Laryngeal Cancer (Cancer of the Voice Box)

The larynx and where cancer starts

The larynx sits in the front of the neck above the windpipe. It contains the vocal cords, protects the airway during swallowing, and helps you breathe and speak. It has three regions:

About 12,000 people are diagnosed in the US each year, most of them over 55.

Symptoms

• hoarseness or voice change lasting more than 3 to 4 weeks
• sore throat that does not go away
• pain or difficulty swallowing
• ear pain, usually on one side, with a normal ear (earache)
• a lump in the neck from enlarged lymph nodes
• chronic cough, sometimes with blood
• noisy breathing or breathlessness
• bad breath
• unexplained weight loss

Many of these symptoms have harmless causes, such as laryngitis, reflux or vocal cord nodules, but persistent symptoms need a look at the larynx.

Risk factors

• Tobacco smoking: the most important cause; risk falls after quitting
• Heavy alcohol use: multiplies the effect of smoking
• Age over 55 and male sex
• Occupational exposures: asbestos, wood dust, paint fumes, some chemicals
• HPV infection: plays a smaller role in laryngeal cancer than in throat (oropharyngeal) cancer
• Poor diet low in fruit and vegetables
• Previous head and neck cancer

Diagnosis

1. Laryngoscopy: an ENT specialist looks at the larynx with a thin flexible camera passed through the nose, in the clinic. Guidelines recommend this for hoarseness lasting more than 4 weeks, or sooner if serious disease is suspected.
2. Biopsy: a tissue sample, often taken under general anesthesia (direct laryngoscopy).
3. Imaging: CT or MRI of the neck to assess spread; PET-CT and chest imaging for advanced disease.
4. Swallowing and voice assessment before treatment.

Stages

Laryngeal cancer is staged from I to IV:

• Stage I and II: confined to the larynx; vocal cords may move normally or be slightly affected
• Stage III: a fixed vocal cord, or spread to one small lymph node
• Stage IV: spread into nearby structures, multiple lymph nodes, or distant organs (often the lungs)

Treatment

The aim is to cure the cancer while preserving the voice and swallowing where possible. A multidisciplinary team of ENT surgeons, oncologists, speech and language pathologists and dietitians plans treatment.

Early-stage cancer

• Radiation therapy, or
• Transoral laser microsurgery through the mouth, or
• Partial laryngectomy

These options have similar cure rates for early glottic cancer and usually preserve a good voice.

Advanced cancer

• Chemoradiation: radiation with chemotherapy, aiming to preserve the larynx
• Total laryngectomy: removal of the whole larynx for large or recurrent tumors. Breathing is then through a permanent opening in the neck (stoma), and speech is restored with a voice prosthesis, an electrolarynx or esophageal speech.
• Neck dissection: removal of affected lymph nodes
• Immunotherapy and targeted therapy (such as pembrolizumab or cetuximab) for recurrent or metastatic disease

Rehabilitation

Speech and swallowing therapy, management of dry mouth and skin changes after radiation, and nutrition support are important parts of recovery.

Outlook

Early glottic cancers have high cure rates. Survival falls when cancer has spread to lymph nodes or beyond. Stopping smoking and alcohol improves treatment results and reduces the risk of a second cancer. Regular follow-up for at least 5 years checks for recurrence and new cancers in the head, neck and lungs.

Prevention

• do not smoke, or quit
• limit alcohol
• protect yourself from workplace fumes and dust
• see a doctor for hoarseness lasting more than 3 to 4 weeks

Frequently asked questions

What are the first signs of laryngeal cancer?

The most common first sign is hoarseness or a change in your voice that lasts more than 3 to 4 weeks. Other early signs include a persistent sore throat, pain when swallowing, ear pain on one side, a neck lump and a persistent cough.

What causes laryngeal cancer?

Most laryngeal cancers are caused by smoking and heavy drinking, which damage the cells lining the larynx. Age over 55, male sex, workplace exposures such as asbestos, and in some cases HPV infection also raise the risk.

Is laryngeal cancer curable?

Yes, especially when found early. Many early cancers of the vocal cords are cured with radiation or laser surgery while preserving the voice. Advanced cancers can also be cured, though treatment is more intensive and may involve removing the larynx.

Can you talk after laryngeal cancer?

Most people treated for early laryngeal cancer keep a useful voice. After total laryngectomy, people can speak again using a voice prosthesis placed between the windpipe and esophagus, an electrolarynx, or esophageal speech, with help from a speech-language pathologist.

When should hoarseness be checked?

See a doctor if hoarseness lasts more than 3 to 4 weeks without a clear cause, such as a cold. Go sooner if you smoke, drink heavily, or have trouble swallowing or breathing, coughing up blood or a neck lump.