You are on page 1of 16

COURSE TITLE: NRSG 428 COURSE CODE: SPECIAL CONDITION SUBMITTED TO: VIOLA SIONGEI SUBMITTED BY: MATAYEN TAIKO REG

NO: BSN-1-292-06 PLACEMENT CASE STUDY

It has personnel strength of 11 consultant specialists from KNH and UON. with an occupancy rate of 65. It does 7 operations per day in satellite theatre while in main theatre10 per week. Established in 1901 with a bed capacity of 40. Inpatient services offered in Ward 5C: ENT/Head/Neck surgery: Outpatient services offered in ENT clinic No. The inpatient services are located in ward 5C of the hospital Tower Block. Out of the total bed capacity of 1800. 7 in the ward and 6 in the clinic. 1 earmould technician. The department has an operation capacity of 60 patients per day seen in consultants clinic while 75 are seen in filter clinic. 2 audiologists. 24 theatres (16 specialised) and Accident & Emergency Department.Introduction KNH has turned 106 years and it had its Centenary Celebration in 2001. The Hospital was built to fulfil the role of being a National Referral and Teaching Hospital. and medical records clerks serving in the clinic.420 patients per year. preventive and rehabilitative care of patients in the hospital and the country as a whole. The department admits 1. KNH became a State Corporation in 1987 with a Board of Management and is at the apex of the referral system in the Health Sector in Kenya. 34: a) Consultation of new and old patients b) Audiological services c) Hearing assessment .2%. The department has a satellite theatre in Clinic No. 36 nurses in the ward and 14 in the clinic. about 8 registrars. KNH has 50 wards. 34. 1 hearing therapist. 34 located in the hospital Clinics Block. as well as to provide medical research environment. while the outpatient is run in ENT clinic No. The ENT department The department offers both inpatient and outpatient services in the hospital. 12 support staff. The departments¶ main goal is to provide an excellent curative. 22out-patient clinics. 209 beds are for the Private Wing.

Staffs attend various workshops. clinical officers and audiology. He has bee to theater on2 3rd March 2011 for alcohol injection and on 11th November 2011 for lingual artery ligation. UON and KMTC. conferences and Continuous Medical Education (CME) both locally and internationally. Each episode consisted of the loss of 2 spoonfuls of bright red blood after which bleeding would spontaneously stop. was a referral from Muranga district hospital. from college of health sciences.d) Fitting of hearing aids e) Speech therapy: Teaching/Training/ Research/Partnership The department offers facilities for teaching and training to ENT surgeons. but also affected the normal life of the patient. Case justification Among the different sites of head and neck hemangiomas. In contrast to vascular malformation. the tongue requires special consideration because of its susceptibility to minor trauma and consequent bleeding and ulceration. although the major concern is cosmetic issues in most cases. . Examination of the mass several years prior at another facility revealed a hemangioma. swallowing difficulties and breathing problem. research work presentation at various forums both locally and internationally. where he has been an inpatient since then. He was then readmitted on 3rd November the year 2011. both medical students and nurses. with a diagnosis of base of tongue hemangioma. Recently. Tongue hemangiomas are common but in base of tongue (BOT) hemangioma are extremely rare. the mass increased in size and he experienced multiple episodes of bleeding. The department is involved in research by all levels of staff cadre: registrars¶ thesis. They pose a difficult problem in view of the tongue being a mobile inquisitive organ is more prone for trauma and subsequent complications. My case study client who had been admitted on 27th October the year 2009. most hemangiomas regress in response to medical treatment or with conservative managements but this case which not only did not regress.

rich and intricate blood vessels which may be a predisposing factor for a variety of vascular lesions. and mixed types. Vast majority of hemangiomas are known to be regressive. Hemangiomas and vascular malformations are diagnosed fairly easily with a careful history and a physical examination. Large lesions.Literature review Hemangiomas are benign tumors of vascular tissue which are caused by newly formed blood vessels and most likely to be seen at the head and neck region. Haemangiomas are among the most common neoplasms which are encountered in the paediatric. they could sometimes cause significant bleeding. Although hemangiomas are common in infancy and childhood. cavernous. and even swallowing. if they are large enough. soft. Cavernous hemangiomas are blue. Although most hemangiomas of the tongue are asymptomatic. They are the most common tumors of the childhood. Most of these lesions are described hematomas instead of tumors. This is why several modalities of less invasive treatment have recently been advocated to avoid functional disability caused by tissue loss. Hemangiomas show rapid growth until 6-8 months and involute by 5-9 year. Vascular malformations show slow growth throughout life with increase in response to infection. trauma. Also. if excised. . they are probably developmental abnormalities rather than true neoplasms. could result in significant functional disability. hence the name hemangiolymphangiomas. pain or difficulty in chewing. Small lesions can be excised with impunity. Epidemiology The oral cavity and the head and neck regions possess complex. Osseous involvement of the hemangiomas is rare but 35% of the vascular malformations show osseous involvement. They show higher prevalence in women. there have been reports of treatment with superselective embolization using polyvinyl alcohol foam (Ivalon) and absorbable gelatin sponge (Gelfoam) particulates. or hormonal fluctuation and they do not involute. Some hemangiomas of the tongue have a lymphangiomatous component. speaking. spongy masses that are not encapsulated. Pathologists distinguish three classes: capillary.

Diagnostic tests Diagnosis of oral hemangiomas requires some form of imaging to determine their extent and flow characteristics. producing cosmetic deformity. a strong (2:1) male predilection in hospital-based studies. Angiography is considered the most definitive of the studies. Lingual haemangiomas pose distressing problems to the patients. although the angiographic appearance of intraosseous lesions is less well defined than that of soft tissue lesions. a central vascular malformation of the bone usually has a honeycombed appearance or cystic radiolucencies. the buccal mucosa (14% of cases) and the lateral borders of the tongue (14% of cases) but they may also occur at any oral or pharyngeal location. such as the trophoblast. On the other hand.4% of all the oral lesions in adults. 4. Causes The causes of vasoformative tumors are unknown. However. On plain films or panoramic radiographs. Frequently traumatized mucosal sites: the lip mucosa (63% of oral cases). may be the cell of origin for hemangiomas. conflicting evidence supports this hypothesis. a separate investigation found immunohistochemical staining of certain trophoblastic markers to be negative in all infantile hemangiomas that were examined. One hypothesis postulates that placental cells. recurrent haemorrhage and functional problems with speaking.In adults. Ultrasonography can be used to determine that a lesion is angiomatous in nature (ie. but it cannot be used to differentiate a hemangioma from a lymphangioma. deglutition and mastication. The relationship between hemangiomas and placental tissues needs further investigation. hemangioma. In population studies. Contrast-enhanced MRI can be used to differentiate a hemangioma from a lymphangioma in the oral cavity. 2. hemangiomas may arise secondary to some event in utero. lymphangioma). It comprises of 3. Therefore. haemangioma of the oral cavity is a rare occurrence. One study found placenta-associated vascular antigens to be expressed by hemangiomas but not by other vascular malformations or tumors. Intraosseous vascular malformations . 3. The following modalities may be helpful: 1. MRI appears to be highly reliable for lesions of either soft tissue or bone.

exhibit a normal rate of endothelial cell turnover. Hemangiomas are subclassified as capillary or cavernous. created by spicules radiating from the center. Hemangiomas (proliferative phase): a) Endothelial cell hyperplasia forming syncytial masses b) Thickened (multilaminated) endothelial basement membrane c) Ready incorporation of tritiated thymidine in endothelial cells d) Presence of large numbers of mast cells 2. A sunburst effect. Performing a biopsy of oral hemangiomas can be potentially dangerous. Moreover. obscuring the lumen of the capillaries.and abnormal appearing blood vessels occurs. immunohistochemistry to GLUT1 is a useful and easy diagnostic method that may be used to avoid such misdiagnosis. Intimal thickening or diverse arteriovenous connections can sometimes be seen in serial sections. The endothelial cells of early lesions may be plump. Hemangiomas (involuting phase): . Spaces are lined by endothelium without muscular support. depending on the size of the vascular channels. vasoformative tumors share many similar microscopic features. is often present. An increase in normal. CT scans often show an expansile process with a high-density amorphous mass that may be suggestive of fibrous dysplasia. Vascular malformations. Johann et al showed that histological diagnosis alone is not sufficient to correct diagnoses of oral hemangioma. Salient histopathologic findings of vasoformative tumors that distinguish them are as follows: 1. Phleboliths may develop as a result of dystrophic calcification in thrombi. as true structural anomalies. Procedures other than a clinical history or examination. including aspiration of intraosseous lesions that are used to diagnose oral hemangiomas readily produce frank blood. and overlap between hemangiomas and vascular malformations exists.show a nonspecific reticulated or honeycombed pattern that is well demarcated from normal bone. 5. Histologic Findings Histopathologically.

Vincristine has been reported to decrease the size of a large segmental mandibular hemangioma in the setting of PHACES syndrome. and airway maintenance. because of the extent of these benign lesions. leaving less of a functional . Complete surgical excision of these lesions offers the best chance of cure. High doses of systemic or intralesional steroids are the first-line treatment. and a dramatic response is observed in 30% of patients. Interferon is rarely used because of the risk of spastic diplegia. speech. As a result. such as swallowing. multiple adjunctive procedures have been introduced to eradicate the disease.a) Less mitotic activity b) Little or no uptake of tritiated thymidine in endothelial cells c) Foci of fibrofatty infiltration d) Normal mast cell counts 3. which is followed by severe functional impairment to vital functions. often. Vascular malformations: a) No endothelial cell proliferation b) Contain large vascular channels lined by endothelium c) Unilamellar basement membrane d) Does not incorporate tritiated thymidine in endothelial cells e) Normal mast cell counts Treatment Medical therapy The 2 primary medical treatments are steroids and beta-blocker therapy. lesions of the tongue may require near-total glossectomy. but. significant sacrifice of tissue is necessary. Steroids have become a mainstay in the treatment of proliferating hemangiomas in infants and children. For example. Surgical Care Surgical or invasive treatment of oral hemangiomas has evolved.

individual references on each therapy should be consulted. . In a broader definition. A full discussion of the procedure for each use and the associated costs and complications is beyond this review. In 1930. As technical expertise with interventional radiology advances. Agents for embolotherapy can be broadly divided into 2 groups: absorbable materials and nonabsorbable materials (see the List below). The tremendous upsurge in interest in embolization came with the advent of advances in catheter technology to allow highly selective delivery of agents. Although embolotherapy has attracted much interest in the last decade and a half. sclerosing. it also means any other occlusion that is obtained with a proliferating reaction of the vessel wall. These adjunctive procedures have also been used to reduce both the blood loss and the morbidity of surgical procedures. The nonabsorbable materials can be further subdivided into particulate. the options for treatment of vascular malformations and hemangiomas become broader. For a full discussion. and Spence described the preoperative injection of melted paraffin-petrolatum into the external carotid arteries of patients with head and neck tumors. and nonparticulate agents. the principle of vascular embolization for head and neck tumors is not new. Embolotherapy Embolotherapy is one of the more commonly used adjunctive procedures in the treatment of vascular tumors. Embolization literally means the occlusion of a vessel by the introduction of a foreign body. In 1904. Vessels can be treated not only via superselective catheterization but also through permucosal and percutaneous techniques. liquid. many are not FDA approved.impairment. Lussenhop. Dawbain. The Food and Drug Administration (FDA) status of the discussed materials should be investigated prior to their use. Brooks introduced particulate embolization when he described the occlusion of a traumatic carotid-cavernous fistula by injecting a fragment of muscle attached to a silver clip into the internal carotid artery.

Embolotherapy agents Absorbable materials are as follows: y y y y Autologous blood clot Modified blood clot Gelfoam Oxycel Nonabsorbable materials are as follows: y Particulate agents are as follows: o o o o o o o Acrylic spheres Autologous fat of muscle Ferromagnetic microspheres Methylmethacrylate spheres Polyvinyl alcohol (Ivalon) Silastic spheres Stainless steel pellets y Injectable (fluids) are as follows: o o o o Amino acid occlusion gel (Ethibloc) Isobutyl 2-cyanoacrylate Microfibrillar collagen (Avitene) Silicone rubber y Sclerosing agents are as follows: o o o o o Absolute ethanol Boiling contrast medium Polidocanol Sodium morrhuate Sodium tetradecyl sulfate (Sotradecol) y Nonparticulate agents are as follows: o o Stainless steel coils Platinum coils .

Additionally. a combination of surgical therapies is often needed. This method is successfully utilized in the treatment of extra oral lesions. Laser surgery costs much more expensive compared to cryosurgery. . it has several disadvantages when compared with cryosurgery. In this method. Laser surgery is a much more complex process compared to cryosurgery and requires general anesthesia. However. Postoperative scar formation is less in cryosurgery. However. with remnants of tumor deliberately left behind in order to preserve the maximum amount of surrounding normal tissues. However in laser surgery. for oral vascular tumors confined to the soft tissues. especially in intramuscular hemangioma. But. Laser surgery application can be hazardous around salivary gland ducts. postoperative edema is less and the procedure does not require to be repeated. a sclerotic agent is injected into or peripheral to the vein that the hemangioma originates from. Recurrence is not unusual unless the tumor is completely excised.o o o Silk streamers Plastic brushes Detachable balloons Laser surgery Laser surgery is another effective method used for the treatment of intraoral hemangiomas (5). Sclerotherapy Another method for the treatment of hemangiomas is sclerotherapy. to be applied together with other treatment methods. Nerve damage is less in cryosurgery and regeneration is quicker. Thus. often forces the surgeon to perform a simple debulking procedure. pressured bandage cannot be applied to the region after the injection of sclerotic agent in intraoral lesions. which should be taken into consideration. sclerotherapy is recommended Combination surgical therapy Complete surgical excision is a mainstay of treatment of vascular malformations if they are small and amenable to such therapy. Laser surgery is a much more complex process compared with cryosurgery. The lack of encapsulation and the infiltrating nature of the lesional border. laser surgery is a faster and more dramatic technique.

The patient complains of progressive dysphagia to solids of two months duration. but not to cryotherapy or intralesional steroids.e. and also growth deformity in the mandible. His past medical history was only significant for migraines.Epithelioid hemangioma responds to low-dosage radiotherapy. . Clinical examination of the neck did not reveal any mass or evidence of neck nodes. His mother reported he was delivered via normal spontaneous delivery and there was no noted vascular formation or hematoma that was evident during birth as well as infancy till three years ago. He has been complaining of moderate burning pain. The case My client by the name S. He has also not had any previous surgical case. The tumor did not have the characteristic features of hemangioma. the patient suffered from recurrent thrush infection and sleep problems i. and a BMI of 18. (approximately 300 cc) which needed pressure and packing. Histopathology revealed a capillary hemangioma with fibrin deposits. Past medical history He has no known chronic illness as well as any noted familial disease. A Christian by religion.8 kg of weight. A direct laryngoscopic examination showed a fleshy lesion over BOT extending across the vallecula next to the epiglottis. Blood group B+. He was a standard six pupil of Muranga township primary school before hospitalization. he had two episodes of small amount of bleeding per orally. but subsequently stopped spontaneously. Both his parents are alive as well as his siblings. He is approximately 4¶3 feet of height. History of presenting illness A 15 year old male presented with a giant mass of tongue which caused functional and aesthetic problem. Additionally. a first born in a family of four children. and submandibullar fluctuant swelling. The overgrowth of the tongue had caused speech and swallowing problems. The cords were free and mobile. snoring.N for anonymity is 15 years. In addition. 32. A biopsy resulted in profuse bleeding.

He is restricted on solid foods and he is also on dietary supplements. there is regularity of elimination. He plays around with his fellow teenagers but some degree of inferiority is noted probably due to inappropriate communication. They are readily compressible and fill slowly when released. Temperature. He is well assisted to cope with stress since his parents are frequently visiting him and the staffs as well are of great assistance to him.i. The speech pattern is also affected as he can not effectively communicate. he is depressed since he should be in school but due to the disease prognosis.e. His vital signs were. snoring at night. He is able to carry out activities of daily living with minimal assistance. .5.N perceived that he was sick and felt that he needed medical assistance. There is great self image disturbance as he feels shy due to the enlarge tongue.i. He also mostly of fluidly feeds as well as been on nasogastric tube on and off. no noticeable or query changes in quality or quantity of excretion. he can not enjoy his favorites foods due to discomfort in swallowing. 37. Assessment. He had an in sight to his medical illness. The tissues have a slightly bluish hue and are soft. On assessing the role-relationships. His elimination patterns are normal .e. He experiences cognitive-perceptual problems such as moderate pain frequently. They lack a prominent pulsation.e. No noted abnormality on other areas but on examination of the oral cavity. altered language pattern due to the size of tongue and greatly altered taste due to the disease condition. the vascular malformations of the mucosa and tongue and the adjacent soft tissues were readily apparent. takes his medication on time. he is force to fore-go school for now due to hospitalization. He reports discomfort in sleeping patterns . as well as diminished quality of sleep at certain occasions in respond to flatulence of tongue swelling. Nutrition. Blood pressure: 107/87 mmHg.i. S. He tries to maintain hygiene so as promote health and complies to medical therapy .On performing a head to toe examination. Venous channels are engorged when placed in a dependent position.

7 .10.5g/dl) with microcytic hypocromic Urea: 38. Cr: 0. liquid nitrogen via large contact tip was .( 4. HB.( 42-54%) MCV: 54.0-10.7 mg/dL) WBC: 15000.1.5. The results of routine laboratory tests were normal. The patient had a subsequent bleeding episode a day later.( 133 .3 g/dl (13.0 mEq/L) Na: 133.Laboratory investigations done Histopathology revealed a capillary hemangioma with fibrin deposits. (82-103fl) PLT: 342000(150-399 x103/mm3) Management He was transfused 450mls of whole blood on 16th November and 10th December 2011. (8.7.5. was performed. The mass was isointense to muscle on«« On flexible laryngoscopy. . Blood test for bacteriology was done and no microbe noted. Computerized Tomography (CT) scan revealed a lobulated soft tissue mass involving the BOT and causing partial obliteration of the laryngeal airway. Following the routine surgical protocol.5-17.5 to 5. except for leukocytosis. On 23rd march 2011. The mass was heterogeneous with hyperdense and hypodense areas. Patient was fixed with a nasogastric tube to ease feeding prior to cryosurgery. Magnetic Resonance (MR) angiography revealed a mass involving the BOT.146 mEq/L) Ca: 11.20 mg/dL) K: 4. to secure the airway.7. An MRI showed that the mass extended into the pterygoid space and involved more than half of the tongue.0 th/uL) HCT: 29. he underwent for cryosurgery of the lesion due to high tendency of bleeding.( 3.1. An emergency tracheostomy.3 (0. the bluish mass extended to the base of the tongue and the vallecula on the right side as well. Also on 1st December 2011 and 9th January 2012 he was transfused 130cc packed cell.75 .

Changing of nasogastric tube every 3days 3. Prednisone at a dose of 20-30 mg/d 2 weeks to 4 months 3.O tds 5. Monitoring of vitals. 7. 4.9% and the patient was prescribed with analgesic. Nursing interventions: 1. 8. Esose 20mg P. Plasil 10mg IV tds 3 days 8. Frusemide 40mg IV 2.i.applied to the entire lesion for 60 seconds.O bd 1month 9. Following this process the area was washed with NaCl 0. Administration of prescribed medication timely. Drug index 1. Monitoring nutrition status of the client. Accurately document all interventions in the nurse cardex.e. 2.O bd 2 wks 7.O tds 4. Panadol 1g P. Transfusing patient with blood products. 10.O 2wks . Reassuring the client. Reviewing of client for speech therapy.5mls P. H2O2 mouth gaggle tds 10. Monitoring input/out chart strictly. DF 118 60mg P. Giving health education to the patient. after 5 days 6. Necrotic and sloughing areas were observed in the postoperative first week and within the first month the lesion was successfully removed and completely healed.O tds 6. Amitryptilline 25mg P. Dentist review was done. Ransferon 10mls P. 5. Weighing of patient regularly . Lactulose 7. anti-inflammatory agents and mouth wash containing antiseptics. 9.

Identify and discuss potential hazards of unproved and/or nonmedical therapies/remedies with client for better compliance . trauma. 2. Consult with dietitian/nutritional support team. or hormonal fluctuation and they do not involute. the size and the exact location of the lesion. or their behavior. the stage of growth or regression. could be performed very safely. but 10-20% require treatment because of their size. and the functional compromise. Refer to home health resources for supervision of home nutrition therapy when used and follow-up care. where as vascular malformations are present at birth but often not diagnosed until second decade of life. for long-term needs. Despite different recommended modalities in managing hemangiomas of the tongue. surgery could be the mainstay treatment and provided that critical care measures are taken in to account. Hemangiomas show rapid growth until 6-8 months and involute by 5-9 year. 4. . advice patient on: 1. Individualized therapy depends on the age of the patient. Conclusion Hemangiomas are usually present at birth and can be diagnosed by 1 year.Discharge plan On discharge. in cases of huge malformations. 5. Most true hemangiomas require no intervention. Suggest parent be present during procedures to comfort child. Vascular malformations show slow growth throughout life with increase in response to infection. as necessary. Weigh at regular intervals and document results to monitor effectiveness of dietary plan. 3. their location.

Spectrum of hepatic hemangiomas: management and outcome. 7. (2004). 3.The treatment of tongue haemangioma by plasma knife surgery. Bhuller A. Korean J Radiol. 4th edition.Radiologic-Pathologic correlation of unusual lingual masses: Part II: Benign and Malignant tumors.htm 8. Pediatric vascular lesions. Alonso MH. 49(11): 312. Tiao GM. Han MH. (2009). 117(2): 328-35.(2008).com/ Bond Book/ softtissue/ softtissue. [MEDLINE: 15148512] 6. 2. Laryngoscope 2007. Sadove AM. Vascular lesions [internet]. J Craniofac Surg. Dasgupta R.Reference 1. Richter GT. Dickie B.Complications in the evolution of haemangiomas and vascular malformations. Available from: www. Park SW. Singapore Med J. Jan.Bond¶s book of oral diseases. Casellas M. . 4. Ryckman FC. Nair R. (2009). Kim SH. Anales del Sistema Sanitario de Navarra. (2003). Eur Arch Otorhinolaryngol. [Medline]. 266(2): 187-97. Eivazi B. Kutluhan A.Arteriovenous malformations of the tongue: A spectrum of disease. Suppl 1:57±69. Chang KH.2:42-51.Update on hemangiomas and vascular malformations of the head and neck. 14(4):566-83. Van Aalst JA. 44(1):125-33. Ugras S. et al. (2001). Belzunce A.maxillofacialcentre. J Pediatr Surg. 5.