(LARYNGEAL CANCER)

The larynx (larinks) 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 cords. houses the vocal

The larynx is composed of a framework of muscles and cartilages bound by elastic tissue. The largest of the cartilages is the thyroid (Adams 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.

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).

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).

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.

 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.

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

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

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

Indirect laryngoscopy initially performed in the otolaryngologists 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 recurrence Positron 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 in side 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 silverwhite 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 - (laryngofissurethyrotomy) 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

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 mucositis Ulceration of the mucus membrane Pain Xerostomia (Dry mouth) Loss of taste

 Dysphagia
Fatigue

Skin

reactions Laryngeal necrosis Edema Fibrosis

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.

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 (BlomSinger) 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

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

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

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

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

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- Fowlers or Fowlers 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 depression
oExpresses

a sense of hope oIs aware of available community organizations and agencies oParticipates in support group

 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=laryngeal+can cer+staging&hl=en&sa=G&biw=1024&bih=494&tbm =isch&tbnid=3caE140PRg7EM:&imgrefurl=http://sarasbioblog.blogspot .com/2011/02/throatcancer.html&docid=PvZ_PZXDflGrWM&imgurl=http:// 1.bp.blogspot.com/lOl8HqYpsy8/TVnvz85gGZI/AAAAAAAAABg/J8siqZSx sDA/s1600/stages-of-throatcancer.jpg&w=927&h=451&ei=3v7oT7mEGsqZmQWF lc2CDg&zoom=1 www.healthgiants.com www.cancer.gov www.cancertrialshelp.org

Andal, Jaybel Anne A. Bolagao, Reymart B. Cortez, Dyan M. Eridao, Keyne Reenne P. Herrera, Reggin Caryl V. Isurea, Melody Ann R. Madroo, Rommel Marvin P. Nuestro, Alyssa Jane L. Papa, Deziree L. Ramos, Shelly Mae A.

IV BSN 1 Group 3