Nursing Management of Throat Disorders: Vocal Polyps and Carcinoma of the Larynx

Anatomy and Physiology of the Larynx

• Structures and Functions:     * Pharynx (向): Common pathway for food and air.     * Larynx (喉): Known as the "voice box," responsible for producing sound.     * Epiglottis: A flap of cartilage that prevents food aspiration into the trachea during swallowing.

• Cartilaginous Framework:     * Hyoid Bone: Located superiorly.     * Thyroid Cartilage: Contains the laryngeal prominence, commonly known as the "Adam's apple."     * Cricoid Cartilage: Lower ring of the larynx.     * Ligaments: Includes the Cricothyroid ligament and Cricotracheal ligament.     * Arytenoid Cartilage: Paired cartilages involved in vocal cord movement.     * Cuneiform and Corniculate Cartilages: Minor cartilaginous structures.

• Vocal Folds:     * Vestibular Fold: Known as the false vocal cord.     * Vocal Fold: Known as the true vocal cord.

• Physiology of Speech:     1. Phonation: The production of sound by the larynx. For normal phonation, vocal cords must meet along their entire length. Abnormal phonation is termed Dysphonia.     2. Articulation: The modification of sound into speech by the lips, teeth, tongue, and palate.

Vocal Polyps

• Definition: Small, soft, benign (non-cancerous) growths that usually appear alone on one vocal cord.

• Pathophysiology:     * The polyp causes edema (swelling), which prevents the normal apposition (meeting) of the vocal cords during phonation.     * Vocal folds normally vibrate several hundred times. Prolonged vocal abuse makes tissues swollen.     * If resting follows abuse, tissues return to normal. If use continues, swollen tissues increase in size, resulting in a polyp.

• Causes:     * Infection.     * Vocal abuse (overuse or misuse).     * Traumatic events.     * Long-term exposure to irritants such as caffeine and alcohol.     * Underlying medical conditions: Allergy, acid reflux (GERD), and hypothyroidism.

• Clinical Manifestations:     * Hoarseness and breathiness.     * A "rough" voice or voice break.     * Sensation of a "lump in the throat" or Foreign Body (FB) sensation.     * Neck pain.     * Decreased pitch range.

• Diagnosis:     * Review of medical history and risk factors (e.g., occupation involving heavy voice use).     * Quality of voice assessment.     * Inspection via laryngeal mirror.     * Flexible Fiber Optic Laryngoscopy:         * Purposes: Detect abnormalities, obtain tissue biopsy, diagnose persistent cough/hemoptysis, or remove FB/lesions.         * Procedure: Patient sits upright; local anesthetic is sprayed in the nose/throat. A scope is inserted through one nostril while the patient makes sounds to check cord apposition. Takes approximately $5-10\,\text{mins}$.

• Treatment Modalities:     1. Voice Therapy: Reducing abusive behaviors and learning correct speaking techniques (e.g., diaphragm voice).     2. Lifestyle Modifications: Smoking cessation; avoiding chili and irritating diets; avoiding late-night meals (to prevent GERD); increasing fluid intake; voice rest.     3. Medical Treatment: Treating causative conditions; Steroid therapy to reduce inflammation and edema.     4. Surgical Removal: Reserved for large or long-standing polyps; carries a risk of changed voice quality.     5. Laser Therapy: Better preservation of natural voice and less scarring compared to excision.     * Note: Polyps are recurrent if underlying root causes are not eliminated.

Carcinoma of the Larynx (Ca Larynx)

• General Information: Cancer of the voice box, most commonly Squamous Cell Carcinoma.

• Risk Factors:     * Cigarette smoking and heavy drinking.     * Age > 50.     * Gender: Males are significantly more affected than females ($M \gg F$).     * Environmental hazards: Sulfuric acid mist, asbestos, wood dust, mustard gas, petroleum products.     * History of chronic laryngitis, voice abuse, or head and neck cancer.

• Tumor Locations:     1. Supraglottic Tumor: Above vocal cords (epiglottis, false cords).     2. Glottic Tumor: On true vocal cords (Most common location).     3. Subglottic Tumor: Below vocal cords (Rare, but often advanced at diagnosis).

• Clinical Manifestations by Location:     * Glottic (Early): Dysphonia for > 2\,\text{weeks}, hoarseness. (Late): Dyspnea, airway obstruction leading to Stridor, dysphagia, pain.     * Supraglottic (Early): Aspiration on swallowing, persistent unilateral sore throat, FB sensation, dysphagia, neck mass (lymph nodes), hemoptysis. (Late): Dysphonia, dyspnea, earache.     * Subglottic: No early symptoms. (Late): Dysphonia, dyspnea, stridor, hemoptysis.

• Investigations:     * Physical examination (P/E) of throat, neck, nasopharynx, and palate.     * Chest X-Ray (CXR).     * Flexible laryngoscopy with biopsy.     * Fine-needle aspiration (FNA) of neck masses.     * CT/MRI for staging; PET scan.

• AJCC TNM Staging System:     * Stage 0: Tumor only in the lining.     * Stage I: Grown deeper but confined to one part of the larynx.     * Stage II: Grown into more than one part; vocal cord movement might be impaired.     * Stage III: Vocal cord fixation or spread to a single lymph node (LN) on the same side.     * Stage IV: Growth into structures outside the larynx (thyroid, trachea, esophagus, etc.) or distant metastasis.

• Prognosis:     * Untreated laryngeal cancer is fatal; $90\%$ of untreated patients die within $3\,\text{years}$.     * Curative rates are $75-95\%$. 5-year survival is > 80-90\%.     * Subglottic tumors have a poorer prognosis due to frequent metastasis.     * Recurrence is most likely within $2-3\,\text{years}$ post-diagnosis.

Medical and Surgical Management of Ca Larynx

• Treatment Goals: Cure cancer, maintain airway function, preserve effective swallowing and voice, and maintain acceptable physical appearance.

• Treatment Types:     * Single-modality: Radiation or surgery (for early stages).     * Multiple modalities: Chemoradiotherapy for advanced cases to preserve the larynx.     * Postoperative adjuvant therapy: Total Laryngectomy followed by radiotherapy or concurrent chemoradiotherapy (highest risk cases).

• Radiotherapy: External beam RT is common. Complications include Xerostomia (dry mouth), mucositis, chondritis, Odynophagia (painful swallowing), hypothyroidism, and stenosis.

• Surgical Options:     1. Transoral Surgery: CO2 Laser microsurgery (TLM) or robotic surgery (TORS). Offers minimal tissue damage and voice preservation.     2. Partial Laryngectomy: Vertical (one cord) or Supraglottic (above cords). Airway remains intact; swallowing is usually preserved, but voice becomes hoarse.         * Management: Keep bed > 45^{\circ}. Cuffed tracheostomy tube is used initially. Decannulation involves deflating the cuff, using a smaller uncuffed tube, then a capped tube, and finally removal.     3. Total Laryngectomy:         * Complete removal of larynx and part of pharynx.         * Trachea is sutured to the neck, creating a permanent Tracheostoma.         * Permanent loss of voice and the stoma becomes the ONLY AIRWAY.         * No risk of aspiration unless a fistula forms.     4. Radical Neck Dissection: For recurrent/residual disease; involves bilateral neck dissection and potentially total thyroidectomy.

Nursing Care for Laryngeal Surgery

• Pre-operative Care:     * Nutritional assessment and oral care.     * Smoking/alcohol cessation.     * Psychosocial support for coping with disfigurement and voice loss.     * Briefing on changes: Loss of smell, stoma breathing, need for suctioning, and temporary enteral feeding (NG tube).     * Speech therapist referral for voice prosthesis.

• Post-operative Care - Airway Management:     * Goal 1: Maintain Patency: Monitor for respiratory distress (restlessness, labored breathing, increased pulse). Frequent suction using sterile technique (first $24-48\,\text{hours}$). Change inner cannula every $8\,\text{hours}$ or if blocked.         * Cleaning inner cannula: Bowl 1 (50/50 hydrogen peroxide and saline); Bowl 2 (Sterile saline rinsing).     * Goal 2: Support Breathing: Semi-Fowler/Fowler position; encourage deep breathing/coughing to prevent atelectasis. Provide humidification via HME (Heat and Moisture Exchanger) or humidifier to prevent mucus plugs.     * Goal 3: Prevent Dislodgement: Check tracheal ties (one-finger space), cuff pressure ($20-30\,cmH_2O$), and anchoring stitches.     * Goal 4: Emergency Prep: Signage at bed head "Permanent Tracheostomy - End Tracheostomy" to notify staff NOT to occlude it. Keep tracheal dilators and spare tubes (one size smaller) at bedside.

• Other Post-operative Care:     * Hypocalcemia: Monitor Calcium/Phosphate levels; common after neck dissection if thyroid/parathyroid glands are affected.     * Wound Care: Support head during movement to reduce strain. Monitor for hemorrhage (emergency: hyper-inflate cuff). Manage drains (remove if output < 25\,ml/24\,\text{hrs}). Stoma care starts Day 1.     * Nutrition: Start enteral feeding (NGT/Entriflex) on Day 1-2. Resume oral feeding after edema subsides and contrast studies exclude leakage.     * Fistula Management: Pharyngocutaneous fistula is common ($D5-10$). Signs: Fever, murky drainage, increased WBC. Treatment includes salivary bypass tubes or NPWT (Negative Pressure Wound Therapy).     * Communication: Call bell must be reachable. Use non-verbal methods initially and facilitate alternative speech learning.

Voice Rehabilitation and Discharge Education

• Voice Restoration Methods:     * Electrolaryngeal Speech: Battery-operated device held to the neck. Fast to learn ($3-4\,\text{days}$ post-op) but produces monotone voice.     * Pneumatic Speech: Uses a device covering the stoma and a tube in the mouth to direct air into a simulated vocal cord.     * Tracheoesophageal Puncture (TEP): Surgical fistula with a one-way valve (Provox). Air is shunted into the esophagus to produce sound.     * Esophageal Speech: Swallowing air and ejecting it to vibrate the muscles of the pharynx/esophagus. Voice is deep and loud but short (6-10 words per breath).

• Discharge Safety:     * Medic alert bracelet for laryngeal breathing.     * Instruction on mouth-to-stoma resuscitation for family.     * Install gas and smoke detectors (patient loses sense of smell).     * Use silicon stoma shields for bathing; wear laryngeal aprons.     * Avoid crowded areas and extreme temperature gradients.