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%. The American Cancer Society predicts approximately 9880 new cases of laryngeal cancer annually, with approximately 3770 deaths. 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. 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.
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.
Nursing care plan assessment and physical examination
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.
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.
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.
Nursing care plan primary nursing diagnosis: Ineffective airway clearance related to obstruction, swelling, and accumulation of secretions.
Nursing care plan intervention and treatment plan
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. 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 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%.
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 (TEP), 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.
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 alternate 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.
Nursing care plan discharge and home health care 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, which identifies her or him as a mouthbreather. 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.