Tuesday, February 15, 2011

Cancer of the larynx is a malignant tumor in the larynx (voice box). 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. Squamous cell carcinoma constitutes about 95% of laryngeal cancers. Rare laryngeal cancer forms adenocarcinoma and sarcoma account for the rest. An intrinsic tumor is on the true vocal cords and tends not to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread easily. Laryngeal 
Cancer is classified by its location: 
Supraglottis (false vocal cords) Glottis (true vocal cords) Sub glottis (rare downward extension from vocal cords). 

Pathophysiology and Etiology of Laryngeal Cancer 
Occurs predominantly in men older than age 60. Most patients have a history of smoking; those with Supraglottis laryngeal cancer frequently have a history of smoking and a high alcohol intake. Other risk factors include vocal straining, chronic laryngitis, industrial exposure, nutritional deficiency, and family predisposition. About two-thirds of carcinomas of the larynx arise in the glottis, almost one-third arise in the Supraglottis region, and about 3% arise in the subglottic region of the larynx. When limited to the vocal cords (intrinsic), spread is slow because of lessened blood supply. When cancer involves the epiglottis (extrinsic), cancer spreads more rapidly because of abundant supply of blood and lymph and soon involves the lymph nodes of the neck. A malignant growth may occur in three different areas of the larynx: the glottis area (vocal cords), Supraglottis area (area above the glottis or vocal cords, including epiglottis and false cords), and sub glottis (area below the glottis or vocal cords to the cricoid). Two thirds of laryngeal cancers are in the glottis area. Supraglottis 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 the vocal. 

Causes for Laryngeal Cancer 
The cause of laryngeal cancer is unknown. Major risk factors include smoking and alcoholism. Minor risk factors include chronic inhalation of noxious fumes and familial disposition. An initial assessment includes a complete history and physical examination of the head and neck. This will include assessment of risk factors, family history, and any underlying medical conditions. Varied assessment findings in laryngeal cancer depend on the tumor’s location and its stage. With stage I disease, the patient may complain of local throat irritation or hoarseness that lasts about 2 weeks. In stages II and III, he usually reports hoarseness. He may also have a sore throat, and his voice volume may be reduced to a whisper. In stage IV, he typically reports pain radiating to his ear, dysphagia, and dyspnea. In advanced (stage IV) disease, palpation may detect a neck mass or enlarged cervical lymph nodes. 

Diagnostic tests 
The usual workup includes laryngoscopy, xeroradiography, biopsy, laryngeal tomography and computed tomography scans, and laryngography to visualize and define the tumor and its borders. Chest X-ray findings can help detect metastases. An indirect laryngoscopy, using a flexible endoscope, is 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. If a tumor of the larynx is suspected on an initial examination, a direct laryngoscopic examination is scheduled. 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 and magnetic resonance imaging (MRI) are used to assess regional adenopathy and soft tissue and to help stage and determine the extent of a tumor. MRI is also helpful in post-treatment follow-up in order to detect a recurrence. Positron emission tomography (PET scan) may also be used to detect recurrence of a laryngeal tumor after treatment. 

Treatment Management For Laryngeal Cancer Depends on sites and stages of cancer. Early malignancy may be removed endoscopically. Early lesions may respond to laser surgery or radiation therapy; advanced lesions to laser surgery, radiation therapy, and chemotherapy. Treatment aims to eliminate cancer and preserve speech. If speech preservation isn’t possible, speech rehabilitation may include esophageal speech or prosthetic devices. Other surgical procedures vary with tumor size and include cordectomy, partial or total laryngectomy, Supraglottic laryngectomy, and total laryngectomy with laryngoplasty. 

Risk Factors for Laryngeal Cancer 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. 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. 

Clinical Manifestations for Laryngeal Cancer Varied assessment findings in laryngeal cancer Depend on tumor location and its stage; sequence in appearance related to pattern and extent of tumor growth. Supraglottic Cancer: Tickling sensation in throat Dryness and fullness (lump) in throat Painful swallowing (odynophagia) associated with invasion of extra laryngeal musculature Coughing on swallowing Pain radiating to ear (late symptom) Glottic Cancer (Cancer of the Vocal Cord): Most common cancer of the larynx Hoarseness or voice change Aphonia (loss of voice) Dyspnea Pain (in later stages) Subglottic Cancer (Uncommon): Coughing Short periods of difficulty in breathing Hemoptysis; fetid odor, which results from ulceration and disintegration of tumor With stage I disease 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. Affected voice sounds are not early signs of subglottic or supraglottic cancer. In stages II and III, he usually reports hoarseness. He may also have a sore throat that does not go away, and his voice volume may be reduced to a whisper and pain and burning in the throat, especially when consuming hot liquids or citrus juices. A lump may be felt in the neck. Later symptoms In stage IV typically reports pain radiating to his ear dysphagia, dyspnea (difficulty breathing), unilateral nasal obstruction or discharge, persistent hoarseness, persistent ulceration, and foul breath. Cervical lymph adenopathy, unplanned weight loss, a general debilitated state, and pain radiating to the ear may occur with metastasis. palpation may detect a neck mass or enlarged cervical lymph nodes. 

Treatment Management For Laryngeal Cancer 
Radiation therapy: Singly or in combination with surgery. Complications of radiation including airway obstruction, edema of larynx, soft tissue and cartilage necrosis, chondritis, pain, and loss of taste (xerostomia). Surgery therapy: Carbon dioxide laser for early-stage disease. Partial laryngectomy removal of small lesion on true cord, along with a substantial margin of healthy tissue. Supraglottic laryngectomy removal of hyoid bone, epiglottis, and false vocal cords, tracheostomy may be done to maintain adequate airway, radical neck dissection may be done. Hemilaryngectomy removal of one true vocal cord, false cord, one half of thyroid cartilage, arytenoid cartilage. Total laryngectomy removal of entire larynx (epiglottis, false or true cords, cricoid cartilage, hyoid bone; two or three tracheal rings are usually removed when there is extrinsic cancer of the larynx [extension beyond the vocal cords]). A radical neck dissection may also be done because of metastasis to cervical lymph nodes. Total laryngectomy with laryngoplasty voice rehabilitation may be attempted through the Asai operation: A dermal tube is made from the upper end of the trachea into the hypo pharynx. The tracheostomy opening is closed off with a finger. The patient expires air up the dermal tube into the pharyngeal cavity. The sound produced is transformed into almost normal speech. 

Complications of Surgery therapy 
  • Salivary fistula may develop after any surgical procedure that involves entering the pharynx or esophagus. (Monitor for saliva collecting beneath the skin flaps or leaking through suture line or drain site. Management NG tube feeding, meticulous local wound care with frequent dressing changes, promotion of drainage) 
  • Hemorrhage (carotid artery rupture) or hematoma formation. A major postoperative complication (e.g. skin necrosis or salivary fistula) usually precedes carotid artery rupture. Management immediate wound exploration in operating room. 
  • Stomas stenosis. 
  • Aspiration. 
  • Long-term complications: Chest infections (from repeated aspiration), Recurrence of cancer in stoma 

Nursing Assessment for Laryngeal Cancer The nurse assesses the patient for the following symptoms: hoarseness, sore throat, dyspnea, dysphagia, or pain and burning in the throat. The neck is palpated for swelling. If treatment includes surgery, the nurse must know the nature of the surgery to plan appropriate care. If the patient is expected to have no voice, a preoperative evaluation by the speech therapist is indicated. The patient’s ability to hear, see, read, and write is assessed. Visual impairment and functional illiteracy may create additional problems with communication and require creative approaches to ensure that the patient is able to communicate any needs. In addition, the nurse determines the psychological readiness of the patient and family. The idea of cancer is terrifying to most people. Fear is compounded by the possibility of permanently losing voice and, in some cases, of having some degree of disfigurement. The nurse evaluates the patient’s and family’s coping methods to support them effectively both preoperatively and postoperatively.

Nursing Diagnosis
Common Nursing Diagnosis found in patient with Laryngeal Cancer Ineffective airway clearance Impaired verbal communication Impaired skin/tissue integrity Impaired oral mucous membrane Acute pain Imbalanced nutrition: less than body requirements Disturbed body image/ineffective role performance deficient knowledge [learning need] regarding prognosis, treatment, self-care, and discharge needs Impaired swallowing Risk for infection

Nursing interventions
Ineffective Airway Clearance May be related to: 

  • Partial or total removal of the glottis, altering ability to breathe, cough, and swallow 
  • Temporary or permanent change to neck breathing dependent on patent stoma 
  • Edema formation surgical manipulation and lymphatic accumulation 
  • Copious and thick secretions 

Nursing Outcomes Evaluation Criteria, Client Will:

  • Respiratory Status: Airway Patency Maintain patent airway with breath sounds clear or clearing. 
  • Clear secretions and be free of aspiration. 

Nursing Intervention and Rationale Nursing Diagnosis Ineffective Airway Clearance:

  • Monitor vital sign respiratory rate and depth note ease of breathing. Auscultate breath sounds. Investigate restlessness, Dyspnea, and development of cyanosis. Rationale Changes in respirations, use of accessory muscles, and presence of crackles or wheezes suggest retention of secretions. Airway obstruction can lead to ineffective breathing patterns even partial Airway obstruction and impaired gas exchange, resulting in complications, such as pneumonia and respiratory arrest. 
  • Elevate head of bed 30 to 45 degrees. Rationale Facilitates drainage of secretions, work of breathing, and lung expansion. 
  • Encourage swallowing, if client is able. Rationale reducing risk of aspiration with Prevents pooling of oral secretions 
  • Encourage and teach effective coughing and deep breathing. Rationale Mobilizes secretions to clear airway and helps prevent respiratory complications. 
  • Suction laryngectomy and tracheostomy tube and oral and nasal cavities. Note amount, color, and consistency of secretions. Rationale Changes in character of secretions may indicate developing problems, such as dehydration and infection, and need for further evaluation and treatment. Prevents secretions from obstructing airway, especially when swallowing ability is impaired. 
  • Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. Rationale Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
  • Maintain proper position of laryngectomy or tracheostomy tube. Check and adjust ties as indicated. Rationale As edema develops or subsides, tube can be displaced, compromising airway. Ties should be snug but not constrictive to surrounding tissue or major blood vessels. 
  • Observe tissues surrounding tube for bleeding. Change client’s position to check for pooling of blood behind neck or on posterior dressings. Rationale bleeding or sudden eruption of uncontrolled hemorrhage presents a sudden and real possibility of airway obstruction and suffocation. 
  • Provide supplemental humidification Rationale: Normal physiological on nasal passages means of filtering and humidifying air are bypassed. Supplemental humidity decreases mucous crusting and facilitates coughing or suctioning of secretions through stoma. 
  • Resume oral intake with caution Rationale Changes in muscle mass and strength and nerve innervations increase likelihood of aspiration. 
  • Monitor serial ABGs or pulse oximetry and chest x-ray. Rationale Pooling of secretions or presence of atelectasis may lead to pneumonia, requiring more aggressive therapeutic measures. 

Nursing Diagnosis Impaired Verbal Communication related to: 

  • Anatomical deficit removal of vocal cords 
  • Physical barrier tracheostomy tube 
  • Required voice rest 

Nursing Outcomes Evaluation Criteria Client Will:

  • Communication Enhancement: Speech Deficit Independent 
  • Communicate needs in an effective manner. 
  • Identify and plan for appropriate alternative speech methods after healing. Nursing Intervention and Rationale 

Nursing Diagnosis Impaired Verbal Communication:

  • Review preoperative instructions and discussion of why speech and breathing are altered, Rationale Reinforces teaching at a time when fear of surviving surgery is past. 
  • Determine whether client has other communication impairments, such as hearing, vision, and literacy. Rationale Presence of other problems influences plan for alternative communication. 
  • Provide immediate and continual means to summon nurse Prearrange signals for obtaining immediate help Rationale Client needs assurance that nurse is vigilant and will respond to summons. May decrease client’s anxiety about inability to speak. 
  • Allow sufficient time for communication. Rationale Loss of speech and stress of alternative communication can cause frustration and block expression, especially when caregivers seem “too busy” or preoccupied. 
  • Encourage ongoing communication with “outside world,” such as newspapers, television, radio, calendar, and clock. Rationale Maintains contact with “normal lifestyle” and continued communication through other avenues. 
  • Caution client not to use voice until physician gives permission. Rationale Promotes healing of vocal cord and limits potential for permanent cord dysfunction. 
  • Consult or refer with appropriate healthcare team members, therapists, speech pathologist, and social services. Refer to hospital-based rehabilitation, and community resources, such as Lost Chord or New Voice Club, International Association of Laryngectomees, and American Cancer Society. Rationale Ability to use alternative voice and speech methods, such as electrolarynx, TEP, voice prosthesis, and esophageal speech. Rehabilitation time may be lengthy and require a number of agencies and resources to facilitate or support learning process. 

Nursing diagnosis Impaired Skin/Tissue Integrity related to: 

  • Surgical removal of tissues and grafting 
  • Radiation or chemotherapeutic agents 
  • Altered circulation or reduced blood supply 
  • Compromised nutritional status 
  • Edema formation 
  • Pooling or continuous drainage of secretions oral, lymph, or chyle 

Nursing Outcomes Evaluation Criteria Client Will:

  • Wound Healing: Primary Intention 
  • Display timely wound healing without complications. 
  • Demonstrate techniques to promote healing and prevent complications. 

Nursing Intervention and Rationale Nursing Diagnosis Impaired Verbal Communication:

  • Assess skin color, temperature, and capillary refill in operative and skin graft areas. Rationale Cyanosis and slow refill may indicate venous congestion, which can lead to tissue ischemia and necrosis. 
  • Protect skin flaps and suture lines from tension or pressure. Provide pillow or rolls and instruct client to support head and neck during activity. Rationale Pressure from tubing and tracheostomy tapes or tension on suture lines can alter circulation and cause tissue injury. 
  • Monitor bloody drainage from surgical sites, suture lines, and drains Rationale Bloody drainage usually declines steadily after first 24 hours. Steady oozing or frank bleeding indicates problem requiring medical attention. 
  • Note and report any milky-appearing drainage. Rationale Milky drainage may indicate thoracic lymph duct leakage, which can result in depletion of body fluids and electrolytes. Such a leak may heal spontaneously or require surgical closure. 
  • Change dressings, as indicated. Rationale Damp dressings increase risk of tissue damage and infection. 
  • Cleanse thoroughly around stoma and neck tubes (if in place), avoiding soap or alcohol. Show client how to do self-care of stoma and tube with clean water and peroxide, using soft, lint-free cloth, not tissue or cotton. Rationale Keeping area clean promotes healing and comfort. Soap and other drying agents can lead to stomal irritation and possible inflammation. Materials other than cloth may leave fibers in stoma that can irritate or be inhaled into lungs. 
  • Monitor all sites for signs of wound infection, such as unusual redness; increasing edema, pain, exudates; and temperature elevation. Rationale Impedes healing, which may already be slow because of changes induced by cancer, cancer therapies, or malnutrition. 
  • Administer oral, IV, and topical antibiotics, as indicated. Rationale Prevents or controls infection. 

Nursing Diagnosis Impaired Oral Mucous Membrane related to 

  • Dehydration or absence of oral intake, decreased saliva production secondary to radiation or surgical procedure 
  • Poor or inadequate oral hygiene 
  • Pathological condition oral cancer, mechanical trauma oral surgery 
  • Difficulty swallowing and pooling of secretions and drooling 
  • Nutritional deficits 

Nursing Outcomes and Evaluation Criteria Client Will:

  • Tissue Integrity: Skin and Mucous Membranes 
  • Report or demonstrate a decrease in symptoms. 
  • Identify specific interventions to promote healthy oral mucosa. 
  • Demonstrate techniques to restore and maintain mucosal integrity. 
  • Oral Health Restoration 

Nursing Intervention and Rationale Nursing Diagnosis Impaired Oral Mucous Membrane:

  • Inspect oral cavity, Tongue, Lips Teeth and gums and Mucous membranes note changes in: Saliva Rationale Surgery or Damage to salivary glands Tongue, Lips Teeth and gums and Mucous membranes may decrease production of saliva, resulting in dry mouth. Pooling and drooling of saliva may occur because of compromised swallowing capability or pain in throat and mouth. 
  • Suction oral cavity frequently. Have client perform self-suctioning when possible or use gauze wick to drain secretions. Rationale Saliva contains digestive enzymes that may be erosive to exposed tissues. 
  • Show client how to brush inside of mouth, palate, tongue, and teeth. Rationale Frequent oral care reduces bacteria and risk of infection and promotes tissue healing and comfort. 
  • Apply lubrication to lips; provide oral irrigations as indicated. Rationale Counteracts drying effects of therapeutic measures and negates erosive nature of secretions. 
  • Avoid alcohol based mouthwashes. Rationale: Alcohol can be drying and irritating. 

Nursing Diagnosis Acute Pain related to: 

  • Surgical incisions 
  • Tissue swelling 
  • Presence of nasogastric or orogastric feeding tube 

Nursing Outcomes and Evaluation Criteria Client Will:

  • Report pain is relieved or controlled. 
  • Demonstrate relief of pain and discomfort by reduced tension and relaxed manner. Nursing Intervention and Rationale 

Nursing Diagnosis Acute Pain:

  • Evaluate pain level frequently. Rationale : Pain is a major concern for clients undergoing laryngectomy and it is believed as many as 32% still suffer severe distress, with the administered dosing less than needed to obtain optimal pain relief 
  • Investigate changes in characteristics of pain. Check mouth and throat suture lines for fresh trauma. Rationale May reflect developing complications requiring further evaluation or intervention. 
  • Provide comfort measures, such as back rub and position change, and Diversional activities, such as television, visiting, and reading. Rationale Promotes relaxation and helps client refocus attention on something beside pain. 
  • Schedule care activities to balance with adequate periods of sleep or rest. Rationale Prevents fatigue or exhaustion and may enhance coping with stress or discomfort. 
  • Administer analgesics such as on a scheduled basis or via patient-controlled analgesia; adjust dosages according to pain level per protocols. Rationale Degree of pain is related to extent and psychological impact of surgery as well as general body condition. 

Patient Teaching Discharge and Home Healthcare Guidelines
Patient Teaching Discharge and Home Healthcare Guidelines for Patient with Laryngeal Cancer. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (wound drainage, poor wound healing, fever, achiness, chills), airway obstruction and tracheostomy stenosis (noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate), vocal straining; fistula formation (redness, swelling, secretions along a suture line), and ruptured carotid artery (bleeding, hypotension).Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications.
Teach the patient the appropriate devices and techniques to ensure a patent airway and prevent complications. Explore methods of communication that work effectively. Encourage the patient to wear a Medic Alert bracelet or necklace, which identifies her or him as a mouth breather. Provide the patient with a list of referrals and support groups, such as visiting nurses, American Cancer Society, American Speech-Learning-Hearing Association, International Association of Laryngectomees, and the Lost Cord Club

  • Before partial or total laryngectomy, instruct the patient in good oral hygiene practices. If appropriate, instruct a male patient to shave off his beard to facilitate postoperative care. 
  • Explain postoperative procedures, such as suctioning, NG tube feeding, and laryngectomy tube care. Carefully discuss the effects of these procedures (breathing through the neck and speech alteration, for example). 
  • After surgery Teach and encourage client to begin self suction procedures as soon as possible. Educate client in “clean” techniques. To Reduces anxiety associated with difficulty in breathing or inability to handle secretions when alone. 
  • Also, prepare the patient for other functional losses. Forewarn him that he won’t be able to smell aromas, blow his nose, whistle, gargle, sip, or suck on a straw. 
  • Reassure the patient that speech rehabilitation measures (including laryngeal speech, esophageal speech, an artificial larynx, and various mechanical devices) may help him communicate again. 
  • Encourage the patient to take advantage of services and information offered by the American Speech-Language-Hearing Association, the International Association of Laryngectomees, the American Cancer Society, or the local chapter of the Lost Chord Club.