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Oncology

Head & Neck Cancer

Head and neck squamous cell carcinoma (HNSCC) High-yield Verified · Sep 2026

Head and neck cancers are cancers that "usually begin in the squamous cells that line the mucosal surfaces of the head and neck (for example, those inside the mouth, throat, and voice box)" — squamous cell carcinomas of the head and neck (NCI). Cancers of the brain, eye, esophagus, thyroid and skin are not usually included.

A sore that will not heal, a lump in the neck, a sore throat that does not go away, trouble swallowing or a changed voice lasting more than two weeks needs a dentist or doctor. For the nurse, the stakes are the airway and the mouth. A total laryngectomy patient is a permanent neck breather: oxygen, suction and any intubation go through the stoma, never the nose or mouth. A tracheostomy patient still has a connected upper airway, and a bleed from the stoma can herald a catastrophic hemorrhage. Radiation brings mucositis, dry mouth, aggressive caries, jaw necrosis and hypothyroidism, so dental care starts before treatment and continues with periodic dental evaluations afterward.

What’s going wrong in the body

The normal physiology, where it fails, and why the body’s compensation backfires.

01 Two roads to the same squamous cancer

NCI: "Alcohol and tobacco use (including secondhand smoke and smokeless tobacco , sometimes called “chewing tobacco” or “snuff”) are the two most important risk factors for head and neck cancers, especially cancers of the oral cavity, hypopharynx, and voice box." "People who use both tobacco and alcohol are at greater risk of developing these cancers than people who use either tobacco or alcohol alone."

HPV-driven oropharyngeal cancer. "Two types of oropharyngeal cancer can be distinguished: HPV-associated, due to an oral human papillomavirus infection, and non-HPV-associated, mainly due to tobacco smoking and alcohol use" (StatPearls). "About three-quarters of all oropharyngeal cancers are caused by chronic HPV infection" (NCI). "In the case of HPV-associated OPSCC, the oral mucosa is exposed to the HPV infection, which persists and is not cleared." StatPearls: "in most HPV-positive oropharyngeal cancers, the tumor originates deep inside the tonsillar crypt epithelium. This is why these cancers are neither visible on inspection nor noticeable by superficial brush biopsy."

Different patient, better outlook. StatPearls: "HPV-associated OPSCC tends to occur in a younger population that smokes and drinks less; a higher percentage are males and report more oral sex partners." NCI: "patients with HPV-positive oropharyngeal tumors have a much better prognosis and higher chance of complete cure than those with HPV-negative tumors following the same treatment."

How it spreads. "If a squamous cell carcinoma of the head and neck is going to spread, it almost always does so locally and/or to the lymph nodes in the neck" (NCI) — which is why a neck lump can be the first sign.

Tobacco and alcohol act on the mucosa of the mouth, pharynx and larynx; persistent HPV infection drives cancers deep in the tonsil crypts and tongue base. Both are squamous cell carcinomas that spread locally and to neck nodes.

02 Laryngectomy versus tracheostomy — two different airways

Total laryngectomy. "After a laryngectomy, the entirety of the trachea is diverted to a stoma in the anterior neck, and the pharyngeal remnant is closed on itself to form a neo-pharynx. Thus there is a complete separation of the respiratory and digestive tracts. Breathing through the nose or mouth is no longer possible, as both now connect to the esophagus only." "All respiration, including any needed oxygen supplementation or intubation, is via the anterior neck stoma, now an unprotected route to the trachea and lower airways" (StatPearls).

Tracheostomy. "Tracheostomy is an important airway adjunct involving the surgical creation of a stoma in the anterior trachea, typically between the 2nd and 3rd tracheal rings, to establish a stable airway." The larynx and upper airway remain connected — in a tracheoinnominate bleed, management includes "orally intubating with the cuff positioned distal to the bleeding site" (StatPearls).

Why hoarseness is the laryngeal clue. "Disruptions to the mucosa or the submucosal structures of the true vocal folds impair vibration and will result in hoarseness" — but "hoarseness is a very nonspecific sign." "Hoarseness is the most common initial symptom of glottic cancers," whereas "pain with swallowing is the most common early symptom of supraglottic cancer" (StatPearls).

After a total laryngectomy the stoma is the only airway; after a tracheostomy the upper airway is still connected. Confusing the two is a dangerous error.

03 What radiation does to the mouth, glands and bone

StatPearls: "The most bothersome adverse effects during treatment include mucositis and dermatitis, as epithelial cells are very radiosensitive. The most significant long-term effects include hypothyroidism, xerostomia (the thyroid and salivary glands are also extremely radiosensitive), and dysphagia." "The basal layer of the oral epithelium has a high mitotic activity, making it more susceptible to radiation injury and leading to oral mucositis."

Mucositis "is a frequent complication of head and neck radiation therapy, occurring in up to 91% of patients." "Symptoms usually appear after the first week of radiation therapy and may last for several months." It can "impair eating, swallowing, and speaking, with consequent loss of weight and appetite"; severe cases need nutrition support and "pausing radiation treatment, significantly affecting patients' prognosis."

Dry mouth and caries. "Xerostomia is an expected side effect of radiotherapy on the head and neck, which starts soon after initiating treatment and may be irreversible in some cases." "Radiation-related caries is a very aggressive type of tooth decay that develops in dental surfaces normally resistant to caries."

Osteoradionecrosis. "Osteoradionecrosis of the jaws is a late complication of radiation therapy of the head and neck, where exposed irradiated bone becomes necrotic and fails to heal for at least 3 months with no signs of tumor recurrence." Risk rises with poor oral hygiene, dental surgery, tobacco and alcohol, and "when the radiation dose exceeds 60 Gy" (StatPearls).

Rapidly dividing mucosa and the salivary and thyroid glands are the most radiosensitive tissues, so radiation causes early mucositis and dry mouth, then caries, fungal infection, jaw necrosis, hypothyroidism and late dysphagia.

Causes & risk factors

Modifiable factors are teaching targets — the patient can act on them.

Tobacco — smoked, secondhand and smokeless ("chewing tobacco" or "snuff"); one of "the two most important risk factors" modifiable Alcohol — the other main risk factor; combined with tobacco the risk is greater than either alone modifiable HPV infection, especially HPV 16 — a risk factor for oropharyngeal cancers of the tonsils and base of tongue; "HPV 16 is responsible for almost 90% of HPV-positive oropharyngeal cancers" (StatPearls) modifiable Paan (betel quid) — "strongly associated with an increased risk of mouth cancers" modifiable Sun exposure — "Cancer of the lip can be caused by sun exposure" (NIDCR) modifiable Epstein-Barr virus — "a risk factor for nasopharyngeal cancer" Male sex and older age — "more than twice as common among men"; diagnosed more often over age 50 (NCI); oral cancer "most often occurs in people over the age of 40" (NIDCR)

Signs & symptoms

Each finding tied to the mechanism that produces it — and the triage it calls for.

A sore in the mouth or throat that does not heal, a lump in the neck, a sore throat that does not go away, trouble swallowing, or a change or hoarseness in the voice early Hold & notify
Why: The core NCI red flags. NIDCR: "If you have any of these symptoms for more than two weeks, see a dentist or a doctor."
A white or red patch in the mouth; numbness of the tongue or mouth; jaw swelling that makes dentures fit poorly; unusual bleeding or pain in the mouth Hold & notify
Why: Oral cavity signs (NCI, NIDCR).
Hoarseness (glottic) or pain on swallowing (supraglottic)
Why: Vocal fold mucosa that cannot vibrate causes hoarseness — the most common first symptom of glottic cancer; painful swallowing is the most common early symptom of supraglottic cancer, with hoarseness later (StatPearls).
Persistent sore throat, dysphagia, painful swallowing, a neck lump, ear pain
Why: Common oropharyngeal presentations (StatPearls); HPV-positive tumors can hide in the tonsil crypts.
Fixed, firm, painless neck mass late
Why: Nodal metastasis — squamous cancers spread to neck nodes (StatPearls, NCI).
Trouble breathing or speaking late
Why: NCI lists trouble breathing among voice-box symptoms.

Diagnostics

Test In this disorder Normal
Screening "Although there is no standard or routine screening test for head and neck cancers, dentists may check the oral cavity for signs of cancer during a routine checkup" (NCI). NIDCR: "Your regular dental checkup is an excellent opportunity to have the examination." No standard or routine screening test NCI —
Laryngoscopy with biopsy; fine-needle aspiration of a node "Multiple methods for obtaining tissue are feasible, including biopsy during direct laryngoscopy of the suspected primary lesion and fine-needle aspiration cytology for suspected nodal disease" (StatPearls). StatPearls: "A referral to an ENT surgeon should be considered if hoarseness persists and is accompanied by other signs suggestive of malignancy." Squamous cell carcinoma on tissue —
HPV status (oropharyngeal cancer) HPV-positive oropharyngeal tumors have "a much better prognosis and higher chance of complete cure" (NCI). HPV-positive or HPV-negative —
[CIS] Before cisplatin — kidney function, electrolytes, hearing test Cisplatin label: renal toxicity is cumulative; "Audiometric testing should be performed prior to initiating therapy and prior to each subsequent dose of drug." Baseline creatinine, BUN, creatinine clearance, magnesium, sodium, potassium, calcium; audiometry —
[CET] During and after cetuximab — magnesium, potassium, calcium ERBITUX label: monitor "during treatment and for at least 8 weeks following the completion. Replete electrolytes as necessary." Watch for low magnesium and related electrolyte losses —
[RT] Thyroid function after neck radiation NCI: "The doctor may monitor thyroid and pituitary gland function, especially if the head or neck was treated with radiation." Rising risk of hypothyroidism —

Complications

Black-box warning — most severe: ■ [TL]/[TRACH] Acute airway compromise after neck surgery Report immediately
"Early complications after total laryngectomy include bleeding, postoperative edema, and airway compromise. The patient should be carefully monitored for these complications in the immediate postoperative period." StatPearls (tracheostomy): the team "must be prepared to perform an emergent tracheostomy immediately in life-threatening cases, including laryngeal disruption or other acute airway compromise."
A postoperative hematoma "will present as a firm or fluctuant swelling and may result in purplish discoloration of the overlying skin; this should be promptly recognized and surgically evacuated." After laryngectomy the stoma "will need frequent suctioning in the first few days."
Black-box warning — most severe: ■ [TRACH] Tube obstruction or dislodgement Report immediately
"Acute tube obstruction may result from blood, mucus, or dislodgement. Preventive measures include regular suctioning, humidified oxygen, and daily cannula cleaning." "Dislodgement into soft tissue or a false passage may lead to airway compromise. Stay sutures placed during surgery can facilitate reentry."
"Early tube changes are discouraged unless absolutely necessary, as the immature tract increases the risk of false passage and airway compromise." The first change "typically occurs on postoperative days 5 to 7." "Backup supplies should include smaller tracheostomy tubes, ETTs, and exchange catheters."
Black-box warning — most severe: ■ [TRACH] Tracheoinnominate fistula — sentinel bleed Report immediately
"Tracheoinnominate fistula is rare (<1%) but carries a high mortality rate, approaching 80%. A sentinel bleed from the stoma may precede catastrophic hemorrhage."
"Immediate management includes removing the tracheostomy tube, orally intubating with the cuff positioned distal to the bleeding site, and applying digital pressure through the stoma to tamponade the artery against the manubrium."
Black-box warning — most severe: ■ [CET] Cetuximab infusion reactions and cardiopulmonary arrest (boxed warnings) Report immediately
"ERBITUX can cause serious and fatal infusion reactions." Signs include "rapid onset of airway obstruction (bronchospasm, stridor, hoarseness), hypotension, shock, loss of consciousness, myocardial infarction, and/or cardiac arrest." "Immediately interrupt and permanently discontinue ERBITUX for serious infusion reactions."
"Cardiopulmonary arrest or sudden death occurred in patients with squamous cell carcinoma of the head and neck receiving ERBITUX with radiation therapy or with a cetuximab product with platinum-based therapy and fluorouracil. Monitor serum electrolytes, including serum magnesium, potassium, and calcium, during and after ERBITUX administration." "Infusion Reactions: Monitor patients following infusion."
Black-box warning — most severe: ■ [CIS] Cisplatin boxed warnings — kidneys, hearing, anaphylactic-like reactions Hold & notify
"Cumulative renal toxicity associated with cisplatin is severe. Other major dose-related toxicities are myelosuppression, nausea, and vomiting." "Ototoxicity, which may be more pronounced in children, and is manifested by tinnitus, and/or loss of high frequency hearing and occasionally deafness, is significant."
"Anaphylactic-like reactions to cisplatin have been reported. Facial edema, bronchoconstriction, tachycardia, and hypotension may occur within minutes of cisplatin administration" (see Anaphylaxis). Pretreatment hydration is recommended. "Care must be taken to avoid inadvertent cisplatin overdose due to confusion with carboplatin or prescribing practices that fail to differentiate daily doses from total dose per cycle."
Warning: [TL] Pharyngocutaneous fistula Hold & notify
"Initial presentation is typically between postoperative days four and five, with neck swelling and erythema of the overlying flaps. If drains are in place and functioning, saliva or mucopurulent fluid may be seen in the drain."
StatPearls: "Overall primary pharyngeal leak rates for non-radiated patients are near 10% but rise to greater than 30% in patients undergoing a post-radiation laryngectomy." Late complications include "pharyngoesophageal stenosis, stoma stenosis, and hypothyroidism."
Warning: [ORN] Osteoradionecrosis of the jaw Hold & notify
"Exposed irradiated bone becomes necrotic and fails to heal for at least 3 months with no signs of tumor recurrence." "Risk factors include poor oral health and hygiene, pre-head and neck radiation surgery, dental surgery, and tobacco and alcohol consumption."
Prevention is dental: treatment before radiation and "periodic systematic dental evaluations" afterward (NCI).
Caution: [HNC] Lymphedema and cellulitis Hold & notify
Head and neck lymphedema "can be reversed, improved, or reduced if treated promptly." "Untreated cellulitis, if severe, can be dangerous and could lead to further swallowing or breathing difficulties" (NCI).
Caution: [HNC] Second primary cancers and recurrence
"People who have been treated for head and neck cancers have an increased chance of developing a new cancer, usually in the head, neck, esophagus, or lungs." "Head and neck cancers not related to HPV infection are especially likely to recur after treatment" (NCI).

Medications for this condition

Why each class is prescribed here — every card links to its full pharmacology page.

Antineoplastic / Chemotherapy Overview First-line High-alert
Oncology

[CIS] Cisplatin with radiation — for the larynx, "definitive radiation concurrent with cisplatin chemotherapy remains an option for laryngeal preservation" (StatPearls, citing ASCO). Boxed warnings: cumulative renal toxicity, ototoxicity (tinnitus, high-frequency hearing loss — audiometry before each dose), anaphylactic-like reactions, myelosuppression, nausea and vomiting; pretreatment hydration; never confuse with carboplatin. [CET] Cetuximab — boxed warnings for "serious and fatal infusion reactions" and cardiopulmonary arrest with radiation; monitor magnesium, potassium and calcium; "Limit sun exposure." No doses here — see the class page.
Opioid Analgesics High-alert
Nervous · morphine

Mucositis pain. Patients "report debilitating pain"; management rests on "basic oral care, dietary advice, and pain control" (StatPearls, citing MASCC/ISOO). The budgeted sources name no specific analgesic — role only.
Vaccines & Immunizations
Immune / Anti-infective

HPV vaccine. "In June 2020, the Food and Drug Administration granted accelerated approval of the HPV vaccine Gardasil 9 for the prevention of oropharyngeal and other head and neck cancers caused by HPV types 16, 18, 31, 33, 45, 52, and 58 in persons aged 9 through 45 years" (NCI). "Avoiding oral HPV infection can reduce the risk of HPV-associated head and neck cancers."

Beyond medications

  • Treatment choice — "surgery, radiation therapy , chemotherapy , targeted therapy , immunotherapy , or a combination of treatments." Patients should discuss how each option "might change the way the patient looks, talks, eats, or breathes" (NCI).
  • Early laryngeal cancer "can often be managed with single-modality therapy, such as surgery or radiation therapy," with local control of 90% to 95% for T1 glottic cancers (StatPearls). Total laryngectomy is standard surgical salvage after failed nonsurgical treatment and is used "as a primary treatment for advanced-stage laryngeal malignancy."
  • Stop smoking — "continued smoking by a patient with head and neck cancer may reduce the effectiveness of treatment" and raises the chance of a second primary cancer; 1-800-QUIT-NOW connects to state quit lines (NCI).
  • Dental care before radiation — "Pre-radiation dental treatment is done to prevent further infection and avoid the need for invasive procedures during and after radiotherapy." NIDCR: "See a dentist for a thorough examination one month, if possible, before starting cancer treatment to give your mouth time to heal after any dental work you might need." If teeth are extracted first, StatPearls gives an ideal interval of 10 days to 3 weeks before radiation starts — though pre-radiation extraction "is a controversial topic since the evidence available is contradictory."
  • Mucositis care — basic oral care (more frequent brushing with a soft brush, interproximal cleaning, replacing the toothbrush often), dietary advice and pain control; bland rinses such as 0.9% saline or saline/sodium bicarbonate; "Most nonmedicated oral care protocols use topical, frequent (every 4–6 hours) rinsing with 0.9% saline" (NCI).
  • Dry-mouth care — "frequently sip water, chew sugar-free gum, suck sugar-free candy, avoid caffeine, tobacco, alcohol, and hard or dry food, and increase fluid intake to prevent dehydration." Drugs (pilocarpine, cevimeline) are "reserved for when local measures are ineffective"; "Pilocarpine is contraindicated in patients with glaucoma, asthma, and hypertension" (StatPearls).
  • Trismus prevention — "Prescribe jaw opening and closing exercises to reduce risk of trismus" (NCI).
  • Rehabilitation — speech-language pathology ("teach speech exercises or alternative methods of speaking"), swallowing therapy, dietitian support, stoma-care teaching; a tracheoesophageal puncture may be done for voice restoration; a prosthodontist can make a prosthesis when reconstruction is not possible (NCI, StatPearls).

Nursing considerations

The RN-specific layer — each action paired with the reason it matters.

Assessment
Know which airway the patient has: total laryngectomy (neck breather) or tracheostomy. Check that signs at the head of the bed and on the room door identify a laryngectomy patient.
Why: StatPearls: signs should indicate "that the patient is a permanent neck breather and cannot be intubated orally or nasally." A tracheostomy patient still has a connected upper airway.
After neck surgery, monitor the airway, stoma or tube patency, secretions, and the neck for swelling or purplish discoloration.
Why: Early complications include "bleeding, postoperative edema, and airway compromise"; a hematoma "should be promptly recognized and surgically evacuated."
On post-op days 4–5 after laryngectomy, check the neck flaps for swelling and redness and the drains for saliva or mucopurulent fluid.
Why: This is the typical presentation of a pharyngocutaneous fistula, more common after prior radiation.
During radiation, inspect the mouth (mucositis, dryness, fungal infection) and track weight, intake and swallowing.
Why: Mucositis affects up to 91%, usually from after the first week, and can force nutrition support and treatment pauses.
On cisplatin, trend creatinine and electrolytes and ask about tinnitus or hearing change; on cetuximab, check magnesium, potassium and calcium and the skin.
Why: Label boxed warnings: cumulative renal toxicity and ototoxicity (cisplatin); electrolyte monitoring and cardiopulmonary arrest risk (cetuximab).
Interventions
Laryngectomy: give oxygen, suction and any ventilation through the stoma — never by face mask or nasal cannula; suction the stoma frequently in the first few days.
Why: "All respiration, including any needed oxygen supplementation or intubation, is via the anterior neck stoma"; "the stoma will need frequent suctioning in the first few days."
Tracheostomy: suction regularly, give humidified oxygen, clean the cannula daily, keep backup tubes at hand, and raise the head of the bed.
Why: StatPearls: "Preventive measures include regular suctioning, humidified oxygen, and daily cannula cleaning"; raising the head of the bed helps minimize aspiration (StatPearls, citing Belgian tracheotomy guidelines); backup supplies allow quick replacement.
Airway compromise, tube dislodgement, or bleeding from a tracheostomy stoma: call for emergency help immediately and stay with the patient.
Why: Dislodgement "may lead to airway compromise"; a sentinel bleed "may precede catastrophic hemorrhage" from a tracheoinnominate fistula with mortality "approaching 80%."
Cetuximab infusion: watch closely during and after the infusion; for airway symptoms, hypotension or collapse, stop the infusion immediately and call for help.
Why: "Immediately interrupt and permanently discontinue ERBITUX for serious infusion reactions"; "Monitor patients following infusion."
Support nutrition: consult the dietitian and speech-language pathologist; get a swallowing evaluation before oral intake after tracheostomy.
Why: Some patients need IV nutrition or a feeding tube "until they can eat on their own"; "early swallowing evaluation by a speech-language pathologist is recommended before initiating oral intake" (StatPearls, citing Belgian tracheotomy guidelines).
Patient and family teaching
Laryngectomy: avoid open water and protect the stoma from things that could be breathed in.
Why: Patients "must take great care to avoid open water and be mindful of other foreign objects that can now be aspirated directly from the surface of the anterior neck."
See a dentist before radiation, keep up excellent oral hygiene, and keep up periodic dental check-ups; report a mouth sore or exposed bone that is not healing.
Why: Radiation caries is "a very aggressive type of tooth decay"; osteoradionecrosis is bone that "fails to heal for at least 3 months."
For dry mouth: sip water often, use sugar-free gum or candy, and avoid caffeine, tobacco, alcohol and hard or dry foods.
Why: StatPearls xerostomia advice; dryness raises caries and fungal infection risk.
Quit tobacco and limit alcohol.
Why: Continued smoking may reduce treatment effectiveness and raises the chance of a second primary cancer (NCI).
Expect thyroid blood tests after neck radiation; report side effects to the doctor or nurse.
Why: Hypothyroidism is a major long-term effect of radiation; NCI: "Patients should report any side effects to their doctor or nurse and discuss how to deal with them."
On cetuximab, limit sun exposure; on cisplatin, report ringing in the ears or hearing change.
Why: ERBITUX label dermatologic warning; cisplatin ototoxicity presents as tinnitus or high-frequency hearing loss.

How a real nurse thinks

The clinical-judgment loop, worked for a typical presentation — reasoning, not reference.

  1. 1
    Recognize cues

    Falling SpO2 despite nasal oxygen, rising respiratory and heart rates, and thick secretions at the stoma in a patient 2 days after total laryngectomy. The nasal cannula is delivering oxygen to a nose that no longer connects to the lungs.

  2. 2
    Analyze cues

    StatPearls: "Breathing through the nose or mouth is no longer possible." "All respiration, including any needed oxygen supplementation or intubation, is via the anterior neck stoma." Secretions are expected — "the stoma will need frequent suctioning in the first few days" — and can obstruct the only airway.

  3. 3
    Prioritize

    Airway first: clear the stoma and deliver oxygen where the patient actually breathes. Airway compromise is an early complication to monitor for.

  4. 4
    Generate solutions

    Suction the stoma, apply oxygen at the stoma instead of the nasal cannula, and reassess saturation and breathing. If breathing does not improve, call for emergency help — any intubation must also go through the stoma.

  5. 5
    Take action

    Suctions the stoma, moves oxygen to the stoma, and notifies the surgeon: POD 2 total laryngectomy; SpO2 fell to 88% with oxygen by nasal cannula; thick secretions at the stoma, now suctioned and oxygen applied at the stoma; RR 26, HR 112. Reinforces the neck-breather signs with the float nurse.

  6. 6
    Evaluate

    SpO2 recovers once the stoma is cleared and oxygen is at the stoma; respiratory rate settles. Continue frequent stoma suctioning and watch the neck and drains for bleeding, swelling or saliva.

Scenario — you’re the nurse

Work each question before revealing the answer. Rationales explain the wrong options too.

Surgical unit · post-op day 2 after total laryngectomy, 0300

A 62-year-old man with advanced laryngeal cancer had a total laryngectomy 2 days ago. He has a permanent neck stoma and neck drains. A float nurse covering the unit has just placed a nasal cannula at 2 L/min because his oxygen saturation dropped.

0200 — SpO2 95%; stoma with thin secretions
0300 — SpO2 88% with the nasal cannula on; RR 26; HR 112
Stoma — audible, thick secretions at the stoma opening
Neck — flaps flat, drains with small serosanguinous output
Signs posted — ‘permanent neck breather’ at the head of the bed and on the door
Q1 Multiple choice
A patient 2 days after total laryngectomy needs supplemental oxygen. How should the nurse give it?
  1. A. By nasal cannula
  2. B. By a face mask over the nose and mouth
  3. C. At the neck stoma
  4. D. Only after orally intubating the patient
Reveal answer & rationale
Answer: C
After total laryngectomy "Breathing through the nose or mouth is no longer possible," and "All respiration, including any needed oxygen supplementation or intubation, is via the anterior neck stoma" (C). A nasal cannula (A) or face mask (B) delivers oxygen to passages that no longer reach the lungs. The patient "cannot be intubated orally or nasally" (D).
Q2 Select all that apply
Which measures help protect the mouth of a patient receiving head and neck radiation? Select all that apply.
  1. A. A dental examination before radiation starts
  2. B. Frequent bland rinses such as 0.9% saline
  3. C. Brushing with a soft toothbrush
  4. D. Sipping water and chewing sugar-free gum for dry mouth
  5. E. Starting pilocarpine as first-line treatment before trying other measures
  6. F. Delaying dental extractions until radiation is finished
Reveal answer & rationale
Answer: A, B, C, D
Pre-radiation dental treatment prevents infection and later invasive procedures (A); bland saline rinses every 4–6 hours (B) and soft brushes (C) are basic mucositis care; sipping water and sugar-free gum ease xerostomia (D). Pilocarpine is "reserved for when local measures are ineffective" (E). Dental treatment is done before radiation "to prevent further infection and avoid the need for invasive procedures during and after radiotherapy," and dental surgery is a risk factor for osteoradionecrosis (F).
Q3 Multiple choice
A patient with a tracheostomy after head and neck surgery has a small spurt of bright red blood from around the stoma that stops on its own. What should the nurse do?
  1. A. Document it and recheck at the next scheduled assessment
  2. B. Treat it as a possible sentinel bleed — stay with the patient and call for emergency help immediately
  3. C. Change the tracheostomy tube to look for the source
  4. D. Give the patient ice chips and reassure him
Reveal answer & rationale
Answer: B
"A sentinel bleed from the stoma may precede catastrophic hemorrhage" from a tracheoinnominate fistula, which carries "a high mortality rate, approaching 80%" (B). Waiting (A) or reassurance (D) loses time. A routine tube change (C) is not the response — immediate management of a tracheoinnominate bleed includes "removing the tracheostomy tube, orally intubating with the cuff positioned distal to the bleeding site, and applying digital pressure," an emergency team intervention.
Q4 Multiple choice
Which statement about HPV-positive oropharyngeal cancer is accurate?
  1. A. It has a worse prognosis than HPV-negative cancer
  2. B. It is mainly caused by heavy smoking and drinking
  3. C. It often arises deep in the tonsil crypts and has a much better prognosis than HPV-negative cancer
  4. D. A routine yearly screening test finds most cases early
Reveal answer & rationale
Answer: C
HPV-positive tumors often originate "deep inside the tonsillar crypt epithelium," and patients have "a much better prognosis and higher chance of complete cure" (C). Answer A reverses the prognosis. HPV-associated cancer occurs in people who smoke and drink less (B). "There is no standard or routine screening test for head and neck cancers" (D).
Q5 Multiple choice
During a cetuximab infusion, a patient develops stridor, hoarseness and a blood pressure of 82/48. What is the nurse's first action?
  1. A. Slow the infusion rate and recheck vital signs in 15 minutes
  2. B. Stop the infusion immediately and call for emergency help
  3. C. Give the remaining dose faster to finish the treatment
  4. D. Check the magnesium level before deciding
Reveal answer & rationale
Answer: B
ERBITUX "can cause serious and fatal infusion reactions," including "rapid onset of airway obstruction (bronchospasm, stridor, hoarseness), hypotension, shock." The label says to "Immediately interrupt and permanently discontinue ERBITUX for serious infusion reactions" (B). Slowing (A) or speeding up (C) the infusion continues exposure; checking magnesium (D) delays emergency care.

Common questions

What causes head & neck cancer?
Common causes and risk factors include tobacco — smoked, secondhand and smokeless ("chewing tobacco" or "snuff"); one of "the two most important risk factors", alcohol — the other main risk factor; combined with tobacco the risk is greater than either alone, hpv infection, especially hpv 16 — a risk factor for oropharyngeal cancers of the tonsils and base of tongue; "hpv 16 is responsible for almost 90% of hpv-positive oropharyngeal cancers" (statpearls), paan (betel quid) — "strongly associated with an increased risk of mouth cancers", sun exposure — "cancer of the lip can be caused by sun exposure" (nidcr), and others.
What is the difference between a laryngectomy stoma and a tracheostomy?
After a total laryngectomy the trachea is brought out to a permanent stoma and fully separated from the mouth and nose — the patient is a "permanent neck breather" who "cannot be intubated orally or nasally." A tracheostomy is a tube in an opening in the trachea with the upper airway still connected, so oral intubation may be possible — but tracheostomy indications "include acute upper airway obstruction," so it is not guaranteed.
Why does HPV matter in throat cancer?
About three-quarters of oropharyngeal cancers are caused by chronic HPV infection, and their incidence is rising while other oropharyngeal cancers fall (NCI). HPV-positive tumors respond better — "a much better prognosis and higher chance of complete cure." The HPV vaccine Gardasil 9 is approved for prevention of oropharyngeal and other head and neck cancers in people aged 9 through 45.
How long should a mouth or throat symptom last before someone gets it checked?
NIDCR: "If you have any of these symptoms for more than two weeks, see a dentist or a doctor" — a sore, lump or thick patch; a white or red patch; persistent sore throat or hoarseness; trouble chewing, swallowing or speaking; or numbness in the mouth.
Why do radiation patients need ongoing dental care?
Radiation dries the mouth, sometimes permanently, and causes a "very aggressive type of tooth decay." Irradiated jaw bone can die and fail to heal (osteoradionecrosis), especially after dental surgery. Dental work before treatment and "periodic systematic dental evaluations" afterward lower that risk.
Why check the thyroid after treatment?
The thyroid is "extremely radiosensitive," and hypothyroidism is among the most significant long-term effects of neck radiation; it is also a late complication of total laryngectomy (StatPearls). NCI notes the doctor may monitor thyroid function after head or neck radiation.

Sources

Reviewed by Hae Suk Lee, RN

Educational summary for nursing students. Scenarios are fictional teaching cases. Always verify against current guidelines and your institution's protocols before acting in practice. Not medical advice.

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