Head & Neck Anatomy Structures & Clinical Significance
Oral Cavity
- Tongue — mobile anterior 2/3 (CN XII motor), taste (CN VII/IX)
- Floor of Mouth — most common site for oral SCC; submandibular duct opens here
- Buccal Mucosa — at risk in paan/gutka users; leukoplakia → malignancy
- Lips — lower lip most common; sun exposure risk; vermillion border
- Hard Palate — minor salivary gland tumours; adenoid cystic carcinoma
- Retromolar Trigone — posterior to last molar; trismus common at this site
Pharynx & Larynx
- Oropharynx — soft palate, tonsils, base of tongue; HPV-associated cancers rising
- Hypopharynx — pyriform sinus (most common), posterior pharyngeal wall; late presentation
- Supraglottic Larynx — epiglottis, false cords; dysphagia & referred otalgia
- Glottic Larynx — true vocal cords; hoarseness is early warning sign
- Subglottic Larynx — rare; presents late; requires total laryngectomy
Salivary Glands
Parotid Gland
- Largest; produces serous saliva
- CN VII (facial nerve) traverses it
- Stensen's duct → opposite upper 2nd molar
- 80% of parotid tumours benign (pleomorphic adenoma)
Submandibular Gland
- Mixed sero-mucous secretion
- Wharton's duct → floor of mouth
- Higher malignancy rate than parotid (~50%)
- CN XII (hypoglossal) runs nearby
Sublingual Gland
- Smallest paired gland
- Multiple ducts of Rivinus
- Highest malignancy rate (~70–90%)
- Ranula: mucous retention cyst
Head & Neck Cancers Epidemiology, Risk Factors & Staging
Primary Histology: Over 90% of head and neck cancers are Squamous Cell Carcinoma (SCC), arising from mucosal epithelium. Adenocarcinoma occurs in salivary gland tumours. Lymphoma may affect Waldeyer's ring.
Risk Factors
- Tobacco Smoking — synergistic with alcohol; 80% of oral cancers
- Smokeless Tobacco — paan, gutka, betel nut; common in South Asian GCC workers; oropharyngeal & oral cavity SCC
- Alcohol — multiplicative risk with tobacco; hypopharynx & supraglottis
- HPV 16/18 — oropharyngeal SCC (tonsil, base of tongue); better prognosis
- Shisha/Waterpipe — falsely perceived as safer; prolonged session = high carcinogen dose
- Sun Exposure — lip SCC (lower lip most common)
- Epstein-Barr Virus — nasopharyngeal carcinoma (NPC); North African & Chinese populations
Presenting Symptoms
| Site | Key Symptoms |
|---|---|
| Oral Cavity | Non-healing ulcer >3 weeks, leukoplakia, erythroplakia |
| Oropharynx | Sore throat, dysphagia, neck mass, referred otalgia |
| Glottic Larynx | Hoarseness (early, >3 weeks requires investigation) |
| Supraglottic | Dysphagia, muffled voice, referred otalgia |
| Hypopharynx | Progressive dysphagia, odynophagia, neck mass |
| Salivary Gland | Painless mass; facial weakness = malignancy |
TNM Staging Overview
T — Primary Tumour
T1≤2 cm
T22–4 cm
T3>4 cm
T4aModerately advanced local disease
T4bVery advanced — encases carotid
N — Regional Nodes
N0No regional node metastasis
N1Single ipsilateral ≤3 cm
N2Single 3–6 cm / multiple / bilateral
N3>6 cm or extranodal extension
M1Distant metastasis (lung most common)
Maxillofacial Trauma Fracture Classification & Dental Injuries
Le Fort Mid-Face Fractures
All Le Fort fractures involve the pterygoid plates. Always assess for CSF rhinorrhoea (base of skull fracture).
Le Fort IHorizontal — above teeth; palate separates from mid-face; "floating palate"
Le Fort IIPyramidal — through nasal bones, orbital rim; "floating maxilla"
Le Fort IIICraniofacial dysjunction — entire mid-face separates from skull; "floating face"
Other Facial Fractures
- Mandibular Fracture — most common at condyle, angle, parasymphysis; trismus, malocclusion, step deformity
- Orbital Blowout — inferior wall (ethmoid); diplopia, enophthalmos, infraorbital paraesthesia (CN V2); entrapment of inferior rectus
- Zygomatic Complex — "tripod fracture"; cheek flattening, trismus, infraorbital numbness
- Dental Injuries (Ellis Classification) — Class I (enamel), II (enamel+dentine), III (pulp exposure — urgent treatment)
- Avulsed Tooth — re-implant within 30 min; store in milk/saliva/saline; handle by crown only
Tracheostomy Nursing Indications, Types & Daily Management
Indications
- Upper Airway Obstruction — Ludwig's angina, laryngeal oedema, bilateral vocal cord palsy
- Prolonged Mechanical Ventilation — >10–14 days predicted; reduces sedation, improves weaning
- Secretion Management — unable to clear secretions independently; neurological impairment
- Laryngeal Cancer Surgery — total laryngectomy creates permanent stoma (not a tracheostomy)
- Prophylactic — major head and neck surgery with anticipated post-op oedema
Surgical Techniques
Surgical OpenOT under GA; tracheal window created between rings 2–4
Percutaneous (Ciaglia)Bedside ICU; Seldinger wire technique; bronchoscopy guided; less scarring
Emergency (Cricothyrotomy)Through cricothyroid membrane; life-saving temporising measure
Percutaneous tracheostomy is increasingly preferred in ICU settings for haemodynamically stable patients requiring long-term ventilation.
Tracheostomy Tube Types & Selection
| Feature | Options | Clinical Consideration |
|---|---|---|
| Cuffed | Portex, Shiley, Bivona | Aspiration protection; ventilator seal; cuff pressure 20–25 cmH₂O |
| Uncuffed | Paediatric / decannulation | Speech possible; no aspiration protection; used in weaning |
| Fenestrated | Inner cannula with hole | Enables phonation with speaking valve (e.g. Passy-Muir); cap off inner for speech |
| Non-Fenestrated | Standard ICU use | Safer for acutely unwell patients; no speech capability |
| Single Cannula | Bivona (foam/adjustable) | Flexible; adjustable neck flange for unusual anatomy |
| Double Cannula | Portex, Shiley | Inner cannula removed & cleaned 4–8 hourly; reduces blockage risk |
Cuff Management
Target cuff pressure: 20–25 cmH₂O. Below 20 = aspiration risk. Above 30 = tracheal mucosal ischaemia.
- Measure with manometer at least twice daily
- Minimal occluding volume (MOV) technique
- Cuff deflation — suction above cuff first; have suction ready
- In-line suction catheter for ventilated patients
- Tracheomalacia risk with prolonged over-inflation
Inner Cannula Care
- Remove every 4–8 hours (disposable: discard; reusable: clean)
- Clean reusable cannula with dilute sodium bicarbonate or prescribed cleaner
- Inspect for secretion build-up, cracks
- Replace immediately — never leave stoma uncovered beyond cannula change time
- Disposable inner cannulas preferred in high-secretion patients
- Blockage of inner cannula is common cause of distress — always check first
Suctioning Technique
- Explain procedure to patient; gain consent/cooperation
- Pre-oxygenate — increase FiO₂ to 100% for 30–60 seconds
- Select appropriate catheter size (French size = tube ID × 3 ÷ 2)
- Use aseptic non-touch technique (ANTT)
- Insert catheter without suction applied
- Advance to carina (resistance felt) — withdraw 1 cm
- Apply suction on withdrawal — rotate gently; duration <15 seconds
- Suction pressure: 80–120 mmHg (adults)
- Allow patient to recover; monitor SpO₂ and HR
- Document colour, consistency, volume of secretions
Humidification
- HME Filter (Heat-Moisture Exchanger) — passive; captures exhaled heat and moisture; changed every 24h or when soiled
- Swedish Nose — HME device adapted for non-ventilated tracheostomy patients
- Heated Humidification Circuit — active; used in ventilated ICU patients; maintains 37°C/44 mg/L absolute humidity
- Inadequate humidification → mucus crusting → tube blockage
- Saline nebulisers (0.9% NaCl) assist in loosening secretions
Stoma Care
- Clean stoma twice daily and when soiled using 0.9% sodium chloride and non-shedding gauze
- Inspect for: erythema, exudate, granulation tissue, pressure injury from flanges
- Tracheostomy dressing (keyhole foam) — Lyofoam, Mepilex tracheostomy foam
- Tracheostomy ties/tapes — should allow 2 fingers between tie and neck; check every shift
- Rotate tube if long-term to reduce mucosal pressure points
- Tape/ties should not be changed alone in first 7 days (stoma not yet mature)
Bedhead Emergency Equipment Mandatory for every tracheostomy patient
MANDATORY at bedhead at ALL times: Spare tracheostomy tube (same size), one size smaller tube, tracheal dilators, 10 mL syringe, suction equipment, BVM mask (for stoma ventilation), spare inner cannula, scissors/wire cutters.
Blocked Tracheostomy — 10-Point Emergency Algorithm
- Call for help — do not leave patient alone; activate emergency response
- Assess airway — look/listen/feel; apply supplemental O₂ via tracheostomy and face simultaneously
- Hyperextend neck — shoulder roll under patient to optimise tracheostomy alignment
- Remove inner cannula — inspect and clear; replace with clean one; reassess
- Pass suction catheter — if catheter passes, tube is patent but secretions may be blocking
- Deflate cuff — may allow air to pass around tube; reassess breathing
- Attempt BVM via stoma — if tube partially patent; call anaesthetics URGENTLY
- Consider decannulation — remove tube if completely blocked and patient deteriorating; attempt ventilation via stoma
- Insert smaller tube / bougie-guided replacement — under direct vision with tracheal dilators
- ARREST CALL — if SpO₂ <90% unresponsive to above; airway cannot be secured
Oral & Dental Surgery Nursing Extractions, IMF & Jaw Surgery
Dental Extractions
- Local Anaesthetic — lignocaine 2% with epinephrine 1:80,000 (vasoconstriction reduces bleeding, prolongs effect)
- Contraindication to epinephrine: uncontrolled hypertension, recent MI, phaeochromocytoma
- Post-Extraction Instructions — bite gauze 30 min; no rinsing for 24h; no smoking; soft diet
- Post-Extraction Haemorrhage — apply pressure (gauze bite); gelfoam/oxidised cellulose (Surgicel); tranexamic acid mouthwash; suturing if ongoing
- Dry Socket (Alveolar Osteitis) — days 3–5; severe throbbing pain radiating to ear; halitosis; empty socket (no clot); NOT infection
- Dry Socket Treatment: gentle irrigation with saline; Alvogyl dressing (eugenol-based); analgesics; repeat dressing every 3–5 days until healed
Dry Socket Risk Factors
- Smoking (most important modifiable risk)
- Oral contraceptive pill (high oestrogen)
- Difficult/traumatic extraction
- Posterior mandibular teeth (wisdom teeth)
- Poor oral hygiene / pre-existing infection
- Premature clot dislodgement (rinsing, spitting, straws)
Dry socket is a non-infective condition. Antibiotics are NOT indicated unless secondary infection develops.
Ludwig's Angina — AIRWAY EMERGENCY
Ludwig's Angina is a bilateral submandibular and sublingual space infection — life-threatening airway emergency. Mortality up to 10% if untreated.
Clinical Features
- Bilateral submandibular swelling — board-like induration
- Floor of mouth elevation — tongue pushed upward and backward
- Trismus, dysphagia, drooling, dysphonia ("hot potato voice")
- Stridor and tripod positioning = IMMINENT AIRWAY LOSS
- Fever, toxaemia, sepsis
- Source: most commonly lower 2nd/3rd molar dental infection
Management
- IMMEDIATE senior review — anaesthetics + ENT/maxfax
- Secure airway — awake fibreoptic intubation or tracheostomy under local
- IV antibiotics — co-amoxiclav + metronidazole (cover streptococci + anaerobes)
- Surgical drainage — floor of mouth incisions bilaterally
- ICU admission for airway monitoring
- Treat dental source once patient stable
Intermaxillary Fixation (Jaw Wiring / IMF)
Wire cutters MUST be at the bedside at ALL times — vomiting with wired jaws = aspiration/asphyxiation.
- Used for: mandibular fractures, orthognathic surgery fixation
- Patient education: cut wires at front if vomiting; lean forward
- Diet: liquid/blended — straws, sippy cups; caloric supplementation
- Oral hygiene: chlorhexidine mouthwash; interdental brushes; irrigating syringe
- Duration typically 4–6 weeks for fracture healing
- Monitor for: weight loss, pressure sores from arch bars
Orthognathic Surgery Post-Op Care
Bimaxillary osteotomy / Le Fort I + BSSO
- Airway monitoring — massive swelling; nasal airways may be used; head elevation 30–45°
- Swelling management — ice packs first 48h; IV dexamethasone; expected to peak at 48–72h
- Haemorrhage — watch for rapid increase in swelling; drain output; surgical emergency
- Diet progression — clear liquids → blended → soft → normal over 6 weeks
- Nausea management — critical; ondansetron preferred; vomiting with elastics in place is dangerous
- Paraesthesia of lower lip/chin — common post BSSO (inferior alveolar nerve); usually temporary
Parotidectomy Nursing
Facial Nerve Monitoring
CN VII traverses parotid — monitor using House-Brackmann Scale
Grade INormal function
Grade IISlight dysfunction — minor weakness
Grade IIIModerate — incomplete closure
Grade IVModerately severe dysfunction
Grade VSevere — barely perceptible movement
Grade VITotal paralysis — eye care essential
Complications
- Facial Nerve Palsy — Grade VI: eye drops, taping, moisture chamber; ophthalmology review
- Salivary Fistula — saliva leaks through wound; pressure dressing; most resolve spontaneously
- Frey's Syndrome — gustatory sweating; auriculotemporal nerve misdirection; may develop months later; botulinum toxin treatment
- Haematoma — early post-op; firm swelling; return to OT if airway compromised
- Drain Management — suction drain; record output; remove when <20–30 mL/24h
Head & Neck Cancer Treatment Surgery, Reconstruction & Chemoradiation
CRITICAL: A laryngectomy stoma is NOT a tracheostomy. Never attempt to intubate from above in a laryngectomee. Ventilation is ONLY via the stoma. All laryngectomees should carry a MedicAlert.
Total Laryngectomy
- Entire larynx removed; pharynx closed and reconstructed; permanent neck stoma created
- Permanent stoma — NOT a tracheostomy; no communication between upper airway and lungs
- Laryngectomy tubes — laryngectomy-specific HME (Provox, Atos Medical); NEVER standard tracheostomy tubes
- Stoma care — similar to tracheostomy but permanent; HME baseplate daily; stoma guard/bib
- Bathing safety — waterproof stoma cover; no swimming unprotected; shower guard
- Voice prosthesis (TEP) — tracheoesophageal puncture at surgery or secondarily; Blom-Singer, Provox devices
Voice Rehabilitation Post-Laryngectomy
TEP (Tracheoesophageal Puncture)Gold standard; valve allows air into oesophagus; 80–90% success
ElectrolarynxExternal vibrating device against neck; robotic but immediate
Oesophageal SpeechAir swallowed and expelled; difficult to master; no device needed
Voice Prosthesis CareDaily cleaning with brush; replace every 3–6 months; leaking = change
SLP (speech-language pathologist) integral to voice rehabilitation team.
Neck Dissection Types
| Type | Structures Removed | Preserved | Indication |
|---|---|---|---|
| Radical | Levels I–V, SCM, CN XI, IJV | Nothing | Bulky nodal disease, rare now |
| Modified Radical | Levels I–V nodal tissue | SCM, CN XI, IJV (one or more) | N+ disease; functional preservation |
| Selective | Specific nodal levels | All non-nodal structures | Elective N0; specific cancer sites |
CN XI (Spinal Accessory Nerve) Sacrifice: Results in shoulder drop, limited abduction, chronic pain. Physiotherapy essential. Monitor for shoulder function every shift post-operatively.
Chyle Leak: Milky/opaque drain output after neck dissection = thoracic duct injury. Management: low-fat diet with MCT oil supplementation; if high output (>500 mL/day) — NPO, TPN, consider surgical repair or sclerotherapy.
Free Flap Reconstruction
Flap failure is an EMERGENCY — act within 72 hours for any sign of compromise. Call surgical team IMMEDIATELY.
Common Flaps
ALTAnterolateral thigh; tongue/pharynx
RFFFRadial forearm; oral cavity; thin, pliable
FibulaBone + skin; mandibular reconstruction
PMMCPectoralis major; pedicled; salvage
Hourly Flap Monitoring
- Colour — pink/salmon = healthy; pale = arterial; blue/purple = venous
- Temperature — warm; compare to adjacent tissue
- Capillary refill — 1–2 seconds (press 2s, release)
- Turgor — firm but not tense
- Doppler signal — audible vessel signal hourly
- Haematoma — expanding swelling = emergency
Flap Compromise Signs
- Arterial failure: pale, cool, no capillary refill, no Doppler
- Venous failure: blue/congested, rapid capillary refill, tense
- Act within 1–2h of first sign change
- Surgical re-exploration — thrombectomy/revision anastomosis
- Keep patient warm, well-hydrated, normotensive
- Avoid external compression (no dressings over flap)
Chemoradiation Complications & Nursing Management
Acute RT Complications
MucositisOral rinses (NaCl/NaHCO₃); Gelclair barrier; sucralfate; morphine PCA
DermatitisAqueous cream; Mepitel; avoid sun; grade per RTOG scale
DysphagiaSLP assessment; NG tube; PEG prophylactic placement considered
XerostomiaArtificial saliva; pilocarpine 5mg TDS; frequent sips water
NauseaOndansetron; metoclopramide; nutritional support
Late RT Complications
OsteoradionecrosisMandibular bone death; dental clearance BEFORE RT prevents this
TrismusFibrosis of pterygoid muscles; TheraBite exercises; >35mm opening normal
Radiation CariesDaily fluoride trays; dental review every 3 months; no extractions post-RT
HypothyroidismTSH 3-monthly if thyroid irradiated; levothyroxine replacement
Carotid StenosisLong-term risk of stroke; annual vascular surveillance in high-dose cases
Dysphagia & Rehabilitation Assessment, Feeding & Quality of Life
Dysphagia Assessment Methods
Bedside Swallow Assessment3 oz (90 mL) water test; observe for cough, wet voice, desaturation; sensitivity 76%
FEESFibreoptic Endoscopic Evaluation; nasoendoscope; direct visualisation; no radiation; can assess secretions
Videofluoroscopy (MBS)Modified barium swallow; gold standard; X-ray; detects aspiration including silent
ManometryPharyngeal/oesophageal pressure; assesses UES function
Silent Aspiration: Entry of material below vocal cords WITHOUT a cough reflex. Common after head and neck surgery/RT. Cannot be detected clinically — requires FEES or videofluoroscopy.
IDDSI Framework (0–7)
| Level | Name | Description |
|---|---|---|
| 0 | Thin | Normal water; flows freely |
| 1 | Slightly Thick | Thicker than water; flows through syringe |
| 2 | Mildly Thick | Nectar consistency; pours slowly |
| 3 | Liquidised | Honey-like; cannot pour continuously |
| 4 | Pureed | Smooth; no lumps; falls off spoon |
| 5 | Minced & Moist | Soft small lumps; fork mashing |
| 6 | Soft & Bite-Sized | Chewing required; soft fork-cuttable |
| 7 | Regular | Normal diet; no restriction |
Enteral Feeding in Head & Neck Cancer
NG TubeFirst-line; post-laryngectomy route is nasal (stoma is separate); confirm placement X-ray + pH <5.5
PEG TubeFor prolonged dysphagia (>4–6 weeks); pre-RT prophylactic PEG in high-risk cases; gastroenterology referral
Caloric Requirements25–35 kcal/kg/day; 1–1.5 g protein/kg/day for oncology patients
Post-laryngectomy patients feed via NG/PEG — tube enters stomach via NOSE/mouth and oesophagus; stoma is airway only and must never be used for feeding.
Swallowing Rehabilitation
- Mendelsohn Manoeuvre — patient holds larynx elevated during swallow; improves UES opening
- Supraglottic Swallow — breath-hold before swallow; voluntarily closes airway; requires intact larynx
- Shaker Exercise — head raise supine; strengthens suprahyoid; improves UES opening
- Masako Manoeuvre — tongue-hold; increases posterior pharyngeal wall movement
- EMST — expiratory muscle strength training; improves cough and swallowing biomechanics
- SLP-directed programme; frequency and intensity depend on baseline function
Trismus Management Post-Radiotherapy
- Trismus: mouth opening <35 mm (interincisal distance)
- Results from fibrosis of pterygoid muscles and TMJ
- Prevention: TheraBite jaw exercises commence during/after RT
- Minimum 3× daily stretching programme
- Stacked tongue depressors as low-cost alternative to TheraBite device
- Physiotherapy referral for adjunctive massage and mobilisation
- Monitor: serial measurement every 4–6 weeks
TheraBite Protocol: Open maximally, hold 30 seconds, perform 6 repetitions, 3 times daily. Should be maintained indefinitely to prevent relapse.
Head & Neck Lymphoedema
- Common after neck dissection ± radiotherapy; disrupts lymphatic drainage
- External: visible facial/neck swelling; submental fullness
- Internal: tongue base, pharyngeal wall swelling; impacts swallowing and speech
- Assessment — Patterson scale; MDADI questionnaire; endoscopic assessment of internal lymphoedema
- Treatment — manual lymphatic drainage (MLD); complete decongestive therapy (CDT); compression garments; self-drainage teaching
- Refer to lymphoedema specialist within 4–6 weeks post-treatment
Psychosocial Rehabilitation
- Body Image — disfigurement from surgery, trismus, xerostomia; profound psychological impact
- Voice Loss — loss of fundamental human communication; grief response; identity
- Social Isolation — eating in public becomes difficult; withdrawal from social eating
- Depression & Anxiety — rates 30–40% in H&N cancer; screen with PHQ-9/GAD-7
- Communication Aids — writing boards, AAC apps (e.g. Proloquo2Go), text-to-speech, call bells
- Multidisciplinary team: oncology + SLP + dietetics + psychology + social work + chaplaincy
GCC-Specific Considerations Epidemiology, Culture & Practice
GCC Tobacco & Cancer Epidemiology
- Shisha/Waterpipe — falsely perceived as safer than cigarettes due to water filtration; one session = 100–200× cigarette smoke volume; HPV transmission risk via shared mouthpieces
- Paan/Gutka/Betel Nut — widespread in South Asian expatriate workers (Bangladesh, India, Pakistan, Sri Lanka) in GCC; oral submucosal fibrosis precancerous condition; buccal/floor of mouth SCC
- Oral Submucous Fibrosis — trismus + burning mouth; precancerous; screen regularly in at-risk communities
- Late presentation of oral cancer common due to stigma and limited screening access for migrant workers
- NPC (nasopharyngeal carcinoma) — elevated in North African and some South Asian GCC populations; EBV-associated
GCC Nursing Practice Context
- Tracheostomy nursing common in GCC ICUs; large tertiary centres (SKMC Abu Dhabi, KFSH&RC Riyadh, HMC Qatar, KHUH Bahrain)
- DHA (Dubai Health Authority) licensing exam tests tracheostomy emergencies frequently
- DOH (Abu Dhabi) requires competency-based tracheostomy assessment
- SCFHS (Saudi Commission for Health Specialties) nursing board includes H&N oncology content
- Multidisciplinary head and neck tumour boards — weekly MDT; nurse coordinators essential
- Language barriers in migrant patient population — interpreter services critical
- Halal dietary requirements must be considered in nutritional products for tube feeds
Interactive Tool Tracheostomy Problem Solver
Tracheostomy Problem Solver
Select a clinical problem to display the emergency response protocol.
GCC Exam Prep — MCQ Practice DHA / DOH / SCFHS
1. A patient with a cuffed tracheostomy tube has an SpO₂ of 88% and is visibly distressed. The inner cannula has been removed and suctioning passed freely to the carina. What is the NEXT most appropriate action?
Deflating the cuff allows air to potentially pass around the tube. BVM via the stoma should be attempted while calling for senior help. Suctioning passing freely rules out a blocked tube but the tube itself may be malpositioned.
2. A 52-year-old male South Asian construction worker presents with a 6-week history of a painless white patch on the left buccal mucosa and trismus. He chews gutka daily. What is the MOST likely diagnosis?
Oral submucous fibrosis (OSMF) is a precancerous condition strongly associated with betel nut/gutka chewing. It causes progressive fibrosis resulting in trismus and burning sensation. It is a recognised premalignant condition with up to 7–13% malignant transformation rate.
3. A patient underwent total laryngectomy 3 days ago. He begins to vomit post-meal. What is the correct nursing action for airway management?
In a laryngectomee, the airway is permanently separated from the upper GI tract. The stoma is the ONLY airway. Oropharyngeal manoeuvres are irrelevant. Vomit exits via the mouth and does NOT enter the airway — but stoma suction clears any secretions. Lean forward for comfort/drainage.
4. Cuff pressure monitoring for a cuffed tracheostomy tube should maintain pressure at:
Target cuff pressure is 20–25 cmH₂O (some guidelines state 20–30). Below 20 cmH₂O risks aspiration of subglottic secretions. Above 30 cmH₂O risks tracheal mucosal ischaemia, ulceration, and long-term tracheomalacia.
5. Following a right parotidectomy, a nurse assesses the patient and notes inability to close the right eye completely and asymmetric smile. Using the House-Brackmann scale, this represents:
Grade III (moderate dysfunction) features incomplete eye closure with effort and obvious weakness. Eye care (lubricating drops, taping at night) is essential to prevent corneal exposure injury. Grade VI would show no movement whatsoever.
6. A patient with a neck dissection has 480 mL of milky-white fluid drained in 24 hours from a neck drain. What is the most appropriate dietary intervention?
Milky drain output after neck dissection indicates a chyle leak from the thoracic duct. Long-chain fats increase chyle flow. MCT (medium chain triglycerides) are absorbed directly into the portal circulation bypassing lymphatics, reducing chylous output. Output >500 mL/day may require NPO and TPN.
7. A patient is 48 hours post free flap reconstruction of the oral cavity. The flap colour has changed from pink to blue-purple with rapid capillary refill of less than 1 second. This indicates:
Blue-purple discolouration with brisk (<1 second) capillary refill indicates venous outflow obstruction (venous congestion). This is distinct from arterial failure (pale, no capillary refill). Venous congestion is a surgical emergency — call the team immediately. Time to re-exploration is critical.
8. A patient develops severe, throbbing jaw pain on day 4 following a lower wisdom tooth extraction. On inspection the socket appears empty with exposed bone and the patient reports halitosis. The diagnosis is:
Dry socket (alveolar osteitis) presents days 3–5 post-extraction with severe throbbing pain, empty socket (no blood clot), exposed bone, halitosis, and pain radiating to the ear. It is NOT infective — antibiotics are not indicated. Treatment: gentle saline irrigation + Alvogyl eugenol dressing repeated every 3–5 days.
9. When performing deep tracheal suctioning via a tracheostomy, what is the correct technique for catheter depth?
The correct technique is to advance the suction catheter without suction until the carina is reached (resistance felt), then withdraw 1 cm before applying suction during withdrawal with a gentle rotating motion. Applying suction on insertion causes trauma and mucosal damage. Duration should not exceed 15 seconds.
10. A patient receiving concurrent chemoradiation for oropharyngeal cancer develops severe oral mucositis (WHO Grade 3 — unable to eat). Which intervention is MOST appropriate to maintain nutrition?
WHO Grade 3 mucositis means the patient cannot eat. Enteral nutrition (NG or PEG) is the preferred route as the gut is functional. Parenteral nutrition is reserved for non-functional gut. Oral supplements are inadequate when swallowing is impossible due to severe mucositis. Pre-emptive PEG placement is recommended in high-risk patients before RT commences.