CARCINOMA OF THE TONGUE CASE STUDY
1. Explain fully the patient’s condition and why surgery was indicated. Additionally, explain why cefoxitin was prescribed and administered.
Carcinoma of the tongue is an oral cancer that is characterized by an ulcerating malignant tumor, usually on the side of the tongue, consisting of scaly (squamous) cells. The tumor may spread to the lymph nodes on the same side of the neck.
Squamous cell carcinoma is the most common type of oral cancer. Nearly 40% of squamous cell carcinomas affect the lower lip; many of the remainder affect the floor of the mouth or the tongue. These cancers form a hard lump or a firm-bordered sore (ulcer) that may bleed intermittently. Affected areas may appear white, red, or mixed white and red and can be smooth or raised.
The commonest histology among tumors of base of tongue is squamous cell carcinoma (> 90%), with salivary, gland tumors comprising small subsets (1-2%). Epithelial-myoepithelial carcinomas have traditionally been categorized under “malignant mixed tumors”, but the term has now been separated and added to the second edition of the World Health Organization’s histological classification of salivary gland tumors. Other synonyms of epithehal-myoepithelial carcinoma include epithelial carcinoma, myoepithelial carcinoma and clear cell carcinoma of salivary, gland origin (Nita, 2004).
A biopsy is essential. Treatment for lesions greater than 2 cm is surgical excision or irradiation. Surgical resection is an effective treatment for primary squamous cell carcinoma arising on the tongue. It is advised that the malignant body be removed from the tongue as this can spread to the surrounding areas and lymph nodes.
Radical neck dissection is the removal of all lymph nodes and certain tissues under the skin of the neck. It is done to prevent the spread of cancer of the head and neck. In the case study presented, this was the procedure done to prevent the spread of the cancer of the tongue. The tumor, nearby tissues, and lymph nodes on the affected side are removed in one mass from the angle of the jaw to the shoulder, forward to the middle, and back again to the angle of the jaw. A total removal of the voicebox (laryngectomy) may be done as part of the surgery.
Cefoxitin was prescribed and given to the patient as this drug belongs to a group of antibiotics called the cephalosporins. Their action is to kill bacteria by interfering with the ability of bacteria to form cell walls. The bacteria therefore break up and die. Cefoxitin is given by injection or infusion, and is generally used in severe infections or before an operation to prevent infection after surgery.
2. Discuss in detail the reaction of this patient to the drug.
Cefoxitin causes induction of chromosomal beta-lactamases in several bacterial organisms. It can be effective against some gram negative bacteria but is unable to get into pseudomonas or enterobacter.
The drug cefoxitin has some common side effects. But what the patient had after intravenous administration of cefoxitin is an uncommon side effect which is low blood pressure or hypotension, wheezing over both lung fields and urticaria.
There can be a degree of hypersensitivity in some people, and as depicted in the case study, which can result to a rash or an IgE mediated ellergy that can result in anaphylaxis or anaphylactic shock.
Various antibiotics including cefoxitin may alter the balance of the body. Generally, hypotension or low blood pressure is defined as a systolic BP of 90 mm Hg or less that causes light-headedness, visual disturbances, decreased level of consciousness, syncope, decreased urine output, and, ultimately, shock. Someone who has a low BP without these signs and symptoms isn’t considered to have hypotension.
Untreated hypotension can lead to shock and organ failure, so promptly assess the cause, type, severity, and duration to prevent ischemia and tissue death. Successful management calls for the following measures.
3. Explain why epinephrine, dexamethasone, diphenhydramine, dopamine and fluids were prescribed. Include in your account the mechanism of action of these drugs.
Epinephrine has a greater effect in stimulating beta receptors and also has greater effect on cardiac stimulation. Epinephrine causes weak constrictions of the blood vessels in the muscles. Epinephrine thus raises the arterial pressure to a lesser extent than norepinephrine but increases the cardiac output more ( 2000).
Dexamethasone is a glucocorticoid which is synthetic and is thirty times as potent as cortisol. The intense glucocorticoid activity of this synthetic hormone, which has almost zero mineralocorticoid activity, makes this an especially important drug for stimulating specific glucocorticoid activity ( 2000). The action of glucocorticoids includes regulating multiple metabolic and developmental processes and they also play a vital role in the maintenance of basal and stress-related homeostasis.
Diphenhydramine is an antihistamine with anticholinergic (drying) and sedative properties that is used to treat allergic reactions. Histamine is released by the body during several types of allergic reactions and–to a lesser extent–during some viral infections. When histamine binds to its receptors on cells, it causes changes within the cells that lead to sneezing, itching, and increased mucus production. Antihistamines compete with histamine for cell receptors; however, when they bind to the receptors they do not stimulate the cells. In addition, they prevent histamine from binding and stimulating the cells.
Dopamine is a chemical which is produced by the body and plays in important role in brain and nervous functions ( 2000). Dopamine can be supplied as a medication that acts on the sympathetic nervous system, producing effects such as increased heart rate and blood pressure (to counter the hypotension experienced as a result of the administration of cefoxitin).
Basically, the actions of all these drugs and fluids are geared towards returning the body into its normal states.
4. Explain in detail why pulmonary edema developed in this patient.
Pulmonary edema is a dramatic and life-threatening manifestation of acute heart failure. A sudden rise in ventricular filling pressure to high levels results in rapid movement of plasma fluid through pulmonary capillaries into the interstitial spaces and alveoli.
When the heart is not pumping blood forward, it must be damming blood in the blood vessels of the lungs or in the systemic circulation. This increases both the left and the right atrial pressures and leads to increased capillary pressures, particularly in the lungs. The acutely diminished cardiac output as a result of the cardiac injury leads to diminished blood flow to the kidneys, and the kidneys fail to excrete enough urine. This adds progressively to the blood volume and, therefore, to the congestive symptoms – pulmonary edema ( 2000).
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