Timby's MedSurg 14e

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UNIT 5 Caring for Clients With Respiratory Disorders

advanced cases, total laryngectomy may be the treatment of choice. If the disease has extended beyond the larynx, a radi cal neck dissection (removal of the lymph nodes, muscles, and adjacent tissues) is performed. Laser surgery may also be used to relieve obstruction in more advanced cases. Chemotherapy and radiation therapy may be used in conjunction with a surgical procedure to treat throat cancers. Cetuximab (Erbitux) is a targeted drug therapy specifically used for laryngeal cancer. Other drugs are in trial stages. A client with a total laryngectomy has a permanent tra cheal stoma (opening) because the trachea is no longer con nected to the nasopharynx. The larynx is severed from the trachea and removed completely. Because the anterior wall of the esophagus connects with the posterior wall of the lar ynx, it must be reconstructed. The only respiratory organs in use are the trachea, bronchi, and lungs. Air enters and leaves through the tracheostomy (Fig. 20-4), and the client will no

longer feel air entering the nose. Tube feeding facilitates healing by preventing muscle activity and irritation of the esophagus (see Chapter 45). Loss of the ability to speak normally is a devastating consequence of laryngeal surgery. Clients with a malignancy of the larynx require emotional support before and after sur gery and help with understanding and choosing an alterna tive method of speech. Some methods of laryngeal speech used after a laryngectomy include the following: • Esophageal speech : requires regurgitation of swallowed air and formation of words with lips; voice quality will be lower pitched and gruff sounding but more natural. • Artificial ( electric ) larynx : a throat vibrator held against the neck that projects sound into the mouth; words are formed with the mouth. The resulting voice sounds mechanical. • Tracheoesophageal puncture (TEP) : a surgical opening in the posterior wall of the trachea, followed by the insertion of a prosthesis such as a Blom–Singer device (Fig. 20-5). Air from the lungs is diverted through the opening in the posterior tracheal wall to the esophagus and out of the mouth. The client covers the stoma with their finger and forces air through the esophagus; this causes the walls of the throat to vibrate as the client speaks. It sounds more natural than an artificial larynx. A speech pathologist works with the client to use an artificial speech device, learn esophageal speech, or speak clearly with a prosthesis. Clients having a partial laryngec tomy also may require speech therapy. Stop,Think, and Respond 20-4 Name three of the most common postoperative com plications of laryngectomy.

Nasal cavity

Soft palate Pharynx

Speech Epiglottis

Larynx Vocal cords

Trachea

Lung

Diaphragm

A

Minimal air entering nose and mouth

Surgical tie-off

Air flowing to lungs in and out of opening in the neck

Voice prosthesis

Tracheostoma valve

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Figure 20-5 Schematic representation of tracheoesophageal puncture speech. Air travels from the lung through a puncture in the posterior wall of the trachea into the esophagus and out of the mouth. A voice prosthesis is fitted over the puncture site.

Figure 20-4 Total laryngectomy changes the airflow for breathing and speaking. (A) Normal airflow. (B) Airflow through a permanent tracheal stoma after total laryngectomy.