The Journal of laryngology and otology
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Practice Guideline
Nutritional management in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
Nutritional support and intervention is an integral component of head and neck cancer management. Patients can be malnourished at presentation, and the majority of patients undergoing treatment for head and neck cancer will need nutritional support. This paper summarises aspects of nutritional considerations for this patient group and provides recommendations for the practising clinician. ⋯ As energy requirements may be elevated post-operatively, monitor weight and adjust intake as required. (R) • Aim for energy and protein intakes of at least 30 kcal/kg/day and 1.2 g protein/kg/day in patients receiving radiotherapy or chemoradiotherapy. Patients should have their weight and nutritional intake monitored regularly to determine whether their energy requirements are being met. (R) • Perform nutritional assessment of cancer patients frequently. (G) • Initiate nutritional intervention early when deficits are detected. (G) • Integrate measures to modulate cancer cachexia changes into the nutritional management. (G) • Start nutritional therapy if undernutrition already exists or if it is anticipated that the patient will be unable to eat for more than 7 days. Enteral nutrition should also be started if an inadequate food intake (60 per cent of estimated energy expenditure) is anticipated for more than 10 days. (R) • Use standard polymeric feed. (G) • Consider gastrostomy insertion if long-term tube feeding is necessary (greater than four weeks). (R) • Monitor nutritional parameters regularly throughout the patient's cancer journey. (G) • Pre-operative: ○ Patients with severe nutritional risk should receive nutrition support for 10-14 days prior to major surgery even if surgery has to be delayed. (R) ○ Consider carbohydrate loading in patients undergoing head and neck surgery. (R) • Post-operative: ○ Initiate tube feeding within 24 hours of surgery. (R) ○ Consider early oral feeding after primary laryngectomy. (R) • Chyle Leak: ○ Confirm chyle leak by analysis of drainage fluid for triglycerides and chylomicrons. (R) ○ Commence nutritional intervention with fat free or medium chain triglyceride nutritional supplements either orally or via a feeding tube. (R) ○ Consider parenteral nutrition in severe cases when drainage volume is consistently high. (G) • Weekly dietetic intervention is offered for all patients undergoing radiotherapy treatment to prevent weight loss, increase intake and reduce treatments interruptions. (R) • Offer prophylactic tube feeding as part of locally agreed guidelines, where oral nutrition is inadequate. (R) • Offer nutritional intervention (dietary counselling and/or supplements) for up to three months after treatment. (R) • Patients who have completed their rehabilitation and are disease free should be offered healthy eating advice as part of a health and wellbeing clinic. (G) • Quality of life parameters including nutritional and swallowing, should be measured at diagnosis and at regular intervals post-treatment. (G).
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Practice Guideline
Palliative and supportive care in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It provides recommendations on the assessments and interventions for this group of patients receiving palliative and supportive care. Recommendations • Palliative and supportive care must be multidisciplinary. (G) • All core team members should have training in advanced communication skills. (G) • Palliative surgery should be considered in selected cases. (R) • Hypofractionated or short course radiotherapy should be considered for local pain control and for painful bony metastases. (R) • All palliative patients should have a functional endoscopic evaluation of swallowing (FEES) assessment of swallow to assess for risk of aspiration. (G) • Pain relief should be based on the World Health Organization pain ladder. (R) • Specialist pain management service involvement should be considered early for those with refractory pain. (G) • Constipation should be avoided by the judicious use of prophylactic laxatives and the correction of systemic causes such as dehydration, hypercalcaemia and hypothyroidism. (G) • Organic causes of confusion should be identified and corrected where appropriate, failing this, treatment with benzodiazepines or antipsychotics should be considered. (G) • Patients with symptoms suggestive of spinal metastases or metastatic cord compression must be managed in accordance with the National Institute for Health and Care Excellence guidance. (R) • Cardiopulmonary resuscitation is inappropriate in the palliative dying patient. (R) • 'Do not attempt cardiopulmonary resuscitation' orders should be completed and discussed with the patient and/or the family unless good reasons exist not to do so where appropriate. This is absolutely necessary when a patient's care is to be managed at home. (G).
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Practice Guideline
Speech and swallow rehabilitation in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. The disease itself and the treatment can have far reaching effects on speech and swallow function, which are consistently prioritised by survivors as an area of concern. This paper provides recommendations on the assessments and interventions for speech and swallow rehabilitation in this patient group. Recommendations • All multidisciplinary teams should have rehabilitation patient pathways covering all stages of the patient's journey including multidisciplinary and pre-treatment clinics. (G) • Clinicians treating head and neck cancer patients should consult the National Cancer Rehabilitation Pathway for head and neck cancers. (G) • All head and neck cancer patients should have a pre-treatment assessment of speech and swallowing. (G) • A programme of prophylactic exercises and the teaching of swallowing manoeuvres can reduce impairments, maintain function and enable a speedier recovery. (R) • Continued speech and language therapist input is important in maintaining voice and safe and effective swallow function following head and neck cancer treatment. (R) • Disease recurrence must be ruled out in the management of stricture and/or stenosis. (R) • Continuous radial expansion balloons offer a safe, effective dilation method with advantages over gum elastic bougies. (R) • Site, length and completeness of strictures as well as whether they are in the presence of the larynx or not, need to be assessed when establishing the likelihood of surgically improved outcome. (G) • Primary surgical voice restoration should be offered to all patients undergoing laryngectomy. (R) • Attention to surgical detail and long-term speech and language therapist input is required to optimise speech and swallowing after laryngectomy. (G) • Patients should commence wearing heat and moisture exchange devices as soon as possible after laryngectomy. (R).
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Practice Guideline
Quality of life considerations in head and neck cancer: United Kingdom National Multidisciplinary Guidelines.
This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. It identifies the current evidence base and role of health-related quality of life assessment for this group of patients. Recommendations • Health-related quality of life is integral to treatment planning, refining treatment protocols, and more personalised follow-up support. (G) • Health-related quality of life and patient concerns should be regularly assessed during patient care. (G) • Health-related quality of life assessment and patient concerns on an individual patient basis can be helpful to trigger multi-professional support and interventions. (G).
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This is the official guideline endorsed by the specialty associations involved in the care of head and neck cancer patients in the UK. Although much commoner in the eastern hemisphere, with an age-standardised incidence rate of 0.39 per 100 000 population, cancers of the nasopharynx form one of the rarer subsites in the head and neck.1 This paper provides recommendations on the work up and management of nasopharyngeal cancer based on the existing evidence base for this condition. Recommendations • Patients with nasopharyngeal carcinoma (NPC) should be assessed with rigid and fibre-optic nasendoscopy. (R) • Nasopharyngeal biopsies should be preferably carried out endoscopically. (R) • Multislice computed tomographic (CT) scan of head, neck and chest should be carried out in all patients and magnetic resonance imaging (MRI) where appropriate to optimise staging. (R) • Radiotherapy (RT) is the mainstay for the radical treatment for NPC. (R) • Concurrent chemoradiotherapy offers significant improvement in overall survival in stage III and IV diseases. (R) • Surgery should only be used to obtain tissue for diagnosis and to deal with otitis media with effusion. (R) • Radiation therapy is the treatment of choice for stage I and II disease. (R) • Intensity modulated radiation therapy techniques should be employed. (R) • Concurrent chemotherapy with radiation therapy is the treatment of choice for stage III and IV disease. (R) • Patients with NPC should be followed-up and assessed with rigid and/or fibre-optic nasendoscopy. (G) • Positron emission tomography-computed tomography (PET-CT), CT or MRI scan should be carried out at three months from completion of treatment to assess response. (R) • Multislice CT scan of head, neck and chest should be carried out in all patients and MRI scan whenever possible and specially in advanced cases with suspected recurrence. (R) • Surgery in form of nasopharyngectomy should be considered as a first line treatment of residual or recurrent disease at the primary site. (R) • Neck dissection remains the treatment of choice for residual or metastatic neck disease whenever possible. (R) • Re-irradiation should be considered as a second line of treatment in recurrent disease. (R).