DP, an 83-year-old African American woman, was admitted to the hospital with difficulty breathing and swallowing. She was diagnosed with supraglottic squamous cell laryngeal carcinoma. Her medical history included hypertension, hypothyroidism, and a 30-year smoking history. She had lost 8.2% of her body weight over 4 months due to decreased oral intake from swallowing difficulties. A PEG tube was placed to improve her nutritional status and prevent further weight loss as she planned to undergo radiation and chemotherapy treatments. Enteral nutrition was initiated and monitored to meet her nutritional needs during cancer treatment.

1. Supraglottic Squamous Cell Laryngeal Carcinoma Brikeda Jazexhiu Sodexo Mid-Atlantic Dietetic Internship February 7, 2010

2. General Information DP 83 year old African-American female Admitted to Maryland General Hospital 12/15/10 Dx: difficulty breathing and swallowing ICU s/p tracheostomy Discharged to nursing home on 12/28/10 Dx: supraglottic squamous cell laryngeal carcinoma, adenocarcinoma of the right upper lobe, healthcare-acquired pneumonia, pulmonary edema w/ possible dx of CHF, thrombocytopenia, normocytic anemia, Clostridium difficile colitis

3. Social History Occupation: housekeeper at St. Agnes Hospital until retirement Education: 9th grade high school Marital Status: legally married, separated Living Arrangements: lives with her son and his family Religious Group: Baptist Smoker: 2PPD x 30 years, quit 5 years ago MD suspected COPD dx in the past

4. Past Medical History Hypothyroidism Hypertension Hysterectomy Tubal Ligation Admitted to St. Agnes Hospital 2o dysphagia on 9/10 St. Agnes: MBS showed aspiration Family History: mother with cancer

5. Outpatient Medications

6. Present Medical Problem Coughing episodes after meals and during the middle of the night x 4 mos Difficulty swallowing x 4 mos 12/10/10- visited outpatient Otolaryngologist for dysphagia 12/15/10- admitted to MGH 2◦ difficulty breathing/swallowing ICU following tracheostomy procedure

7. Procedures

8. Laryngeal Carcinoma Etiology Statistics 2007-2nd most common malignancy of the head and neck 2007-11th most common form of cancer among men worldwide 2010-10,110 men and 2,610 women diagnosed 2010-3,600 mortalities Polulations at risk: African-American males over the age of 55 years old Rare in individuals under the age of 30 (1%)

9. Laryngeal Carcinoma Etiology Primary risk factor Tobacco use: constitutes 85% of laryngeal malignancies Smokers:10-20 times higher risk Smoking cessation: reduces risk by 60% in patients who have not smoked in 10-15 years Smoking history: 14% increased chance in developing second head and neck carcinoma

10. Laryngeal Carcinoma Etiology Co-risk factor Alcohol use: synergistic risk factor Additional risk factors Asbestos, nickel compounds, wood dust, leather products, paint diesel fumes and glass wool Chronic GERD and HPV-16 suspected risk factors, however no causal link

11. Anatomy of the Larynx Supraglottis Glottis Subglottis

12. Anatomy of the Larynx Supraglottis: extends from the tip of the epiglottis to the laryngeal ventricle 1. Epiglottis 2. False vocal cords 3. Aryepiglottic folds 4. Arytenoids Glottis:1 cm below the vocal cords 1. True vocal folds 2. Anterior and posterior commissure Subglottis: expands to the inferior margin of the cricoid cartilage

13. Normal Swallowing Function Three stages: oral pharyngeal esophageal

14. Supraglottic Carcinoma Various diagnosis 95% are squamous cell carcinomas Remainder 5% consist of: Salivary gland tumors Mesenchymal tumors Benign neoplasms

15. Pathophysiology Begins at the cellular level with mutations in the DNA, caused either form genetic, environmental or lifestyle factors Supraglottic and subglottic: More likely to metastasize due to location Glottic: Less likely to metastasize due to anatomic barriers

16. Pathophysiology Anatomical concepts: Pre-epiglottic space: filled with fat between the epiglottis and hyoid bone. Epiglottic cartilage allows the tumor to have access to the soft tissues around the neck.

17. Pathophysiology Anatomical concepts: Paraglottic space: filled with fat laterally within the supraglottis. Allows transglottic tumor formation through mucosa access

18. Survival Rates/Treatment Most recurring malignancies occur 2 years post primary treatment 65% of patients diagnosed with laryngeal cancer live ~5 years Radiation Chemotherapy Laryngectomy Combination of chemoradiotherapy

19. DP’s Supraglottic Tumor Surgeon removed ~90% of tumor with the cup-biting forceps Tumor was large enough to block view of vocal cords Suspected probable squamous cell carcinoma Tumor stage: T2, N0, MX Could be M1 if lung mass was metastatic cancer from the larynx

20. Laryngeal Tumor Staging TNM staging: Divided into three subgroups of the supraglottis, glottis and subglottis.

21. Influence on Nutritional Status Supraglottic laryngeal cancer often leads to nutritional depletion causing: Dysphagia Odynophagia Dysgeusia Fatigue leading to decreased po intake Further contribution to wt loss The main nutrition related problem resulting from head and neck cancer is dysphagia

22. Physical Assessment (12/16) Asymptomatic bradycardia BP of 118/56 mm Hg Temperature: 97.1◦ F Pulse rate: 50 BPM Respiratory rate: 16 BPM Chest: bilateral breath sounds without wheezes/crackles/murmurs

23. Physical Assessment (12/16) HEENT: atraumatic and normocephalic Oral: upper and lower dentures Skin: intact, no signs of jaundice Abdomen: soft, non-tender with present bowel sounds Extremeties: no signs of clubbing/cyanosis/edema CNS: alert and oriented x 3 Appearance: nourished, yet noted w/ wt loss

24. Admission Medications (12/16) Albuterol Diovan Hydrochlorothiazide Oxycodone Protonix Simvastatin Synthroid

25. Lab Values-Initial Assessment (12/16) Na:139 mEq/L K: 3.7 mEq/L Cl: 108 mEq/L CO2: 26 mEq/L BUN: 15 mg/dL Creat: 0.74 mg/dL Gluc: 136mg/dL H MCV: 93.7 fL Ketones: 5 mg/dL Ca: 8.2 mg/dL L Mg:1.9 mEq/L Phos: 2.7 mg/dL WBC: 7,500 mcL RBC: 3.51 Mi l/mm3 L H/H: 10.1/32.9% L TSH: 0.023 L Free T4: 1.69 H

26. Nutrition History (12/16) Decreased appetite x 4 mos Never finished meals and stopped eating after several bites Coughing episodes after each meal Urged by family to increase oral intake

27. Nutrition Assessment (12/16) NKA Diet order: NPO Oral intake: poor PTA Complained of mostly nausea at times Complained of pain affecting oral intake near throat area and behind ears

28. Nutrition Assessment (12/16) Anthropometrics Ht: 63” BMI: 25 Wt: 134#, 61 kg IBW: 115#, 52 kg % IBW: 127#, 58 kg UBW: 146#, 66 kg % UBW: 92% Adjusted BW: 123#, 56kg % wt change: 8.2% x 4 mos

29. Nutrition Assessment (12/16) Estimated Needs Kcals: 30-35 kcal/kg ~1,680-1,960 kcal Protein: 1.5-2 g protein ~84-112 g protein/kg Fluids: 30 ml/kg ~1,680 ml/kg

30. Nutrition Diagnosis (12/16) PES Statement Swallowing difficulty related to mechanical causes, as evidenced by pt with coughing episodes during meals Unintended weight loss related to decreased oral intake 2◦ difficulty swallowing, as evidenced by 8.2% weight loss x 4 mos

31. Intervention/Recommendations (12/16) Rec: as medically safe to eat, consistency per SLP evaluation/recommendation Rec: begin TF if FEES failed Initiate at low infusion rate to prevent refeeding syndrome: Infuse @10 ml/hr and increase 10 ml every 8 hours Provides 77 g of CHO initially Fibersource HN 65 ml/hr, 100 ml flushes q6h Provides 1,872 kcal, 82 g protein and 1,679 total fluids Provides 33 kcal per kg of body weight

32. Monitoring and Evaluation (12/16) Weight Maintain weight Monitor for fluctuation Protein-energy needs Pt to meet ~75-100% of estimated nutritional needs

33. SLP Evaluation (12/17) Bedside evaluation-done with applesauce to rule out aspiration No signs of penetration or aspiration Silent aspiration suspected FEES Showed silent aspiration on own secretions Pt lacked reflexive cough and presented decreased sensation Recommendation for PEG tube

34. Regimen of Therapies PEG tube placed to improve nutritional status and prevent further weight loss, as DP planned to undergo radiation and chemotherapy PEG tube is preferred for head and neck cancer 2◦ radiation induced oral and esophageal ulcerations

35. Nutrition Role Nutrition intervention benefits the patient by: preventing nutritional deterioration improving kcal/protein intake maintaining anthropometric measurements improving the quality of life

36. Enteral Nutrition EN is recommended if the patient is malnourished or po intake has declined for more than 7-10 days Standard formula recommended Glucose tolerance may be impaired in cancer patients EN recommended in patients undergoing radio-chemotherapy Helps prevent therapy associated wt loss Helps limit interruption of radiation therapy

37. Enteral Nutrition According to the EAL, intensive nutrition therapy of 40 kcals/kg minimized weight loss and preserved fat-free body mass in patients with head and neck cancers Radiation therapy: outpatient EN improved weight status, increased calories and protein and improved tolerance of therapy for better outcomes Recommendations begin with 30-35 kcal/kg and 1.0-1.5 g protein/kg and increase per patient needs

38. EN Initiated (12/18) Fibersource HN @ 65 ml/hr, 100 ml flushes q6h-Rec begin @ 10 ml/hr Initiated @ 40 ml/hr Provided: 1,152 kcal, 61 g protein Refeeding syndrome

39. Refeeding Syndrome Repleted with: Potassium Phosphate Magnesium Sulfate Potassium Chloride Guidelines: Don’t advance nutrition until electrolytes are WNL Thiamine: 100 mg daily for 5-7 days Folate: 1mg/day 5-7 days

40. Follow Up (12/21) Temperature: 101.1◦ F Suspected pneumonia 2◦ to febrile state-X-ray completed Results positive for healthcare-acquired pneumonia 2◦ improper suctioning of trach tube Treated with Vancomysin, Zosyn and Levaquin Complains of persistent diarrhea Suspected C.diff.-stool sample checked Treated with Flagyl Recommended d/c Docusate

41. Follow Up Medications (12/21) Bisacodyl Calcium with Vit. D Docusate Sodium Ferrous Sulfate Levoxyl

42. Follow Up Tube Feeding Rate (12/21) TF upon admit (12/16): Fibersource HN @ 65 ml/hr, 100 ml flushes q6h Provided: 1,872 kcal, 82 g protein and 1,679 total ml Provided: 33 kcal per kg of body wt MD prescribed TF: Fibersource HN @100ml/hr, 100 ml flushes q6h Provided: 2,880 kcal, 127 g protein, 2,344 ml total fluids Provided: 51 kcal per kg of body wt

43. Follow Up Labs (12/21) Na:140 mEq/L K: 4.4 mEq/L Cl: 107 mEq/L CO2: 27 mEq/L BUN: 16 mg/dL Creat: 0.64 mg/dL Gluc: 150mg/dL H MCV: 94.3 fL Ca: 8.2 mg/dL L Mg:1.7 mEq/L L Phos: 1.3 mg/dL L WBC: 8,400 mcL RBC: 3.31 Mi l/mm3 L H/H: 9.7/31.5% L Prealbumin: 6.9 L Ketones: negative

44. Electrolytes

45. Follow Up Nutrition Assessment (12/21) Estimated Needs (based on actual body weight 61 kg) 35-40 kcal/kg ~2,135-2,440 kcal 1.5-2.0 g protein/kg ~92-122 g protein 25 ml/fluid-decreased fluid needs- pt developed pulmonary edema 1,525 ml fluid

46. Follow Up Nutrition Diagnosis (12/21) PES Excessive enteral nutrition infusion related to current diet order, as evidenced by pt receiving ~2,880 kcal per TF formula, 135% of estimated kcal needs.

47. Follow Up Recommendations (12/21) Rec: Change TF to Resource 2.0 @ 55 ml/hr, water flushes at 150ml q6h Provides: 2,640 kcal, 110 g protein, 1,524 ml total fluids Provides: 43 kcals per kg of body weight

48. Monitoring/Evaluation (12/21)

49. Discharge Discharged to nursing home on 12/28/10 Follow up with chemotherapy and radiation Discharge dx: Squamous cell laryngeal carcinoma Adenocarcinoma of lung Healthcare-associated pneumonia Hypothyroidism, HTN Pulmonary edema Thrombocytopenia Normocytic anemia Clostridium difficile colitis

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53. Questions?