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CHAPTER 20 Caring for Clients With Upper Respiratory Disorders

factors. As noted earlier, people over 65 years and males are more at risk than females. Laryngeal cancer is more preva lent in Black and White people. Most laryngeal malignan cies are squamous cell carcinomas, which arise from the epithelial cells lining the larynx. The tumor may be located on the glottis (true vocal cords), above the glottis (supraglot tis or false vocal cords), or below the glottis (subglottis). Laryngeal cancers that start in the glottis generally cause persistent and progressive hoarseness (longer than 2 weeks), usually the earliest symptom. The hoarseness may be slight initially, and clients tend to ignore it. Cancers that start else where in the larynx may not cause hoarseness until later and may not be diagnosed as early. Later, the client notes a sen sation of swelling or a lump in the throat or the neck, fol lowed by dysphagia and pain when talking. The client may also complain of burning in the throat when swallowing hot or citrus liquids. Weight loss often occurs because impaired swallowing and pain reduces caloric intake. If the malignant tissue is not removed promptly, symptoms of advancing car cinoma such as dyspnea, weakness, weight loss, enlarged TABLE 20-1 Descriptions of Laryngeal Surgery SURGERY DESCRIPTION Assessment Findings Signs and Symptoms

cervical lymph nodes, pain, and anemia develop. Halitosis or bad breath is also characteristic of laryngeal cancer. Clients may complain of earaches. Diagnostic Findings Visual examination of the larynx (laryngoscopy) and fine needle aspiration biopsy confirm the diagnosis and identify the type of malignancy. For clients who have difficulty swallowing, a barium swallow may be done. In addition, imaging tests such as x-rays, endoscopy, CT scanning, MRI, and positron emission tomography (PET) are used to detect metastasis and to determine tumor size. The primary provider also assesses the mobility of the vocal cords. Limited mobility indicates that the tumor growth is affecting Treatment depends on factors such as the size of the lesion, the client’s age, and metastasis. Medical treatment may in clude chemotherapy, which appears to have only minimal effects, and radiation therapy, either alone or with surgery. Surgical treatment (Table 20-1) includes laser surgery for early lesions or a partial or total laryngectomy. In more the surrounding tissue, muscle, and airway. Medical and Surgical Management

INDICATION

POSTOPERATIVE EXPECTATIONS

Vocal cord stripping Cordectomy

The affected cord is stripped of mucosa; may be treated with radiation therapy. Excision of a vocal cord, usually laser surgery

For very early-stage vocal cord lesions For tumors confined to the middle third of the vocal cord

Voice will be hoarse; extremely high cure rate. Voice quality depends on the amount of tissue removed.

Laser

Early-stage lesions are treated and removed with a laser process. The affected vocal cord and affected tissue around the cord are removed; other structures remain intact. Hyoid bone, glottis, and false cords removed; radical neck dissection done on involved side; remaining structures left intact Thyroid cartilage of trachea is split at midline; one true cord and one false cord are removed along with arytenoid cartilage and half the thyroid cartilage. Both vocal cords removed along with the hyoid bone, epiglottis, cricoid cartilage, and two or three rings of the trachea; the tongue, pharyngeal walls, and trachea remain intact; usually, a radical neck dissection is done on the affected side. The neck is opened from the jaw to the clavicle from the midline to the interior border of the trapezius muscle. The following are removed: subcutaneous and soft tissue, sternocleidomastoid muscle, jugular vein, and the spinal accessory nerve that innervates the trapezius muscle—client’s shoulder will droop after surgery as the trapezius muscle atrophies. A split-thickness skin graft is applied over the carotid artery.

For early glottis cancers Few side effects; slight hoarseness

microsurgery

Partial

For early-stage laryngeal cancer when only one cord is involved

Voice will be hoarse; intact trachea; no problems with swallowing; high cure rate.

laryngectomy

Supraglottic

For supraglottic tumors Voice will be hoarse; postoperative tra cheostomy until glottic airway func tions; nutrition administered through nasogastric tube until surgical sites heal; recurrence is possible.

laryngectomy

Hemivertical

When tumor extends beyond the vocal cord but is < 1 cm

Client will have a tracheostomy and nasogastric tube after surgery until healed; voice will be hoarse and diminished; client will have an intact airway and the ability to swallow. Permanent tracheal stoma; prevents aspiration; no voice but ability to swallow remains. Metastasis to cer vical lymph nodes is common. Permanent tracheal stoma; no voice; ability to swallow remains. Client requires physical therapy for neck muscles along with a prescribed ex ercise program.

laryngectomy

Total

When the cancer

laryngectomy

extends beyond the vocal cords

Radical neck dissection

When cancer has me

tastasized to cervical lymph nodes

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