ear, nose, and throat disorders
Laryngeal Cancer
Treatment of Laryngeal Cancer
Early-stage (T1 and T2): Surgery or radiation therapy Moderately advanced (T3): Radiation therapy and sometimes chemotherapy Advanced (T4): Surgery (often followed by radiation therapy and sometimes chemotherapy) or sometimes chemotherapy and radiation therapy Early-stage glottic carcinoma is treated with laser excision, radiation therapy, or occasionally open laryngeal surgery. Endoscopic laser resection and radiation therapy usually preserve a normal voice and post-treatment function and have similar cure rates. Whether surgery or radiation is used to treat early-stage glottic cancer usually depends on the location of the lesion in the glottis, the preferences of the treating institution, and the patient. For moderately advanced glottic carcinoma, defined by a lack of vocal cord mobility or extension into the tongue, most patients are treated with both chemotherapy and radiation therapy. If the patient presents with extension outside of the larynx or with cartilage invasion, a laryngectomy provides the best oncologic results; the laryngectomy is commonly total, but endoscopic laser resection or open partial laryngectomy can be used in select appropriate cases. A total laryngectomy is also commonly used for salvage situations; however, endoscopic resection or open partial laryngectomy may sometimes be used in these situations. Early supraglottic carcinoma can be effectively treated with radiation therapy or partial laryngectomy. Laser resection has shown considerable success on early-stage supraglottic squamous cell carcinomas and minimizes functional changes after surgery. If the carcinoma is more advanced but does not affect the true vocal cords, a supraglottic partial laryngectomy can be done to preserve the voice and glottic sphincter. If the true vocal cords also are affected, a supracricoid laryngectomy or a total laryngectomy is required if surgery is chosen. As with glottic carcinoma, most advanced-stage supraglottic cancers initially are treated with chemotherapy and radiation therapy. The supraglottis has a rich lymphatic network, so in all patients with supraglottic cancer, the neck must be treated with surgery, radiation, or both. Early subglottic carcinoma is rarely treatable with endoscopic resection so radiation is the mainstay of treatment. For more advanced subglottic lesions or lesions with metastasis, chemoradiation is the standard of care unless there is extension outside of the larynx or extensive cartilage invasion in which case total laryngectomy provides the best outcome. (See also the National Cancer Institute’s summaryLaryngeal Cancer Treatment.) Rehabilitation may be required after either surgical or nonsurgical treatment. Significant swallowing problems are common after chemotherapy and radiation therapy and may require esophageal dilation, swallowing therapy, or, in severe cases, surgical replacement of the pharynx or gastrostomy tube feedings. Swallowing also is affected by surgery and may require swallowing therapy or dilation as well. Speech, on the other hand, is more significantly affected by surgery. After total laryngectomy, the patient requires creation of a new voice by way of Esophageal speech A tracheoesophageal puncture An electrolarynx In all 3 techniques, sound is articulated into speech by the pharynx, palate, tongue, teeth, and lips. Esophageal speech involves taking air into the esophagus during inspiration and gradually eructating the air through the pharyngoesophageal junction to produce a sound. A tracheoesophageal puncture involves placement of a one-way valve between the trachea and esophagus to facilitate phonation. This valve forces air into the esophagus during expiration to produce a sound. Patients receive physical rehabilitation, speech therapy, and appropriate training in the maintenance and use of this valve and must be cautioned against the possible aspiration of food, fluids, and secretions. An electrolarynx is a battery-powered sound source that is held against the neck to produce sound. Although it carries a great deal of social stigma for many patients, it has the advantage of being functional immediately with little or no training. 