Corinne Larson

Lacy Sprague, Ann Belforti, Cindy

Fitteron, Liz Valente, Nowen Beebe,
Rose Cretella, Kayla Hickerson, Mary
Jennings
3/3/15

Overview

Introduction to the Patient

Background
Patient Presentation

Surgical history
Reason for admission
Patient Assessments
Interventions

Ideal Nutritional Management before Discharge

Discussion
Conclusion
References

Patient Presentation

68, 185lbs 10oz

Admitted for salvage laryngectomy s/p failed
radiotherapy for laryngeal cancer
Left supraglottic cancer, chemoradiation in
2011
Plan: 10 days in SICU for monitoring

PMH: CAD s/p CABG in 2010, COPD, DM,

GERD, hx of prostate cancer s/p prostatectomy
2013, hx of throat cancer s/p tracheostomy
2010

Left Supraglottic
Cancer

Epiglottis, vocal cords

Symptoms

Sore throat/Painful
swallowing
Ear pain
Change in voice quality
Enlarged neck nodes 1

Chemoradiation therapy
Radiation + cisplatin
Dysphagia and MBS4

Salvage Laryngectomy

Performed for recurrent disease

5

Total laryngectomy
Separation of airway from esophagus

Supraomohyoid Neck dissection

Removes lymph nodes

Sternocleidomastoid muscle
Bilateral muscle flaps

Salvage
Laryngectomy
Nutrition
Needs
HNC functional GI tract 9
Radiotherapy risk of
xerostomia, dysguesia,
odynophagia, dysphagia,
anorexia, N/V 10
Laryngectomy withhold
oral feeding ~3 weeks to
decrease the rate of fistula
formation
Swallowing
Longer meal times
6

Surgical History

Tracheostomy 2010 with G tube placement d/t

throat cancer
CABG x 4 in 2010
Prostatectomy 2013

Surgical history

~ 4 years s/p chemoradiation for advanced

left supraglottic cancer
12/17
Left otalgia, persistent left sore throat
Pre-op dx of malignant neoplasm of
mediastinum
Direct laryngoscopy, biopsy
Found fibrinous ulceration over left false cord

Biopsy returned with malignant SCC

Timeline

Reason for Admission

2/6 admitted

Total laryngectomy
Neck dissection (I, II, III) 7
Reconstructive surgery of the SCM

Maintain NPO until POD 10

Oral diet transition

Shiley tube placed into stoma

Patient Data

Food/Nutrition History
Followed regular healthy diet PTA

Anthropometrics
Admit weight: 185# 10 oz, 58, BMI = 28.23
kg/m2
Weight history: 190# on 12/17 admit
Estimated Needs: 2039kcal, 101-126 g protein,
2039mL

Biochemical
BG: 120 DM
H&H: 11.2/32.6 surgical blood loss

Home Medications

COPD: Albuterol, Budesonide

DM: Levemir, Humalog, Metformin
HTN: Metoprolol, Olmesartan
GERD: Omeprazole (Ca supplement usually
advised)11

HLD: Rosuvastatin
Bladder control agent: Solifenacin (may interact
with grapefruit)

LOS Care

Tracheostomy care by RN
SLP visits for use of electrolarynx
ENT physician
Respiratory therapist

Timeline

Assessment 1 2/7

RN: total laryngectomy

NGT in place, team members providing care

BG: 227
PES: Inadequate oral intake r/t need to await
return of bowel function s/p laryngectomy AEB
pt NPO
Prescription: Once medically able, initiate
Glucerna 1.2 at 10mL/hr until 70mL/hr + 1 oz
prostat
2116 kcal, 116g pro, 2102mL water

Goal: Tolerate TF within 72 hours

Timeline

Assessment 2 2/10

RN consult: tube feed recs

Pt sitting in chair with TFs infusing at 70mL/hr,
diet ordered in EMR at 80mL/hr
2/8: 14% total formula, 2/9: 75% total formula

PES: Inadequate oral intake r/t s/p

laryngectomy AEB need for enteral nutrition
support
Prescription: Glucerna 1.2 at 70mL/hr, 1 oz
prostat
Discussed TF recs with team & were in
agreement
Goal: Tolerate goal within 72 hours, met and

Timeline

Oral Intake

TFs began 2/8/15 at 15:00

Bolus on 2/11
10 cans 2/12 = 119%

Assessment 3 2/13

Noted change to bolus feeds without proper

goal reached
BG: from 187-221
Called ENT, spoke to nurse, new bolus goal
confirmed and agreed upon
Prescription: Glucerna 1.2 = 480ml bolus at
8a, 12p, 4, & 240ml at 8p

Timeline

*Nasogastric tube
removed*

Assessment 4 2/16

Pt with NG tube removed, mouthing words,

nodding
BG: 233, Wt: 178 lbs 8 oz
New needs: 2000 kcal, 97-121g pro, 2000 mL
PES: Inadequate oral intake r/t s/p laryngectomy
AEB enteral feeds x 9 days, clear liquid diet
prescription
Prescription: Continue diabetic clears, advance to
CCD with textures per SLP
Goals: Advance in 1-3 days, consume 75% of
meals and supplements

Discharge

Feb 17th discharged

On dental soft diet

BG: 339
Start taking tramadol opioid
Sent to STR facility

Prognosis
Careful surveillance and monitoring by SLP
Fistula complication 12,13,14
Study by Yeun et. al, 21% patients with
recurrence had TL. 14

An Ideal Diet
Progression

Keep TFs at rate until SLP seen

Begin clear liquid diet
Discontinue TFs when 60% energy and 100%
fluid needs are met
Slow diet progression 15
Check for dysphagia

Discussion RDs

Cancer: nutrition related symptoms, make

recommendations
Laryngectomy: meet needs with alternate
nutrition, monitor symptoms
Work alongside ENT and SLP
Pt with TF experience, long hospital stay
LOS 10 days was ready to leave
Pt and ENT pushing for discharge

Conclusions/Summar
y

Laryngeal Cancer decreased oral intake,

tolerance
Laryngectomy need with failed
chemoradiation therapy, need for enteral
nutrition
Critical care, close monitoring multiple team
members following
Ideal setting follow nutrition guidelines

References

1. National Cancer Institute. Laryngeal Cancer Treatment: General Information about Laryngeal Cancer. National Cancer Institute at the
National Institutes of Health Website. Available at: http://www.cancer.gov/cancertopics/pdq/treatment/laryngeal/HealthProfessional/page1.
Published July 31, 2014. Accessed February 20, 2015.
2. Bataini JP, Ennuyer A, Poncet P, Ghossein NA. Treatment of supraglottic cancer by radical high dose radiotherapy. Cancer.
1974;33(5):1253-1262.
3. Forastiere AA, Goepfert H, Maor M, Pajak TF, Weber R, Morrison W, Glisson B, Trotti A, Ridge JA, Chao C, Peters G, Lee DJ, Leaf A, Ensley J,
Cooper J. Concurrent chemotherapy and radiotherapy for organ preservation in advance laryngeal cancer. The New England Journal of
Medicine. 2003;349:2091-2098.
4. Rosenthal DI, Lewin JS, Eisbruch A. Prevention and treatment of dysphagia and aspiration after chemoradiation for head and neck cancer.
Journal of Clinical Oncology. 2006;24(17):2636-2643.
5. Li M, Lorenz RR, Khan MJ, Burkey BB, Adelstein DJ, Greskovich Jr JF, Koyfman SA, Sharpf J. Salvage laryngectomy in patients with recurrent
laryngeal cancer in the setting of nonoperative treatment failure. Otolaryngology Head and Neck Surgery. 2013;149(2):245-251.
6. Landera MA, Lundy DS, Sullivan PA. Dysphagia after total laryngectomy. Perspectives on Swallowing and Swallowing Disorders
(Dysphagia). 2010;19:39-44.
7. Medina JE, Byers RM. Supraomohyoid neck dissection: rationale, indications, and surgical technique. Head & Neck. 1989;11(2):111-122.
8. Conley J, Gullane PJ. The sternocleidomastoid muscle flap. Head & Neck Surgery. 1980;2(4):308-311.
9. Raykher A, Russo L, Schattner M, Schwarts L, Scott B, Shike M. Enteral nutrition support of head and neck cancer patients. Nutrition in
Clinical Practice. 2007;22(1):68-73.
10. Ravasco P, Monteiro-Grillo I, Vidal PM, Camilo ME. Impact of nutrition on outcome: a prospective randomized controlled trial in patients
with head and neck cancer undergoing radiotherapy. Head & Neck. 2005;27(8):659-668.
11. Pronsky ZM, Crowe JP. Food-Medication Interactions. 17th ed. Birchrunville, PA: Food-Medication Interactions; 2012.
12. Eustaquio M, Medina JE, Krempl GA, Hales N. Early oral feeding after salvage laryngectomy. Head & Neck. 2009;31(10):1341-1345.
13. Gooi Z, Richmon J. Long-term oral intake through a salivary bypass tube with chronic pharyngocutaneous fistula. American Journal of
Otolaryngology. 2012;33(6):762-763.
14. Yeun APW, Ho CM, Wei WI, Lam LK. Prognosis of recurrent laryngeal carcinoma after laryngectomy. Head & Neck, 1995;17(6):526-530.
15. Compass Group. Manual of Clinical Nutrition Management. Morrison, Inc; 2014.