CANCER OF LARYNX AND ITS DETAILED MANAGEMENT

Cancer of the larynx is a malignant tumour in and around the larynx (voice box). Squamous centre carcinoma is the most common form of cancer of the larynx (95%).
Cancer of the larynx occurs more frequently in men than in women, and it is most common in people between the ages of 50 to 70 years of age.
It accounts for approximately half of all head and neck cancers. Almost of all malignant tumours of the larynx arise from the surface epithelium and are classified as squamous cell carcinoma.
It is an organ that provides a protective sphincter at the inlet of the air passage and is responsible for voice production.
It extends from the tongue to the trachea (from the level of the upper border of the epiglottis to the level of the 6th vertebra).
Above :- Continous with pharynx
Below :- Continous with trachea
Anteriorly :- Covered by skin, superficial facia, deep fascia and infrahyoid muscles.
On each side :- to the thyroid lobe.
Maintain an open passageway for air movement (thyroid and cricoid cartilages)
Epiglotis and vestibular folds prevent swallowed material from moving into larynx.
vocal folds are primary source of sound production.Greater amplitude of vibration.
The Pseudostratified ciliated columnar epithelium traps debris, preventing their entry into the lower respiratory tract.
Respiration

fixation of chest
Helps in promoting venous return
Aspiration on swallowing
Sore throat
Foreign body sansation
Dysphagia
Neck mass
Dyspnea
Pain in the throat reffered to the ear
Hoarseness of voice
Persistent cough
Sore throat
Thorat pain
Throat burning (when consuming hot liquids or citrus fruits juices)
Lump fekt in the neck
Dysphagia
Dyspnea
Unilateral nasal obstruction
Nasal discharge
Foul breathing
MEDICAL MANAGEMENT
Chemotherapy
- For patients with more advanced disease
- Cisplatin based chemo with radation is used.
- 5 flurouresil also used
Radiation therapy
- Goal of radiation is destroy cancer cells and preserve the function of the larynx
- It can be used pre operatively and post operatively
- It is combined with surgery in advanced conditions as adjuvant therapy.

Vocal cord strapping
Stripping of vocal cord is used to treat dysphagia, hyperkerotosis and leukoplagia.
the procedure involves removal of the mucosa of the edge of the vocal cord, is by using an operating microscope.
surgical removal of the vocal cord, is usually performed via transoral laser.
Laser surgery
When the tumour size is of small tumour are eradicated with the used of uaser. Microelectrodes of small tuours of the lungs.
Partial laryngectomy
A partial laryngectomy is often used smaller cancers of larynx. It is recommended in the early stage of cancer in thr glotis area when only one vocal cord is involved.
In this prition is removed along with the vocal cord and the tumor, all other structure remain.
In total laryngectomy, the laryngeal structure are removed, including the hyoid bone, epiglotis, cricoids ca

1. CANCER LARYNX SUBMITTED BY SATHEAHWARI N MSC N II YR

2. INTRODUCTION Cancer of the larynx is a malignant tumour in and around the larynx (voice box). Squamous centre carcinoma is the most common form of cancer of the larynx (95%). Cancer of the larynx occurs more frequently in men than in women, and it is most common in people between the ages of 50 to 70 years of age. It accounts for approximately half of all head and neck cancers. Almost of all malignant tumours of the larynx arise from the surface epithelium and are classified as squamous cell carcinoma.

3. LARYNX It is an organ that provides a protective sphincter at the inlet of the air passage and is responsible for voice production. It extends from the tongue to the trachea (from the level of the upper border of the epiglottis to the level of the 6th vertebra).

4. RELATIONS Above :- Continous with pharynx Below :- Continous with trachea Anteriorly :- Covered by skin, superficial facia, deep fascia and infrahyoid muscles. On each side :- to the thyroid lobe.

5. STRUCTURE

6. CARTILAGE FRAMEWORK OF THE LARYNX Three large unpaired cartilages Thyroid Cricoid Epiglotis Three small paired cartilages Arytenoid Corniculate Cuneiform

7. FUNCTIONS OF LARYNX Maintain an open passageway for air movement (thyroid and cricoid cartilages) Epiglottis and vestibular folds prevent swallowed material from moving into larynx. vocal folds are primary source of sound production. Greater amplitude of vibration. The Pseudostratified ciliated columnar epithelium traps debris, preventing their entry into the lower respiratory tract. Respiration fixation of chest Helps in promoting venous return

8. Voice Production

9. DEFINITION

10. CLASSIFICATION CANCER LARYNX Cancer of glotis Subclotic structure Supra glotic Region ( True vocal ( below the vocal cords ) cords)

11. CAUSES AND RISK FACTORS

12. PATHOPHYSIOLOGY

13. CLINICAL MANIFESTATIONS Depends on the site of tumour

14. SUPRAGLOTIC TUMOUR Aspiration on swallowing Sore throat Foreign body sensation Dysphagia Neck mass Dyspnoea Pain in the throat referred to the ear

15. SUBGLOTTIC Airway obstruction Dysphagia Weight loss Hemoptysis

16. OTHER SYMPTOMS Hoarseness of voice Persistent cough Sore throat Throat pain Throat burning (when consuming hot liquids or citrus fruits juices) Lump felt in the neck Dysphagia Dyspnoea Unilateral nasal obstruction Nasal discharge Foul breathing

17. DIAGNOSTIC EVALUATION

18. MANAGEMENT MEDICAL MANAGEMENT Chemotherapy - For patients with more advanced disease - Cisplatin based chemo with radiation is used. - 5 fluorouracil also used

19. Radiation therapy - Goal of radiation is destroy cancer cells and preserve the function of the larynx - It can be used pre operatively and post operatively - It is combined with surgery in advanced conditions as adjuvant therapy.

20. SURGICAL MANAGEMENT Vocal cord strapping Stripping of vocal cord is used to treat dysphagia, hyperkerotosis and leukoplagia . the procedure involves removal of the mucosa of the edge of the vocal cord, is by using an operating microscope.

21. Cordectomy surgical removal of the vocal cord, is usually performed via transoral laser. Laser surgery When the tumour size is of small tumour are eradicated with the used of user. Microelectrodes of small tumours of the lungs. Partial laryngectomy A partial laryngectomy is often used smaller cancers of larynx. It is recommended in the early stage of cancer in the glottis area when only one vocal cord is involved. In this portion is removed along with the vocal cord and the tumour, all other structure remain.

22. Total laryngectomy In total laryngectomy, the laryngeal structure are removed, including the hyoid bone, epiglottis, cricoid cartilage and 2 or 3 rings of trachea. it results in permanent loss of the voice and change in the airway, requiring a permanent tracheostomy.

23. NURSING MANAGEMENT PRE-OPERATIVE Risk of aspiration related to cancer larynx and excessive secretions Ineffective airway clearance related to increased tracheo branchial secretions Risk of impaired gas exchange related to airway blockage secondary to tumour Imblanced nutrition less than body requirement related to dysphagia

24. Post operative Acute pain related to surgical incision Ineffective airway pattern related to tracheo branchial secretions Fluid volume deficit related to nil per ora status Imbalanced nutrition less than body requirement related to less oral intake ineffective communication pattern related to surgical removal of vocal cord and loss of voice. Risk for aspiration related to surgical procedure

25. Anxiety related to diagnosis ( disease condition and surgery) Deficit knowledge about surgical procedure Body image disturbance related to surgical corrections and tracheostomy Self care deficit related to pain and weakness

26. SWALLOWING TECHNIQUE AFTER A PARTIAL LARYNGECTOMY Being with soft or semi solid foods. Stay with a nurse or swallowing therapist during meals until you master the technique of swallowing without choking. Be patient, learning to swallow again frustrating. Follow these steps in squence Take a deep breathe Bear down to close the vocal cords Place food into your mouth

27. Swallow Cough to rid the closed cord of accumulated food particles Swallow cough Breathe

28. NURSING CARE AFTER LARYNGECTOMY NUTRITION Immediately after surgery, the client’s nutrition is supplemented with tube feedings. The client contious to receive tube feedings until edema has subcided and suture line healing ha occured. When the client can swallow saliva, oral feedings can begin. The client usually begins with liquid or semi-solid foods and progresses as healing occurs.

29. COMMUNICATION For the first days after surgery, the client should communicate by writing. Even though cannot speak, conversation should still include the client’s input through noddding and pointing and not to be directed only to others, such as the family. Avoiding conversation or excessive talking with client because of difficulty in communication is demeaning to the client and leads to frustration.

30. ARTIFICIAL LARYNX An artificial larynx may be used asearly 3 to 4 days after surgery. These battery operated speech devices are held alongside the neck or can be adapted with a plastic tube that is inserted with a plastic tube that is inserted into the mouth. The air inside the mouth is vibrated and the client articulates as usual. The speech quality is monitone amd mechanical soulding but intelligeible.

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32. ESOPHAGEAL SPEECH Esophageal speech is a technique that requires the client to swallow and hold the air in the upper esophagus. By Controlling the flow of air, the client cannpronounce as many as 6 to 10 words before stopping to allow more air. The voice is deep but is one and effective the technique is mastered.

33. TRACHEO ESOPHAGEAL PUNCTURE It is a technique that also restores speech. A small puncture is made into upper tracheo stoma to the cervical esophagus for creation of a fistula. After fistula tract has healed, a small one way valve, or voice prosthesis is inserted. By occlusion of the prothesis, air can be stunted into the esophagus and used to produce speech. The TEP may be done concurrently with total laryngectomy.

34. SPEECH THERAPY To plan post operative communication strageiesnand speech therapy, the speech therapist or pathologist conduct a pre- operative evaluation. During this time, the nurse discussess with the patient and family about methods of communication that will be available in the immediate post- operative period. These include writing, lip, speaking and reading and communication or word boards. In addition, a long term post perative communication plan for a laryngeal communiction is developed. The inpatient common techniques of alaryngeal communication are elcetrodes esophageal speech and tracheo esophageal puncture.

35. COMPLICATIONS Respiratory distress ( hypoxia, airway obstruction) Haemorrhage Infection Wound breakdown Aspiration Dehydration