DIAGNOSIS: LEFT PAROTID TUMOR 2O DYSPHAGIA

WARD: WARD 1

SEX: FEMALE

AGE: FORTY FOUR YEARS

OCCUPATION: ARTISAN

RELIGION: CHRISTIANITY (PENTECOSTAL)

PLACE OF ORIGIN: ABIA STATE.

DATE OF ADMISSION: 9th JUNE, 2022.

DATE OF STUDY COMMENCEMENT: 16TH JUNE, 2022.

DURATION OF STUDY: FOUR WEEKS (29 DAYS)

DISCHARGE DATE: 14th OF JULY, 2022.

SUPERVISOR: DTN MODESTA UGWUANYI

PHYSICIAN IN-CHARGE: Prof EZEANOLUE, Dr OFOEGBU

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 OVERVIEW

The human salivary glands are a group of compound exocrine glands that produce saliva, an

important fluid required for lubrication, immunity, mastication, deglutition, taste, speech etc.

They synthesize and secrete saliva, a multifunctional fluid which provides mucosal lubrication,

salivary electrolytes, antibacterial compounds and various enzymes to protect the oral mucosa

and teeth surface (Carpenter, 2013; Feller et al., 2013). Normal outflow of saliva in an adult is 1-

2l/day. Tumors of the salivary gland are not common and generally compromise 2%- 4% of

neoplasms in the head and neck (Kadletz et al., 2017). It has been reported that 80% of salivary

gland tumors arise in the parotid glands while 10%- 20% arise in the other major salivary glands

(Tian, Li and Li, 2010). Causes of salivary gland tumors is mostly due to infections, liver

cirrhosis, salivary duct stones, major hip and abdominal repair surgeries, Sjorensyndronme,

dehydration, salivary gland infections, other cancers, sarcoidosis.

Classification of Salivary Glands

1. On the basis of secretion, they are classified as a) serous b) mucous

2. On the basis of size and location, they are classified as

Salivary gland

Major
Minor

Parotid Labial and Glossopa Palatine Lingual

Submandibular Sublingual
buccal latine

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There are hundreds of minor salivary glands throughout the mouth and the aero digestive tract.

Unlike the major salivary glands, these glands are too small to be seen without a microscope.

Most are found in the lining of the lips, the tongue, and the roof of the mouth, as well as inside

the cheeks, nose, sinuses, and larynx. Their major function is to lubricate the walls of the oral

cavity. Minor salivary gland tumors are extremely rare. However, they are more likely to be

cancerous than benign. Cancers of the minor salivary glands most often begin in the roof of the

mouth.

The Submandibular gland: they are found under the jaw and are smaller. They produce saliva

underneath the tongue. Around 1 to 2 of 10 tumors benign in these glands and around half are

cancerous.

The Sublingual glands: these are the smallest and are located under the floor of the mouth

below either side of the tongue. It’s rare to have tumors start in these gland.

The Parotid gland: these are located right in front of the ears on each side of the face and are

the largest salivary glands. The parotid gland is the largest of the three major salivary glands; the

gland is roughly wedge-shaped and is divided into two lobes (superficial lobe-80% and deep

lobe- 20%). It is the most affected by tumor among other salivary glands. Around 7 out of 10

salivary gland tumors develop here. Most are benign, but most malignant also start at the parotid

gland. Parotid tumors are more common in females than males and it has a peak incidence in the

4th and 5th decade of life (Bello, Famurewa and Omoregie, 2020), this may be due to slow

growing nature of the benign tumors. The relationship of the facial nerve to the parotid gland is

responsible for many of the difficulties and complications of parotid sugery (Shashinder et al.,

2009).

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Anatomy of the Parotid Gland

As the term ‘parotid’ implies, the parotid glands are situated anteriorly and inferiorly to the

external ear. It arises as an epithelial proliferation from the lining of the oral cavity at 5 weeks

post ovulation. Saliva drains via a parotid duct (Stensen duct) that pierces the buccal mucosa in

the region of the 2nd upper molar tooth, the facial nerve and its multiple branches pass through

the parotid gland. About 70% of the gland is superficial to the facial nerve and its branches. It

contains lymph nodes that may become involved by metastatic disease, lymphoma or infection.

Parotid tumors occur mostly in the superficial lobe. The deep lobe extends into the retro

mandibular sulcus and is related on its deep aspect, to the styloid process and deep to the internal

carotid artery.

Etiology

Two main theories of how parotid gland tumors arise are;

1. The multicellular theory: this theory states that each tumor type forms from a specific

differentiated cell of origin within the salivary gland unit.

2. The stem theory: this states that the tumors arise from reserved stem cells of the salivary

duct system. The excretory stem cells give rise to mucoepidermoid and squamous cell

carcinoma, while intercalated stem cells can lead to pleomorphic adenomas, adenoid

cystic carcinomas, oncocytomas and acinic cell carcinomas.

Epidermiology

Salivary glands are a common sour e of benign pathology; malignant tumors are rare.

Approximately 300 cases per year of primary salivary gland malignancy are registered in the

United Kingdom, of which fewer than ten occur in children (Sood, McGurk and Vaz, 2016).

Patients with malignant lesions typically present in their sixth decade. The worldwide incidence

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is estimated at 0.5 to 3.0 per 100,000 per year, accounting for about 5% of all head and neck

malignancies (Stenner and Klussmann, 2009). The overall 5 year survival of malignant salivary

disease depends on the stage of the disease but has been reported around 70%.

Risk Factors

1. Exposure to substances or metals in the workplace such as plumbing, asbestos mining,

wood making and presence of nitroso compounds in rubber manufacturing

2. Older age: while salivary gland tumors can develop at any age, they often develop in

older adults.

3. Radiation exposure: medical radiation or UV light therapeutic treatments like that used

for treating neck and head cancers increases the risk of parotid, also exposure to full

mouth dental x-rays have been linked to and increased risk.

4. Excessive cigarette smoking, tobacco and alcohol consumption.

5. Certain viral infections such as Epstein-Barr virus, human papilomavirus and human

immunodeficiency disease might lead to an increased risk of salivary glands cancers.

Signs and Symptoms

1. Lump Or swelling close to or on the jaw or in the mouth or neck.

2. Muscle weakness on one facial side.

3. Dysphagia

4. Persistent pain in the salivary gland area

5. Difficulty opening the mouth wide.

6. Numbness and weakness of the muscles on one side of the face

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Classification of Parotid Tumour
1. Epithelial

Benign (Adenomas)
a. plemorphic adenoma
b. monomorphic adenoma
 warthins tumor
 omocytoma
 basal cell adenoma

2. NON epithelial
a. Hemangioma
b. Lymphangioma
c. Neurofibroma
3. Malignant Lymphoma

Functions of Parotid Glands

1. Protection of the oral cavity and oral environment. The constant secretion of saliva

prevents desiccation of oral cavity.

2. Lubrication and cleansing of oral cavity: provides a washing action to flush away debris

and non-adherent bacteria and provide lubrication for smooth and shading movement.

3. Initiation of starch digestion: the action of amylase on ingested carbohydrate to produce

glucose and maltose in the mouth.

4. Immunological defense: the defensive substance in saliva is the immunoglobulin’s. The

predominant salivary immunoglobulin is IgA.

Diagnosis

 Physical examination

 Imaging tests: such as, x-ray, ultrasounds scans.

 Biopsy: collection of a sample of the tissue to know whether the cells are cancerous.

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Management

1. parotidectomy

2. parotidomandibulectomy

3. temporoparotoidectomy

Prevention

1. avoid exposure to certain infections

2. avoid tobacco

3. avoid certain workplace exposures

Treatment

• Surgery

• Chemotherapy

• Radiation therapy

DYSPHAGIA

According to Philipsen (2019), dysphagia means difficulty with chewing or swallowing

food or liquid.It is caused by a blockage or malfunction in the mouth or nervous system.It

can affect the person’s ability to maintain nutrition and hydration thus affecting health

and quality of life. Dysphagia can be a serious health threat because of the risk

of aspiration pneumonia, malnutrition, dehydration, weight loss, and airway obstruction,

and it exerts a large influence on the outcome of rehabilitation (eg, length of hospital

stay, mortality/morbidity) (Patel et al., 2018).

Types of Dysphagia

 Esophageal dysphagia

 Oropharyngeal dysphagia. Source; (Jameson et al., 2009)

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Dysphagia can be secondary to defects in any of the 3 phases of swallowing, which are as

follows;

 Oral phase: This involves the oral preparatory phase and the oral transit phase.

 Pharyngeal phase

 Esophageal phase

Causes

 Bad dentition
 Xerostomia
 Tumors
 Complications of head or neck surgery
 Problems with the jaw
 Alzheimer disease
 Stroke
 Traumatic brain injury (TBI)
 Parkinson disease
 Cerebral palsy
 Multiple sclerosis
 Vitamin B-12 deficiency

Signs and Symptoms

 Regurgitation
 Pain while swallowing
 persistent drooling of saliva
 Frequent heartburn
 Food or stomach acid backing up into the throat
 Unexpected weight loss
 Coughing or choking on food or liquid

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Complications of Dysphagia

 Pulmonary complications such as pulmonary fibrosis.

 Dehydration
 Malnutrition
 Anorexia
 Weight loss
 Respiratory problems, such as aspiration pneumonia or respiratory infections
 Fatigue
 Cognitive confusion
 Loss of dignity
 Feelings of isolation, anxiety and depression
 Decreased quality of life

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Family/ Social History

A forty-four (44) year old woman who hails from Amankpu, Ugwunakpo Local Government

Area in Abia State. She is the second child and first daughter in a family five (two boys and three

girls) who are all alive. She is single and resides at Independence Layout Enugu in a one

bedroom apartment. She is a member of the United Evangelical by Religion and artisan by

occupation. Her main source of drinking water is sachet water and the method of fecal disposal is

water closet.

Past Medical History

Patient has never been admitted on account of any illness. She is not hypertensive, diabetic and

has no history of sickle cell anaemia. She has no drug allergy and there is no history of such in

her family. No history of blood transfusion.

Present Medical History

Patient was apparently well until eight (8) months ago prior to admission when she noticed a

small swelling about the size of a peanut in the left part of her face (behind her ear). She

presented it to an unknown chemist who started injecting an unknown substance into the mass;

which later became purulent and incised in the centre. There was substantial loss of blood on two

occasions of the intra lesioral injection and on one of the occasions, she slipped into

unconsciousness and she was rushed to a hospital where she was resuscitated but there was no

blood transfusion.

The mass continued to increase in size with gross ulceration of the surrounding skin and about

two (2) months ago before admission; she noticed a facial deviation to the right, increase in pain,

difficulty in swallowing, pedal oedema. There was occasional iniput sweats and fever, weakness

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and obvious weight loss. She was admitted in ward 1 at UNTH on the 9 th of June, 2022, and on

the 16th of June, 2022, she was referred to the nutrition and dietetics department for expert

dietary management. She was seen and assessed on the same day.

Anthropometry

Weight and height were obtained using a bathroom scale (HANA) and non-stretchy tape

respectively. Body mass index (BMI) was determined using the Lambert AdolphenQuetelet

formula. Which state;

BMI= weight (kg)

height (m2)
Weight obtained was 46kg with bilateral pedal edema present.

Weight =46kg
Height=152cm=1.52m2

BMI=19.9kgm−2 normal range (18.5-24.99kgm−2).

Broca’s theory for calculating ideal body weight(IBW):

This was used to determine the ideal body weight and it is gotten by subtracting 100 from the

height of an individual.

=Height (cm) ̶ 100

=152-100= 52kg
Therefore the ideal body weight of the woman is 52kg whereas she was weighing 46kg
Subsequent anthropometric assessment:

Date Weight (kg) Height (m2) BMI (kg/m2)

29/06/22 42 1.52 18.2
06/07/22 42.3 1.52 18.3
14/07/22 42.8 1.52 18.5
21/7/22 44 152 19.5

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Biochemical Assessment

Table 1: Serum creatinine test (09/06/2022)

SEUCr RESULT NORMAL RANGES REMARK

Sodium 132mmol/L 135-145 Hyponatraemia

Potassium 3.5mmol/L 3.5-5.0 Normal

Bicarbonate 24mmol/L 22-28 Normal

Chloride 100mmol/L 97-108 Normal

Urea 3.1mmol/L 2.1-7.1 Normal

Creatinine 6.3umol/L 53-150 Normal

Hyponatremia occurred as a result of increased production of the anti-diuretic hormone (ADH)

leading to excessive water retention which dilutes the sodium concentration hence increasing

sodium retention in the body.

Table 2: Liver function test (LFT) (10/6/22)

LFT RESULT NORMAL RANGES REMARK

Total bilirubin 4.9mmol/L 0-34 Normal

Alkaline phosphatase 25 IU/L 25-92 Normal

Alanine transaminase 10 IU/L <45 Normal

Alanine transaminase 15 IU/L <45 Normal

Hemoglobin level (Hb) =5g/dl(severely anemic) (13-15g/dl). (This was as a result of the

ulcerated tumor and inadequate food intake).

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Nutrition-Focused Physical Findings

Patient was met in a sitting position, conscious and alert, in no obvious respiratory distress but

have difficulty in speech due to facial swelling on the left side, afebrile, anicteric, pale, not

dehydrated, presence of bilateral leg edema.

Table 3: Vital Signs Chart

Day TEMP (0C)(36.5- BP (mmHg) PR (b/m)(80- RR (c/m)(25-35)

37.2) (80- 130)
130mmHg)

16/6/22 36.6 120/90 104 26

17/6/22 37.2 110/70 130 30

18/6/22 36 110/70 84 24
19/6/22 37 110/80 114 26
20/6/22 36.7 120/70 88 26
21/6/22 36 120/80 136 24
22/6/22 36.8 120/80 121 24

23/6/22 35.9 110/80 103 22

24/6/22 36.6 110/70 110 26
25/6/22 36.5 100/70 82 26
26/6/22 36.2 100/70 82 26
27/6/22 36.2 110/70 82 24
28/6/22 36 110/80 30
29/6/22 36.6 120/80 80 26

30/6/22 36.2 130/80 82 24

31/6/22 36.8 110/80 121 24

1/7/22 36.4 120/70 130 26

2/7/22 36.2 120/80 96 26
3/7/22 36 100/70 96
4/7/22 37.5 120/70 82 26
5/7/22 37.2 120/80 84 28

6/7/22 37 120/80 82 26

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 7/7/22 37.1 120/70 102 26
8/7/22 36.8 120/80 92 30

9/7/22 36.1 120/70 110 26

10/7/22 36.4 110.80 103 24
11/7/22 36 110/80 92 30
12/7/22 36.2 110/80 102 24
13/7/22 36.5 110/80 116 24

Food And Nutrition Related History:

Food frequency, likes and dislikes was used to obtain information on patient’s food intake.

Food history gotten from caregiver (sister) showed that she eats and tolerates all locally available

foods prior to onset of the disease condition. She likes rice and stew or swallows (akpu or garri)

with any available soup and also eats cocoyam and yam. She mostly buys her food from food

vendors and eats 3-4 times daily. She rarely takes fruit nor drinks water. She takes spirit

sparingly (100ml weekly) but does not take cigarette or tobacco in any form. She also likes

confectionaries like meat pie, doughnut, and cakes.

24-hour dietary recall revealed;

Breakfast: 400ml tea (fortified with one sachet of milk and milo 20g each) with bread (5
slice=150g).
Lunch: 133g jollof rice +90g fish.

Supper: 300g garri+200ml okro soup+90g fish.

Breakfast: At the time of arrival, the patient had not eaten.

The estimated energy intake was 1500kcal/day against normal range

(2000kcal/day-2200kcal/day).

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Calculation of Energy RequirementUsingHarris Benedict Equation

Basal energy expenditure (BEE) for female

=655.1 + (9.56×ideal body weight (kg)) + (1.85×height (cm))- (4.68×age (years)).
BEE=655.1+ (9.56×52)+(1.85×152)-(4.68×44)
Activity Level (AL)
=1595.75kcal. Confined to bed=1.2
Estimated energy needs (EEN)= BEE×AL×IF Ambulatory =1.3
EEN=1595.75×1.3×1.2
Injury factor (IF)
2489.37 Approximately 2500Kcal/day Infection factor=1.2-2.6

Calculating patient’s energy need using Estimated Energy Requirement (EER)

The EER of patient is 2500Kcal/day.

Percentage calorie distribution according to ADA, 2010

CHO = 50-65% (60%)

PROTEIN= 10-20% (20%)

FATS=20-35% (20%)

Patient percentage (%) caloric distribution

CHO= 60 x 2500/100

=1500/4 =375g

PROTEIN = 20 x 2500/100

=500/4 =125g

FAT= 20 x 2500/100

=500/9 =55.6g.

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Table 4: Estimation Of Energy Intake Using 24-Hours DietaryIntake

FOOD QUANTITY ENERG CARBOYDRATE PROTEIN FAT SOURCE

Y (g) (g) (g)
(KCAL)

BREAKFAST

Milk 20g 98.95 15.2 10.1 10.5 FAO,

2019

Milo 20g 80.6 - 3.2 3.2 FAO,2019

Sugar 10g 40 10 - - PLATT,

1985

Bread 150g 373.5 75.75 11.1 19.5 FAO,

2019

LUNCH

Fish 90g 65.7 - 6.33 0.18 FAO,

6 2019

Jollof rice 133g 194.2 36.68 3.53 1.78 NFCT,

2016

DINNER

Fish 90g 65.7 - 6.33 0.18 FAO,

6 2019

Okro soup 200ml 293.6 8.26 6.42 2.96 FAO,

2019

Garri 300g 283.15 69.8 0.57 0.17 FAO,

2019

Total 1495.8 215.7 47.3 38.5

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Nutritional Diagnosis

 Swallowing difficulty related to medical condition (parotid tumor) as evidenced by

food/nutrition related history (decreased estimated food intake) and client history

(dysphagia). (NC-1.1).

 Inadequate energy intake related to increased nutrient needs due to prolonged catabolic

illness (ulcerated tumor) as evidenced by biochemical data (low hemoglobin 5g/dl)

and chronic pain management. (NI- 1.2).

Goals for Medical Nutrition Therapy TherapyIn Tumor And Dysphagia

The main goal is to maintain optimum nutritional status.

Its Specific goals are to;

• Maximizenutritional intake while maintaining safe eating.

• Achievea desirable body weight.

• Provide a therapeutic diet that will help patient manage symptoms.

• Protect immune function.

• Prevent further complications

Source: (Politzer, 1998).

Nutrition Intervention

 Patient/caregiver were counseled on adequate diet and patient was placed on

2500kcal/day of high carbohydrate, high protein soft diet.

 Caregiver was counseled to use small but frequent feeding method to help increase food

intake.

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  She was counseled on iron rich foods to help build her hemoglobin level.

 To increase fruit and vegetable intake (smoothie recommended).

 Liberal intake of water.

 Caregiver was counseled on the need to maintain proper hygiene.

TABLE 5: A Day Menu Of Food Patient Ate While In The Hospital

Ingredient Quantity Energy Carbohydrate Protein Fat Reference

Breakfast

Stew 200mls 26 6.35 14.52 21.9 NFCT, 2016

Soft boiled yam 300g 396 80.4 8.5 1.2 NFCT, 2016

Pap 400mls 289.6 69.6 0.578 0.24 Platt, 1985

Milk 20g 100 7.51 5.08 3.21 Platt, 1985

Soya bean 20g 76.4 5.96 6.97 2.47 Platt, 1985

Sugar 10g 40 10 - - Platt, 1985

Lunch

Beef 90g 166.5 - 17.2 13 FAO. 2019

Okro soup 200mls 293,6 8.26 6.42 2.96 FAO, 2019

Semovita 300g 283.15 69.8 0.57 0.17 FAO,2019

Dinner

Frozen fish 135g 137.5 - 10.2 0.3 FAO, 2019

Jollof rice 300g 438.1 82.5 7.95 4.025 NFCT, 2016

Water melon 150g 46.44 0.84 0.56 - NFCT, 2016

Total 2534.29 341.22 78.55 49.47

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Monitoring And Evaluation

 Patient was monitored for a period of Twenty nine (29) days. I monitored;

 Compliance and adherence to dietary regimen: She was strictly complaint to the dietary

regimen as she started feeding from the therapeutic kitchen at UNTH.

 Food intake and tolerance (she tolerated soft foods and smoothies better than solid food

but after the surgery, her food intake increased and her appetite level returned to normal)

 Her surgery was cancelled twice on (21/6/22 and 23/6/22) by the doctors but she was

later operated on the 24/6/22.

 Five unit of whole blood (four units before surgery and one unit post operation) was

transfused to her during this period.

 Weight gain (she lost 3kg after surgery due to catabolic breakdown that occurred during

surgery and also as a result of the tracheostomy inserted to clear the airway thus causing

difficulty in swallowing but she gradually gained weight as she began tolerating foods

better).

 Her condition improved and the objectives of the case study were achieved as evidenced

by weight gain of 42.8kg.

 She was discharged on 14/07/2022on account of coming for regular checkup and dressing

every Thursday until told otherwise.

 Biopsy done showed that the tumor was not malignant.

Counseling on Discharge

 Patient was encouraged toeat vegetables and fruits and also to take ample of water.

 She was encouraged to maintain optimum hygiene.

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 Caregiver was encouraged to provide food for her on demand so that she can attain her

ideal body weight as she (caregiver) was already complaining that the patient is eating

too much based on her demand.

 She was adviced to come back for check up in the medical out-patient dietetic clinic.

Follow up

On the 21/07/2022, patient came for dressing and checkup after which she came to the

medical out-patient dietetic clinic. Her weight was 44kg against 42.8kg when discharged.

She also said that she now eats well just like she does before the onset of the

disease.condition.

Other Medical Professionals that Managed the Patient

 Nurses.

 Doctors.

 Medical laboratory scientists.

 Pharmacists

 Radiologist.

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 NUTRIENT-DRUG INTERACTION

Drug Route Function Nutrient-Drug Interaction

Vit A (10,000 Iu) Oral Aids In normal vision and boost Fat helps with Vit A
Immune System absorption
VitBco Oral Prevents infection and help promote No known interaction
cell health.
Vit C (500mg) Oral Aids to boost immunity and production Enhances the absorption of
of white blood cells iron
Vit E (1000iu) Oral Acts as an antioxidant and aids in It might decrease some
proper functioning of many organs in beneficial effects of niacin.
the body.
Cocodamol Oral Used to treat aches & pains No known drug-nutrient
interaction
Losartan Oral For high blood pressure and protect the Potassium supplements, high
kidneys from damage due to dm. It potassium foods and juices
belongs to a class of drug called should be avoided by those
angiotensin ii receptor antagonists taking losartan
Flagyl (8mg) IV An antibiotic and antiprotozoal used to Foods That Contain
treat infections Tyramine (An Amino Acid)
That Cause Bp To Spike If
Taken With Flagyl
Fesolate (200mg) Oral Used to treat anaemia, brittle bones and Vit D & K Increase
deficiency syndromes Metabolism Of Folate
Ciproflaxacin Oral An antibiotic used to treat bacterial Products That Contain
(500mg) infections Mg,Ca, Fe, Al And Other
Minerals May Interfere With
The Drug
Syrup Brochylolyte Oral Used in the treatment of cough with No Know Interaction
(10mls) mucus
Ibuprofen (B/D Oral Used as an anti-inflammatory drugs Can Cause Calcium Loss
×1/52) Through The Urine And May
Cause Sodium And Water
Retention

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