Squamous cell CA of Face (graphic content)

[seasonedlpn]

I have a 65 YO male with squamous cell CA of the face. After the initial shock at how far this had progressed, I'm trying to figure out how to keep the drainage at bay.

The growth encompasses the entire side of the head, having already fully consumed the ear, and is working through the cheek. From the side, you can see no facial features, just the rolled edge of the advancing CA. The eye is compressing, the edge of the mouth is disappearing, speech is difficult, as the jaw involvement makes movement painful. His nutrition is liquid only, as he cannot chew. To be honest, although painfully graphic, the side of his head looks like a cheese pizza.

He has been using Dakin's solution, followed by colloidal silver...but the odor lingers. We've been using several layers of calcium alginate and ABD pads secured with gauze wrap. The dressing needs to be changed BID. He is alert and ambulatory, but unable to dress the area himself. Does anyone have ideas for a dressing that would not saturate for a full 24 hours? The process is quite painful, and, being ambulatory, he is reluctant to use the MS, it makes him dizzy.

Needless to say, he is a Hospice patient. I've never encountered this scenario, at least not to this degree. What is the expected cause of death here, bleed out?

Any help is much appreciated.

[zooparade]

No great ideas on the drainage. However for odor, it sometimes works to crush a Flagyl tablet in KY jelly and apply to the would bed. I have used this successfully with fungating tumors.

Good luck...

[northga gal]

From EPERC's Fast Fact #46 on Malignant Wounds:

Malignant wounds carry a high risk of superficial infection, especially with anaerobic or fungal species. Odor is frequently the first sign of anaerobic infection along with a purulent exudate. If the infection is only superficial, topical treatment (metronidazole, silver sulfadiazine) may be sufficient. However, if there is evidence of deeper tissue infection, then systemic metronidazole should be used. If the wound is determined to be non-healing, then topical agents like povidone can be used; note some patients find it irritating and painful.

This is just an excerpt. I recommend reading the whole thing because it has additional info which you may find of value.

http://www.eperc.mcw.edu/

[seasonedlpn]

It is definitely non-healing. He is using topical colloidal silver to keep infection down, but infection would be a blessing at this point. I do recall using a metronidazole mixture a few years ago on another tumor..it helped. I think the very act of spreading anything would be painful. Perhaps we could use a thin mixture that could be sprayed on, I'll put the idea to our team.

[marachne]

I've used metronidazole with good results in situations like this. We just crushed and crumbled in the wound, and I've seen information about formulating in a gel...you may be able to dissolve and spray, but even that could be more uncomfortable than just sprinkling.

Also when you were talking about your wound dressing, it made me think about some of our poor head and neck guys who were getting radiation -- we would use bandnet to hold on dressing sometimes and it worked well, particularly if you made a kind of "snood" out of it.

[hospicemom]

I dont have any new ideas as far as drainage and bandaging goes. I have used ostomy bags on fungating tumors however that would not work on the face. I also used flagyl, crushed and dissolved in 0.9NS and syringed onto the tumor.

[finn11707]

I had a younger hospice patient with a similar very large fulminating (large cantalope sized) tumor that encompassed his neck, shoulder and lower face. Also, a younger woman with a fulminating (no treatments) breast cancer tumor of large area. No tricks for decreasing drainage--just leave lower dressing intact---xeroform guaze/mepilex--silvadene cream an be soothing. Change the outer fluffs and abds as needed. Change bottom layers every 2-3 days if possible---sprinkle liberally with crushed flagyl into the wound. Flexnet fashioned 'hood to keep all inplace. This is where antibiotics work to decrease some drainage if copious or foul odor. Yes, lots of bleeding risk with whole dressing changes--keep silver nitrate stix onhand. You are a blessing to this patient and family.

[morte, LPN, LVN]

only had one patient like this (not a hospice nurse) and indeed the expected cause of death was a bleed out.....

[leslie :-D]

in order to contain drainage and odor, these dsgs sometimes need to be changed 5-6 times daily.

there isn't any known dsg or product available that enables only daily changes.

they do have charcoal dsgs or placing charcoal under the bed, can be helpful with odors.

these wounds are horrible for the pt.

social death occurs much earlier than physical death, r/t smells and disfigurement.

and they're painful.

very painful.

flagyl solution (crushed in gel or flagyl iv) is commonly used.

foam dsgs are useless since they're saturated within an hr.

lots of alginate, plenty of padding and frequent changes are the only ways to contain drainage and odor.

and i hope he's heavily sedated, d/t high risk of spontaneous bleed.

leslie

[seasonedlpn]

Believe it or not, he doesn't like the liquid morphine, says it makes him too unsteady when showering, (yes, he showers himself, to soak off old dressing) There is usually some bleeding noted, but nothing near hemorrhage. We use a LOT of alginate and 4x4s, the dressing is being changed BID. I'm going to ask our Doctor about metronidazole in solution.