Special Considerations in Patients with Laryngeal cancer

Special considerations

• Psychological support and good preoperative and postoperative care can minimize complications and speed recovery.
• Before partial or total laryngectomy:
• Instruct the patient to maintain good oral hygiene. If appropriate, instruct a male patient to shave off his beard.
• Encourage the patient to express his concerns before surgery. Help him choose a temporary nonspeaking method of communication (such as writing).
• If appropriate, arrange for a laryngectomee to visit him. Explain postoperative procedures (suctioning, nasogastric [NG] tube feeding, and care of laryngectomy tube) and their results (the need to breathe through the neck, altered speech). Also, prepare him for other functional losses: He won’t be able to smell, blow his nose, whistle, gargle, sip, or suck on a straw.

After partial laryngectomy:

• Give I.V. fluids and, usually, tube feedings for the first 2 days postoperatively; then give the patient oral fluids. Keep the tracheostomy tube (inserted during surgery) in place until edema subsides.
• Keep the patient from using his voice until he has medical permission (usually 2 to 3 days postoperatively). Then caution him to whisper until healing is complete.

After total laryngectomy:

• As soon as the patient returns to his bed, place him on his side and elevate his head 30 to 45 degrees. When you move him, remember to support his neck.
• The patient will probably have a laryngectomy tube in place until his stoma heals (7 to 10 days). This tube is shorter and thicker than a tracheostomy tube, but requires the same care.
• Watch for crusting and secretions around the stoma, which can cause skin breakdown. To prevent crust formation, provide adequate room humidification. Remove crusting with petroleum jelly, antimicrobial ointment, and moist gauze.
• Teach the patient stoma care.
• Watch for fistula formation (redness, swelling, and secretions on the suture line). A fistula may form between the reconstructed hypopharynx and the skin. This eventually heals spontaneously, but may take weeks or months.
• Watch for carotid artery rupture (bleeding), which usually occurs in a patient who has had preoperative radiation, particularly a patient with a fistula that constantly bathes the carotid artery with oral secretions. If carotid rupture occurs, apply pressure to the site, immediately call for help, and take the patient to the operating room for carotid ligation.
• Watch for tracheostomy stenosis (constant shortness of breath), which occurs weeks to months after laryngectomy; treatment includes fitting the patient with successively larger tracheostomy tubes until he can tolerate a large one.
• If the patient has a fistula, feed him through an NG tube; otherwise, food will leak through the fistula and delay healing.
• Monitor the patient’s vital signs (be especially alert for fever, which indicates infection).
• Record fluid intake and output, and watch for dehydration.
• Provide frequent mouth care.
• After insertion of a drainage catheter (usually connected to a blood drainage system or a GI drainage system), don’t stop suction until drainage is minimal. After the catheter is removed, check dressings for drainage.
• Give the patient an analgesic if necessary.
• If the patient has an NG feeding tube, check tube placement and elevate the patient’s head to prevent aspiration.
• Reassure the patient that speech rehabilitation may help him speak again. Encourage him to contact the International Association of Laryngectomees and other sources of support.