laryngeal cancer
(redirected from Larynx cancer)Laryngeal Cancer
Definition
Description
Causes and symptoms
- persistent sore throat
- pain when swallowing
- difficulty swallowing or frequent choking on food
- bad breath
- lumps in the neck
- persistent ear pain (called referred pain; the source of the pain is not the ear)
- change in voice quality
Diagnosis
- Endoscopy. Similar to a laryngoscopy, this test is done when it appears that cancer may have spread to other areas, such as the esophagus or trachea.
- Computed tomography (CT or CAT) scan. Using x-ray images taken from several angles and computer modeling, CT scans allow parts of the body to be seen as a cross section. This helps locate and size the tumors, and provides information on whether they can be surgically removed.
- Magnetic resonance imaging (MRI). MRI uses magnets and radio waves to create more detailed cross-sectional scans than computed tomography. This detailed information is needed if surgery on the larynx area is planned.
- Barium swallow. Barium is a substance that, unlike soft tissue, shows up on x rays. Swallowed barium coats the throat and allows x-ray pictures to be made of the tissues lining the throat.
- Chest x ray. Done to determine if cancer has spread to the lungs. Since most people with laryngeal cancer are smokers, the risk of also having lung cancer or emphysema is high.
- Fine needle aspiration (FNA) biopsy. If any lumps on the neck are found, a thin needle is inserted into the lump, and some cells are removed for analysis by the pathologist.
- Additional blood and urine tests. These tests do not diagnose cancer, but help to determine the patient's general health and provide information to determine which cancer treatments are most appropriate.
Treatment
Staging
- Supraglottis: The cancer is only in one area of the supraglottis and the vocal cords can move normally.
- Glottis: The cancer is only in the vocal cords and the vocal cords can move normally.
- Subglottis: The cancer has not spread outside of the subglottis.
- Supraglottis: The cancer is in more than one area of the supraglottis, but the vocal cords can move normally.
- Glottis: The cancer has spread to the supraglottis or the subglottis or both. The vocal cords may or may not be able to move normally.
- Subglottis: The cancer has spread to the vocal cords, which may or may not be able to move normally.
- The cancer has not spread outside of the larynx, but the vocal cords cannot move normally, or the cancer has spread to tissues next to the larynx.
- The cancer has spread to one lymph node on the same side of the neck as the cancer, and the lymph node measures no more than 3 centimeters (just over 1 inch).
- The cancer has spread to tissues around the larynx, such as the pharynx or the tissues in the neck. The lymph nodes in the area may or may not contain cancer.
- The cancer has spread to more than one lymph node on the same side of the neck as the cancer, to lymph nodes on one or both sides of the neck, or to any lymph node that measures more than 6 centimeters (over 2 inches).
- The cancer has spread to other parts of the body.
Treatment
Alternative treatment
Prognosis
Prevention
Resources
Periodicals
Organizations
Other
Key terms
laryngeal cancer
laryngeal cancer
Cancer of voice box, larynx cancer, throat cancer Head & neck surgery An epithelial CA–usually SCC, that arises in the vocal cords in Pts > age 55, linked to smoking/tobacco use Clinical Painless hoarseness, dysphagia Diagnosis Laryngoscopy Management RT, surgery; chemotherapy is rarely useful. See Oral cancer.Laryngeal Cancer
DRG Category: | 12 |
Mean LOS: | 10 days |
Description: | SURGICAL: Tracheostomy for Face, Mouth, and Neck Diagnoses With CC |
DRG Category: | 148 |
Mean LOS: | 3.2 days |
Description: | MEDICAL: Ear, Nose, Mouth, and Throat Malignancy Without CC or Major CC |
Cancer of the larynx is the most common malignancy of the upper respiratory tract. About 95% of all laryngeal cancers are squamous cell carcinomas; adenocarcinomas and sarcomas account for the other 5%. In 2013, approximately 12,260 people developed laryngeal cancer in the United States, and global rates of the disease in countries with high tobacco and alcohol use are high.
Most cases of laryngeal cancer are diagnosed before metastasis occurs. If it is confined to the glottis (the true vocal cords), laryngeal cancer usually grows slowly and metastasizes late because of the limited lymphatic drainage of the cords. Sixty percent of the cancers begin in the glottis, 35% begin in the supraglottis, and 5% begin in the subglottis. Laryngeal cancer that involves the supraglottis (false vocal cords) and subglottis (a rare downward extension from the vocal cords) tends to metastasize early to the lymph nodes in the neck because of the rich lymphatic drainage of this area.
Causes
The cause of laryngeal cancer is unknown, but the two major predisposing factors are prolonged use of alcohol and tobacco. Each substance poses an independent risk, but their combined use causes a synergistic effect. Other risk factors include a familial tendency, a history of frequent laryngitis or vocal straining, chronic inhalation of noxious fumes, poor nutrition, human papillomavirus, and a weakened immune system.
Genetic considerations
Ongoing studies indicate a role for genetics in the susceptibility and course of laryngeal cancer. Several gene mutations (e.g., PTEN and TP53) have been associated with risk, especially in the presence of alcohol and tobacco intake.
Gender, ethnic/racial, and life span considerations
Cancer of the larynx is more common in men than in women (5:1 ratio). The increased incidence likely occurs because men have higher rates of cigarette and alcohol use, although the incidence in women is rising as more women smoke and drink. Cancer of the larynx occurs most frequently between the ages of 50 and 70. Women are more likely to get laryngeal cancer between the ages of 50 and 60 and men between the ages of 60 and 70. Laryngeal cancer is 50% more common in African American individuals than in white individuals of European origin.
Global health considerations
The global incidence of laryngeal cancer is approximately 5 per 100,000 for males per year and 1 per 100,000 females per year. The incidence is twice as high in developed regions of the world as compared to developing regions.
Assessment
History
Be aware as you interview the patient that hoarseness, shortness of breath, and pain may occur as the patient speaks. Obtain a thorough history of risk factors: alcohol or tobacco usage, voice abuse, frequent laryngitis, and family history of laryngeal cancer. Obtain detailed information about the patient’s alcohol intake; ask about drinks per day, days of abstinence, and patterns of drinking. Ask the patient how many packs of cigarettes he or she has smoked per day for how many years.
Most patients describe hoarseness or throat irritation that lasts longer than 2 weeks and may report a change in voice quality. Ask about dysphagia, persistent cough, hemoptysis, weight loss, dyspnea, or pain that radiates to the ear, which are late symptoms of laryngeal cancer. Because of potential problems with alcohol and weight loss, inquire about the patient’s nutritional intake and dietary habits.
Physical examination
A change in the quality of people’s voices is often the first symptom. Inspect and palpate the neck for lumps and involved lymph nodes. A node may be tender before it is palpable. Inspect the mouth for sores and lumps. Palpate the base of the tongue to detect any nodules. Perform a cranial nerve assessment because some tumors spread along these nerves.
Psychosocial
The patient with laryngeal cancer is faced with a potentially terminal illness. The patient may experience guilt, denial, or shame because of the association with cigarette smoking and alcohol consumption. Efforts to cure patients of this disease often result in a loss of normal speech and permanent lifestyle changes. Patients may experience radical changes in both body image and role relationships (interpersonal, social, and work). Assess both the patient’s and the significant others’ coping mechanisms and support system because extensive follow-up at home is necessary.
Diagnostic highlights
Test | Normal Result | Abnormality With Condition | Explanation |
---|---|---|---|
Nasopharyngoscopy/laryngoscopy | Normal structures with no evidence of cancer | Visible cancers of the oral cavity and nasopharynx | Special fiberoptic scopes and mirrors allow for visual inspection of the mouth and behind the nose and biopsy of nodes |
Panendoscopy | Normal structures with no evidence of cancer | Visible cancers of larynx, hypopharynx, esophagus, trachea, and bronchi | Special fiberoptic scopes and mirrors allow for visual inspection of larynx, hypopharynx, esophagus, trachea, and bronchi and biopsy of nodes |
Barium swallow | Normal structures with no evidence of cancer | Locations and extent of cancers evident | X-rays performed while the patient swallows a liquid that contains barium |
Other Tests: Magnetic resonance imaging, computed tomography scan, chest x-rays, arterial blood gases, pulmonary function tests, positron emission tomography, endoscopic biopsy, fine-needle aspiration
Primary nursing diagnosis
Diagnosis
Ineffective airway clearance related to obstruction, swelling, and accumulation of secretionsOutcomes
Respiratory status: Gas exchange and ventilation; Comfort level; Knowledge: Treatment regimenInterventions
Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistancePlanning and implementation
Collaborative
A multidisciplinary team of speech pathologists, social workers, dietitians, respiratory therapists, occupational therapists, and physical therapists provide preoperative evaluation and postoperative care. The goal is to eliminate the cancer and preserve the ability to speak and swallow. The two types of therapy commonly used are radiation therapy and surgery. Chemotherapy has not been found to be beneficial in treating this type of cancer and, if used, is always employed in conjunction with surgery or radiation. Chemotherapy may be useful in treating cancer that has metastasized beyond the head and neck, however, and it may be useful as a palliative treatment for cancers that are too large to be surgically removed or for cancer that is not controlled by radiation therapy.
Treatment choice depends on cancer staging. Stage 0 cancer is treated either by surgical removal of the abnormal lining layer of the larynx or by laser beam vaporizing of the abnormal cell layer. Stages I and II are treated either surgically or with radiation therapy. A common course of radiation therapy consists of daily fractions or doses administered 5 days a week for 7 weeks. Radiation therapy is frequently used as the primary treatment of laryngeal cancer, especially for patients with small cancers. Radiation successfully treats 80% to 90% of patients with stage I laryngeal cancer and 70% to 80% of patients with stage II laryngeal cancer. A partial laryngectomy is an alternative treatment; however, voice results are generally better with radiation.
Stages III and IV laryngeal cancer are generally treated with a combination of surgery and radiation, radiation and chemotherapy, or all three treatments. Almost always, a total laryngectomy is performed, although a few laryngeal cancers may be treated by partial laryngectomy. The patient loses her or his voice and sense of smell; the patient breathes through a permanent tracheostomy stoma. A radical neck dissection is done, in conjunction with a partial or a total laryngectomy, to remove carcinoma that has metastasized to adjacent areas of the neck. The 5-year survival rate for stages III and IV cancers treated with surgery and radiation is 50% to 80%. Newer treatments combining laser therapy and radiation for early-stage laryngeal cancer have promising outcomes.
Preoperatively, the physician and speech therapist should discuss the anticipated effect of the surgical procedure on the patient’s voice. Postoperatively, the most immediate concern is maintaining a patent airway, and aspiration is a high risk. Suctioning needs to be done gently so as not to penetrate the suture line. Suction the patient’s laryngectomy tube and nose because the patient can no longer blow air through the nose. Observe the suture lines for intactness, hematoma, and signs of infection. Assess the skin flap for any signs of infection or necrosis and notify the physician of any problems.
Restoring speech after a laryngectomy is a concern. Patients can use an electrolarynx, an electrical device that is pressed against the neck to produce a “mechanical voice.” A new advance in restoring speech is a procedure called tracheoesophageal puncture, which is performed either at the time of the initial surgery or at a later date. Through the use of a small one-way shunt valve that is placed into a small puncture at the stoma site, patients can produce speech by covering the stoma with a finger and forcing air out of the mouth.
Pharmacologic highlights
Medication or Drug Class | Dosage | Description | Rationale |
---|---|---|---|
Analgesics | Varies with drug | Morphine sulfate, fentanyl | Relieve pain |
Other Drugs: Chemotherapy (usually 5-fluorouracil and cisplatin) may be used in certain circumstances; however, no improvement in overall survival rate has been demonstrated. Targeted therapies (monoclonal antibodies such as cetuximab) may be used in larynx preservation.
Independent
Spend time with the patient preoperatively exploring changes in the patient’s body, such as the loss of smell and the inability to whistle, gargle, sip, use a straw, or blow the nose. Explain that the patient may need to breathe through a stoma in the neck, learn esophageal speech, or learn to use mechanical devices to speak. Encourage the expression of feelings about a diagnosis of cancer and offer to contact the appropriate clergy or clinical nurse specialist to counsel the patient.
Postoperatively, assess the patient’s level of comfort. Reposition the patient carefully; after a total laryngectomy, support the back of the neck when moving the patient to prevent trauma. Provide frequent mouth care, cleansing the mouth with a soft toothbrush, toothette, or washcloth. After a partial laryngectomy, the patient should not use his or her voice for at least 2 days. The patient should have an alternative means of communication available at all times, and the nurse should encourage its use. After 2 to 3 days, encourage the patient to use a whisper until complete healing takes place. Because the functional impairments and disfigurement that result from this surgery are traumatic, close attention should be paid to the patient’s emotional status.
As soon as possible after surgery, the patient with a total laryngectomy should start learning to care for the stoma, suction the airway, care for the incision, and self-administer the tube feedings (if the patient is to have tube feedings after discharge). Assist the patient in obtaining the equipment and supplies for home use. Discuss safety precautions for patients with a permanent stoma. If appropriate, refer the patient to smoking and alcohol cessation counseling.
Evidence-Based Practice and Health Policy
Islami, F., Tramacere, I., Rota, M., Bagnardi, V., Fedirko, V., Scotti, L., …La Vecchia, C. (2010). Alcohol drinking and laryngeal cancer: Overall and dose-risk relation—A systematic review and meta-analysis. Oral Oncology, 46(11), 802–810.
- A meta-analysis of 38 case-control studies and two cohort studies revealed that drinking alcohol when compared to no alcohol was associated with nearly double the risk of laryngeal cancer (relative risk, 1.90; 95% CI, 1.59 to 2.28).
- Although light alcohol drinking had no significant effects on laryngeal cancer risk, moderate drinking (two to three drinks per day) was associated with 1.47 times increased risk (95% CI, 1.25 to 1.72), and heavy drinking (four or more drinks per day) was associated with 2.62 times increased risk (95% CI, 2.13 to 3.23) of laryngeal cancer compared to no alcohol.
- The relative risk of laryngeal cancer when compared to no alcohol was 1.2 times for 12.5 g (95% CI, 1.15 to 1.25), 1.45 times for 25 g (95% CI, 1.33 to 1.57), 1.72 times for 37.5 g (95% CI, 1.52 to 1.90), 2.04 times for 50 g (95% CI, 1.76 to 2.36), and 3.77 times for 100 g (95% CI, 2.93 to 4.86) per day.
Documentation guidelines
- Preoperative health and social history, physical assessment, drinking and smoking history
- Postoperative physical status: Incisions and drains, patency of airway, pulmonary secretions, nasogastric feedings, oral intake, integrity of the skin
- Pain: Location, duration, frequency, precipitating factors, response to analgesia
- Preoperative, postoperative, and discharge teaching
- Patient’s ability to perform self-care: Secretion removal, laryngectomy tube and stoma care, incision care, tube feedings
Discharge and home healthcare guidelines
Teach the patient the name, purpose, dosage, schedule, common side effects, and importance of taking all medications. Teach the patient signs and symptoms of potential complications and the appropriate actions to be taken. Complications include infection (symptoms: wound drainage, poor wound healing, fever, achiness, chills); airway obstruction and tracheostomy stenosis (symptoms: noisy respirations, difficulty breathing, restlessness, confusion, increased respiratory rate); vocal straining; fistula formation (symptoms: redness, swelling, secretions along a suture line); and ruptured carotid artery (symptoms: bleeding, hypotension).
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 that 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.