Anatomy

The Larynx (also called the voice box) is a very complex structure that sits above our breathing tube (the Trachea), and in front of the swallowing tube (the esophagus). In addition to speaking, the larynx helps with swallowing and preventing food from mistakenly passing into the trachea and down to the lung, which can cause pneumonia. The coordination between swallowing and breathing is very complicated and is performed with great accuracy by the larynx; thus, tumors in this area can interfere with swallowing, breathing and voice. By the same token, treatment of tumors in this area has to take into account these important functions, and every effort needs to be made to preserve function.

The outer framework of the voice box is compromised of several firm cartilages, the Thyroid cartilage (Adam’s Apple) and Cricoid cartilage, that are connected to each other by muscles and ligaments. The Mucosal covering on the surface of the larynx has many nerves and sensors that help coordinate the functions of the voice box. The larynx is divided into 3 anatomical subdivisions: Supraglottis, Glottis, and Sub-glottis. The glottis is the mid portion of the larynx that includes the vocal cords (TVC), the portion of the voice box that moves to create our voice. Everything above the vocal cords is part of the supraglottis and all below it are the sub-glottis. Tumors in the larynx occur mostly in the glottis, and less often in the supraglottis, and only very rarely in the Sub-glottis.

	Larynx Front View		Larynx Back View

	Larynx Top View		Larynx Closed		Larynx Open

Symptoms

Tumors in the larynx can cause a variety of symptoms. Hoarseness or voice changes lasting more than a few weeks is always a concern and requires close examinations. Other symptoms include chronic sore throat, one sided ear pain, swallowing problems, chronic cough and/or blood tinged sputum. A person who has a tumor in their voice box may have only one of the symptoms or a combination of symptoms. Any of these symptoms present for more than 2 to 3 weeks requires examination by a specialist.

Risk Factors

Men are more often affected by cancer of the larynx than women. Laryngeal cancer is closely associated with cigarette smoking. Exposure to the chemicals in tobacco as they pass by the structures in the mouth, throat, voice box, and lungs is thought to lead to development of cancer.  Tobacco and alcohol use each have been found to increase the risk by many folds (as high 20-30 folds).  However, tobacco and alcohol use together can increase the risk of cancer by 70 folds. There is also an association with HPV (human papilloma virus) infection.

Diagnosis

	Larynx view through the laryngoscope

The diagnosis is made by looking at the voice box with a small fiberoptic camera (laryngoscope) performed in the office.This simple procedure takes less than 20 seconds and shows the larynx clearly so that size of the tumor can be assessed. When larger more extensive tumors are formed we often perform a CT scan, MRI, or even a PET scan.

To confirm the diagnosis a biopsy must be done of the larynx. This also is a simple procedure taking only a few minutes that involves using a laryngoscope and sampling a small piece of the tumor in the larynx. In a majority of cases, our gag reflex prevents us from being able to have this done in the office.

Staging

The TNM Staging is a universally used system based on size (T), lymph node involvement (N), and distant spread or metastasis (M).

Treatment

Leukoplakia & Dysplasia

Leukoplakia

The Tumors in the voice box usually develop first as a small white plaque on the surface of the larynx; this small white plaque is called Leukoplakia. These tumors gradually change their character and become more aggressive. In the early stages these tumors are called dysplasia, and in time it becomes moderate dysplasia and then severe dysplasia. These are still pre-cancerous stages. Once the tumor changes and becomes cancer, it is now very aggressive and can destroy the tissue around it, additionally it can it can spread to other parts of the body.

So during this early stage, the tumor is less aggressive and more easily treated, which is why seeing a doctor or specialist immediately soon after symptoms start is very crucial. When a biopsy confirms that the tumor is not cancerous but rather Dysplasia, the treatment involves removing the superficial surface layer only where the lesion (Dysplasia) is and nothing more. This procedure is called vocal cord stripping and it is not much more complicated then the biopsy itself.

	Early Larynx Cancer		Larger Larynx Cancer

T1 & T2 The smaller tumors of the Larynx do not involve the deeper structures; as such they can be readily treated with high cure rates. The treatment options include Transoral endoscopic laser surgery (surgery through the mouth rather than through a cut in the neck) or radiation therapy. Our expert team of doctor’s assesses the patient to determine which treatment option is most appropriate for the patient in terms of cure and voice outcomes.  Cure rates and voice outcomes for the two different treatment types can be very similar.  Each patient though is individually evaluated to make sure they receive the best treatment possible.

	Before Laser Surgery		After Laser Surgery

T3 & T4 These larger tumors obviously involve deeper structures of the Larynx. The treatment of choice is a combination of chemotherapy and radiation. This is an involved and rigorous treatment and requires the patient not only to work closely with his/her doctor’s (Head & Neck Surgeon, Oncologist, and Radiation Oncologist), but also have a strong bond with them. This is a difficult therapy and our doctors believe that this bond is of an utmost importance in helping to assure success.

Recurrent Tumors

When cancer recurs its best that it be diagnosed early, which is the reason all of our patients are followed closely, at least once every 3 months, if not more closely and with regular imaging studies such as CT, MRI, or PET scans. In a patient that has not been treated with radiation therapy before for their original tumor, then the option of radiation therapy exists. (Radiation therapy can be only used once on each area of the body) Most recurrences are, however, after previous radiation or a combination of chemo-radiation treatments. All patients whom have had a recurrence are considered for Transoral Endoscopic Laser Microsurgery.  If this approach is not permissible due to the size and location of the tumor than an open surgical procedure is considered.  The criterion to proceed with a transoral approach is, simply put, visibility and therefore accessibility to the entire tumor through the mouth.  This is dictated by the experience of your surgeon and availability of the appropriate equipment.  Our team of expert surgeons will consider each case individually to decide the appropriate course of action.

Partial & Hemi-Laryngectomy

Hemi-laryngectomy refers to a surgical procedure to remove close to half of the voicebox.  Parital laryngectomy is when only a portion of the larynx is removed. In most cases, the patients are still able to eat effectively, breath comfortably, and speak proficiently (although often their voice is rough).  This procedure can be done either endoscopically with the laser or through an external incision.  Open partial or hemi-laryngectomy is rarely done due to improved endoscopic techniques and laser technology.

 Supra-glottic Laryngectomy

Supra-glottic laryngectomy is removal of the voicebox above the level of the true vocal cords.  This procedure is now done almost exclusively via Transoral Endoscopic Laser Microsurgery.  Patients have good voice quality as the vocal cords are maintained.  Swallowing initially can be difficult, but overtime most patients regain normal swallowing.  All patients are encouraged to undergo swallowing and speech therapy so that speaking and swallowing improves more rapidly and effectively.

Total Laryngectomy

Total laryngectomy refers to a procedure to remove the entire voicebox.  In doing so the breathing tube or the trachea is attached to the skin of the neck directly, and so the patient breathes through a hole in the neck called a tracheostoma (or stoma for short).  This usually is the procedure of last resort, however, with therapy patients can communicate effectively by mouth, and are able to eat normally.  This is a very complex procedure to describe, but our surgeons would be more than happy to discuss it in detail.