Describe carcinoma of the larynx with its management.

Nature, Presentation and Staging

• Carcinoma of the larynx is almost always squamous cell carcinoma.
• It is one of the commonest head and neck cancers, is strongly related to tobacco and alcohol, and is among the most curable when detected early — which places a high premium on the symptom of hoarseness.
• Risk factors — smoking.
• Premalignant lesions — leukoplakia and erythroplakia, with dysplasia on histology. Erythroplakia carries the higher risk of malignancy despite being less conspicuous.
• The site determines the presentation, the spread and the prognosis.

Management

• Treatment is decided by a multidisciplinary team and turns on the stage, the site, the patient’s fitness and their wishes about the voice
• The modern principle is organ (voice) preservation wherever oncologically safe, with surgery reserved for advanced disease and for salvage
• Early disease (T1 and T2) — radiotherapy or transoral laser microsurgery (cordectomy), which have comparable cure rates above 90% for T1 glottic disease
• The choice between them — laser surgery is a single treatment, is cheaper, avoids radiation and keeps radiotherapy in reserve for a later primary; radiotherapy may give a better voice, particularly for anterior commissure disease, but takes weeks and can be used only once
• Anterior commissure involvement is a poor prognostic feature and influences the choice
• Intermediate and advanced disease (T3 and selected T4) — concurrent chemoradiotherapy with cisplatin as organ preservation; or partial laryngectomy (vertical, supraglottic or supracricoid) in carefully selected patients
• The candidate for organ preservation must have adequate lung function and swallowing.
• Advanced disease (T4) and salvage — total laryngectomy with neck dissection and postoperative radiotherapy
• Indications for total laryngectomy — T4 disease with cartilage invasion or extralaryngeal spread; recurrence after radiotherapy (salvage); a non-functional larynx after treatment, with intractable aspiration; and extensive subglottic or postcricoid disease
• The consequences OF total laryngectomy must BE understood.
• The patient cannot be resuscitated by mouth-to-mouth and cannot swim, and must carry identification — practical points that are frequently omitted from counselling
• Voice rehabilitation, in order of current preference:
• Tracheo-oesophageal puncture with a one-way voice prosthesis.
• Oesophageal speech — swallowing and controlled eructation of air; no device is needed, but it is difficult to learn and only a minority become fluent
• The electrolarynx — a vibrating device held against the neck.
• Comprehensive rehabilitation — speech therapy, stoma care and humidification with a heat and moisture exchanger, swallowing rehabilitation, dietary support, psychological support and smoking cessation
• Prognosis — excellent for early glottic disease (over 90% at 5 years for T1), and substantially worse for advanced and supraglottic disease; with long-term surveillance for recurrence and second primary tumours.
• Cord mobility is the stage; impaired movement is T2 and fixation is T3, so it is assessed deliberately
• Glottic cancer presents early and metastasises late.
• Supraglottic cancer presents with a neck node.
• Alcohol and tobacco are synergistic, not merely additive.
• Erythroplakia carries the higher malignant risk despite being less conspicuous than leukoplakia
• Laser surgery keeps radiotherapy in reserve, which matters because radiotherapy can be given only once
• Radiotherapy may give a better voice, particularly at the anterior commissure.
• A preserved larynx that aspirates is worse than none, and the aim is a working voice rather than a retained organ
• Assess lung function before organ preservation, since these patients must tolerate some aspiration
• Panendoscopy excludes a second primary, which occurs in a significant minority because of field change
• Tracheo-oesophageal puncture is the gold standard for voice rehabilitation, giving fluent near-normal speech
• Oesophageal speech needs no device but is difficult, and only a minority become fluent with it
• A laryngectomee cannot be resuscitated by mouth and cannot swim, and should carry identification
• Smell and taste diminish after laryngectomy, since air no longer passes the olfactory cleft