Neoplastic Disorder of The Larynx

1. Prepare by:Arpana Bhusal
BNS

2. • Papillomas are one type of benign tumor of
the larynx.
They are small, wart like growths believed
to be viral in origin.
Papillomas may be removed by surgical
excision or laser, surgery must be exact,
because the nondiseased portion of the
larynx are nodules and polyps.
Nodules and polyps frequently occur in
people who abuse or overuse their voice.

3.  Cancer of the larynx is a malignant tumor in
and around the larynx (voice box).
 Squamous cell carcinomas is the most
common form of cancer of the larynx (95%).
 Adenocarcinoma or sarcoma of the larynx is
diagnosed less often.
 Cancer of the larynx occurs more frequently
in men than in women, and is most common
in people between the ages of 50 and 70
years.

4. Supraglottic (false vocal cords):1/3rd
 Glottic (true vocal cords): 2/3rd, seldom
spreads if found early, because of the
limited lymph vessels found in the vocal
cords.
And sub glottic (downward extension of
disease from the vocal cord); fewer than
1%

5. Larynx cancer - endoscopic view

6. Laryngeal cancer may spread by direct
extension to adjacent structures, by
metastasis to regional cervical lymph
nodes, or more distantly, through the blood
stream.
 Distant metastases to the lung are most
common.

7.  Approximately 25-50% of patients with laryngeal
cancer present with involved lymph nodes.
Metastatic disease from the true vocal cords is
very rare, because they are devoid of lymph
nodes.
 The prognosis for patients who have small
laryngeal cancers without evidence of spread to
the lymph nodes is about 75% to 95% .
 Recurrence occurs usually within the first 2-3
years after diagnosis.
 The presence of disease after 5 years is very
often secondary to a new primary malignancy.

8. Carcinogens
 Tobacco (smoke, smokeless)
 Combined effects of alcohol and
tobacco(synergistic effect)
 Asbestos
 Secondhand smoke
 Paint fumes
 Wood dust
 Cement dust
 Chemicals
 Tar products
 Mustard gas
 Leather and metals

9. Other factors
 Straining the voice
 Chronic laryngitis
 Nutritional deficiencies (riboflovin)
 History of alcohol abuse
 Familial predisposition
 Age (higher incidence after 60 years of age)
 Gender (more common in men)
 Race (more prevalent in African Americans)
 Weakened immune system
 People with a history of head and neck cancer.

10.  Squamous cell carcinoma is the most common
malignant tumor of the larynx, arising from the
membrane lining the respiratory tract.
 Metastasis from cancer of the glottis is unusual
because of the spares lymphatic drainage from
the vocal cords.
 Cancer else where in the larynx spreads more
quickly because there are aboundant lymphatic
vessels.
 Metastatic disease often may be palpated as
neck masses.
 Distant metastasis may occur in the lungs.

11. The symptoms of laryngeal cancer depend on the size
and location of the tumor. Symptoms may include the
following:
 Hoarseness, lower in pitch or other voice changes more
than 2 weeks
 A lump in the neck
 A sore throat or feeling that something is stuck in the
throat
 Persistent cough
 Pain and burning in the throat, especially when
consuming hot liquids or citrus juices.
 Stridor
 Earache

12. Later : dysphagia, aspiration during
swallowing, dyspnea, unilateral nasal
obstruction or discharge persistent
hoarseness, persistent ulceration and foul
breath
Cervical lymphadenopathy
Unintentional weight loss
General debilitated state
Pain radiating to the ear may occur with
metastasis.

13.  History, physical examination
 Chest x-ray, barium swallow study or
esophagography
 Endoscopy /laryngoscopy
 CT
 MRI
 Tissue biopsy
 Laboratory analysis: CBC, serum electrolytes
including calcium. Kidney and liver function
test.ABG analysis
Staging / TNM classification

14.  T (a, CIS,(0),1–4): size or direct extent of the primary tumor
 N (0–3): degree of spread to regional lymph nodes
• N0: tumor cells absent from regional lymph nodes
• N1: regional lymph node metastasis present; (at some sites:
tumor spread to closest or small number of regional lymph
nodes)
• N2: tumor spread to an extent between N1 and N3
• N3: tumor spread to more distant or numerous regional lymph
nodes
 M (0/1): presence of metastasis
• M0: no distant metastasis
• M1: metastasis to distant organs (beyond regional lymph nodes)

15.  Stage 0: carcinoma in situ, derived from the Latin
phrase meaning “in its place”
 Stage I: Tumor limited to the tissue of origin, localized
tumor growth
 Stage II: Limited tissue spread
 Stage III: extensive local and regional spread
 Stage IV: Metastasis

16.  Treatment/ management depends on the
staging of the tumor and also whether this is
an initial diagnosis or recurrence.
 Treatment options: surgery, radiation therapy
, and chemotherapy.
 The prognosis depends upon various factors;
tumor stage, the patients gender and age and
pathologic features of the tumor, including the
grade and depth of infiltration.

17.  Patient with early – staged disease (stage I or II),
can be treated with either radiation therapy or
surgery. Survival with radiation alone is 80-90%
for patient with stage I disease and 70-80% for
patient with stage II disease.
 Surgery alone can be used; however voice
preservation is better with radiation alone than
with partial laryngectomy.
 Patient with stage III or IV or advanced tumors
require a combined treatment modality
approach, consisting of either surgery and
irradiation, radiation therapy and chemotherapy,
or all three treatment regimens.

18.  In advance disease, often requires complete removal
of the larynx
 Patient with advance laryngeal cancer have longer
disease free survival when treated with chemotherapy
along with radiotherapy rather than with radiotherapy
alone.
 Treatment with hyperfractionated accelerated
irradiation and concomitant cisplatin has also been
effective against locally advanced laryngeal cancer.
 Surgery and radiation therapy are both effective
methods in the early stages of cancer of the larynx.
 Chemotherapy has been used in conjunction with
radiation therapy, to avoid a total laryngectomy, or
preoperatively, to shrink a tumor before surgery.

19.  Combined treatment for patient with stage III cancer
yields a survival rate of 30% -50% at 3 years.
 The survival rate decreases to 20-30% at 5 years.
 Patient with resectable stage disease treated with
combined therapy have a 5 year survival rate of 15-
25%.
 Before treatment, a complete dental examination is
performed to rule out any oral disease. Any dental
problems are resolved if possible before surgery and
radiation therapy.
 If surgery is to be performed, a multidiciplinary team
evaluates the needs of the patient and the family to
develop a successful plan of care .

20. Partial laryngectomy
Supraglottic laryngectomy
Hemilaryngectomy
Total laryngectomy

21.  It is recommended in the early stages of cancer in
the glottic area when only one vocal cord is involved.
 Very high cure rate
 It may also be performed for recurrence when high-
dose radiation has failed. A portion of the larynx is
removed, along with one vocal cord and the tumor;
all other structure remain.
 The airway remain intact, and the patient is expected
to have no difficulty swallowing. The voice quality
may change, or the patient may sound hoarse.

22.  This is a voice sparing operation that can be
tailored to the supraglottic lesion.
 It is used for lesions that involves the epiglottis, a
single arytenoid cartilage, the aryepiglottic fold,
and false vocal cords.
 A neck dissection of one or both sides may also
be performed.
 Postoperative irradiation is indicated based on the
pathologic findings from the surgery.
 The supraglottic laryngectomy is indicated in the
management of early (stage I) supraglottic and
stage II leisons.

23.  The hyoid bone, glottis, and false sords are removed.
 The true vocal cords, cricoid cartilage, and trachea remain
intact.
 A tracheostomy tube is left in the trachea until the glottic
airway is established. It is usually removed after a few days,
and the stoma is allowed to close.
 Nutrition is provided through internal feedings until there is
healing, followed by a semisolid diet.
 Patient may experience some difficulty swallowing for the
first 2 weeks.
 Aspiration is a potential complication, because the patient
must learn a new method of swalloing(supraglottic
swallowing).
 It preserves the voice, eventhough the quality of voice may
change.

24. Speech therapy is required before
and after the s,urgery.
High risk for recurrence of cancer ,
therefore patient are selected
carefully.
For patient with early disease, the
surgery may consider an endoscopic
supraglottic laryngectomy with
postoperative radiation therapy.

25.  It is performed when the tumor extends beyound the
vocal cord but is less than 1 cm in size and is limited
to the subglottic area.
 It may be used in stage I glottic lesions.
 In this procedure the thyroid cartilage of the larynx is
split in the midline of the neck, and the portion of the
vocal cord( one true cord and one false cord) is
removed with the tumor.
 The arytenoid cartilage and half of the thyroid are
removed.
 The patient will have a tracheostomy tube and
nesogastric tube in place for a number of days after
the surgery.

26. Patient is in risk of aspiration
postoperatively.
Some change may occur in voice quality.
The voice may be rough , raspy, and horse
and have limited projection.
The airway and swallowing remain intact.
Usually, this procedure is reserved for
patients with lesions that involve only one
cord, or intraarytnoid areas is a
contraindication to a hemilaryngectomy.

27.  Performed in advance stage IV laryngeal cancers, when
the tumor extends beyond the vocal cords, or for cancer
that recurs or persists after radiation therapy.
 The laryngeal structures are removed, including the hyoid
bone, epiglottis, cricoid cartilage, and two or three rings of
the trachea.
 The tongue, pharyngeal walls, and trachea are preserved.
 Total laryngectomy results in permanent loss of the voice
and a change in the airway, requiring a permanent
tracheostomy.
 Patient requires alternatives to normal speech (prosthetic
device such as the Singer- Blom valve to speakwithout
aspirating)

28.  Although this procedure can be performed
with or without neck dissection, many
surgeons recommend that a radical neck
dissection.
 Patient will have no voice but will have normal
swallowing.
 Complications that may occur include a
salivery leak, wound infection from the
development pharyngocutaneous fistula,
stomal stenosis, an dysphagia secondary to
pharyngeal and cervical esophageal stricture.

29.  In some cases the patient may be a candidate
for a near total laryngectomy ( NTL). In this
situation ,the patient would be candidate for
chemotherapy and radiotherapy regimens
postoperatively .
Voice preservation can be achieved in most
cases.
NTL inhances speech rehabilitation options for
the patient by adding a physiologic, non
prosthetic tissue technique (i.e the myomucosal
shunt) that provides a prosthesis free method
for rehabilitating the voice

30. Other Surgical Approaches;
Supra cricoid laryngectomy(an alternative
to total laryngectomy)
Two types of this procedure exist
• Supra cricoid partial laryngectomy (SCPL): the
true and false cord, both paraglottic spaces, and
the thyroid cartilage are resected. It is also termed
as cricohydoepiglottopexy.
• The second cricohydopexy: involves resection of
both true and false cords, both paraglottic spaces,
the entire preepiglottic space, the epiglottis and
entire thyroid cartilage .

31.  The goal is to eradicate the cancer and preserve the
function of the larynx.
 The decision for radiation therapy depends in
various factors: staging of tumor( usually for stage I
and II) and the patient’s health status, lifestyles (i.e
occupation) and personal preferences.
 Excellent result of it in patient with early stage(I &II)
glottic tumors when only one vocal cord is involved,
is normal mobility and as well as supraglottic
lesions.
 Patient retain a near normal voice
 A few patient may develop chondritis , or stenosis
and a small number may later require laryngectomy.

32. Radiation therapy may also be used
preoperatively to reduce the tumor size.
It is combined with surgery in advance
laryngeal cancer as adjunctive therapy to
surgery or chemotherapy and as a
palliative measure.
Radiation therapy with combined with
chemotherapy may be an alternative to a
total laryngectomy.
Its complications are; external radiation to
head and neck, may include parotid gland

33.  The patient who undergo a laryngectomy faces
potentially complex and frustrating communication
problems.
 Loss or alteration of the speech should discussed
with patient and family before surgery, and the
speech therapist conducts a preoperative
evaluiation.
 A system of communication is established with the
patient, family, nurse, and physician and
implemented consistently after surgery.
 A longterm postoperative communication plan for
laryngeal communication is developed.

34. Three most common technique of
laryngeal communication are;
• Esophageal speech
• Artificial larynx(electro larynx)
• And tracheoesophageal puncture.

35.  The patient needs the ability to compress air into the
esophagus and expel it, setting off a vibration of the
pharyngeal esophageal segment.
 The technique can be taught once the patient begins
oral feedings, approximately 1 week after surgery.
 First, the patient learns to belch and is reminded to do
so an hour after eating.
 Then the technique is practiced repeatedly.
 Later, this conscious belching actions is transformed
into simple explosions of air from the esophageous for
speech purposes.
 It takes a long time to become proficient, the success
rate is low.

36.  If oesophageal speech is not successful, or until the
patient masters the technique, an electric larynx may be
used for communication.
 This battery powered apparatus projects sound into the
oral cavity.
 When the mouth form words (articulated), the sounds
from the electric larynx become audible words.
 The voice that is produced sounds mechanical,and some
words may be dificult to understand.
 the patient is able to communicate with relative ease
while working to become proficient at either esophageal
or tracheoesophageal puncture.

37.  Most widely used because the speech associated
with it most resembles normal speech and it is
easily learned.
 A valve is placed in the tracheal stoma to divert air
into the esophagus and out the mouth.
 Once the puncture is surgically created and has
healed a voice prosthesis (Singer Blom) is fitted
over the puncture site.
 Moving the tongue and lips to form the sound into
words produces speech as before.
 To prevent airway obstruction the prosthesis is
removed and cleaned when mucus builds up.
 Speech therapist teaches the patient how to
produce sound.

38. Black M. Joyce and Hawka H. Jane
(2009),Medical Surgical Nursing, 8th
edition, volume ,2
Brunner & Suddarths, (2008),Text Book of
Medical Surgical Nursing, 11th edition,
volume 1
Lippincott (2009), Manual of Nursing
Practice, 9th edition
www.wikipedia.org/wiki/files