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

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, as well as to provide medical research environment. Established in 1901 with a bed capacity of 40, 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. KNH has 50 wards, 22out-patient clinics, 24 theatres (16 specialised) and Accident & Emergency Department. Out of the total bed capacity of 1800, 209 beds are for the Private Wing. The ENT department The department offers both inpatient and outpatient services in the hospital. The inpatient services are located in ward 5C of the hospital Tower Block, while the outpatient is run in ENT clinic No. 34 located in the hospital Clinics Block. The department has a satellite theatre in Clinic No. 34. The departments main goal is to provide an excellent curative, preventive and rehabilitative care of patients in the hospital and the country as a whole. It has personnel strength of 11 consultant specialists from KNH and UON, about 8 registrars, 2 audiologists, 1 hearing therapist, 1 earmould technician, 36 nurses in the ward and 14 in the clinic, 12 support staff, 7 in the ward and 6 in the clinic, and medical records clerks serving in the clinic. The department has an operation capacity of 60 patients per day seen in consultants clinic while 75 are seen in filter clinic. It does 7 operations per day in satellite theatre while in main theatre10 per week. The department admits 1,420 patients per year, with an occupancy rate of 65.2%. Inpatient services offered in Ward 5C: ENT/Head/Neck surgery: Outpatient services offered in ENT clinic No. 34: a) Consultation of new and old patients b) Audiological services c) Hearing assessment

d) Fitting of hearing aids e) Speech therapy: Teaching/Training/ Research/Partnership The department offers facilities for teaching and training to ENT surgeons, clinical officers and audiology, both medical students and nurses, from college of health sciences, UON and KMTC. Staffs attend various workshops, conferences and Continuous Medical Education (CME) both locally and internationally. The department is involved in research by all levels of staff cadre: registrars thesis, research work presentation at various forums both locally and internationally. My case study client who had been admitted on 27th October the year 2009, with a diagnosis of base of tongue hemangioma, was a referral from Muranga district hospital. Examination of the mass several years prior at another facility revealed a hemangioma. Recently, the mass increased in size and he experienced multiple episodes of bleeding. Each episode consisted of the loss of 2 spoonfuls of bright red blood after which bleeding would spontaneously stop. He was then readmitted on 3rd November the year 2011, where he has been an inpatient since then. He has bee to theater on2 3rd March 2011 for alcohol injection and on 11th November 2011 for lingual artery ligation. Case justification
Among the different sites of head and neck hemangiomas, the tongue requires special consideration because of its susceptibility to minor trauma and consequent bleeding and ulceration, swallowing difficulties and breathing problem; although the major concern is cosmetic issues in most cases.

Tongue hemangiomas are common but in base of tongue (BOT) hemangioma are extremely rare. They pose a difficult problem in view of the tongue being a mobile inquisitive organ is more prone for trauma and subsequent complications.
In contrast to vascular malformation, most hemangiomas regress in response to medical treatment or with conservative managements but this case which not only did not regress, but also affected the normal life of the patient.

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. They are the most common

tumors of the childhood. They show higher prevalence in women. Most of these lesions are described hematomas instead of tumors. 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. 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, or hormonal fluctuation and they do not involute. Osseous involvement of the hemangiomas is rare but 35% of the vascular malformations show osseous involvement. Although hemangiomas are common in infancy and childhood, they are probably developmental abnormalities rather than true neoplasms. Pathologists distinguish three classes: capillary, cavernous, and mixed types. Cavernous hemangiomas are blue, soft, spongy masses that are not encapsulated. Some hemangiomas of the tongue have a lymphangiomatous component, hence the name hemangiolymphangiomas.

Although most hemangiomas of the tongue are asymptomatic, they could sometimes cause significant bleeding, pain or difficulty in chewing, speaking, and even swallowing, if they are large enough. Small lesions can be excised with impunity. Large lesions, if excised, could result in significant functional disability. This is why several modalities of less invasive treatment have recently been advocated to avoid functional disability caused by tissue loss. Also, there have been reports of treatment with superselective embolization using polyvinyl alcohol foam (Ivalon) and absorbable gelatin sponge (Gelfoam) particulates. Epidemiology The oral cavity and the head and neck regions possess complex, rich and intricate blood vessels which may be a predisposing factor for a variety of vascular lesions. Haemangiomas are among the most common neoplasms which are encountered in the paediatric.

In adults, haemangioma of the oral cavity is a rare occurrence. It comprises of 3.4% of all the oral lesions in adults. Frequently traumatized mucosal sites: the lip mucosa (63% of oral cases), 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. In population studies, a strong (2:1) male predilection in hospital-based studies. Lingual haemangiomas pose distressing problems to the patients, producing cosmetic deformity, recurrent haemorrhage and functional problems with speaking, deglutition and mastication. Causes The causes of vasoformative tumors are unknown. One hypothesis postulates that placental cells, such as the trophoblast, may be the cell of origin for hemangiomas. Therefore, hemangiomas may arise secondary to some event in utero. However, conflicting evidence supports this hypothesis. One study found placenta-associated vascular antigens to be expressed by hemangiomas but not by other vascular malformations or tumors. On the other hand, a separate investigation found immunohistochemical staining of certain trophoblastic markers to be negative in all infantile hemangiomas that were examined. The relationship between hemangiomas and placental tissues needs further investigation. Diagnostic tests Diagnosis of oral hemangiomas requires some form of imaging to determine their extent and flow characteristics. The following modalities may be helpful:
1.

Angiography is considered the most definitive of the studies, although the angiographic appearance of intraosseous lesions is less well defined than that of soft tissue lesions.

2.

Ultrasonography can be used to determine that a lesion is angiomatous in nature (ie, hemangioma, lymphangioma), but it cannot be used to differentiate a hemangioma from a lymphangioma.

3.

Contrast-enhanced MRI can be used to differentiate a hemangioma from a lymphangioma in the oral cavity. MRI appears to be highly reliable for lesions of either soft tissue or bone.

4.

On plain films or panoramic radiographs, a central vascular malformation of the bone usually has a honeycombed appearance or cystic radiolucencies. Intraosseous vascular malformations

show a nonspecific reticulated or honeycombed pattern that is well demarcated from normal bone. A sunburst effect, created by spicules radiating from the center, is often present.
5.

CT scans often show an expansile process with a high-density amorphous mass that may be suggestive of fibrous dysplasia.

Procedures other than a clinical history or examination, including aspiration of intraosseous lesions that are used to diagnose oral hemangiomas readily produce frank blood. Performing a biopsy of oral hemangiomas can be potentially dangerous. Histologic Findings Histopathologically, vasoformative tumors share many similar microscopic features, and overlap between hemangiomas and vascular malformations exists. Hemangiomas are subclassified as capillary or cavernous, depending on the size of the vascular channels. Vascular malformations, as true structural anomalies, exhibit a normal rate of endothelial cell turnover. Spaces are lined by endothelium without muscular support. An increase in normal- and abnormal appearing blood vessels occurs. The endothelial cells of early lesions may be plump, obscuring the lumen of the capillaries. Phleboliths may develop as a result of dystrophic calcification in thrombi. Intimal thickening or diverse arteriovenous connections can sometimes be seen in serial sections. Johann et al showed that histological diagnosis alone is not sufficient to correct diagnoses of oral hemangioma. Moreover, immunohistochemistry to GLUT1 is a useful and easy diagnostic method that may be used to avoid such misdiagnosis. Salient histopathologic findings of vasoformative tumors that distinguish them are as follows: 1. 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. Hemangiomas (involuting phase):

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. 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. Interferon is rarely used because of the risk of spastic diplegia. Vincristine has been reported to decrease the size of a large segmental mandibular hemangioma in the setting of PHACES syndrome. Steroids have become a mainstay in the treatment of proliferating hemangiomas in infants and children. High doses of systemic or intralesional steroids are the first-line treatment, and a dramatic response is observed in 30% of patients. Surgical Care Surgical or invasive treatment of oral hemangiomas has evolved. Complete surgical excision of these lesions offers the best chance of cure, but, often, because of the extent of these benign lesions, significant sacrifice of tissue is necessary. For example, lesions of the tongue may require near-total glossectomy, which is followed by severe functional impairment to vital functions, such as swallowing, speech, and airway maintenance. As a result, multiple adjunctive procedures have been introduced to eradicate the disease, leaving less of a functional

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

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

Injectable (fluids) are as follows:

o o o o

Amino acid occlusion gel (Ethibloc) Isobutyl 2-cyanoacrylate Microfibrillar collagen (Avitene) Silicone rubber

Sclerosing agents are as follows:

o o o o o

Absolute ethanol Boiling contrast medium Polidocanol Sodium morrhuate Sodium tetradecyl sulfate (Sotradecol)

Nonparticulate agents are as follows:

o o

Stainless steel coils Platinum coils

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

Epithelioid hemangioma responds to low-dosage radiotherapy, but not to cryotherapy or intralesional steroids.
The case

My client by the name S.N for anonymity is 15 years, a first born in a family of four children. He was a standard six pupil of Muranga township primary school before hospitalization. Both his parents are alive as well as his siblings. He is approximately 43 feet of height, 32.8 kg of weight, and a BMI of 18. Blood group B+. A Christian by religion. Past medical history He has no known chronic illness as well as any noted familial disease. He has also not had any previous surgical case. 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. His past medical history was only significant for migraines, History of presenting illness A 15 year old male presented with a giant mass of tongue which caused functional and aesthetic problem. The patient complains of progressive dysphagia to solids of two months duration. In addition, he had two episodes of small amount of bleeding per orally. He has been complaining of moderate burning pain, and submandibullar fluctuant swelling. Clinical examination of the neck did not reveal any mass or evidence of neck nodes. A direct laryngoscopic examination showed a fleshy lesion over BOT extending across the vallecula next to the epiglottis. The cords were free and mobile. The tumor did not have the characteristic features of hemangioma. A biopsy resulted in profuse bleeding, (approximately 300 cc) which needed pressure and packing, but subsequently stopped spontaneously. Histopathology revealed a capillary hemangioma with fibrin deposits.

The overgrowth of the tongue had caused speech and swallowing problems, and also growth deformity in the mandible. Additionally, the patient suffered from recurrent thrush infection and sleep problems i.e. snoring.

On performing a head to toe examination; No noted abnormality on other areas but on examination of the oral cavity, the vascular malformations of the mucosa and tongue and the adjacent soft tissues were readily apparent. The tissues have a slightly bluish hue and are soft. Venous channels are engorged when placed in a dependent position. They are readily compressible and fill slowly when released. They lack a prominent pulsation. Assessment, His vital signs were; Temperature; 37.5, Blood pressure: 107/87 mmHg, S.N perceived that he was sick and felt that he needed medical assistance. He had an in sight to his medical illness. He tries to maintain hygiene so as promote health and complies to medical therapy .i.e. takes his medication on time. Nutrition; he can not enjoy his favorites foods due to discomfort in swallowing. He also mostly of fluidly feeds as well as been on nasogastric tube on and off. He is restricted on solid foods and he is also on dietary supplements. His elimination patterns are normal .i.e. there is regularity of elimination, no noticeable or query changes in quality or quantity of excretion. He is able to carry out activities of daily living with minimal assistance. He reports discomfort in sleeping patterns .i.e. snoring at night, as well as diminished quality of sleep at certain occasions in respond to flatulence of tongue swelling. He experiences cognitive-perceptual problems such as moderate pain frequently, altered language pattern due to the size of tongue and greatly altered taste due to the disease condition. There is great self image disturbance as he feels shy due to the enlarge tongue. The speech pattern is also affected as he can not effectively communicate. On assessing the role-relationships, he is depressed since he should be in school but due to the disease prognosis, he is force to fore-go school for now due to hospitalization. He plays around with his fellow teenagers but some degree of inferiority is noted probably due to inappropriate communication. 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.

Laboratory investigations done Histopathology revealed a capillary hemangioma with fibrin deposits. The patient had a subsequent bleeding episode a day later. An emergency tracheostomy, to secure the airway, was performed. Computerized Tomography (CT) scan revealed a lobulated soft tissue mass involving the BOT and causing partial obliteration of the laryngeal airway. The mass was heterogeneous with hyperdense and hypodense areas. Magnetic Resonance (MR) angiography revealed a mass involving the BOT. The mass was isointense to muscle on On flexible laryngoscopy, the bluish mass extended to the base of the tongue and the vallecula on the right side as well. An MRI showed that the mass extended into the pterygoid space and involved more than half of the tongue. Blood test for bacteriology was done and no microbe noted. The results of routine laboratory tests were normal, except for leukocytosis. HB; - 7.3 g/dl (13.5-17.5g/dl) with microcytic hypocromic Urea: 38, Cr: 0.3 (0.75 - 1.20 mg/dL) K: 4.1,( 3.5 to 5.0 mEq/L) Na: 133,( 133 - 146 mEq/L) Ca: 11.5, (8.7 - 10.7 mg/dL) WBC: 15000,( 4.0-10.0 th/uL) HCT: 29.5,( 42-54%) MCV: 54.7, (82-103fl) PLT: 342000(150-399 x103/mm3)
Management

He was transfused 450mls of whole blood on 16th November and 10th December 2011. Also on 1st December 2011 and 9th January 2012 he was transfused 130cc packed cell. Patient was fixed with a nasogastric tube to ease feeding prior to cryosurgery. On 23rd march 2011, he underwent for cryosurgery of the lesion due to high tendency of bleeding. Following the routine surgical protocol, liquid nitrogen via large contact tip was

applied to the entire lesion for 60 seconds. Following this process the area was washed with NaCl 0.9% and the patient was prescribed with analgesic, anti-inflammatory agents and mouth wash containing antiseptics. Necrotic and sloughing areas were observed in the postoperative first week and within the first month the lesion was successfully removed and completely healed. Dentist review was done. Reviewing of client for speech therapy.

Nursing interventions: 1. Monitoring of vitals. 2. Changing of nasogastric tube every 3days 3. Reassuring the client. 4. Administration of prescribed medication timely. 5. Weighing of patient regularly .i.e. after 5 days 6. Giving health education to the patient. 7. Transfusing patient with blood products. 8. Monitoring input/out chart strictly. 9. Monitoring nutrition status of the client. 10. Accurately document all interventions in the nurse cardex.

Drug index

1. Frusemide 40mg IV 2. Prednisone at a dose of 20-30 mg/d 2 weeks to 4 months 3. Lactulose 7,5mls P.O tds 4. DF 118 60mg P.O tds 5. Panadol 1g P.O tds 6. Esose 20mg P.O bd 2 wks 7. Plasil 10mg IV tds 3 days 8. Ransferon 10mls P.O bd 1month 9. H2O2 mouth gaggle tds 10. Amitryptilline 25mg P.O 2wks

Discharge plan

On discharge, advice patient on: 1. Weigh at regular intervals and document results to monitor effectiveness of dietary plan. 2. Consult with dietitian/nutritional support team, as necessary, for long-term needs. 3. Refer to home health resources for supervision of home nutrition therapy when used and follow-up care. 4. Suggest parent be present during procedures to comfort child. 5. Identify and discuss potential hazards of unproved and/or nonmedical therapies/remedies with client for better compliance .
Conclusion

Hemangiomas are usually present at birth and can be diagnosed by 1 year, where as vascular malformations are present at birth but often not diagnosed until second decade of life. 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, or hormonal fluctuation and they do not involute. Most true hemangiomas require no intervention, but 10-20% require treatment because of their size, their location, or their behavior. Individualized therapy depends on the age of the patient, the size and the exact location of the lesion, the stage of growth or regression, and the functional compromise.
Despite different recommended modalities in managing hemangiomas of the tongue, in cases of huge malformations, surgery could be the mainstay treatment and provided that critical care measures are taken in to account, could be performed very safely.

Reference 1. Kim SH, Han MH, Park SW, Chang KH. (2001).Radiologic-Pathologic correlation of unusual lingual masses: Part II: Benign and Malignant tumors. Korean J Radiol;2:42-51. 2. Eivazi B. (2009).Update on hemangiomas and vascular malformations of the head and neck. Eur Arch Otorhinolaryngol; 266(2): 187-97. 3. Richter GT.Arteriovenous malformations of the tongue: A spectrum of disease. Laryngoscope 2007; 117(2): 328-35. 4. Kutluhan A, Ugras S.(2008).The treatment of tongue haemangioma by plasma knife surgery. Singapore Med J; 49(11): 312. 5. Belzunce A, Casellas M. (2004).Complications in the evolution of haemangiomas and vascular malformations. Anales del Sistema Sanitario de Navarra; Suppl 1:5769. [MEDLINE: 15148512] 6. Van Aalst JA, Bhuller A, Sadove AM. (2003). Pediatric vascular lesions. J Craniofac Surg; 14(4):566-83. 7. Vascular lesions [internet].Bonds book of oral diseases, 4th edition. Available from: www.maxillofacialcentre.com/ Bond Book/ softtissue/ softtissue.htm 8. Dickie B, Dasgupta R, Nair R, Alonso MH, Ryckman FC, Tiao GM, et al. (2009). Spectrum of hepatic hemangiomas: management and outcome. J Pediatr Surg. Jan; 44(1):125-33. [Medline].