Laryngeal cancer
Laryngeal cancer: Excerpt from Handbook of Diseases
The most common form of laryngeal cancer is squamous cell carcinoma (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 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 early. Laryngeal cancer is nine times more common in males than in females; most victims are between ages 50 and 65.
Causes
With laryngeal cancer, major predisposing factors include smoking and alcoholism; minor factors include chronic inhalation of noxious fumes and familial tendency.
Laryngeal cancer is classified according to its location:
❑ supraglottis (false vocal cords)
❑ glottis (true vocal cords)
❑ subglottis (downward extension from the vocal cords [rare]).
Signs and symptoms
With intrinsic laryngeal cancer, the dominant and earliest indication is hoarseness that persists longer than 3 weeks; with extrinsic cancer, it’s a lump in the throat or pain or burning in the throat when drinking citrus juice or hot liquid. Later signs and symptoms 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.
A firm diagnosis also requires xeroradiography, a biopsy, laryngeal tomography, computed tomography scan, or laryngography to define the borders of the lesion, and a chest X-ray to detect metastasis.
Treatment
Early lesions are treated with surgery or radiation; advanced lesions, with surgery, radiation, and chemotherapy. Chemotherapeutic agents may include methotrexate, cisplatin, bleomycin, fluorouracil, and vincristine.
The treatment goal is to eliminate the cancer and preserve speech. If speech preservation is impossible, speech rehabilitation may include esophageal speech or prosthetic devices; surgical techniques to construct a new voice box are still experimental. Surgical procedures vary with tumor size and can include cordectomy, partial or total laryngectomy, supraglottic laryngectomy, or total laryngectomy with laryngoplasty.
Special considerations
❑ Psychological support and good preoperative and postoperative care can 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 method of communication (such as writing).
❑ If appropriate, arrange for a laryngectomee to visit him. Explain postoperative procedures (suctioning, nasogastric [NG] tube feeding, and care of laryngectomy tube) and their results (the need to breathe through the neck, altered speech). 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 for the first 2 days postoperatively; then give the patient 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 (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 the patient stoma care.
❑ Watch for fistula formation (redness, swelling, and secretions on the suture line). A fistula may form between the reconstructed hypopharynx and the skin. This eventually heals spontaneously, but may take weeks or months.
❑ Watch for carotid artery rupture (bleeding), which usually occurs in a patient who has had preoperative radiation, particularly a patient with a fistula that constantly bathes the carotid artery with oral secretions. If carotid rupture occurs, apply pressure to the site, immediately call for help, and take the patient to the operating room for carotid ligation.
❑ Watch for tracheostomy stenosis (constant shortness of breath), which occurs weeks to months after laryngectomy; treatment includes fitting the patient with successively larger tracheostomy tubes until he can tolerate 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 the patient’s vital signs (be especially alert for fever, which indicates infection).
❑ Record fluid intake and output, and watch for dehydration.
❑ Provide frequent mouth care.
CLINICAL TIP: Suction gently unless otherwise instructed. Don’t attempt deep suctioning, which could penetrate the suture line. Suction through the tube and the patient’s nose because he can no longer blow air through his nose; suction his mouth gently.
❑ After insertion of a drainage catheter (usually connected to a blood drainage system or a GI drainage system), don’t stop suction until drainage is minimal. After the catheter is removed, check dressings for drainage.
❑ Give the patient an analgesic if necessary.
❑ 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 him to contact the International Association of Laryngectomees and other sources of support.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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