The larynx, also called the voicebox, is located above the windpipe and in front of the food tube. Cancer of the larynx, or laryngeal cancer, can occur in the upper, middle or lower part of the larynx. The upper part of the larynx includes the supraglottis and epiglottis, the middle part or glottis houses the vocal cords, and the lower part or subglottis is located between the vocal cords and the start of the trachea.
People usually first notice a problem because of changes in the voice such as hoarseness, a persistent cough, a sore throat or the sensation that something is caught in the throat. Remember that the symptoms you experience might also be caused by other medical conditions so it’s important for you to consult a physician to confirm a diagnosis.
It’s normal for you to wonder how you got cancer of the larynx. Although we still don’t have all the answers, we do know that there are risk factors associated with people developing this cancer, especially age and sex, alcohol and tobacco use, personal history, environmental exposures and diet. Remember that there is no single cause for developing this type of cancer.
Screening and Diagnosis
You may need to undergo a number of tests for the screening and diagnosis, which will help your team to assess the stage, or severity of the cancer. Your head and neck specialist will first perform a physical examination to look for signs and symptoms of cancer, and then may order one or more of the most commonly used tests such endoscopy, laryngoscopy, and panendoscopy.
Learn about some of the other tests commonly used for head and neck cancers
For cancers of the larynx that involve the vocal cords but that have not spread to the neck lymph nodes, the treatment approaches most favored are transoral laser surgery or radiation. Transoral laser surgery is used for small tumors where the removal of a portion of the vocal cord will not dramatically alter speech. Radiation is offered to patients with more extensive tumors or voice professionals whose livelihood would suffer from any changes to the vocal cords.
For more advanced stages of laryngeal cancer, patients are offered radiation with or without chemotherapy.[/accordion_son][accordion_son title=”Surgery”]Surgery is offered for the most severe cases of laryngeal cancers that unable to be cured by radiation or chemotherapy. In such cases, surgery involves the complete removal of the voice box, leaving the patient unable to speak normally. Radiation and/or chemotherapy may be given after the surgery to ensure the complete eradication of the tumor and to prevent its spread.
If laryngeal cancer returns after radiation and/or chemotherapy, surgery will be considered. Patients are offered either a partial or total laryngectomy. Patients with small tumors may need only a partial laryngectomy, but the majority of patients with recurrent laryngeal cancer will require a total laryngectomy to remove the tumor.[/accordion_son][accordion_son title=”Early and Late Stage Cancer of the Larynx”]The surgical approaches to treating laryngeal cancer will depend on the whether the cancer is at an early or late stage of development. Small, early-stage laryngeal cancers are typically treated with radiation or by transoral laser. During the transoral laser procedure, a viewing tool called a laryngoscope is placed into the patient’s mouth to help the surgeon see the cancer and remove it using the laser.
Larger tumors that extensively damage the larynx during later stages of laryngeal cancer are treated by radical surgery followed by radiation. During the radical surgery, the entire larynx is removed during a procedure called a total laryngectomy. As a result, patients will have a permanent hole in the neck, also called a stoma, and will no longer be able to breath through the nose but will breathe through the stoma. Although swallowing may still be normal, some patients may require reconstructive surgery of the back of the throat (pharynx).
The majority of patients with late stage laryngeal cancer will also require neck dissection surgery where the lymph nodes close to the cancer are removed and then assessed by a pathologist. In cases where multiple lymph nodes test positive or where the laryngeal cancer is growing along nearby nerves, patients are treated with radiation and/or chemotherapy after surgery.
When tumors recur following radiation or chemotherapy treatment, patients are offered surgery as an option to remove the tumor. In such cases, the majority of patients will require a total laryngectomy. A small subset of patients in whom early stage laryngeal cancer recurs following radiation treatment may be eligible for partial laryngectomy.
Depending on the complexity of the surgery, patients will be left with either a straight-line excision across the neck, a side-to-side excision or a U-shaped incision, from ear to ear, which includes the stoma.[/accordion_son][accordion_son title=”Surgical Complications of Total Laryngectomy”]If the throat area does not heal properly following removal of the larynx, some patients may develop what is called a fistula. When that happens, an unwanted connection between the throat and the outside skin of the neck develops that may allow saliva or food to leak out onto the skin or space between the throat and the neck.In such cases, careful wound management on the part of the nurses and head and neck specialist may be enough to help the area to heal.
If further measures are needed, surgeons may attempt to reconstruct the area using free or attached flaps. Patients who experience this complication will require longer hospital stays, longer recovery times to swallow normally and will have to wear a tracheostomy tube for 2-4 weeks. With the help of a speech pathologist, patients may regain speech by 3-4 weeks after surgery.[/accordion_son][accordion_son title=”Preparing for Your Surgery”]Prior to surgery, all patients will have an appointment at the pre-admission clinic located at the Toronto General Hospital. You must bring all the information about recent medical tests, as well as the names and phone numbers of physicians you have seen in the past. A pre-admission nurse will perform the admission, assessment and blood work, usually 2-3 weeks before the surgery. A clinical nurse coordinator will supervise the preadmission appointment, explain the information about your surgery, introduce you to the staff and take you on a tour of the surgical inpatient unit if you request it. The pre-admission clinic is responsible for providing all tests, assessments and educational information to patients and family members before the scheduled surgery.
Starting at midnight on the night before your surgery, you must not eat, drink, chew or suck on candies as it is of the utmost importance that your stomach be empty when you have your surgery.
On the morning of your surgery, you must arrive at the hospital 2 hours before the scheduled surgery time. The preadmission nurse and nursing staff will prepare you for surgery, and insert an intravenous (IV) needle that will allow fluids, antibiotics and pain medications to be injected into your blood during the surgery.[/accordion_son][accordion_son title=”During Your Surgery”]When the tumor is removed, the head and neck surgeon will also remove a 1.5 cm section of tissue surrounding the tumor. This tissue is immediately frozen and cut into sections so that a pathologist can identify whether the tissue surrounding the tumor edges is normal or cancerous. The head and neck surgeon will await the pathologist’s diagnosis before completing the surgery.
The pathologist will give a diagnosis of ‘negative margins’ when the thin slice of tissue surrounding the tumor contains only normal cells.
Alternatively, the pathologist will give a diagnosis of ‘positive margins’ if cancer cells are observed in the thin slice of tissue surrounding the tumor. In the case of a ‘positive margin’ diagnosis, the head and neck surgeon will remove additional tissue at the tumor site before completing the surgery. The additional tissue is frozen, cut into sections and sent to a pathologist to check for cancer cells. Patients will be informed of the results during their first visit with their oncology surgeon.
For a significant number of patients, their cancer will spread to the lymph nodes in the neck region. For some, the spread to the lymph nodes will not be seen or felt. For others, the lymph nodes will be visibly swollen and lumpy to the touch. The fact that even early stage cancers spread to the lymph nodes in the neck 20-30% of the time has led to the common practice of surgically removing the neck lymph nodes closest to the cancer. This intervention will help to prevent the spread of cancer to other areas of the body.[/accordion_son][accordion_son title=”Your Recovery”]Depending on the treatments received, you may require a second, more extensive surgery to rebuild the larynx. This additional surgery is called reconstructive surgery and it may happen when the tumor is removed or at a later date after you have recovered from the first surgery.
When the surgery is finished, you will be taken to the recovery room. If it is safe to transfer you once you are awake, you will be taken to the Head and Neck surgical ward. If you require more attention, you will be transferred to the Step Down Unit where you will be closely monitored by a nurse. In the Step Down Unit you may find that you are attached to a number of tubes.[/accordion_son][accordion_son title=”Your Pain Management”]Your multidisciplinary treatment team will make it a priority to ensure that you are not in pain after surgery. During recovery, patients are able to manage their own pain using PCA (patient controlled analgesia). The word ‘analgesia’ means ‘without pain’ and an ‘analgesic’ is any medication that relieves pain. When patients are in pain, they simply press a button to immediately receive a dose of pain medication. Both the dose and number of times a patient can push the button each minute are preset by the nursing staff who follows the instructions of the patient’s head and neck specialist. The medication is usually delivered either into a vein (intravenously), under the skin (subcutaneously) or between outside of the brain and skull (epidurally). Although the medication dose is typically low, patients can press the button frequently enough to maintain an even level of pain medication that brings sustained relief to their bodies over time.[/accordion_son][accordion_son title=”Returning Home after Your Surgery”]You may need to stay in the hospital for 3-14 days, depending on the speed of your recovery or the complications that resulted from surgery. For more complicated surgical procedures, the hospital stay is typically 10-14 days. When you leave the hospital, you should have very little pain and be able to eat and breathe on your own. For minor surgical procedures, speech should return within 3-4 weeks. However, if patients undergo a total laryngectomy, they will require speech rehabilitation with the assistance of a speech pathologist.
During your stay in the hospital and also when you return home, you may need to work with a number of specialists to restore normal function to your body. A speech pathologist will help you deal with difficulties in speaking, swallowing, and chewing. A physiotherapist will help you to strengthen the muscles that may have been affected as a result of your treatment. Your head and neck specialist refer you to these specialists.
The Nurse Coordinator will help you to get ready to return home. You may need a nurse to visit you at home, and you may need to consider getting help with other issues such as smoking, drinking heavily, returning to normal activities, managing pain, and diet. Your multidisciplinary health care team will provide you with guidance and make recommendations to other specialists to help you tackle these issues.
You will need to return to see your oncology surgeon about 2-4 weeks after you leave the hospital. At that visit, the surgeon will let you know the results of your surgery and discuss the long-term considerations.[/accordion_son][accordion_son title=”Rehabilitation”]Depending on the treatments received, you may have to undergo a period of rehabilitation to help restore the function of the larynx or learn to use the devices that replace it. Various members of the multidisciplinary treatment team, such as physiotherapists and speech therapists, will be involved in your ongoing rehabilitation to help you regain swallowing movement and/or speech. These individuals will also make referrals for community support upon your return home.[/accordion_son][accordion_son title=”Speech Therapy”]Writing pad
This option is where patients write their thoughts down on a writing pad.
This device is held under the jaw and acts as a mechanical larynx byproducing vibrations that are create sound when words are made.
This is a technique where patients learn to swallow air and release it back up through the foodtube (esophagus) to create vibrations and sounds.
Tracheoesophageal Puncture (TEP)
This is the most popular method for creating speech in patients who have had a total laryngectomy. The tracheoesophagel puncture (TEP) is a small hole made between the windpipe and foodtube. The valve (voice prosthesis)placed in the hole isa one way device that allows air from the lungs to pass into the food tube but prevents food from entering the windpipe.[/accordion_son][/accordion_father]
Patients who have had cancer of the larynx will need to be closely monitored for the rest of their lives. During regular check-ups your doctor will evaluate your general health and assess whether the cancer treatments were effective. It may be necessary to have repeat blood tests and/or diagnostic tests to check for the recurrence of cancer.
Remember to monitor how your body feels so that you can let your doctor(s) know during the regular check-ups about any changes that are worrisome, such as:
- constant pains
- unexplained weight loss
- lumps, rashes, bruises, swellings, bleeding
- fever, cough, or persistent hoarseness