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Surgical CP Parotid
Surgical CP Parotid
NO CONTENT PAGE NO
I INTRODUCTION
II OBJECTIVES
III HEALTH ASSESSMENT
A)HEALTH HISTORY
B)PHYSICAL EXAMINATION
C)SYSTEM REVIEW
D) INVESTIGATION
IV DISEASE CONDITION
A)DEFINITION
B)REVIEW OF ANATOMY &
PHYSIOLOGY
C)ETIOLOGY
D) PATHOPHYSIOLOGY
F)CLINICAL MANIFESTATION
G)DIAGNOSTIC EVALUATION
H)MANAGEMENT-MEDICAL
-SURGICAL
-NURSING
I)COMPLICATION
J)PATIENT MANAGEMENT-MEDICAL
-SURGICAL
NURSING
V LIST OF NURSING DIAGNOSIS
VI NURSING CARE PLAN
VII HEALTH EDUCATION
VIII SUMMARY
IX CONCLUSION
X BIBLIOGRAPHY
INTRODUCTION
Salivary gland cancer starts in one of the salivary glands. It’s not just a single
disease. There are actually several different salivary glands found inside and
near your mouth. Many types of cancer and benign (non-cancerous) tumors can
Salivary glands make saliva – the lubricating fluid found in the mouth and
throat. Saliva contains enzymes that begin the process of digesting food. It also
contains antibodies and other substances that help prevent infections of the
The parotid glands, the largest salivary glands, are just in front of the ears.
About 7 out of 10 salivary gland tumors start here. Most of these tumors are
benign (not cancer), but the parotid glands still are where most malignant
The submandibular glands are smaller and are below the jaw. They secrete
saliva under the tongue. About 1 or 2 out of 10 tumors start in these glands, and
The sublingual glands, which are the smallest, are under the floor of the mouth
patient.
AGE : 56YRS
SEX : MALE
WARD
UNIT : 214
RELIGION : HINDU
OCCUPATION : FARMER
ALLAMPATTI,
VIRUDHUNAGAR DISTRICT .
SUPROMYOHOID NECK
DISSECTION
Patient came with H/O painless ulceration in the tongue in left lateral
side for past two months and excessive salivation present for past 10 days.
FAMILY HISTORY:
KEYS :
died male
died female
- patient
- female
SOCIO ECONOMIC HISTORY:
Type of housing: pucca
Pet animals : no
PERSONAL HISTORY:
Pattern of rest and sleep: rest is adequate and he sleeps 8 hours per day.
Habit of alcohol,
PHYSICAL EXAMINATION:
GENERAL APPEARENCE:
HEAD:
Scalp is clean.
Hair is black and grey in colour.
Hairs are evenly distributed.
No scar is seen.
SKIN:
Skin is warmth.
Skin colour is pale.
Skin integrity is poor.
Skin turgor is impaired.
No lesion is seen.
EYES:
Vision normal.
Sclera is pale.
Eye ball movement is normal.
Eye lashes are evenly present.
Conjunctiva is white in colour.
EARS:
Hearing acuity is normal.
Wax is present.
Ear pinna is normal.
NOSE:
MOUH:
Lips:
- Pink in colour.
- Dry which indicates dehydrated.
- No crackles is seen.
Tongue :
- Pallor
- Severe ulceration present
- Excessive salivation present.
Teeth:
- Teeth alingnment is normal.
NECK:
CHEST:
Chest wall movement is symmetrical.
No scar is seen.
Chest is evenly distributed.
ABDOMEN:
Abdomen soft.
No scar is seen.
Bowel sound is heard all quadrant.
Umbilicus present at centre of the abdomen.
UPPER LIMBS:
LOWER LIMBS:
GENITOURINARY:
RESPIRATORY SYSTEM:
INSPECTION:
AUSCULTATION:
PERCUSSION:
CARDIOVASCULAR SYSTEM:
INSPECTION:
PALPATION:
AUSCULTATION:
PERCUSSION:
Normal resonance is heard.
INSPECTION:.
Tongue ulceration
Umbilicus normal.
Abdomen moves with respiration.
Skin over abdomen is normal.
No dilated vein/ sinus.
PALPATION:
PERCUSSION:
Normal .
No evidence of fluid thrill.
AUSCULTATION:
LYMPHATIC SYSTEM:
GENITOURINARY SYSTEM:
INTEGUMENTARY SYSTEM:
VITAL SIGNS:
TEMPERATURE : 98.4 F
OXYGEN SATURATION:
The oxygen saturation of the patient not in room air is 98%
0 1 2 3 4 5 6 7 8 9 10
ANTHROPOMETRIC MEASUREMENT:
HEIGHT : 158CM
WEIGHT : 54KG
BMI : WEIGHT/HEIGHT m2
= 24Kg/ m2
INVESTIGATION:
S.N Name of the Patient Normal
Impression
O investigation value value
1. Haemoglobin 8.7 g/dl 12-16 g/dl Anaemia
80-120
2. Glucose 82 mg/ dl Normal
mg /dl
3. Sr.urea 20 15-45 Normal
4. Sr.creatinine 1.0 0.6-1.2 Normal
135-145
5. Sr.sodium 135mEq/L Normal
mEq/L
3.5-
6. Sr. Potassium 3.8mEq/L Normal
4.5mEq/L
90-
7. Chloride 96mEq/L Normal
105mEq/L
8. Total bilirubin 2.0mg/dl 0.2-1mg/dl Incresed
0.2-
9. Direct bilirubin 0.7 mg/dl Normal
0.8mg/dl
10. Indirect bilirubin 1.3
20-40
11. SGOT 29mmol/dl Normal
Mmol/dl
25-
12. SGPT 23mmol/dl Normal
50mmol/dl
Base of the
11. CECT skull and
root of neck
Dorsal Surface
• Convex on all sides
• Covered with moist and pink mucous membrane
• Divided by a V shaped(sulcus terminalis) into ant. 2/3rd (oral or pre-sulcal )facing upward
and post.1/3rd (pharyngeal or post-sulcal) facing backward at rest
• Limbs passes anterolaterally from a median depression( foramen caecum) indicate
site of upper end of thyroid diverticulum
Presulcal part
• Mucous memb. Adherent to
underlying muscles by lamina
propria
• Provided with numerous
papillae of different types
• Each papilla is a projection of
lamina propria covered by
mucous memb (characterstic
roughness)
Types of Papilla
• Vallate
• Fungiform
• Foliate
• Filliform
Vallate
• 8-12 in no. , 1-2 mm diameter
• Arranged in V shaped , single row
• Immediately in front of sulcus
Fungiform
• Rounded reddish elevation , distrbuted discretely
numerous along margins and tip of tongue –bright
red colour (contain taste buds)
Foliate
3-4 vertical mucous folds at margins of tongue in front of sulcus (contain taste buds)
Filiform
Numerous tiny conical projections over the entire dorsal surface of ant. 2/3rd of tongue
appearance)
Post sulcal (Pharyngeal) part
• Lie behind palatoglossal arch and sulcus & form ant. wall of oropharynx
• Connected to epiglottis by a median and a pair of lateral glosso-epiglottic folds with a
depression in b/w (epiglottic vallecula)
• Mucous memb. Devoid of papilla
• Separated from underlying muscles by a loose sub mucous coat which contain mucous
and serous glands and numerous lymphoid follicles(Lingual Tonsil)
Tongue – Inferior surface
• Reflected on floor of mouth
• Covered by mucous memb.
• devoid of Papillae
Features
• (Frenulum) Median fold connecting tongue to floor
• Applied – Tongue Tie
• Sublingual papilla
• Deep lingual veins prominance
Tongue - Musculature
• Tongue divided into two symmetrical halves by a median fibrous septum
• Each half contain striated muscles arranged in two groups
• Extrinsic& Intrinsic
Tongue - Musculature
Extrinsic – Five Pair
Connect to
• Genio-glossus (mandible)
• Hyo-glossus (Hyoid)
• Chondro-glossus
• Stylo-glossus (Styloid process)
• Palato-glossus (Palate)
Alter position of tongue
Tongue - Musculature
Intrinsic muscles –
occupy upper part & are Attached to submucous
fibrous layer and to median fibrous septum
• Superior Longitudinal
• Inferior Longitudinal
• Transverse muscle
• Vertical muscle
Alter shape of Tongue
Tongue - Musculature
Genioglossus
• Fan shaped , form main bulk of tongue
Origin – Sup. Genial tubercles of mandible
Insertion
• Lowest fibers – to body of hyoid
• Intermediate– pass deep to hyoglossus and are
continuous with middle constrictor of pharynx
• Upper – turn forward and upward from root to apex
Action -Protrude tip of tongue and make dorsal surface concave
Hyoglossus
• Quadrilateral muscle
Origin
• Upper surface of greater cornu and partly from body of hyoid
• Passes upward & forward under cover of mylohoid
Insertion
side of tongue b/w styloglossus laterally and
inferior longitudinal muscle medially
Action
Depresses sides of tongue , make dorsal surface
Convex
Chondroglossus detached part of hyoglossus, seperated by genoiglossus
Originate from lesser cornu & attached to side of tongue
Styloglossus
Arise from tip of styloid process & stylomandibular
ligament
Passes downward and forward
Inserted to side of tongue
Oblique fibers interdigitate with hyoglossus
Longitudinal fibres continue with inf. Longitudinal muscle
Action – retracts tongue backward & upward Antagonist in action to genioglossus
DEFINITION
Oral tongue is an area limited posteriorly by circumvallate papillae. These cancers are
a distinct clinical entity and must be differentiated from the cancers of the base of tongue.
This write up is restricted to the cancers arising in oral tongue.
Most common site of involvement is lateral border of tongue accounting for 85% of cases.
Dorsum,ventral surface and tip of the tongue (5% each) form rest of the cases.
RISK FACTORS
History
• History of habits and addictions
•Medical and family history, including any prior malignancy
• Coexisting co morbidity
• Prior treatment with details
Examination
Important points to consider are –
• Size
• Location
• Extent
• Posterior- base of tongue / vallecula / tonsil involvement
• Lateral/ deep extent of the tumor, relationship to midline, mandible and hyoid
• Ankyloglossia
• Hypoglossal nerve palsy
• Cervical adenopathy
Histological Diagnosis
i. Biopsy
Biopsy of the lesion to confirm the presence of carcinoma and to know the histological type.
Assessment of grading is difficult and not mandatory on a biopsy specimen.
•• Punch biopsy from most representative area avoiding obviously necrotic areas
•• Incisional biopsy for submucosal lesions/patch/verrucous lesions when punch biopsy is not
feasible or non contributory.
ii Scrape cytology
Acts as an adjunct and not a substitute for formal biopsy. A negative scrape cytology with
strong clinical suspicion warrants biopsy. Occasionally the confirmatory biopsy that follows
positive scrape cytology may be negative. This is usually due to inadequate sampling of a
representative area from the lesion. The biopsy needs to be repeated in such cases.
Imaging
i. Pretreatment imaging
a. OPG
Evaluating bone erosion in tongue cancers due to low specificity owing to high
incidence of periodontitis and odontogenic infections . It is useful for planning
mandibulotomy and for dental treatment prior to radiotherapy.
b. High resolution Ultrasonography (USG) with guided FNAC
c. CT/MRI
d. PETCT- for evaluating distant metastases in stage III & IV tongue cancers
TNM Staging :
Staging is for oral cavity in general. No separate staging for tongue cancers, applicable for
buccal cancers
STAGING
T1- Stage I
T2 -Stage II
T3 -Stage III
T4a -Stage IV A- Surgically operable cancers
T4b -Stage IV B- Surgically inoperable cancers
MEDICAL MANAGEMENT:
SURICAL MANAGEMENT:
SURGICAL CONSIDERATIONS
a. Excision of primary Wide local resection of tumor with adequate margins.
1. Resection with clear margin
Assessment of depth of tumor by digital palpation and imaging is an essential
prerequisite for obtaining appropriate deep margin. It is preferable to have a 1 cm clear
margin around tumor in all dimensions at surgery as margins shrink 20-30% after resection.
Any margin less than 5 mm is compromised and warrants adjuvant treatment.
Three treatment modalities are available-
A. Observation
B. Elective neck dissection
C. Elective neck irradiation
A. Observation alone
1.Tumors with low risk of metastasis (<20 % 1. - T1, tumor thickness < 4 mm, well
differentiated, no LVE, PNI)
2. Early T1/T2 low risk cancer (read above) cancers treated per orally with no violation of the
neck for the approach
3. Patients with reliable follow up
4. Patients with thin neck in whom satisfactory clinical examination is possible
5. Ultrasound negative
B. Elective neck dissection
1. Thick tumor (tumor thickness more than 4 mm)
2. Entry into the neck
3. Cases with unreliable follow up
4. Patients with fat, short neck in whom satisfactory clinical examination is not possible
C. Elective irradiation
1. In cases where primary tumor is treated by radiotherapy
b) Extent of neck dissection
c) Special issues
• Dissection of level IV
ii. Node positive disease
iii. Contralateral neck
C. Reconstruction
i. Primary closure
ii. Skin graft
iii. Local flap
iv. Regional flap
v. Distant flap
vi. Free flap
OTHER MANAGEMENT:
CHEMOTHERAPY
i. Concurrent chemoradiation
ii. Chemotherapy for recurrent/metastatic disease
i. Concurrent chemoradiation
Concurrent chemoradiation is useful either as adjuvant treatment in operable tongue cancer or
as definitive treatment in advanced (inoperable) tongue cancer.
ii. Chemotherapy for recurrent and metastatic disease
The mainstay of the treatment of patients with recurrent/metastatic tongue cancer is
palliation. Pain relief and maintaining the nutrition takes priority in the overall management
of these patients.
Chemotherapy may be offered to patients with good performance status. Before
planning the treatment for recurrent tongue cancer, efforts should be made to identify the
occasional patient who may be candidate for surgical salvage or re-radiation.
1. First line
Palliative chemotherapy is usually a two drug regimen unlike the three drug taxane
based chemotherapy described in the preceding section. The most widely used and
recommended doublet is cisplatinum and 5-flurouracil. The combination of carboplatin and
paclitaxel or docetaxel has been described. The regimen is cisplatin, 5-FU and cetuximab.
Cetuximab is given weekly till the progression of disease.
2. Subsequent line
The outcome of patient failing first line therapy is even poorer. Patients with poor
performance status or those progressing while on first line chemotherapy are best offered
only palliative care.
Radiation therapy
INJ.TRAMADOL / 100MG/ IM / BD
4.
TAB.ALPRASOLAM 0.5mg/P/O / HS Depresses Benzodiazepin Dizziness, Assess the patient
subcortical e anti-anxiety Confusion, mental status
levels of CNS, (funct.class) Headache, especially in
including limbic Anxiety, geriatric patient prior
system, Depression, to and during
reticular Insomnia, treatment.
formation. Tachycardia,
Hypotension, Assess and monitor
Vomiting, patient blood
Weight pressure.
gain/loss
PRE OPERATIVE NURSING DIAGNOSIS:
scale assessment.
skin turgor.
of the eye
by frequent questioning.
NURSING DIAGNOSIS: Acute pain related to surgical intervention as evidenced by patient verbalisation and pain
scale assessment
INJ.TRAMADOL 100mg IV
Administer analgesics as per
Reduce the pain level .
BD is administered to the
physician order.
patient.
Patient verbalised that now
Evaluate the patient the pain level is reduced. The Know the outcome of the
condition. pain level is 3. nursing care.
1 2 3 4 5 6 7 8 9 10
Temperature: 98.6*F;
Pulse:84beats/minute;
Reassess the patient Know the patient condition.
Respiration :
condition. 28breath/minute;
Blood pressure: 110/80mm
Hg
SBJECTIVE DATA :Client verbalized that, he has not able to take fluid
OBJECTIVE DATA :Client looks dull, present with sunken eyes, dry lips, B.P.90/70 mm of Hg.
NURSING DIAGNOSIS: Fluid volume deficit related to NPO( nil per oral) Evidenced by dry lips, Blood Pressure-
100/70mmof Hg
1.Assess the vital signs. 1. Assessed the vital signs 1. It gives the baseline data for
treatment.
Temp-1000 F,
IMPLEMENTATION RATIONALE
PLANNING
Encouraged the patient to take more It helps to promote the fluid level
amount of fluid such as fresh juices,
3. Advice more fluid intake
kanjee, more amount of water as per
DR’S order
Induce appetite.
Advice the patient to Brush your teeth several times each day.
REGARDING MEDICATION:
BOOK REFERENCE:
JOURNAL REFERENCE:
WEB REFERENCE:
1. http://medplus.org
2. http://medsurg.org
3. http://medversery.org