The larynx is anatomically continuous with the nasal and oral cavities and serves as the entry into the airway. The trachea and lungs are situated inferiorly while the oesophagus and the start of the peptic system towards the back. Its position makes the larynx a very important organ. It allows speech and protects the airway during swallowing. The latter is achieved by the elevation of the larynx and the closure of the epiglottis, thus directing the food bolus created in the mouth by chewing and the action of saliva, into the oesophagus. Speech is produced with the closure of the vocal cords during expiration and the resulting vibration as the air from the lungs squeezes through. The unique character of a person’s voice is achieved by the resonance of the produced sound in the oropharynx and nasopharynx.
Laryngeal cancer is the commonest in the head and neck area but remains relatively rare accounting for 1% of all cancers. It presents around 60 – 70 years of age and it is more common in men. The last few decades, there has been a gradual increase in the number of women presenting with laryngeal cancer due to more women smoking. International studies show that more than 95% of patients with diagnosed laryngeal cancer have been smokers.
Cigarettes contain at least 60 recognised carcinogenic compounds with more important the binding action of the polycyclic aromatic hydrocarbons to human DNA. These compounds cause a mutation to the genes coding for protective proteins that lead to cell death (apoptosis). Therefore, there is uncontrolled multiplication and growth of cells leading to cancer. Another very important risk factor is the consumption of alcohol. This has a separate action but also works synergistically if the person smokes. Family history, atmospheric pollution and the human papilloma virus (HPV) have all been implicated in developing laryngeal cancer. The HPV is more specifically linked with developing oral cavity cancer.
Early laryngeal cancer presents with mild symptoms of voice hoarseness and pharyngeal globus. In more advanced stages there can be difficulty or pain on swallowing, difficulty breathing, neck lumps (lymphadenopathy), weight loss and loss of appetite. Symptoms that persist beyond two weeks should be investigated by the Ear, Nose & Throat (ENT) Surgeon. During the consultation the doctor will take the patient's history and perform a clinical examination, including assessment of the larynx with a flexible endoscope. Narrow Band Image (NBI) technology must be used, where available, since it is proven that in the hands of an experienced ENT Surgeon it can increase the pick-up rate for early cancer. Sometimes, a biopsy or a scan might be required.
Like in all cancers, the sooner the diagnosis is made the better the prognosis. Early laryngeal cancer has a 5-year survival rate of 75 – 100%. The treatment modalities aim at organ and function preservation. The decision about the treatment is taken in a multidisciplinary team setting. The patient must be informed and presented with all the treatment options available and aided by the doctor to decide the treatment. Generally, for early laryngeal cancer single modality treatment is followed with surgery having the main role. In advanced stages, there is combination or utilisation of all the modalities (surgery, radiotherapy, chemotherapy) as well as management of the neck metastases. The patient remains in regular follow-up for at least 5 years after treatment to catch early recurrences or new primary cancers.
Prevention is very important in reducing the incidence of laryngeal cancer. Increasing awareness and educating the general public, as early as school age, about the negative impact of smoking and alcohol consumption, implementing the anti-smoking law and other preventative measures like increasing taxation on cigarettes can help in this campaign.
In conclusion:
• Laryngeal cancer is not very common
• Do not ignore symptoms of voice hoarseness, difficulty swallowing or breathing problems that persist for more than 2 weeks
• Early diagnosis allows the management of the laryngeal cancer, maintaining the functions of speech, swallowing and breathing
• Prevention and not smoking play important roles in decreasing the incidence of laryngeal cancer
Dr. Panayiotis Symeonides MBChB MRCS DOHNS
Ear, Nose & Throat – Rhinology and Anterior Skull Base Surgeon