What is laryngeal (larynx) cancer? Causes, symptoms and treatment

Laryngeal (larynx) cancer is a type of cancer affecting the vocal cords that is especially common in men. The most important cause is tobacco and alcohol use. Poor nutrition, vitamin deficiency and genetic predisposition are the other risk factors. It is possible to prevent laryngeal cancer by exercising a healthy life-style and balanced diet. It is common in men over 50 years old; and its prevalence increased even more with the increasing tobacco use. Main symptoms of laryngeal cancer include hoarseness and voice change. Main treatment methods include surgery, radiotherapy and chemotherapy; the treatment method is based on the cancer site and stage. It can be successfully treated with early diagnosis, but there is always a risk of cancer recurrence or new cancer development in the head-neck region. The patients should be closely followed up even after the treatment.

What is laryngeal (larynx) cancer?

Laryngeal cancer is a sub-type of head-neck cancers. Cancerous tumors growing in the throat and oral area are termed based on the involved site. Almost all cancers in larynx or throat develop from the thin and flat squamous cells in the innermost layer.

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Causes of laryngeal cancer

The exact cause of laryngeal cancer remains to be unknown; however, certain factors may increase the risk:

• Smoking and using any kind of tobacco
• Excessive alcohol consumption
• Familial history of head-neck cancer
• Personal history of a head-neck cancer
• Unhealthy nutrition
• Exposure to detrimental substances such as asbestos, coal-wood dust, and paint mists
• Sexually transmitted human papilloma virus (HPV)
• Genetic syndromes
• Being male (it is five-fold more frequent than women)
• Old age (it usually develops over many years, it is not common in young individuals)

Symptoms of laryngeal cancer

• Hoarseness, voice changes
• Swallowing difficulty, sore throat
• Lump and swelling on the neck
• Prolonged cough
• Persistent earache
• Breathing difficulty
• Involuntary weight loss

Types of laryngeal cancer

Larynx has 3 sub-divisions; the site of cancer onset determines the type of the tumor and the treatment method:

• Supraglottic cancer: It starts on the upper part of vocal cords. Supraglottis is the cartilage part which contains the valve that prevents food and fluid entering the lungs
• Glottic cancer: Glottis contains the vocal cords. Approximately 60% of the laryngeal cancers start from this site.
• Subglottic cancer: It starts in the lower part of vocal cords (subglottis) and it is rare.

Some rare types of cancer may also start in larynx:

• Minor salivary gland cancers: They may develop in the cells of the small glands placed below the lining layer of larynx
• Sarcomas: They may develop in the laryngeal connective tissues
• Melanomas: They usually start in the skin, however, rarely develop inner side of body

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Diagnosis of laryngeal cancer

Physical examination includes, information about the symptoms, risk factors, familial history and personal medical history. The inner and outer parts of the throat are examined for lumps, abnormal regions and swollen lymph nodes.

Blood test

Blood tests are performed to see the functioning of liver and kidneys, and assess general health condition before treatments such as surgery or chemotherapy.

Medical procedures

• Nasendoscopy: Following the nose and the throat are narcotized using a local anesthetic spray, an endoscope is sent down through the nose to the back of the throat and a clear image of the larynx is obtained. Since laryngeal cancer patients are also at high risk for other head-neck cancers, the mouth, tongue and the neck region are also examined well.
• Laryngoscopy: It is the detailed examination of the larynx with the use of laryngoscope inserted through mouth under general anesthesia.
• Panendoscopy: Esophagus, windpipe, larynx, hypopharynx, stomach and bowels are examined with the use of endoscope.
• Biopsy: They can be performed via different methods:
• Conventional biopsy: Under general anesthesia, an incision is made, and a tissue piece is removed from the tumor for examination.
• Endoscopic biopsy: Under general anesthesia, a cell sample is taken from the larynx with the use of endoscope for microscopic examination.
• Fine needle aspiration: A tissue sample is taken from the lumps or enlarged lymph nodes on the neck with the use of a fine, empty needle for microscopic examination.

Imaging tests

Imaging tests are not used for diagnosing the laryngeal cancers, they are performed to determine the exact margins of spread after biopsy results confirm the cancer.

• Computerized tomography (CT): It is performed to see the size of the tumor, and its spread to the adjacent tissues and lymph nodes.
• Magnetic resonance (MR): Strong magnetic fields and radio waves are used for the detailed imaging of the larynx, neck and surrounding tissues.
• PET scanning: It is performed to possible sites of cancer spread.
• Ultrasound scanning: Using high-frequency sound waves, signs of cancer are assessed in the lymph nodes adjacent to larynx.
• Barium swallow: It is usually the first test to perform when there is a problem with swallowing. The patient drinks a limy fluid called barium to cover the walls of the throat and esophagus, and images are taken by a series of X-rays.
• Chest X-ray: It is performed to see whether there is cancer spread in the lungs.

Stages of laryngeal cancer

• Stage 0: Being called carcinoma in situ (CIS), the first stage is stage 0 and affects the cells in the top layer of the affected throat region.
• Stage 1: It is called the early stage. The tumor is smaller than 2 cm and limited to the entry of the larynx, vocal cords can move normally.
• Stage 2: It may have started on, under or over the vocal cords, and is starting to extend towards another part of the larynx, vocal cords can move normally. Tumor is 2 to 4 cm and did not spread to the adjacent lymph nodes and distant body regions.
• Stage 3: It is called locally advanced cancer. Tumor is still limited to larynx but larger than 3 cm, and it prevents one of the local cords from moving and is extending to adjacent regions or the inner part of the thyroid cartilage or spread to a lymph node.
• Stage 4: Tumor is larger than 6 cm and extended to the body tissues other than larynx. It may have spread to thyroid gland, windpipe, esophagus, tongue-neck muscles or spread to lymph nodes and distant organs.

Laryngeal cancer metastasis

Metastasis is called spreading of cancer from the onset site to other body regions via tissue, lymphatic system and blood. Being mostly fatal, metastatic tumor is of the same type of cancer with the original tumor which is called the primary tumor. Laryngeal cancer may spread to adjacent tissues such as neck, windpipe, thyroid, esophagus, or distant regions such as lungs, liver and bones.

Treatment of laryngeal cancer

Is there a definitive treatment for laryngeal cancer?

The treatment success of laryngeal cancer is based on the cancer stage. It can mostly be detected at early stages and the success rate is very high.

Medical (chemotherapy) treatment and side effects

In chemotherapy, potent medications are used to damage the DNAs of the cancerous cells or kill these cells. It can be administered before the surgery and radiotherapy, or together with radiotherapy; it can alleviate the symptoms when used for the treatment of advanced and recurrent cancer, it may slow down the tumor growth. Medications are usually administered via intravenous route every 3-4 weeks for 6 months at most.

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A few days of hospitalization might be necessary for each treatment session. As medications may damage the healthy tissues as much as they damage the cancerous tissue, there may be some side effects. These include:

• Feeling sick
• Hair loss
• Loss of appetite, diarrhea
• Throat, mouth ulcer
• Fatigue and the risk of infection

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Surgery for laryngeal cancer

Endoscopic resection

When the cancer is at an early stage, a magnified image of the larynx is taken by a special microscope and the cancer is removed using laser or surgical instruments under general anesthesia. After the operation, persistent voice changes or sore throat lasting for a few weeks may be seen.

Partial laryngectomy

Total laryngectomy

In large, advanced cancer, all larynx, vocal cords and adjacent lymph nodes are removed. After the operation, a permanent hole (stoma) will be opened on the neck to provide breathing (tracheotomy). The patient needs to work with a speech pathologist to learn speaking without vocal cords.

Neck dissection

If the cancer spreads to your neck, your physician may recommend operation to remove a part or all of the lymph nodes.

Cordectomy

All or a part of the vocal cords is removed. Cordectomy can be used for very small cancers or cancers on the glottic surface, and its effect on speech is based on the number of the vocal cords removed.

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Reconstructive surgery

After the operations performed to remove the cancer, muscle and skin is transplanted from a region close to the throat to improve the structure or functioning of the affected areas.

• Tracheo-esophageal puncture (TEP): It is the most common method used by surgeons to restore speech. It can be performed during or after the operation. This procedure creates a bridge between the windpipe and esophagus through a small hole on the stoma region.
• Tracheostomy: To facilitate breathing by providing air entrance to the lungs, the windpipe is bridged to a hole (stoma) in front of the neck.
• Gastrostomy tube: As the operations may affect the swallowing ability, you may need to be fed via a tube descending from your nose to your stomach to help with adequate nutrition during the healing process of your throat.

Post-operative rehabilitation

Radiotherapy

In radiotherapy, high-energy radiation doses are used to destroy the cancerous cells. It can be used as main therapy in early-stage laryngeal cancers or added to chemotherapy after the operation in recurrent cancer. A special plastic mask is produced by taking a mold of the face before the treatment to provide correct head positioning and sending the rays directly to the larynx during the procedure.

The type of radiation delivery is based on the type and stage of the cancer; external radiotherapy which sends rays from an external machine or internal radiotherapy in which a sealed radioactive substance is placed into tumor or surrounding area inside a needle, seed, wire or catheter.

The treatment usually lasts for 3 to 7 weeks; it is given in short sessions for 5 days a week, and the patient rests on the remaining 2 days. Side effects include skin reactions similar to sunburn, mouth ulcers, fatigue, and loss of taste and appetite.

Is laryngeal cancer fatal?

The condition is based on the size, stage and treatment response of the cancer; in general, early-stage cancers have higher survival rates. However, many other factors including the patient’s age and general health status may affect the prognosis.

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Life expectancy in laryngeal cancer

Survival rates for laryngeal cancers are based on the onset site and stage of the laryngeal cancer. If early diagnosis is possible, 5-year survival rate after the treatment is around 80-90%. In general, 60% of the patients have a chance of surviving 5 years or longer.

Medicinal herbs that are good for laryngeal cancer

• Rosemary: Its antioxidant, and tumor- and inflammation-preventing effects protect from cancer by strengthening the immune system. You can wash your mouth by rosemary juice or consume rosemary tea.
• Ginger: It is antibacterial, prevents against inflammation and is effective against upper airway infections. It can be consumed in food, salads or as tea. Ginger tea alleviates the throat and protects the vocal cords against irritation.
• Echinacea: It is effective in a range of conditions causing hoarseness from infection to allergy. It is effective in strengthening the immune system for the treatment of cancer and preventing the damage caused by chemotherapy.
• Garlic: Being a natural antibiotic, garlic is effective against hoarseness, reduces irritation, and prevent tumor formation and advanced. You can prepare a natural syrup by mixing sliced 1-2 cloves of garlic with honey and apple cider vinegar.

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Moreover, sage, chamomile, juniper seed, basil, mustard, dead nettle, black mulberry, blackberry, black pepper, thyme, rose hip and pomegranate minimize the negative effects of the laryngeal cancer and alleviate the throat.

Diet for laryngeal cancer patients

A balanced diet is an important part of being healthy. Consuming various food at accurate rations means keeping the healthy weight. Eating plenty of fruits and vegetables that are sources of vitamin and minerals, and consuming plenty of cheese, yoghurt, milk and soy drinks, and water may reduce the risk of cancer.

Legumes, fish, eggs and meat are the necessary protein sources to allow body to repair itself. Food and beverages which contain high fat, salt and sugar should be avoided.

Recommendations for laryngeal cancer patients

• Avoid using alcohol and tobacco products.
• Eat healthily (Mediterranean diet which contains fruits, vegetables, tomato, citrus fruits, olive oil and fish oil reduces the risk of laryngeal cancer).
• Alternative treatment methods such as acupuncture, massage therapy, meditation and relaxing techniques may help you cope with the adverse effects of the diagnosis and treatment.
• Educate yourself about laryngeal cancer to feel relaxed when making treatment decisions.
• Talk with close friends or family members who can help you cope with your feelings.
• Take good care of yourself during treatment; avoid stress, get good sleep, walk or exercise, and make time for listening music or reading.
• Show up for all follow-up visits for the first two years after the treatment to monitor your recovery and check for cancer recurrence.

References: 1- What is throat cancer?, 2- Throat Cancer, 3- Laryngeal (larynx) cancer