Case Report: Nutritional

Management of Head and

Neck Cancer
Priscilla E. Bloom
ARAMARK Dietetic Internship
March 9, 2014
Abstract
52 year old Caucasian male
Hypopahryngeal cancer
Scheduled follow up showed uncontrolled
diabetes and hyponatremia
PEG tube placement
Enteral Nutrition
Disease Description
Hypopharyngeal cancer occurs when malignant
cancer cells are found on the tissues of the
hypopharynx (1).
The chances of developing hypopharyngeal
cancer increase with the use of tobacco products,
alcohol, an unbalanced diet, and having Plummer-
Vinson syndrome, a disorder resulting in iron
deficiency and web-like growth of membranes in
the throat.
Disease Description Cont.
Stages of hypopharyngeal cancer:
Stage 0 (Carinoma in Situ): abnormal cells are found in the
lining of the hypopharynx, which can become cancerous or
metastasize.
Stage 1: cancer has formed in the hypopharynx and/or tumor
size is two centimeters or smaller
Stage 2: in this stage the tumor is either between two and four
centimeter large and has not spread to the larynx or the tumor is
found in more than area of the hypopharynx
Stage 3: the tumor is larger than 4 centimeter and/or has
metastasized to the larynx, esophagus, or nearby tissues of the
hypopharynx
Stage 4:
Tumor has spread to cartilage around the thyroid, trachea, or
nearby tissue.
Timor has spread to one or more surrounding lymph nodes

Evidence Based
Recommendations
Evidence Analysis Library
Use enteral nutrition (EN) to increase calorie and
protein intake for outpatients with stage III or IV
head and neck cancer undergoing intensive
radiation treatment. Maintenance of nutritional
status by EN during radiation therapy may
improve tolerance of therapy to promote better
outcomes.

Role of nutritional status in predicting quality of life
outcomes in cancer- a systemic review of the
epidemiological literature
Twenty-six articles
Six article specific to head and neck cancer
All six articles concluded that better nutritional
status positively correlated with quality of life,
three of which showed a relationship between
weight loss and swallowing function.
Nutritional Surveillance and Weight Loss in Head
and Neck Cancer Patients
Two-year study evaluated if therapeutic approach,
tumor site, tumor stage, BMI, gender, age, and
civil status predicted body weight loss.
Strongest predictor for weight loss was tumor
stage
Mean maximum weight loss for patients receiving
EN and per oral feeding was 13% and 6%
respectively
Wait-and-See approach for PEG insertion
Case Presentation
A 52-year old Caucasian male who had a scheduled
follow up with his physician.
Upon arrival the patient presented with severe
hyperglycemia with a blood sugar of 712. The patient
was also found to be hyponatremic with sodium of 120
and a creatinine level of 2.4 with a GFR of 30.
Patient was recently diagnosed with moderately
differentiated squamous cell carcinoma of the
hypopharynx and was receiving chemotherapy and
radiation treatment.

Nutrition Care Process
Assessment
Client History
Married and lives at home with his wife.
The patient has a significant history of alcohol use and
had a 30-50 pack year history of smoking, although, he
stated that he quit six months ago.
Family history shows that cancer is prevalent in this
patients family with his father passing away from
cancer at the age of 69 and his mother passing away
at the age of 68 from liver and bone cancer.
The patients medial history is remarkable for diabetes
and compensated liver cirrhosis of unknown etiology
and hypopharyngeal cancer.
Food/Nutrition-Related
History
No specific diet or the use of supplements.
Meds: Hydrochlorothiazide 12.5 mg one table by
mouth daily, Lisonopril 20 mg one table by mouth
daily, Metoprolol 100 mg one table by mouth,
Compazine 10 mg one tablet by mouth every 6
hours as needed for nausea and vomiting.
The patient was previously on Glipizide 5 mg by
mouth twice a day, and was previously on
Metformin 1000 mg one table by mouth twice a
day.
Nutrition-Focused Physical
Findings
Severe swallowing difficulties
Dentures
Poor p.o. intake
Glucerna shakes
1800 kcal ADA diet
Anthropometric
Measurements
5 feet 9 inches and weighed 240#
BMI of 35.4 (Obese)

Biochemical data, Medical
Tests, and Procedures
Nutrient Needs
Estimated needs were based on patients current
cancer condition, acute renal failure, and ideal
body weight as actual body weight was greater
than 125% IBW

Nutrient Needs cont.
ARAMARK Nutrition Status
Classfications
Fair appetite (75% of needs for > 2 weeks) (2
points)
BMI Range >35-39 (3 points)
Albumin 3.0-3.4/Prealbumin 10-15 (2 points)
Uncontrolled Diabetes (3 points)

Malnutrition Identification
Six characteristics suggest malnutrition
Insufficient energy intake
Weight loss
Loss of muscle mass
Loss of subcutaneous fat
Localized or generalized fluid accumulation that may
sometimes mask weight loss
Diminished functional status as measured by
handgrip strength.

Nutrition Care Process
Nutrition Diagnosis
Swallowing difficulty (NC-1.1) RT mechanical
causes AEB pt's comments, decreased estimated
food intake, reports of drinking Ensure TID prior to
admission.

Intervention
1. Carbohydrate-modified diet (ND-1.2): Continue with
1800 ADA diet, as tolerated by patient, to meet caloric
needs and aid with glucose control.
2. Commercial beverage (ND-3.1.1): Will send Glucerna
TID per pt's request. Glucerna TID will provide
additional 660 kcal and 29.7 g protein 432mL water if
consumed.
3. Enteral Nutrition (2.1): Continuous feeding of Glucerna
1.5 at 55 ml/hr with 30 ml flush every hour to provide
1584 kcals, 79.2 g PRO, and 1782 ml total fluid. *


Nutritional Goals
1. Patient will drink 100% supplement
2. Tolerance to enteral nutrition
3. Maintain skin integrity
4. Maintain current weight
5. Nutrition labs within normal limits

Monitoring and Evaluation
Nutrition-Focused Physical Findings (PD): skin
(1.1.8)
Anthropometric Measurements: weight/weight
change (1.1)
Biochemical Data, Medical Tests and Procedures
(BD): glucose (1.5),
Food/Nutrition-Related History (FH): Enteral
nutrition (1.3), nutritional supplements (1.2.1)

Conclusion
Intern was allowed to sit in on the last follow up
visit with the patient who reported a 14 pound
weight gain and better swallowing function.
The patient did report some taste alterations but
overall the patient and his wife seemed to be very
excited over the patients improvement.
References
1.Hypopharyngeal Cancer Treatment (PDQ). National Cancer Institute at the National institutes of
Health. http://www.cancer.gov/cancertopics/pdq/treatment/hypopharyngeal/HealthProfessional Updated
on February 28, 2014. Accessed on March 2, 2014.
2. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682571.html#side-effects
3. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a692051.html#side-effects
4. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682864.html#side-effects
5. http://www.nlm.nih.gov/medlineplus/druginfo/meds/a682116.html#side-effects
6. Ehrrson Y, Langius-Eklof A, Laurell G. Nutritional surveillance and weight loss in head and neck
cancer patients. Support Care Cancer. 2012; 20: 757-756.
7. Lis C, Gupta D, Lammerfeld C, Markman M, Vashi M. Role of nutritional status in predicting quality of
life outcomes in cancer- a systemic review of the epidemiological literature. Lis et al, Nutrition Journal.
2012; 11(27): 1-18.
8. Oncology (Onc) Head and Neck Cancer: Radiation and Use of Enteral Nutrition (EN). Evidence
Analysis Library.
http://andevidencelibrary.com/template.cfm?template=guide_summary&key=1754&highlight=Radiation%
20and%20Use%20of%20Enteral%20Nutrition&home=1. Accessed on March 6, 2014.