- Transfacial Approaches
- Lateral Skullbase Approaches
Cancer of Larynx
The larynx or voice box is located in the neck. The large cartilage that forms the front of the larynx produces a sharp bulge in the neck in men and is called the ‘Adams apple’. It contains the vocal cords and the muscles, which move them. The vocal cords vibrate and make sound when air is directed against them. The sound echoes through pharynx, mouth, nose and sinuses to make a person’s voice. Air passes through the pharynx, then the larynx on the way to the windpipe and lungs. The food passes through the pharynx to the esophagus. The larynx has a leaf like structure called epiglottis, which prevents the food going into the airway.
The larynx include the:
Like other parts of the body, the larynx is made up of many types of cells. When cells divide in an abnormal, uncontrolled way, they can form a non-cancerous (benign) or cancerous (malignant) tumour. Approximately 95% of laryngeal cancers are squamous cell cancers arising from the mucous membranes. Cancers forming in the glands and connective tissues of the larynx are rare. Cancers of the larynx is especially common in smokers. It is typical for the cancers of the squamous cells of the larynx to begin as pre-cancerous conditions, such as an abnormal growth (dysplaisa). Not all pre-cancerous conditions develop into cancer. They sometimes go away without treatment, especially if the person stops smoking or eliminates other risk factors. Approximately 25% of patients diagnosed with laryngeal cancers have another cancer in a nearby area, such as mouth, oesophagus or lung. Another 15% will later develop cancer in one of these areas. That’s why patients should continue with follow-up examinations throughout their lifetime.
Most of the cancers of the larynx begin on the vocal cords (atleast 70%). These tumours are seldom painful, but they almost always cause hoarseness. Tumours that begin in the area below the vocal cords are rare. Such tumours can make it hard to breathe. Breathing may even become noisy.
Early detection of laryngeal cancer is important because treatment is most effective before the disease has spread. These types of cancers usually spread to lymph nodes in the neck, the back of the tongue, other parts of the throat and neck and the lungs. Spread of cancer to lymph nodes of patients with true cord cancer is extremely rare. The reverse is true for patients with supraglottic cancers, where up to 40% of patients will have some spread of cancer to the lymph nodes of the neck.
The ENT surgeon with the help of small mirrors or a fibreoptic endoscope will examine the larynx. The fibreoptic flexible laryngoscopy can be done as an out patient procedure under local anesthesia by passing a thin endoscope through the nose in to the pharynx.
If something suspicious is seen, then the next step is doing endoscopy under general anesthesia. The larynx is examined with the help an operating microscope (Microlaryngoscopy). If some area looks abnormal, then biopsy is done from that area.
If neck nodes are enlarged, fine needle aspiration is done for cytological examination (FNAC) by the pathologist to rule out metastatic carcinoma. If cancer is found, the doctor will need to know the extent of the disease. This is called staging. In most cases, the most important factor in considering treatment options is the stage of the disease. The stage is based on the size of the tumour, as well as whether or not the cancer has spread (metastasized) and where it has spread. To obtain more information about the location and extent of the cancer, the doctor may perform the following investigations.
Surgery may also be needed later if the cancer recurs. Advanced laryngeal cancer may be treated with chemotherapy and radiation therapy in an effort to avoid surgical removal of the larynx. Locally advanced lesions, intermediate-sized cancers and recurrent cancers require different treatment therapies altogether.
The treatment plan should be individualized depending on the location of the cancer, its size, the stage of the disease and the patient’s general health.
With a partial laryngectomy, the surgeon creates a breathing hole in the neck. This artificial opening (called a stoma) may be temporary. The stoma is the hole through which air enters the trachea and lungs. Once the stoma closes, they are able to breathe normally and speak. When the tumour involves a large portion of the larynx, a more aggressive surgery is done to remove entire voice box. This procedure is called total laryngectomy. In order to complete this operation the windpipe must be brought out to the neck to form a permanent opening called stoma. Air can no longer pass from the lungs into the mouth and nose. The inhaled air passes directly through the stoma into the trachea and then into the lungs. The connection between the mouth and oesophagus is usually not affected, so food and liquid can be swallowed just as they were before the operation. As the vocal cords were removed, a laryngectomee patient will no longer have laryngeal speech. This does not mean that speech is lost and there are ways to talk without a larynx.