Cancer of larynx

Most common in people between the ages of 60 and

70 years
Men is more prone to get Ca larynx than women
 Causes and risk factors
Tobacco
Other factors
Combined effects of •straining the voice
alcohol and tobacco •Chronic laryngitis
Asbestos
•Nutritional deficiencies
Paint fumes
Wood dust •Family predisposition
Chemical •Age more than 60
•Gender- males
•Race – african americans
•Weakened immune system
 Types
Squamous cell carcinoma – 95% - develops in the flat, skin

like squamous cells that cover the surface of the epiglottis, vocal
cords and other parts of the larynx
Adenocarcinoma – starts in the adenomatous cells that

scattered around the surface of the larynx. Adenomatous cells

are gland cells that produce mucus
Sarcoma – starts in the connective tissues. These are the

supporting tissues of the body, such as bone, muscle and nerves.

Chondrosarcomas – cancers in the cartilage of larynx
Benign tumours
Giant cell tumors
Granular cell tumours
Benign tumours of muscle (rhabdomyomas)
Benign tumours of nerves (schwannomas)
Laryngeal nodules – caused by smoking, acid reflux
and straining the voice
Papillomas – these are wart like growth on the larynx.
Caused by virus called human papilloma virus (HPV)
 Clinical features
Persistent hoarseness associated with otalgia and
dyphagia
The voice may sound harsh, raspy, and lower in pitch
A smoker, who becomes progressively hoarse or is hoarse
for longer than 2 weeks should be urged to seek medical
attention.
A lump may be felt in the neck
a cough that doesn't go away
persistent sore throat
breathing difficulties, or feeling that something is
catching in the throat
ear pain, coughing up of blood
Signs of metastasis – lump in the throat, pain in

the adams apple that radiates to the ear, dyspnea,

dysphagia, enlarged lymph nodes and cough.
Lymphadenopathy, weight loss, general weakness

may occur.
 Diagnostic test
Complete history and physical

examination of head and neck

Barium swallow – to rule out metastasis

to esophagus
Biopsy – for pathologic confirmation of

the diagnosis
Chest x ray examination – to determine

whether there is metastasis to lung, a

second primary tumor, or chronic
obstructive pulmonary disease.
Endoscopy – virtual endoscopy (3 dimentional view of

hollow structures is conducted through the utilization

of high resolution imaging and unique computer
processing methods)
Computed tomography scan- to determine if there is

metastasis to lymph nodes or adjacent structures

Fiberoptic laryngoscopy – to determine diagnosis,

locate mass or ulceration.

MRI, PET SCAN
Management
Goals of treatment
Cure of the disease
Preservation of safe, effective swallowing
Preservation of useful voice
Avoidance of permanent Tracheostomy
Treatment option includes:
Surgery
Radiation therapy
chemotherapy
Prognosis depends on the tumor stage, the patients

gender and age, and pathologic features of the tumor,

including the grade and depth of infiltration
Complete dental examination should be done. If any

dental problem is there, it should be resolved before

surgery and radiotherapy
Early stage tumors and lesions without lymph node

involvement, radiation therapy or surgery may effective.

Chemo – radiotherapy provides high rates of laryngeal

preservation.
Surgical management
Goals –
Minimizing the effects of surgery on speech,
swallowing and breathing
Maximizing the cure of cancer
Patient with more extensive tumors (T3 and T4)

require a combined approach of surgical resection

and preoperative and post operative radiotherapy
Chemotherapy with cisplatin and 5-flurouracil along

with radiotherapy is also suggested.

Hemilaryngectomy / vertical partial
laryngectomy
In this half of the larynx is removed

This procedure is usually well tolerated

The patient not allowed to swallow for 7 to 10 days

postoperatively
Removal of more than half the larynx or a portion of

the second vocal cord is called a SUBTOTAL

LARYNGECTOMY.
Opening into larynx through thyroid cartilage with
removal of diseased false cord, and one side thyroid
cartilage
Voice result – hoarse voice
Swallowing ability – initially need swallowing therapy
to learn how to swallow without aspirating
Supraglotic laryngectomy
When cancer invades the supraglottis, a supraglottic
laryngectomy is done
True vocal cords are preserved
Aspiration may occur because the major reflex arc that
causes closure of the larynx is initiated by sensory
receptors in the supraglottic larynx, which has been
removed
These patients need special swallowing training
postoperatively
When aspiration is suspected the patient swallows a
drink with methylene blue dye, grape juice or food
coloring added – then check the tracheal secretions
Horizontal incision passes above true cords (leaving
cords intact) with removal of epiglottis and diseased
tissue
Voice result – normal voice
Swallowing therapy should be start initially itself
After a partial laryngectomy a temporary
tracheostomy tube is inserted
It is removed when edema in the surrounding tissues
subsides
Patient is not allowed to use voice for about 3 days
after surgery
Vocal cord stripping
Stripping of the cord is used to treat dysplasia
(abnormal development), hyperkeratosis (is
thickening of the stratum corneum (the outermost
layer of the epidermis), often associated with the
presence of an abnormal quantity of keratin,)and
leukoplakia
It involves removal of the mucosa of the edge of the
vocal cord using operating microscope
Cordectomy
 Excision of the vocal cord via transoral laser

Laser surgery
 Have several advantages
 Treatment and recovery are shorter, with few side
effects and less costly
 Microelectrodes are useful for surgical resection
 Carbon dioxide laser can be used for the treatment
of many laryngeal tumors
Total laryngectomy
When cancer of the larynx is advanced – total

laryngectomy
It includes – removal of the epiglottis, thyroid cartilage,

hyoid bone, cricoid cartilage and three or four rings of

the trachea
The pharyngeal opening to the trachea is closed and the

remainder of the trachea is brought out to the neck

wound and sutured to the skin to form a permanent
tracheostomy through which the patient breaths
The person has no voice because of loss of the larynx

The patient loses the sense of smell because

breathing through the nose is impossible

Initially the person has runny nose because sniffing

in and out is not possible

Radical neck dissection
A radical neck dissection may be performed along
with the laryngectomy when risk of metastasis to the
neck is high
In this the surgeon removes the submandibular

salivary gland, sterno cleido mastoid muscle, internal

jugular vein, and spinal accessory nerves
This extensive surgery is done to prevent nodal spread.
Selective, modified, conservative or functional neck
dissections
Radical neck dissection causes atrophy of the

trapezius muscle and the shoulder droops on the side

of surgery.
The physical therapist or nurse can assist patients with

range of motion exercises, which will gradually replace

the function of the lost muscles
Mid fowlers position is best – it can helps reduce facial

edema, improve circulation and reduce or prevent

headaches from lymphedema.
Reconstructive surgery
In past skin grafts were used for reconstruction

Today myocutaneous flaps and free flaps are most

commonly used to reconstruct large deficits caused by

extensive tumor resection
Myocutaneous flaps
Myocutaneous flaps use the axial blood supply that
supplies muscle mass, as well as cutaneous and
subcutaneous tissue.
The inclusion of muscle with its blood supply when
transferring the skin allows for a much greater range of
rotation of the flap
The pectoralis major, latissimus dorsi, trapezius and
sternocleidomastoid muslces can be used for
myocutaneous flap
Free flaps
It consist of harvested tissue separated from the donor
site with the vein and artery.
The vein and artery are anastomosed to recipient
vessels close to the defect (microvascular
anastomosis)
Low dose aspirin or even heparin to prevent clot
formation
Nursing management
Preoperative care
Explain the patient that after total laryngecotmy the
breathing will occur through a permanent opening
made in the neck and that normal speech will not be
possible
This will leads to depression to the patient
The patient should meet a speech pathologist before
surgery to learn about options for post operative
rehabilitation and speech
In some cases, a visit from another persons who
undergone same surgery can be useful
Sometimes the visit of that patient can leads to

depression again, so careful assessment must be

handle and fix that when the patient should meet
(before or after surgery)
Referring to Lost chord club or new voice club

Local speech rehabilitation centers supply instructive

films and other resources

Care of the patient after total laryngectomy
Provide comfort care and airway management
Elevate head of bed 45 degrees
Encourage deep breathing every 4 hours
Assess airway patency every shift as needed
Maintain oxygen to tracheostomy collar
Assess vitals – quality, rate of respiration and skin
color (pallor, cyanosis)
Auscultate lungs every shift as needed
Provide care for suture line and stoma site
Assess suture line and stoma site every 4 hours
Report erythema, purulent drainage or hematoma
Monitor drain function and output
Maintain suction to drain at level ordered
Milk tubing every 1 to 2 hours for 24 hours and then
every 4 hours
Report changes in amount and color of drainage or air
leak
Clean the stoma site and suture line with hydrogen
peroxide, normal saline and dry it with dry gauze.
Attention to fluid, food and hygiene needs
Monitor hydration and ensure adequate fluid intake to
maintain healthy oral mucosa
Provide mouth care atleast three times a day
Record intake and output every shift
Weigh the patient daily, at the same time and in the
same amount of clothing
Provide stoma care every shift as needed
Administer enteral feedings as ordered
Assess patients tolerance to feedings
Assess bowel sounds every shift as needed
Report intolerance to feedings (nausea, fullness,
inability to feed)
Record amount, consistency and frequency of stools
Assess swallowing ability, and provide support when
oral diet resumes
Provide support and education for the
patient family
Assess anxiety level and provide emotional support
Assist patient in communicating
Provide patient with writing materials or picture board
Use questions that can be answered yes or no
Instruct about use of artificial speech device and
encourage its use
Be sensitive to patients reactions to changes in
appearance
Provide time to listen to patient
Encourage use of lost chord or new voice club
Prepare patient for discharge
Begin teaching laryngectomy care
Monitor ability of patient to perform airway
management care
Provide information about soft diet
Review written instructions in home going booklet with
patient and family
Refer the patient to a speech pathologist for voice and
speech rehabilitation
Speech rehabilitation
Tracheoesophageal speech – in this a
tracheoesophageal puncture (TEP) is made to create a
tracheoesophageal fistula large enough for insertion of
a valve prosthesis.
Artificial larynx or electro larynx – mechanical
device which create natural type of speech
Complications due to surgeries
Hematoma, wound dehiscence, tissue loss,

pharyngocutaneous fistula , carotid artery rupture,

problems with appearances
Complications of myocutaneous and free flaps

includes venous or arterial congestion, flap necrosis

and slough.
Regional lymph nodes (N)
NX Regional nodes cannot be assessed
N0 No regional lymph node metastasis
N1 Metastasis in a single ipsilateral lymph node =3cm in greatest
dimension
N2 Metastasis in a single ipsilateral lymph node >3cm but not more than
6cm in greatest dimension; or in multiple ipsilateral lymph nodes,
none >6cm in greatest dimension; or in bilateral or contralateral
lymph nodes, none >6cm in greatest dimension

N2a Metastasis in a single ipsilateral lymph node >3cm but not more than
6cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, none >6cm in greatest
dimension
N2c Metastasis in bilateral or contralateral lymph nodes, none >6cm in
greatest dimension
N3 Metastasis in a lymph node >6cm in greatest dimension
Distant metastasis (M)
M0 No distant metastasis
M1 Distant metastasis
Stage T N M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IVA T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
IVB T Any N3 M0
T4b N Any M0
IVC T Any N Any M1