse who is knowledgeable about postoperative management of the head and neck cancer patient. Teaching can be done in the physician’s office, the otolaryngology-head and neck clinic, or a rehabilitation setting. When possible, the social worker and speech-language pathologist participate in the teaching session.
The social worker performs a psychosocial assessment to determine the patient’s preillness personality, coping skills, and support systems and to identify potential emotional, marital, family, financial, and vocational implications of the illness. The speech-language pathologist evaluates the patient’s current communication and swallowing status, which provides important baseline information.
The nurse completes a head and neck assessment to identify actual and potential health problems and identify the patient’s physical and emotional strengths and limitations. The nurse also completes a health history, including presenting symptoms, past medical and surgical history, risk factors, allergies, current medications, current methods of pain control, and nutritional status. When indicated, an oral assessment should be performed to determine the size, location, and characteristics of oral cavity lesions. Since altered communication can be an ongoing issue, the patient’s educational level and literacy is also determined.
Preoperative teaching, directed at the patient’s level of understanding, clarifies and enhances information previously provided by the physician. Patients often have misconceptions or a limited understanding of the surgery, not because the physician failed to provide information but because anxiety prevents the patient from comprehending and processing the overwhelming details of information.
Preoperative teaching is individualized but should include a basic review of normal airway anatomy and physiology and the alterations that will occur as a result of surgery. Using “before and after” diagrams is helpful in illustrating these changes. The nurse should discuss the postoperative plan of care, including an explanation of all equipment and procedures to be used, such as the surgical intensive care experience, airway management via tracheostomy with suctioning, nutritional management via nasogastric tube or gastrostomy tube, wound drains, pain management, and expected progress.
Patients undergoing total laryngectomy can benefit from meeting with a rehabilitated laryngectomee who has achieved a good level of communication. This preoperative session is a key element in successful rehabilitation as the staff begins to establish rapport and trust with the patient and significant others, which, in turn, helps minimize anxiety.
Effective rehabilitation is contingent upon conscientious postoperative nursing care aimed at promoting wound healing, preventing complications, and fostering self-care abilities. Postoperative patient management includes care of the altered airway, wound and flap care, oral hygiene, nutritional management, speech and swallowing therapy, self-care teaching, and discharge planning.
The placement of a tracheostomy in conjunction with a planned head and neck operation eliminates the presence of an endotracheal tube in the operating field and ensures preservation of the airway in the face of upper airway edema. The presence of a temporary or permanent tracheostomy (as with total laryngectomy) requires meticulous airway management to maintain an adequate airway and preserve pulmonary function. A cuffed tracheostomy tube is used initially since the inflated cuff creates a seal between the oral cavity and the lungs, preventing aspiration until the patient is able to safely manage secretions. Using the minimal leak technique, cuffs should be inflated to the resting volume, which should not exceed 25 mm Hg.
It is beyond the scope of this paper to discuss the variety of tube materials and designs that address the individualized needs of tracheostomy patients. Tracheostomy care should be performed as a sterile procedure every 4 hours and when necessary to maintain a patent airway and prevent obstruction. The components of care include instilling normal saline, suctioning as needed, cleaning the inner cannula, care of the peristomal skin, and maintenance of humidity via a mist collar. Universal precautions must always be utilized.
Decannulation of a temporary tracheostomy is accomplished when upper airway edema has subsided and the patient demonstrates the ability to manage oral secretions without aspiration. Weaning the patient from a temporary tracheostomy is accomplished by decreasing the size of the tube to a smaller, uncuffed tube and placing a cork or decannulation stopper in the inner cannula. If the patient tolerates corking for a 24-hour period, the tube is removed and an occlusive dressing is placed over the tracheostomy site. The patient is instructed to place two fingers over the dressing when talking or coughing to create a seal until the wound has healed. The patient is also taught to change the dressing when soiled or wet. The wound will begin to heal within a few days.
Wound and Flap Care
Radical surgical resections often result in defects that require the use of reconstructive flaps for wound closure and carotid artery protection, as well as restoration of function and cosmesis. The surgeon individualizes reconstruction based on the patient’s health status, vascular integrity, rehabilitation potential, and the size and location of the defect. Small, intraoral defects may be closed primarily and covered with a skin graft or local flap, while larger defects may require a myocutaneous or free flap. Myocutaneous flaps can be used to repair defects in both anterior and posterior oral cavity sites. A myocutaneous flap utilizes muscle, subcutaneous tissue, and a pedicle of skin, including an extensive blood supply. The flap is exposed and tunneled under the skin to cover the defect. Muscle donor flaps include the pectoralis major, latissimus dorsi, trapezius, and sternocleidomastoid.
Frequent wound assessment and wound care are essential to determine the status of the wound and ensure the integrity of both internal and external suture lines. Assessment parameters include color, temperature, and capillary refill. Flaps are usually pale pink in color. A bluish, dusky, or cyanotic flap indicates venous congestion. A pale or white flap indicates an absence of blood supply. Flaps should feel warm to the touch; a cool flap indicates a compromised arterial blood supply. The tissue should display evidence of good capillary refill by blanching under gentle finger pressure with a quick return of color when pressure is released. All external suture lines should be cleansed using hydrogen peroxide and normal saline followed by the application of an antibiotic ointment.
During surgery, drains are placed in the incision to remove blood and serum and prevent the formation of hematomas and seromas. The nurse maintains patency of the wound drainage catheters and continuous suction via the closed drainage system. Using sterile technique, drains should be emptied and measured every 4 hours, noting the color, amount, and consistency of the drainage. It is important to avoid pressure on the flaps from tracheostomy ties and tracheostomy mist collars and position the patient to avoid tension on the flap.
The advent of microvascular surgery has enabled the use of free flaps, allowing tissue to be transferred from a distant site without the attachment of a pedicle. Common free flaps include the radial forearm flap, used to reconstruct posterior pharyngeal defects, and the fibular free flap, used for mandibular reconstruction. The flap donor site is covered with a split-thickness skin graft and immobilized for several days. Free flap viability is assessed using a Doppler probe, which detects an audible pulse. It is helpful to mark the pulse point with a skin marker if possible. Although the Doppler pulse is an important parameter, clinical observations must also be utilized in total flap assessment.
Assessment of intraoral suture lines is best accomplished using a flashlight to inspect the tissues and identify flap dehiscence, crust formation, poor oral hygiene, and pooling of secretions. Intraoral wound care is administered using oral irrigations and mouth rinses, which keep the operative area free of debris, stimulate blood supply, aid in the formation of granulation tissue, and promote a comfortable, functional oral cavity.
If the patient has good oral competence, a mouth rinse or “swish” may be used. Patients who have excessive crusting or thickened saliva benefit from the mechanical action provided by an oral irrigation solution or irrigation device (eg, Water Pik). The most effective irrigating solutions are combinations of normal saline, hydrogen peroxide, and soda bicarbonate. Commercial mouthwashes containing alcohol should be avoided because of their drying and irritating effects on the oral tissues. Unless contraindicated, a Yankauer oral suction tip is a useful aid for the patient who is unable to control saliva. However, patients should be encouraged to swallow the saliva as healing occurs.
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