Oto-rhino-laryngological Nursing_2504_Ca Larynx_Std

• Prevent infection
• Promote healing
• Detect complications early

Specific actions include:

1. Daily dressing (and as necessary)
2. Check for signs of infection (redness, swelling, discharge, foul odour)
3. Document wound appearance
4. Monitor for signs of pharyngocutaneous fistula (saliva leakage from wound)
5. Maintain aseptic technique during dressing
6. Ensure humidification to prevent crust
7. Prevent tension by supporting the neck during movement to avoid stress on sutures and avoiding pressure on the flap.

To prevent fluid accumulation and reduce the risk of infection.

Closed suction drains such as Jackson-Pratt or Hemovac are commonly used.

Ensure that the drain tubing is not kinked or blocked.

Drainage volume and characteristics should be recorded daily, with normal characteristics being serosanguinous.

Suction force should be maintained by compressing the reservoir after emptying.

Signs include a sudden increase in drainage indicating possible bleeding and milky drainage indicating a chyle leak.

Patients experience visible changes such as a neck stoma and scars, along with the loss of natural voice. Emotionally, they may face anxiety, depression, and social withdrawal.

The key components include:

1. Pharynx: Divided into nasopharynx, oropharynx, and laryngopharynx; involved in both respiratory and digestive systems.
2. Larynx: Contains vocal cords; responsible for sound production and protecting the airway during swallowing.
3. Trachea: A tube that connects the larynx to the bronchi; lined with ciliated mucosa to trap particles and facilitate airflow.

Clinical features of laryngeal carcinoma may include:

• Hoarseness: Persistent change in voice.
• Sore throat: Unexplained and persistent.
• Difficulty swallowing: Dysphagia.
• Lump in the neck: Enlarged lymph nodes.

Assessment techniques include:

• Physical examination: Inspection of the throat and neck.
• Laryngoscopy: Direct visualization of the larynx.
• Imaging studies: CT or MRI for staging.

Therapeutic management strategies include:

1. Surgery: Options range from partial laryngectomy to total laryngectomy.
2. Radiotherapy: Often used as a primary treatment or adjuvantly post-surgery.
3. Chemotherapy: May be used in advanced cases or in combination with other treatments.
4. Targeted therapy: Focused on specific molecular targets in cancer cells.

An integrative nursing care plan should include:

1. Assessment: Comprehensive evaluation of physical, emotional, and social needs.
2. Goals: Establish clear, measurable goals for patient outcomes.
3. Interventions: Multidisciplinary approaches including pain management, nutritional support, and psychological counseling.
4. Evaluation: Regularly assess the effectiveness of the care plan and make necessary adjustments.

The pharynx is divided into three parts: nasopharynx, oropharynx, and laryngopharynx.

The pharynx serves multiple functions including:

1. Air passage for respiration
2. Food passage for digestion
3. Swallowing
4. Speech
5. Immune defense against pathogens.

The pharynx is a muscular tube measuring 12-14 cm in length, located behind the nasal and oral cavities, extending from the skull base to the C6 vertebra.

The primary functions of the larynx include:

1. Air passage: Allows air to travel to and from the trachea.
2. Phonation: Houses the vocal cords, enabling sound production.
3. Airway protection: The epiglottis prevents solid material from entering the trachea during swallowing.

The larynx is composed of:

• Cartilage: Forms the walls of the larynx.
• Ciliated mucous membrane: Lines the interior of the larynx, aiding in protection and function.

The larynx contributes to airway protection primarily through the epiglottis, which closes over the trachea during swallowing to prevent food and liquids from entering the airway.

The epiglottis folds back over the glottis, preventing liquid and solid food from entering the respiratory tract.

The thyroid cartilage is enlarged in males to form the bump commonly known as the 'Adam's apple'.

The cricoid cartilage is the only complete cartilaginous ring located below the thyroid cartilage.

The glottis is the opening between the vocal cords in the larynx.

Vocal cords are ligaments controlled by muscular movement to produce sound.

The trachea extends from the cricoid cartilage at C6 to the carina at T4-T5.

The trachea is supported by 16-20 C-shaped rings of cartilage, elastic ligaments, and the trachealis muscle.

The primary functions of the trachea include:

1. Air transport
2. Muco-ciliary clearance
3. Cough reflex

A flexible laryngoscope is used to visualize the pharynx, larynx, and vocal cords for diagnostic evaluation.

A nasal endoscope is used to visualize the nasal cavity, sinuses, and nasopharynx.

The endoscopic view shows:

• Irregular, bulbous growth obscuring normal structures
• Pale color, suggesting neoplastic tissue
• A small opening into the trachea visible through the growth
• Surrounding tissue appears inflamed

Laryngeal cancer is the most common head and neck cancer, accounting for 25% of head and neck cancers and 1% of all cancers.

The male to female ratio for laryngeal cancer is around 4:1.

More than 90% of laryngeal cancers are squamous cell cancers, which originate from the skin of the larynx.

Laryngeal cancers develop in three areas:

1. Supraglottis: 40% (aggressive)
2. Glottis: 59%
3. Subglottis: 1%

The primary risk factors for laryngeal cancer include:

1. Male gender
2. Age: Greater than 65 years old
3. Tobacco use
4. Alcohol abuse
5. Poor nutrition
6. Previous radiation to the neck
7. Exposure to asbestos and other occupational pollutants
8. Race: More common in African Americans and Caucasians

• Hoarseness of voice for more than 2 weeks
• Sore throat or cough
• Pain or difficulty in swallowing
• Pain radiating to the ear
• Difficulty breathing
• A lump or mass in the neck
• Unintentional weight loss
• Stridor (Late stage) – Noisy breathing resulting from narrowing of the airway at or below the larynx

• Identification of risk factors, family history, and underlying medical conditions
• Inspection and palpation of the larynx
• Flexible laryngoscopy to examine the nasal cavity, pharynx, and larynx for possible tumors and vocal cord mobility
• Palpation of the lymph nodes in the neck and thyroid gland for any enlargement

• CT (Computed Tomography)
• MRI (Magnetic Resonance Imaging)
• PET-CT (Positron Emission Tomography-Computed Tomography)

These imaging techniques help evaluate the size of the tumor and check for metastasis, such as lung metastasis.

The purpose of fine-needle aspiration (FNA) biopsy is to obtain samples from any enlarged lymph nodes in the neck to assist in the diagnosis of laryngeal carcinoma.

1. Tumour control: Eliminate or reduce cancer cells.

2. Preserve laryngeal function: Maintain voice, swallowing, and airway whenever possible.

3. Prevent recurrence and metastasis.

4. Improve quality of life through rehabilitation and symptom management.

• Surgery
• Radiotherapy
• Chemotherapy
• Targeted Therapy
• Immunotherapy
• Voice Rehabilitation & Supportive Care

These can be used alone or in combination, depending on stage, location, and patient factors.

The main treatment options for laryngeal cancer include:

1. Surgery
2. Radiation therapy
3. Adjuvant chemo-radiation therapy

The choice depends on the type of cancer, extent of the tumor, location and size, and the patient’s expectations.

TNM staging stands for:

• T: The extent of the main tumor
• N: The spread to nearby lymph nodes
• M: The spread (metastasis) to distant sites

Targeted therapy is more selective and has fewer systemic side effects than traditional chemotherapy drugs.

• Single-modality therapy options include:
  • Radiation or surgical resection
  • For T1 and T2: radiotherapy or surgery alone
  • For small T3: partial laryngectomy
  • For T3 and T4: total laryngectomy

• Chemoradiotherapy aims at:

  • Laryngeal preservation
  • Improving survival rates

• Risks include:

  • Locoregional recurrence

• Treatment options include:

  • Postoperative adjuvant therapy for high recurrent cases
  • Total Laryngectomy + Postoperative radiotherapy (PORT)
  • Postoperative Concurrent CRT for the highest risk cases

Radiotherapy is primarily indicated as a treatment for early-stage (T1–T2) cancers, as well as for adjuvant therapy after surgery and in combination with chemotherapy for advanced disease.

The most common technique used in radiotherapy for laryngeal cancer is External Beam Radiation Therapy.

The main advantage of Radiotherapy (RT) in the treatment of laryngeal carcinoma is organ and voice preservation, particularly in the early stages of the disease.

Common side effects of Radiotherapy (RT) include:

• Skin problems: blistering and peeling
• Hearing problems
• Mouth sores
• Dry mouth
• Trouble swallowing
• Change of taste
• Possible breathing trouble

• Primary treatment: Combined with radiation for advanced stages (e.g., distant metastasis)
• Adjuvant chemotherapy: After surgery
• Neoadjuvant chemotherapy: Before surgery
• Supportive or palliative care: For locally advanced cancer

• Administration routes: IV (intravenous) or PO (oral)
• Common regimens: Cisplatin-based regimens and 5-fluorouracil

• Enhances radiation effect
• Controls micro-metastases

• Nausea & vomiting
• Loss of appetite
• Weight loss
• Mouth sores
• Diarrhoea
• Hair loss
• Nail & skin changes
• Affects the blood-forming cells in the bone marrow

Immunotherapy uses drugs to help the immune system fight cancer.

Immunotherapy is indicated for recurrent or metastatic cases of cancer.

Examples of self-financed drugs include Pembrolizumab and Nivolumab.

A key advantage of immunotherapy is that it boosts the immune system to attack cancer cells.

Common side effects include fatigue and immune-related adverse events such as colitis and dermatitis.

To use drugs that target specific parts of cancer cells, particularly in advanced or recurrent disease, often in combination with radiation or chemotherapy.

Cetuximab, which is an EGFR inhibitor that targets the EGFR protein.

Common side effects include fatigue and an acne-like rash.

Surgical treatment is indicated for early-stage tumours or advanced tumours that are not suitable for organ-preserving therapy.

The techniques include:

1. Endoscopic surgery
2. Partial laryngectomy
3. Total laryngectomy

The advantages include:

• Effective tumour removal
• Partial procedures may preserve voice

Potential side effects include:

• Bleeding
• Infection
• Swallowing difficulty
• Permanent voice changes

The three regions of the larynx are:

1. Supraglottis: Extends from the epiglottis to the vocal cords; involved in protecting the airway during swallowing.
2. Glottis: Contains the vocal cords; opens for breathing and closes for speech/swallowing.
3. Subglottis: Located below the vocal cords; connects to the trachea.

The primary functions of the larynx are:

• Producing sound: It is essential for speech.
• Protecting the lungs: It prevents aspiration during swallowing by closing off the airway.

Removing cancer with a margin of normal tissue is crucial to:

• Prevent recurrence: Ensures that all cancerous cells are excised, reducing the risk of cancer returning.

Early-stage supraglottic cancers.

1. Transoral laser microsurgery (TLM): Uses CO2 laser for precise excision.

2. Transoral robotic surgery (TORS): Utilizes robotic instruments for precision in complex cases.

• Minimally invasive
• No external incision
• Faster recovery
• Better voice preservation

• Bleeding
• Aspiration
• Voice changes

A partial laryngectomy is a surgical procedure that removes part of the larynx while preserving some vocal function. It is indicated for early to moderately advanced laryngeal cancer that is confined to one region.

The techniques used in partial laryngectomy include:

1. Supraglottic laryngectomy: Removes structures above the vocal cords, preserving voice.
2. Hemilaryngectomy: Removes one vocal cord and part of the larynx.

The primary advantage of partial laryngectomy is the possible preservation of voice after the procedure.

• Temporary tracheostomy tube for breathing during healing.
• Gradual return to oral intake after swallowing assessment.
• Speech therapy for voice rehabilitation.

• Airway management (tracheostomy care, suctioning).
• Pain control and wound care.
• Nutritional support (NG initially).
• Patient education on communication methods and stoma care.

A total laryngectomy is the surgical removal of the entire larynx, including the vocal folds, hyoid bone, epiglottis, thyroid and cricoid cartilage, and a few tracheal cartilage rings (2-3 rings). This procedure creates a permanent tracheostomy for breathing and results in the complete loss of the natural voice.

The primary indication for a total laryngectomy is the presence of a malignant tumor involving the larynx or hypopharynx.

It decreases the internal diameter, which can affect gas flow.

After a total laryngectomy, the tracheostoma becomes the patient's only airway, allowing for breathing post-surgery.

• Permanent stoma care for airway management.
• Nutritional support (initially via NG tube).
• Pain management and wound care.
• Voice rehabilitation using alternative methods.

• Airway management: Humidification, suctioning, stoma care.
• Infection prevention and monitoring for fistula formation.
• Psychological support for body image and communication changes.
• Education on stoma care and emergency precautions.

1. Haemorrhage / Haematoma: Risk of airway compromise and shock.

2. Airway obstruction: Caused by mucus plugs, oedema, or stoma blockage.

3. Wound infection: Common due to contamination from saliva.

4. Pharyngocutaneous fistula: Leakage of saliva through the surgical wound; the most frequent major complication.

5. Chyle leak: Leakage of milky fluid consisting of lymph and emulsified fat due to damage of the thoracic duct, especially after neck dissection.

6. Aspiration pneumonia: More common in patients who have undergone partial laryngectomy.

Tracheostomal stenosis is the narrowing of the stoma, which can lead to breathing difficulties for the patient.

Patients may experience delayed or failed rehabilitation of voice and speech after a laryngectomy, impacting their ability to communicate effectively.

Swallowing dysfunction, or dysphagia, can occur due to scar tissue or strictures that develop post-surgery, affecting the patient's ability to swallow.

Hypothyroidism may occur if the thyroid gland is removed or damaged during the laryngectomy procedure, leading to hormonal imbalances.

Patients may experience depression, anxiety, and an altered body image as psychosocial impacts following a laryngectomy.

Systemic risks include infection and sepsis from wounds or fistulas, nutritional deficits due to prolonged NPO status, and pulmonary complications like pneumonia and atelectasis due to impaired airway clearance.

• Maintain stoma patency
• Ensure humidification
• Perform suctioning as needed

• Look for redness
• Check for swelling
• Monitor for leakage (fistula)

• Use NG (nasogastric) or PEG (percutaneous endoscopic gastrostomy) feeding until safe swallowing is confirmed.

• Offer counselling for speech loss and body image issues
• Provide family support

• Teach stoma care
• Discuss emergency precautions
• Explain voice rehabilitation options

The key components of preoperative assessment include:

1. Full health history
2. Airway evaluation
3. Nutritional status
4. Identification of comorbidities such as COPD, diabetes, and cardiac issues
5. Multidisciplinary team involvement for initial assessment of the patient and family.

For a patient undergoing total laryngectomy, it is essential to provide the following educational information:

• Explanation of the diagnosis and discussion of treatment options
• Clarification of misconceptions regarding the surgery
• Written materials about the surgery
• Understanding that the natural voice will be lost, but that special training can provide means for communication
• Introduction of communication alternatives post-surgery.

Preoperative speech pathology counselling includes a pre-op voice and swallowing assessment and discussions about rehabilitation options.

Preoperative psychosocial support should address anxiety, depression, and body image concerns.

Key preparation steps include:

1. NPO status (usually from midnight).
2. Blood taking: CBC, Type & Screen (consider reserving blood products).
3. Booking frozen section pathology.

Smoking and alcohol cessation improves healing and reduces complications during the postoperative period.

1. Maintain stoma patency and provide humidified oxygen.
2. Assess SpO2 and monitor for signs of airway occlusion such as dyspnoea, agitation, and non-productive cough.
3. Check the wound site for bleeding or surgical emphysema.
4. Position the patient in the semi-Fowler's or Fowler's position to reduce surgical oedema and enhance lung expansion.
5. Provide humidification to prevent drying of pulmonary secretions and mucus plug formation.
6. Perform suction of the tracheostomy tube to clear secretions, changing and cleaning the inner tube every shift when present.

Administering analgesics is crucial for adequate pain relief after surgery, as postoperative pain can lead to shallow breathing and an ineffective cough, which can compromise airway patency.

Patients should be encouraged to:

1. Turn
2. Cough
3. Take deep breaths

These actions help clear the airway and improve respiratory function.

Early ambulation helps prevent:

1. Atelectasis
2. Venous thromboembolism (e.g., pulmonary embolism, deep vein thrombosis)
3. Pneumonia

This is essential for maintaining respiratory health post-operatively.

A physiotherapist should be referred for respiratory rehabilitation to assist in the recovery of respiratory function and to promote effective airway management post-surgery.

• Encourage non-verbal methods such as writing, gestures, and pictures using a whiteboard or smartphone.
• Provide adequate time for communication to anticipate patient needs.
• Ensure a call bell is within easy reach for patient safety.
• Refer to a speech therapist to assess the patient's function and ability to use alternative speaking devices.

1. Enteral feeding via Entriflex feeding tube until safe swallowing is confirmed.
2. Oral feeding can begin once the suture line heals and contrast study shows no leakage or fistula.
3. Consult a speech therapist to perform a swallow study to assess aspiration risk.
4. Observe for swallowing difficulties and report any abnormalities (e.g., food noted from T/T).
5. Instruct the patient to maintain oral hygiene.
6. Monitor weight and laboratory data to ensure adequate nutritional and fluid intake.
7. Consult a dietitian for nutritional support, including tube feeding regimen.
8. Assess skin turgor and vital signs for signs of decreased fluid volume.

They can cause lung de-recruitment, leading to reduced lung capacity and function.

Interventions include:

1. Encouraging expression of concerns about appearance and communication.
2. Teaching stoma care and voice rehabilitation options early.
3. Connecting patients with peers who have undergone similar surgery (e.g., The New Voice Club).
4. Encouraging independence by teaching self-care for stoma and communication devices.
5. Involving family by educating them to provide emotional support and reduce stigma.
6. Referring to specialists such as speech therapists, psychologists, and social workers for comprehensive care.

A tracheostomy tube is inserted into a surgically created opening (stoma) in the trachea to maintain airway patency and allow breathing.

The main types of tracheostomy tubes are:

Cuffed tubes have a soft balloon at the distal end that inflates to seal the airway.

Cuffed tubes are indicated for positive pressure ventilation and provide airway protection to minimize aspiration.

Non-cuffed tubes cannot sustain positive pressure ventilation due to the absence of a cuff.

Non-cuffed tubes are indicated for long-term patients who have an effective cough/gag reflex.

The cuff in cuffed tubes is not an absolute barrier to secretions, allowing some potential for aspiration.

Single Cannula Tubes:

• Feature: No removable inner cannula.
• Indication: Temporary use in critical care.
• Risk: Occlusion with secretions; requires tube change for cleaning.

Double Cannula Tubes:

• Feature: Outer cannula + removable inner cannula.
• Benefit: Easier cleaning; safer for long-term and non-specialist settings.
• Care: Clean inner cannula every 6-8 hours; keep spare at bedside.

Fenestrated tracheostomy tubes allow airflow to the upper airway, enabling speech and a more effective cough.

The two options for inner cannulas are:

1. Fenestrated inner cannula: Aligns with outer fenestration, allowing the patient to speak.
2. Non-fenestrated inner cannula: Blocks fenestrations, used for suctioning or ventilation.

• Increased aspiration risk.
• Avoid in patients on positive pressure ventilation unless a non-fenestrated inner cannula is in place.

Suction only with a non-fenestrated inner cannula to prevent mucosal injury.

The primary feature is a movable flange that allows for adjustment of the tube length to accommodate deep trachea.

They are indicated for obese patients, those with severe oedema, burns, and post-surgical swelling.

A key aspect of care is the daily review of the flange position and adjustment as swelling changes.

The use of adjustable flange tubes is considered complex and is associated with various complications.

• Reduces risk of obstruction
• Allows for easy cleaning
• Facilitates emergency management

The inner diameter (ID) of a tracheostomy tube determines airflow resistance and suitability for ventilation. A larger ID allows for better airflow and easier suctioning, while a smaller ID increases resistance and may limit the size of the suction catheter.

The outer diameter (OD) of a tracheostomy tube must fit the stoma without causing pressure injury. If the OD is too large, it can cause tissue damage; if it is too small, it may lead to leakage and instability.