News

Looking at laryngeal cancer [ - 19.05.2008]

Looking at laryngeal cancer LINDA SCHIECH RN, AOCN, MSN Nursing2007 May 2007 Volume 37 Number 5 Pages 50 - 55

Abstract

Learn how to support your patient through the physical and emotional challenges of diagnosis, treatment, and rehabilitation.



ABOUT 2 MONTHS AGO, Joe Bender, 65, became persistently hoarse. His primary care provider prescribed a 2-week course of oral antibiotics, but the hoarseness didn't improve. Mr. Bender then saw an ear, nose, and throat specialist, who performed a direct laryngoscopy and found a lesion in the glottic portion of his larynx. A biopsy showed invasive squamous cell carcinoma. ( Examining the larynx, part by part provides a look at the structures.)

Laryngeal cancer accounts for about half of all head and neck cancers, which together comprise about 3% of all cancers. 1 The American Cancer Society (ACS) estimates about 11,300 new cases and about 3,660 deaths due to this disease in 2007. 2 The 5-year survival rate is 65%.Squamous cell carcinoma accounts for most larynx cancers. 1,3

Laryngeal cancer takes a heavy physical and emotional toll on the patient. Read on to learn what you can do to help Mr. Bender confront the challenges.

Trouble in the Adam's apple

Located in the neck, the larynx is in the area most people call the Adam's apple. Containing the vocal cords, it produces sound for speaking and protects the airway during swallowingwhile keeping it openfor good airflow during breathing.

Cancer affecting the larynx is almost always a primary tumor, although renal cell cancer sometimes metastasizes to this site. Traditionally striking people in their 60s and 70s with a history of smokingand possibly alcohol abuselaryngeal cancer is beginning to develop more frequently in younger people, many who don't have these risk factors. 1 According to the ACS, cancers of the larynx and hypopharynx (the area of the esophagus next to the larynx) affect men four to five times more commonly than women and African-Americans one and a half times more commonly than whites. 2

Risks and symptoms

The main risk associated with laryngeal cancer is long-term tobacco smoking of any kind. (See Smoking Cessation on page 57 for a teaching tool.) Alcohol use combined with smoking increases the risk.

Hoarseness is commonly the first sign of laryngeal cancer. Other signs and symptoms include persistent ear pain, sore throat, or coughing; pain or difficulty swallowing; difficulty breathing; weight loss; and a lump or mass in the neck. Stridor can occur with late-stage disease.

Mr. Bender reports that he smoked two packs of cigarettes a day for 35 years but quit 10 years ago. He describes his alcohol consumption as social. With his smoking and alcohol history, age, initial symptom of hoarseness, and tumor cell type of squamous cell carcinoma, he fits the classic profile of someone with laryngeal cancer.

Reaching a diagnosis

The standard approach to diagnosis of laryngeal cancer is direct laryngoscopy performed with a fiber-optic scope. Using this technique, the clinician can visualize the tumor site and extension and remove tissue for biopsy.

Computed tomography (CT) or magnetic resonance imaging may be used to determine tumor size and borders and to identify artery, nerve, and bone involvement. A CT scan, which is less costly and provides adequate imaging of cervical lymph nodes, is preferred. Positron emission tomography can be useful to detect disease, but it's more commonly used to stage recurrent cancer. During the diagnostic process, the patient should also have a chest X-ray and CT scans to assess for lung or liver metastasis.

Staging for cancer of the larynx depends on the anatomic area affected, tumor size, whether the vocal cords are fixed or unmovable, lymph node involvement, and distant metastasis. The lymph nodes are the most common sites for metastasis, followed by the lungs, liver, and bone.

Coordinating care

After getting a diagnosis of laryngeal cancer, your patient needs plenty of support, education, and guidance. Depending on the cancer stage, he may be treated with surgery, radiation, chemotherapy, or a combination.

Mr. Bender meets with the surgeon and learns that he needs a total laryngectomy. Pathologic examination of the surgical specimen will determine additional treatment. After scheduling surgery, he meets with the following members of the multidisciplinary team:

* a social worker, to provide emotional support and help him come to terms with risky habits such as smoking and alcohol use
* a clinical nurse specialist, to explain details of his planned treatment
* a speech therapist, who may audiotape his speech, assess his swallowing, and observe him during certain oral and facial exercises
* a dietitian, to discuss nutrition, especially if surgery is planned.
Reviewing surgical options

Surgical procedures for laryngeal cancer depend on the site and stage. A patient with early-stage cancer may have just one vocal cord or all the structures in a certain region removed.

For later cancer stages, the surgeon typically performs a total laryngectomy, removing the true and false vocal cords, epiglottis, hyoid bone, and arytenoid, thyroid, and cricoid cartilages. He creates two new passageways: one through the mouth into the pharynx and esophagus for eating; the other, a permanent stoma for breathing created by suturing the trachea to the neck. If the tumor involves the subglottic larynx, the cancer has probably spread, so total thyroidectomy and lymph node dissection in the paratracheal area are normally required too.

Caring for your patient after surgery

After a total laryngectomy, the patient will recover in the hospital for 6 to 12 days. Mr. Bender has a nasogastric feeding tube and drains on either side of the supraclavicular area of his neck. A surgically created airway stoma is sutured to the front of his neck with a silicone tube inserted to prevent shrinkage during healing. He spends the first 24 hours after surgery in the intensive care unit, then he's transferred to a unit where specially trained nurses care for patients after head and neck surgery.

Perform these nursing measures:

* Frequently assess his level of consciousness, vital signs, and airway patency.
* Keep him N.P.O. for the first 7 to 10 days after surgery and administer enteral nutrition as ordered.
* Perform frequent stoma care, including suctioning and removing the stoma tube for adequate cleaning. (Get details in Caring for your patient and his stoma. )Teach the patient and his family how to care for the stoma and give them appropriate printed materials to take home.
* Perform tracheostomy care if appropriate. If your patient has had a hemilaryngectomy , the tube will probably be removed shortly after surgery if he's swallowing safely. If he's had a supraglottic laryngectomy, he has a strong potential for aspiration and will probably be discharged with tracheostomy and feeding tubes. Teach him and his family how to care for them.
* Monitor for hematoma formation at the surgical site and assess the drainage.
* Monitor for signs and symptoms of possible withdrawal from habits he may have continued until surgery (such as smoking and alcohol abuse) and contact the social worker or a psychiatrist for consultation if appropriate.
* Help him communicate his needs. Explain that a speech therapist will begin working with him to aid vocalization.
* Ambulate him early and aggressively to prevent atelectasis, pneumonia, and venous thromboembolism.
* Teach him and his family how to care for his incision. If he's had a total thyroidectomy, teach them that he has a risk of hypocalcemia and make sure that they know the signs and symptoms to report, such as numbness and tingling around his mouth, fingers, and toes; muscle cramps or spasms; irritable mood or personality changes; and seizures.
On the road to rehabilitation

Regardless of the type of surgery a patient undergoes for laryngeal cancer, he may need speech rehabilitation to learn how to swallow safely or new ways of communicating. He also may require postoperative radiation to the lymph nodes in his neck if his risk of metastasis is high.

Leakage at the anastomosis between the pharynx and the top of the esophagus is possible after total laryngectomy. When a leak is present, taking clear liquids by mouth and increasing the patient's diet changes the supraclavicular drainage from serosanguineous to cloudy tan or gray. This problem is more likely if he's had previous radiation therapy, which affects healing.

After 10 days, Mr. Bender undergoes a swallowing test and no signs of leakage are found. If leakage were present, he'd be kept N.P.O. and continue nasogastric feedings until the anastomosis healed.

At discharge after total laryngectomy, a patient who's passed the swallowing test and progressed is typically eating a mechanical soft diet and communicating using an artificial larynx. Tell him he'll need a medical-alert bracelet explaining that he's a neck breather, that he should never swim, and that he should cover his stoma with a stoma shield or plastic-backed baby bib while showering to keep water out.

Radiation for some

A patient with an early-stage laryngeal cancer may undergo radiation therapy for cure, and radiation is also used as primary treatment if a patient can't tolerate surgery because of age, poor physical condition, or a comorbid condition. Although primary radiation preserves the vocal cords, it's less effective when the vocal cords are immobile at diagnosis.

Radiation also may be used postoperatively. Mr. Bender's pathology report indicates 3 positive lymph nodes out of 25 on the right side of his neck. His oncologist encourages radiation treatment.

Radiation therapy for laryngeal cancer has these disadvantages:

* The patient must undergo daily treatments for up to 6 weeks.
* Radiation-induced fibrosis of the skin and subcutaneous tissues can cause long-term swallowing and speaking difficulties.
* Radiation therapy may fail, and he may need surgery anyway. Because of the delay, the surgery could be more extensive.

A newer technique, intensity-modulated radiation therapy (IMRT), delivers precise radiation doses to the tumor or specific areas within it. Sparing normal tissues as much as possible, IMRT helps minimize some adverse reactions.

Responding to radiation's adverse effects

Perform these measures if your patient is undergoing radiation therapy:

* Assess his neck for signs of skin desquamation, including redness, edema, and soreness. If the site is dry or early stages of moist desquamation are present, any water-based emollient cream that isn't radiosensitive (such as Aquaphorpetrolatum ointment) can help manage the signs and symptoms. For later stages of moist desquamation, the radiation oncologist may order different treatments because added moisture can be detrimental.
* Monitor for neck edema, which could compromise breathing. Some patients require emergency treatment, such as a temporary tracheotomy, when edema is severe.
* Assess him for weight loss and dehydration due to swallowing difficulty caused by edema and soreness. He may need a temporary feeding tube.
* Help him manage chronic dry mouth, which may develop if the radiation field involves the salivary glands. Administering the radioprotective agent amifostine before each treatment session helps decrease damage to the salivary glands, and oral pilocarpine can help increase saliva production. Teach your patient to use water and other fluids to help him swallow food and to keep his mouth moist.
* Assess him for trismus, a long-term effect of radiotherapy that prevents fully opening the mouth because of hardened mastication muscles. A speech therapist can teach him exercises to help him open his mouth as fully as possible.
Chemotherapy in combination

Chemotherapy alone isn't very beneficial to treat laryngeal cancer, but treatment with cisplatin and 5-fluorouracil (5-FU) before (neoadjuvant) and after (adjuvant) surgery or radiation has achieved a very good response. In patients who can't undergo surgery, chemotherapy administered in conjunction with radiation has reduced tumor size and improved 3-year survival up to 50%. However, the disease eventually may recur or the patient may get a new primary upper airway tumor after therapy. 5

Because surgery for head and neck cancers can take a drastic toll on body image, researchers have been trying to achieve success similar to that of surgery and radiation with combined chemotherapy and radiation.

Recently, researchers have been using chemotherapy with cetuximab (a monoclonal antibody against the epidermal growth factor receptor) with radiation therapy. Compared with radiotherapy alone, this combination markedly improved local tumor control plus overall and progression-free survival while causing fewer long-term adverse reactions.

Managing chemotherapy's adverse effects

Here's what you can do to help a patient undergoing chemotherapy:

* Monitor for potential adverse reactions and teach him how to manage them. Stress the importance of hydration with intravenous fluids and encourage him to drink six to eight glasses of liquids a day (unless contraindicated) to protect his kidneys against cisplatin's renal toxic effects. Explain the available treatments for nausea and vomiting.
* Cisplatin may cause neuropathies of the hands and feet, so detail how he can protect himself. For example, teach him to inspect his feet daily, to always wear shoes, and to have a podiatrist perform routine foot care such as cutting his nails.
* Advise rinsing his mouth with salt water and baking soda to help prevent and soothe mouth sores.
* Therapy will cause his white blood cell count to drop, so teach him how to prevent and recognize infection.
* Explain that 5-FU frequently causes diarrhea and, in rare cases, severe chest pain. Tell him to call 911 if he has chest pain and to notify the oncologist if he develops diarrhea.

For some patients, cetuximab may be included in the chemotherapy regimen. A common adverse reaction during the infusion consists of bronchospasm, hypotension, and flushing. If your patient develops this reaction, the infusion must be stopped and not restarted.

Getting back to everyday living

Surgery and other treatments for laryngeal cancer can pose physical and emotional challenges to your patient. As he returns to everyday living, he may need help learning new speech methods, restoring muscle strength after surgery, and adapting to his altered body image.

Speech. Your patient's most intensive rehabilitation will be with a speech therapist who has expertise in treating patients with head and neck cancer. Mr. Bender, who's had a total laryngectomy, will learn new speaking techniques and may continue speech therapy for months. See Speaking without a larynx to review his options.

A patient who's had a supraglottic laryngectomy has a strong risk of aspiration and needs to learn swallowing techniques to decrease the risk. But even a patient who hasn't undergone laryngectomy needs speech therapy. For example, if he's received radiation, he'll need to learn techniques to assist with swallowing and to prevent or rehabilitate trismus.

Muscle rehabilitation. A neck dissection affects the arm and shoulder muscles. A physical therapist will teach your patient exercises to restore strength and range of motion to these muscles.

Self-image. Surgery can take a heavy toll on Mr. Bender's self-image. As he learns to deal with disfigurement and to communicate with a different-sounding voice, he may fear social situations. He needs emotional support to adapt to these changes and continue functioning in society. He can get support by working with a social worker or joining a support group for laryngectomees.Some patients are self-conscious about their stoma during lovemaking. Teach him to use a stoma cover, high-necked shirt, or scarf during intimate periods and when he's out in public.

Looking ahead

Having undergone a total laryngectomy and right-sided neck dissection, Mr. Bender has started speaking with an artificial larynx. Thanks to your postoperative care and teaching, he and his family are caring for his stoma at home and he's looking forward to having a tracheoesophageal prosthesis implanted in about 6 months.

Examining the larynx, part by part

The larynx is 1.5 to 2 inches (3.8 to 5 cm) long. It lies in the anterior neck in front of the esophagus at the level of the 4th to 6th cervical vertebrae. Lined with mucous membranes, it has three main sections consisting of cartilage, ligaments, and muscles.


Graphic
Figure. No caption available.
Caring for your patient and his stoma

Explain to your patient that his stoma opens directly into his main airway and lungs so he can breathe. It'll never completely close, but the opening could shrink during healing, so a tube was inserted to keep it as large as possible. The tube will remain for 1 to 6 months, held in place by a hook-and-loop fastener, until the swelling goes down.

Tell him that the stoma produces mucus and he should cough it out to clear his airway. As you care for his stoma, teach him and his family what to do at home:

* Remove the tube every 4 to 6 hours or more often as needed for cleaning. It can remain out for 30 to 60 minutes. Clean it with warm water and a tracheostomy brush or bottle brush. Use diluted hydrogen peroxide to remove hardened mucus, then rinse with 0.9% sodium chloride solution or tap water.
* While the tube is out, clean the stoma and skin around it with soap and water and a soft cloth or gauze. Carefully remove dried-on mucus. Prevent water and soap from entering the stoma and apply a protective barrier cream to shield the skin from irritation by dried-on mucus.
* Teach your patient and his family how to suction his stoma and how to manage secretions . Mucus increases after surgery because filtration in the lungs is lacking. The patient may go home with portable suctioning equipment to clear large amounts of mucus produced during sleep. He'll probably use mechanical suctioning for about 3 months until he learns to manage secretions without it.
* Teach him to humidify secretions , a very important measure because the stoma bypasses natural humidification in the nose and mouth. A stoma cover will help humidify his airway and keep out foreign objects such as insects and dust. A bedside humidifier at home will help keep his secretions moist.
Speaking without a larynx

After laryngectomy, your patient has these options:

Artificial larynx (electrolarynx). He can learn this technique immediately after surgery. When edema is still present, he places a strawlike extension in the corner of his mouth, presses a button on the battery-operated device, and moves his mouth and tongue to make a vibrating sound to form words. Patients typically dislike having to hold the equipment and the mechanical sound, so he may need encouragement. When the edema decreases, he can remove the strawlike extension and place the device directly against his neck or cheek to form words.

Esophageal speech. With a great deal of speech therapy, the patient learns to inject a bolus of air into the esophagus and release it while forming words. Usually, postoperative swelling has decreased and the patient is swallowing foods before using this method. Not everyone can master esophageal speech, which sounds like a cross between hoarseness and a burp.

Tracheoesophageal prosthesis. This requires a separate surgical procedure at the time of the original surgery or later. The surgeon punctures a hole in the patient's stoma through to the esophagus, then places a valve in the hole. The patient learns to produce a hoarse-sounding voice by placing his finger over the end of the valve and passing air from his lungs through the valve while forming words. The valve requires daily care and generally must be replaced every 2 to 6 months.

REFERENCES

1. Carr E. Nursing care of the client with head and neck cancer. In Itano JK, Taoka KN (eds), Core Curriculum for Oncology Nursing, 4th edition . St. Louis, Mo., Elsevier/Saunders, 2005. [Context Link]

2. American Cancer Society: All about laryngeal and hypopharyngeal cancer. http://www.cancer.org/docroot/CRI/CRI_2x.asp?sitearea=&dt=23 . Accessed January 18, 2007. [Context Link]

3. Mendenhall WM, et al. Management of head and neck cancers. In DeVita VT, et al. (eds), Cancer: Principles and Practice of Oncology, 7th edition. Philadelphia, Pa., Lippincott Williams & Wilkins, 2005. [Context Link]

4. Mojica-Manosa P, et al. Larynx squamous cell carcinoma: Concepts and future directions. Surgical Oncology Clinics of North America. 13(1):99112, January 2004.

5. Myers EN, et al. (eds). Cancer of the Head and Neck, 4th edition . Philadelphia, Pa., W.B. Saunders Co., 2004. [Context Link]

resources

Bonner JA, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. The New England Journal of Medicine. 354(6):567578, February 9, 2006.

Clarke LK, Dropkin MJ (eds). Head and Neck Cancer. Pittsburgh, Pa., ONS Publishing, 2005.

National Comprehensive Cancer Network. Clinical Practice Guidelines in Oncology (May 23, 2006): Head and Neck Cancers. Version 1.2006. http://www.nccn.org/professionals/physician_gls/PDF/head-and-neck.pdf . Accessed August 4, 2006.

Papadas T, et al. Rehabilitation after laryngectomy: A practical approach and guidelines for patients. Journal of Cancer Education . 17(1):3739, Spring 2002.

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