A Technical Explanation
Mr P Morar M.D. FRCS Ed (ORL) Consultant Otolaryngologist Head & Neck Surgeon

Laryngeal Cancer

Within the group of head and neck malignancies, laryngeal cancer is the most common. Ninety percent of laryngeal cancers are called squamous cell carcinomas, that is, they originate from the lining of the voice box membrane. The likely cause of the malignancy is mainly related to smoking and alcohol intake, particularly the combination of both.
A clear distinction needs to be made between cancer of the true vocal cords (glottis), cancer of the upper part of the voice box (false vocal cords, arytenoids, aryepiglottic folds and the epiglottis) and cancer below the vocal cords (subglottic cancer). Cancer involving the glottis accounts for approximately 65% of the laryngeal cancers. Subglottic cancer is rare (5%). This distinction is made because of the differences in symptoms, tumor spreading patterns and therapy modalities of these different sites.

DIAGRAMATIC LOOK AT THE TOP OF THE VOICE BOX

The most important symptom in the patient group with vocal cord cancer is persistent hoarseness. In a more advanced stage difficulty swallowing and shortness of breath occurs. Referred pain into the ear may be present and generally indicates deeper involvement of the tumour.
Lymph node enlargement and involvement is more frequent in sites that involve more than just the true vocal cords. This is because the lymphatic drainage of areas other than true vocal cords is richer. As a result cancer confined to the vocal cord usually presents with a hoarse voice. Cancers from other regions of the voice box presents with lymph node involvement. Since hoarseness is a relative early symptom in glottic cancer, these tumors are generally smaller than supraglottic cancers at first detection. It is very rare for a cancer from the voice box to spread beyond the confines of the neck without having first affected the glands of the neck.

Treatment Modalities of Laryngeal Cancer

Treatment depends upon a number of factors. As with any cancer the diagnosis has to be confirmed with a positive biopsy. This is usually performed at endoscopy under a general anaesthetic. Precise staging is of utmost importance as it dictates the treatment modalities. This may require the need for a CAT scan.
The treatment modalities differ to some extent for the sub-sites within the larynx and also for the institution involved. Depending on the stage the therapy will consist of radiation or surgery (including laser treatment) or a combination of the two. Chemotherapy is of some value in certain cases.
It is impossible to determine a standard treatment for each tumor stage and sub-site because many factors play a role in the final decision of which therapy is best. Anatomic considerations and the patient’s health and preference, are additional factors that can play a decisive role in therapy choice.
Decisions in respect of the best form management for any particular patient is made by a multi-disciplinary team. Guidelines issued by the British Association of Otorhinolaryngologists, head and Neck Surgeons are followed in respect of the optimum form of management.

PRESENTATION OF PATIENTS

A suspicion that something might be amiss usually leads the patient to seek advice from the Family Doctor. An urgent referral is made for specialist consultation at the Hospital. The appointment for this consultation should be within no more than 2 weeks.

The first appointment will be in the General ENT outpatients. Patients are encouraged to bring a friend or relative. The specialist will take a history of what has been happening. A preliminary examination will include a look at the voice box using an instrument called a fibreoptic nasoendoscope. This instrument is introduced through the nose. It may cause mild temporary discomfort but no major pain. The patient may also have a Fine Needle Aspirate taken for Cytology (FNAC), if a lump is found in the neck on palpation.

Depending on preliminary findings or even a suspicion of anything out of the ordinary, the patient may be listed to come in for a day case procedure to come into hospital for a short general anaesthetic endoscopy. This may or may not include a small biopsy.

If a strong suspicion of a malignancy is thought – the patient may be requested to have a CT Scan (CTS).

The diagnosis of the findings will be relayed to the patient by the original investigating Consultant ENT surgeon in the General ENT outpatients. Again patients are encouraged to bring along a friend or relative.

If the diagnosis confirms the suspicion of cancer then the patient is referred to the next Head & Neck Clinic held on a Tuesday afternoon. Prior to the clinic each new patients’ case is discussed by the panel of the MDT in a joint meeting. The CT Scans and histology reports are viewed and a decision is derived by the panel as to the best course of management of that patients’ condition.

Usually the treatment is clear and the information relayed to the patient. On occasions this decision is not so clear and it may be necessary for the patient to undergo a further endosopy under a general anaesthetic by the treating Head & Neck surgeon before a treatment plan can be finalised.

Any decision to treat is jointly made by the Patient and the Surgeon. A fully informed consent is required from the patient.

Unfortunately when the patient is seen in the clinic their may be a lot of strange faces present. The people present will be introduced. Due to the complex nature of the treatment the patient will need to see the different members of the multidisciplinary team at stages through and beyond the treatment. Once the diagnosis and treatment modality have been discussed – the patient is able to ask questions they may feel unsure about. The patient is then able to have a chat with the Head & Neck Nurse in respect of date of operation, what to expect following surgery, and to clear any confusions they may have. The speech therapist will also be at hand if required to discuss speech and swallowing following the procedure. They will be given an opportunity to meet up with a patient who has undergone similar treatment.

LARYNGECTOMY

Laryngectomy is mostly performed in the more advanced stages of disease and in radiation therapy failures. The procedure may be combined with a procedure on the neck glands. Occasionally partial forms of laryngectomy are performed but the indication for this is rare.

A minimum 10 day stay on the ward is usually planned for the patient. Due to the fact that the gullet (Pharynx) has been reformed the patient has to be fed via a Nasogastric tube – until the wounds have healed. The first night following surgery may be spent on the Intensive Care Unit or the High Dependency Unit. The patient is usually attached to a number of ‘tubes, drains, catheters and lines’. One after another these start being removed. The last one remaining is the Nasogastric tube. Prior to this tube being removed a Contrast Swallow may be requested to make sure that no leak occurs from the newly formed gullet. The swallowing occurs first with water for a day and then soft diet, progressing onto a normal diet if possible.

An assessment of home circumstances is made and the patient is discharged with an appointment for the head and neck clinic at about a week post discharge. At this time following further discussion at the MDT and after reviewing the final histology a decision is made whether a course of Radiotherapy is also required. This ultimately depends upon the margins of clearance and the type of lymph node involvement. If a decision is made for a course of Radiotherapy then the patient is introduced to the Radio-oncologist.

DIAGRAMATIC APPEARANCE FOLLOWING LARYNGECTOMY

AFTER A LARYNGECTOMY

The operation of Laryngectomy necessitates the separation of the voice box from the pharynx. The pharynx has to be refashioned and completely separated from the original airway. The windpipe is brought to the surface of the skin of the neck.

The main concerns following a laryngectomy are in respect of the voice, swallowing and care of the tracheostoma.

Nursing staff on the ward will teach the patient and relatives to look after the stoma and give information about getting supplies.

As the normal physiology of the airways has been changed, the patient is put on a filter called a HME (Heat/Moisture Exchange Filter). The filter is an attempt to recreate the normal physiology of the upper airways that have been short-circuited. (Nose, Pharynx and Larynx). Some patients are not able to tolerate the filter and may be required to wear a Stoma Protector

The Artificial larynx

Held against the neck, the artificial larynx transmits an electronic sound through the tissues, which is then shaped into speech sounds by the lips and tongue. The user articulates in the normal way.

It is not an appropriate means of communication immediately after the operation or if the tissues have hardened as a result of

Oesophageal Voice

Oesophageal voice is achieved by learning to swallow air into the gullet and then ‘burping’. The air is released, causing the pharynx to vibrate to produce a low-pitched voice. The fluency achieved varies and also depends upn practice, not all laryngectomees are able to learn this technique

Surgical Voice Restoration

Voice may he restored by fitting a prosthesis or valve into a puncture hole between the trachea and oesophagus either at the time of surgery or at a later date. There are various types of prosthesis but the most commonly known is the Blom-Singer valve and the Provox. The laryngectomee occludes the stoma when he or she wishes to speak. Air then passes from the wind pipe through the valve into the gullet, producing voice in the same way as for oesophageal voice.

Not all people undergoing laryngectomy are suitable candidates for a valve.

Silent Mouthing/Writing/Gesture

A small percentage of laryngectomees never acquire a voice and are unable to use an electronic larynx. They communicate by silently articulating words or a mixture of writing and gesture.