indiacancer.org - Larynx Cancer

Larynx Cancer

		What is the Larynx?
		What is Cancer of the Larynx?
		How does Laryngeal Cancer present?
		What are the possible causes of Laryngeal Cancer and how do you prevent Laryngeal Cancer?
		How is Laryngeal Cancer detected?
		What are staging and grading?
		How is Laryngeal Cancer treated?
		What are the side effects of treatment for Laryngeal Cancer?
		What are the effects of treatment on eating?
		How do patients of Laryngeal Cancer return to normal life after surgery?
		Can total Laryngectomees be taught to speak again?
		What is the importance of followup care?

What is the Larynx?

The voice box or the larynx is a tubular, 2-inch long organ in the neck. The larynx is used by humans to talk, breath, or swallow. The larynx sits atop the windpipe or the trachea. It is made of a material called cartilage. The main cartilage, which forms the front of the larynx, is referred to in common parlance as Adam's apple.

Inside Adam's apple, forming a 'V', are two bands of muscle called the vocal cords. During the process of breathing air, the vocal cords inside the larynx are narrowed or relaxed voluntarily and the air passing in between them sets up vibrations, which produces the sound of our voice. The tongue, the teeth, and the lips form the sound into coherent words.

Just behind the trachea and the larynx in the neck lies the food pipe or the esophagus, which carries the food from the mouth to the stomach. The opening of the esophagus and the larynx are adjacent to each other in the throat.

When we swallow food, a small flap called the epiglottis moves down to cover the larynx in order to prevent the food from going down the wrong passage and into the lungs.

The three other medically significant anatomical areas of the larynx are:

The Larynx viewed from the front and the sides.

The glottis, which is where the vocal cords are.

The supraglottis, which is the area above the vocal cords.

The subglottis, which is the area which connects the larynx to the trachea.

What is Cancer of the Larynx?

The Vocal Cords (Seen from the top).

Cancer of the larynx or laryngeal cancer, can develop in any region of the larynx; the glottis, the supraglottis, or the subglottis. The cancer can also go outside the larynx into the neighboring lymph nodes or lymph glands in the neck. Lymph nodes are small bean-shaped structures, which act as stations for drainage of lymph from various organs.

Cancer cells have a tendency to spread to other tissues, either using lymph channels or blood vessels. Laryngeal cancer can also spread to other parts of the throat and neck, the lungs, and to the back of the tongue, and other distant parts of the body such as the bones and the brain.

Cancer of the larynx, which seeds itself in other parts of the body, is still known as metastatic laryngeal cancer.

How does Laryngeal Cancer present?

The presentation of laryngeal cancer depends on the size and the location of the tumor within the larynx.

Most of the cancers commence from the vocal cords. These are painless tumors, which almost always cause a change in the voice or hoarseness.

Tumors which are located in the supraglottis cause a feeling of a lump or 'something stuck down the throat', a sore throat, or an earache.

Tumors below the vocal cords are a rarity but they make it very hard to breathe and produce stridor, which is, basically noisy, difficult breathing.

A cough, which refuses to go away, or the feeling of a lump in the throat are early warning signs of cancer of the larynx.

As the tumor keeps progressing, it causes weight loss, pain, halitosis or bad breath, and frequent choking upon food.

In some cases, a tumor in the larynx may become so big that it may make the patient absolutely unable to swallow.

These signs and symptoms can also be produced by other conditions, therefore, the moment you do develop these signs, please go and show an ear, nose, and throat (ENT) specialist or and otorhinolaryngologist.

What are the possible causes of Laryngeal Cancer and how do you prevent Laryngeal Cancer?

	The following factors have strong links with laryngeal cancer:
		It is most often seen in people aged above 55 years and it is seen more commonly in men than in women.
		Smoking is a very strongly linked factor with laryngeal cancers; smokers are far more likely than nonsmokers to develop this disease.
		The risk is extremely high if these smokers are also heavy alcohol drinkers. People who stop smoking can greatly reduce their risk of cancer of the larynx as well as cancer of the pancreas, mouth, bladder, esophagus, and last but not the least, the lungs. Also, if smoking is stopped after a patient has developed laryngeal cancer and has been treated successfully, then his chances of developing a second cancer of the larynx or a new cancer of another area are greatly reduced.
		Asbestos workers also run the risk of getting cancer of the larynx. All safety rules and norms should be followed by the workers while they are working with asbestos fibers.

How is Laryngeal Cancer detected?

There are several steps for establishing the presence of a laryngeal cancer:
	The doctor takes a history of the patient's symptoms.
	The doctor examines the patient physically, including an internal examination, i.e., a rectal examination, to rule out spread of the cancer.
	The doctor orders a series of investigations; those specific for laryngeal cancer include:
		Indirect laryngoscopy, which comprises of a small, long-handled mirror being used to check the larynx and the vocal cords indirectly to look for abnormal areas. The test is painless but some patients cannot avoid gagging while the test is being performed. So your doctor may prefer to use a spray in your throat to anesthetize your posterior pharyngeal wall. This test is done on an outpatient basis.
		Direct laryngoscopy is a more specific investigation in which a self-lit or indirectly lit metallic tube is inserted into the patient's nose or mouth. This tube is called a laryngoscope. As the tube descends down the throat, the doctor can look at areas that cannot be seen with the simple mirror used in indirect laryngoscopy. A local anesthetic eases discomfort and prevents gagging, but many patients may have to get this test done under general anesthesia. Thus this test may be done on an OPD basis or after admission in a hospital.
		If the doctor visualizes any abnormalities, he performs a biopsy, which is the removal of a small piece of representative tissue. This tissue piece is then forwarded to a pathologist to examine under a microscope to rule out the presence or absence of cancer.
	Usually cancers of the larynx are squamous cell carcinomas. Squamous cells are cells lining the epiglottis, the vocal cords, and other parts of the larynx and they are flat, scale-like cells. Once the pathologist has established the presence of cancer, the doctor may order further investigations for the purpose of staging.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

How is Laryngeal Cancer treated?

A lot depends on the patient's constitution, the grade of his disease, and its staging. Patients are usually treated by a team of specialists, which utilizes a multipronged approach. This includes an otorhinolaryngologist (ENT surgeon), a surgical oncologist, a reconstructive or plastic surgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add-on.

Sometimes a patient of larynx cancer, with a lesion so located that it causes extreme breathing difficulty, may have to undergo a tracheostomy in emergency. Tracheostomy is a procedure in which a small opening is made in the front of your neck and into your trachea in order to produce a temporary or a permanent conduit for breathing. This is a lifesaving procedure, and may have to be performed, without your consultant being present, by the residents of the hospital.

Treatment strategies.

The bastions of treatment for cancer of the larynx are radiotherapy or surgery. These types of local therapies affect mainly cancer cells in the treated area.

The ideal local therapy is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It also affects cancer cells only in the zones treated. Radiation therapy is also employed for palliation, i.e., control of symptoms alone in an advanced laryngeal cancer.

Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after.

Teletherapy or external radiation is given via a machine remote from the body, while brachytherapy or internal radiation is given by implanting a radioactive source within the laryngeal cavity. Patient may or may not require both modalities of radiation.

Radiation therapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used.

If the tumor on the vocal cord is very small, the surgeon may prefer to use a powerful beam of light called laser. The beam can remove the tumor in the same way that a scalpel does, but causes less bleeding and less trauma and scarring of the adjacent tissues.

Surgery to remove the complete larynx or a portion of it is known as total or partial laryngectomy respectively. In either operation, it is mandatory for the surgeon to perform the procedure of tracheostomy, which has been described earlier. This stoma is either temporary or permanent. The tracheostomy tube or a trach tube is inserted into the tracheostomy to keep the airway open and patent.

In those patients who undergo a total laryngectomy, the tracheostomy tube can finally be dispensed with.

The importance of a procedure like partial laryngectomy is that it is a voice preserving surgery. Only a part of the larynx is removed, and that means at least one cord or a part of the cord is left behind. After a brief period, the tracheostomy can be removed and the hole in the neck closes up automatically. The patient can then breathe and talk in the usual way.

At times, a total laryngectomy has to be combined with central compartment clearance, which is clearance of all the lymph nodes located in the anterior part of the neck.

Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the larynx is by using systemic therapy (therapy which affects the entire systems of the body), which is in the form of injections or oral drugs. This form of treatment is called chemotherapy.

This treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3 to 4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy, or both, either before or after.

A special form of chemotherapy is also being tested out in laryngeal cancer, in which the drugs, when given, sensitize the tissues of the tumor to radiotherapy. Hence this type of drug is called a radiosensitizer.

What are the side effects of treatment for Laryngeal cancer?

	Unfortunately, the various modalities, which are employed for treating laryngeal cancer, are not without their side effects. The severity and the quality of these side effects depends largely upon the type of modality of treatment employed, and also the general condition of the patient during and before the treatment. Doctors and nurses play a very important role in explaining to the patient the side effects and the symptoms associated with the same during therapy. The effects of anesthesia include a soreness in the throat or hoarseness, and a drowsiness if general anesthesia has been given. There also could be a temporary limitation of physical activity. While the standard side effects of any surgery are also applicable after surgery for laryngeal cancer, there are certain special problems, which are seen with laryngectomees. For a few days after surgery, the patient is neither able to eat or drink and usually is fed intravenously. The patient may also have, as an alternative in some institutes, a nasogastric tube which is a small PVC tube inserted through the nose into the stomach at the time of surgery. Feeding through the nasogastric tube continues until there is sufficient evidence of healing of the surgical area, in which case the nasogastric tube is removed and the patient can feed in the normal manner. After the surgery, the lungs and the windpipe, which have been subjected to a great deal of irritation, produce a tremendous amount of mucus, which is expectorated by the patient in the form of sputum. The nursing staff and the residents of the hospital may apply gentle suction with a small plastic tube placed in the stoma regularly to remove the sputum which, if it thickens and forms crusts, may drastically decrease the quality of breathing. Eventually, the patient learns to cough out the sputum or to suck it out himself with a suction tube without the help of any nursing staff. The patient may also have to get the saliva sucked out from his mouth because the swelling in the throat prevents swallowing. All these are, however, just temporary phenomena. The commonest side effects associated with radiation therapy depend largely upon the part of the body radiated, and the dosage of the treatment, including the size of each fraction of radiotherapy. The commonest symptom is extreme fatigue, and, therefore, often patients are requested to rest. One of the common symptoms, which are seen after radiotherapy, is dry, reddened skin, and loss of appendages of the skin such as hair, from the area radiated. There is also a decrease in the white blood cell count which have got an immunoprotective effect against infections. Radiation to the larynx causes a change in salivation and a drastic decrease in the amount of saliva, which is produced. Because, saliva is normally dentoprotective, tooth decay can be a problem after treatment. Therefore good mouth care and oral hygiene can help keep the teeth and gums healthy and make the patient feel more comfortable. Patients should do their utmost to keep their teeth clean. If they find it difficult to floss or brush the teeth in the usual manner, patients should try gauze, soft toothbrushes, or special toothbrushes to that have spongy tips instead of bristles. A mouthwash made with diluted hydrogen peroxide, salt water, or chlorhexidine solution can keep the mouth fresh and protect the teeth from decay. It may also be helpful to use a fluoride toothpaste or rinse, to reduce the risk of cavities. The dentist may be able to help the patient in this respect. If reduced saliva makes the mouth uncomfortably dry, it would be helpful if the patient drank plenty of fluids. Some patients prefer to use artificial saliva delivered with the help of a special spray to relieve this dryness. All those patients who receive radiation as an alternative to surgery in the form of a radical procedure do not have a tracheostomy. They breathe and talk in the usual manner but the treatment sometimes has a drastic effect on their voice quality. The voice may sound weak and it is not unusual for weather patterns to decide the quality of the voice. The change in vocal quality and the feeling of a permanent lump in the throat may come from a swelling in the larynx caused by the radiation. This will eventually settle down. Sore throat is also quite common while treatment is going on. Usually, the nose and the throat and the oral cavity moisten the air when it goes to the windpipe. Because this entire route has been short-circuited by the tracheostomy; there is no natural mechanism by which the air which is being inhaled can be moistened. If this is not done,then the lungs are exposed to dry air, which is a severe irritant. Therefore, an artificial way has to be employed to moisten the air, which is now entering through the tracheostomy. Patients are usually kept comfortable with a device, which adds moisture to the air. This device is called a humidifier. A layrngectomy which has been associated with some form of neck dissection, may make parts of the neck and throat feel numb because nerves have been cut. There may also be a stiffness and weakness around the shoulder and neck. Chemotherapy The various drugs used in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Infections.
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist (chemotherapist) will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. The better psychologically prepared the patient is, the better are his or her chances of having decreased side effects. The patient should drink large quantities of liquids while therapy is in progress, and preferably avoid uncooked or raw food. Water for drinking should be filtered or boiled. Any relative or person who has any infection such as common cold should be asked to desist from coming close to the patient.

What are the effects of treatment on eating?

Patients who have had a laryngectomy, understandably, lose their interest in food because the operation changes the way things smell and taste. Radiation also tends to affect the sense of taste. Chemotherapy can make it extremely hard to eat if it is being given for palliation because initially, the lesion swells up in size. Yet good nutrition is extremely important. And eating well means getting enough calories to avoid a negative nitrogen balance, and this prevents weight loss, helps you regain your strength, and rebuild normal tissues.

The patient must be taught to swallow again with the help of a speech therapist or a nurse. Initially patients find liquids easier to swallow but some do find it better to swallow solids. If the mouth is too dry following radiotherapy, patients may prefer to indulge in soft, planned foods moistened with sauces or gravies. Others prefer to have thick soups, milk shakes, puddings, or crushed bananas. The dietitian and the nursing staff can help plan the diet for the patient. It is better to divide the meals into small meals and snacks than follow the conventional pattern of breakfast, lunch, and dinner.

How do patients of Laryngeal cancer return to normal life after surgery?

Learning to live with cancer of the larynx or the consequences of surgical intervention in the same poses a special challenge for most patients. Rehabilitation is a very important aspect of the treatment plan. It is vitally important that the doctor, nurses and especially the close relatives get together and make the patient feel as much at home as is possible.

During rehabilitation, it is important for both clinician and relatives to realize that physical recovery always outpaces emotional recovery and just the removal of the final stitch does not signify the end of the recovery phase. A significant part of the rehabilitation process is for the relatives to be as positive as possible and get the patient off his or her emotional crutches as quickly as possible. Stoma care specialists and speech therapists play a very important role in the rehabilitation of patients of laryngectomy.

Laryngectomees must be made to realize that they are employed gainfully in almost every type of business and can do nearly all the things they used to do before. Voice loss is an impediment but it is not a total handicap. The only real physical restrictions would possibly be in occupations where heavy weight lifting is required or holding the breath is required ( such as diving) because their capacity to do so is greatly reduced. Those laryngectomees who are involved in underwater work need special instructions because water going directly into the windpipe may be extremely dangerous for their lungs.

Can total Laryngectomees be taught to speak again?

It is natural for patients who are to undergo a total laryngectomy to be extremely fearful and upset. Talking is a natural part of nearly everything we do and even temporarily losing the capacity to use our voice is a frightening phenomena. Patients and their friends and relatives need to form a cohesive team to allow the patient to come through this extreme episode comfortably.

Until patients learn to vocalize again, it is important that their ability to communicate is not taken away from them. They should be equipped with writing material, slates, chalks, pencils, pens, stationary and should be watched at all times by the person or the attendant who is with the patient so that they can get through their message in the form of visual gestures. Many people like to use the magic slate for writing notes.

There are many different ways in which a total laryngectomyy can be taught how to talk. But this is greatly dependent upon the psychological motivation that the laryngectomee has. The usual and cheapest way is to teach the patient how to use esophageal speech.

Esophageal speech is a form of speech in which the patient is asked to swallow a certain amount of air, and eructate it or belch it in a controlled manner, which produces a low, gruff-sounding voice.

Sometimes, the patient may be equipped with a mechanical or electronic larynx.

Many patients can use a mechanical or electronic larynx until they learn to use esophageal speech; where some decide that they would prefer to use only esophageal speech, while some prefer to use both.

Even though esophageal speech may sound low-pitched and gruff, many people prefer to use this instead of a mechanical larynx, because it sounds more like regular speech. Also, the person becomes hands-free, and there is nothing to carry around.

Some laryngectomees may use esophageal speech after a tracheoesophageal puncture or a TEP has been performed at the time of surgery. In this procedure, after the laryngectomy is over, the surgeon makes a small opening between the trachea and the esophagus and introduces a plastic or silicone valve into the opening through the stoma. This valve acts as a one-way mechanism, and prevents food from coming into the trachea, but allows air from the lungs to be forced into the esophagus. This air produces sounds by making the walls of the throat vibrate. The words are formed in the mouth. It takes extreme practice and patience to learn esophageal speech and, unfortunately, not everyone is successful. A lot of support is required from loved ones, and the patient's psychological motivation as mentioned before is of utmost importance.

A pneumatic larynx is held over the stoma, and uses air from the lungs instead of batteries to make it vibrate. The sound it makes travels to the mouth through a plastic tube.

What is the importance of followup care?

The importance of follow up cannot be over emphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of the treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit.

Each such visit will include a detailed history, a physical examination, a chest X ray, an ultrasonography or CT scan and various blood studies where indicated.

People who have been treated for laryngeal cancer have a higher-than-average risk of developing a new cancer in the mouth, throat, or other areas of the head and neck. This is especially true for smokers. Most doctors lay a great deal of stress on patients, who have been smokers, even though they have been cured, to stop smoking immediately to avoid the eventuality of a second cancer either in the larynx or in other parts of the body.