laryngeal cancer

Laryngeal Cancer

 

Definition

Laryngeal cancer is cancer of the larynx or voice box.

Description

The larynx is located where the throat divides into the esophagus and the trachea. The esophagus is the tube that takes food to the stomach. The trachea, or windpipe, takes air to the lungs. The area where the larynx is located is sometimes called the Adam's apple.

The larynx has two main functions. It contains the vocal cords, cartilage, and small muscles that make up the voice box. When a person speaks, small muscles tighten the vocal cords, narrowing the distance between them. As air is exhaled past the tightened vocal cords, it creates sounds that are formed into speech by the mouth, lips, and tongue.

The second function of the larynx is to allow air to enter the trachea and to keep food, saliva, and foreign material from entering the lungs. A flap of tissue called the epiglottis covers the trachea each time a person swallows. This blocks foreign material from entering the lungs. When not swallowing, the epiglottis retracts, and air flows into the trachea. During treatment for cancer of the larynx, both of these functions may be lost.

Cancers of the larynx develop slowly. About 95% of these cancers develop from thin, flat cells similar to skin cells called squamous epithelial cells. These cells line the larynx. Gradually, the squamous epithelial cells begin to change and are replaced with abnormal cells. These abnormal cells are not cancerous but are pre-malignant cells that have the potential to develop into cancer. This condition is called dysplasia. Most people with dysplasia never develop cancer. The condition simply goes away without any treatment, especially if the person with dysplasia stops smoking or drinking alcohol.

The larynx is made up of three parts, the glottis, the supraglottis, and the subglottis. Cancer can start in any of these regions. Treatment and survival rates depend on which parts of the larynx are affected and whether the cancer has spread to neighboring areas of the neck or distant parts of the body.

The glottis is the middle part of the larynx. It contains the vocal cords. Cancers that develop on the vocal cords are often diagnosed very early because even small vocal cord tumors cause hoarseness. In addition, the vocal cords have no connection to the lymphatic system. This means that cancers on the vocal cord do not spread easily. When confined to the vocal cords without any involvement of other parts of the larynx, the cure rate for this cancer is 75% to 95%.

The supraglottis is the area above the vocal cords. It contains the epiglottis, which protects the trachea from foreign materials. Cancers that develop in this region are usually not found as early as cancers of the glottis because the symptoms are less distinct. The supraglottis region has many connections to the lymphatic system, so cancers in this region tend to spread easily to the lymph nodes and may spread to other parts of the body (lymph nodes are small bean-shaped structures that are found throughout the body; they produce and store infection-fighting cells). In 25% to 50% of people with cancer in the supraglottal region, the cancer has already spread to the lymph nodes by the time they are diagnosed. Because of this, survival rates are lower than for cancers that involve only the glottis.

The subglottis is the region below the vocal cords. Cancer starting in the subglottis region is rare. When it does, it is usually detected only after it has spread to the vocal cords, where it causes obvious symptoms such as hoarseness. Because the cancer has already begun to spread by the time it is detected, survival rates are generally lower than for cancers in other parts of the larynx.

About 12,000 new cases of cancer of the larynx develop in the United States each year. Each year, about 3,900 die of the disease. Laryngeal cancer is between four and five times more common in men than in women. Almost all men who develop laryngeal cancer are over age 55. Laryngeal cancer is about 50% more common among African-American men than among other Americans.

It is thought that older men are more likely to develop laryngeal cancer than women because the two main risk factors for acquiring the disease are lifetime habits of smoking and alcohol abuse. More men are heavy smokers and drinkers than women, and more African-American men are heavy smokers than other men in the United States. However, as smoking becomes more prevalent among women, it seems likely that more cases of laryngeal cancer in females will be seen.

Causes and symptoms

Laryngeal cancer develops when the normal cells lining the larynx are replaced with abnormal cells (dysplasia) that become malignant and reproduce to form tumors. The development of dysplasia is strongly linked to life-long habits of smoking and heavy use of alcohol. The more a person smokes, the greater the risk of developing laryngeal cancer. It is unusual for someone who does not smoke or drink to develop cancer of the larynx. Occasionally, however, people who inhale asbestos particles, wood dust, paint or industrial chemical fumes over a long period of time develop the disease.

The symptoms of laryngeal cancer depend on the location of the tumor. Tumors on the vocal cords are rarely painful, but cause hoarseness. Anyone who is continually hoarse for more than two weeks or who has a cough that does not go away should be checked by a doctor.

Tumors in the supraglottal region above the vocal cords often cause more, but less distinct symptoms. These include:

• 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

Tumors that begin below the vocal cords are rare, but may cause noisy or difficult breathing. All the symptoms above can also be caused other cancers as well as by less seriousness illnesses. However, if these symptoms persist, it is important to see a doctor and find their cause, because the earlier cancer treatment begins, the more successful it is.

Diagnosis

On the first visit to a doctor for symptoms that suggest laryngeal cancer, the doctor first takes a complete medical history, including family history of cancer and lifestyle information about smoking and alcohol use. The doctor also does a physical examination, paying special attention to the neck region for lumps, tenderness, or swelling.

The next step is examination by an otolaryngologist, or ear, nose, and throat (ENT) specialist. This doctor also performs a physical examination, but in addition will also want to look inside the throat at the larynx. Initially, the doctor may spray a local anesthetic on the back of the throat to prevent gagging, then use a long-handled mirror to look at the larynx and vocal cords. This examination is done in the doctor's office. It may cause gagging but is usually painless.

A more extensive examination involves a laryngoscopy. In a laryngoscopy, a lighted fiberoptic tube called a laryngoscope that contains a tiny camera is inserted through the patient's nose and mouth and snaked down the throat so that the doctor can see the larynx and surrounding area. This procedure can be done with a sedative and local anesthetic in a doctor's office. More often, the procedure is done in an outpatient surgery clinic or hospital under general anesthesia. This allows the doctor to use tiny clips on the end of the laryngoscope to take biopsies (tissue samples) of any abnormal-looking areas.

Laryngoscopies are normally painless and take about one hour. Some people find their throat feels scratchy after the procedure. Since laryngoscopies are done under sedation, patients should not drive immediately after the procedure, and should have someone available to take them home. Laryngoscopy is a standard procedure that is covered by insurance.

The locations of the samples taken during the laryngoscopy are recorded, and the samples are then sent to the laboratory where they are examined under the microscope by a pathologist who specializes in diagnosing diseases through cell samples and laboratory tests. It may take several days to get the results. Based on the findings of the pathologist, cancer can be diagnosed and staged.

Once cancer is diagnosed, other tests will probably be done to help determine the exact size and location of the tumors. This information is helpful in determining which treatments are most appropriate. These tests may include:

• 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

Once cancer of the larynx is found, more tests will be done to find out if cancer cells have spread to other parts of the body. This is called staging. A doctor needs to know the stage of the disease to plan treatment. In cancer of the larynx, the definitions of the early stages depend on where the cancer started.

STAGE I. The cancer is only in the area where it started and has not spread to lymph nodes in the area or to other parts of the body. The exact definition of stage I depends on where the cancer started, as follows:

• 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.

STAGE II. The cancer is only in the larynx and has not spread to lymph nodes in the area or to other parts of the body. The exact definition of stage II depends on where the cancer started, as follows:

• 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.

STAGE III. Either of the following may be true:

• 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).

STAGE IV. Any of the following may be true:

• 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.

RECURRENT. Recurrent disease means that the cancer has come back (recurred) after it has been treated. It may come back in the larynx or in another part of the body.

Treatment

Treatment is based on the stage of the cancer as well as its location and the health of the individual. Generally, there are three types of treatments for cancer of the larynx. These are surgery, radiation, and chemotherapy. They can be used alone or in combination based in the stage of the caner. Getting a second opinion after the cancer has been staged can be very helpful in sorting out treatment options and should always be considered.

SURGERY. The goal of surgery is to cut out the tissue that contains malignant cells. There are several common surgeries to treat laryngeal cancer.

Stage III and stage IV cancers are usually treated with total laryngectomy. This is an operation to remove the entire larynx. Sometimes other tissues around the larynx are also removed. Total laryngectomy removes the vocal cords. Alternate methods of voice communication must be learned with the help of a speech pathologist. Laryngectomy is treated in depth as a separate entry in this volume.

Smaller tumors are sometimes treated by partial laryngectomy. The goal is to remove the cancer but save as much of the larynx (and corresponding speech capability) as possible. Very small tumors or cancer in situ are sometimes successfully treated with laser excision surgery. In this type of surgery, a narrowly-targeted beam of light from a laser is used to remove the cancer.

Advanced cancer (Stages III and IV) that has spread to the lymph nodes often requires an operation called a neck dissection. The goal of a neck dissection is to remove the lymph nodes and prevent the cancer from spreading. There are several forms of neck dissection. A radical neck dissection is the operation that removes the most tissue.

Several other operations are sometimes performed because of laryngeal cancer. A tracheotomy is a surgical procedure in which an artificial opening is made in the trachea (windpipe) to allow air into the lungs. This operation is necessary if the larynx is totally removed. A gastrectomy tube is a feeding tube placed through skin and directly into the stomach. It is used to give nutrition to people who cannot swallow or whose esophagus is blocked by a tumor. People who have a total laryngectomy usually do not need a gastrectomy tube if their esophagus remains intact.

RADIATION. Radiation therapy uses high-energy rays, such as x rays or gamma rays, to kill cancer cells. The advantage of radiation therapy is that it preserves the larynx and the ability to speak. The disadvantage is that it may not kill all the cancer cells. Radiation therapy can be used alone in early stage cancers or in combination with surgery. Sometimes it is tried first with the plan that if it fails to cure the cancer, surgery still remains an option. Often, radiation therapy is used after surgery for advanced cancers to kill any cells the surgeon might not have removed.

There are two types of radiation therapy. External beam radiation therapy focuses rays from outside the body on the cancerous tissue. This is the most common type of radiation therapy used to treat laryngeal cancer. With internal radiation therapy, also called brachytherapy, radioactive materials are placed directly on the cancerous tissue. This type of radiation therapy is a much less common treatment for laryngeal cancer.

External radiation therapy is given in doses called fractions. A common treatment involves giving fractions five days a week for seven weeks. Clinical trials are underway to determine the benefits of accelerating the delivery of fractions (accelerated fractionation) or dividing fractions into smaller doses given more than once a day (hyperfractionation). Side effects of radiation therapy include dry mouth, sore throat, hoarseness, skin problems, trouble swallowing, and diminished ability to taste.

CHEMOTHERAPY. Chemotherapy is the use of drugs to kill cancer cells. Unlike radiation therapy, which is targeted to a specific tissue, chemotherapy drugs are either taken by mouth or intravenously (through a vein) and circulate throughout the whole body. They are used mainly to treat advanced laryngeal cancer that is inoperable or that has metastasized to a distant site. Chemotherapy is often used after surgery or in combination with radiation therapy. Clinical trials are underway to determine the best combination of treatments for advanced cancer.

The two most common chemotherapy drugs used to treat laryngeal cancer are cisplatin and 5-fluorouracil (5-FU). There are many side effects associated with chemotherapy drugs, including nausea and vomiting, loss of appetite, hair loss, diarrhea, and mouth sores. Chemotherapy can also damage the blood-producing cells of the bone marrow, which can result in low blood cell counts, increased chance of infection, and abnormal bleeding or bruising.

Alternative treatment

Alternative and complementary therapies range from herbal remedies, vitamin supplements, and special diets to spiritual practices, acupuncture, massage, and similar treatments. When these therapies are used in addition to conventional medicine, they are called complementary therapies. When they are used instead of conventional medicine, they are called alternative therapies.

Complementary or alternative therapies are widely used by people with cancer. One large study published in the Journal of Clinical Oncology in July, 2000 found that 83% of all cancer patients studied used some form of complementary or alternative medicine as part of their cancer treatment. No specific alternative therapies have been directed toward laryngeal cancer. However, good nutrition and activities that reduce stress and promote a positive view of life have no unwanted side-effects and appear to be beneficial in boosting the immune system in fighting cancer.

Unlike traditional pharmaceuticals, complementary and alternative therapies are not evaluated by the United States Food and Drug Administration (FDA) for either safety or effectiveness. These therapies may have interactions with traditional pharmaceuticals. Patients should be wary of "miracle cures" and notify their doctors if they are using herbal remedies, vitamin supplements or other unprescribed treatments. Alternative and experimental treatments normally are not covered by insurance.

Prognosis

Cure rates and survival rates can predict group outcomes, but can never precisely predict the outcome for a single individual. However, the earlier laryngeal cancer is discovered and treated, the more likely it will be cured.

Cancers found in stage 0 and stage 1 have a 75% to 95% cure rate depending on the site. Late stage cancers that have metastasized have a very poor survival rate, with intermediate stages falling somewhere in between. People who have had laryngeal cancer are at greatest risk for recurrence (having cancer come back), especially in the head and neck, during the first two to three years after treatment. Check-ups during the first year are needed every other month, and four times a year during the second year. It is rare for laryngeal cancer to recur after five years of being cancer-free.

Prevention

By far, the most effective way to prevent laryngeal cancer is not to smoke. Smokers who quit smoking also significantly decrease their risk of developing the disease. Other ways to prevent laryngeal cancer include limiting the use of alcohol, eating a well-balanced diet, seeking treatment for prolonged heartburn, and avoiding inhaling asbestos and chemical fumes.

Resources

Periodicals

Ahmad, I., B. N. Kumar, K. Radford, J. O'Connell, and A. J. Batch. "Surgical Voice Restoration Following Ablative Surgery for Laryngeal and Hypopharyngeal Carcinoma." Journal or Laryngology and Otolaryngology 114 (July 2000): 522-5.

Organizations

American Cancer Society. 1599 Clifton Rd. NE, Atlanta, GA 30329. 800 (ACS)-2345. http://www.cancer.org.

National Cancer Institute. Cancer Information Service. Bldg. 31, Room 10A19, 9000 Rockville Pike, Bethesda, MD 20892. (800) 4-CANCER. 〈http://www.nci.nih.gov/cancerinfo/index.html〉.

National Cancer Institute Office of Cancer Complementary and Alternative Medicine. http://occam.nci.nih.gov.

National Center for Complementary and Alternative Medicine. P. O. Box 8218, Silver Spring, MD 20907-8281. (888) 644-6226. http://nccam.nih.gov.

Other

"Laryngeal Cancer." CancerNet. July 19, 2001. 〈http://www.graylab.ac.uk/cancernet/201519.html#3_STAGEEXPLANATION〉.

"What you Need to Know About Cancer of the Larynx." CancerNet November 2000. [cited July 19, 2001]. http://www.cancernet.nci.nih.gov.

Key terms

Dysplasia — The abnormal change in size, shape or organization of adult cells.

Lymph — Clear, slightly yellow fluid carried by a network of thin tubes to every part of the body. Cells that fight infection are carried in the lymph.

Lymph nodes — Small, bean-shaped collections of tissue found in a lymph vessel. They produce cells and proteins that fight infection, and also filter lymph. Nodes are sometimes called lymph glands.

Lymphatic system — Primary defense against infection in the body. The lymphatic system consists of tissues, organs, and channels (similar to veins) that produce, store, and transport lymph and white blood cells to fight infection.

Malignant — Cancerous. Cells tend to reproduce without normal controls on growth and form tumors or invade other tissues.

Metastasize — Spread of cells from the original site of the cancer to other parts of the body where secondary tumors are formed.

laryngeal cancer

Etymology: Gk, larynx + L, cancer, crab

a malignant neoplastic disease characterized by a tumor arising from the epithelium of the structures of the larynx. Laryngeal tumors are more common in men than in women and occur most frequently between 50 and 70 years of age. Chronic alcoholism and heavy use of tobacco increase the risk of developing the cancer. Persistent hoarseness is usually the first sign. Advanced lesions may cause a sore throat, dyspnea, dysphagia, and cervical adenopathy. Diagnostic measures include direct laryngoscopy, biopsy, MRI, and radiological examination, including tomographic studies and chest films. Malignant tumors of the larynx are usually epidermoid carcinomas. Radiation is generally recommended for small lesions. Total laryngectomy, often combined with radiotherapy, is indicated for extensive lesions. Chemotherapy may be used to try to spare the larynx. After the operation many persons with laryngectomies learn esophageal speech. Some use an electric larynx, and a few undergo surgical reconstruction. See also laryngectomy.

Squamous cell carcinoma of the larynx

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

Stage I The cancer is confined to site of initial lesion; the definition of stages I & II depends on where the cancer started

• Supraglottis CA is only in one area of the supraglottis; the vocal cords can move normally

• Glottis CA is only in the vocal cords; the vocal cords move normally

• Subglottis CA is confined to the subglottis

Stage II CA is confined to the larynx and has not spread to lymph nodes in the area or to other parts of the body

• Supraglottis The cancer is in > one area of the supraglottis; the vocal cords can move normally.

• Glottis CA has spread to supraglottis and/or subglottis; the vocal cords may/may not be able to move normally

• Subglottis The cancer has spread to the vocal cords, which may/may not be able to move normally

Stage III CA is confined to the larynx, but vocal cords are fixed or CA has spread to perilaryngeal tissues; or CA has spread to one lymph node on the same side of the neck as original tumor, and measures ≤ 3 cms

Stage IV CA has spread to tissues around the larynx, eg, pharynx or perilaryngeal tissues; regional lymph nodes in the area may/may not contain cancer; or, the cancer has spread to > 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 measures > 6 cms; or metastasized

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 secretions

Outcomes

Respiratory status: Gas exchange and ventilation; Comfort level; Knowledge: Treatment regimen

Interventions

Airway insertion; Airway management; Airway suctioning; Oral health promotion; Respiratory monitoring; Ventilation assistance

Planning 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.