Larynx (voice box)

Head and Neck Cancer Introduction Page
oral cavity
oropharynx (soft palate, tonsil, base of tongue)
larynx (voice box)
hypopharynx (pyriform sinus, posterior phanryngeal wall, post-cricoid region)
nasal cavity/paranasal sinuses
nasopharynx
salivary glands
paragangliomas (glomus tumors)
thyroid


Larynx (voice box)

Background
Signs and Symptoms
Clinical Evaluation
Treatment
Follow-Up

Background


Illustration courtesy of Lippincott Williams & Wilkins © 2004

The larynx, or voice box, consists of three major anatomic areas: the supraglottic larynx; the glottic larynx; and the subglottic larynx.

The supraglottic larynx is the portion of the larynx above the vocal cords. It consists of the false cords, the laryngeal ventricles, the epiglottis and the aryepiglottic folds. The glottic larynx consists of the vocal cords themselves. The subglottic larynx is the portion of the larynx below the vocal cords. This area is continuous with the upper trachea.

The combination of tobacco use and alcohol use significantly increases the possibility of laryngeal cancer.

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Signs and Symptoms

The symptoms of laryngeal cancer may vary according to the exact location within the larynx from which the tumor is arising. Tumors of the supraglottic larynx tend to bring on sore throat and painful swallowing. Hoarseness is also possible, if the tumor extends onto the vocal cords. Tumors arising from the true vocal cords, as well as those arising from the subglottic larynx, usually lead to hoarseness. Hoarseness is often an early sign of laryngeal cancer. Because hoarseness occurs very early in the natural history of vocal cord cancer, most patients with cancer of the vocal cords have early stage tumors.

It is very uncommon for cancers of the true vocal cords to spread outside the larynx. Therefore, it is very unlikely that these patients will have evidence of lymph node metastasis to the neck. However, patients with supraglottic larynx cancers tend to have a higher incidence of neck involvement. Some patients even see their doctor with a lump in their neck, only for the primary tumor to be discovered after additional evaluation.

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Clinical Evaluation

The first step in a proper clinical evaluation is a complete history and physical examination, which should include a thorough head and neck examination. Once a lesion in the larynx has been identified, a biopsy (which involves removing a piece of living tissue from the suspicious area and examining it with a microscope) should be performed to establish the diagnosis. If there is an enlarged lymph node in the neck, a fine needle aspiration biopsy is often done to obtain the diagnosis of the neck node. A fine needle aspiration biopsy involves inserting a small needle into the mass and withdrawing cells. The pathologists examines these cells under a microscope to see if they are cancerous.

Usually, a biopsy is performed on the larynx as well. A CT scan, which uses X-rays to create a two-dimensional image of the area, and/or an MRI scan, which uses a magnetic field and pulses of radio wave energy to visualize the detailed anatomy, will often be done to evaluate the extent of the primary tumor, and to assess if cancer has spread to the lymph nodes. A PET scan, which creates computerized images of the metabolic changes that occur in tissue, may also be performed for further evaluation of the extent of the primary tumor, as well as the presence of metastases in the neck. Today, PET/CT scans can be performed together, which gives a higher level of radiologic information. It also helps to explore the rest of the body for any evidence of cancer spread outside the head and neck region.

An examination under anesthesia including direct laryngoscopy and biopsy is a very important part of the clinical evaluation. This involves an examination under anesthesia, which allows physicians to assess the exact extent of disease. Along with proper biopsy and tissue sampling, this is essential in the treatment planning process.

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Treatment

Early stage supraglottic larynx cancers can be treated with either radiation therapy or surgery. The decision as to which modality to use is based upon the exact extent of disease, how well the patient is functioning, and his/her medical condition. When radiation therapy is utilized, the standard of care is to deliver appropriate radiation therapy to the larynx as well as to the lymph nodes on both sides of the neck. Surgery in the form of a supreglottic laryngectomy is a more conservative procedure that preserves the vocal cords. It is a consideration for patients with good lung function. Patients with poor lung function should not be considered for this surgery.

Early cancers of the true vocal cord are usually treated with definitive radiation therapy. This means that radiation is directed to the larynx itself, since there is no need to treat the surrounding lymph nodes. The cure rates are very high, and the functional and voice outcomes are good or excellent for most patients. Surgery may also be selected for certain patients with true glottic cancer. For some patients, laser vaporization, or directed surgical excision, may be appropriate. In general, radiation therapy provides a better functional and voice outcome, which is the reason it is usually selected.

Early cancers of the subglottic cancer are uncommon. However, they are usually treated with radiation therapy. As mentioned above, selected patients may be offered surgical options.

More advanced lesions of the supraglottic larynx present more complex management issues. If the patient is a candidate for a surgical procedure that does not require total laryngectomy, then primary surgery may be an option. The majority of patients are now treated on combined modality programs, usually referred to as Larynx Preservation Programs. These programs usually involve a combination of chemotherapy and radiation therapy delivered together. Surgery is generally reserved for recurrence, if the radiotherapy/chemotherapy does not work. It is absolutely essential that patients are evaluated by a multidisciplinary team, including otolaryngologists, radiation oncologists and medical oncologists. This ensures that the patient receives all of his/her treatment options, and that a proper strategy can be executed. At Continuum Cancer Centers of New York, we are committed to using state-of-the-art treatments for cancer, which includes a multidisciplinary, multi-institutional approach.

Advanced cancers of the glottic larynx have many of the same issues as advanced cancers of the supraglottic larynx. The goal is to perform surgery without a total laryngectomy (total removal of the voice box). Today, most patients are managed on a larynx preservation program. A larynx preservation program involves the use of combined chemotherapy and radiation therapy. Often, surgery to the neck is added after the chemotherapy/radiotherapy. It is absolutely essential for the patient to undergo a multidisciplinary evaluation, which includes the head and neck surgeon, radiation oncologist and medical oncologist, so that an appropriate decision about management can be made.

If a patient with either advanced supraglottic or glottic cancer has metastatic disease to the neck, a neck dissection is usually performed after the chemotherapy/radiotherapy is completed. The general approach is to complete the chemotherapy/radiotherapy, and perform a neck dissection about 6 to 8 weeks later. If the patient has no obvious spread to the neck, or minimal spread to the neck, then treatment may be chemotherapy/radiotherapy alone. These decisions are made by the multidisciplinary team and the patient.

Despite the availability of all treatment options mentioned above, certain patients may still require a total laryngectomy (total removal of the voice box) as part of their treatment. When this is necessary, patients are eligible for a variety of rehabilitation and reconstructive procedures. These are geared to restoring as much of their voice function as possible.

Click Here for more information about radiation oncology treatments for head and neck cancer.

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Follow-up

After treatment is completed, the patient enters the follow-up phase. Usually, all of the treating physicians are involved in follow-up evaluations. For the first year, patients are usually seen every one to two months. During the second year, they are often seen every two to three months. After the second year, patients are usually seen every three to six months. Of course, the follow-up schedule is individualized for each patient.

Imaging procedures like CT scans, PET scans, or fused PET/CT scans, are done according to a routine that is individualized for each patient. Not all patients require these studies. A chest X-ray is usually done on an annual basis. Regular dental evaluation is done, because good dental care is essential to the head and neck health.

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