Mr P Morar M.D. FRCS Ed (ORL) Consultant Otolaryngologist
Head & Neck Surgeon
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
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
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’
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
|Consultant Head & Neck Surgeons
||Mr P Morar, Mr S Langton, Mr G Smith
||Dr A Biswas, Dr A Mehta
||Dr D Gavan
|Head & Neck Clinical Nurse Specialist
|Specialist Speech & Language Therapist
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
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 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.
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.