Laryngeal cancer

The larynx is the short stretch of airway between the throat and the windpipe, and the vocal cords are stretched across the inside of it. A tumour growing there sooner or later alters the voice, and it is usually the voice that brings someone to a doctor. In cancer medicine that is a rare piece of luck: the disease gives warning while it can still be cured with breathing and speech intact. The difficulty lies elsewhere — hoarseness is easily put down to a cold, to cigarettes or to tiredness, and six months go by that way.

How the larynx is built and why that matters

It helps to picture three floors. The top one, the supraglottis, takes in the epiglottis and the entrance to the larynx, the part that closes when you swallow. The middle floor is the vocal cords themselves. The bottom one, the subglottis, runs straight on into the windpipe. Which floor a tumour grows on determines both how the illness announces itself and how it is treated.

A tumour on the cords themselves stops them meeting properly, and the voice suffers while the growth is still tiny. There are few lymph vessels there, so this kind of tumour reaches the neck nodes late. It is the commonest form and also the one with the best outlook.

The top floor works the other way round: the voice stays normal for a long time, but lymph drainage is rich, and an enlarged node in the neck may be the first thing anyone notices. Such a tumour announces itself not with hoarseness but with throat irritation, pain on swallowing that shoots into the ear, a lump-in-the-throat feeling and a muffled voice, as though the person were speaking round a hot potato. The bottom floor is rarely affected and usually declares itself with shortness of breath and noisy breathing.

The voice changes first

The one point worth reading this whole page for: hoarseness, or any change in the voice, that lasts longer than three weeks and is not explained by a cold calls for someone to look at the larynx. Not waiting, not gargles — a look. In a smoker over forty the rule allows no exceptions.

The rest of what laryngeal cancer can produce:

• a firm painless lump in the neck that does not shrink and grows slowly;
• pain or difficulty swallowing, a sense that food catches on something;
• persistent pain in one ear while that ear is healthy — referred pain from the upper larynx;
• throat irritation and a lump-in-the-throat sensation that persists for weeks;
• a stubborn dry cough, sometimes with streaks of blood in the phlegm;
• noisy breathing, a whistle on breathing in, breathlessness on ordinary exertion;
• bad breath with no dental problem to account for it;
• weight loss without any change in eating.

None of these on its own means cancer: in most people the explanation is laryngitis, reflux, vocal cord nodules or a palsy after thyroid surgery. The point is not to take fright but not to delay — early laryngeal cancer is cured in most patients, and the voice can usually be preserved as well.

What needs help straight away

A tumour can block the airway. Call an ambulance (in Spain, Italy, Portugal, Poland and Ukraine on the single European number 112) if any of the following appears:

• rapidly worsening shortness of breath, a feeling of suffocating;
• a loud whistling or harsh sound on breathing in, breathing audible across the room;
• the person cannot finish a sentence, is gasping, the lips turn blue;
• heavy bleeding from the mouth;
• being unable to swallow even saliva.

Driving to hospital in that state is not an option. While waiting for the ambulance it is better to sit the person up than to lay them down: sitting makes breathing easier.

What raises the risk and what lowers it

Two causes outweigh all the others: tobacco and alcohol. Any tobacco is harmful — cigarettes, roll-ups, a pipe, a waterpipe, chewing and snuff alike. Alcohol acts independently of tobacco, and together the two do not add up but multiply, so someone who both smokes and drinks carries a risk out of all proportion to what either habit would suggest on its own.

The remaining circumstances count for less, but are worth knowing:

• age over forty and male sex — the disease is markedly commoner in men;
• laryngeal cancer or another head and neck tumour in a close relative;
• years of acid passing from the stomach up into the larynx;
• work involving asbestos, wood or cement dust, paint and solvent fumes, acid mists or nickel;
• previous radiotherapy to the neck;
• human papillomavirus, whose part is large in tumours of the throat and tonsils and considerably smaller in the larynx proper, though the vaccine offers protection here too.

The encouraging part is that the risk falls. After stopping smoking it drops year on year and after a decade or two approaches that of someone who never smoked. Cutting down alcohol pushes in the same direction. If work involves dust and fumes, respiratory protection deserves to be taken seriously rather than treated as paperwork. And reflux of many years is something to treat, not to smother with bicarbonate.

How the diagnosis is confirmed

The first step belongs to the ear, nose and throat specialist: a fine flexible endoscope is passed through the nose and the larynx is inspected. It takes a couple of minutes, is done under local anaesthetic and shows the cords themselves and how they move. Separately, the doctor feels the neck.

If something is found, a piece of tissue is needed. It is taken during an examination of the larynx under general anaesthetic, a short procedure in which the surgeon also maps out the edges of the tumour. An enlarged neck node is sampled with a fine needle under ultrasound guidance. Only the pathologist makes the diagnosis, looking at the material down a microscope; neither endoscopy nor scanning provides it on its own.

Next the extent is established: computed tomography of the neck and chest and, where needed, magnetic resonance imaging and PET. The lungs and the gullet are looked at as well, because in people with the same tobacco-and-alcohol background a second, independent tumour is occasionally found there. All of it adds up to a stage, and the stage governs the treatment. Waiting for results usually takes two or three weeks, and that pause is the hardest part; asking about timings and ringing the hospital is entirely normal.

How it is treated

The plan is drawn up by a team: head and neck surgeon, clinical oncologist, medical oncologist, together with a speech and language therapist and a dietitian. The choice depends on which floor of the larynx is involved, the size of the tumour, the state of the nodes, and on what matters most to the person when the chances of cure are equal.

For an early tumour of the cords, either radiotherapy or laser removal through the mouth is used. The likelihood of cure is comparable; what differs is the length of treatment, the side effects and the quality of the voice afterwards — worth asking about directly and in detail.

For a larger tumour the choice lies between an organ-preserving approach — radiotherapy combined with platinum-based chemotherapy — and surgery. Surgery may mean removing part of the larynx, or removing it entirely. When the whole larynx goes, the airway is brought out onto the front of the neck: a permanent opening, a stoma, is created there, and the person breathes through it from then on. Neck nodes are often removed at the same operation.

When the tumour returns or has spread to distant sites, drug treatments come into play: agents that block the epidermal growth factor receptor, and immunotherapy with checkpoint inhibitors. They are chosen according to what the tumour tests show, and they are not interchangeable.

There is one thing a person does themselves that measurably changes the outcome: stopping smoking before treatment starts. Continuing to smoke reduces how well radiotherapy works, makes it harder to tolerate and increases the chance of a second tumour. Asking for help to stop at this stage is not too late; it is exactly the right moment.

Voice and breathing after treatment

Speech is restored even after the whole larynx has been removed, and it is worth knowing that in advance, because the fear of being left mute frightens people more than the operation does. Most often a voice prosthesis is fitted into the wall between the windpipe and the gullet: by closing the stoma with a finger or a valve, the person directs air into the gullet and speaks. There is also oesophageal speech, taught by a speech therapist, and the electrolarynx, a small device held against the neck. Rehabilitation starts early, and the first sounds come sooner than most people expect.

The stoma brings a set of skills of its own. Air no longer passes through the nose, so it is not warmed, moistened or filtered — a filter and humidification are needed, or secretions thicken. The sense of smell changes, water and bathing call for care, and every doctor and dentist should be told about the stoma.

After the neck is irradiated, a dry mouth, altered taste, difficulty swallowing, thick saliva and more vulnerable teeth are all common — which is why dental work is done before radiotherapy begins, not after. The thyroid deserves separate mention: if it lies in the treated area it often stops keeping up over time, so TSH is checked regularly, and tiredness, feeling the cold and weight gain may not be "the after-effects of treatment" at all but an underactive thyroid that can be corrected.

Follow-up runs for years: checks of the larynx, examination of the neck, attention to the lungs and the gullet. Any new hoarseness, a new lump or a sore throat between visits is a reason to come in early rather than wait for the scheduled date.

Online consultation

At an online appointment the doctor works through what lies behind a change in the voice or a lump-in-the-throat feeling and judges whether there are signs calling for the larynx to be examined within days. You will be advised which specialist to see and which investigations to raise, so that weeks are not lost on repeated courses of gargles. If the diagnosis has already been made, the doctor helps you make sense of the plan you have been offered, explains what the choice between surgery and radiotherapy really involves and prepares you for the conversation with the oncologist. Recovery afterwards can be discussed separately — stoma care, dry mouth, swallowing, thyroid checks — along with support in stopping smoking, which at this stage counts for as much as the treatment itself.

This material is for information only and does not replace medical advice.