"Management of the Patient Irradiated for Head and Neck Cancer"


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"Management of the Patient Irradiated for Head and Neck Cancer"
A.Effects of Radiation or Chemotherapeutic Drug
B. Prevention & Management of the Effects of Radiation & Chemotherapy
C.The Use of Hyperbaric Oxygen Therapy
D.The Use of Lasers & Cryosurgery in Oral & Maxillofacial Surgery

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"Management of the Patient Irradiated for Head and Neck Cancer"

  1. 1. Management of the Patient Irradiated for Cancer By: DMD4-AA Group 2
  2. 2. • More than 1.5 million men and women were diagnosed with some form of cancer in 2010, the National Cancer Institute estimates.
  3. 3. • The treatment options for most of them probably included chemotherapy, radiation therapy and surgery.
  4. 4. •For patients, such side effects can take over daily life. They can make patients uncomfortable at
  5. 5. best and miserable at worst sometimes affecting their ability to stick to their treatments, or making treatments less effective than they could be.
  6. 6. 1. Nausea and vomiting
  7. 7. Over half of all patients receiving chemotherapy will experience these conditions. Doctors will usually prescribe anti-emetics for this.
  8. 8. 2. Alopecia (Hair loss)
  9. 9. Some chemotherapy medications cause hair loss while others don't. If hair does start to fall out this will usually happen a few weeks after treatment starts.
  10. 10. On some occasions the hair will just become thinner and more brittle. Hair loss can occur in any part of the body.
  11. 11. 3. Fatigue
  12. 12. Most patients receiving chemotherapy will experience some degree of fatigue.
  13. 13. This may be a general feeling which exists most of the day, or may only appear after certain activities.
  14. 14. 4. Neutropenia (low white blood cells)
  15. 15. When receiving chemotherapy the immune system will be weakened because the white blood cell count will go down.
  16. 16. Consequently, patients become more susceptible to infections.
  17. 17. 5. Thrombocytopenia (Blood clotting problems)
  18. 18. Chemotherapy may lower the patient's blood platelet count. If you are affected you will bruise more easily, you will be more
  19. 19. likely to have nosebleeds and bleeding gums, and if you cut yourself it may be harder to stop the bleeding.
  20. 20. 6. Anemia
  21. 21. Chemotherapy will lower your red blood cell count. Tissues and organs inside your body get their oxygen from the red blood cells.
  22. 22. If your red blood cell count goes down too many parts of your body will not get enough oxygen and you will develop anemia.
  23. 23. 1. Hearing impairment 2. Mucositis (inflammation of the mucous membrane) 3. Loss of appetite 4. Nails and skin problems
  24. 24. 5. Cognitive problems 6. Decreased sex drive 7. Bowel movement problems (diarrhea or constipation) 8. Depression
  25. 25. Oral complications are common in cancer patients, especially those with head and neck cancer.
  26. 26. Complications are new medical problems that occur during or after a disease, procedure, or treatment and that make recovery
  27. 27. harder. The complications may be side effects of the disease or treatment, or they may have other causes.
  28. 28. Chemotherapy and radiation therapy upset the healthy balance of bacteria in the mouth.
  29. 29. It may also cause changes in the lining of the mouth and the salivary glands, which make saliva.
  30. 30. This can upset the healthy balance of bacteria. Cancer treatment can cause mouth and throat problems.
  31. 31. Inflammation and ulcers of the mucous membranes in the stomach or intestines. Easy bleeding in the mouth. Nerve damage.
  32. 32. Oral Complications caused by Radiation Therapy to the Head & Neck
  33. 33. Fibrosis (growth of fibrous tissue) in the mucous membrane in the mouth. Tooth decay and gum disease.
  34. 34. Fibrosis of muscle in the area that receives radiation. Breakdown of bone in the area that receives radiation.
  35. 35. Inflamed mucous membranes in the mouth. Infections in the mouth or that travel through the bloodstream. These can reach and affect cells all over the body.
  36. 36. Taste changes Dry mouth Pain Changes in dental growth and development in children. Malnutrition caused by being unable to eat.
  37. 37. Dehydration (not getting the amount of water the body needs to be healthy) caused by being unable to drink.
  38. 38. Tooth decay and gum disease. Oral complications may be caused by the treatment itself (directly) or by side effects of the treatment (indirectly).
  39. 39. “Preventing and controlling oral complications can help you continue cancer treatment and have a better quality of life.”
  40. 40. Finding and treating oral problems before cancer treatment begins can prevent oral complications or make them less severe.
  41. 41. Problems such as cavities, broken teeth, loose crowns or fillings, and gum disease can get worse or cause problems during cancer treatment.
  42. 42. Bacteria live in the mouth and may cause an infection when the immune system is not working well or when white blood cell counts are low.
  43. 43. If dental problems are treated before cancer treatments begin, there may be fewer or milder oral complications.
  44. 44.  Prevention of Oral Complications includes a healthy diet, good oral care, and dental checkups
  45. 45. Eat a wellbalanced diet. Healthy eating can help the body stand the stress of cancer treatment, help keep up your energy, fight infection, and rebuild tissue.
  46. 46. Keep your mouth and teeth clean. This helps prevent cavities, mouth sores, and infections. Have a complete oral health exam.
  47. 47. “It is important that patients who have head or neck cancer stop smoking.”
  48. 48. Continuing to smoke tobacco may slow down recovery. It can also increase the risk that the head or neck cancer will recur or that a second cancer will form.
  49. 49. Regular Oral Care “Good dental hygiene may help prevent or decrease complications.” Everyday oral care for cancer patients includes keeping the mouth clean and being gentle with the tissue lining the mouth.
  50. 50. Oral Mucositis “Oral mucositis is an inflammation of mucous membranes in the mouth.” Care of mucositis during chemotherapy and radiation therapy includes cleaning the mouth and relieving pain.
  51. 51. Swishing ice chips in the mouth for 30 minutes, beginning 5 minutes before patients receive fluorouracil, may help prevent mucositis. Patients
  52. 52. who receive high-dose chemotherapy and stem cell transplant may be given medicine to help prevent mucositis or keep it from lasting as long.
  53. 53. Pain A cancer patient's pain may come from the following: - The cancer. - Side effects of cancer treatments. - Other medical conditions not related to the cancer.
  54. 54. Non-drug treatments may also help, including the following: Physical therapy. TENS (transcutaneous electrical nerve stimulation). Applying cold or heat.
  55. 55. Hypnosis. Acupuncture. (See the PDQ summary on Acupuncture.) Distraction. Relaxation therapy or imagery.
  56. 56. Cognitive behavioral therapy. Music or drama therapy. Counseling.
  57. 57. Infection Infections may be caused by bacteria, a fungus, or a virus. Treatment of bacterial infections in patients who have gum disease and receive high-dose chemotherapy may
  58. 58. include the following: a. Using medicated and peroxide mouth rinses. b. Brushing and flossing. c. Wearing dentures as little as possible. d. Patients receiving cancer treatment may
  59. 59. be given drugs to help prevent fungal infections from occurring. e. Giving antiviral drugs before treatment starts can lower the risk of viral infections.
  60. 60. Bleeding Bleeding may occur when anticancer drugs make the blood less able to clot. Most patients can safely brush and floss while blood counts are low.
  61. 61. Treatment for bleeding during chemotherapy may include the following: Medicines to reduce blood flow and help clots form. Topical products that cover and seal bleeding areas.
  62. 62. Topical products that cover and seal bleeding areas. Rinsing with a mixture of saltwater and 3% hydrogen peroxide. (The mixture should have 2 or 3 times the amount of saltwater than hydrogen
  63. 63. peroxide.) To make the saltwater mixture, put 1/4 teaspoon of salt in 1 cup of water. This helps clean wounds in the mouth. Rinse carefully so clots are not disturbed.
  64. 64. Dry Mouth “Dry mouth (xerostomia) occurs when the salivary glands don't make enough saliva.” Salivary glands usually return to normal after chemotherapy ends.
  65. 65. Salivary glands may not recover completely after radiation therapy ends. “Careful oral hygiene can help prevent mouth sores, gum disease, and tooth decay caused by dry mouth.”
  66. 66. Care of dry mouth may include the following: Clean the mouth and teeth at least 4 times a day. Floss once a day. Brush with a fluoride toothpaste.
  67. 67. Apply fluoride gel once a day at bedtime, after cleaning the teeth. Rinse 4 to 6 times a day with a mixture of salt and baking soda (mix ½ teaspoon salt and ½ teaspoon baking soda in 1 cup of warm water).
  68. 68. Avoid foods and liquids that have a lot of sugar in them. Sip water often to relieve mouth dryness. A dentist may give the following treatments: • Rinses to replace
  69. 69. minerals in the teeth. Rinses to fight infection in the mouth. Saliva substitutes or medicines that help the salivary glands make more saliva. Fluoride treatments to prevent tooth decay.
  70. 70. Taste Changes Changes in taste (dysguesia) are common during chemotherapy and radiation therapy. In most patients receiving chemotherapy and in some patients receiving radiation therapy, taste
  71. 71. returns to normal a few months after treatment ends. However, for many radiation therapy patients, the change is permanent. In others, the taste buds may recover 6 to 8 weeks or more after radiation therapy ends.
  72. 72. Zinc sulfate supplements may help some patients recover their sense of taste.
  73. 73. Malnutrition Loss of appetite can lead to malnutrition. Nutrition support may include liquid diets and tube feeding.
  74. 74. The following may help patients with cancer meet their nutrition needs: • Serve food chopped, ground, or blended, to shorten the amount of time it needs to stay in the mouth before being swallowed.
  75. 75. • Eat between-meal snacks to add calories and nutrients • Eat foods high in calories and protein. • Take supplements to get vitamins, minerals, and calories.
  76. 76. Swallowing Problems Pain during swallowing and being unable to swallow (dysphagia) are common in cancer patients before, during, and after treatment. • Swallowing problems are managed by a team of
  77. 77. experts. • Speech therapist: A speech therapist can assess how well the patient is swallowing and give the patient swallowing therapy and information to better understand the problem.
  78. 78. • Dietitian: A dietitian can help plan a safe way for the patient to receive the nutrition needed for health while swallowing is a problem. • Dental specialist: Replace missing teeth and damaged area of the
  79. 79. mouth with artificial devices to help swallowing. • Psychologist: For patients who are having a hard time adjusting to being unable to swallow and eat normally, psychological counseling may help.
  80. 80. Tooth Decay • Dry mouth and changes in the balance of bacteria in the mouth increase the risk of tooth decay (cavities). • Careful oral hygiene and regular care by a dentist can help prevent cavities.
  81. 81. Mouth and Jaw Stiffness “Treatment for head and neck cancers may affect the ability to move the jaws, mouth, neck, and tongue” Treatment should begin as soon as possible to keep the condition from getting
  82. 82. worse or becoming permanent. Treatment may include the following: • Medical devices for the mouth. • Pain treatments. • Medicine to relax muscles. • Jaw exercises. • Medicine to treat depression
  83. 83. Tissue and Bone Loss • Radiation therapy can destroy very small blood vessels within the bone. This can kill bone tissue and lead to bone fractures or infection. Radiation can also kill tissue in the mouth. Ulcers may form, grow, and cause pain, loss of feeling, or infection.
  84. 84. The following may help prevent and treat tissue and bone loss: • Eat a well-balanced diet. • Wear removable dentures or devices as little as possible. • Don't smoke. • Don't drink alcohol.
  85. 85. • Use topical antibiotics. • Use painkillers as prescribed. • Surgery to remove dead bone or to rebuild bones of the mouth and jaw. • Hyperbaric oxygen therapy
  86. 86. I. DEFINITION: •Medical use of oxygen at a level higher than atmospheric pressure
  87. 87. • It involves breathing pure oxygen in a pressurized room • During treatment, patients can breathe 100% oxygen
  88. 88. II. HISTORY: • First proposed as a treatment for cancer and other conditions in the 1960s
  89. 89. • 1970's: - treating damage of the maxilla and mandible occurring during radiation treatments
  90. 90. III. PROCESSES: Monoplace Chambers Multiplace Chambers
  91. 91. Monoplace Chambers • single patient is placed in a pressurized clear, acrylic chamber, about seven feet long, while pure oxygen is compressed into the chamber
  92. 92. • Chamber is comfortable, with an atmosphere similar to that of an airplane • Chamber pressures typically rise to two-anda-half times the normal atmospheric pressure
  93. 93. • Session can last anywhere from thirty minutes to two hours • Cost less to operate • Internal environment is maintained at 100% oxygen
  94. 94. Monoplace Chambers
  95. 95. Multiplace Chambers • large tanks able to accommodate anywhere from two to fourteen people
  96. 96. • Allows patients to be directly cared for by staff within the chamber
  97. 97. • Chamber is filled with compressed air, and patients breathe 100% oxygen through a facemask, head hood, or endotracheal tube.
  98. 98. Multiplace Chambers
  99. 99. IV. USES: This therapy can be used on patients having/ suffering from: • Air or gas embolism • Cyanide poisoning • Crush injury
  100. 100. • Decompression sickness • Enhancement of healing wounds • Exceptional blood loss • Gas gangrene • Necrotizing Soft tissues infection
  101. 101. •Actinomycosis •Skin grafts or flaps •Osteomyelitis •Radiation necrosis •Acute Thermal Burn Injury
  102. 102. This therapy can also be applied as: • Adjunctive treatment with maxillofacial reconstructive procedures such as
  103. 103. dental extractions, dental implants and jaw reconstruction in the radiated patient.
  104. 104. V. ADVANTAGES: • help promote a wellvascularized wound • enhancing healing and the reconstructive process
  105. 105. • painless • increased oxygen delivery to injured tissue • improved infection control •preservation of damaged tissue • elimination and reduced effects of toxic substances
  106. 106. VI. COMPLICATIONS: • patients often feel light headedness and tiredness • Milder problems: – claustrophobia – fatigue – headache
  107. 107. Serious problems: – myopia (short sightedness) that can last for weeks or months – sinus damage – ruptured middle ear – lung damage
  108. 108. • Major complications: – Oxygen toxicity – convulsions –fluid in the lungs –respiratory failure
  109. 109. • Severe complications: – central nervous system (CNS) toxicity – pulmonary toxicity
  110. 110. 119
  111. 111. Cryosurgery is a technique for freezing and killing abnormal cells. • is used to treat some kinds of cancer and some precancerous or 120
  112. 112. noncancerous conditions • can be used both inside the body and on the skin. 121
  113. 113. WHAT IS CRYOSURGERY? Cryosurgery (also called cryotherapy or cryoablation ) is the use of extreme cold produced by liquid nitrogen (or argon gas) to destroy abnormal tissue. 122
  114. 114. BRIEF HISTORY The first cryogens were liquid air and compressed carbon dioxide snow. Liquid nitrogen became available in the 1940s and currently is the most widely used cryogen. 123
  115. 115. 124
  116. 116. MECHANISM OF ACTION Liquid nitrogen or argon gas is circulated through a hollow instrument. The doctor uses ultrasound or MRI to guide the cryoprobe. 125
  117. 117. A ball of ice crystals forms around the probe, freezing nearby cells. 126
  118. 118. ADVANTAGE OF CRYOSURGERY 1.Reduced bleeding 2.Limited to the cancerous tissue 3.Reduced pain 4.low risk of infection 5.Short recovery time 127
  119. 119. 6. Cryosurgery requires little time and fits easily into the physician's office schedule 7. Minimal wound care suture removal 128
  120. 120. 8. no expensive supplies 9. treat AIDS-related Kaposi’s sarcoma when the skin lesions are small and localized 129
  121. 121. DISADVANTAGE 1. Scarring 2. loss of sensation 3. loss of pigmentation 4. loss of hair in the treated area 130
  122. 122. 131
  123. 123. Benign Lesions • viral warts, skin tags, and xanthelasmas • Spider naevi, pyogenic granulomas, and Campbell de Morgan spots • labial lentigenous macules • Labial mucoceles 132
  124. 124. For most of the lesions mentioned above, a single freeze cycle of 5 to 10 seconds is adequate. 133
  125. 125. Seborrhoeic keratosis treated with cryosurgery A, Seborrhoeic keratosis pretreatment. 134
  126. 126. B, Post- treatment view showing excellent cosmetic result. 135
  127. 127. Melanotic macules of the lower lip A, Preoperative view. B, Postoperative view. 136
  128. 128. Premalignant and malignant Lesions • Bowens Disease • Solar Keratosis • Actinic Cheilitis • Basal cell carcinoma • Squamous cell carcinoma 137
  129. 129. Auricular basal cell carcinoma. A, Preoperative view of basal cell carcinoma of the ear. B, Basal cell carcinoma of the ear 1 week posttreatment C, Left ear 6 weeks post-treatment. 138
  130. 130. Complications • 24 and 72 hours following cryotherapythere is edema and sometimes blister formation • hemorrhage and ulceration. • Pigmentary changes are the most common. 139
  131. 131. LASER stands for: L ight A mplification by S timulated E mission of R adiation
  132. 132. HISTORICAL BACKGROUND • Albert Einstein – 1917 – Quantum theory • Theodore Maiman – 1960 – 1st Laser using Ruby crystal • Leon Goldman – 1963 – Father of modern lasers
  133. 133. TISSUE EFFECTS Temperat Visual ure Change 37-60˚C No change Biological changes Warming, welding 60-65 ˚C Blanching Coagulation 65-90 ˚C White/ gray Protein denaturizatio n, necrosis
  134. 134. Tempera ture Visual Change Biological changes 90-100 ˚C Puckering Drying 100-150 ˚C Plume Vaporization 150-210 ˚C Carbonizati Potential Scar on
  135. 135. COMPLICATIONS 1.Herpes Simplex 2.Dyschromias 3.Scarring 4.Eye and Teeth Injuries
  136. 136. COMMONLY USED LASERS TYPE 1) Erbium:YAG (pulsed) (2490 nm) USE Ablative skin resurfacing, epidermal lesions 2) Nd: YAG, Pigmented frequencyLesions, doubled (532 nm) red/orange/yello w tattoos
  137. 137. TYPE Nd : YAG (1064 nm) QS Normal mode Nd: YAG, longpulsed (1320 nm) USE Pigmented lesions, blue/black tattoos Hair removal, leg veins, non-ablative dermal remodelling Non-ablative dermal remodelling
  138. 138. 3) Alexandrite (755 nm) QSNormal mode Pigmented lesions, blue/black/green tattoos Hair removal, leg veins 4) Pulsed dye (510 nm) (585-595 nm) Pigmented lesions Vascular lesions, hypertrophic/kelo id scars, striae,
  139. 139. FIRST LASER
  140. 140. PRESENT LASERS
  141. 141. HAND PIECE
  142. 142. Advantages 1.Principles – simple 2.Technique – easy 3.Applications – unique 4.Results – outstanding
  143. 143. 5.remote application 6.precise cutting 7.hemostasis 8.low cicatrization 9.reduced postoperative pain and swelling,
  144. 144. Disadvantages 1. Thermal alteration around the zone of laser tissue ablation. 2. One major is the lack of haptic feedback during laser surgery.
  145. 145. 3. no option for switching between different wavelengths. 4.laser surgery systems are bulky, which particularly limits their use in the narrow space of the oral cavity. 5. no flexible light guide
  146. 146. Oral Tumors squamous cell carcinoma is the most common oral cancer. Laser used : CO2 and Er-YAG-lasers Nd:YAG lasers KTP lasers (potassium titanyl phosphate laser)
  147. 147. FACIAL SKIN RESURFACING Indications: 1.Photo damage: Dyschromias & Rhytides 2.Atrophic (depressed) scars : Post acne
  148. 148. Mechanism: Thermal ablation of Epidermis & papillary dermis Lasers a) Single pass CO2 b) Modulated Er : YAG
  149. 149. PHOTO DAMAGE
  151. 151. VASCULAR LESIONS • Chromophore – Oxyhaemoglobin • Absorption wavelengths – 418, 542, 577 nm • Laser of Choice : FPPDL – wavelength – 585, 590, 595, 680 nm
  153. 153. Nasal Telangiectasias
  154. 154. • HYPERTROPHIC SCARS, KELOIDS & STRIAE DISTANSAE • FPPDL (585nm) – Laser of Choice • Sessions – 4-6 weekly intervals • Future • Atrophic scars : Non-ablative lasers
  160. 160. Seborrheic Keratosis
  161. 161. Tattoos 1.Black pigment QS ALEXANDRITE 2. Blue & green pigments QS ALEXANDRITE (755 nm) 3. Red, orange & yellow FPPDL (510nm)
  162. 162. AMATEUR TATTOO
  165. 165. • HAIR REMOVAL • Hair follicle thermal relaxation time : 10-100 milli seconds • Lasers & IPL (600-1200nm) • QS & LP Nd:YAG (1064 nm) • IPL (590-1200 nm)
  166. 166. HAIR REMOVAL
  167. 167. HAIR REMOVAL