CANCER OF THE LARYNX

(LARYNGEAL CANCER)

Anatomical Part InvolveThe larynx (lar’inks) is an

enlargement in the airway at the top of the trachea and below the pharynx.

  It conducts air in and out of

the trachea and prevents foreign objects from entering the trachea.

 It also houses the vocal cords. The larynx is composed of a

framework of muscles and cartilages bound by elastic tissue. The largest of the cartilages is the thyroid (Adam’s apple), cricoids, and epiglottic cartilages

Inside the larynx, two pairs of horizontal vocal folds composed of muscle tissue and connective tissue with a covering of mucous membrane extend inward from the lateral walls. The upper folds are called the false vocal cords because they do not produce sounds. Muscle fiber within these folds helps close the airway during swallowing.

The lower folds of muscle tissue and elastic fibers are the true vocal cords. Air forced between the vocal cords causes them to vibrate from side to side, generating sound waves.

Cancer of the larynx is a malignant tumor in the larynx (voicebox). It is potentially curable if detected early. It represents less than 1% of all cancers and occurs about four times more frequently in men than in women, and most commonly in persons 50 to 70 years of age.

Understanding Laryngeal Cancer

The incidence of laryngeal cancer continues to decline, but the incidence in women versus men continues to increase.

Each year in the United States, approximately 9,000 new cases are discovered, and 3,700 persons with cancer of the larynx will die (American Cancer Society, 2002).

A malignant growth may occur in three different areas of the larynx: the glottic area (vocal cords), supraglottic area (area above the glottis or vocal cords, including epiglottis and false cords), and subglottis (area below the glottis or vocal cords to the cricoid).

Two thirds of laryngeal cancers are in the glottic area. Supraglottic cancers account for approximately one third of the cases, subglottic tumors for less than 1%. Glottic tumors seldom spread if found early because of the limited lymph vessels found in thevocal cords (Lenhard, Osteen, & Gansler, 2001).

What are the stages of laryngeal cancer?

T1: Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility.

T2: Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.

T3: Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g., inner cortex).

Tumor (T)

T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck, including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).

T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

◦NX: Regional lymph nodes cannot be assessed (eg. Previously removed).

◦N0: No regional lymph node metastasis.

◦N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension.

Regional Lymph Nodes (N)

◦N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.

◦N3: Metastasis in a lymph node more than 6 cm in greatest dimension

◦MX Distant metastasis cannot be assessed.

◦M0 No distant metastasis. ◦M1 Distant metastasis.

Distant Metastasis (M)

Carcinogens Tobacco (smoke, smokeless) Combined effects of alcohol and tobacco Asbestos Second-hand smoke Paint fumes Wood dust Cement dust Chemicals Tar products Mustard gas Leather and metals

What are the risk factors of acquiring Laryngeal cancer?

Other Factors Straining the voice Chronic laryngitis Nutritional deficiencies (riboflavin) History of alcohol abuse Familial predisposition Age (higher incidence after 60 years of age) Gender (more common in men) Race (more prevalent in African Americans) Weakened immune system

Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech.

  The voice may sound harsh, raspy, and lower in

pitch.   cough or sore throat that does not go away and

pain and burning in the throat, especially when consuming hot liquids or citrus juices.

 What are the clinical Manifestations of Laryngeal cancer?

lump may be felt in the neck   dysphagia, dyspnea (difficulty breathing),

unilateral nasal obstruction or discharge   persistent hoarseness

persistent ulceration   Foul breath   Cervical lymph adenopathy

Unplanned weight loss   General debilitated state   Pain radiating to the ear

Complete history To identify any familial predisposition to the

disease, risk factors, and any underlying condition that may be ruled out

What are the diagnostic examinations needed?

Indirect laryngoscopy initially performed in the otolaryngologist’s

office to visually evaluate the pharynx, larynx, and possible tumor. Mobility of the vocal cords is assessed; if normal movement is limited, the growth may affect muscle, other tissue, and even the airway. The lymph nodes of the neck and the thyroid gland are palpated to determine spread of the malignancy

Direct Laryngoscopic examination

This examination is done under local or general anesthesia and allows evaluation of all areas of the larynx. Samples of the suspicious tissue are obtained for histologic evaluation. The tumor may involve any of the three areas of the larynx and may vary in appearance.

Computed tomography (CT) scan to assess regional adenopathy and soft

tissue and to help stage and determine the extent of a tumor.

 Magnetic resonance imaging (MRI) helpful in post-treatment follow-up in order

to detect a recurrencePositron Emission Tomography (PET)

Scan may also be used to detect recurrence of a

laryngeal tumor after treatment

Endoscopy A procedure to look

at organs and tissues inside the body to check for abnormal areas. An endoscope (a thin, lighted tube) is inserted through an incision (cut) in the skin or opening in the body, such as the mouth. Tissue samples and lymph nodes may be taken for biopsy

Barium swallow A series of x-rays of

the esophagus and stomach. The patient drinks a liquid that contains barium (a silver-white metallic compound). The liquid coats the esophagus and stomach, and x-rays are taken. This procedure is also called an upper GI series.

Biopsy The removal of cells or tissues so they can be

viewed under a microscope to check for signs of cancer

Surgical Intervention Partial laryngectomy- (laryngofissure–thyrotomy) is recommended

in the early stages of cancer in the glottic area when only one vocal cord is involved.

Supraglottic laryngectomy- A supraglottic laryngectomy is indicated in

the management of early (stage I) supraglottic and stage II lesions. The hyoid bone, glottis, and false cords are removed

What are the therapies needed to treat laryngeal cancer?

Hemilaryngectomy- A hemilaryngectomy is performed when the

tumor extends beyond the vocal cord but is less than 1 cm in size and is limited to the subglottic area.

Total laryngectomy- A total laryngectomy is performed in the

most advanced stage IV laryngeal cancer, when the tumor extends beyond the vocal cords, or for recurrent or persistent cancer following radiation therapy. In a total laryngectomy, the laryngeal structures are removed, including the hyoid bone, epiglottis, cricoid cartilage, and two or three rings of the trachea. The tongue, pharyngeal walls, and trachea are preserved. A total laryngectomy will result in permanent loss of the voice and a change in the airway.

Radiation Therapy to eradicate the cancer and preserve the

function of the larynx. Excellent results have been achieved with

radiation therapy in patients with early stage (I and II) glottic tumors when only one vocal cord is involved and there is normal mobility (ie, moves with phonation) and in small supraglottic lesions.

One of the benefits of radiation therapy is that patients retain a near-normal voice. A few may develop chondritis (inflammation of the cartilage) or stenosis; a small number may later require laryngectomy.

Result of external radiation to the head and neck area

Acute mucositisUlceration of the mucus membrane

PainXerostomia (Dry mouth)Loss of taste

Complications of Radiation Therapy

DysphagiaFatigueSkin reactionsLaryngeal necrosisEdemaFibrosis

Speech Therapy Includes writing, lip reading communication

or word board, and alaryngeal communication

Esophageal speech- patient needs the ability to compress air into the esophagus and expel it, setting off a vibration of the pharyngeal esophageal segment. The technique can be taught once the patient begins oral feedings, approximately 1 week after surgery. First, the patient learns to belch and is reminded to do so an hour after eating. Then the technique is practiced repeatedly.

Alaryngeal Communication

Electric larynx- If esophageal speech is not successful, or until the patient masters the technique, an electric larynx may be uses for communication. This battery-powered apparatus project sound into the oral cavity. When the mouth forms words (articulated), the sounds from the electric larynx become audible words.

Tracheoesophageal Puncture - This technique is the most widely used because the speech associated with it most resembles normal speech (the sound produced is a combination of esophageal speech and voice), and it is easily learned. A valve is placed in the tracheal stoma to divert air into the esophagus and out of the mouth.

Once the puncture is surgically created and has healed, a voice prosthesis (Blom–Singer) is fitted over the puncture site. To prevent airway obstruction, the prosthesis is removed and cleaned when mucus builds up. A speech therapist teaches the patient how to produce sounds. Moving the tongue and lips to form the sound into words produces speech as before. Tracheoesophageal speech is successful in 80% to 90% of patients

Prognosis (chance of recovery) depends on the following:

The stage of the disease. The location and size of the tumor. The grade of the tumor. The patient's age, gender, and general

health, including whether the patient is anemic.

Treatment options depend on the following: The stage of the disease. The location and size of the tumor. Keeping the patient's ability to talk, eat, and

breathe as normal as possible. Whether the cancer has come back

(recurred).

Smoking tobacco and drinking alcohol decrease the effectiveness of treatment for laryngeal cancer. Patients with laryngeal cancer who continue to smoke and drink are less likely to be cured and more likely to develop a second tumor. After treatment for laryngeal cancer, frequent and careful follow-up is important

What are the nursing management for Laryngeal cancer?

The nurse should look for the following assessment findings:

Hoarseness of more than 2 weeks’ duration is noted early in the patient with cancer in the glottic area because the tumor impedes the action of the vocal cords during speech.

The voice may sound harsh, raspy, and lower in pitch.

cough or sore throat that does not go away and pain and burning in the throat, especially when consuming hot liquids or citrus juices.

lump may be felt in the neck

Assessment

dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge

persistent hoarseness persistent ulceration Foul breath Cervical lymph adenopathy Unplanned weight loss General debilitated state Pain radiating to the ear

Deficient knowledge about the surgical procedure and postoperative course

Anxiety and depression related to the diagnosis of cancer and impending surgery

Ineffective airway clearance related to excess mucus production secondary to surgical alterations in the airway

Impaired verbal communication related to anatomic deficit secondary to removal of the larynx and to edema

Nursing Diagnoses

Imbalanced nutrition: less than body requirements, related to inability to ingest food secondary to swallowing difficulties

Disturbed body image and low self-esteem secondary to major neck surgery, change in the structure and function of the larynx

Self-care deficit related to pain, weakness, fatigue, musculoskeletal impairment related to surgical procedure and postoperative course

Attainment of an adequate level of knowledge Reduction of anxiety Maintenance of a patent airway (able to

handle own secretions) Effective use of alternative means of

communication Attainment of optimal levels of nutrition and

hydration Improvement of body image and self-esteem Improved self care management Absence of complications

Planning

Teaching the patient preoperatively Clarify any misconceptions by identifying

the location of the larynx, its function, the nature of the surgical procedure, and its effect on speech.

For complete laryngectomy, inform the patient that the natural voice will be lost, but that special training can provide a means for communication

Intervention

Reducing Anxiety and Depression Provide patient and family with the

opportunity to ask questions, verbalize feelings and discuss perceptions.

Maintaining a patent airway Position patient in semi- Fowler’s or Fowler’s

position. Observe for any signs of respiratory

distress, e.g. restlessness, labored breathing, apprehension, increased pulse

Encourage patient to turn, cough, and take deep breaths.

Instruct for early ambulation Clean the laryngectomy tube stoma daily

with saline solution. Provide adequate humidification to

decrease cough, mucus production and crusting around the stoma.

Promoting alternative communication methods

Nurses and other personnel who come in contact with the patient should use a well establishes and consistent means of communication

Promoting adequate nutrition Explain that the diet initially includes thick

liquid because it is easy to swallow (after NPO status)

Instruct to avoid sweet foods which increase salivation and suppress the appetite

Inform to wash mouth with warm water or mouthwash and brush the teeth frequently

Observe for any difficulty in swallowing.

Promoting positive body image and self esteem

Encourage the patient to express any feelings brought about by surgery, particularly those related to fear, anger, depression, and isolation

Use a positive approach in caring for the patient

Be a good listener and support to the family esp. when explaining the tubes, dressings, and drains that are in place post-operatively

Monitoring and managing potential complications

Respiratory distress and hypoxia Monitor the patient for any signs and

symptoms of respiratory distress and hypoxia Hemorrhage notify the surgeon in presence of any signs of

bleeding apply direct pressure over the carotid artery Infection Observe for any signs of infection Report to surgeon immediately Wound breakdown Observe the stoma area for wound breakdown,

hematoma, and bleeding Report any significant changes to the physician

Acquires an adequate knowledge, verbalizing an understanding of the surgical procedure and performing self-care adequately

Demonstrates less anxiety and depressionoExpresses a sense of hopeoIs aware of available community organizations and agenciesoParticipates in support group

Evaluation

Maintains a clear airway and handles own secretions; also demonstrates practical, safe and correct technique for cleaning and changing the laryngectomy tube

Acquires effective communication techniques•Uses assistive devices and strategies for

communication (Magic Slate, call bell, picture board, sign language, lip reading, computer aids)•Follows the recommendations of the speech

therapist

Maintains balance nutrition and adequate fluid intake

Exhibits improved body image self esteem and self concept

Exhibits no complications

(Suddarth's, 11th edition) http://www.google.com.ph/imgres?q=laryng

eal+cancer+staging&hl=en&sa=G&biw=1024&bih=494&tbm=isch&tbnid=3caE-140PRg7EM:&imgrefurl=http://sarasbioblog.blogspot.com/2011/02/throat-cancer.html&docid=PvZ_PZXDflGrWM&imgurl=http://1.bp.blogspot.com/-lOl8HqYpsy8/TVnvz85gGZI/AAAAAAAAABg/J8siqZSxsDA/s1600/stages-of-throat-cancer.jpg&w=927&h=451&ei=3v7oT7mEGsqZmQWFlc2CDg&zoom=1

www.healthgiants.com www.cancer.gov www.cancertrialshelp.org

References:

Andal, Jaybel Anne A. Bolagao, Reymart B. Cortez, Dyan M. Eridao, Keyne Reenne P. Herrera, Reggin Caryl V. Isureña, Melody Ann R. Madroño, Rommel Marvin P. Nuestro, Alyssa Jane L. Papa, Deziree L. Ramos, Shelly Mae A. IV BSN 1 Group 3

Thank You!