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Pronunciations anesthesia computed tomography electrolarynx esophageal esophagus fistula laryngectomy larynx metastasis pharynx positron emission tomography tonsillar trachea tracheoesophageal fistula

• People may be hoarse or have a lump in the neck or difficulty breathing or swallowing.
• A biopsy is needed for diagnosis.
• Prognosis depends on how advanced the cancer is.
• Treatment is usually with surgery and radiation therapy, but sometimes chemotherapy is also used.

Cancer of the voice box (larynx), a common area of cancer within the head and neck, occurs more often in men than in women. It is linked to cigarette smoking and alcohol consumption.

Did You Know? A person who has been hoarse for more than 2 to 3 weeks should be checked by a doctor.

Symptoms and Diagnosis

This cancer commonly originates on the vocal cords or the surrounding structures and often causes hoarseness. A person who has been hoarse for more than 2 to 3 weeks should seek medical attention. Cancer in other parts of the larynx can cause weight loss, pain, pain in the ear, and difficulty in swallowing or breathing or a combination. Sometimes, however, a lump in the neck resulting from the cancer's spread to a lymph node (metastasis) may be noticed before any other symptoms.

To make the diagnosis, a doctor initially examines the larynx with a mirror or with a thin viewing tube used for direct viewing of the larynx (laryngoscope) and removes a tissue sample for examination under a microscope (biopsy). A biopsy is most often performed in the operating room with the person under general anesthesia. Occasionally, it may be performed in the doctor's office, after a topical anesthetic has been applied. If cancer is present, people also may undergo a computed tomography (CT) scan of the neck and a chest x-ray or CT scan of the chest. A positron emission tomography (PET) scan also may be done.

Staging and Prognosis

Staging is a way for doctors to describe how advanced the cancer has become, taking into account both the size and spread (metastasis) of the cancer (see Symptoms and Diagnosis of Cancer: Staging). Staging helps the doctor guide therapy and assess prognosis. Cancer of the larynx is staged according to the size and location of the original tumor, the number and size of metastases to the lymph nodes in the neck, and evidence of metastases in distant parts of the body. Stage I cancer is the least advanced, and stage IV is the most advanced.

The larger the cancer and the more it has spread, the worse the prognosis. If the tumor also has invaded muscle, bone, or cartilage, cure is less likely. About 85 to 95% of people with small cancers that have not spread anywhere survive for 5 years, compared with fewer than 50% of those who have cancer that has spread to the local lymph nodes. For people who have metastases beyond the local lymph nodes, the chance of surviving longer than 2 years is poor.

Treatment

Treatment depends on the stage and the precise location of the cancer within the larynx. For early-stage cancer, doctors may use either surgery or radiation therapy. Usually, radiation is aimed not only at the cancer but also at the lymph nodes on both sides of the neck, because many of these cancers spread to those lymph nodes. When the vocal cords are affected, radiation therapy may be preferred over surgery because it may preserve a more normal voice. However, for very early-stage cancers of the larynx, microsurgery, sometimes performed with a laser, provides identical cure rates with equal preservation of the voice and can be completed in a single treatment. Using an endoscope to remove a laryngeal tumor has gained in popularity and is a viable alternative to radiation for larger tumors as well.

Tumors larger than ¾ inch (about 2 centimeters) and those that have invaded bone or cartilage are usually treated with combination therapy. One combination consists of surgery to remove part or all of the larynx and vocal cords (partial or total laryngectomy) followed by radiation therapy. Radiation therapy is also commonly combined with chemotherapy as the primary treatment for advanced laryngeal cancers. This treatment provides cure rates equivalent to the surgery and radiation combination, and the voice is preserved in a significant number of people. However, surgery still may be required to remove any cancer that remains after this treatment. If the cancer is too advanced for surgery or radiation therapy, chemotherapy can help reduce the pain and the size of the tumor but is unlikely to provide a cure.

Treatment almost always has significant side effects. Surgery often affects swallowing and speaking. In such cases, rehabilitation is necessary. Using an endoscope to remove cancer reduces side effects on swallowing and speech when compared to surgery done through a neck incision. A number of methods have been developed that allow people without vocal cords to speak, often with good results. Depending on the specific tissue removed, reconstructive surgery may be performed. Radiation may cause skin changes (such as inflammation, itching, and loss of hair), scarring, loss of taste, and dry mouth, and occasionally, destruction of normal tissues. People whose teeth will be exposed to the radiation treatments must have dental problems corrected and any unhealthy teeth removed, because radiation makes any subsequent dental work more likely to fail, and severe infections of the jawbone may occur. Chemotherapy typically causes a variety of side effects, depending on the drug used. These side effects may include nausea, vomiting, hearing loss, and infections.

Speech Without Vocal Cords Speech requires a source of sound waves (vibrations) and a means of shaping those vibrations into words. The vocal cords normally provide the vibrations, which are then shaped into words by the tongue, palate, and lips. People whose vocal cords have been removed can regain their voice if a new source of sound vibrations can be provided, because their tongue, palate, and lips remain able to shape these new vibrations into words. There are three ways that people with no larynx can produce sound vibrations: esophageal speech, an electrolarynx, or a tracheoesophageal fistula (TEF). In all 3 techniques, sound is articulated into speech by the throat (pharynx), palate, tongue, teeth, and lips. For esophageal speech, a person is taught to swallow air into the esophagus and gradually expel the air, as in a belch, to produce a sound. Esophageal speech is difficult for the person to learn and may be hard for other people to understand, but it requires no surgery or mechanical accessories. An electrolarynx is a battery-powered vibrating device that acts as a sound source when held against the neck. It produces an artificial, mechanical sound. An electrolarynx is easier to use and understand than esophageal speech, but it requires batteries and must be carried with the person. Although it carries a great deal of social stigma for many people, an electrolarynx is functional immediately with little or no training. A TEF is a one-way valve surgically inserted between the windpipe (trachea) and the esophagus. The valve diverts air into the esophagus while the person exhales, producing a sound. TEF requires significant practice and training but eventually can produce easy and fluent speech in many people. The valve may stay in place for many months, but it requires daily cleaning. If the valve malfunctions, secretions, fluids, and food may accidentally enter the windpipe. Some types of valves require the person to block the opening in the windpipe with a finger to operate the valve, while others can be operated hands-free.

Last full review/revision July 2008 by Richard V. Smith, MD