Cancer of the Oral Cavity
Cancers of the oral cavity, which can occur in any part of the mouth or throat, are curable if discovered early. These cancers are associated with the use of alcohol and tobacco. The combi-nation of alcohol and tobacco seems to have a synergistic carcinogenic effect. About 95% of cases of oral cancer occur in people older than 40 years of age, but the incidence is increas-ing in men younger than age 30 because of the use of smokeless tobacco, especially snuff (Centers for Disease Control and Pre-vention, 2002).
Cancer of the oral cavity accounts for less than 2% of all can-cer deaths in the United States. Men are afflicted more often than women; however, the incidence of oral cancer in women is increasing, possibly because they use tobacco and alcohol more frequently than they did in the past. The 5-year survival rate for cancer of the oral cavity and pharynx is 55% for whites and 33% for African Americans. Of the 7400 annual deaths from oral cancer, the distribution by site is estimated as follows: tongue, 1700; mouth, 2000; pharynx, 2100; other, 1600 (American Cancer Society, Cancer Facts and Figures, 2002).
Chronic irritation by a warm pipestem or prolonged exposure to the sun and wind may predispose a person to lip cancer. Pre-disposing factors for other oral cancers are exposure to tobacco (including smokeless tobacco), ingestion of alcohol, dietary defi-ciency, and ingestion of smoked meats.
Malignancies of the oral cavity are usually squamous cell cancers. Any area of the oropharynx can be a site for malignant growths, but the lips, the lateral aspects of the tongue, and the floor of the mouth are most commonly affected.
Many oral cancers produce few or no symptoms in the early stages. Later, the most frequent symptom is a painless sore or mass that will not heal. A typical lesion in oral cancer is a painless indurated (hardened) ulcer with raised edges. Tissue from any ulcer of the oral cavity that does not heal in 2 weeks should be ex-amined through biopsy. As the cancer progresses, the patient may complain of tenderness; difficulty in chewing, swallowing, or speaking; coughing of blood-tinged sputum; or enlarged cervical lymph nodes.
Diagnostic evaluation consists of an oral examination as well as an assessment of the cervical lymph nodes to detect possible metastases. Biopsies are performed on suspicious lesions (those that have not healed in 2 weeks). High-risk areas include the buccal mu-cosa and gingiva for people who use snuff or smoke cigars or pipes. For those who smoke cigarettes and drink alcohol, high-risk areas include the floor of the mouth, the ventrolateral tongue, and the soft palate complex (soft palate, anterior and posterior tonsillar area, uvula, and the area behind the molar and tongue junction).
Management varies with the nature of the lesion, the preference of the physician, and patient choice. Surgical resection, radiation therapy, chemotherapy, or a combination of these therapies may be effective.
In cancer of the lip, small lesions are usually excised liberally; larger lesions involving more than one third of the lip may be more appropriately treated by radiation therapy because of su-perior cosmetic results. The choice depends on the extent of the lesion and what is necessary to cure the patient while preserving the best appearance. Tumors larger than 4 cm often recur.
Cancer of the tongue may be treated with radiation therapy and chemotherapy to preserve organ function and maintain quality of life. A combination of radioactive interstitial implants (surgical implantation of a radioactive source into the tissue ad-jacent to or at the tumor site) and external beam radiation may be used. If the cancer has spread to the lymph nodes, the sur-geon may perform a neck dissection. Surgical treatments leave a less functional tongue; surgical procedures include hemiglossec-tomy (surgical removal of half of the tongue) and total glossectomy (removal of the tongue).
Often cancer of the oral cavity has metastasized through the extensive lymphatic channel in the neck region (Fig. 35-1), re-quiring a neck dissection and reconstructive surgery of the oral cavity. A common reconstructive technique involves use of a radial forearm free flap (a thin layer of skin from the forearm along with the radial artery).
The nurse assesses the patient’s nutritional status preoperatively, and a dietary consultation may be necessary. The patient may re-quire enteral (through the intestine) or parenteral (intravenous) feedings before and after surgery to maintain adequate nutrition. If a radial graft is to be performed, an Allen test on the donor arm must be performed to ensure that the ulnar artery is patent and can provide blood flow to the hand after removal of the radial artery. The Allen test is performed by asking the patient to make a fist and then manually compressing the ulnar artery. The pa-tient is then asked to open the hand into a relaxed, slightly flexed position. The palm will be pale. Pressure on the ulnar artery is re-leased. If the ulnar artery is patent, the palm will flush within about 3 to 5 seconds.
Postoperatively, the nurse assesses for a patent airway. The pa-tient may be unable to manage oral secretions, making suction-ing necessary. If grafting was included in the surgery, suctioning must be performed with care to prevent damage to the graft. The graft is assessed postoperatively for viability. Although color should be assessed (white may indicate arterial occlusion, and blue mottling may indicate venous congestion), it can be difficult to assess the graft by looking into the mouth. A Doppler ultra-sound device may be used to locate the radial pulse at the graft site and to assess graft perfusion.
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