Laryngeal cancer
Laryngeal cancer: Excerpt from Professional Guide to Diseases (Eighth Edition)
The most common form of laryngeal cancer is squamous cell cancer (95%); rare forms include adenocarcinoma, sarcoma, and others. Such cancer may be intrinsic or extrinsic. An intrinsic tumor is on the true vocal cord and doesn't tend to spread because underlying connective tissues lack lymph nodes. An extrinsic tumor is on some other part of the larynx and tends to spread early.
Causes and incidence
In laryngeal cancer, major predisposing factors include smoking and alcoholism; minor factors include chronic inhalation of noxious fumes and familial tendency. Cancer of the larynx rarely occurs in nonsmokers.
Laryngeal cancer is classified according to its location:
❑supraglottis (false vocal cords)
❑glottis (true vocal cords)
❑subglottis (downward extension from vocal cords [rare]).
The ratio of male to female incidence is 3.8:1. Most victims are between ages 50 and 65.
Signs and symptoms
In intrinsic laryngeal cancer, the dominant and earliest symptom is hoarseness that persists longer than 3 weeks; in extrinsic cancer, it's a lump in the throat or pain or burning in the throat when drinking citrus juice or hot liquid. Later clinical effects of metastasis include dysphagia, dyspnea, cough, enlarged cervical lymph nodes, and pain radiating to the ear.
Diagnosis
Any hoarseness that lasts longer than 2 weeks requires visualization of the larynx by laryngoscopy. (See Staging laryngeal cancer, pages 66 and 67.)
CONFIRMING DIAGNOSIS Firm diagnosis also requires xeroradiography, biopsy, laryngeal tomography, computed tomography scan, or laryngography to define the borders of the lesion and chest X-ray to detect metastasis.
Treatment
Early lesions are treated with surgery or radiation; advanced lesions with surgery, radiation, and chemotherapy. In early stages, laser surgery can excise precancerous lesions; in advanced stages it can help relieve obstruction caused by tumor growth. Surgical procedures vary with tumor size and can include cordectomy, partial or total laryngectomy, supraglottic laryngectomy, or total laryngectomy with laryngoplasty. The treatment goal is to eliminate the cancer and preserve speech. If speech preservation isn't possible, speech rehabilitation may include esophageal speech or prosthetic devices; surgical techniques to construct a new voice box are still experimental.
Special considerations
Provide psychological support and good preoperative and postoperative care to minimize complications and speed recovery.
Before partial or total laryngectomy:
❑Instruct the patient to maintain good oral hygiene. If appropriate, instruct a male patient to shave off his beard.
❑Encourage the patient to express his concerns before surgery. Help him choose a temporary nonspeaking communication method (such as writing).
❑If appropriate, arrange for a laryngectomee to visit him. Explain postoperative procedures (suctioning, nasogastric [NG] feeding, laryngectomy tube care) and their results (breathing through neck, speech alteration). Also prepare him for other functional losses: He won't be able to smell, blow his nose, whistle, gargle, sip, or suck on a straw.
After partial laryngectomy:
❑Give I.V. fluids and, usually, tube feedings in the initial postoperative period; then resume oral fluids. Keep the tracheostomy tube (inserted during surgery) in place until edema subsides.
❑Keep the patient from using his voice until he has medical permission (usually 2 to 3 days postoperatively). Then caution him to whisper until healing is complete.
After total laryngectomy:
❑As soon as the patient returns to his bed, place him on his side and elevate his head 30 to 45 degrees. When you move him, remember to support his neck.
❑The patient will probably have a laryngectomy tube in place until his stoma heals (about 7 to 10 days). This tube is shorter and thicker than a tracheostomy tube but requires the same care. Watch for crusting and secretions around the stoma, which can cause skin breakdown. To prevent crust formation, provide adequate room humidification. Remove crusting with petroleum jelly, antimicrobial ointment, and moist gauze.
❑Teach stoma care.
❑Watch for and report complications: fistula formation (redness, swelling, secretions on suture line), carotid artery rupture (bleeding), and tracheostomy stenosis (constant shortness of breath). A fistula may form between the reconstructed hypopharynx and the skin. This eventually heals spontaneously but may take weeks or months. Carotid artery rupture usually occurs in patients who have had preoperative radiation, particularly those with a fistula that constantly bathes the carotid artery with oral secretions. If carotid rupture occurs, apply pressure to the site; call for help immediately and take the patient to the operating room for carotid ligation. Tracheostomy stenosis occurs weeks to months after laryngectomy; treatment includes fitting the patient with successively larger tracheostomy tubes until he can tolerate insertion of a large one. If the patient has a fistula, feed him through an NG tube; otherwise, food will leak through the fistula and delay healing. Monitor vital signs (be especially alert for fever, which indicates infection). Record fluid intake and output, and watch for dehydration.
❑Give frequent mouth care.
❑Suction gently; unless ordered otherwise. Don't attempt deep suctioning, which could penetrate the suture line. Suction through both the tube and the patient's nose because the patient can no longer blow air through his nose; suction his mouth gently.
❑After insertion of a drainage catheter (usually connected to a wound-drainage system or a GI drainage system), don't stop suction without the physician's consent. After catheter removal, check dressings for drainage.
❑Give analgesics as ordered.
❑If the patient has an NG feeding tube, check tube placement and elevate the patient's head to prevent aspiration.
❑Reassure the patient that speech rehabilitation may help him speak again. Encourage contact with the International Association of Laryngectomees and other sources of support.
❑Support the patient through the grieving process. If the depression seems severe, consider a psychiatric referral.
Pictures
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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- "Professional Guide to Diseases (Eighth Edition)" (2005)
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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