Upper Airway Problems: Laryngeal Cancer Flashcards
Head & Neck Cancer
Throat cancer includes cancer of the nasopharynx, oropharynx, and hypopharynx
Cancer of the larynx may also be included as a type of throat cancer; most throat cancers are squamous cell carcinomas (aka pharyngeal cancer)
Review of the Larynx
- Airway protection
- Phonation
- Respiration
Cancer of the Larynx
Categories
Supraglottic: false vocal cords above vocal cords
Glottic: true vocal cords
Subglottic: below vocal cords
- Head & neck cancers are usually squamous cell carcinoma & slow-growing & curable when treated early
- Prognosis for more advanced dz depends on the extent & location; left untreated, fatal within 2 yrs
Etiology
- Smoking/tobacco use
- Alcohol (moderate or heavy)
- Both smoking & alcohol use
- Voice abuse
- HPV infection of the throat for some throat cancers like the tonsils & hypopharynx but very rarely a factor in laryngeal cancer
- Chronic laryngitis
- Poor oral hygiene
- Nutritional deficiencies
- Workplace exposures
- Genetic mutations
Clinical Manifestations
- Lumps in mouth, throat, neck that don’t go away
- Difficulty swallowing
- Color changes in mouth or tongue
- Oral lesion or sore that does not heal in 2 wks
- Persistent, unilateral ear pain
- Persistent/unexplained oral bleeding
- Numbness of mouth, lips, or face
- Change in fit of dentures
- Hoarseness or change in voice quality
- Persistent/recurrent sore throat
- SOB
- Anorexia & wt loss
- Burning sensation when drinking citrus or hot liquids
Diagnostics
- History & assessment
- Identification of risk factors (chronic ETOH will have low protein & albumin lvls from poor nutrition)
- Labs (CBC/PT/INR/PTT/UA/chem/LFT’s)
- Laryngoscopy, bronchoscopy, esophagoscopy
- Biopsy
- Imaging
Medical Management
Staging, location, size, cervical node involvement
- Radiation therapy
- Surgery
- Radiation therapy & surgery
- Radiation therapy & chemotherapy [used alone or w/radiation (regimens include cisplatin)]
Supra & subglottic regions are often managed w/radiation therapy w/generally satisfactory results
- B/c of their higher tendency to spread, the cure rates aren’t quite as high as for glottic tumors
- Over 80% of early tumors can be cured by radiation therapy alone
s/e’s
- Necrosis
- Edema
- Fibrosis
- Ulceration
- Pain
- Xerostomia (loss of saliva when salivary glands are irradiated)
- Loss of taste
- Dysphagia
- Biotherapy, a form of chemo (epidermal growth factor receptor inhibitors [EGFRIs], may be used if the tumor over-expresses the receptor)
> cetuximab [Erbitux] - Laser surgery may be used for small/early staged cancers, h/e, it’s rare that they’re found & dx’d this early; most need extensive surgery & reconstruction
Surgical Management
A hemi-laryngectomy and supraglottic laryngectomy are types of partial voice conservation laryngectomies
- To protect the airway, a trach is needed; a partial trach may be temporary
- Airway and swallowing remain intact
Overall Goal
Minimize effects on breathing, speech, & swallowing while maximizing cure
With ___ ___, the airway is separated from the throat & esophagus & a permanent laryngectomy stoma in the neck is created
! permanent loss of voice & change in airway
total laryngectomy
With ___ ___, a surgeon removes the top portion of the larynx from the false vocal cords to the epiglottis & part of the base of the tongue
supraglottic laryngectomy
The biggest post-op risk is ___ → epiglottis is removed & can’t close over/protect; larynx is gone
- Pt has a trach & then needs to relearn supraglottic swallowing
aspiration
With neck dissection, they remove the lymph nodes, sternocleidomastoid muscle, jugular vein, 11th cranial nerve (works to move head & muscles around head/neck/shoulders), & surrounding tissue
Shoulder drop is expected after extensive surgery & PT can help the drop by learning to use other muscles
Preoperative Teaching
- Psychosocial assessment
- Sobriety & nutritional status (smokers & heavy alcohol users have poor dentition)
- Good oral hygiene practices
- Shave beard
- Discuss post-op procedures (e.g., suctioning, NG tube feeding, & laryngectomy tube care) & their effects (e.g., breathing through the neck, speech alteration)
- Discuss functional losses
- Speech therapy/post-op communication method
- Support services
Surgical Procedures for Laryngeal ca & their effect on voice quality
- Voice quality may change or pt will be hoarse
- Give IV fluids & usually tube feedings for the first 2 days >surgery, then resume oral fluids
- Keep the tracheostomy tube (inserted during surgery) in place until tissue edema subsides
- Make sure pt doesn’t use their voice until MD gives permission (usually 2-3 days post-op), then caution pt to whisper until heals completely
Partial Vertical Laryngectomy (Hemilaryngectomy)
Radical neck incision w/drains
Changes in Airflow w/Total Laryngectomy
Supraglottic Swallowing
- Take a deep breath & hold it
- Put a small bit of food @ the back of your tongue
- Swallow
- Do not breathe in! Cough forcefully, and then begin breathing again
Avoid inhaling before coughing so the food does not enter your lungs. The cough helps clear out the food off your airway
TEP Voice Prosthesis (Tracheoesophageal Puncture)
Might be used if the esophageal speech is ineffective & it pt meets strict criteria
Potential for Aspiration
- Keep HOB elevated during & after tube feedings
- Check gastric residual when administering tube feedings
- When pt begins oral feeding, maintain upright bed position during & after feedings
- Swallowing maneuvers to prevent aspiration
- Use of thickened liquids
