Copyright January 2015
Copyright January 2015 J Wound Ostomy Continence Nurs. 2015;42(2):190-192. Published by Lippincott Williams & Wilkins
C HALLENGES IN PRACTICE
Palliative Management of Malodorous Squamous Cell Carcinoma of the Oral Cavity With Manuka Honey Jerri Drain Michael O. Fleming
■ ABSTRACT
■ Case History
BACKGROUND: The management of malignant malodor-
Ms J was an 80-year-old woman who was admitted to home health care for advanced oral squamous cell carcinoma with bony involvement resulting in fracturing and protrusion of the mandible through the lower face. She was not a surgical candidate for excision due to the advanced stage of the cancer. Ms J was treated with chemotherapy for palliation; however, she elected to stop treatments because she did not feel that the chemotherapy had improved her symptoms. She was receiving nutrition and medications via gastrostomy tube. Ms J reported retaining some ability to swallow very small amounts of liquid but was unable to chew or swallow solids and she reported an impaired sense of taste. She presented with an open wound to the lower face with bone protrusion, and multiple tumors with ulcerations were observed in the oral cavity along the mandible. The nurse contacted the certified WOC nurse for recommendations and suggestions for managing odor. The odor was described as similar to rotting flesh that permeated the entire house; it was distressing to both Ms J and her family. The home health care nurse reported that Ms J was reluctant to talk as the odor increased when she opened her mouth to speak. In addition, the nurse reported that the wound on her face was inflamed and producing purulent drainage. The wound measured 2 cm × 2 cm with the depth extending back through the face into the oral cavity. While Ms J and caregivers understood that wound was caused by the malignancy and would not heal; they nevertheless sought relief from the odor and discomfort caused by the wound.
ous wounds within the oral cavity can be challenging due to limited availability of dressings that are safe, efficacious, and ingestible. CASE DESCRIPTION: An 80-year-old woman with squamous cell carcinoma of the oral cavity was admitted to home care with complaints and distress related to extreme malodor. CONCLUSION: Manuka honey proved a safe, effective, palliative treatment to reduce odor and inflammation in wounds secondary to squamous cell carcinoma of the oral cavity in this patient. KEY WORDS: Manuka honey, odor, oral malignancy, palliative care, squamous cell carcinoma.
■ Introduction Squamous cell carcinoma of the oral cavity accounts for approximately 2% to 3% of all cancers; approximately 50% are advanced stage at the time of diagnosis.1 Malignant wounds occur in approximately 5% to 10% of cancer patients,2,3 and between 24% and 33% occur on the head and neck.3 These wounds are often friable, highly exudative, malodorous, and painful. The oral cavity is critical to physiologic functions such as speech, mechanical and chemical digestion, and swallowing. Patients with advanced stage squamous cell carcinoma may face loss of physiological functions coupled with the development of a chronic malodorous wound resulting in severe impairment of health-related quality of life. Odor, pain, loss of function, and disfigurement associated with malignancies of this type are distressing for both patients and caregivers and can lead to depression, social isolation, low self-esteem, shame, and embarrassment.2,3 Managing malignant malodorous wounds occurring in the oral cavity can be difficult due to limitations on dressings and products that provide symptom management and are safe for ingestion.
190 J WOCN ■ March/April 2015
Jerri Drain, RN, BSN, CWON, Amedisys Home Health Care, Baton Rouge, Louisiana. Michael O. Fleming, MD, FAAFP, Amedisys Home Health Care, Baton Rouge, Louisiana. The authors declare no conflict of interest. Correspondence: Jerri Drain, RN, BSN, CWON, Amedisys Home Health Care, 5959 S Sherwood Forest Blvd, Baton Rouge, LA 70816 ([email protected]). DOI: 10.1097/WON.0000000000000114
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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FIGURE 1. (A and B) Photos taken after 1 week of Manuka honey use.
Multiple options for odor control were discussed, including placement of kitty litter and open jars of vinegar in the room in an attempt to mask or absorb the order. However, Ms J's caregiver stated that these options had been tried but proved ineffective in alleviating the odor. Since the malodor primarily originated from inside the oral cavity, it was deemed necessary to choose a product that was safe for oral consumption. We elected to try a medical grade Manuka honey product. Calcium alginate impregnated with Manuka honey (Medihoney, Derma Sciences, Princeton, New Jersey) was applied to the external wound and Manuka honey paste (Medihoney) was applied twice daily with a swab in the oral cavity. We chose a calcium alginate with Manuka honey for the external wound to manage inflammation and drainage. The Manuka honey paste was selected for the oral wounds due to its viscosity and palatable taste of the paste. After 1 week of using the Manuka honey, the exudate was no longer purulent in appearance, the wound appeared less inflamed, and Ms J reported that the pain was somewhat improved. Most importantly for all concerned, the pungent odor caused by the wound was completely gone. Ms J and her family were delighted with this outcome. Assessment following 1 month of continued use revealed that although the wound size was unchanged, the drainage had decreased, and no inflammation or purulence was noted. No odor could be detected in the home, even when Ms J's mouth was open. The nurse reported that Ms J was much more willing to speak and was pleased with this approach to odor management. After 3 months of using the Manuka honey, the nurse reported that the external wound had actually decreased in size and measured 1 cm × 1 cm, drainage was low-volume and serosanguineous in nature. No signs and symptoms of infection were noted, and no odor was noted. The patient reported that the wound remained tender and painful to touch, but less painful than before treatment began. Ms J was able to manage her own wound care at that time. She was discharged to a palliative
care provider for oversight, and the Manuka honey dressing and paste continued as a palliative plan for wound maintenance and odor management (Figure 1).
■ Discussion Honey has multiple properties that support its use in wound care; it is antiseptic, has a low pH, and has a high osmolality leading to its antimicrobial, deodorizing, debridement, and anti-inflammatory actions in the wound bed.2-6 Although many dressing products have demonstrated an ability to reduce malodor in the wound bed, such as silver sulfadiazine, silver-impregnated dressings, cadexomer iodine, and charcoal dressings,2,3,5 they are indicated only for external use. Metronidazole can be applied topically or orally,3,5 but systemic metronidazole absorption can produce side effects such as nausea.3 Administration of metronidazole was anticipated to prove particularly difficult for this patient, who already found it difficult to swallow. Honey can be safely ingested, barring allergy, and when coupled with the deodorizing, antimicrobial, and anti-inflammatory properties, honey seems to be an ideal choice for managing wounds in the oral cavity. The use of honey specifically for oral wounds secondary oncology-related conditions such as radiation-induced mucositis, stomatitis, and periodontal conditions, and malignant ulcers is not as well studied and documented but has shown to be promising.4,7 Anecdotal evidence for use of honey in oral conditions has been reported as far back as 50 AD when honey was documented in the treatment of throat and tonsil inflammation.4 Hampton5 reviewed more recent studies of honey and found evidence of its efficacy in reducing the duration and severity of mucositis. Ghashm and coworkers7 evaluated the anticarcinogenic properties of Tualang honey specific to oral squamous cell carcinoma. Study findings suggested that Tualang honey may exert beneficial antiproliferative and apoptotic effects on oral squamous cell carcinoma, but
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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further studies are needed to evaluate the clinical relevance of these observations.7
■ Summary Honey proved safe and effective for palliative management of external and oral wounds secondary to squamous cell carcinoma in this elderly female patient. It also provided effective odor management, which was critically important to the psychological and emotional well-being of our patient and her caregivers. The anti-inflammatory and antimicrobial benefits of honey were an added bonus resulting in improvement in inflammation, pain, and exudate management. Based on our experiences in this patient and limited supporting evidence, we recommend considering honey as a safe, ingestible option for management of challenging wounds occurring within the oral cavity.
■ References 1. Kademani D. Oral cancer: symposium on solid tumors. Mayo Clin Proc. 2007:82(7):878-887. 2. Lund-Nielsen B, Adamsen L, Kolmos HJ, Rorth M, Tolver A, Gottrup F. The effect of honey-coated bandages compared with silver-coated bandages on treatment of malignant wounds—a randomized study. Wound Rep Reg. 2011;19:664-670. 3. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med. 2006;9:285-295. 4. Bardy J, Slevin NJ, Mais KL, Molassiotis A. A systemic review of honey uses and its potential value within oncology care. J Clin Nurs. 2008;17:2604-2623 5. Hampton S. Malodorous fungating wounds: how dressing alleviate symptoms. Wound Care. 2008;13:531-538 6. Belcher J. A review of medical-grade honey in wound care. Br J Nurs. 2012;15:S4-S9 7. Ghashm A, Othman NH, Khattak MN, Ismail NM, Saini R. Antiproliferative effect of Tualang honey on oral squamous cell carcinoma and osteosarcoma cell lines. BMC Complement Altern Med. 2010;10:49
Surgical Management of Extensive Peristomal Pyoderma Gangrenosum Associated With Colon Cancer: Erratum In the article referenced below, the affiliation of Dr. Hiroshi was incorrectly listed and Figure 3 did not show the correct images. The correct affiliation of Dr. Hiroshi Furukawa is the Department of Plastic and Reconstructive Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan. Below are the correct images for Figure 3A and B.
FIGURE 3. A, Drapes were applied over and over without removing #2 layer. B, An ostomy appliance was applied with
a stoma belt.
■ Reference Ishikawa K, Minamimoto T, Mizuki T, Furukawa, H (2015). Surgical management of extensive peristomal pyoderma gangrenosum associated with colon cancer. J Wound, Ostomy & Continence Nurs, 42(1):102-105.
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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Copyright January 2015 J Wound Ostomy Continence Nurs. 2015;42(2):190-192. Published by Lippincott Williams & Wilkins
C HALLENGES IN PRACTICE
Palliative Management of Malodorous Squamous Cell Carcinoma of the Oral Cavity With Manuka Honey Jerri Drain Michael O. Fleming
■ ABSTRACT
■ Case History
BACKGROUND: The management of malignant malodor-
Ms J was an 80-year-old woman who was admitted to home health care for advanced oral squamous cell carcinoma with bony involvement resulting in fracturing and protrusion of the mandible through the lower face. She was not a surgical candidate for excision due to the advanced stage of the cancer. Ms J was treated with chemotherapy for palliation; however, she elected to stop treatments because she did not feel that the chemotherapy had improved her symptoms. She was receiving nutrition and medications via gastrostomy tube. Ms J reported retaining some ability to swallow very small amounts of liquid but was unable to chew or swallow solids and she reported an impaired sense of taste. She presented with an open wound to the lower face with bone protrusion, and multiple tumors with ulcerations were observed in the oral cavity along the mandible. The nurse contacted the certified WOC nurse for recommendations and suggestions for managing odor. The odor was described as similar to rotting flesh that permeated the entire house; it was distressing to both Ms J and her family. The home health care nurse reported that Ms J was reluctant to talk as the odor increased when she opened her mouth to speak. In addition, the nurse reported that the wound on her face was inflamed and producing purulent drainage. The wound measured 2 cm × 2 cm with the depth extending back through the face into the oral cavity. While Ms J and caregivers understood that wound was caused by the malignancy and would not heal; they nevertheless sought relief from the odor and discomfort caused by the wound.
ous wounds within the oral cavity can be challenging due to limited availability of dressings that are safe, efficacious, and ingestible. CASE DESCRIPTION: An 80-year-old woman with squamous cell carcinoma of the oral cavity was admitted to home care with complaints and distress related to extreme malodor. CONCLUSION: Manuka honey proved a safe, effective, palliative treatment to reduce odor and inflammation in wounds secondary to squamous cell carcinoma of the oral cavity in this patient. KEY WORDS: Manuka honey, odor, oral malignancy, palliative care, squamous cell carcinoma.
■ Introduction Squamous cell carcinoma of the oral cavity accounts for approximately 2% to 3% of all cancers; approximately 50% are advanced stage at the time of diagnosis.1 Malignant wounds occur in approximately 5% to 10% of cancer patients,2,3 and between 24% and 33% occur on the head and neck.3 These wounds are often friable, highly exudative, malodorous, and painful. The oral cavity is critical to physiologic functions such as speech, mechanical and chemical digestion, and swallowing. Patients with advanced stage squamous cell carcinoma may face loss of physiological functions coupled with the development of a chronic malodorous wound resulting in severe impairment of health-related quality of life. Odor, pain, loss of function, and disfigurement associated with malignancies of this type are distressing for both patients and caregivers and can lead to depression, social isolation, low self-esteem, shame, and embarrassment.2,3 Managing malignant malodorous wounds occurring in the oral cavity can be difficult due to limitations on dressings and products that provide symptom management and are safe for ingestion.
190 J WOCN ■ March/April 2015
Jerri Drain, RN, BSN, CWON, Amedisys Home Health Care, Baton Rouge, Louisiana. Michael O. Fleming, MD, FAAFP, Amedisys Home Health Care, Baton Rouge, Louisiana. The authors declare no conflict of interest. Correspondence: Jerri Drain, RN, BSN, CWON, Amedisys Home Health Care, 5959 S Sherwood Forest Blvd, Baton Rouge, LA 70816 ([email protected]). DOI: 10.1097/WON.0000000000000114
Copyright © 2015 by the Wound, Ostomy and Continence Nurses Society™
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
JWOCN-D-14-00064.indd 190
25/02/15 1:58 AM
Drain and Fleming
Drain and Fleming
Drain and Fleming 191
J WOCN ■ Volume 42/Number 2
FIGURE 1. (A and B) Photos taken after 1 week of Manuka honey use.
Multiple options for odor control were discussed, including placement of kitty litter and open jars of vinegar in the room in an attempt to mask or absorb the order. However, Ms J's caregiver stated that these options had been tried but proved ineffective in alleviating the odor. Since the malodor primarily originated from inside the oral cavity, it was deemed necessary to choose a product that was safe for oral consumption. We elected to try a medical grade Manuka honey product. Calcium alginate impregnated with Manuka honey (Medihoney, Derma Sciences, Princeton, New Jersey) was applied to the external wound and Manuka honey paste (Medihoney) was applied twice daily with a swab in the oral cavity. We chose a calcium alginate with Manuka honey for the external wound to manage inflammation and drainage. The Manuka honey paste was selected for the oral wounds due to its viscosity and palatable taste of the paste. After 1 week of using the Manuka honey, the exudate was no longer purulent in appearance, the wound appeared less inflamed, and Ms J reported that the pain was somewhat improved. Most importantly for all concerned, the pungent odor caused by the wound was completely gone. Ms J and her family were delighted with this outcome. Assessment following 1 month of continued use revealed that although the wound size was unchanged, the drainage had decreased, and no inflammation or purulence was noted. No odor could be detected in the home, even when Ms J's mouth was open. The nurse reported that Ms J was much more willing to speak and was pleased with this approach to odor management. After 3 months of using the Manuka honey, the nurse reported that the external wound had actually decreased in size and measured 1 cm × 1 cm, drainage was low-volume and serosanguineous in nature. No signs and symptoms of infection were noted, and no odor was noted. The patient reported that the wound remained tender and painful to touch, but less painful than before treatment began. Ms J was able to manage her own wound care at that time. She was discharged to a palliative
care provider for oversight, and the Manuka honey dressing and paste continued as a palliative plan for wound maintenance and odor management (Figure 1).
■ Discussion Honey has multiple properties that support its use in wound care; it is antiseptic, has a low pH, and has a high osmolality leading to its antimicrobial, deodorizing, debridement, and anti-inflammatory actions in the wound bed.2-6 Although many dressing products have demonstrated an ability to reduce malodor in the wound bed, such as silver sulfadiazine, silver-impregnated dressings, cadexomer iodine, and charcoal dressings,2,3,5 they are indicated only for external use. Metronidazole can be applied topically or orally,3,5 but systemic metronidazole absorption can produce side effects such as nausea.3 Administration of metronidazole was anticipated to prove particularly difficult for this patient, who already found it difficult to swallow. Honey can be safely ingested, barring allergy, and when coupled with the deodorizing, antimicrobial, and anti-inflammatory properties, honey seems to be an ideal choice for managing wounds in the oral cavity. The use of honey specifically for oral wounds secondary oncology-related conditions such as radiation-induced mucositis, stomatitis, and periodontal conditions, and malignant ulcers is not as well studied and documented but has shown to be promising.4,7 Anecdotal evidence for use of honey in oral conditions has been reported as far back as 50 AD when honey was documented in the treatment of throat and tonsil inflammation.4 Hampton5 reviewed more recent studies of honey and found evidence of its efficacy in reducing the duration and severity of mucositis. Ghashm and coworkers7 evaluated the anticarcinogenic properties of Tualang honey specific to oral squamous cell carcinoma. Study findings suggested that Tualang honey may exert beneficial antiproliferative and apoptotic effects on oral squamous cell carcinoma, but
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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further studies are needed to evaluate the clinical relevance of these observations.7
■ Summary Honey proved safe and effective for palliative management of external and oral wounds secondary to squamous cell carcinoma in this elderly female patient. It also provided effective odor management, which was critically important to the psychological and emotional well-being of our patient and her caregivers. The anti-inflammatory and antimicrobial benefits of honey were an added bonus resulting in improvement in inflammation, pain, and exudate management. Based on our experiences in this patient and limited supporting evidence, we recommend considering honey as a safe, ingestible option for management of challenging wounds occurring within the oral cavity.
■ References 1. Kademani D. Oral cancer: symposium on solid tumors. Mayo Clin Proc. 2007:82(7):878-887. 2. Lund-Nielsen B, Adamsen L, Kolmos HJ, Rorth M, Tolver A, Gottrup F. The effect of honey-coated bandages compared with silver-coated bandages on treatment of malignant wounds—a randomized study. Wound Rep Reg. 2011;19:664-670. 3. McDonald A, Lesage P. Palliative management of pressure ulcers and malignant wounds in patients with advanced illness. J Palliat Med. 2006;9:285-295. 4. Bardy J, Slevin NJ, Mais KL, Molassiotis A. A systemic review of honey uses and its potential value within oncology care. J Clin Nurs. 2008;17:2604-2623 5. Hampton S. Malodorous fungating wounds: how dressing alleviate symptoms. Wound Care. 2008;13:531-538 6. Belcher J. A review of medical-grade honey in wound care. Br J Nurs. 2012;15:S4-S9 7. Ghashm A, Othman NH, Khattak MN, Ismail NM, Saini R. Antiproliferative effect of Tualang honey on oral squamous cell carcinoma and osteosarcoma cell lines. BMC Complement Altern Med. 2010;10:49
Surgical Management of Extensive Peristomal Pyoderma Gangrenosum Associated With Colon Cancer: Erratum In the article referenced below, the affiliation of Dr. Hiroshi was incorrectly listed and Figure 3 did not show the correct images. The correct affiliation of Dr. Hiroshi Furukawa is the Department of Plastic and Reconstructive Surgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan. Below are the correct images for Figure 3A and B.
FIGURE 3. A, Drapes were applied over and over without removing #2 layer. B, An ostomy appliance was applied with
a stoma belt.
■ Reference Ishikawa K, Minamimoto T, Mizuki T, Furukawa, H (2015). Surgical management of extensive peristomal pyoderma gangrenosum associated with colon cancer. J Wound, Ostomy & Continence Nurs, 42(1):102-105.
Copyright © 2015 Wound, Ostomy and Continence Nurses Society™. Unauthorized reproduction of this article is prohibited.
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