TUMOR GANAS LARING T.

SITI HAJAR HARYUNA Bagian Patologi Anatomi Fakultas Kedokteran Universitas Sumatera Utara PENDAHULUAN Tumor ganas laring bukanlah hal yang jarang ditemukan di bidang THT. Sebagai gambaran, diluar negeri tumor ganas laring menempati urutan pertama dalam urutan keganasan di bidang THT, sedangkan di RSCM menempati urutan ketiga setelah karsinoma nasofaring, tumor ganas hidung dan sinus paranasal. 1 Tumor Ganas laring lebih sering mengenai laki-laki dibanding perempuan, dengan perbandingan 5 : 1. Terbanyak pada usia 56-69 tahun. 1,2 Etiologi pasti sampai saat ini belum diketahui, namun didapatkan beberapa hal yang berhubungan erat dengan terjadinya keganasan laring yaitu : rokok, alkohol, sinar radioaktif, polusi udara radiasi leher dan asbestosis. 1,3 Untuk menegakkan diagnosa tumor ganas laring masih belum memuaskan, hal ini disebabkan antara lain karena letaknya dan sulit untuk dicapai sehingga dijumpai bukan pada stadium awal lagi. Biasanya pasien datang dalam keadaan yang sudah berat sehingga hasil pengobatan yang diberikan kurang memuaskan. Yang terpenting pada penanggulangan tumor ganas laring ialah diagnosa dini. 1,4,5 Secara umum penatalaksanaan tumor ganas laring adalah dengan pembedahan, radiasi, sitostatika ataupun kombinasi daripadanya, tergantung

stadium penyakit dan keadaan umum penderita. 1,6 ANATOMI 7,8,9 Laring dibentuk oleh sebuah tulang di bagian atas dan beberapa tulang rawan yang saling berhubungan satu sama lain dan diikat oleh otot intrinsik dan ekstrinsik serta dilapisi oleh mukosa. Tulang dan tulang rawan laring yaitu : 1. Os Hioid: terletak paling atas, berbentuk huruf U, mudah diraba pada leher bagian depan. Pada kedua sisi tulang ini terdapat prosesus longus dibagian belakang dan prosesus brevis bagian depan. Permukaan bagian atas tulang ini melekat pada otot-otot lidah, mandibula dan tengkorak. 2. Kartilago tiroid : merupakan tulang rawan laring yang terbesar, terdiri dari dua lamina yang bersatu di bagian depan dan mengembang ke arah belakang. 3. Kartilago Krikoid : terletak di belakang kartilago tiroid dan merupakan tulang rawan paling bawah dari laring. Di setiap sisi tulang rawan krikoid melekat ligamentum krikoaritenoid, otot krikoaritenoid lateral dan di bagian belakang melekat otot krikoaritenoid posterior. Otot-otot laring terdiri dari 2 golongan besar, yaitu : 1. Otot-otot ekstrinsik : Otot elevator : - M. Milohioid, M. Geniohioid, M. Digrastikus dan M. Stilohioid Otot depressor : - M. Omohioid, M. Sternohioid dan M. Tirohioid 2004 Digitized by USU digital library 12. Otot-otot Intrinsik : Otot Adduktor dan Abduktor : - M. Krikoaritenoid, M. Aritenoid oblique dan transversum Otot yang mengatur tegangan ligamentum vokalis :

- M. Tiroaritenoid, M. Vokalis, M. Krikotiroid Otot yang mengatur pintu masuk laring : - M. Ariepiglotik, M. Tiroepiglotik. KEKERAPAN Kekerapan tumor ganas laring di beberapa tempat di dunia ini berbeda-beda. Di Amerika Serikat pada tahun 1973 1976 dilaporkan 8,5 kasus karsinoma laring per 100.000 penduduk laki-laki dan 1.3 kasus karsinoma laring per 100.000 penduduk perempuan. Pada akhir-akhir ini tercatat insiden tumor ganas laring pada wanita meningkat. Ini dihubungkan dengan meningkatnya jumlah wanita yang merokok. 9,10 Di RSUP H. Adam Malik Medan, Februari 1995 Juni 2003 dijumpai 97 kasus karsinoma laring dengan perbandingan laki dan perempuan 8 : 1. Usia penderita berkisar antara 30 sampai 79 tahun. Dari Februari 1995 Februari 2000, 28 orang diantaranya telah dilakukan operasi laringektomi total. ETIOLOGI Penyebab pasti sampai saat ini belum diketahui, namun didapatkan beberapa hal yang berhubungan erat dengan terjadinya keganasan laring yaitu : rokok, alkohol, sinar radio aktif, polusi udara, radiasi leher dan asbestosis. Ada peningkatan resiko terjadinya tumor ganas laring pada pekerja-pekerja yang terpapar dengan debu kayu. 1,3,9,10,11 HISTOPATOLOGI Karsinoma sel skuamosa meliputi 95 98% dari semua tumor ganas laring, dengan derajat difrensiasi yang berbeda-beda. Jenis lain yang jarang kita jumpai adalah karsinoma anaplastik, pseudosarkoma, adenokarsinoma dan sarkoma.

2,10 Karsinoma Verukosa. Adalah satu tumor yang secara histologis kelihatannya jinak, akan tetapi klinis ganas. Insidennya 1 2% dari seluruh tumor ganas laring, lebih banyak mengenai pria dari wanita dengan perbandingan 3 : 1. Tumor tumbuh lambat tetapi dapat membesar sehingga dapat menimbulkan kerusakan lokal yang luas. Tidak terjadi metastase regional atau jauh. Pengobatannya dengan operasi, radioterapi tidak efektif dan merupakan kontraindikasi. Prognosanya sangat baik. 2,12 Adenokarsinoma. Angka insidennya 1% dari seluruh tumor ganas laring. Sering dari kelenjar mukus supraglotis dan subglotis dan tidak pernah dari glottis. Sering bermetastase ke paru-paru dan hepar. two years survival rate-nya sangat rendah. Terapi yang dianjurkan adalah reseksi radikal dengan diseksi kelenjar limfe regional dan radiasi pasca operasi. 12 Kondrosarkoma. Adalah tumor ganas yang berasal dari tulang rawan krikoid 70%, tiroid 20% dan aritenoid 10%. Sering pada laki-laki 40 60 tahun. Terapi yang dianjurkan adalah laringektomi total. 12 KLASIFIKASI 1-10 Berdasarkan Union International Centre le Cancer (UICC) 1982, klasifikasi dan stadium tumor ganas laring terbagi atas : 1. Supraglotis 2. Glotis

3. Subglotis Yang termasuk supraglotis adalah : permukaan posterior epiglotis yang terletak di sekitar os hioid, lipatan ariepiglotik, aritenoid, epiglotis yang terletak di bawah os hioid, pita suara palsu, ventrikel. Yang termasuk glottis adalah : pita suara asli, komisura anterior dan komisura posterior. Yang termasuk subglotis adalah : dinding subglotis. Klasifikasi dan stadium tumor berdasarkan UICC : 1. Tumor primer (T) Supra glottis : T is: tumor insitu T 0 : tidak jelas adanya tumor primer l T 1 : tumor terbatas di supra glotis dengan pergerakan normal T 1a : tumor terbatas pada permukaan laring epiglotis, plika ariepiglotika, ventrikel atau pita suara palsu satu sisi. T 1b : tumor telah mengenai epiglotis dan meluas ke rongga ventrikel atau pita suara palsu T 2 : tumor telah meluas ke glotis tanpa fiksasi T 3 : tumor terbatas pada laring dengan fiksasi dan / atau adanya infiltrasi ke dalam. T 4 : tumor dengan penyebaran langsung sampai ke luar laring. Glotis : T is : tumor insitu T 0 : tak jelas adanya tumor primer T 1 : tumor terbatas pada pita suara (termasuk komisura anterior dan posterior) dengan pergerakan normal T 1a : tumor terbatas pada satu pita suara asli T 1b : tumor mengenai kedua pita suara T 2 : tumor terbatas di laring dengan perluasan daerah supra glotis maupun subglotis dengan pergerakan pita suara normal atau terganggu.

T 3 : tumor terbatas pada laring dengan fiksasi dari satu atau ke dua pita suara T 4 : tumor dengan perluasan ke luar laring Sub glotis : T is : tumor insitu T 0 : tak jelas adanya tumor primer T 1 : tumor terbatas pada subglotis T 1a : tumor terbatas pada satu sisi T 1b : tumor telah mengenai kedua sisi T 2 : tumor terbatas di laring dengan perluasan pada satu atau kedua pita suara asli dengan pergerakan normal atau terganggu T 3 : tumor terbatas pada laring dengan fiksasi satu atau kedua pita suara T 4 : tumor dengan kerusakan tulang rawan dan/atau meluas keluar laring. 2. Pembesaran kelenjar getah bening leher (N) N x : kelenjar tidak dapat dinilai N 0 : secara klinis tidak ada kelenjar. N 1 :klinis terdapat kelenjar homolateral dengan diameter 3 cm N 2 :klinis terdapat kelenjar homolateral dengan diameter >3 <6 cm atau klinis terdapat kelenjar homolateral multipel dengan diameter 6 cm N 2a :klinis terdapat satu kelenjar homolateral dengan diameter > 3 cm - 6 cm. N 2b :klinis terdapat kelenjar homolateral multipel dengan diameter 6 cm N 3 :kelenjar homolateral yang masif, kelenjar bilateral atau kontra lateral N 3 a :klinis terdapat kelenjar homolateral dengan diameter >6 cm N 3 b :klinis terdapat kelenjar bilateral N 3 c : klinis hanya terdapat kelenjar kontra lateral

3. Metastase jauh (M) M 0 : tidak ada metastase jauh

M 1 : terdapat metastase jauh 4. Stadium : Stadium I : T1 N0 M0 Stadium II : T2 N0 M0 Stadium III : T3 N0 M0; T1, T2, T3, N1, M0

Stadium IV : T4, N0, M0; Setiap T, N2, M0; setiap T, setiap N , M1 GEJALA DAN TANDA Gejala dan tanda yang sering dijumpai adalah : 1-3,15 Suara serak Sesak nafas dan stridor Rasa nyeri di tenggorok Disfagia Batuk dan haemoptisis Pembengkakan pada leher DIAGNOSIS Diagnosis ditegakkan berdasarkan : 1-3,15 1. Anamnese 2. Pemeriksaan THT rutin 3. Laringoskopi direk 4. Radiologi foto polos leher dan dada 5. Pemeriksaan radiologi khusus : politomografi, CT-Scan, MRI 6. Pemeriksaan hispatologi dari biopsi laring sebagai diagnosa pasti DIAGNOSA BANDING Tumor ganas faring dapat dibanding dengan : 1. TBC laring 2. Sifilis laring

3. Tumor jinak laring. 2,7 4. Penyakit kronis laring PENGOBATAN Secara umum ada 3 jenis penanggulangan karsinoma laring yaitu pembedahan, radiasi dan sitostatika, ataupun kombinasi daripadanya. 13,8,10,11,13-16 2004 Digitized by USU digital library 4I. PEMBEDAHAN Tindakan operasi untuk keganasan laring terdiri dari : 8,9,15,16 A. LARINGEKTOMI 1. Laringektomi parsial Laringektomi parsial diindikasikan untuk karsinoma laring stadium I yang tidak memungkinkan dilakukan radiasi, dan tumor stadium II. 2. Laringektomi total Adalah tindakan pengangkatan seluruh struktur laring mulai dari batas atas (epiglotis dan os hioid) sampai batas bawah cincin trakea. B. DISEKSI LEHER RADIKAL Tidak dilakukan pada tumor glotis stadium dini (T1 T2) karena kemungkinan metastase ke kelenjar limfe leher sangat rendah. Sedangkan tumor supraglotis, subglotis dan tumor glotis stadium lanjut sering kali mengadakan metastase ke kelenjar limfe leher sehingga perlu dilakukan tindakan diseksi leher. Pembedahan ini tidak disarankan bila telah terdapat metastase jauh. 2,10 II. RADIOTERAPI

Radioterapi digunakan untuk mengobati tumor glotis dan supraglotis T1 dan T2 dengan hasil yang baik (angka kesembuhannya 90%). Keuntungan dengan cara ini adalah laring tidak cedera sehingga suara masih dapat dipertahankan. Dosis yang dianjurkan adalah 200 rad perhari sampai dosis total 6000 7000 rad. 2,10 Radioterapi dengan dosis menengah telah pula dilakukan oleh Ogura, Som, Wang, dkk, untuk tumor-tumor tertentu. Konsepnya adalah untuk memperoleh kerusakan maksimal dari tumor tanpa kerusakan yang tidak dapat disembuhkan pada jaringan yang melapisinya. Wang dan Schulz memberikan 45005000 rad selama 46 minggu diikuti dengan laringektomi total. 2 III. KEMOTERAPI Diberikan pada tumor stadium lanjut, sebagai terapi adjuvant ataupun paliativ. Obat yang diberikan adalah cisplatinum 80120 mg/m2 dan 5 FU 8001000 mg/m2 . 3 REHABILITASI Rehabilitasi setelah operasi sangat penting karena telah diketahui bahwa tumor ganas laring yang diterapi dengan seksama memiliki prognosis yang baik. rehabilitasi mencakup : Vocal Rehabilitation, Vocational Rehabilitation dan Social Rehabilitation. 3 PROGNOSA Tergantung dari stadium tumor, pilihan pengobatan, lokasi tumor dan

kecakapan tenaga ahli. Secara umum dikatakan five years survival pada karsinoma laring stadium I 90 98% stadium II 75 85%, stadium III 60 70% dan stadium IV 40 50%. Adanya metastase ke kelenjar limfe regional akan menurunkan 5 year survival rate sebesar 50%. 2,7,12

DAFTAR PUSTAKA
1. Hermani B. Abdurrahman H. Tumor laring. Dalam Soepardi EA, Iskandar N Ed. Buku Ajar Ilmu Kesehatan Telinga Hidung Tenggorok Bedah Kepala Leher. Edisi ke-5. Jakarta. Balai Penerbit FKUI. 2001. h. 156-62. 2. Spector, Ogura JH. Tumor Laring dan Laringofaring. Dalam. Ballenger JJ, Ed. Penyakit Telinga Hidung Tenggorok, Kepala dan Leher. Jilid I. Edisi ke13. Jakarta : Binarupa Aksara. 1997. h. 621-77. 3. Ramalingam KK, Sreeramamoorthy B. A. Short Practice of Otolaryngylogy India : All Publisher & Disatributor, 1993. h. 335-43. 4. Basyiruddin H. Penanggulangan Karsinoma Laring di Bagian THT RSAPD Gatot Subroto. Disampaikan pada Kongres Nasional Perhati. Ujung Pandang, 1986. h.185-93. 5. Mulyarjo. Hasil Pembedahan pada Karsinoma Laring di UPF THT RSUD DR.Sutomo Surabaya. Disampaikan pada Kongres Nasional Perhati, Batu Malang, 27-29 Oktober 1996. h. 1075-9. 6. Adam GL., IR, Paparella MW. Fundamental of Otolaryngology. Edisi ke-5 ed. Philadelphia WB. Saunders, 1978. h. 446-7. 7. Becker W, Naumann HH, Pfaltz CR. Ear Nose and Throat diseases, A. Pocket Reference. Edisi ke-2. New York. Thieme Med. 1994. h. 423-32. 8. Bailey BJ. Early Glottic Carcinoma. Dalam : Bailey BJ. Ed. Head and Neck Surgery Otolaringology. Vol. 2. ed Philadelphia. JB Lippincot. h. 1313-60. 9. Lawson W, Biller HFM, Suen JY. Cancer of the Larynx. Dalam Myers EN, Suem JY. Ed. Cancer of the Head and Neck. Churchill Livingstone. h. 53360. 10.Hanna E, Suen JY. Larynx. Dalam : Closel G, Larson DL, Shah JP, Essential of Head and Neck Oncology. New York Thieme, 1998. h. 223-39. 11.Robin PE, Oloffosn J. Tumors of the Laring. Dalam : Hibbert J. Ed. ScottBrowns. Otolaryngology. Laryngology and Head and Neck Surgery. Vol. 3. Edisi ke-6. Great Brittain : Butterworth-Heinemann, 1997. h. 5/11/1-43.

12.Shumrick K. Malignant Lesions of the Larynx. Dalam : Lee KJ, Ed. Text Book of Otolaryngology and Head and Neck Surgery Elsevier. 1989. h. 647-57. 13.Montgomery WW. Surgery of Upper Respiratory System. Edisi ke-2. Philadelphia. Lea and Febiger, 1989. h. 533-604. 14.Hanafee WN, Ward PH. The Laring, Radiology, Surgery, Pathology. Vol. I. NewYork. Thieme Med, 1990. h. 46-7. 15.Lore JM. An Atlas of Head and Neck Surgery. Edisi ke-3 Philadelphia. WB Saunders. 1998. h. 886-937. 16.Wright D. Total Laryngectomy. Dalam : Rob and Smith. Ballantine JC, HarrisonDFN Ed. Operative Surgery Nose and Throat. Edisi ke-4. London: Butterworths, 1986. h. 317-46. (SUMBER: http://library.usu.ac.id/download/fk/tht-siti%20hajar.pdf) http://www.kalbe.co.id/files/cdk/files/52_05_KarsinomaLaringdiRSDr.Kardiadi.p df/52_05_KarsinomaLaringdiRSDr.Kardiadi.html
SELASA, 19 APRIL 2011

askep karsinoma laring

A. Pengertian Secara anatomi tumor laring dibagi atas tiga bagian yaitu supra glotik, tumor pada plika ventrikularis, aritenoid, epiglotis dan sinus piriformis (Glotis : tumor pada korda vokalis , Subglotis : tumor dibawah korda vokalis). B. Patofisiologi Karsinoma laring banyak dijumpai pada usia lanjut diatas 40 tahun. Kebanyakan pada orang lakilaki.Hal ini mungkin berkaitan dengan kebiasaan merokok, bekerja dengan debu serbuk kayu, kimia toksik atau serbuk, logam berat. Bagaimana terjadinya belum diketahui secara pasti oleh para ahli.Kanker kepala dan leher menyebabkan 5,5% dari semua penyakit keganasan.Terutama neoplasma laringeal 95% adalah karsinoma sel skuamosa.Bila kanker terbatas pada pita suara (intrinsik) menyebar dengan lambat.Pita suara miskin akan pembuluh limfe sehingga tidak terjadi metastase kearah kelenjar limfe.Bila kanker melibatkan epiglotis (ekstrinsik) metastase lebih umum terjadi.Tumor supraglotis dan subglotis harus cukup besar, sebelum mengenai pita suara sehingga mengakibatkan suara serak.Tumor pita suara yang sejati terjadi lebih dini biasanya pada waktu pita suara masih dapat digerakan. C. Gambaran klinik Paling dini adalah berupa suara parau atau serak kronik, tidak sembuh-sembuh walaupun penderita sudah menjalani pengobatan pada daerah glotis dan subglotis. Tidak seperti suara serak laringitis,

tidak disertai oleh gejala sistemik seperti demam.Rasa tidak enak ditenggorok, seperti ada sesuatu yang tersangkut. Pada fase lanjut dapat disertai rasa sakit untuk menelan atau berbicara.Sesak napas terjadi bila rima glotis tertutup atau hampir tertutup tumor 80%. Sesak napas tidak timbul mendadak tetapi perlahan-lahan. Karena itu penderita dapat beradaptasi, sehingga baru merasakan sesak bila tumor sudah besar (terlambat berobat). Stridor terjadi akibat sumbatan jalan napas.Bila sudah dijumpai pembesaran kelenjar berarti tumor sudah masuk dalam stadium lanjut.Bahkan kadang-kadang tumornya dapat teraba, menyebabkan pembengkakan laring. Bila tumor laring mengadakan perluasan ke arah faring akan timbul gejala disfagia, rasa sakit bila menelan dan penjalaran rasa sakit kearah telinga.Apabila dijumpai kasus dengan jelas diatas, khususnya dengan keluhan suara parau lebih dari dua minggu yang dengan pengobatan tidak sembuh, diderita orang dewasa atau tua, sebaiknya penderita segera dirujuk. D. Stadium Tergantung keadaan tumor (T), pembesaran kelenjar regional ( N ), dan metastasis jauh ( M ). Stadium : I : T1 No Mo II : T2 No Mo III : T3 No Mo, T2 N1 Mo, T3 N1 Mo IV : T4 No Mo, semua T N2 M1, semua T semua N dan M. E. Diagnostic studies Pemeriksaan laring dengan kaca laring atau laringoskopi langsung dapat menunjukkan tumor dengan jelas.Tempat yang sering timbul tumor dapat dilihat pada gambar.Sinar X dada,scan tulang, untuk mengidentifikasi kemungkinan metastase. Darah lengkap, dapat menyatakan anemi yang merupakan masalah umum. Laringografi dapat dilakukan dengan kontras untuk pemeriksaan pembuluh darah dan pembuluh limfe., Kemudian laring diperiksa dengan anestesi umum dan dilakukan biopsi pada tumor.Gigi yang berlubang, sebaiknya dicabut pada saat yang sama. F. Medical Managament Pada kasus karsinoma laring dapat dilakukan pengobatan dengan radiasi dan pengangkatan laring (Laringektomi). Pengobatan dipilih berdasarkan stadiumnya. Radiasi diberikan pada stadium 1 dan 4. Alasannya mempunyai keuntungan dapat mempertahankan suara yang normal, tetapi jarang dapat menyembuhkan tumor yang sudah lanjut, lebih-lebih jika sudah terdapat pembesaran kelenjar leher. Oleh karena itu radioterapi sebaiknya digunakan untuk penderita dengan lesi yang kecil saja tanpa pembesaran kelenjar leher. Kasus yang ideal adalah pada tumor yang terbatas pada satu pita suara, dan masih mudah digerakkan. Sembilan dari sepuluh penderita dengan keadaan yang demikian dapat sembuh sempurna dengan radioterapi serta dapat dipertahankannya suara yang normal. Fiksasi pita suara menunjukkan penyebaran sudah mencapai lapisan otot. Jika tumor belum

menyebar kedaerah supraglotik atau subglotik, lesi ini masih dapat diobati dengan radioterapi, tetapi dengan prognosis yang lebih buruk. Penderita dengan tumor laring yang besar disertai dengan pembesaran kelenjar limfe leher, pengobatan terbaik adalah laringektomi total dan diseksi radikal kelenjar leher. Dalam hal ini masuk stadium 2 dan 3. Ini dilakukan pada jenis tumor supra dan subglotik. Pada penderita ini kemungkinan sembuh tidak begitu besar, hanya satu diantara tiga penderita akan sembuh sempurna. Laringektomi diklasifikasikan kedalam : 1. Laringektomi parsial. Tumor yang terbatas pada pengangkatan hanya satu pita suara dan trakeotomi sementara yang di lakukan untuk mempertahankan jalan napas. Setelah sembuh dari pembedahan suara pasien akan parau. 2. Hemilaringektomi atau vertikal. Bila ada kemungkinan kanker termasuk pita suara satu benar dan satu salah.Bagian ini diangkat sepanjang kartilago aritenoid dan setengah kartilago tiroid.Trakeostomi sementara dilakukan dan suara pasien akan parau setelah pembedahan. 3. Laringektomi supraglotis atau horisontal. Bila tumor berada pada epiglotis atau pita suara yang salah, dilakukan diseksi leher radikal dan trakeotomi. Suara pasien masih utuh atau tetap normal.Karena epiglotis diangkat maka resiko aspirasi akibat makanan peroral meningkat. 4. Laringektomi total. Kanker tahap lanjut yang melibatkan sebagian besar laring, memerlukan pengangkatan laring, tulang hihoid, kartilago krikoid,2-3 cincin trakea, dan otot penghubung ke laring.Mengakibatkan kehilangan suara dan sebuah lubang ( stoma ) trakeostomi yang permanen. Dalam hal ini tidak ada bahaya aspirasi makanan peroral, dikarenakan trakea tidak lagi berhubungan dengan saluran udara pencernaan.Suatu sayatan radikal telah dilakukan dileher pada jenis laringektomi ini.Hal ini meliputi pengangkatan pembuluh limfatik, kelenjar limfe di leher, otot sternokleidomastoideus, vena jugularis interna, saraf spinal asesorius, kelenjar salifa submandibular dan sebagian kecil kelenjar parotis (Sawyer, 1990).Operasi ini akan membuat penderita tidak dapat bersuara atau berbicara. Tetapi kasus yang dermikian dapat diatasi dengan mengajarkan pada mereka berbicara menggunakan esofagus (Esofageal speech), meskipun kualitasnya tidak sebaik bila penderita berbicara dengan menggunakan organ laring.Untuk latihan berbicara dengan esofagus perlu bantuan seorang binawicara. G. Dasar data pengkajian keperawatan Data pre dan posoperasi tergantung pada tipe kusus atau lokasi proses kanker dan koplikasi yang ada. INTEGRITAS EGO Gejala : Perasaan takut akan kehilangan suara,mati, terjadi atau berulangnya kanker.Kuatir bila pembedahan mempengaruhi hubungan keluarga, kemampuan kerja dan keuangan. Tanda : Ansietas, depresi, marah dan menolak operasi.

MAKANAN ATAU CAIRAN Gejala :Kesulitan menelan. Tanda : Kesulitan menelan, mudah tersedak, sakit menelan, sakit tenggorok yang menetap.Bengkak, luka. Inflamasi atau drainase oral, kebersihan gigi buruk. Pembengkakan lidah dan gangguan gag reflek. HIGIENE Tanda : kemunduran kebersihan gigi. Kebutuhan bantuan perawatan dasar. NEUROSENSORI Gejala : Diplopia (penglihatan ganda), ketulian. Tanda : Hemiparesis wajah (keterlibatan parotid dan submandibular). Parau menetap atau kehilangan suara (gejala dominan dan dini kanker laring intrinsik). Kesulitan menelan. Kerusakan membran mukosa. NYERI ATAU KENYAMANAN Gejala : Sakit tenggorok kronis, benjolan pada tenggorok. Penyebaran nyeri ke telinga, nyeri wajah (tahap akhir, kemungkinan metastase). Nyeri atau rasa terbakar dengan pembengkakan (kususnya dengan cairan panas), nyeri lokal pada orofaring. Pascaoperasi : Sakit tenggorok atau mulut (nyeri biasanya tidak dilaporkan kecuali nyeri yang berat menyertai pembedahan kepala dan leher, dibandingkan dengan nyeri sebelum pembedahan). Tanda : Perilaku berhati-hati, gelisah, nyeri wajah dan gangguan tonus otot. PERNAPASAN Gejala : Riwayat merokok atau mengunyah tembakau. Bekerja dengan debu serbuk kayu, kimia toksik atau serbuk, dan logam berat. Riwayat penyakit paru kronik. Batuk dengan atau tanpa sputum. Drainase darah pada nasal. Tanda : Sputum dengan darah, hemoptisis, dispnoe ( lanjut ), dan stridor. KEAMANAN Gejala : Terpajan sinar matahari berlebihan selama periode bertahun-tahun atau radiasi.Perubahan penglihatan atau pendengaran. Tanda : Massa atau pembesaran nodul. INTERAKSI SOSIAL Gejala : masalah tentang kemampuan berkomunikasi, dan bergabung dalam interaksi sosial. Tanda : Parau menetap,perubahan tinggi suara, bicara kacau, enggan untuk bicara,dan menolak orang lain untuk memberikan perawatan atau terlibat dalam rehabilitasi. H. Prioritas keperawatan pre dan post operasi PREOPERASI

1. Ansietas berhubungan dengan kurang pengetahuan tentang pra dan pascaoperasi dan takut akan kecacatan. Batasan Karakteristik : Mengungkapkan keluhan khusus, merasa tidak mampu, meminta informasi, mengungkapkan kurang mengerti dan gelisah, menolak operasi. Goal : Cemas berkurang atau hilang. Kriteria Hasil : Mengungkapkan perasaan dan pikirannya secara terbuka, melaporkan berkurangnya cemas dan takut, mengungkapkan mengerti tentang pre dan posoprasi, secara verbal mengemukakan menyadari terhadap apa yang diinginkannya yaitu menyesuaikan diri terhadap perubahan fisiknya. Rencana Tindakan : 1. Jelaskan apa yang terjadi selama periode praoperasi dan pascaoperasi, termasuk tes laboratorium praoperasi, persiapan kulit, alasan status puasa,obat-obatan praoperasi,obat-obatan posoperasi, tinggal di ruang pemulihan, dan program paskaoprasi. Informasikan pada klien obat nyeri tersedia bila diperlukan untuk mengontrol nyeri.Rasional pengetahuan tentang apa yang diperkirakan membantu mengurangi kecemasan dan meningkatkan kerjasama pasien. 2. Jika laringektomi total akan dilakukan, konsultasikan dulu dengan pasien dan dokter untuk mendapatkan kunjungan dari anggota klub laringektomi.Atur waktu untuk berdiskusi dengan terapi tentang alternatif metoda-metoda untuk rehabilitasi suara.Rasional mengetahui apa yang diharapkan dan melihat hasil yang sukses membantu menurunkan kecemasan dan memungkinkan pasien berpikir realistik. 3. Izinkan pasien untuk mengetahui keadaan pascaoperasi : satu atau dua hari akan dirawat di UPI sebelum kembali ke ruangan semula, mungkin ruangan penyakit dalam atau ruangan bedah.Mungkin saja akan dipasang NGT. Pemberian makan per sonde diperlukan sampai beberapa minggu setelah pulang hingga insisi luka sembuh dan mampu untuk menelan (jika operasi secara radikal di leher dilaksanakan).Alat bantu jalan napas buatan (seperti trakeostomi atau selang laringektomi) mungkin akan terpasang hingga pembengkakan dapat diatasi.Manset trakeostomi atau selang T akan terpasang di jalan napas buatan, untuk pemberian oksigen yang telah dilembabkan atau memberikan udara dengan tekanan tertentu. Rasionalpengetahuan tentang apa yang diharapkan dari intervensi bedah membantu menurunkan kecemasan dan memungkinkan pasien untuk memikirkan tujuan yang realistik. 4. Jika akan dilakukan laringektomi horizontal atau supraglotik laringektomi, ajarkan pasien dan latih caracara menelan sebagai berikut: Ketika makan duduk dan tegak lurus ke depan dengan kepala fleksi, letakan porsi kecil makanan di bagian belakang dekat tenggorok, tarik napas panjang dan tahan (ini akan mendorong pita suara bersamaan dengan menutupnya jalan masuk ke trakea), menelan dengan menggunakan gerakan

menelan,batukan dan menelan kembali untuk memastikan tidak ada makanan yang tertinggal di tenggorok. Rasional karena epiglotis sudah diangkat pada jenis laringektomi seperti ini, aspirasi karena makanan per oral merupakan komplikasi yang paling sering terjadi. Belajar bagaimana beradaptasi dengan perubahan fisiologik dapat menjadikan frustrasi dan menyebabkan ansietas.Berlatih secara terus menerus dapat membantu mempermudah belajar dan beradaptasi terhadap perubahan tersebut 2. Menolak operasi berhubungan dengan kurang pengetahuan tentang prosedur pre dan paskaoperasi, kecemasan, ketakutan akan kecacatan dan ancaman kematian. Karakteristik data : kurang kerjasama dan menolak untuk dioperasi,menanyakan informasi tentang persiapan pre dan prosedur posoperasi. Goal : Klien akan bersedia dioperasi. Kriteria hasil : Mengungkapkan perasaan dan pikirannya secara terbuka, mengatakan mengerti pre dan posoperasi, mengatakan berkurangnya kecemasan, klien dioperasi. Rencana tindakan : 1. Kaji faktor-faktor yang menyebabkan klien menolak untuk dioperasi. 2. Anjurkan keluarga untuk memberikan suport seperti dukungan spiritual. 3. Direncanakan tindakan sesuai diagnosa keperawatan no.1. POST OPERASI 1. Mempertahankan jalan napas tetap terbuka, ventilasi adekuat. 2. Membantu pasien dalam mengembangkan metode komunikasi alternatif. 3. Memperbaiki atau mempertahankan integritas kulit. 4. Membuat atau mempertahankan nutrisi adekuat. 5. Memberikan dukungan emosi untuk penerimaan gambaran diri yang terganggu. 6. Memberikan informasi tentang proses penyakit atau prognosis dan pengobatan. Tujuan Pemulangan 1. Ventilasi atau oksigenasi adekuat untuk kebutuhan individu. 2. Komunikasi dengan efektif. 3. Komplikasi tercegah atau minimal. 4. Memulai untuk mengatasi gambaran diri. 5. Proses penyakit atau prognosis dan program terapi dapat dipahami. Diagnosa Keperawatan I. Bersihan jalan napas tidak efektif berhubungan dengan pengangkatan sebagian atau seluruh glotis, gangguan kemampuan untuk bernapas, batuk dan menelan, serta sekresi banyak dan kental.

Batasan karakteristik : sulit bernapas, perubahan pada frekwensi atau kedalaman pernapasan,penggunaan otot aksesori pernapasan, bunyi napas tidak normal,sianosis. Goal : Klien akan mempertahankan jalan napas tetap terbuka. Kriteria hasil : bunyi napas bersih dan jelas, tidak sesak, tidak sianosis,frekwensi napas normal. Rencana tindakan : Mandiri 1. Awasi frekwensi atau kedalaman pernapasan.Auskultasi bunyi napas. Selidiki kegelisahan, dispnea, dan sianosis. Rasional perubahan pada pernapasan, adanya ronki,mengi,diduga adanya retensi sekret. 2. Tinggikan kepala 30-45 derajat. Rasional memudahkan drainase sekret, kerja pernapasan dan ekspansi paru. 3. Dorong menelan bila pasien mampu. Rasional mencegah pengumpulan sekret oral menurunkan resiko aspirasi. Catatan : menelan terganggu bila epiglotis diangkat atau edema paskaoperasi bermakna dan nyeri terjadi. 4. Dorong batuk efektif dan napas dalam. Rasional memobilisasi sekret untuk membersihkan jalan napas dan membantu mencegah komplikasi pernapasan. 5. Hisap selang laringektomi atau trakeotomi, oral dan rongga nasal. Catat jumlah, warna dan konsistensi sekret. Rasional mencegah sekresi menyumbat jalan napas, khususnya bila kemampuan menelan terganggu dan pasien tidak dapat meniup lewat hidung. 6. Observasi jaringan sekitar selang terhadap adanya perdarahan. Ubah posisi pasien untuk memeriksa adanya pengumpulan darah dibelakang leher atau balutan posterior.Rasional sedikit jumlah perembesan mungkin terjadi. Namun perdarahan terus-menerus atau timbulnya perdarahan tiba-tiba yang tidak terkontrol dan menunjukkan sulit bernapas secara tiba-tiba. 7. Ganti selang atau kanul sesuai indikasi. Rasional mencegah akumulasi sekret dan perlengketan mukosa tebal dari obstruksi jalan napas. Catatan : ini penyebab umum distres pernapasan atau henti napas pada paskaoperasi. Kolaborasi 8. Berikan humidifikasi tambahan, contoh tekanan udara atau oksigen dan peningkatan masukan cairan.Rasional fisiologi normal ( hidung) berarti menyaring atau melembabkan udara yang lewat.Tambahan kelembaban menurunkan mengerasnya mukosa dan memudahkan batuk atau penghisapan sekret melalui stoma. 9. Awasi seri GDA atau nadi oksimetri, foto dada. Rasional pengumpulan sekret atau adanya ateletaksis dapat menimbulkan pneumonia yang memerlukan tindakan terapi lebih agresif. II. Kerusakan komunikasi verbal berhubungan dengan defisit anatomi (pengangkatan batang suara) dan hambatan fisik (selang trakeostomi). Karakteristik data :Ketidakmampuan berbicara, perubahan pada karakteristik suara.

Goal : Komunikasi klien akan efektif . Kriteria hasil : Mengidentifikasi atau merencanakan pilihan metode berbicara yang tepat setelah sembuh. Rencana tindakan : Mandiri 1. Kaji atau diskusikan praoperasi mengapa bicara dan bernapas terganggu,gunakan gambaran anatomik atau model untuk membantu penjelasan.Rasional untuk mengurangi rasa takut pada klien. 2. Tentukan apakah pasien mempunyai gangguan komunikasi lain seperti pendengaran dan penglihatan.Rasional adanya masalah lain mempengaruhi rencana untuk pilihan komunikasi. 3. Berikan pilihan cara komunikasi yang tepat bagi kebutuhan pasien misalnya papan dan pensil, papan alfabet atau gambar, dan bahasa isyarat.Rasional memungkingkan pasien untuk menyatakan kebutuhan atau masalah. Catatan : posisi IV pada tangan atau pergelangan dapat membatasi kemampuan untuk menulis atau membuat tanda. 4. Berikan waktu yang cukup untuk komunikasi.Rasional kehilangan bicara dan stres menganggu komunikasi dan menyebabkan frustrasi dan hambatan ekspresi, khususnya bila perawat terlihat terlalu sibuk atau bekerja. 5. Berikan komunikasi non verbal, contoh sentuhan dan gerak fisik. Rasional mengkomunikasikan masalah dan memenuhi kebutuhan kontak dengan orang lain. 6. Dorong komunikasi terus-menerus dengan dunia luar contoh koran,TV, radio dan kalender. Rasional mempertahankan kontak dengan pola hidup normal dan melanjutkan komunikasi dengan cara lain. 7. Beritahu kehilangan bicara sementara setelah laringektomi sebagian dan atau tergantung pada tersedianya alat bantu suara. Rasional memberikan dorongan dan harapan untuk masa depan dengan memikirkan pilihan arti komunikasi dan bicara tersedia dmungkin. 8. Ingatkan pasien untuk tidak bersuara sampai dokter memberi izin.Rasional meningkatkan penyembuhan pita suara dan membatasi potensi disfungsi pita permanen. 9. Atur pertemuan dengan orang lain yang mempunyai pengalaman prosedur ini dengan tepat. Rasional memberikan model peran, meningkatkan motivasi untuk pemecahan masalah dan mempelajari cara baru untuk berkomunikasi. Kolaborasi 10. Konsul dengan anggota tim kesehatan yang tepat atau terapis atau agen rehabilitasi (contoh patologis wicara, pelayanan sosial, kelompok laringektomi) selama rehabilitasi dasar dirumah sakit sesuai sumber komunikasi (bila ada). Rasional Kemampuan untuk menggunakan pilihan suara dan metode bicara (contoh bicara esofageal) sangat bervariasi, tergantung pada luasnya prosedur pembedahan, usia pasien, dan motivasi untuk kembali ke hidup aktif. Waktu rehabilitasi memerlukan waktu panjang dan memerlukan sumber dukungan untuk proses belajar.

III. Kerusakan integritas kulit atau jaringan berhubungan dengan bedah pengangkatan, radiasi atau agen kemoterapi, gangguan sirkulasi atau suplai darah,pembentukan udema dan pengumpulan atau drainase sekret terus-menerus. Karakteristik data : kerusakan permukaan kulit atau jaringan, kerusakan lapisan kulit atau jaringan. Goal : Menunjukkan waktu penyembuhan yang tepat tanpa komplikasi. Kriteria hasil : integritas jaringan dan kulit sembuh tanpa komplikasi Rencana tindakan : 1. Kaji warna kulit, suhu dan pengisian kapiler pada area operasi dan tandur kulit.Rasional kulit harus berwarna merah muda atau mirip dengan warna kulit sekitarnya. Sianosis dan pengisian lambat dapat menunjukkan kongesti vena, yang dapat menimbulkan iskemia atau nekrosis jaringan. 2. Pertahankan kepala tempat tidur 30-45 derajat. Awasi edema wajah (biasanya meningkat pada hari ketiga-kelima pascaoperasi).Rasional meminimalkan kongesti jaringan paskaoperasi dan edema sehubungan dengan eksisi saluran limfe. 3. Lindungi lembaran kulit dan jahitan dari tegangan atau tekanan. Berkan bantal atau gulungan dan anjurkan pasien untuk menyokong kepala atau leher selama aktivitas. Rasional tekanan dari selang dan plester trakeostomi atau tegangan pada jahitan dapat menggangu sirkulasi atau menyebabkan cedera jaringan. 4. Awasi drainase berdarah dari sisi operasi, jahitan dan drein.Rasional drainase berdarah biasanya tetap sedikit setelah 24 jam pertama. Perdarahan terus-menerus menunjukkan masalah yang memerlukan perhatian medik. 5. Catat atau laporkan adanya drainase seperti susu. Rasional drainase seperti susu menunjukkan kebocoran duktus limfe torakal (dapat menyebabkan kekurangan cairan tubuh dan elektrolit).Kebocoran ini dapat sembuh spontan atau memerlukan penutupan bedah. 6. Ganti balutan sesuai indikasi bila digunakan. Rasional balutan basah meningkatkan resiko kerusakan jaringan atau infeksi. Catatan : balutan tekan tidak digunakan diatas lembaran kulit karena suplai darah mudah dipengaruhi. 7. Bersihkan insisi dengan cairan garam faal steril dan peroksida (campuran 1 : 1) setelah balutan diangkat. Rasional mencegah pembetukan kerak , yang dapat menjebak drainase purulen, merusak tepi kulit, dan meningkatkan ukuran luka. Peroksida tidak banyak digunakan karena dapat membakar tepi dan menggangu penyembuhan. 8. Bersihka sekitar stoma dan selang bila dipasang serta hindari sabun dan alkohol.Tunjukkan pada pasien bagaimana melakukan perawatan stoma atau selang sendiri dalam membersihkan dengan air bersih dan peroksida, menggunakan kain bukan tisu atau katun. Rasional mempertahankan area bersih meningkatkan penyembuhan dan kenyamanan. Sabun dan agen kering lainnya dapat

menimbulkan iritasi stoma dan kemungkinan inflamasi.Bahan lain selain kain dapat meninggalkan serat pada stoma yang dapat mengiritasi atau terhisap ke paru. Kolaborasi 9. Berikan antibiotik oral, topikal dan IV sesuai indikasi. Rasional mencegah atau mengontrol infeksi. IV. Perubahan membran mukosa oral berhubungan dengan dehidrasi, kebersihan oral tidak adekuat, kanker oral, penurunan produksi saliva sekunder terhadap radiasi atau prosedur pembedahan dan defisit nutrisi. Karakteristik data : Xerostomia ( mulut kering ), ketidaknyamanan mulut, saliva kental atau banyak, penurunan produksi saliva, lidah kering,pecah dan kotor,bibir inflamasi, tidak ada gigi. Goal : menunjukkan membran mukosa oral baik atau integritas membran mukosa baik. Kriteria Hasil : mulut lembab atau tidak kering, mulut terasa segar, lidah normal, bersih dan tidak pecah, tidak ada tanda inflamasi pada bibir. Rencana tindakan : Mandiri 1. Inspeksi rongga oral dan perhatikan perubahan pada saliva.Rasional kerusakan pada kelenjar saliva dapat menurunkan produksi saliva, mengakibatkan mulut kering. Penumpukan dan pengaliran saliva dapat terjadi karena penurunan kemampuan menelan atau nyeri tenggorok dan mulut. 2. Perhatikan perubahan pada lidah, bibir, geligi dan gusi serta membran mukosa. Rasional pembedahan meliputi reseksi parsial dari lidah, platum lunak, dan faring. Pasien akan mengalami penurunan sensasi dan gerakan lidah, dengan kesulitan menelan dan peningkatan resiko aspirasi sekresi, serta potensial hemoragi. Pembedahan dapat mengankat bagian bibir mengakibatkan pengaliran saliva tidak terkontrol. Geligi mungkin tidak utuh ( pembedahan ) atau mungkin kondisinya buruk karena malnutrisi dan terapi kimia. Gusi juga dapat terinflamasi karena higiene yang buruk, riwayat lama dari merokok atau mengunyah tembakau atau terapi kimia. Membran mukosa mungkin sangat kering, ulserasi,eritema,dan edema. 3. Hisapan rongga oral secara perlahan atau sering. Biarkan pasien melakukan pengisapan sendiri bila mungkin atau menggunakan kasa untuk mengalirkan sekresi. Rasional saliva mengandung enzim pencernaan yang mungkin bersifat erosif pada jaringan yang terpajan. Karena pengalirannya konstan, pasien dapat meningkatkan kenyamanan sendiri dan meningkatkan higiene oral. 4. Tunjukkan pasien bagaimana menyikat bagian dalam mulut, platum, lidah dan geligi dengan sering. Rasional menurunkan bakteri dan resiko infeksi, meningkatkan penyembuhan jaringan dan kenyamanan. 5. Berikan pelumas pada bibir; berikan irigasi oral sesuai indikasi. Rasional mengatasi efek kekeringan dari tindakan terapeutik; menghilangkan sifat erosif dari sekresi.

V. Nyeri akut berhubungan dengan insisi bedah, pembengkakan jaringan,adanya selang nasogastrik atau orogastrik. Karakteristik data : Ketidaknyamanan pada area bedah atau nyeri karena menelan, nyeri wajah, perilaku distraksi, gelisah, perilaku berhati-hati. Goal : Nyeri klien akan berkurang atau hilang. Kriteria hasil : klien mengatakan nyeri hilang, tidak gelisah, rileks dan ekpresi wajah ceria. Rencana tindakan : 1. Sokong kepala dan leher dengan bantal.Tunjukkan pada pasienbagaimana menyokong leher selama aktivitas.Rasional kelemahan otot diakibatkan oleh reseksi otot dan saraf pada struktur leher dan atau bahu. Kurang sokongan meningkatkan ketidaknyamanan dan mengakibatkan cedera pada area jahitan. 2. Dorong pasien untuk mengeluarkan saliva atau penghisap mulut dengan hati-hati bila tidak mampu menelan. Rasional menelan menyebabkan aktivitas otot yang dapat menimbulkan nyeri karena edema atau regangan jahitan. 3. Selidiki perubahan karakteristik nyeri, periksa mulut, jahitan tenggorok untuk trauma baru.Rasional dapat menunjukkan terjadinya komplikasi yang memerlukan evaluasi lanjut atau intervensi.Jaringan terinflamasi dan kongesti dapat dengan mudah mengalami trauma dengan penghisapan kateter dan selang makanan. 4. Catat indikator non verbal dan respon automatik terhadap nyeri. Evaluasi efek analgesik. Rasional alat menentukan adanya nyeri dan keefektifan obat. 5. Anjurkan penggunaan perilaku manajemen stres, contoh teknik relaksasi, bimbingan imajinasi. Rasional meningkatkan rasa sehat, dapat menurunkan kebutuhan analgesik dan meningkatkan penyembuhan. 6. Kolaborasi dengan pemberian analgesik, contoh codein, ASA, dan Darvon sesuai indikasi. Rasional derajat nyeri sehubungan dengan luas dan dampak psikologi pembedahan sesuai dengan kondisi tubuh.Diharapkan dapat menurunkan atau menghilangkan nyeri. VI. Perubahan nutrisi kurang dari kebutuhan tubuh berhubungan dengan gangguan jenis masukan makanan sementara atau permanen, gangguan mekanisme umpan balik keinginan makan, rasa, dan bau karena perubahan pembedahan atau struktur, radiasi atau kemoterapi. Karakteristik data : tidak adekuatnya masukan makanan,ketidakmampuan mencerna makanan, menolak makan, kurang tertarik pada makanan,laporan gangguan sensasi pengecap, penurunan berat badan, kelemahan otot yang diperlukan untuk menelan atau mengunyah. Goal : Klien akan mempertahankan kebutuhan nutrisi yang adekuat. Kriteria hasil : Membuat pilihan diit untuk memenuhi kebutuhan nutrisi dalam situasi individu, menunjukkan peningkatan BB dan penyembuhan jaringan atau insisi sesuai waktunya. Rencana tindakan :

1. Auskultasi bunyi usus. Rasional makan dimulai hanya setelah bunyi usus membik setelah operasi. 2. Pertahankan selang makan, contoh periksa letak selang : dengan mendorongkan air hangat sesuai indikasi. Rasional selang dimasukan pada pembedahan dan biasanya dijahit.Awalnya selang digabungkan dengan penghisap untuk menurunkan mual dan muntah. Dorongan air untuk mempertahankan kepatenan selang. 3. Ajarkan pasien atau orang terdekat teknik makan sendiri, contoh ujung spuit, kantong dan metode corong, menghancurkan makanan bila pasien akan pulang dengan selang makanan. Yakinkan pasien dan orang terdekat mampu melakukan prosedur ini sebelum pulang dan bahwa makanan tepat dan alat tersedia di rumah. Rasional membantu meningkatkan keberhasilan nutrisi dan mempertahankan martabat orang dewasa yang saat ini terpaksa tergantung pada orang lain untuk kebutuhan sangat mendasar pada penyediaan makanan. 4. Mulai dengan makanan kecil dan tingkatkan sesuai dengan toleransi. Catat tanda kepenuhan gaster, regurgitasi dan diare.Rasional kandungan makanan dapat mengakibatkab ketidaktoleransian GI, memerlukan perubahan pada kecepatan atau tipe formula. 5. Berikan diet nutrisi seimbang (misalnya semikental atau makanan halus) atau makanan selang (contoh makanan dihancurkan atau sediaan yang dijual) sesuai indikasi. Rasional macam-macam jenis makanan dapat dibuat untuk tambahan atau batasan faktor tertentu, seperti lemak dan gula atau memberikan makanan yang disediakan pasien. VII. Gangguan citra diri berhubungan dengan kehilangan suara,perubahan anatomi wajah dan leher. Karakteristik data :perasaan negatif tentang citra diri, perubahan dalam keterlibatan sosial, ansietas, depresi, kurang kontak mata. Goal : Mengidentifikasi perasaan dan metode koping untuk persepsi negatif pada diri sendiri. Kriteria hasil : menunjukkan adaptasi awal terhadap perubahan tubuh sebagai bukti dengan partisipasi aktivitas perawatan diri dan interaksi positip dengan orang lain.Berkomunikasi dengan orang terdekat tentang perubahan peran yang telah terjadi.Mulai mengembangkan rencana untuk perubahan pola hidup. Berpartisipasi dalam tim sebagai upaya melaksanakan rehabilitasi. Rencana tindakan : 1. Diskusikan arti kehilangan atau perubahan dengan pasien, identifikasi persepsi situasi atau harapan yang akan datang.Rasional alat dalam mengidentifikasi atau mengartikan masalah untuk memfokuskan perhatian dan intervensi secara konstruktif. 2. Catat bahasa tubuh non verbal, perilaku negatif atau bicara sendiri. Kaji pengrusakan diri atau perilaku bunuh diri. Rasional dapat menunjukkan depresi atau keputusasaan, kebutuhan untuk pengkajian lanjut atau intervensi lebih intensif.

3. Catat reaksi emosi, contoh kehilangan, depresi, marah. Rasional pasien dapat mengalami depresi cepat setelah pembedahan atau reaksi syok dan menyangkal. Penerimaan perubahan tidak dapat dipaksakan dan proses kehilangan membutuhkan waktu untuk membaik. 4. Susun batasan pada perilaku maladaptif, bantu pasien untuk mengidentifikasi perilaku positip yang akan membaik. Rasional penolakan dapat mengakibatkan penurunan harga diri dan mempengaruhi penerimaan gambaran diri yang baru. 5. Kolaboratif dengan merujuk pasien atau orang terdekat ke sumber pendukung, contoh ahli terapi psikologis, pekerja sosial, konseling keluarga. Rasional pendekatan menyeluruh diperlukan untuk membantu pasien menghadapi rehabilitasi dan kesehatan. Keluarga memerlukan bantuan dalam pemahaman proses yang pasien lalui dan membantu mereka dalam emosi mereka. Tujuannya adalah memampukan mereka untuk melawan kecendrungan untuk menolak dari atau isolasi pasien dari kontak sosial. DAFTAR PUSTAKA Doenges, M. G. (2000). Rencana Asuhan Keperawatan, Edisi 3 EGC, Jakarta. Dunna, D.I. Et al. (1995). Medical Surgical Nursing ; A Nursing Process Approach 2 nd Edition : WB Sauders. Lab. UPF Ilmu Penyakit Telinga, Hidung dan tenggorokan FK Unair, Pedoman Diagnosis Dan Terapi Rumah Sakit Umum Daerah Dr Soetom FK Unair, Surabaya. Makalah Kuliah THT. Tidak dipublikasikan Prasetyo B, Ilmu Penyakit THT, EGC Jakarta Rothrock, C. J. (2000). Perencanaan Asuhan Keperawatan Perioperatif. EGC : Jakarta. Sjamsuhidajat & Wim De Jong. (1997). Buku Ajar Ilmu Bedah. EGC : Jakarta. Soepardi, Efiaty Arsyad & Nurbaiti Iskandar. (199 . Buku Ajar Ilmu penyakit THT. FKUI : Jakarta.

(http://duniakeperawatan2011.blogspot.com/2011/04/askep-karsinomalaring.html TUMOR LARING GEJALA DAN TANDA Gejala dan tanda yang sering dijumpai adalah : Suara serak Sesak nafas dan stridor Rasa nyeri di tenggorok Disfagia Batuk dan haemoptisis Pembengkakan pada leher

DIAGNOSIS Diagnosis ditegakkan berdasarkan : 1. Anamnese 2. Pemeriksaan THT rutin 3. Laringoskopi direk 4. Radiologi foto polos leher dan dada 5. Pemeriksaan radiologi khusus : politomografi, CT-Scan, MRI 6. Pemeriksaan hispatologi dari biopsi laring sebagai diagnosa pasti DIAGNOSA BANDING Tumor ganas faring dapat dibanding dengan : 1. TBC laring 2. Sifilis laring 3. Tumor jinak laring. 4. Penyakit kronis laring PENGOBATAN Secara umum ada 3 jenis penanggulangan karsinoma laring yaitu pembedahan, radiasi dan sitostatika, ataupun kombinasi daripadanya. I. PEMBEDAHAN Tindakan operasi untuk keganasan laring terdiri dari : A. LARINGEKTOMI 1. Laringektomi parsial Laringektomi parsial diindikasikan untuk karsinoma laring stadium I yang tidak memungkinkan dilakukan radiasi, dan tumor stadium II. 2. Laringektomi total Adalah tindakan pengangkatan seluruh struktur laring mulai dari batas atas (epiglotis dan os hioid) sampai batas bawah cincin trakea. B. DISEKSI LEHER RADIKAL Tidak dilakukan pada tumor glotis stadium dini (T1 T2) karena kemungkinan metastase ke kelenjar limfe leher sangat rendah. Sedangkan tumor supraglotis, subglotis dan tumor glotis stadium lanjut sering kali mengadakan metastase ke kelenjar limfe leher sehingga perlu dilakukan tindakan diseksi leher. Pembedahan ini tidak disarankan bila telah terdapat metastase jauh. II. RADIOTERAPI Radioterapi digunakan untuk mengobati tumor glotis dan supraglotis T1 dan T2 dengan hasil yang baik (angka kesembuhannya 90%). Keuntungan dengan cara ini adalah laring tidak cedera sehingga suara masih dapat dipertahankan. Dosis yang dianjurkan adalah 200 rad perhari sampai dosis total 6000 7000 rad. Radioterapi dengan dosis menengah telah pula dilakukan oleh Ogura, Som, Wang, dkk, untuk tumor-tumor tertentu. Konsepnya adalah untuk memperoleh kerusakan maksimal dari tumor tanpa kerusakan yang tidak dapat disembuhkan pada jaringan yang melapisinya. Wang dan Schulz memberikan 4500 5000 rad selama 4 6 minggu diikuti dengan laringektomi total. III. KEMOTERAPI

Diberikan pada tumor stadium lanjut, sebagai terapi adjuvant ataupun paliativ. Obat yang diberikan adalah cisplatinum 80 120 mg/m2 dan 5 FU 800 1000 mg/m2. REHABILITASI Rehabilitasi setelah operasi sangat penting karena telah diketahui bahwa tumor ganas laring yang diterapi dengan seksama memiliki prognosis yang baik. rehabilitasi mencakup : Vocal Rehabilitation, Vocational Rehabilitation dan Social Rehabilitation. PROGNOSA Tergantung dari stadium tumor, pilihan pengobatan, lokasi tumor dan kecakapan tenaga ahli. Secara umum dikatakan five years survival pada karsinoma laring stadium I 90 98% stadium II 75 85%, stadium III 60 70% dan stadium IV 40 50%. Adanya metastase ke kelenjar limfe regional akan menurunkan 5 year survival rate sebesar 50%. (http://www.docstoc.com/docs/26428311/TUMOR-LARING)

30 April 2009 Askep Ca Laring I. Konsep Dasar Medis A. Pengertian Secara anatomi tumor laring dibagi atas tiga bagian yaitu supra glotik: tumor pada plikaventrikularis, aritenoid, epiglottis dan sinus piriformis; Glotis: tumor pada korda vokalis;Subglotis: tumor dibawah korda vokalis. B. Anatomi Saluran penghantar udara hingga mencapai paru-paru adalah hidung, faring, laring, trakea, bronkus dan bronkiolus. Saluran pernafasan dari hidung sampai bronkiolus dilappisi olehmembran mukosa yang bersilia. Gerakan silia mendorong lapisan muskus ke posterior didalam rongga hidung, dan reseptor di dalam sistem pernafasan bagian bawah menuju kefaring. Udara mengalir dari faring menuju ke laring atau kotak suara. Laring merupakan rangkaiancincin tulang rawan yang dihubungkan oleh otot dan mengandung pita suara. Di antara pitasuara terdapat ruang berbentuk segitiga yang bermuara ke dalam trakea dan dinamakanglofis. Glofis merupakan saluran yang memisahkan antara saluran pernafasan atas dan bawah. Meskipun laring terutama dianggap berhubungan dengan forasi, tetapi fungsinyasebagai organ pelindung jauh lebih penting.Pada waktu menelan, gerakan laring ke atas, penutupan glottis, dan fungsi seperti pintu padaaditus laring dari epiglottis yang berbentuka daun, berperan untuk mengantarkan makanandan minuman masuk ke dalam esophagus. Namun jika tiada benda asing masih mampumasuk melampaui glottis, maka laring yang mempunyai fungsi batuk akan membantumenghalau benda dan secret keluar dari saluran pernafasan bagian bawah.

C. Etiologi Kanker laring mewakkili 1% dari semua kanker dan terjadi lebih sering pada pria, faktorfaktor penyebabnya adalah:1. Tembakau2. Alkohol dan efek kombinasinya3. Ketegangan vocal4. Laringitis kronis5. Pemajanan industrial terhadap karsinogen6. Defisiensi nutrisi (riboflavin) dan7. Predisposisi keluarga D. Patofisiologi

Karsinoma laring banyak dijumpai pada usia lanjut diatas 40 tahun. Kebanyakan pada oranglaki-laki. Hal ini mungkin berkaitan dengan kebiasaan merokok, bekerja dengan debu serbuk kayu, kimia toksik atau serbuk, logam berat. Bagaimana terjadinya belum diketahui secara pasti oleh para ahli. Kanker kepala dan leher menyebabkan 5,5% dari semua penyakitkeganasan. Terutama neoplasma laryngeal, 95% adalah karsinoma sel skuamosa. Bila kanker terbatas pada pita suara (intrinsik) menyebar dengan lambat. Pita suara miskin akan pembuluh limfe sehingga tidak terjadi metastase ke arah kelenjar limfe. Bila kanker melibatkan epiglottis (ekstrinsik) metastase lebih umum terjadi. Tumor superglotis dansubglotis harus cukup besar, sebelum mengenai pita suara sehingga mengakibatkan suaraserak. Tumor pita suara yang sejati terjadi lebih dini biasanya pada waktu pita suara masihdapat digerakan. E. Manifestasi 1. Sesak terjadi pada awal dan di area glotis 2. Nyeri dan rasa terbakar pada tenggorok ketika minum cairan panas dan jus jeruk 3. Mungkin teraba benjolan di leher 4. Gejala-gejala akhir termasuk disfagia, dispnea, sesak dan nafas bau 5. Pembesaran nodus servikal, penurunan BB, debilitas umum dan nyeri yang menjalar ketelinga dapat menandakan adanya metastasis (transfer penyakit dari satu organ ke organ lain). F. Tes Diagnostik Pada karsinoma laring, dilakukan pemeriksaaan larigoskopik langsung di bawah anestesiumum.Pemeriksaan laring dengan kaca laring atau laringoskopi langsung dapat menunjukantumor dengan jelas. Tempat yang sering timbul tumor dapat dilihat pada gambar. Sinar-Xdada, scan tulang, untuk mengidentifikasi kemungkinan metaphase. darah lengkap, dapatmenyatakan anemi yang merupakan masalah umum. Laringografi dapat dilakukan dengankontras untuk pemeriksaan pembuluh darah dan pembuluh limfe, kemudian laring diperiksadengan anestesi umum dan dilakukan biopsy pada tumor.Gigi yang berlubang sebaiknyadicabut pada saat yang sama. G. Penatalaksanaan Pengobatan bervariasi tergantung pada kemajuan malignasi, termasuk terapiradiasi dan pembedahan. 1. Pemeriksaan gigi lengkap untuk menyingkirkan penyakit gigi 2. Masalah-masalah gigi harus dibereskan sebelum pembedahan pilihannya

3. Terapi radiasi mencapai hasil yang sangat baik jika hanya satu sisi pita suara yang terkena 4. Laringektomi parsial dianjurkan pada tahap dini, terutama pada kanker laring intrinsik 5. Laringektomi supraglofik (horizontal) digunakan untuk beberapa tumor ekstrinsik,keuntungan utama operasi ini adalah pemulihan suara 6. Laringektomi henivertikal dilakukan jika tumor sudah menjalar melebihi pita suara, tetapikurang dari 1 cm dalam area subglotis 7. Laringektomi total untuk kanker ekstrinsik (menjalar melebihi pita suara). Pasien akan mengalami kehilangan pita suara, tetapi akan mempunyai kemampuan menelan normal. II. Konsep Dasar Keperawatan A Pengkajian 1. Integritas Ego Gejala : Perasaan takut akan kehilangan suara, mati, terjadi atau berulangnya kanker, kuatir bila pembedahan mempengaruhi hubungan keluarga, kemampuan kerja dan keuangan. Tanda : Ansietas, depresi, marah dan menolak operasi.2. Makanan atau cairanGejala : Kesulitan menelanTanda : Kesulitan menelan, mudah tersedak, sakit menelan, sakit tenggorok yang menetap, bengkak, luka, inflamasi atau drainase oral, kebersihan gigi buruk, pembengkakan lidah dangangguan gag reflek.3. HigieneTanda : Kemunduran kebersihan gigi, kebutuhan bantuan perawatan dasar 4. NeurosensoriGejala : Diplopia (penglihatan ganda), ketulianTanda : Hemiparesis wajah (keterlibatan parotid dan submandibular), parau menetap ataukehilangan suara (gejala dominan dan dini kanker laring intrinsik), kesulitan menelan,kerusakan membran mukosa.5. Nyeri atau KenyamananGejala : Sakit tenggorok kronis, benjolan pada tenggorok, penyebaran nyeri ke telinga, nyeriwajah (tahap akhir, kemungkinan metastase), nyeri atau rasa terbakar dengan pembengkakan(khususnya dengan cairan panas), nyeri local pada orofaring.Pascaoperasi : Sakit tenggorok atau mulutTanda : Perilaku berhati-hati, gelisah, nyeri wajah dan gangguan tonus otot.6. PernafasanGejala : Riwayat merokok atau mengunyah tembakau, bekerja dengan debu, serbuk kayu,kimia toksik atau serbuk, dan logam berat. Riwayat penyakit paru.Batuk dengan atau tanpasputum. Drainase darah pada nasalTanda : Sputum dengan darah, hemoptisis, dispnoe (lanjut) dan stridor 7. KeamananGejala : Terpajan sinar matahri berlebihan selama periode bertahun-tahun atau radiasi, perubahan penglihatan atau pendengaran.Tanda : Massa atau pembesaran nodul.8. Interaksi sosialGejala : Masalah tentang kemampuan berkomunikasi, dan bergabung dalam interaksi sosial.Tanda : Parau menetap, perubahan tinggi suara, bicara kacau, enggan untuk berbicara, danmenolak orang lain untuk memberikan perawatan atau terlibat dalam rehabilitasi.B. Diagnosa Keperawatan1. Bersihan jalan nafas tidak efektif berhubungan dengan pengangkatan sebagian atau seluruhglotis, gangguan kemampuan untuk bernafas, batuk dan menelan, serta sekresi banyak dan kentalBatasan Karakteristik: sulit bernafas, perubahan pada frekuensi atau kedalaman pernafasan, penggunaan aksesoris pernafasan, bunyi nafas tidak normal, sianosis.Tujuan: Klien akan mempertahankan jalan nafas tetap terbuka.Kriteria Hasil: Bunyi nafas bersih dan jelas, tidak sesak, tidak sianosis, frekuensi nafasnormal.2. Kerusakan komunikasi verbal berhubungan dengan deficit anatomi (pengangkatan batangsuara) dan hambatan fisik (selang trakeostomi).Batasan Karakteristik: Ketidakmampuan berbicara, perubahan pada

karakteristik suara.Tujuan: Komunikasi klien akan efektif.Kriteria Hasil: Mengidentifikasi atau merencanakan pilihan metode berbicara yang tepatsetelah sembuh3. Kerusakan kulit atau jaringan berhubungan dengan bedah pengangkatan, radiasi atau agenkemoterapi, gangguan sirkulasi atau suplai darah, pembentukan edema dan pengumpulan ataudrainase secret terus menerus.Batasan Karakteristik: Kerusakan permukaan kulit atau jaringan, kerusakan lapisan kulit atau jaringan.Tujuan: Menunjukan waktu penyembuhan yang tepat tanpa komplikasiKriteria Hasil: Intergritas kulit dan jaringan sembuh tanpa komplikasiCA.NASOFARINGI. Konsep Dasar MedisA. PengertianKarsinoma faring merupakan tumor ganas yang tumbuh didaerah nasofaring dengan predileksi di fossa rossenmuller pada nasofaring yang merupakan daerah transisional dimanaepitel kuboid berubah menjadi epitel skuamosa (Effiaty, 2001).Tumor ganas nasofaring ( karsinoma faring) adalah sejenis kanker yang dapat menyerang danmembahayakan jaringan yang sehat dan bagian-bagian organ tubuh kita.B. Etiologi1. Pertumbuhan sel kanker yang tidak terkontrol2. Keturunan/genetic3. Lingkungan4. VirusC. PatofisiologiTerbukti juga infeksi virus Epstein Barr dapat menyebabkan karsinoma nasofaring. Hal inidapat dibuktikan dengan dijumpai adanya keberadaan protein-protein laten pada penderitakarsinoma nasofaring. Pada penderita ini sel yang teerinfeksi oleh EBV akan menghasilkan protein tertentu yang berfungsi untuk proses poliferasi dan mempertahankan kelangsunganvirus didalam sel host. Protein laten ini dapat dipakai sebagai pertanda delam mendiagnosakarsinoma nasofaring.Terdapat lima stadium pada karsinoma nasofaring, yaitu:1. Stadium 0: sel-sel kanker masih berada dalam batas nasofaring, biasa disebut nasopharynxin situ2. Stadium 1: Sel kanker menyebar di bagian nasofaring3. Stadium 2: Sel kanker sudah menyebar pada lebih dari nasofaring ke rongga hidung. ataudapat pula sudah menyebar di kelenjar getah bening pada salah satu sisi leher 4. Stadium 3: Kanker ini sudah menyerang pada kelenjar getah bening di semua sisi leher 5. Stadium 4: Kanker ini sudah menyebar di saraf dan tulang sekitar wajahD. Manifestasi Klinis1. Gejala nasofaring sendiri berupa mimisan ringan (keluar darah lewat hidung) atausumbatan hidung, ini terjadi jika kanker masih dini.2. Gejala telinga, merupakan gejala dini yang timbul karena tempat asal tumor dekat muaratuba eustachius (saluran penghubung hidung-telinga). Gejalanya berupa telinga berdengingatau berdengung, rasa tidak nyaman di telinga sampai nyeri.3. Gejala mata dan saraf, gejalanya nyeri di bagian kepala, leher, wajah, pandangan kabur dandiplopia.4. Gejala metastasis, berupa bengkak di leher karena pembengkakan kelenjar limfeE. Tes Diagnostik 1. Endoskopi2. Pengambilan biopsy3. MRI4. CT scan5. Sinar XF. Penatalaksanaan1. Terapi radiasi2. Kemoterapi3. PembedahanII. Konsep Dasar KeperawatanA. Pengkajian1. AktivitasKelemahan atau keletihan.Perubahan pada pola istirahat; adanya faktor-faktor yangmempengaruhi tidur seperti nyeri dan ansietas.2. SirkulasiAkibat metastase tumor terdapat palpitasi, nyeri dada, penurunan TD, epistaksis.3. Intergritas EgoFaktor stress, perubahan penampilan, tidak ada kepercayaan diri, depresi.4. EliminasiPerubahan pola defekasi, konstipasi atau diare, perubahan eliminasi urine, perubahan bisingusus distensi abdomen.5. Makanan atau cairanKebiasaan diit buruk (rendah serat, aditif, bahan pengawet), anoreksia, mual muntah, mulutrasa kering, intoleransi makanan, perubahan BB.6. NeuroesnsorisSakit kepala, tinnitus, tuli, diplopia,juling7. Nyeri/kenyamananRasa tidak nyaman di telinga sampai rasa nyeri telinga, rasa kaku di daerah leher karnafibrosis jaringan akibat penyinaran8. PernafasanRiwayat Merokok 9. KeamananPemajanan pada kimia toksik,

karsinogen, pemajanan matahari lama atau berlebihan, demam,ruam kulit10. Interaksi sosialB. Diagnosa Keperawatan1. Nyeri berhubungan dengan konversi atau destruksi jaringan saraf Tujuan: Rasa nyeri teratasi atau terkontrolKriteria Hasil: Mendemonstrasikan penggunaan keterampilan relaksasi nyeri2. Gangguan sensori persepsi berhubungan dengan gangguan status organ sekunder metastasetumor Tujuan: Mampu beradaptasi terhadap perubahan sensori persepsiKriteria Hasil: Mengenal gangguan dan berkompensasi terhadap perubahan3. Nutrisi kurang dari kebutuhan tubuh berhubungan dengan anoreksia, mual muntahsekunder kemoterapi radiasi.Tujuan: Kebutuhan nutrisi pasien terpenuhiKriteria Hasil:a. Melaporkan penurunan mual dan insiden muntah b. Mengkonsumsi makanan dan cairan yang adekuatc. Mennunjukan turgor kulit normal dan membran mukosa yang lembabd. Melaporkan tidak adanya penurunan berat badan tambahan (http://www.scribd.com/doc/40037178/ca-laring)

Laryngeal Carcinoma Imaging

Author: Nasir Iqbal, MD; Chief Editor: James G Smirniotopoulos, MD

Overview
Laryngeal cancer is the most common cancer of the upper aerodigestive tract. The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers. The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption. Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for nonsmokers. Furthermore, active smoking by patients with head and neck cancer is associated with significant increases in the annual rate of second primary tumor development compared to former smokers or nonsmokers. The use of unfiltered cigarettes or dark, air-cured tobacco is associated with further increases in risk. Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors. In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer. For excellent patient education resources, visit eMedicine's Cancer and Tumors Center. Also, see eMedicine's patient education article Cancer of the Mouth and Throat.

Anatomy
The larynx is divided into 3 anatomic regions: the supraglottic larynx, the glottis, and the subglottic region. The cartilaginous framework of the larynx includes the thyroid cartilage, cricoid cartilage, arytenoid cartilage, and corniculate cartilage, as shown in the images below.

Image shows membranes of the larynx. Courtesy of Wesley Norman, PhD, DSc.

Anterior view of the laryngeal skeleton. Courtesy of Wesley Norman, PhD, DSc.

Posterior view of the laryngeal skeleton. Courtesy of Wesley Norman, PhD, DSc.

Sagittal view of the larynx. Courtesy of Wesley Norman, PhD, DSc.

Sagittal view of the larynx. Courtesy of Wesley Norman, PhD, DSc. Posterior view of the laryngeal muscles. Courtesy of Wesley Norman, PhD, DSc.

Anterior view of the laryngeal muscles. Courtesy of Wesley Norman, PhD, DSc.

Lateral radiograph of the neck showing the different structures of the larynx: a, vallecula; b, hyoid bone; c, epiglottis; d, pre-epiglottic space; e, ventricle (air-space between false and true cords); f, arytenoid; g, cricoid; and h, thyroid cartilage.

The pre-epiglottic fat is located in the anterior and lateral aspects of the larynx and is often invaded by advanced cancers. The anatomic borders are as follows: superior, hyoid bone and hyoepiglottic ligament; inferior, conus elasticus; anterior, thyrohyoid membrane; posterior, anterior wall of the pyriform sinus; and lateral, thyroid cartilage wall. Invasion of the pre-epiglottic fat has significant surgical implications, so evaluation of this space should be part of any radiologic analysis. The recurrent laryngeal nerve innervates the intrinsic laryngeal muscles. Damage to this nerve causes hoarseness clinically and medialization of the arytenoid cartilage radiographically. Enlargement of the pyriform sinus is an important secondary sign of recurrent laryngeal nerve paralysis. The superior laryngeal nerve innervates the cricothyroid muscle, an extrinsic laryngeal muscle that tenses the true vocal cords. Damage to this nerve produces bowing of the vocal cord. The anatomy of the cervical lymph nodes is relevant to the treatment of all laryngeal cancer. The American Joint Committee on Cancer (AJCC) and the American Academy of OtolaryngologyHead and Neck Surgery classification systems are widely used. Radiologists use the hyoid bone as a marker for the carotid bifurcation, and the inferior cricoid cartilage as a marker for the omohyoid muscle, which may be difficult to discern radiographically.

The Radiation Therapy Oncology Group, in collaboration with 2 European research groups, has established guidelines for delineation of nodal levels.

Staging system
The AJCC has designated staging by using the tumors, nodes, and metastases (TNM) classification. Definitions for the stages are described below. For primary tumors, TX indicates that the primary tumor cannot be assessed; T0 means there is no evidence of primary tumor; and Tis indicates carcinoma in situ. In the supraglottis, the T stages are as follows: T1, tumor limited to 1 subsite of the supraglottis with normal vocal cord mobility Stage T1 can be subdivided into T1a, in which the tumor is limited to 1 vocal cord and T1b, in which the tumor involves both vocal cords T2, tumor invasion of the mucosa of more than 1 adjacent subsite of the supraglottis or glottis or of a region outside the supraglottis (eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus), without fixation of the larynx T3, tumor limited to the larynx with vocal cord fixation and/or invasion of any of the postcricoid area or pre-epiglottic tissues T4, tumor invasion through the thyroid cartilage and/or extension into soft tissues of the neck, thyroid, and/or esophagus In the glottis, the T stages are as follows: T1, tumor limited to the vocal cord (may involve anterior or posterior commissure) with normal mobility Stage T1 can be subdivided into T1a, in which the tumor is limited to 1 vocal cord and T1b, in which the tumor involves both vocal cords T2, tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobility T3, tumor limited to the larynx with vocal cord fixation T4, tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx (eg, trachea or soft tissues of the neck, including the thyroid and pharynx) In the subglottis, the T stages are as follows: T1, tumor limited to the subglottis T2, tumor extension to a vocal cord with normal or impaired mobility T3, tumor limited to the larynx with vocal cord fixation T4, tumor invasion through cricoid or thyroid cartilage and/or extension to other tissues beyond the larynx (eg, trachea or soft tissues of neck, including the thyroid and esophagus) The N stages are as follows: NX, regional lymph nodes cannot be assessed N0, no regional lymph node metastasis N1, metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension N2, metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension, metastases in multiple ipsilateral lymph nodes with none more than 6 cm in greatest dimension, or metastases in bilateral or contralateral lymph nodes none more than 6 cm in greatest dimension Stage N2 may be further subdivided as follows: N2a, metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension; N2b, metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; and N2c, metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension. N3, metastasis in a lymph node more than 6 cm in greatest dimension M stages are as follows: MX indicates that distant metastasis cannot be assessed M0, no distant metastasis M1, distant metastasis

Preferred examination

Radiologic examination should include cross-sectional imaging (CT or MRI) of the head and neck to delineate the extent of primary disease, the presence of bone or cartilage invasion, and the presence of nodal disease. Imaging is particularly useful for submucosal regions such as the pre-epiglottic space and subglottis.[1, 2, 3, 4, 5] T1 tumors of the glottis may not require imaging, though CT is often used to exclude nodal metastases. Plain chest radiography or chest CT may be used to rule out pulmonary metastasis. Although some authors claim that MRI provides a more accurate depiction of tumor extent, most institutions continue to use CT as the primary cross-sectional modality. Advances in high-resolution multi-channel helical CT have kept CT competitive with MRI. MRI is more sensitive, but less specific, than CT for the diagnosis of cartilage invasion. The information sought at imaging depends on the size and position of the primary tumor and the type of therapy planned. A small tumor without evidence of deep extension does not require imaging because all information needed for the therapeutic decision may be obvious at endoscopy. Treatment options include cord stripping, laser excision or radiation therapy.[6] Alternatively, the lesion may be so large that a total laryngectomy is the only option considered; thus, imaging of the primary lesion is of limited usefulness.[7, 8] For intermediate-sized lesions, imaging can provide useful information. Radiation therapy remains an option. If surgery is considered, a decision must be made as to whether a patient is a candidate for a voice-sparing partial laryngectomy or whether total laryngectomy is required.[7, 8] Supraglottic carcinomas are associated with a high incidence of nodal metastases at diagnosis; therefore, complete evaluation of the internal jugular lymph nodes with imaging studies is needed. The reported incidence of clinically positive lymph nodes is 55% at initial diagnosis, with a 16% incidence of bilateral involvement.

Radiography
Soft tissue radiographs of the neck are good survey studies (see the image below). Air is used as a natural contrast agent to visualize the lumen of the larynx and trachea. Retropharyngeal tissue thickness can be appreciated. Epiglottis and the aryepiglottic folds are visualized. However, radiography has no role in the current management of laryngeal cancer.

Lateral radiograph of the neck showing the different structures of the larynx: a, vallecula; b, hyoid bone; c, epiglottis; d, pre-epiglottic space; e, ventricle (air-space between false and true cords); f, arytenoid; g, cricoid; and h, thyroid cartilage.

The barium swallow is used to evaluate the pharyngeal wall. The motility and pliability of the pharyngeal wall and the mucosal surfaces are assessed. Tumor infiltration causes lack of pliability or distensibility, as well as mucosal irregularity.

Computed Tomography
Currently, the imaging of laryngeal cancer includes contrast-enhanced helical CT scanning from the C1 vertebral body to the thoracic inlet, with the section plane parallel to the true vocal cords or the hyoid bone (see the images below). The section thickness should not exceed 3 mm. Patients should be instructed to breathe quietly. With new multidetector-row CT scanners, collimation can be 1 mm,

and the larynx can be imaged in a few seconds, providing near-isometric Z -axis resolution with minimal motion artifacts.[9]

CT scan shows tumoral involvement of the right vocal cord.

CT scan shows a subglottic cancer along the cricoid cartilage.

All laryngeal studies should be reconstructed using soft tissue algorithms. The area extending from the thyroid bone to the base of the cricoid cartilage is additionally reconstructed with a high-resolution bone algorithm to evaluate for cartilage invasion by tumor. Intravenous contrast enhancement helps to distinguish vascular structures from lymph nodes. CT has a high sensitivity and negative predictive value for detection of cartilage invasion using the following criteria: sclerosis, erosion, lysis, and extralaryngeal spread. By applying a combination of these criteria to all cartilages, a sensitivity as high as 91% and a negative predictive value of 95% can be obtained[9] .

Magnetic Resonance Imaging

MRI has several advantages over CT that may be helpful for presurgical planning. The multiplanar capabilities of MRI are superior to the reformations available with traditional CT, although multidetector-row CT shows early promise. Coronal imaging is helpful for determining involvement of the laryngeal ventricle and transglottic spread. Midsagittal images are helpful for demonstrating the relationship between the tumor and the anterior commissure. MRI is also superior to CT for specific tissue characterization. However, the longer imaging time may contribute to image degradation by motion. Hypointensity on T1-weighted images, hyperintensity on T2-weighted images, and gadolinium enhancement is suggestive of cartilage involvement. However, the only truly diagnostic finding is involvement of the strap muscles due to anterior extension of the tumor through the cartilage. MRI has a sensitivity of 89-94%, a specificity of 74-88%, and negative predictive value of 94-96% for the detection of neoplastic cartilage invasion[9] . Interest in the use of dextran-coated ultrasmall supramagnetic iron oxide (USPIO) to detect metastatic nodal disease is growing. Patients are usually imaged 24-36 hours after the intravenous administration of USPIO. Compared with its noncontrast signal intensities, the signal intensity of a normally functioning lymph node after the administration of USPIO is markedly reduced on T1- and T2-weighted MRI as a result of both T2 relaxation and magnetic susceptibility effects due to the uptake of the iron particles by macrophages. A metastatic lymph node does not have a signal loss on contrast-enhanced images because the macrophages of the node have been replaced. The reported sensitivity and specificity in detecting nodal metastases are in the range of 87% to 90%, respectively. These results suggest that the use of USPIO contrast agents may become an important adjunct in evaluating metastatic nodal disease.

The positive predictive value of MRI for neoplastic cartilage invasion (71%) is lower than the negative predictive value[9] . In particular, the specificity of MRI for neoplastic invasion of thyroid cartilage is lower than that in the cricoid and arytenoid cartilages.

MRI technique
MRI is performed by using an anterior neck surface coil. T1- and T2-weighted images are obtained in the axial and coronal planes by using 3- or 5-mm-thick sections with a 1-mm gap. Peripheral gating and/or flow compensation may be used to decrease artifact from vascular flow.[9] Unlike CT, portions of the MRI examination should be performed before and after contrast enhancement. On nonenhanced studies, tumors are of intermediate signal intensity and easily distinguished from adjacent fat. After gadolinium enhancement, fat suppression helps in differentiating enhancing tumor from the normal pre-epiglottic and paraglottic fat. Gadolinium-based contrast agents have been linked to the development of nephrogenic systemic fibrosis (NSF) or nephrogenic fibrosing dermopathy (NFD). The disease has occurred in patients with moderate to end-stage renal disease after being given a gadolinium-based contrast agent to enhance MRI or MRA scans. NSF/NFD is a debilitating and sometimes fatal disease. Characteristics include red or dark patches on the skin; burning, itching, swelling, hardening, and tightening of the skin; yellow spots on the whites of the eyes; joint stiffness with trouble moving or straightening the arms, hands, legs, or feet; pain deep in the hip bones or ribs; and muscle weakness.

Supraglottic carcinomas
The epiglottis is the most frequent location for cancers that arise in thesupraglottic larynx. Tumors may arise from either the suprahyoid or infrahyoid epiglottis. Radiographically, these lesions are often exophytic and circumferential masses that, when detected early, are confined to the midline of the supraglottis. On MRI, these lesions are of intermediate signal intensity and homogeneously enhancing with the administration of contrast material. Advanced lesions may extend superiorly to invade the vallecula and base of the tongue and also laterally to involve the aryepiglottic folds, false vocal cord, and paralaryngeal space. Direct inferior extension to involve the anterior commissure and subglottis is seen only in advanced lesions. Tumors arising from the epiglottis may extend anteriorly to involve the pre-epiglottic space. This form of spread is facilitated by the presence of numerous foramina that provide access for tumoral invasion. Invasion of the pre-epiglottic space is often difficult to detect by means of clinical examination and, when present, alters the tumor stage (stage T3). Invasion of the pre-epiglottic space is readily seen on MRIs and best evaluated with nonenhanced T1 weighted images, which show replacement of normal high-signal-intensity fat by intermediate-signal-intensity tumor. Tumors of the aryepiglottic fold are typically exophytic lesions that, when detected early, are confined laterally along the aryepiglottic fold. Advanced lesions may extend laterally to involve the adjacent wall of the pyriform sinus or medially to invade the epiglottis. These malignancies may also grow superiorly to involve the pharyngoepiglottic folds, and they may eventually involve the suprahyoid portion of the epiglottis. Inferiorly, these lesions may involve the false vocal cords and ventricle. Advanced lesions may extend to involve the cricoarytenoid joint, resulting in fixation of the true vocal cord. They may invade the laryngeal cartilages, and they may also extend into the base of the tongue and pharyngeal walls. Radiographically, early lesions are identified as lobulated masses arising from the aryepiglottic fold. Early mucosal lesions may not be depicted on MRIs. Squamous cell cancers that arise from the false vocal cords and laryngeal ventricle tend to be ulcerative and infiltrative with a limited exophytic component. Deep invasion by such tumors results in their access to the paraglottic space, and this may lead to fixation of the supraglottic larynx. Because of their close proximity, these tumors may extend inferiorly to involve the true vocal cords. Such submucosal spread is often occult on clinical examination, and understaging of the lesions is possible if this extension is undetected before surgery.

Tumors of the false vocal cords may extend laterally to involve the medial wall of the pyriform sinus and medially to the inferior portion of the epiglottis, thereby increasing the likelihood of invasion of the pre-epiglottic space. MRI is well suited for the imaging of false vocal cord carcinomas. Coronal imaging is beneficial for evaluating the superior and inferior extent of these lesions and for evaluating the presence of transglottic spread.

Glottic carcinomas
The true vocal cords are the most common site of laryngeal carcinomas; the ratio of glottic carcinomas to supraglottic carcinomas is approximately 3:1. The anterior portion of the true vocal cord is the most common location of squamous cell cancer, with most lesions occurring along the free margin of the vocal cord. Anteriorly, the tumor may extend to anterior commissure, where it may involve the contralateral true vocal cord. Advanced lesions arising within the anterior aspect of the vocal cord or tumors arising along the posterior one third of the cord may extend posteriorly to involve the cricoarytenoid joint and interarytenoid region. Tumors may extend inferiorly, either mucosally or submucosally, to involve the subglottic region. Early superficial mucosal lesions may not be detected with either CT or MRI. Larger lesions may result in thickening of the involved vocal cord. The combination of coronal and axial images may be used to determine the amount of subglottic extension and the presence of cartilage invasion. Because the mucosa is near the perichondrium of the thyroid cartilage anteriorly and the cricoid cartilage posteriorly, the presence of soft tissue thicker than 1 mm in both of these areas is considered abnormal. Invasion of the cartilage may be detected with both CT and MRI, and is more common in glottic tumors than in subglottic carcinomas. MRI is more sensitive, but less specific, than CT in demonstrating cartilage involvement. The fatty marrow in the ossified cartilage has high signal intensity on T1-weighted images. Tumor infiltration into the cartilage results in decreased signal intensity of the marrow. If the cartilage is nonossified, T2-weighted images are more helpful because the tumor is usually hyperintense relative to the non-ossified cartilage. Unfortunately, edema may be mistaken for tumor invasion on T2-weighted images. The likelihood of nodal involvement associated with glottic carcinomas depends on the stage of the tumor. The incidence of early T1 lesions has been reported to be as low as 2%. This figure increases to approximately 20% for T3 and T4 lesions. The lymph nodes most at risk of metastases are those of the internal jugular chain. Paratracheal lymph nodes may be involved in glottic tumors that have significant subglottic spread.

Subglottic carcinomas
Subglottic carcinomas are rare and account for only 5% of all laryngeal carcinomas. The subglottic region is more commonly involved by the direct extension of a glottic or supraglottic carcinoma than by tumors elsewhere. When present, these lesions are characteristically circumferential and often extend to involve the undersurface of the true vocal cords. They have a tendency for early invasion of the cricoid cartilage and extension through the cricothyroid membrane. Primary subglottic carcinomas have a propensity to drain to the paratracheal lymph nodes. The reported incidence of clinically positive nodes in patients with subglottic carcinoma is 10%. Hypopharyngeal carcinomas Hypopharyngeal tumors can remain relatively asymptomatic for a long time. Extensive submucosal growth is common. At the time of diagnosis, as many as 75% of patients with hypopharyngeal tumors have metastases to cervical lymph nodes. Systemic metastases also develop in 20-40% of patients with hypopharyngeal tumors. CT or MRI studies of hypopharyngeal cancer may demonstrate tumor that is more extensive than is apparent on clinical examination, usually because of submucosal spread of the cancer.[10] Carcinoma

of the hypopharynx is most common in the pyriform sinus (60%), followed by the postcricoid region (25%) and the post-pharyngeal wall (15%).

Tumors of the pyriform sinus

Superficial mucosal extension into the apex of the pyriform sinus is not well seen with cross-sectional imaging, and it is best evaluated by means of endoscopy. A pyriform sinus tumor may spread submucosally into the posterior wall of the hypopharynx, the postcricoid region, or the aryepiglottic fold. Large tumors also extend up into the paraglottic fat, the pre-epiglottic fat, and the base of the tongue. These tumors may erode the posterosuperior cricoid cartilage and invade the upper pole of the thyroid gland. Tumors arising from the lateral wall or apex of the pyriform sinus have often already invaded the thyroid cartilage at the time of diagnosis. Lesions of the medial wall of the pyriform sinus may spread along the aryepiglottic fold into the false vocal cord and anterior cartilage. They also may grow posteriorly into the postcricoid region and then cross the midline to involve the contralateral pyriform sinus. Medial wall lesions also invade paraglottic and pre-epiglottic fat. Tumors of the postcricoid region Tumors confined to the postcricoid region are rare. The exception occurs in patients (mostly women) with Plummer-Vinson syndrome. Often, tumors of the posterior wall invade the posterior larynx (arytenoids and posterior cricoid cartilage), causing vocal cord paralysis and hoarseness. Large tumors concentrically infiltrate and narrow the lumen of the hypopharynx. These tumors may extend to the cervical esophagus. The junction of the postcricoid region with the esophageal verge should be evaluated for tumor involvement.

Nuclear Imaging
Positron emission tomography (PET) with or without CT is emerging as a critical modality in the staging and monitoring of many head and neck cancers. Although PET provides little information about the extent of tumor within the larynx, the detection of metastases and the follow-up of treated patients increasingly relies on these modalities. PET with CT is also becoming a critical component of intensity-modulated radiation treatment (IMRT).[9] PET imaging relies on the increased glycolytic activity of neoplastic cells. Although highly sensitive, it does not provide the same anatomic detail that CT or MRI does, and therefore, it does not necessarily allow for precise localization of pathology or determination of involved structures within the larynx. Combined PET and CT scanners may help circumvent this limitation. FDG-PET has been used to look for unknown primary lesions and second primaries, to stage disease prior to therapy, to detect residual and or recurrent disease after therapy, to assess the response to therapy, and to detect distant metastases. A significant limitation of 2-[fluorine-18]-fluoro-2-deoxy-Dglucose (FDG) PET scanning is its insensitivity to small tumor deposits, in the order of 3-4 mm or less. PET has an advantage over CT and MRI for detection of distant metastases, and for N-staging. It should be considered in patients with a high risk for distant metastases. However, the negative predictive value in nodal metastasis assessment may not be sufficient to justify a change in treatment. Currently, the major value of PET may be in evaluation of the post-treatment larynx. In a meta-analysis of 8 studies, PET showed a sensitivity of 89% and specificity of 74% for the diagnosis of recurrent laryngeal carcinoma after radiotherapy[11] . False-positive PET studies due to inflammation are not uncommon, particularly after therapy. However, the use of combined PET/CT imaging will reduce false-positive results.

1. Som PM, Curtin HD. Larynx. Head and Neck Imaging. 4th ed. St Louis: Mosby-Year Book;.
2003: 1595-699.

2. Tarnawski W, Fraczek M, Jelen M, Krecicki T, Zalesska-Krecicka M. The role of computerassisted analysis in the evaluation of nuclear characteristics for the diagnosis of precancerous and cancerous lesions by contact laryngoscopy. Adv Med Sci. 2008;53(2):221-7. [Medline].

3. Becker M, Burkhardt K, Dulguerov P, Allal A. Imaging of the larynx and hypopharynx. Eur J
Radiol. Jun 2008;66(3):460-79. [Medline].

4. Varghese BT, Sebastian P, Mathew A. Treatment outcome in patients undergoing surgery for
carcinoma larynx and hypopharynx - a follow-up study. Acta Otolaryngol. Feb 24 2009;16. [Medline].

Throat cancer (larynx cancer) facts

The larynx is the voice box located at the top of the windpipe (trachea). Cancer of the larynx occurs most often in people over the age of 55 years. People who stop smokingcan greatly reduce their risk of cancer of the larynx. Painless hoarseness can be a symptom of cancer of the larynx. The larynx can be examined with a viewing tube called a laryngoscope.

Treatment of cancer of the larynx depends on the location and size of thetumor as well as the age and health of the patient. Cancer of the larynx is usually treated with radiation therapy or surgery.Chemotherapy can also be used for cancers that have spread.

What is the larynx?

The larynx is an organ in your throat. It's at the front of your neck. This organ is about 2 inches (5 centimeters) wide, which is about the size of a lime. The larynx is also called the voice box. It has two bands of muscle that form the vocal cords. The cartilage at the front of the larynx is sometimes called the Adam's apple. The larynx has three main parts:

Top: The top part of the larynx is the supraglottis. Middle: The middle part is the glottis. Your vocal cords are in this part. Bottom: The bottom part is the subglottis. It connects to the windpipe (trachea).

Your larynx opens or closes to allow you to breathe, talk, or swallow:

Breathing: When you hold your breath, your vocal cords shut tightly. When you let out your breath or breathe in, your vocal cords relax and open. Talking: Your larynx makes the sound of your voice. When you talk, your vocal cords tighten and move closer together. Air from your lungs is forced between the cords and makes them vibrate. The vibration makes the sound. Your tongue, lips, and teeth form this sound into words.

Swallowing: Your larynx protects your lungs from food and liquid. When you swallow, a flap called the epiglottis covers the opening of your larynx to keep food and liquid out of your lungs. The picture below shows how food or liquid passes through the esophagus on its way from the mouth to the stomach.

Cancer cells
Cancer begins in cells, the building blocks that make up tissues. Tissues make up the larynx and the other organs of the body. Normal cells grow and divide to form new cells as the body needs them. When normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor. Tumors in the larynx can be benign (not cancer) or malignant (cancer). Benign tumors are not as harmful as malignant tumors:
o o o o o o o o

Benign tumors (such as polyps or nodules): are usually not a threat to life can be treated or removed and usually don't grow back don't invade the tissues around them don't spread to other parts of the body Malignant growths: may be a threat to life usually can be treated or removed but can grow back can invade and damage nearby tissues and organs can spread to other parts of the body

Laryngeal cancer cells can spread by breaking away from the tumor in the larynx. They can travel through lymph vessels to nearby lymph nodes. They can also spread through blood

vessels to the lungs, bones, or liver. After spreading, laryngeal cancer cells may attach to other tissues and grow to form new tumors that may damage those tissues.

Risk factors
When you get a diagnosis of laryngeal cancer, it's natural to wonder what may have caused the disease. Doctors can't always explain why one person gets laryngeal cancer and another doesn't. However, we do know that people with certain risk factors may be more likely than others to develop laryngeal cancer. A risk factor is something that may increase the chance of getting a disease. Smoking tobacco causes most laryngeal cancers. Heavy smokers who have smoked tobacco for a long time are most at risk for laryngeal cancer. Also, people who are heavy drinkers are more likely to develop laryngeal cancer than people who don't drink alcohol. The risk increases with the amount of alcohol that a person drinks. The risk of laryngeal cancer increases even more for people who are heavy drinkers and heavy smokers. However, not everyone who drinks or smokes heavily will develop the disease. Many other possible risk factors are under study. For example, researchers are studying whether an HPV infection in the throat may increase the risk of laryngeal cancer. HPV is a group of viruses that can infect the body. Another area of research is whether reflux (the backward flow of liquid from the stomach to the throat) may increase the risk of laryngeal cancer.
How to Quit Tobacco

Quitting is important for anyone who uses tobacco. Quitting at any time is beneficial to your health. For people who already have laryngeal cancer, quitting may reduce the chance of cancer returning after treatment. Quitting may also reduce the chance of getting another type of cancer (such as lung, esophagus, or oral cancer), lung disease, or heart disease caused by tobacco. In addition, quitting can help cancer treatments work better. There are many ways to get help:

Ask your doctor about medicine or nicotine replacement therapy. Your doctor can suggest a number of treatments that help people quit. Ask your doctor or dentist to help you find local programs or trained professionals who help people stop using tobacco.

Symptoms
The symptoms of laryngeal cancer depend mainly on the size and location of the tumor. Common symptoms of laryngeal cancer include:

A hoarse voice or other voice changes for more than 3 weeks A sore throat or trouble swallowing for more than 6 weeks A lump in the neck

Other symptoms may include:

Trouble breathing A cough that doesn't go away An earache that doesn't go away

These symptoms may be caused by laryngeal cancer or by other health problems. People with these symptoms should tell their doctor so that any problem can be diagnosed and treated as early as possible.

Diagnosis
If you have symptoms that suggest laryngeal cancer, your doctor may do a physical exam. Your doctor looks at your throat and feels your neck for lumps, swelling, or other problems. You may have one or more of the following tests:

Indirect laryngoscopy: Your doctor uses a small mirror with a long handle to see your throat and larynx. Your doctor will check whether your vocal cords move normally when you make certain sounds. The test does not hurt. To prevent you from gagging, your doctor may spray local anesthesia on your throat. The test is usually done in your doctor's office.

Direct laryngoscopy: Your doctor uses a lighted tube (laryngoscope) to see your throat and larynx. The lighted tube can be flexible or rigid: Flexible: Your doctor puts a flexible tube through your nose into your throat. This test is usually done in your doctor's office with local anesthesia.
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Rigid: Your doctor puts a rigid tube through your mouth into your throat. A tool on the rigid tube can be used to collect tissue samples. This test may be done in your doctor's office, an outpatient clinic, or a hospital. Usually, general anesthesia is used.

Biopsy: The removal of a small piece of tissue to look for cancer cells is called a biopsy. Usually, tissue is removed with a rigid laryngoscope under general anesthesia. A pathologist then looks at the tissue under a microscope to check for cancer cells. A biopsy is the only sure way to know if the abnormal area is cancer.
If you need a biopsy, you may want to ask your doctor some of the following questions: Why do I need a biopsy?

How much tissue do you expect to remove? How long will it take? Will I need general anesthesia?

Are there any risks? What are the chances of infection or bleeding after the biopsy? Will I lose my voice for a while? Will I be able to eat and drink normally after the biopsy? How long will it take for my throat to heal? How soon will I know the results? If I do have cancer, who will talk with me about treatment? When?

Staging

If laryngeal cancer is diagnosed, your doctor needs to learn the extent (stage) of the disease to help you choose the best treatment. When laryngeal cancer spreads, cancer cells may be found in the lymph nodes in the neck or in other tissues of the neck. Cancer cells can also spread to the lungs, liver, bones, and other parts of the body. To learn whether laryngeal cancer has invaded nearby tissues or spread, your doctor may order one or more tests: Chest x-ray: An x-ray of your chest can show a lung tumor. CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your neck, chest, or abdomen. You may receive an injection of contrast material so your lymph nodes show up clearly in the pictures. CT scans of the chest and abdomen can show cancer in the lymph nodes, lungs, or elsewhere. MRI: A large machine with a strong magnet linked to a computer is used to make detailed pictures of your neck, chest, or abdomen. MRI can show cancer in the blood vessels, lymph nodes, or other tissues in the abdomen. When cancer spreads from its original place to another part of the body, the new tumor has the same kind of abnormal cells and the same name as the primary (original) tumor. For example, if laryngeal cancer spreads to a lung, the cancer cells in the lung are actually laryngeal cancer cells. The disease is metastatic laryngeal cancer, not lung cancer. It's treated as laryngeal cancer, not as lung cancer. Doctors sometimes call the new tumor "distant" disease. Doctors describe the stage of laryngeal cancer based on the size of the tumor, whether the vocal cords move normally, whether the cancer has invaded nearby tissues, and whether the cancer has spread to other parts of the body:

Early cancer: Stage 0, I, or II laryngeal cancer is usually a small tumor, and cancer cells are rarely found in lymph nodes. Advanced cancer: Stage III or IV laryngeal cancer is a tumor that has invaded nearby tissues or spread to lymph nodes or other parts of the body. Or the cancer is only in the larynx, but the tumor prevents the vocal cords from moving normally.

Treatment
People with early laryngeal cancer may be treated with surgery or radiation therapy. People with advanced laryngeal cancer may have a combination of treatments. For example, radiation therapy and chemotherapy are often given at the same time. Targeted therapy is another option for some people with advanced laryngeal cancer. The choice of treatment depends mainly on your general health, where in your larynx the cancer began, and whether the cancer has spread. You may have a team of specialists to help plan your treatment. Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat laryngeal cancer include:

Ear, nose, and throat doctors (otolaryngologists) General head and neck surgeons Medical oncologists Radiation oncologists

Other health care professionals who work with the specialists as a team may include a dentist, plastic surgeon, reconstructive surgeon, speech-language pathologist, oncology nurse, registered dietitian, andmental health counselor. Your health care team can describe your treatment choices, the expected results of each, and the possible side effects. You'll want to consider how treatment may affect eating, swallowing, and talking, and whether treatment will change the way you look during and after treatment. You and your health care team can work together to develop a treatment plan that meets your needs. Before, during, and after cancer treatment, you can have supportive care to control pain and other symptoms, to relieve the side effects of treatment, and to ease emotional concerns. You may want to talk with your doctor about taking part in a clinical trial. Clinical trials are research studies testing new treatments. They are an important option for people with all stages of laryngeal cancer.
You may want to ask your doctor these questions before you begin treatment: How large is the tumor? What is the stage of the disease? Has the tumor grown outside

the larynx or spread to other organs?

What are my treatment choices? Do you suggest surgery, radiation therapy, or a combination of treatments? Why? What are the expected benefits of each kind of treatment?

What is my chance of keeping my voice with surgery, radiation therapy, or a combination of treatments? What can I do to prepare for treatment? Will I need to stay in the hospital? If so, for how long?

What are the risks and possible side effects of each treatment? How can side effects be managed? What is the treatment likely to cost? Will my insurance cover it? How will treatment affect my normal activities? Is a research study (clinical trial) a good choice for me?

Can you recommend a doctor who could give me a second opinion about my treatment options? How often should I have checkups?

Surgery
Surgery is a common treatment for people with cancer of the larynx. The surgeon may use a scalpel or laser. Laser surgery may be performed with a laryngoscope. You and your surgeon can talk about the types of surgery and which may be right for you:

Removing part of the larynx: The surgeon removes only the part of the larynx that contains the tumor.

Removing all of the larynx: The surgeon removes the entire larynx and some nearby tissue. Some lymph nodes in the area may also be removed. It takes time to heal after surgery, and the time needed to recover is different for each person. It's common to feel weak or tired for a while, and your neck may be swollen. Also, you may have pain or discomfort for the first few days. Medicine can help control your pain. Before surgery, you should discuss the plan for pain relief with your doctor or nurse. After surgery, your doctor can adjust the plan if you need more pain control. Surgery may change your ability to swallow, eat, or talk. You may need to have reconstructive or plastic surgery to rebuild the tissue. The surgeon may use tissue from another part of your body to repair the throat. You can have reconstructive or plastic surgery at the same time as you have the cancer removed, or you can have it later on. Talk with your doctor about which approach is right for you. If you lose the ability to talk for a short time after surgery, you may find it helpful to use a notepad, writing toy (such as a magic slate), cell phone, or computer to write messages. Before surgery, you may want to make a recording for your answering machine or voicemail that tells callers that you have lost your voice. Some people may need a temporary feeding tube. Stoma The surgeon may need to make a stoma. The stoma is a new airway through an opening in the front of your neck. Air enters and leaves the trachea and lungs through this opening. A metal or plastic tube (a trach tube) keeps the new airway open. Before you leave the hospital, your health care team will teach you how to care for the stoma. You will learn to remove and clean the trach tube, clean out your airway, and care for the skin around the stoma. You may want to follow these tips:

Keep the skin around the stoma clean. If the air is dry, use a humidifier. If the air is dusty or smoky, cover your stoma with a scarf, tie, or specially made cover. Protect your stoma from water.Cover your stoma before you take a shower. Cover your stoma when you cough or sneeze.

For many people, the stoma is needed only until recovery from surgery. Several days after surgery, the tube will be removed, and the stoma will close up. If your entire larynx is removed, the stoma will be permanent. People with stomas work in almost every type of business and can do nearly all of the things they did before surgery. However, they can't hold their breath, so heavy lifting may be hard. Also, swimming and water skiing are not possible without a special device and training to keep water out of the lungs.

Some people may feel self-conscious about the way they look and speak with a stoma. They may be concerned about how other people feel about them. They may also be concerned about how their sex life may be affected. Many people find that talking about these concerns is helpful. You may want to ask your doctor these questions before having surgery:

Do you recommend surgery to remove the tumor? Why? Do I need any lymph nodes removed? Will other tissues in my neck need to be removed?

After surgery to remove the cancer, will my throat area need to be repaired with tissue from another part of my body? What is the goal of surgery? How will I feel after surgery? How long will I be in the hospital? What are the risks of surgery?

Will I have trouble swallowing, eating, or speaking? Will I need to see a speech-language pathologist for help? What will my neck look like after surgery? Will I have a scar?

If I need a stoma, do you recommend that I get a medical bracelet that says "neck breather"? Will I need reconstructive or plastic surgery? When can that be done?

Radiation Therapy
Radiation therapy uses high-energy rays to kill cancer cells. It's an option for people with any stage of laryngeal cancer. People with small tumors may choose radiation therapy instead of surgery. It may also be used after surgery to destroy cancer cells that may remain in the area. The radiation comes from a large machine outside the body. You may go to the hospital or clinic once or twice a day, generally 5 days a week for several weeks. Each treatment takes only a few minutes. Radiation therapy aimed at the neck may cause side effects:

Sore throat and difficulty swallowing: Your throat may become sore, or you may feel like there's a lump in your throat. It may be hard for you to swallow. Changes in your voice: Your voice may become hoarse or weak during radiation therapy. Your larynx may swell, causing voice changes. Your doctor may suggest medicine to reduce the swelling.

Skin changes in the neck area: The skin on your neck may become red or dry. Good skin care is important. It's helpful to expose your neck to air while also protecting it from the sun. Also, avoid wearing clothes that rub your neck, and don't shave the area. You should not use lotions or creams on your neck without your doctor's advice. These skin changes usually go away when treatment ends.

Changes in the thyroid: Radiation therapy can harm your thyroid (an organ in your neck beneath the voice box). If your thyroid doesn't make enough thyroid hormone, you may feel

tired, gain weight, feel cold, and have dry skin and hair. Your doctor can check the level of thyroid hormone with a blood test. If the level is low, you may need to take thyroid hormone pills.

Fatigue: You may become very tired, especially in the later weeks of radiation therapy. Resting is important, but doctors usually advise people to stay as active as they can. Weight loss: You may lose weight if you have eating problems from a sore throat and trouble swallowing. Some people may need a temporary feeding tube. Some side effects go away after radiation therapy ends, but others last a long time. Although the side effects of radiation therapy can be upsetting, your doctor can usually treat or control them. It helps to report any problems that you are having so that your doctor can work with you to relieve them. You may want to ask your doctor these questions before having radiation therapy:

What is the goal of this treatment? When will the treatments begin? When will they end?

What are the risks and side effects of this treatment? What can I do about them? How will I feel during therapy? What can I do to take care of myself? Are there any long-term effects?

If the tumor grows back after radiation therapy, will surgery be an option?

Chemotherapy
Chemotherapy uses drugs to kill cancer cells. The drugs that treat laryngeal cancer are usually given through a vein (intravenous). The drugs enter the bloodstream and travel throughout your body. Chemotherapy and radiation therapy are often given at the same time. You may receive chemotherapy in an outpatient part of the hospital, at the doctor's office, or at home. Some people need to stay in the hospital during treatment. The side effects depend mainly on which drugs are given and how much. Chemotherapy kills fast-growing cancer cells, but the drugs can also harm normal cells that divide rapidly:

Blood cells: When drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel weak and tired. Your health care team will check for low levels of blood cells. If your levels are low, your health care team may stop the chemotherapy for a while or reduce the dose of the drug.

Cells in hair roots: Chemotherapy may cause hair loss. If you lose your hair, it will grow back, but it may change in color and texture.

Cells that line the digestive tract: Chemotherapy can cause a poor appetite, nausea and vomiting, diarrhea, or mouth and lip sores. Your health care team can give you medicines and suggest other ways to help with these problems. Also, chemotherapy can cause painful mouth and gums, dry mouth, infection, and changes in taste. Some drugs used for laryngeal cancer can cause tingling or numbness in the hands or feet. You may have these problems only during treatment or for a short time after treatment ends.

Targeted Therapy
Some people with laryngeal cancer receive a type of treatment known as targeted therapy. It may be given along with radiation therapy. Cetuximab (Erbitux) was the first targeted therapy approved for laryngeal cancer. Cetuximab binds to cancer cells and interferes with cancer cell growth and the spread of cancer. You may receive cetuximab through a vein once a week for several weeks at the doctor's office, hospital, or clinic. During treatment, your health care team will watch for signs of problems. Some people get medicine to prevent a possible allergic reaction. Side effects may include rash,fever, headache, vomiting, and diarrhea. These effects usually become milder after the first treatment. You may want to ask your doctor these questions about chemotherapy or targeted therapy:

Why do I need this treatment? Which drug or drugs will I have How does the drug work?

When will treatment start? When will it end? How will I feel during treatment? What are the side effects? Are there any lasting side effects? What can I do about them?

Second Opinion
Before starting treatment, you may want a second opinion about your diagnosis, stage of cancer, and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion. If you get a second opinion, the second doctor may agree with your first doctor's diagnosis and treatment plan. Or, the second doctor may suggest another approach. Either way, you'll have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at all of your options.

It may take some time and effort to gather your medical records and see another doctor. The delay in starting treatment usually will not make treatment less effective. To make sure, you should discuss this delay with your doctor. There are many ways to find a doctor for a second opinion. You can ask your doctor, a local or state medical society, a nearby hospital, or a medical school for names of specialists.

Nutrition
Your diet is an important part of your medical care for laryngeal cancer. You need the right amount of calories, protein, vitamins, and minerals to maintain your strength and to heal. However, when you have laryngeal cancer, it may be difficult to eat. You may be uncomfortable or tired, and you may have trouble swallowing or not feel like eating. You also may have nausea, vomiting, dry mouth,constipation, or diarrhea from cancer treatment or pain medicine. Tell your health care team if you're having any problems eating or drinking. Also tell your health care team if you have diarrhea, constipation, heartburn, gas, belly pain, nausea, or vomiting after eating. If you're losing weight, a dietitian can help you choose the foods and nutrition products that will meet your needs. Trouble Swallowing If there's a chance that swallowing will become too difficult for you, your dietitian and doctor may recommend another way for you to receive nutrition. For example, after surgery or during radiation therapy for laryngeal cancer, some people need a temporary feeding tube. A feeding tube is a flexible tube that is usually passed into the stomach through an incision in the abdomen. A liquid meal replacement product (such as Boost or Ensure) can be poured through the tube. These liquid products provide all of the calories, protein, and other nutrients you need until you are able to swallow again.

Rehabilitation
Laryngeal cancer and its treatment can make it hard to swallow, talk, and breathe. Your health care team will help you return to normal activities as soon as possible. The goals of rehabilitation depend on the extent of the disease and type of treatment. After surgery or radiation therapy, your neck and shoulders may become stiff or weak. Your health care team can teach you exercises that help loosen your neck and shoulder muscles. Learning to Speak Again Laryngeal cancer and its treatment can cause problems with talking. A speech-language pathologist can assess your needs and plan therapy, which may include speech exercises. If you need your entire larynx removed, you must learn to speak in a new way. Talking is part of nearly everything you do, so it's natural to be scared if your larynx must be removed. Losing the ability to talk is hard. It takes practice and patience to learn new ways to speak. Before surgery or soon after, the speech-language pathologist can describe your choices for speech:

Electric larynx: An electric larynx is a small device that can help you talk after your larynx has been removed. It's powered by a battery. The electric larynx makes a humming sound like the vocal cords. Some models are used in the mouth whereas other models are placed on the neck.

Esophageal speech: There is no device to carry around for esophageal speech because the sound is made with air. A speech-language pathologist can teach you how to release air like a burp from the walls of your throat. It takes practice, but you can learn how to form words from the released air with the lips, tongue, and teeth.

Tracheoesophageal puncture: The surgeon makes a small opening between your trachea and esophagus, and a small device is placed in the opening. With practice, you can learn to speak by covering the stoma and forcing air through the device. The air makes sound by vibrating the walls of your throat. Speech therapy will generally begin as early as possible. If you have surgery, speech therapy may continue after you leave the hospital. You may want to ask your speech-language pathologist these questions:

What kind of swallowing and speech problems should I tell my health care team about? What can a speech-language pathologist do for me? If I have surgery to remove the larynx, how will I communicate with my health care team while I'm in the hospital? What can I do to prepare myself and my family?

If my larynx is removed, which methods of speech do you suggest for

me?

If an electric larynx is right for me, how would I choose the best model? Can you recommend a support group for people with swallowing or speech problems?

Follow-Up Care
You'll need regular checkups (such as every two months for the first year) after treatment for laryngeal cancer. Checkups help ensure that any changes in your health are noted and treated if needed. Laryngeal cancer may come back after treatment. Your doctor will check for return of cancer. Checkups may include a physical exam, blood tests, a chest x-ray, a CT scan, or an MRI. People who have had laryngeal cancer have a chance of developing a new cancer. A new cancer is especially likely for those who use tobacco or who drink alcohol heavily. Doctors strongly urge people who have had laryngeal cancer to stop using tobacco and stop drinking alcohol to cut down the risk of a new cancer and other health problems.

Sources of Support

Learning that you have laryngeal cancer can change your life and the lives of those close to you. These changes can be hard to handle. It's normal for you, your family, and your friends to need help coping with the feelings that a diagnosis of cancer can bring. Concerns about treatments and managing side effects, hospital stays, and medical bills are common. You may also worry about caring for your family, keeping your job, or continuing daily activities. Here's where you can go for support:

Doctors, nurses, and other members of your health care team can answer questions about treatment, working, or other activities. Social workers, counselors, or members of the clergy can be helpful if you want to talk about your feelings or concerns. Often, social workers can suggest resources for financial aid, transportation, home care, or emotional support.

Support groups also can help. In these groups, patients or their family members meet with other patients or their families to share what they have learned about coping with cancer and the effects of treatment. Groups may offer support in person, over the telephone, or on the Internet. You may want to talk with a member of your health care team about finding a support group.

Taking Part in Cancer Research

Doctors all over the world are conducting many types of clinical trials (research studies in which people volunteer to take part). Clinical trials are designed to find out whether new treatments are safe and effective. Even if the people in a trial do not benefit directly from a treatment, they may still make an important contribution by helping doctors learn more about laryngeal cancer and how to control it. Although clinical trials may pose some risks, doctors do all they can to protect their patients. Doctors are studying new treatments and combinations of treatments for laryngeal cancer:

Surgery and targeted therapy Surgery, radiation therapy, and targeted therapy Surgery, radiation therapy, chemotherapy, and targeted therapy Radiation therapy and chemotherapy Chemotherapy and targeted therapy

If you're interested in being part of a clinical trial, talk with your doctor. NCI's Web site includes a section on clinical trials at http://www.cancer.gov/clinicaltrials. It has general information about clinical trials as well as detailed information about specific ongoing studies for people with laryngeal cancer.
Last Editorial Review: 1/21/2011 (http://www.medicinenet.com/larynx_cancer/page12.htm)

The lymphatic system

What the lymphatic system is
The lymphatic system is a system of thin tubes that runs throughout the body. These tubes are called lymph vessels or lymphatic vessels. The lymphatic system is like the blood circulation - the tubes (vessels) branch through all parts of the body like the arteries and veins that carry blood. But the lymphatic system tubes are much finer and carry a colourless liquid called lymph. Lymph is a clear fluid that circulates around the body tissues. It contains a high number of lymphocytes (white blood cells). Plasma leaks out of the capillaries to surround and bathe the body tissues. This then drains into the lymph vessels. The fluid, now called lymph, then flows through the lymphatic system to the biggest lymph vessel - the thoracic duct. The thoracic duct then empties back into the blood circulation.

Lymph glands
Along the lymph vessels are small bean-shaped lymph glands or 'nodes'. You can probably feel some of your lymph nodes. There are lymph nodes in many parts of your body including

Under your arms, in your armpits In each groin (at the top of your legs)

In your neck There are also lymph nodes that you cannot feel in

Your abdomen Your pelvis Your chest

Other lymphatic system organs

The lymphatic system includes other body organs. These are the

Spleen Thymus Tonsils Adenoids

The spleen is under your ribs on the left side of your body. The spleen has two main different types of tissue, red pulp and white pulp. The red pulp filters worn out and damaged red blood cells from the blood and recycles them. The white pulp contains many B lymphocytes and T lymphocytes. These are white blood cells that are very important for fighting infection. As blood passes through the spleen, these blood cells pick up on any sign of infection and begin to fight it. The thymus is a small gland under your breast bone. The thymus helps to produce white blood cells. It is usually most active in teenagers and shrinks in adulthood.

The tonsils are two glands in the back of your throat. The adenoids are at the back of your nose, where it meets the back of your throat. The tonsils and adenoids (also called the 'nasopharyngeal' tonsils) help to protect the entrance to the digestive system and the lungs from bacteria and viruses.

What the lymphatic system does

The lymphatic system does several jobs in the body. It

Drains fluid back into the bloodstream from the tissues Filters lymph Filters the blood Fights infections

Draining fluid into the bloodstream

As the blood circulates, fluid leaks out from the blood vessels into the body tissues. This fluid is important because it carries food to the cells and waste products back to the bloodstream. The leaked fluid drains into the lymph vessels. It is carried through the lymph vessels to the base of the neck where it is emptied back into the bloodstream. This circulation of fluid through the body goes on all the time.

Filtering lymph
The lymph nodes filter the lymph fluid as it passes through. White blood cells attack any bacteria or viruses they find in the lymph as it flows through the lymph nodes. If cancer cells break away from a tumour, they often become stuck in the nearest lymph nodes. This is why doctors check the lymph nodes first when they are working out how far a cancer has grown or spread.

Filtering the blood

This is the job of the spleen. It filters the blood to take out all the old worn out red blood cells and then destroys them. They are replaced by new red blood cells that are made in the bone marrow. The spleen also filters out bacteria, viruses and other foreign particles found in the blood. White blood cells in the spleen attack bacteria and viruses as they pass through.

Fighting infection
When people say "I'm not well, my glands are up" they are really saying they have swollen lymph nodes because they have an infection. The lymphatic system helps fight infection in many ways such as

Helping to make special white blood cells (lymphocytes) that produce antibodies

Having other blood cells called macrophages inside the lymph nodes which swallow up and kill any foreign particles, for example germs This function of the lymphatic system is really part of the immune system. There is more about this in the the immune system section of CancerHelp UK.

What is Lymph?
Lymph is the name given to interstitial fluid which enters the lymphatic vessels.

Lymphatic capillaries are present in nearly all tissues. Significant exceptions are the central nervous system and bone. Small interstitial channels are present in the brain and the fluid flows into the CSF and then passes back into the circulation via the arachnoid villi. The lymph capillaries are blind-ending and possess flap valves between adjacent lymphatic endothelial cells. These functional valves permit entry of ISF but prevent its return to the interstitium. The pressure inside the lymph capillary is about 1 mmHg at rest and the flap valves are closed. The lymph capillaries interconnect and join together to form lymph venules, and then large lymph veins which drain via lymph nodes into the thoracic duct (on the left) and the right lymphatic duct. By these two final pathways, lymph returns into the circulation.

Factors in Lymph Flow

There is no central pump in the lymphatic system Forward flow is due to a pressure gradient within lymph vessels aided by one-way valves which Lymph enters lymph capillaries when the pressure in the tissue in low (up to 2mmHg) as the ISF enters lymphatic capillaries in the phase after the external pressure has passed as external When ISF pressure increases beyond +2 mmHg then these flap valves close (passively due to With flap valves closed, the increased external (ISF) pressure tends to promote forward lymph

prevent backflow flap valves between lymph capillary cells are open connective tissue fibres tend to tent open the lymph capillaries, opening the flap valves the pressure gradient) flow provided pressure is not too high (eg <=2 mmHg). At higher pressures, the unevenness of the pressure tends to close proximal lymph channels and lymph does not flow (Starling resistor effect)

The main sources of suitable levels of external pressure to promote flow are arterial pulsations The close association of lymph channels with arteries tends to favour flow Larger lymph vessels have smooth muscle in their walls. 'Intrinsic contraction' of these smooth Lymph vessels have bi-leaflet valves every few mm and these are extremely important: no

and muscular contractions

muscle cells assists forward flow forward flow is ever lost

3.4.2 Functions of Lymph

The three functions of the lymphatic system are:

Return of protein and fluid from the ISF to the circulation to maintain a low interstitial fluid

protein concentration and maintain the oncotic pressure gradient across the capillary membrane. Oedema will occur if ISF oncotic pressure is not kept low.

Role in absorption and transport of fat from the small intestine. Immunological role -lymph glands & circulation of immune cells such as lymphocytes and

dendritic cells, removal of bacteria. Lymph from most parts of the body usually has a low protein concentration. Liver lymph is different because:

It normally has a high protein concentration (due to low reflection coefficient) It contributes more than half of all the thoracic duct lymph

Consequently, the average lymph protein concentration in thoracic duct lymph is much higher than expected based on protein concentration in lymph from other body tissues.

The thoracic duct carries about 80% of the total lymph flow. This total flow at rest is about 120 mls/hr. If interstitial hydrostatic pressure rises (ie becomes less negative) due to excess fluid filtration & accumulation, the total lymph flow can increase quite markedly. Chyle is lymph from the intestines which has a milky-while appearance due to the presence of large numbers of chylomicrons. Chylomicrons are 100nm diameter complexes of mostly triglycerides (containing the long chain fatty acids) enclosed in a hydrophobic protein coat. Chylomicrons enter the lymphatic lacteals in the villi, travel in the lymph and then enter the circulation via the thoracic duct. Absorption of snake venoms (for Australian elapid snakes) occurs principally via lymph channels. If the bite is on a limb, the rate of venom absorption can be very much retarded by firm external compression of the lymph channels (pressure) and by not exercising the muscles of the limb (immobilisation). The aim of this 'pressure-immobilisation technique' for bites on limbs is to minimise entry of venom into the circulation and to 'buy time' so the person can reach medical care where specific anti-venom is available. As absorption is not directly into the venous system at the bite site, a torniquet is unnecessary and should NOT be used.

Anatomi Colli Leher adalah bagian tubuh yang terletak diantara inferior mandibula dan linea nuchae superior (diatas), dan incsura jugularis dan tepi superior clavicula (dibawah). Jaringan leher dibungkus oleh 3 fasia, fasia colli superfisialis membungkus m.sternokleidomastoideus dan berlanjut ke garis tengah di leher untuk bertemu dengan fasia sisi lain. Fasia colli media membungkus otot pretrakeal dan bertemu pula dengan fasia sisi lain di garis tengah yang juga merupakan pertemuan dengan fasia colli superfisialis. Ke dorsal fasia colli mediam embungkus a.carotis communis, v.jugularis intema dan n.vagus menjadi satu. Fasia colli profunda membungkus m.prevertebralis dan bertemu ke lateral dengan fasia colli lateral. Pembuluh darah arteri pada leher antara lain a.carotis communis (dilindungi oleh vagina carotica bersama dengan v.jugularis intema dan n.vagus, setinggi comu superior cartilago thyroidea bercabang menjadi a.carotis intema dan a.carotis extema), a.subclavia (bercabang menjadi a.vertebralis dan a.mammaria intema). Pembuluh darah vena antara lain v.jugularis externa dan v.jugularis interna. Vasa lymphatica meliputi nnll.cervicalis superficialis (berjalan sepanjang v.jugularis externa) dan nnll.cervicalis profundi (berjalan sepanjang v.jugularis interna). Inervasi oleh plexus cervicalis, n.facialis, n.glossopharyngeus, dan n.vagus. Sistem aliran limfe leher penting untuk dipelajari karena hampir semua bentuk radang atau keganasan kepala dan leher akan terlihat dan bermanifestasi ke kelenjar limfe leher. Kelenjar limfe yang selalu terlibat dalam metastasis tumor adalah kelenjar limfe rangkaian jugularis interna yang terbentang antara klavikula sampai dasar tengkorak, dimana rangkaian

ini terbagi menjadi kelompok superior, media dan inferior. Kelompok kelenjar limfe yang lain adalah submental, submandibula, cervicalis superficial, retrofaring, paratrakeal, spinalis asesorius, skalenus anterior dan supraclavicula. Daerah kelenjar limfe leher, menurut Sloan Kattering Memorial Cancer Center Classification dibagi dalam 5 daerah penyebaran kelompok kelenjar yaitu daerah: I . Kelenjar yang terletak di segitiga submental dan submandibula II. Kelenjar yang terletak di 1/3 atas dan termasuk kelenjar limfe jugular superior, kelenjar digastrik dan kelenjar servikal posterior superior III. Kelenjar limfe jugularis di antara bifurkasio karotis dan persilangan m.omohioid dengan m.sternokleidomastoideus dan batas posterior m.sternokleidomastoideus. IV. Grup kelenjar di daerah jugularis inferior dan suprac1avicula V. Kelenjar yang berada di segitiga posterior servikal