Laryngeal Cancer

Risk Factors for Laryngeal Cancer
-Tobacco use -Chronic laryngitis
-Alcohol intake -Exposure to Industrial Chemicals
-Marijuana use -Hardwood Dust
-Voice abuse
-Poor oral hygiene

Who gets Laryngeal Cancer?
-men get it 3x more often than women
-people >65 y.o.

Cancer Larynx Disease Process
1. Tumor in the Larynx
-Laryngoscopy/Biopsy
-CT scan/MRI/PET scan to see if spread
2. Tumor impedes action of vocal cords during speech
3. Treat w/ chemotherapy, radiation, & surgery

Warning Signs of Head & Neck Cancer
-Pain -Lump in the mouth, throat, or neck
-Difficulty Swallowing -Shortness of Breath
-Color changes in mouth or tongue to red, white, gray, dark brown,or black
-Oral lesions or sore that does not heal in 2 weeks
-Persistent or unexplained oral bleeding
-Numbness of mouth, lips, or face
-change in fit of dentures
-Burning sensation when drinking citrus juices/hot liquids
-persistent, unilateral ear pain
-hoarseness or change in voice quality
-Persistent/recurrent sore throat
-Anorexia or weight loss

Tumor Impedes Action of Vocal Cords during Speech
-Lump left in neck
-Difficulty swallowing
-Dyspnea
-Lymph node enlargement
-Weight Loss
-Pain radiating to ear w/ metastases
-Glottic area: Hoarse & low pitch voice
-Subglottic & Supraglottic area: pt complaines of pain & burning in throat when drinking hot liquids or citrus juices
-Foul breath
-Unilateral nasal obstruction or discharge

Labs for Laryngeal Cancer
-CBC
-Bleeding time
-Urine analysis
-Complete Metabolic panel
-Total protein
-Albumin
-Renal
-Liver Function Test

Treatment for Laryngeal Cancer
-Surgery
-Radiation
-Chemotherapy

Nonsurgical Management of Laryngeal Cancer
Monitor Respiratory System: RR, breath sounds, pulse oximetry, arterial blood gas values, & results of pulmonary function tests
-Fowler’s or Semi-Fowlers position for best air exchange
-Radiation Therapy
-Chemotherapy

Radiation Therapy for Laryngeal Cancer
-Treats small cancers in specific locations
-Cure rate of at least 80%
-S/E: hoarseness, dysphagia, skin problems, dry mouth (xerostomia) for few weeks after therapy
-Teach: gargling saline or sucking ice decrease discomfort; mouthwashes & throat sprays w/ anesthetic temporary relief, avoid exposing skin to sun, heat, cold & abrasive treatments (shaving); wear protective clothing & wash area gently W/ mild soap

Surgery for Laryngeal Cancer
Tumor size & location (TNM classification) determines type of surgery needed
-Laryngectomy (partial or total)
-Cord Stripping: remove tumor from cord, save the cord
-Cordectomy: removal of a vocal cord
-“Radial neck” dissection:removal of lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve (shoulder drop), & surrounding soft tissue

Partial Laryngectomy
1 cord involved
High cure rate
Leaves hoarse voice
AIRWAY INTACT

Supraglottic Laryngectomy
Early supraglottis tumors
PRESERVES VOICE
Temporary tracheostomy
ASPIRATION POTENTIAL COMPLICATION
NG tube feeding until healing & no danger of aspiration
Some difficulty swallowing for 1st 2 weeks
Speech Therapy
Risk that cancer will recur

Hemi-Vertical Laryngectomy
Tumor extends beyond vocal cord, but <1 cm & limited to subglottic area Tracheostomy & NG tube 10-14 days post-op Increased risk for aspiration after surgery Voice-rough, raspy, hoarse AIRWAY & ABILITY TO SWALLOW REMAIN INTACT

Total Laryngectomy
Cancer extends beyond vocal cords
For recurrent or persistent CA following RT
PERMANENT TRACHEAL STOMA.
NO VOICE
NORMAL SWALLOWING- no risk for aspiration b/c airway & esophagus completely separated
Metastasis to cervical Lymph Node
COMPLICATIONS: infection, wound breakdown, fistulas, stomal stenosis, dysphagia secondary to pharyngeal & esophageal structure

Post-Operative Care (Laryngeal CA)
1st priority are airway maintenance & ventilation
-raise head of bed
-monitor airway patency & vital signs
-frequent suctioning (gently-fragile tissue)
Observe surgical site for bleeding (lots of veins/arteries)
Place call light w/in easy reach b/c pt can’t talk
Monitor pain level & administer analgesics
Monitor: hemodynamic status. BP
Wound Care: cleanse & dress wounds. Monitor skin/wound for breakdown & document
Monitory skin flap for adequate circulation hourly for 1st 72 hours post-op
Initiate nutritional intake: NG tube feedings
BLOOD-TINGED SECRETIONS NORMAL 1-2 DAYS

Speech & Language Rehabilitation
Pt’s voice & quality of speech are altered after surgery. Discuss principles of speech therapy w/ the pt & family early in course of treatment.
-Esophageal Speech
-Tracheoesophageal Puncture (TEP)
-Artificial Larynx (Electro Larynx)

Esophageal Speech
Sound produced by “burping” and shaping words in the mouth. Difficult to master! Speech is monotone
1. Tongue press to inject air into esophagus
2. Air enters esophagus
3. Air releases from esophagus to produce sound-use abdominal muscles to burp
4. Sound shaped into speech
5. Location of tissue vibration for sound

Tracheoesophageal Puncture (TEP)
AKA: Tracheoesophageal fistula. Used if esophageal speech ineffective
1. Small hole is made rear of stoma leading to esophagus (between trachea & esophagus)
2. A prosthesis is fitted & inserted into opening
3. To speak, pt has to close stoma w/ finger & force air through prosthesis into the esophagus & out the mouth
4. Lip & tongue movement, not prothesis itself produces speech

Tracheotomy
Surgical incision into trachea for purpose of establishing an airway (tracheostomy). Temporary or permanent. Emergency or scheduled.

Stoma Care – Tracheostomy
-Use saline & cotton-tipped swabs to cleanse stoma
-Use humidifier &/or saline atomizer
-Wear buttoned cotton shirt or stoma covering (keeps dust & other particles out of lungs)
-Wear shower shield over stoma during showers
-Report signs of infection: fever, purulent drainage, redness, foul odor, swelling
-Diet high in Protein & Calories
-Avoid water sports
-No lifting (epiglottis doesn’t close)
-All other activities allowed

Complications of Laryngectomy
-Airway Obstruction
-Aspiration

Complications of Laryngectomy:
Airway Obstruction
Following laryngectomy there are copious amounts of secretions. If not removed a mucous plug forms which occludes the airway.

Preventing Airway Obstruction
Monitor Respiratory Status:
-SaO2, breath sounds, RR, depth
Maintain humidity. Humidify Oxygen. (helps remove crusts)
Suction but remember to oxygenate before
Encourage deep breathing & coughing to help remove secretions

Complications of Laryngectomy:
Aspiration
Causes pneumonia.
Pt’s with 1 vocal cord or epiglottis removed are @ risk.
-Total laryngectomy not @ risk because esophagus is farther away.

Preventing Aspiration
-Sit upright
-Tuck chin down when swallowing
-Thickened liquids. Cut food in small pieces. Chew well. Mechanical soft/pureed diet
-Give foods that form into bolus before swallowing (meat,bread)
-Suspect Aspiration?
Call doctor. NPO

Home Care Assessment: Pts After Laryngectomy
Assess:
-Respiratory Status
-Condition of the Wound
-Psychosocial Status
-Temperature
-Pt’s understanding of illness & adherence to treatment
-Nutritional Status

Laryngectomy Home Care, Assess Pt’s:
Respiratory Status
-Observe rate & depth of respiration
-Auscultate lungs
-Check patency of airyway
-Examine tracheostomy drainage for amount, color & character
-Examine nail beds & mucous membranes for cyanosis
-Pulse oximetry

Laryngectomy Home Care, Assess Pt’s:
Wound
-Remove dressings (note condition of dressing)
-Cleanse wound
-Compare w/ previous notations of wound condition (presence/amount/nature of exudate, presence/absence of cellulitis, presence/absence of odor)

Laryngectomy Home Care, Assess Pt’s:
Psychosocial Status
-Ask pt about passing the time, visitors, & trips outside house
-Observe if pt communicates directly or if family member speaks for the pt
-Observe pt & family member interactions
-Determine what method of communication pt has selected & observe pt’s skill w/ it
-Observe if pt is dressed in pj’s or street clothes

Laryngectomy Home Care, Assess Pt’s:
Understanding of Illness & Adherence to Treatment
-Manifestations to report to healthcare provider
-Medication plan (correct timing & dose)
-Ambulation or positioning schedule
-Dressing changes/skin care
-Diet modifications (24 hr diet recall)
-Skill in tracheostomy or dressing care

Laryngectomy Home Care, Assess Pt’s:
Nutritional Status
-Change in muscle mass
-Lackluster nails/sparse hair
-Recent weight loss greater than 10% of usual weight
-Impaired oral intake
-Difficulty swallowing
-Generalized edema