Related narrative: Total Laryngectomy
Cancer of the larynx is a relatively rare malignancy but one whose incidence has significantly increased over the last four decades. This rise has directly paralleled the increase in tobacco use. As women have begun to make up a larger percentage of smokers in the United States, so too have their rates of laryngeal cancer. Currently, 12,500 new diagnoses of laryngeal cancer are made each year in the United States. Of these, 9,800 are men and 2,700 are women. Most patients with laryngeal carcinoma present between their 5th and 7th decades, and the vast majority of lesions are squamous cell carcinoma in origin. Other risk factors associated with laryngeal cancer include alcohol consumption as well as asbestos, nickel, and mustard gas exposure.
Because three-quarters of all patients with laryngeal cancer have tumors that originate on the true vocal folds, hoarseness is the most common presenting sign. These lesions tend to present in their early stages as nearly any size of tumor will cause symptoms. Supraglottic and subglottic lesions tend to present with advanced disease as they do not cause functional deficits until they have become larger. With these lesions, patients often present with dysphagia, odonyphagia, otalgia, hemoptysis, and airway compromise.
The diagnosis of laryngeal cancer is made by direct observation and tissue examination. Any patient with hoarseness for greater than two weeks without a clear etiology should be examined using direct or indirect laryngoscopy. This is most often accomplished using flexible endoscopes in the clinical setting. Any suspicious lesion warrants biopsy. General anesthesia is required and rigid endoscopes are used to fully visualize the entire upper aerodigestive tract. CT and MR imaging of the head and neck often add critical information to better define tumor margins and potential adenopathy.
Laryngeal cancer staging is defined not by primary tumor size but by extent of laryngeal involvement. Each of the three divisions of the larynx, the supraglottis, the glottis, and the subglottis, define advanced lesions as those that compromise vocal cord motion. This functional deficit often implies deep muscular involvement and portends eventual tumor spread outside the confines of the larynx. Squamous cell carcinoma tends to metastasize by lymphatic spread in a relatively predictable pattern within the cervical lymph node chains. While early lesions show a 10-30% rate of metastasis at diagnosis, advanced lesion show rates greater than 50%. Of those with metastatic lymph node involvement, 40% will show no clinical evidence of lymphadenopathy.
Early carcinomas of the larynx that do not compromise laryngeal motion and do not show evidence of spread to local lymph nodes are treated with a high degree of success by either radiation, or surgery alone. With either modality, voice preservation is often accomplished and minimal deficit is noted. Advanced laryngeal lesions are most often treated with multiple modalities. Historically, total laryngectomy was a frequent approach to these tumors. Within the last two decades, chemotherapy, radiation therapy, and partial laryngectomy procedures have all become tools used in conjunction with one another.
Laryngeal conservation, in limited tumors, has now become an established practice that does not compromise overall survival rates. Neoadjuvant chemotherapy regimens followed by radiation therapy regimens now show reasonable rates of laryngeal preservation. These approaches do place the patient at a higher risk for local recurrence when compared with surgery, but resection remains an option for salvage treatment.
Our current patient illustrates a number of these treatment issues. Presenting with an advanced supraglottic lesion, he was initially treated with an "organ sparing" regimen of chemotherapy and radiation. Despite an intial response, this patient showed evidence of persistent disease not amenable to partial resection. By removing the larynx, the patient was no longer at risk for aspiration and had the potential to take a normal oral diet.
The inability to communicate with voice can be devastating to patients. Rehabilitation options now offer a high degree of restoration to a patient's quality of life. While older external vibratory devices are still available (the "electrolarynx" resulting in a monotone, robotic voice) new surgical procedures can frequently provide a fluent, comprehensible voice. With these procedures, a fistula is created between the trachea and the esophagus. After a removable one-way valve is placed, patients are able to purposely draw air into the esophagus and then create sound as the air is expelled through the esophagus and shaped by the oral and nasal cavities. With this method, a majority of laryngectomy patients choosing this option are able to create a surprisingly normal voice.
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