Cancer Larynx

Aetiology
Both tobacco and alcohol are well established risk factors
in laryngeal cancer. Cigarette smoke contains benzopyrene
and other hydrocarbons which are carcinogenic
in man. Combination of alcohol and smoking increases
the risk 15-folds compared to each factor alone (2-3
folds). Previous radiation to neck for benign lesions or
laryngeal papilloma may induce laryngeal carcinoma.
Japanese and Russian workers have reported cases of
familial laryngeal malignancy incriminating genetic factors.
Occupational exposure to asbestos, mustard gas and
other chemical or petroleum products has also been
related to the genesis of laryngeal cancer but without
conclusive evidence.

Diagnosis of Laryngeal Cancer
1. History. Symptomatology of glo ttic, subglottic
and supraglo ttic lesions would vary and is described
under appropriate heads. It is a dictum that any patient in
cancer age group having persistent or gmduall)' increasing
hoarseness of voice for 3 weeks must have laryngeal examination
to exclude cancer.
2. Indirect laryngoscopy
(a) Appearance of lesion. Appearance of lesion will vary
with the site of o ri gin.
(i) Lesions of suprahyoid epiglottis are usually
exophytic while those of infrahyoid epiglo ttis
are ulcerative.
(ii) Lesion of voca  cord may appear as raised nodule,
ulcer o r thickening.
(iii) Les ion of anterior commissure may appear as
gran ulation tissue.
(tv) Lesion of subglottic region appears as a raised
submucosal nodule, mostly involving the anterior
half
(b) Vocal cord mobility. Impairment or fixation of vocal
cord indicates deeper infiltration into thyroarytenoid
muscle, cricoarytenoid Joint or invasion of
recurrent laryngeal nerve, and is an important sign.
(c) Extent of disease. Spread of disease to vallecula, base
of tongue, pyriform fossa should be noticed .
3. Examination of neck. It is done to find (i) extralaryngeal
spread of disease, and (ii) nodal metastasis.
Growths of anterior commissure and subglottic region
spread through cricothyro id membrane and may produce
a midline swelling. They may a lso invade the thyrOid
cartilage and cause perichondritis wh en cartilage will be
tender on palpation. ThyrOid gland and strap muscles
may also be invaded.
Search should be made for metastatic lymph nodes,
their size and number; and also if they a re mobile or
fixed, unilateral, bilateral or contralateral.
4. Radiography
(a) X-ray chest is essential for co-existent lung disease
(e.g. tuberculosis), pulmonary metastasis or mediastinal
nodes.
(b) Soft tissue lateral view neck Extent or lesions of epiglottiS,
aryepiglottic folds, arytenoids and involvemenc
of preepiglottic space may be seen. Destruction of
thyroid cartilage may be seen.
(c) Contrast laryngograms. Rad o-opaque dye, dionosil, is
instilled into the larynx. Laryngograms outline the
surface extent of tumours. This investigation has now
been replaced by CT scan.
5. CT scan. It is a very useful investigation to find
the extent of tumour, invasion of pre-epiglottic or
paraepiglottic space, destruction of cartilage and lymph
node involvement.
6. Direct laryngoscopy. It is done to see (a) the hidden
areas of larynx and (b) extent of disease.
Hidden areas of the larynx include infrahyoid epiglottis,
anterior commissure, subglottis and ventricle, which
may not be clearly seen by mirror examination making
direct laryngoscopy essential.
7. Microlaryngoscopy. For small lesions of vocal
cords, laryngoscopy is done under microscope to better
visualise the lesion and take more accurate biopsy specimens
without damaging the cord.
S. Supravital staining and biopsy. Toluidine blue
is applied to the laryngeal lesion and then washed with
saline and examined under the operating microscope.
Carcinoma-in-situ and superficial carcinomas take up
the dye while leukoplakia does not. Thus, it helps to
select the area for biopsy in a leukoplakic patch.
Treatment of Laryngeal Cancer
It depends upon the site of lesion, extent of lesion, presence
or absence of nodal and distant metastases. Treatment
consists of:
1. Radiotherapy,
2. Surgery, (a) conservation laryngeal surgery, (b) total
laryngectomy,
3. Combined therapy.
1. Radiotherapy. Curative radiotherapy is reserved
for early lesions which neither impair cord mobility nor
invade cartilage or cervical nodes. Cancer of the vocal
cord without impairment of its mobility gives a 90% cure
rate after irradiation and has the advantage of preservation
of voice. Superficial exophytic lesions, especially of the tip
of epiglottis, and aryepiglottic folds give 70-90% cure rate.
Radiotherapy does not give good results in lesions with
fixed cords, subglottic extension, cartilage invasion, and
nodal metastases. These lesions require surgery.
2. Surgery. (a) Conservation surgery. Earlier total
laryngectomy was done for most of the laryngeal cancers
and the patient was left with no voice and a permanent
tracheostome. Lately, there has been a trend for conservation
laryngeal surgery which can preserve voice and also
avoid a permanent tracheal opening. However, few cases
would be suitable for this type of surgery and they should
be carefully selected. Conservation surgery includes:
(i) Excision of vocal cord after splitting the larynx
(cordectomy via laryngofissure),
(ii) Excision of vocal cord and anterior commissure
region (partial frontolateral laryngectomy),
(iii) Excision of supraglottis, i.e. epiglottis, aryepiglottic
folds, false cords and ventricle-a sort of transverse
section of larynx above the vocal cords (partial
horizontal laryngectomy).
(b) Total laryngectomy. The entire larynx including
the hyoid bone, pre-epiglottic space, strap muscles, and one
or more rings of trachea are removed. Pharyngeal wall is
repaired and lower tracheal stump sutured to the skin for
breathing.
Laryngectomy may be combined with block dissection
for nodal metastasis.
Total laryngectomy is indicated in the follOWing
conditions:
• T3 lesions (i.e. with cord fixed)
• All T4 lesions
• Invasion of thyroid or cricoid cartilage
• Bilateral arytenoid cartilage involvement
• Lesions of posterior commissure
• Failure after rad iotherapy or conservation surgery
• Transglottic cancers, i.e. tumours involving supraglottis
and glottis across the ventricle, causing fixation
of the vocal cord.
It is contraindicated in patients with distant metastasis.
3 . Combined therapy. Surgical ablation may be
combined with pre- or post-operative radiation to
decrease the incidence of recurrence. Pre-operative radiation
may also render fixed nodes resectable.

Vocal Rehabilitation After Total
Laryngectomy
After laryngectomy, patient loses his speech completely.
Various methods by which communication can be established
are listed in Table 603.
1. Oesophageal speech. In this, patient is taught to
swallow air and ho ld it in the upper oesophagus and then
slowly ej ect it from the oesophagus into the pharynx.
Patient can speak 6-10 words before re-swallowing air.
Voice is rough but loud and understandable.
2. Artificial larynx. It is used in those who fall to learn
oesophageal speech.
(a) Electrolarynx. It is a transistor ised, battery operated
portable de,' ice. Its vibrating disc is held against the soft

tissues of the neck and a low pitched sound is produced in
the hypopharynx which is further modulated into speech
by the tongue, lips, teeth and palate
(b) Transoral pneumatic device. Another tyre of art ificial
larynx is a transoral device. Here vibrations produced
in a rubber diaphragm are ca rried by a pbstic tube
into the back of the oral cavity where sound is converted
into speech by modulators. This is a pneumatic type of
device and uses expired air from the tracheostome to
vibrate the diaphragm.
3. Tracheo-oesophageal speech. Here attempt is made
to carry air from trachea to oesophagus or hypopharynx
by the creation of skin-lined fistula or by placement of an
artificial prosthes is. The vibrating column of air entering
the pharynx is then modulated into speech. This technique
has the disadvantage of food entering the trachea.
These days prosthesis (Blom-Singer or Panje) are being
used to shunt air from trachea to the oesophagus. They
have inbuilt valves which work only in one direction
thus preventing problems of aspiration.