Your doctor will use a very thin flexible tube with a tiny light and camera on it to look inside your larynx. This is an essential part of the full head and neck examination and is performed in the office or clinic using local anaesthesia.
Laryngeal Cancer (Voice Box Cancer)
Also known as Voice Box Cancer
Introduction
What is Laryngeal Cancer?
Laryngeal Cancer is a type of Throat Cancer that is also known as Voice Box Cancer. If it's not the cancer type you're looking for, please explore the information about other types of Throat Cancers or other types of Head and Neck Cancers.
There are many types of tumours (lumps) that occur in the larynx. Cancer occurs when cells become abnormal, grow uncontrollably and have the potential to spread to other parts of the body. These cells build up to form a mass (or lump).
Many of tumours or lumps in the larynx are not cancers but are what doctors call ‘growths’ or ‘lesions’. Common examples include vocal cord nodules or papillomas.
Watch a 3D video explainer about Laryngeal Cancer:
What is the larynx?
The larynx (or voice box) is an organ in the front of the neck. The larynx is made up of cartilage (a firm tissue), muscles and ligaments which move to make different sounds and protect your lungs when swallowing. The cartilage in front of the larynx is sometimes called the Adam’s apple.
The larynx has three parts which doctors may refer to when describing where a cancer is located within the larynx:
- upper (supraglottis): the area from the epiglottis down to the vocal cords at the top of the larynx. The epiglottis is responsible for protecting the lungs when swallowing foods and liquids
- middle (glottis): this area contains the vocal cords which open when breathing, and close when talking and swallowing
- lower (subglottis): the area below the vocal cords where the larynx joins the trachea (or windpipe). The trachea links the larynx to the lungs
Behind and around the larynx is a horseshoe shaped area called the hypopharynx. The hypopharynx directs food into the oesophagus ( or food pipe). The larynx, hypopharynx and oesophagus all work together to make sure food is directed to the stomach when you swallow. If they are not working together properly, food can enter the lungs, causing a chest infection, and known as aspiration.
What does the larynx do?
The larynx does three important things, it:
- allows air to pass into the lungs when you breathe
- makes the sound of your voice so you can talk and sing by vibrating the vocal cords
- has a flap (epiglottis) which works together with the vocal cords to close the larynx when swallowing to prevent food and drinks from going down the wrong path and entering the lungs.
The larynx, hypopharynx and oesophagus all work together to make sure food and drinks are directed to the stomach when you swallow. The epiglottis and the vocal cords close tightly when you swallow, blocking food entering the windpipe. The laryngeal muscles and nerves control the vocal cords and the swallowing action and may be damaged by cancers of the larynx and hypopharynx.
Diagram of the larynx and surrounding areas:
Diagram of the larynx and surrounding areas
What causes Laryngeal Cancer?
Doctors often can’t explain why a person gets cancer. But we do know what makes some cancers more likely. The two main causes of Laryngeal Cancer are:
- Smoking (cigarettes, cigars or pipes) or using ‘smokeless’ tobacco (snuff and chewing tobacco) — If a person smokes or has smoked in the past, they have a higher risk of getting laryngeal cancer than someone who has never smoked.
- Drinking alcohol — If a person drinks a lot of alcohol over many years, they have a higher risk of getting laryngeal cancer, especially combined with smoking.
Get information about quitting smoking and reducing how much alcohol you drink.
Other factors that may increase the risk of laryngeal cancer are:
- Being male – in Australia men are almost three times more likely than women to get Laryngeal Cancer
- Age — Most Laryngeal Cancers occur in people aged 55 years and over
- Family history — Those who have close family members with Laryngeal Cancer (a parent, sibling, or child) have a higher risk of getting Laryngeal Cancer
- Low immunity — For example if you take medications to suppress the immune system
- Exposure to asbestos — People who have lived or worked in an environment that has exposed them to asbestos have a higher risk of developing Laryngeal Cancer
Symptoms and Signs of Laryngeal Cancer
The signs and symptoms of Laryngeal Cancer depend on where the cancer is, its size and how far it has spread in the body.
The most common early symptom associated with Laryngeal Cancer is hoarseness or change in voice.
Other signs and symptoms include:
- pain on swallowing
- difficulty swallowing
- sore throat or pain in the ears
- a lump in the neck (swollen lymph nodes or glands)
- noisy or difficulty breathing
Some people with Laryngeal Cancer may not experience any symptoms at all. However if you have any of these symptoms for more than a few weeks, talk to your doctor as early as possible. They may be able to help diagnose and treat you.
What are the Tests for Laryngeal Cancer?
It is important that your doctor establishes the diagnosis of Laryngeal Cancer, assess the size of the cancer and whether it has spread to the lymph nodes in the neck or elsewhere in the body. To answer these questions your doctor will need to do the following things:
- talk with you about your medical history. This includes signs you may have noticed, any health conditions, medications that you are taking, and whether you smoke or drink alcohol
- order diagnostic tests, which may include scans.
Not everyone will need to have to every test for Laryngeal Cancer . Your doctor will recommend tests that are right for you.
Common tests include:
Nasonendoscopy (Flexible Fiberoptic)
This involves taking a small piece (sample) from the cancer. The sample is then examined under a microscope to check for cancer cells. This is often the only sure way to tell if you have cancer.
Your doctor may recommend:
- Biopsy of the larynx: This is commonly referred to as microlaryngoscopy and will need to be performed under a general anaesthetic (medicine to keep you unconscious), so that you don't feel any pain. During this procedure which is performed through the open mouth, your doctor will be able to accurately map the cancer and take a small sample for assessment. There may be some bleeding after the biopsy. If you take blood thinners you may need to stop these before the biopsy.
- Needle biopsy (Fine Needle Aspiration or FNA): This is used when there is a lump (enlarged lymph node) in the neck that could have cancer cells in it. During the procedure, your doctor will take some cells from the lump using a needle. Usually this is done with guidance from an ultrasound to make sure the needle is in the right spot. You may feel a bit uncomfortable during the biopsy.
This uses X-rays to take pictures of the inside of the body. If the person has cancer, a CT scan can help the doctor to see where it is, measure how big it is, and if it has spread into nearby organs or other parts of the body.
MRI (Magnetic Resonance Imaging) Scan
This uses magnetic fields to take pictures of the inside of the body. This helps the doctor see how far a cancer has grown into the tissue around it.
PET (Positron Emission Tomography) Scan
This is a whole body scan that uses a adioactive form of sugar which can show if Laryngeal Cancer has spread to the lymph nodes or elsewhere in the body.
Treatment Options for Laryngeal Cancer
Following a diagnosis of Laryngeal Cancer, your cancer care team will discuss the treatment options including the possibility of participating in a clinical trial that is suitable for you. This is also a good time to consider if you would like a second opinion.
The most suitable treatment of Laryngeal Cancer depends on many things including:
- size and location of the cancer
- whether the cancer has spread
- personal factors (e.g. age, general health and treatment history)
- types of treatment available (and whether any clinical trials are available)
- your preferences for treatment
There are two broad categories of treatment for Laryngeal Cancers; surgery and radiation therapy. Chemotherapy is sometimes used at same time with radiation therapy (called concurrent chemotherapy).
Surgery for Laryngeal Cancer
Surgery is generally used for advanced stage Laryngeal Cancer. Your doctor may consider removing the cancer using a robot (Transoral Robotic Surgery, or TORS). TORS may be performed by a head and neck cancer surgeon, which is carried out through the mouth without any external cuts.
How can I prepare for the surgery?
Your doctor will explain details of the surgery, general risks and side effects of surgery. Ask your doctor if you have questions. They may recommend:
- stopping blood thinners (e.g. aspirin) before surgery to reduce the risk of bleeding
- special stockings to reduce the risk of blood clots
- early mobilisation (i.e. not staying in bed) to reduce the risk of blood clots and chest infection
- antibiotics to lower the risk of wound infection.
If you smoke, it is important that you consider stopping smoking before starting treatment to help reduce the risk of infection and help you recover after your treatment.
The surgery options for early and advanced Laryngeal Cancers are:
Trans-Oral Laser or Trans-Oral Robotic Surgery
Download PDF on Trans-Oral Laser Surgery
Download PDF on Trans-Oral Robotic Surgery
Some advanced laryngeal cancers can be removed without any external cuts using a robotic system or by using laser surgery.
Download PDF on Laryngectomy
A laryngectomy is the removal of all (total laryngectomy) or part of the larynx (partial laryngectomy).
Download PDF on Partial Laryngectomy
Partial laryngectomy is removal of part of your larynx. The larynx is the medical name for the voice box.
Download PDF on Hypopharyngectomy
This is removal of part of the hypopharynx via an open neck approach.
Download PDF - Laryngopharyngectomy
This is the removal of all the larynx and pharynx. It is different to laryngectomy, where only the larynx (or part of it) is removed.
Download PDF - Neck Dissection
Download PDF - Return to Activity Following Neck Dissection
This involves removal of lymph nodes from the neck. This is important even when there is no sign of cancer in the lymph nodes on the scan, because there is a risk of microscopic cancer in the lymph glands of the neck.
Download PDF - Reconstructive Surgery
This may be considered if a large area of tissue is removed. This may involve taking tissue from another part of the body called a free flap repair. This operation is carried out by a surgeon who specialises in reconstructive surgery, your head and neck surgeon or another surgeon.
A tracheostomy is used to create an opening in the trachea (windpipe) in the lower neck, where a tube is inserted to allow air to flow in and out, when you breathe. This is used as swelling after major head and neck surgery may affect your ability to breathe. The tracheostomy tube is usually removed within a week of surgery once normal breathing is possible.
- A gastrostomy tube (called a PEG tube) goes through the skin and the muscles of your abdominal wall into the stomach. Gastrostomy is recommended if feeding is needed for a medium to longer time (months or years).
- A nasogastric tube goes through the nose down into the stomach. Nasogastric feeding is used for short time (days or weeks).
Side Effects of Surgery
Treatment for laryngeal cancer may lead to a number of side effects . You may not experience all of the side effects. Speak with your doctor if you have any questions or concerns about treatment side effects.
Radiation Therapy for Laryngeal Cancer
The most common radiation therapy treatment for Laryngeal Cancer is called external beam radiation. This type of radiation therapy applies radiation from outside the body.
Radiation therapy can be used in both the early and advanced stages of Laryngeal Cancer in the following ways:
Small field
This is frequently used in the definitive treatment (curative) of early (stage I or II) laryngeal cancer in an outpatient setting. This is when radiation therapy is targeted at the larynx alone. Treatments are usually given daily, for a period of 7 weeks.
Definitive
This is a curative treatment option for patients with advanced stage Laryngeal Cancer. The aim of the therapy is to preserve the larynx and its function. It is another option to removing the voice box (total laryngectomy). Radiation therapy comprehensively treats the cancer of the voice box, its surrounding region, and the lymph nodes at both sides of the neck. Radiation therapy is typically delivered daily (but not on weekends) for 7 weeks and can be given as:
- definitive radiation therapy alone; or
- definitive radiation therapy with concurrent chemotherapy (adding chemotherapy to radiation therapy (chemoradiation) to make it more effective).
Adjuvant
This is given after the surgical removal of the voice box and the lymph nodes (on both or either sides of the neck). It is used as an additional treatment to kill cancer cells that may not have been removed during surgery. It usually starts about 4 weeks after surgery to allow recovery from surgery. Radiation therapy treatment usually lasts for about 6 weeks. Sometimes chemotherapy is added to the adjuvant radiation therapy (chemoradiation) to make it more effective.
Palliative
In cases where a cure is not possible, radiation therapy is used to relieve symptoms of advanced laryngeal cancer. Symptoms that may require palliative radiation therapy include pain, bleeding, breathing and swallowing difficulties.
How do I prepare for Radiation Therapy?
You will meet with many members of the cancer care team, who will help you learn how to look after yourself through radiation therapy, recovery and long term follow-up. They will also talk to you about side effects and how to manage them. It may be helpful to write down questions as they come up, so you can ask anyone in your cancer care team when you see them.
Radiation Therapy Mask-Making and Simulation
- Radiation therapy is a precise treatment. In order to make sure, that the cancer is covered by the treatment, you will need to be very still during the treatment, usually for about five minutes. A radiation therapy mask that is made to fit perfectly to your shape, will be put on you during each treatment to help the machine target where the cancer is.
- You will have a planning CT scan (and sometimes other scans) with the mask on. Your radiation oncologist and radiation therapists will use these scans with all your other clinical information to develop a radiation therapy plan just for you (a personalised plan). Your plan will be checked by the radiation therapy and radiation oncology physics team before it is ready to be used for your treatment. This whole process can take approximately 2-3 weeks.
Teeth and Mouth Care
If you are having radiation therapy for advanced stage Laryngeal Cancer, dental extraction may be needed to remove any broken or infected teeth before radiation therapy. It is important to take out any broken or infected teeth before radiation therapy. Taking out unhealthy teeth after radiation therapy can cause problems with the jaw bone.
Diet, Nutrition and the Role of your Dietitian
Your cancer and its treatment can make it hard to eat and drink. Your doctor will recommend you see a dietitian to maximise your nutrition during treatment as well as while you are recovering. Sometime feeding tubes may be recommended depending on the area being treated and the dose of radiation therapy.
There are two common types of feeding tubes:
- Gastrostomy tube (know as a PEG tube): this type of tube is inserted through your abdominal wall into your stomach, with part of the tube staying outside the stomach. A syringe can be attached to the tube to give you food this way if needed. The tube is inserted using a camera through the mouth into the stomach (gastroscopy) or using a CT scanner to guide insertion directly through the skin. If a PEG tube is needed, your doctor will organise this before starting your radiation therapy
- Nasogastric tube: this type of tube goes through the nose down into the stomach and is usually used for short periods (days or weeks). A nasogastric tube can be inserted at any time (before, during or after treatment).
Speech, Voice and Swallowing
Your cancer and its treatment can make swallowing and speech difficult. Your doctor will recommend you see a speech pathologist, who can help you with ways to manage swallowing and communication difficulties, during and after treatment. Your speech pathologist will also help with your voice rehabilitation during and after treatment.
There are many other aspects of supportive care that are available, ask your doctor if you have any specific needs.
Side Effects
The side-effects of radiation therapy start around two weeks into treatment and progress through treatment to peak in the last week or just after treatment ends. The side effects start to improve 2-3 weeks after the end of treatment.
Side effects associated with radiation therapy depend on:
- the dose of radiation therapy
- the area being treated
- whether or not chemotherapy is added to the radiation.
Each person responds to radiation therapy differently. Some people may experience a few side effects while others may not experience any at all. The following are some common side effects of radiation therapy.
- tiredness
- hoarse voice
- skin irritation in the treated area e.g. redness, dryness and itching, weeping skin, scaling or sometimes skin breakdown (sores)
- pain on swallowing or difficulty with swallowing
- irritation in the throat progressing to sore throat requiring pain killers
- dry mouth and throat (with advanced stage laryngeal cancer treatment).
Most side effects are short lived and may go away within 4–6 weeks of finishing radiation therapy. Some side effects may last for months after you finish radiation therapy and some may be permanent.
Uncommon side effects of radiation therapy for laryngeal cancer include aspiration (coughing and infection due to food/fluids trickling into your windpipe) and swelling in the airway causing obstruction and difficulty breathing. This can be relieved by the insertion of a temporary tracheostomy.
Once your radiation therapy ends, you will continue to have follow-up appointments so that your doctor can check your recovery and monitor any side effects that you may have. If you've had advanced stage laryngeal cancer, your doctor may arrange for a PET scan about 12 weeks after finishing radiation therapy to make sure the cancer has completely gone. If the cancer doesn't go away after radiation therapy, or comes back again in the future, you may still be able to have salvage surgery (Total laryngectomy) to try to cure the cancer.
Your doctor may recommend that you receive specific supportive care to help during your treatment and recovery.
Chemotherapy for Laryngeal Cancer
Chemotherapy works by destroying or damaging cancer cells. For laryngeal cancer, it is usually given into a vein through a needle with a cannula (tube) attached.
There are a number of ways that chemotherapy may be used to treat laryngeal cancer including:
Definitive
Sometimes chemotherapy is added to definitive radiation therapy (chemoradiation). It is usually used for advanced stage laryngeal cancers. This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. The addition of chemotherapy makes the radiation more effective at killing cancer cells but also leads to increased side effects in most patients.
Adjuvant
This is when chemotherapy is given after surgery in combination with radiation therapy (chemoradiation). This may be given once every 3 weeks or once a week throughout the duration of radiation therapy. The addition of chemotherapy makes the radiation more effective at killing cancer cells but also leads to increased side effects in most patients.
Neo-adjuvant
This is when chemotherapy is given before surgery or radiation therapy to help shrink large cancers and make them easier to remove or target with radiation therapy. This is not commonly used for laryngeal cancer.
Palliative
This is used when the cancer is incurable. The cancer may be too large or has spread too much to be removed by surgery. Palliative chemotherapy helps to slow the growth of cancer and reduce symptoms. It is important to remember that palliative chemotherapy is not as intense as other types and is much less likely to have significant side effects.
Before you start treatment, your medical oncologist will choose one or more chemotherapy medications that will be best to treat the type of cancer you have.
The chemotherapy medications your doctor chooses may depend on:
- whether the treatment is curative or palliative
- when it is used
- your medical history
Side Effects
The side effects of chemotherapy depend on the medication used and and how much you are given by your doctor (the dose). The most common medications used are called cisplatin, carboplatin and cetuximab.
Each person responds to chemotherapy differently. Some people may experience a few side effects while others may not experience any at all. The following are common side effects of chemotherapy:
- a feeling of wanting to vomit (nausea) or vomiting
- more side effects of radiation, if you have chemotherapy at the same time as radiation
- loss of feeling in the fingers and toes
- kidney damage (caused by some medications)
- hearing loss/thinning
- ringing in the ears
- rash
- higher risk of infection (if the chemotherapy reduces the number of white cells in the blood)
Most of these side effects are short lived and may go away once you finish chemotherapy. Some side effects can take months or years to improve or may be permanent.
Once your treatments end, you will have regular follow-up appointments so that your doctor can check your recovery, make sure the cancer has not returned and monitor and treat any side effects that you may have.
Your doctor may recommend that you receive some specific supportive care to help during your recovery.
Questions to Ask
- Exactly what type of Laryngeal Cancer do I have? Where is it located?
- Why did I get this cancer? Is it related to the HPV virus?
- What stage is the cancer?
- What are my treatment options? Which treatment do you recommend for me and why?
- Have you discussed my case at a Multidisciplinary Team meeting and what were the recommendations?
- Who will be part of the cancer care team, and what does each person do? Should I see another specialist before treatment, such as a radiation oncologist, medical oncologist, plastic surgeon, dentist, dietician or speech pathologist?
- What are the possible side effects of treatment in the short- and long-term? How can they be prevented or managed?
- Will the treatment affect my ability to eat, swallow, or speak? Will I need a feeding tube?
- What will happen if I don't have any treatment?
- How much will the treatment and/or operation cost? Will Medicare or my health insurance cover it?
- What follow-up tests will I need? How often will they be?
- Am I suitable for any clinical trials?
- What lifestyle changes (diet, exercise) do you recommend I make
- Who can I call if I have any problems or questions?
- Where can I find emotional support for me and my family? Is there a support group or psychologist you can recommend?
- If I wanted to get a second opinion, can you provide all my medical details? Do you mind if I get a second opinion?
Follow-Up Care
You will need regular check-up of your throat and neck after for Laryngeal Cancer. This will include a physical exam and checking your nose and throat using a thin, flexible tube with a light and camera (nasendoscopy). You may need to have follow-up CT, MRI or PET scans to catch any early signs of reapperance of the cancer. It is important to keep up with follow-up appointments to make sure that if the cancer comes back it is caught early and can be treated. If you have any concerns between appointments you should contact your doctor.
People who smoke and/or drink alcohol can reduce the risk of their cancer coming back or getting a new cancer if they quit smoking and reduce the amount of alcohol they drink. Ask your cancer care team for advice if this applies to you.
Importance of Ongoing Dental Care
A dentist plays an important role in your Head and Neck Cancer treatment. Side-effects can often be prevented or reduced through regular dental check-ups before, during and after cancer treatment. After your treatment, you should visit the dentist every six months for a check-up because the side effects of radiation therapy on your teeth can last for your whole life.
Mental Health for People with Cancer
Sometimes this is referred to as psychosocial aspects or survivorship.
Being diagnosed with cancer and having treatment can lead to extra worries or concerns for you and the people caring for you. Depending on the treatment, you may experience any of the following:
- low mood or depression
- anxiety
- disfigurement
- difficulties with eating
- difficulties with speaking
- changes in sexual activity
You may have got through the diagnosis and treatment for Laryngeal Cancer, but you may be finding it difficult to deal with some of the side effects of treatment. Speak with you doctor about any difficulties you may be experiencing. Your doctor may give you a referral to a psychologist or another healthcare professional who can help you. Speak with your family and friends too about any concerns you may have.
You may find it helps to join a patient support group and speak with others who are having treatment for head and neck cancer. See our Find Support database.
You can also find help and advice in online self-help resources such as beyondblue.
For more information about coping with cancer visit Cancer Council Australia.
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