Overview

Laryngeal cancer is a type of cancer which affects the larynx. The larynx, more familiarly known as your voice box, is the hollow, cartilaginous tube which is positioned down the middle of your neck above the trachea at the C3 to C7 vertebrae and divided into anatomic subregions, namely the supraglottic, glottic and subglottic larynx, to form part of your respiratory tract.^1,3 The primary function of the larynx is to prevent swallowed food and drink from accidentally entering the lungs in the respiratory tract when breathing. As the larynx contains the vocal cords, its secondary function is to produce sound and enable speech to be articulated. The pathophysiology of most laryngeal cancers is well-differentiated squamous cell carcinoma, meaning the lining in the tissue of the larynx is most affected.² Laryngeal cancer is responsible for a third of all head and neck cancers and is predominantly found in individuals around 65 years of age, in males over females, and in those with a significant history of smoking.⁴

Stages of laryngeal cancer

The stage of laryngeal cancer is determined by the part of the larynx affected by the tumour, the mobility of the vocal cords, extra-nodal extension of the tumour into the lymph nodes and whether the cancer is metastatic, with the ability to spread around the body.³

The NHS uses the tumour-node-metastasis (TNM) system to stage laryngeal cancer.⁵ T describes the tumour size, N describes whether the tumour has infiltrated the lymph nodes and M indicates metastasis. The T stage is numbered from 1 to 4. Tumours smaller in size and localised to one area of the larynx are numbered as T1 tumours, whereas larger tumours which have spread to tissues outside of the larynx are numbered as T4.

The N stage is numbered from 0 to 3. N0 indicates no lymph nodes have been affected while N3 is indicative of one or more lymph nodes having been affected. Laryngeal cancer is further graded from 1 to 3, grade 1 describes cancers which grow slowly and remain localised compared to grade 3 which grows quickly and is metastatic. 

Causes of laryngeal cancer

The cause of laryngeal cancer is not well established, however there are various risk factors which increase the likelihood of developing laryngeal cancer.⁶ 

Risk factors

• Smoking 
• Alcohol 
• Advanced age 
• Unbalanced diet
• Human papillomavirus (HPV) infection 
• Paint, asbestos, gasoline fume and radiation exposure 

Signs and symptoms of laryngeal cancer

Symptoms: 

• Hoarse voice >3 weeks
• Change in the sound of voice
• Difficulty swallowing
• Swollen neck
• Long-lasting cough
• Breathlessness
• Persistent sore throat
• Earache
• Bad breath
• Unintentional weight loss
• Fatigue⁴

Clinical presentations: 

Laryngeal cancer presents itself differently depending on the anatomic region of the larynx affected. Increased lymph node metastasis, a mass in the neck, a compromised airway, or symptoms of dysphasia, meaning an individual’s ability to produce or understand spoken language, are signs associated with supraglottic tumours. Similarly, signs associated with glottic tumours include dysphagia, as well as presenting with a hoarse voice, earache, a persistent cough, blood in mucus and high-pitched breath sounds known as stridor. Subglottic tumours also present with stridor.^3,7

Diagnosis

Patients presenting with suspected laryngeal cancer often undergo magnetic resonance imaging (MRI) or computed tomography (CT) of the head and neck. 

Endoscopic procedures are used to retrieve a tissue biopsy of an area of the larynx, pharynx and/or upper oesophagus suspected to be infected with cancerous cells or presenting as a tumour, which is sent to a pathology laboratory for histological examination. 

The information retrieved from image and histological examination enables the doctor to stage the tumour according to the TNM system previously outlined to determine a treatment plan.⁸

Management and treatment for laryngeal cancer

Patient treatment depends on the patient’s preferences and characteristics of the tumour, including size and degree of metastasis. Management and treatment options for laryngeal cancer include radiotherapy, surgeries, chemotherapy, and targeted cancer medicines.⁸

Radiotherapy involves the use of megavoltage photons in the form of a high-energy beam which is directed towards the cancer. The toxicity of radiotherapy is associated with side effects including increased production of thick and/or sticky mucus secretions, a hoarse voice, and skin reactions.⁹

Radiotherapy in combination with surgery is the most used treatment offered in the UK. Early-stage laryngeal cancer may require an endoscopic resection, which involves a doctor retrieving a tissue biopsy by use of a laser or by use of smaller surgical instruments, in contrast, a laryngectomy involves the removal or some (partial laryngectomy) or all your larynx surgically removed (total laryngectomy).⁹

Chemotherapy is used before surgery or radiotherapy, or in combination with radiotherapy to treat advanced-stage or recurrent laryngeal cancer, to increase the effectiveness of the latter treatments by damaging the DNA of cancer cells. Due to the nature of medications used for chemotherapy, healthy cells are often killed alongside cancerous cells and therefore the immune system is often compromised. This can cause side effects such as feeling sick, experiencing hair loss, a loss of appetite and fatigue.⁹

Targeted cancer medications, such as Cetuximab, can be used in combination with radiotherapy to treat advanced-stage cancer when chemotherapy is not an option. Side effects include rashes, feeling sick, diarrhoea and experiencing shortness of breath.⁹ 

Complications

Due to the complexity of surgical intervention for advanced laryngeal cancer, postoperative complications are common which include an inflamed mouth (mucositis), a dry mouth (xerostomia), difficulty swallowing (dysphagia), oesophageal stricture requiring dilation, an inflamed oesophagus termed oesophagitis, pneumonia and sepsis.¹⁰

FAQs

How can I prevent laryngeal cancer?

Laryngeal cancer can be prevented by following a healthy lifestyle by avoiding or limiting the use of risk factors which increase the chance of developing laryngeal cancer, including tobacco, alcohol, and unhealthy foods.¹²

How common is laryngeal cancer?

In the UK, the chance of developing laryngeal cancer is relatively rare, with only approximately 2000 cases per year. It is most commonly seen in individuals over the age of 65 and there is a greater incidence of cases in men compared to women.⁴

What can I expect if I have laryngeal cancer?

Symptoms of laryngeal cancer are not limited to but include changes in the sound of your voice, having trouble swallowing solids and liquids, having a long-lasting cough and a persistently sore throat. 

Treatment options for laryngeal cancer include radiotherapy, surgery, chemotherapy and targeted cancer medicines. 

For early-stage laryngeal cancer, radiotherapy is recommended. Radiotherapy requires a mould of your face to be taken before the start of treatment, which helps to hold your head correctly to allow high-energy radiation beams to be directed to target the cancer cells in the larynx. Radiotherapy is given in short, daily sessions 5 days a week, and lasts for 3 to 7 weeks. You should be aware of the side effects of radiotherapy, which include sore skin, mouth ulcers, dryness of the mouse and loss of taste and/or appetite. 

There are 3 types of surgery used to treat laryngeal cancer, including an endoscopic resection and a partial or total laryngectomy. 

Early-stage laryngeal cancer may require an endoscopic resection, which involves a doctor removing your cancer by use of a laser or smaller surgical instruments. You will be put under general anaesthetic and therefore will be unconscious and pain-free during the procedure. 

You will need to stay within the intensive care unit for 1-2 days if you decide to undergo a laryngectomy procedure, which entails the removal of some or all of your larynx surgically removed. The surgeon will create a hole in your throat, called a stoma, to assist your breathing. Your stoma may produce excess amounts of mucus which may make breathing difficult and therefore requires cleaning at least once a day. With this treatment option, you will be fed using a feeding tube inserted into your nose to pass food into your stomach as you will be unable to eat for approximately 2 weeks until your throat has healed. Additionally, you will be unable to speak normally due to the resection of your vocal cords and you must be willing to communicate differently such as by pen and paper, and learn new forms of communication. You will meet with a speech and language therapist, who is a healthcare professional trained to provide help and support for individuals with speaking and language difficulties, to discuss the best treatment option for you.¹¹

Chemotherapy, a strong type of medication used to damage the DNA of cancer cells with the aim to kill them, is often used before surgery and radiotherapy, or in combination with radiotherapy to treat advanced or recurring laryngeal cancer. When receiving chemotherapy, you can expect it in the form of an injection into your veins, which may require you to stay in the hospital for a few days at a time during treatment. Like radiotherapy, chemotherapy does cause harm to your body’s healthy cells alongside the cancer cells, and therefore you may experience side effects such as feeling sick, hair loss, loss of appetite, and fatigue.⁹

Targeted cancer medications can be used in combination with radiotherapy to treat advanced-stage cancer when chemotherapy is not an option, and is administered intravenously by a drip into your veins. Side effects include rashes, feeling sick, diarrhoea, and experiencing shortness of breath.⁹

Emotionally, you may have feelings of sadness with your initial cancer diagnosis and feel relief once you are cancer-free, however, you may begin to feel depressed with the adjustments in your way of living following a total laryngectomy.

You should contact your GP for advice for feelings of depression or The National Association of Laryngectomee Clubs (NALC), which is a support group for patients who have undergone a laryngectomy.¹¹

When should I see a doctor?

You should contact your GP if you experience symptoms of laryngeal cancer, including changes in the sound of your voice and pain when swallowing.

Summary

Although rare, laryngeal cancer is prevalent in individuals aged >65, in males, and in those presenting with risk factors such as significant tobacco and alcohol use. Laryngeal cancer is associated with symptoms including a change in the sound of the voice and difficulty swallowing. It is diagnosed by doctors following imaging and by retrieval of tissue biopsies and can be managed and treated by the use of radiotherapy, surgery, chemotherapy, or by use of targeted cancer medicines. Life adjustments need to be made for individuals who undergo a total laryngectomy due to the discomfort of eating following surgery, adjusting to caring for a stoma, and learning new forms of communication following therapy with a speech and language therapist.