Malignant Tumors of the Larynx

Author: Jonas T Johnson, MD, FACS; Chief Editor: Arlen D Meyers, MD, MBA more...

Background
Malignancies of the upper aero-digestive tract are a leading cause of death in the United States of America.
Among all the cancers of the upper aero-digestive tract, squamous cell carcinoma is the most common.
Approximately 40,000 new patients are diagnosed with squamous cell carcinoma of the head and neck each
year in the United States. An estimated 12,500 men and women in the United States will be diagnosed with
laryngeal squamous cell carcinoma in 2008.

Treatment of laryngeal carcinoma has changed during the last years. At the beginning of the century, therapies
were surgically directed. Total and partial laryngectomy surgeries were and still are the mainstream surgical
procedures to treat malignant tumors of the larynx. A paradigm change in treatment was experienced in the
early 1990s. The organ preservation treatments using concurrent chemoradiation therapy were introduced. This
treatment approach demonstrated survival rates similar to total laryngectomy plus radiation therapy, while
preserving the larynx in 63% of the patients. In addition, new developments in endoscopic surgical techniques
and laser equipment are opening a new era in the treatment of malignant tumor of the larynx.
History Of The Procedure
The development of the technique of direct laryngoscopy by Manuel Garcia in 1855 provided the ability to
examine the larynx in a living person for the first time. The first laryngofissure procedure for cancer was
performed by Gurdon Buck in 1851, while Theodor Billroth is credited with the first laryngectomy in 1873.
Postoperative mortality from this procedure was very high (around 40%), mainly due to aspiration and sepsis.

Constant improvement in technique and perioperative care led to improved outcomes. A standardized
laryngectomy technique perfected by Gluck and Soerensen by 1922 yielded excellent surgical outcomes with
few fatalities. Billroth and Gluck also described hemilaryngectomies, but these procedures resulted in high
recurrence rates and intractable dysphagia. Partial laryngectomies gradually regained an important role as a
therapeutic option for laryngeal cancer mainly through improved techniques and recognition of appropriate
indications. In recent years, surgery of laryngeal cancer has evolved to refined endoscopic and laser techniques.

ew strategies using chemotherapy, radiotherapy and surgery have not substantially changed the survival rate of
patients with advanced malignant tumors of the larynx in the last 30 years. Tobacco and alcohol are recognized
as the major risk factors for developing malignant tumors of the larynx. New efforts in understanding the
molecular biology and carcinogenesis of laryngeal malignancies have given us knowledge in the evolution of
this disease and have shown therapeutic potential. The main challenge in laryngeal cancer treatment is
improving survival while preserving function by limiting treatment toxicities.
Epidemiology
Frequency

According to the SEER Cancer Statistics Review of the National Cancer Institute, an estimated 12,250 men and
women will be diagnosed with cancer of the larynx in 2008; of those, 3,670 patients will die. The age-adjusted
incidence is 3.6 per 100,000 with a mortality of 1.3 per 100,000.
Etiology
Until the complex molecular interactions of all associated etiologic agents for any cancer can be understood,
these interactions are best thought of as associations. Thinking of intrinsic (eg, genetic) factors and/or extrinsic
(eg, smoking) factors as causes is too simple.

To most people, a cause implies a condition that is both necessary and sufficient to produce a prespecified
result. Laryngeal carcinomas have multiple associations.

The foremost risk factor for the development of laryngeal cancer is tobacco use. The risk of developing
laryngeal cancer with tobacco increases with use and decreases after cessation. When associated with the intake
of alcohol, a strong synergistic effect is created. However, whether or not alcohol alone is an independent risk
factor is still unclear.

All the potential risk factors for laryngeal cancer that have been studied are as follows:

Tobacco use
Excessive ethanol use
Male sex
Infection with human papillomavirus
 Increasing age
Diets low in green leafy vegetables
Diets rich in salt preserved meats and dietary fats
Metal/plastic workers
Exposure to paint
Exposure to diesel and gasoline fumes
Exposure to asbestos
 Exposure to radiation
Laryngopharyngeal reflux

Pathophysiology
The larynx is an essential organ that is responsible for the following vital functions:

Maintaining an open air way

Vocalizing
 Protecting the lungs from more direct exposure to noxious fumes and gases of unsuitable temperatures
Protecting the lungs from aspiration of solids and liquids
Allowing leverage, by closing the glottis during a Valsalva maneuver, to increase upper-body strength
and to ease solid-waste removal

Malignant tumors of the larynx affect laryngeal physiology depending on tumor location and size. Supraglottic
tumors usually cause upper airway obstruction. Conversely, glottic tumors affect initially voice quality. In
addition, malignant tumors of the larynx affect swallowing physiology. The mechanism of swallowing is altered
when tumors invade and alter the physiology of the swallowing muscles. This is expressed as difficulty
swallowing and aspiration. Liquids and solid food gain access into the trachea.
Pathophysiology of malignant tumors of the larynx is at the molecular and histologic level. Histologic
progression occurs from normal laryngeal mucosa to dysplastic mucosa to carcinoma in situ to invasive
carcinoma. This progression is a multistep process of accumulated genetic events that lead to the development
of larynx tumors.

Presentation
Given the functions of the larynx mentioned above, one can easily imagine the consequences of a carcinoma
destroying and/or obstructing the laryngeal structures and their mechanisms (eg, vocal-cord movement).
Symptoms vary with the structures involved by malignancy and its accompanying inflammatory reaction.
Although the particular tumor, the site, and the patient's constitution play key roles in any given individual,
laryngeal cancers as a whole can cause any of the following findings, alone or in combination:

Dysphonia/aphonia
Dysphagia

Dyspnea

Aspiration

Blood-tinged sputum
 Fatigue and weakness

Cachexia

Pain

Halitosis

Actual expectoration of tissue

Neck mass
 Otalgia (Outside the field of otorhinolaryngology, many physicians do not realize that otalgia may be a sign of
laryngeal cancer. This seems to be especially true if the arytenoids are involved.)

History

As in all clinical evaluations, the history is the first step in gathering the facts. Assess or inquire about the
following:

Weight loss
Fatigue
 Pain

Difficulty breathing or swallowing

Vocal changes noted by the patient and his or her family

Ear pain

Coughing up blood or solid material

Physical examination

The patient's general condition and nutritional status should be evaluated. A full head and neck examination
should be completed. Head and neck examination includes inspection and palpation of the oral cavity and
oropharynx to rule out second primary tumors or other lesions, as well as evaluation of dentition. Inspection of
the larynx is best accomplished using a flexible laryngoscope. Flexible laryngoscopy allows the
otolaryngologist to evaluate the function and anatomy of the entire larynx. Evaluation of vocal cord motility
and the location and extension of the tumor are crucial to stage the patient accurately.

Palpation of the neck looking for enlarged lymph nodes is paramount in the patient's evaluation. Thorough
evaluation of the cranial nerves should also be included in the physical examination.
Indications
Many laryngeal tumors may appear late with distant metastasis and near-total destruction of some neck
structures. Others may appear early. Treatment is necessary for all tumors. Although supplying comfort may be
only palliative, it should still be addressed because tumors of the larynx can cause severe misery for the patient
and his or her loved ones.

Treatment may include single therapy or combinations of surgery, radiation therapy, and/or chemotherapy. To
select proper therapy, all of the necessary information must first be obtained before available options are
discussed with the patient. The anatomy of the larynx is complex and difficult to visualize. Nevertheless, the
team caring for each patient must understand it. Specialists in the areas of surgery, pathology, radiation
oncology, and radiology understand this anatomy well. For family members, patients, and clinicians who do not
deal with anatomic detail in their daily practice, this is a complicated arena. The entire team must effectively
unders

Relevant Anatomy
Entire books are written about gross and microscopic laryngeal anatomy. The discussion below is an
abbreviated version of the relevant anatomy. It should provide the information any clinician needs to understand
this anatomic region, and it should explain why different procedures are indicated in different areas. It also
helps in clarifying the consequences of each procedure.
Based on anatomic location, the larynx is divided into the supraglottic larynx, the glottis or glottic larynx, and
the subglottic larynx. The supraglottic larynx includes the epiglottis, the preepiglottic space, the laryngeal
aspects of the aryepiglottic folds, the false vocal cords, the arytenoids, and the ventricles. The inferior boundary
is a horizontal plane drawn trough the apex of the ventricle. This corresponds to the area of transition from
squamous to respiratory epithelium. The glottis consists of the true vocal cords extending to roughly 1 cm
below the true cords, the paraglottic space, and the anterior and posterior commissures extending inferiorly
about 1 cm. The subglottic larynx has its superior border at the inferior border of the glottis, that is,
approximately 1 cm below the true vocal cords and extending inferiorly to the trachea.

See the image below.

Contraindications
Therapy has no "contraindications." However, a multitude of issues must be discussed in deciding which
therapy is best for each patient. These issues include such things as the tumor stage, the patient's co-morbid
status, prior treatments, and, of course, the patient's desires. Even in the setting of tumor recurrence and
incurability, the patient should be offered palliative care.

Laboratory Studies
Arterial blood gas analysis

The patient's symptoms or clinical findings may indicate the need to obtain arterial blood gases.
This analysis may be preformed preoperatively to provide a baseline to monitor the patient's course.

Blood studies for clotting parameters

These studies might be ordered when surgery is a consideration.

Include a platelet count.
Blood typing and cross matching are also prudent.
 Every experienced head and neck surgeon or trauma physician is aware of the tremendous potential for
hemorrhage in this area. Anomalous blood vessels often yield unexpected complications.

Thyroid function studies

These studies may be indicated, as may tests of serum calcium levels, because the results are
occasionally anomalous after surgery. Having baseline data for reference is ideal.
In some cases, especially with cases of fibrosis, either radiation or tumor induced, the thyroid may be
biopsied during laryngectomy to assess for occult carcinoma.

Studies of renal and hepatic function

 These studies are necessary before any informed discussion of chemotherapeutic regimens can occur.
Many chemotherapeutic agents are metabolized by the liver and/or kidneys.

Nutrition studies: Albumin and transferrin serum levels are important to establish nutritional status.

Imaging Studies
CT scanning

Contrast-enhanced CT scans obtained with appropriate section thickness aid in the evaluation of neck
masses.
 CT scans and MRIs may demonstrate the extension of tumor into vital structures such as the
surrounding soft tissue, the preepiglottic space. They may also show invasion though the thyrohyoid-
ligament and cartilage invasion. See the image below. Axial view on CT scan of an advanced right
laryngeal tumor invading through the thyroid cartilage.

Plain radiography of the chest

Plain films of the chest may be useful in planning surgery.

If metastases are already present in the chest, the therapeutic decision tree changes entirely.

Positron emission tomography-computerized tomography scan (PET-CT)

 This is a radiologic tool that detects metabolic signals from cells with high metabolic activity like cancer
cells. The patient receives intravenously a glucose analog called fluorodeoxyglucose (FDG) that is
tagged with a radioisotope. This analog is taken up by cells with high metabolic activity. A CT scanner
is used to correlate the nuclear medicine image with anatomic abnormality.
This is the most sensitive test available to detect metastasis or second primary tumors. The clinician
must be aware, however, that some tumors do not take FDG and that small tumors (< 5 mm) are not be
identified. See the image below. PET/CT image of a laryngeal cancer showing increased FDG avidity.

Other Tests
Pulmonary function tests are necessary before one decides whether the patient is a suitable candidate for radical
surgery that involves airway function.

Diagnostic Procedures
Direct laryngoscopy provides an opportunity for examination under general anesthesia, palpation and biopsy.
Suspension laryngoscopy provides an excellent view of the extent of the tumor and the overall condition of the
airway mucosa.

Fine needle aspiration (FNA) of a neck mass may yield a positive result when the certainty of a malignant
lymph node is not 100%.
Single, well-targeted biopsy reveals the nature (type and perhaps grade) of the tumor. Several biopsy procedures
may be extremely useful in mapping the tumor to optimally plan surgery.

Reminders

The rationale behind the entire work-up is to have as much staging information available as possible to
present to a tumor board before definitive study is performed. Treatment options are frequently
discussed in a multidisciplinary format called a tumor board. Although a tumor board may comprise
only a few physicians, the ideal head and neck tumor board is a powerful ally. Diverse experts on these
boards widely expand and exchange knowledge, such as awareness of new open clinical trials (on the
part of radiation or medical oncologists); the patient in question may be ideal for such a trial. Likewise,
 the surgeon may know of a new technique that may obviate postoperative therapy or considerably
decreases disfigurement, and the pathologist may know that certain histologic features suggest an
improved prognosis or a different responds to therapy. This level of information is impossible for any
one individual to know, and well-earned CME credits are a natural outcome.
The value of this tumor board is greater than the sum of its parts. Therefore, the tumor board approach is
strongly advocated. In the United States, such tumor boards may include the following members:
o Surgeons

o Anesthesiologists

o Radiologists
o Pathologists

o Radiation oncologists

o Medical oncologists

o Psychiatrists and or the patients' spiritual advisors

o Speech and swallowing therapists

o Nursing staff

o Relevant clinical research teams

 o Social workers and placement teams

o Reconstructive, plastic, and cosmetic surgeons

Histologic Findings
The vast majority of laryngeal cancers are of the squamous cell carcinoma variety. Variations include standard
squamous cell carcinoma (in situ or invasive, well, moderately or poorly differentiated), verrucous carcinoma,
spindle cell carcinoma, basaloid-squamous cell carcinoma, and papillary squamous cell carcinoma. Other types
of carcinoma are neuroendocrine carcinoma,[1] lymphoepitheliomatous carcinoma, adenocarcinoma, and rare
tumors (including sarcomas, lymphomas, adenocarcinomas, and metastases).
 Because 96% of laryngeal carcinomas in the United States are squamous cell carcinomas, the following
discussion is limited to this neoplasm.

Laryngeal squamous cell carcinoma histology is similar in many ways to squamous cell carcinoma found
elsewhere in the body.

It arises in stages from hyperplasia, dysplasia of various degrees, in situ carcinoma, and invasive squamous cell
carcinoma. At times, these stages cannot be observed in an invasive carcinoma. In addition, some squamous cell
carcinomas of the larynx arise de novo without an in situ stage. This process was demonstrated for oral tumors,
and some indications suggest that this may be true in laryngeal tumors as well.
About 5-7 cell layers line the normal larynx. In some regions, this lining is stratified squamous epithelium, and
in others (eg, ventricle, false cord, and subglottis), this is pseudostratified respiratory epithelium.

The nuclei at the base are elongated, with their long axis perpendicular to the basement membrane. Normal
mitotic figures are present in the basal layer, which is 1 layer above the parabasal layer. Mitotic figures should
be absent above this second layer. As the cells move toward the surface, the nuclei become oval, then full
circles. By the fourth to fifth layer from the bottom, all of the squamous cells should have circular nuclei. The
nuclei then continue upward and elongate again, first to ovals then to flattened variants. However, this time, the
elongated nuclei have their long axis parallel to the surface and are therefore parallel to the basement
membrane. Surface keratinization may or may not be present.
In situ carcinoma is simply full-thickness atypia of the squamous cells. The basal nuclei have round, oval, and
elongated forms. The long axes of the elongated forms are haphazardly arranged and not perpendicular to the
basement membrane except by occasional chance. Typical and atypical mitotic figures are observed throughout
the epithelial surface, with some at the surface or 1 layer below. These figures are usually but not always
abundant.

The individual cells themselves are bizarre in appearance, with angulated nuclei, multipoled mitotic figures,
apoptotic cells (individually necrotic cells), hyperchromasia, and high nuclear-to-cytoplasmic ratios.

Invasive squamous cell carcinoma simply means that the wild-appearing squamous cells, and often keratin, are
beneath the area where the usual basement membrane lies. The cells may extend deeply into soft tissue, and
they may invade cartilage, nerves, blood vessels, and lymphatics. They may invade as nests, broad and pushing
fronts, as individual cells, or as any combination of these.

The pathologists classify the degree of atypicality as follows: well, moderately, or poorly differentiated or
undifferentiated. Use of the undifferentiated classification is best avoided. The term undifferentiated carcinoma
is an oxymoron in that an undifferentiated neoplasm cannot show any morphologic features of epithelium (ie,
carcinoma). In addition, the pathologist may subtype the tumor according to the types of tumors listed at the
beginning of this section (eg, papillary carcinoma or verrucous carcinoma).

Staging
The 2002 AJCC classification for laryngeal tumors is determined by the following 3 main factors:[2]

Number of subsites involved

Vocal fold mobility

Presence of cervical or distant metastases

Furthermore, one must pay attention to specific factors who are essential for initial staging and can help
determine the optimal therapeutic option(s) for the patient. These factors are as follows:

Involvement of the base of tongue

 Involvement of the preepiglottic space, ie, the tissue anterior to the epiglottis, posterior to the thyrohyoid
membrane, superior to the petiole, and inferior to the hyoepiglottic ligament

Paraglottic space

Thyroid cartilage

Soft tissue, including strap muscles

Carotid artery and sheath

Esophagus
 Neck lymph nodes, their location, involvement (ipsilateral, bilateral, contralateral), size, and extranodal spread

Distant metastases and location

The American Joint Committee on Cancer Sixth Edition Larynx Staging Schema is discussed below.

Primary tumor (T)

TX: Primary tumor cannot be assessed.
T0: No evidence of primary tumor T is carcinoma in situ .

Supraglottis
 T1: Tumor is limited to one subsite of supraglottis with normal vocal cord mobility.
T2: Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the
supraglottis (eg, mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the
larynx.

T3: Tumor is limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-
epiglottic tissues, paraglottic space, and/or minor thyroid cartilage erosion (eg, inner cortex).

T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft
tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).

T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
Glottis

T1: Tumor is limited to the vocal cord or cords (may involve anterior or posterior commissure) with normal
mobility.
T1a: Tumor is limited to one vocal cord.

T1b: Tumor involves both vocal cords.

T2: Tumor extends to the supraglottis and/or subglottis, and/or with impaired vocal cord mobility.

T3: Tumor is limited to the larynx with vocal cord fixation and/or invades paraglottic space, and or minor thyroid
cartilage erosion (eg, inner cortex).
 T4a: Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft
tissues of the neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus).

T4b: Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.

Subglottis

T1: Tumor is limited to the subglottis.

T2: Tumor extends to the vocal cord(s), with normal or impaired mobility.

T3: Tumor is limited to the larynx with vocal cord fixation.

 T4a: Tumor invades the cricoid or thyroid cartilage and/or invades tissues beyond the larynx (eg, trachea, soft
tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus).

T4b: Tumor invades the prevertebral space, encases carotid artery, or invades mediastinal structures.

Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed.
N0: No regional lymph node metastasis exists.

N1: Metastasis is in a single ipsilateral lymph node, 3 cm or less in greatest dimension.

 N2: Metastasis is in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension; or in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension; or in bilateral or
contralateral lymph nodes, none more than 6 cm in greatest dimension.

N2a: Metastasis is in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest
dimension.

N2b: Metastasis is in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.

N2c: Metastasis is in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.

N3: Metastasis is in a lymph node, more than 6 cm in greatest dimension.

Distant Metastasis (M)
MX: Distant metastasis cannot be assessed.
M0: No distant metastasis.

M1: Distant metastasis.

Stage Grouping

Stage groupings can be seen in the table below.

Table 1. Stage Tumor, Node, and Metastasis Groupings

 Stage Grouping

Stage 0 Tis N0 M0

Stage I T1 N0 M0

Stage II T2 N0 M0

Stage III T3 N0 M0

T1 N1 M0
 T2 N1 M0

T3 N1 M0

Stage IVA T4a N0 M0

T4a N1 M0

T1 N2 M0

T2 N2 M0
 T3 N2 M0

T4a N2 M0

Stage IV B T4b Any N M0

Any T N3 M0

Stage IV C Any T Any N M

Medical Therapy
Treatment of patients with laryngeal carcinoma is complex because of the crucial functions of this anatomic
area. If possible, the goal of treatment is to remove the tumor and prevent recurrence while maintaining
laryngeal function.

To discuss the treatment options for laryngeal cancer, one must differentiate early (I-II) and advanced (III-IV)
stage disease. Subsite location of the primary tumor, glottic, supraglottic or subglottic is also an important
consideration when selecting therapy. Early-stage laryngeal carcinomas (stage I-II) are ideally treated with
voice-saving surgery. Advanced-stage laryngeal carcinomas (stage III) are usually treated with concurrent
chemo-radiation therapy for organ preservation. On the other hand, advanced laryngeal cancer (stage IV) is
usually treated with total laryngectomy, reconstruction, and adjuvant postoperative chemoradiation therapy.

For carcinoma in situ or early-stage invasive glottic or supraglottic cancer, endoscopic surgical removal or
radiation therapy are both equally effective with similar functional outcomes. The treatment modality depends
on the patients wishes and compliance and the surgeon's and the institution's preferences and experience. A
more complete discussion of surgical options is presented in Surgical Therapy.

Remarkable progress has been made in the past 20 years in the management of laryngeal cancer. Where total
laryngectomy held a central role in the treatment of advanced laryngeal tumors, organ preservation strategies
using chemotherapy and radiation therapy protocols have now become the standard of care. Landmark studies
such as The Veteran Affairs Laryngeal Cancer Study Group in 1991 and the RTOG 91-11 intergroup trial helped
establish the basis of laryngeal preservation therapies using chemotherapy (cisplatinum and fluorouracil) and
radiation therapy protocols.[3] Support for chemotherapy as part of a multimodality approach has been
strengthened by many subsequent clinical trials with a slight benefit of concurrent chemoradiation protocols.

Current recommendations of the NCCN Practice Guidelines in Oncology for achieving laryngeal preservation
in cases of locally advanced laryngeal cancer are concurrent radiation therapy and cisplatin 100mg/m2 on days
1, 22, and 43.[4] Radiation therapy alone can be considered for patients who are medically unfit to undergo
chemotherapy. Good evidence exists that radiation efficacy is improved with accelerated and hyperfractionated
treatment schemes. Concurrent chemoradiotherapy protocols are associated with significant acute and late
toxicities. Some patients remain with dysfunctional swallowing and life-threatening aspiration episodes that
require salvage laryngectomy.

Although the pendulum has swung toward larynx preservation protocols, laryngectomy is the best initial
therapeutic option in certain situations. Primary surgical treatment should be considered in patients with high
volume disease, patients with T4a tumors, or patients with anticipated poor functional outcome (eg. poor voice,
intractable aspiration).

Significant early and late toxicities associated with concurrent chemoradiation protocols led to recent interest in
targeted therapies such as monoclonal antibodies (eg, cetuximab). Cetuximab is presently used in many organ
preservation protocols for laryngeal cancer following a landmark multicenter trial. Many other targeted
therapies are under investigation.

In summary, therapy is predicated on histology type, grade, tumor stage, and overall health of the patient.
Treatment must be individualized to consider each patient and his or her social circumstances.

Surgical Therapy
Although laryngeal preservation strategies using chemoradiation have taken a central role in the treatment of
advanced laryngeal cancer, late toxicities have led us to rethink the paradigm of laryngeal cancer treatment. The
refinement of laryngeal surgeries and the sophistication of endolaryngeal laser techniques offer a wide array of
laryngeal preservation options that should be carefully considered by the multidisciplinary team. As described
in the previous section, total laryngectomy must be considered in cases of bulky or advanced disease, clear
cartilage invasion, and failures of larynx-sparing strategies. The description of the surgical technique of partial
and total laryngectomy is beyond the scope of this article.

Transoral laser microsurgery

Popularized and legitimized by Steiner and Ambrosch, transoral laser microsurgery is ideal for the treatment of
early-intermediate glottic and supraglottic cancer. It is performed under suspension micro-laryngoscopy with a
CO2 laser. Adequate instrumentation and surgeon's experience are paramount.
The tumor is transected and removed piecemeal (which allows for precise tumor removal by margin
visualization). The tumor must be well exposed through the laryngoscope.

This treatment has the same indications and contraindications as open partial laryngectomies. A functional
cricoarytenoid unit must be preserved.

Survival and laryngeal preservation is comparable to other conventional treatments and results in excellent
functional outcomes.

Open partial laryngectomy (cricohyoidopexy [CHP] and cricohyoidoepiglottopexy [CHEP])

Data from one study support previous reports of the efficacy of open horizon partial laryngectomy techniques.
These techniques are a form of voice conservation procedures available for management of laryngeal cancer.
[5]
Open partial laryngectomy is useful for cancer involving the anterior commissure with or without spread onto
the pediole of the epiglottis and is a sound option for more advanced tumors (T3 or early T4).

Open partial laryngectomy involves resection of the vocal fold, thyroid cartilage, and paraglottic space, as well
as impaction of the cricoid and hyoid bone for larynx reconstruction. The surgeon must preserve at least 1
functional cricoarytenoid unit for speech and swallowing. This procedure can be performed with (CHEP) or
without (CHP) epiglottis preservation, depending on glottic or supraglottic involvement.
Contraindications include cartilage invasion, bilateral vocal fold fixation, interarytenoid involvement,
significant tongue base involvement, transglottic lesion, or poor performance status.

Cure and organ preservation rates are comparable with chemoradiation. Decreased voice quality may result, but
adequate swallowing can be achieved with rehabilitation.

Preoperative Details
When a patient is considering surgery, ascertaining that medical care is optimized is essential. Nutrition should
be stable. Pain must be controlled. A trip to the dentist is essential to be sure the dentition is free of active
infection. Tobacco and alcohol are best avoided.

Patients with severe lung disease may not be candidates for larynx-sparing surgery. Similarly, patients with
compromised heart and renal disease may not be candidates for chemotherapy.

The patient who has had prior irradiation to the head and neck area represents a special problem. Re-irradiation
can be undertaken, sometimes with good results, but the risk of severe complications is increased.

Intraoperative Details
This chapter does not allow for an in-depth discussion of operative technique. The author would refer the
interested reader to an atlas where the various techniques are depicted.

Under most circumstances, endoscopic resections are carried out with a tracheotomy. Many patients can be
discharged on the day of the procedure. Extensive supraglottic resections do cause dysphagia and potentiate
aspiration, so these patients require hospitalization and swallowing therapy.

Open partial laryngeal resections are almost always accompanied by a temporary tracheotomy. Most patients
are decannulated prior to or soon after discharge. The vocal result is generally reflective of the extent of
surgery. Most patients have a dysphonic but serviceable voice.
Following total laryngectomy, the authors recommend immediate insertion of a tracheoesophageal stent to
accommodate a voice prosthesis. These patients can be speaking about 3 weeks after surgery. See the image
below.

Postoperative Details
Recovery from laryngeal surgery is reflective of the structures removed, the extent of the resection, and the
patient's underlying cardio-pulmonary health. The patient who undergoes resection for a small tumor can be
predicted to have excellent functional recovery with good voice. Treatment of advanced cancer always results
in compromise of some quality of life and functional capabilities.
Follow-up
Follow-up care is necessary because second primary cancers, recurrences, and late metastases are all strong
possibilities. In the course of a lifetime, one third of patients with head and neck cancer may develop another
cancer.

The assistance of speech therapists, occupational therapists, and physical therapists with experience in
swallowing or secretion control should also be considered.

Complications
The complications and consequences of surgery, radiation therapy, and chemotherapy are well known.
However, in the larynx, unique or at least unusual complications must be considered. These are listed as
follows:

Loss of upper body strength after laryngectomy

Psychosocial trauma from surgery and/or radiation therapy[6]
Limited mobility of the neck
Daily stoma care
Vocal cordpowered voice loss in some procedures
 Aspiration pneumonia, in some procedures
Radiation-induced neoplasms of the neck
Osteoradionecrosis
Chondroradionecrosis
Chronic pain
Breathing difficulties
Stoma infections
 Potential stoma malignancies

Outcome and Prognosis

Outcomes in malignant tumor of the larynx are measured by relative survival rates. Data from Surveillance,
Epidemiology and End Results Program shows that the 5-year relative survival rates of laryngeal cancer by
stage at diagnosis, 1989-1996 is as follows:

All stages - 65%

Local - 81%
 Regional - 51%
Distant - 41%

Keep in mind that the outcome for laryngeal carcinoma depends on the initial staging. In general, early-stage
disease is treated with single modality therapy, either surgery or radiation therapy. The outcomes in early
disease are quite good, approaching over 90% 5-year survival rates with either modality of treatment.

Advanced disease (stage III-IV) is generally treated with multimodality therapy, concurrent chemoradiation
therapy and surgery. The 5-year survival rates vary depending on the treatment modality. The 5-year survival
rate after concurrent chemoradiation therapy is 54% with preservation of 88% of the larynx at 2 years. The 5-
year survival after endoscopic laser laryngeal surgery is 55%.

Quality of life is emerging as an outcome measure in the treatment of laryngeal carcinoma. New data are
showing the functional outcomes and quality of life after different treatment modalities.[7]

Future and Controversies

Functional preservation of the larynx remains a challenging goal in the treatment of malignant laryngeal
tumors. Organ-sparing chemoradiation protocols have become the standard of care for advanced laryngeal
cancer. Although these strategies were proven effective in preserving the larynx, the may not necessarily
preserve the function. Improving surgical techniques such as endolaryngeal lasers, sophistication of radiation
techniques such as IMRT, and the development of novel targeting agents such as cetuximab will surely change
the landscape of current trends in laryngeal cancer treatment. Novel work in tumor angiogenesis and
immunotherapy also holds promise. In the near future, individualizing treatment through optimal patient
selection and biomarker analysis will be an interesting challenge.