Laryngeal cancer

Overview
Malignant cells in the tissues of the larynx or voice box
Squamous cell carcinoma—most common form (95% of cases)
Adenocarcinoma and sarcoma—rare (5% of cases)
Intrinsic tumor (located on the true vocal cords; tends not to spread because underlying connective tissues lack lymph nodes) or extrinsic tumor (located on another part of the larynx; tends to spread easily)
Overview-Pathophysiology
Laryngeal cancer is classified by its location:
supraglottic (on the false vocal cords)

glottic (on the true vocal cords)

subglottic (rare downward extension from the vocal cords).
supraglottic (on the false vocal cords)
glottic (on the true vocal cords)
subglottic (rare downward extension from the vocal cords).
Malignant cells that proliferate can cause swallowing and breathing impairment.
A tumor can decrease mobility of the vocal cords.

Overview-Causes
Unknown
Overview-Risk Factors
Smoking
Alcoholism
Chronic inhalation of noxious fumes, such as paint, diesel and gasoline fumes
Exposure to absestos
Familial disposition
History of gastroesophageal reflux disease
Human papillomavirus infection
Increasing age
High intake of salt-preserved meats and dietary fats
Poor oral hygiene; periodontal disease
Overview-Incidence
Laryngeal cancer is the most common cancer of the

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upper aerodigestive tract (the area including the oral cavity, sinonasal tract, larynx, pyriform sinus, pharynx, and esophagus).
It’s about two to four times more common in men than in women; however, the incidence is increasing among women who smoke.
Laryngeal cancer is three times more common in blacks than in whites.
It most commonly occurs in patients ages 60 to 70. (See Understanding laryngeal cancer.)
Overview-Complications
Increased swallowing difficulty and pain
Tracheostomal stenosis
Aspiration (after partial laryngectomy)
Dysphagia
Metastasis
Limited neck mobility
Loss of upper body strength (after surgery)
Wound dehiscence (after surgery)
Fistula formation (after surgery)
Assessment-History
Weight loss
Fatigue
Vocal changes noted by patient or family (see Signs and symptoms by location)
Assessment-Stage I
Complaints of local throat irritation
2-week history of hoarseness
Assessment-Stages II and III
Hoarseness
Sore throat
Voice volume reduced to a whisper
Assessment-Stage IV
Pain radiating to ears
Dysphagia
Dyspnea
Assessment-Physical Findings
None
Assessment-Stage I
None
Assessment-Stage II
Possible abnormal movement of vocal cords
Assessment-Stage III
Abnormal movement of vocal cords
Possible lymphadenopathy
Assessment-Stage IV
Neck mass or enlarged cervical lymph nodes
Diagnostic Test Results-Laboratory
Liver function tests rule out metastatic disease.
Diagnostic Test Results-Imaging
Xeroradiography, laryngeal tomography, computed tomography, and laryngography confirm the presence of a mass.
Chest X-rays rule out metastasis.
Bone scans identify possible bone metastasis.
Diagnostic Test Results-Diagnostic Procedures
Laryngoscopy with biopsy of multiple specimens establishes a primary diagnosis, determines the extent of the disease, and identifies additional premalignant specimens or second primary tumors.
Diagnostic Test Results-Other
Biopsy results identify cancer cells.
Treatment-General
Radiation therapy for possible early lesions or tumors limited to true vocal cords
Speech preservation
Speech rehabilitation (when speech preservation is impossible)—esophageal speech, prosthetic devices, or experimental surgical reconstruction of the voice box
Treatment-Diet
Based on treatment options
Enteral feeding possibly required
Treatment-Activity
Frequent rest periods
Treatment-Medications
Chemotherapeutic agents such as cisplatin and 5-fluorouracil, docetaxel, carboplatin
Opioid analgesics for pain control
Nystatin mouth rinses for oral thrush due to radiation therapy
Treatment-Surgery
Cordectomy
Partial or total laryngectomy with or without neck dissection
Supraglottic laryngectomy or total laryngectomy with laryngoplasty
Transoral laser microsurgery for precancerous and early lesions
Nursing Considerations-Nursing Diagnoses
Acute pain
Anxiety
Disturbed body image
Disturbed energy field
Impaired gas exchange
Impaired skin integrity
Impaired swallowing
Impaired verbal communication
Ineffective airway clearance
Ineffective breathing pattern
Ineffective coping
Ineffective role performance
Risk for aspiration
Risk for infection
Nursing Considerations-Expected Outcomes
express feelings of increased comfort
verbalize feelings of decreased anxiety
express positive feelings about body image
express an increased sense of well-being
maintain adequate ventilation
remain free from complications with surgical wounds
swallow without coughing or choking
use language or an alternative speech method to effectively communicate needs
maintain a patent airway
maintain an effective breathing pattern
demonstrate positive coping mechanisms
continue to function in usual roles as much as possible
remain free from signs and symptoms of aspiration
remain free from signs or symptoms of infection.
Nursing Considerations-Nursing Interventions
Prepare the patient for scheduled treatments, such as radiation therapy or surgery.
Provide support. Encourage the patient to verbalize feelings, concerns, and fears. Help the patient develop positive coping strategies, and emphasize positive aspects of the patient’s body image.
Arrange for patient to meet with a laryngectomee for support prior to surgery if indicated.
Assist with establishing a method of communication.
Enlist the aid of a speech therapist to assist with meeting the patient’s communication needs.
Institute aspiration precautions as indicated. Auscultate lung sounds for changes; have suction readily available if patient begins to aspirate.
Administer analgesics as ordered to manage pain.
Institute measures to minimize the effects of chemotherapy as appropriate.
Administer nasogastric or gastrostomy feedings as ordered.
Prepare the patient and family physically and psychologically for surgery.
Prepare the patient for functional losses (inability to smell, blow his nose, whistle, gargle, sip, or suck on a straw).
Encourage patient participation in self-care and decision making to foster feelings of self-esteem and control.
Provide frequent mouth care preoperatively and postoperatively.
Maintain a patent airway; suction when needed.
After total laryngectomy, elevate the head of the bed 30 to 45 degrees and support the back of the neck to prevent tension on sutures and, possibly, wound dehiscence.
Provide tracheotomy care as appropriate.
Nursing Considerations-Monitoring
Pain level
Coping ability
Airway patency
Respiratory status
Swallowing ability
Nutritional status
Weight
Skin and mucous membrane integrity. (See Recognizing and managing complications of laryngeal surgery.)
Nursing Considerations-After Partial Laryngectomy
Hydration and nutritional status
Tracheostomy tube care
Use of voice
Nursing Considerations-After Total Laryngectomy
Laryngectomy tube care
Vital signs
Postoperative complications (airway obstruction, hemorrhage, carotid artery rupture, and fistula formation)
Pain control
Nasogastric (NG) tube placement and function
Communication methods
Nursing Considerations-Associated Nursing Procedures
Chemotherapeutic drug administration
Chemotherapeutic drug preparation and handling
Health history interview and physical assessment
IV bag preparation
IV bolus injection
IV catheter insertion
Impaired swallowing and aspiration precautions
Postoperative care
Preoperative care
Radiation therapy, external
Sputum collection by expectoration
Throat specimen collection
Patient Teaching-General
disorder; diagnosis; possible underlying risk factors, such as smoking and alcohol abuse; and treatment
appropriate oral hygiene practices (before and after partial or total laryngectomy)
measures to address adverse effects of radiation therapy, such as pain control and use of nystatin for oral thrush
postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care
preparation for any functional losses
possible speech therapy to assist with communication
measures to minimize aspiration
tracheostomy care, including site care, tube changes, and suctioning as indicated
importance of a well-balanced diet
performance of enteral feedings, if indicated
cure rate (greater than 90%) with early identification and treatment
need for repeat indirect laryngoscopy and complete head and neck examinations for at least 5 years after treatment to detect recurrence
need for yearly chest X-rays and liver function tests to rule out metastasis
signs and symptoms of complications after surgery, including the need to notify a practitioner if any occur
importance of continued follow-up care to evaluate the condition.
Patient Teaching-Discharge Planning
Refer the patient to a smoking-cessation or alcohol abuse support group, as necessary.
Arrange for rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices).
Refer the patient to home health care for assistance after discharge.
Refer the patient to local resources and support services, such as support groups for laryngectomees.
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