The Voice Foundation

Overview | Understanding the Disorder | Symptoms | Diagnosis | Treatment

Key Glossary Terms

Laryngeal/Voice Box
Composed of vocal folds, muscles, and framework cartilages; key for voice, breathing, airway protection

Early Cancer
T1 = affects only one site on larynx, no spread, normal vocal fold motion; T2 = involves more than one site of larynx, vocal fold function abnormal but still moving

Advanced Cancer
T3 = complete non-movement of one vocal fold; T4=invades thyroid cartilage or structures outside of the voice box

TNM Staging
T, tumor type; N, lymph nodes involved; M, spread to other body parts or metastasis

Vocal Folds (also called Vocal Cords)
A pair of specialized tissue in the voice box that vibrate for sound production; comprised of ordered layers of epithelium, superficial lamina propria, vocal ligament, and thyroarytenoid muscle

Glossary

What are the treatment options for advanced cancer?

Treatment for advanced laryngeal cancer (stages II-IV) focuses on the role of the three main types of head and neck cancer therapies:

• Surgery (surgical)
• Radiation therapy (non-surgical)
• Chemotherapy (non-surgical)
• Multi-Modality Therapy – Combination of Treatment Options for T3 and T4 Tumors

Note: Radiochemotherapy is a combination of radiation therapy and chemotherapy.

In tumors that are advanced (T3 and T4), multi-modality therapy is likely to be recommended. With multi-modality therapy, more than one treatment will be combined to improve the cure rates and survival as well as preserve the larynx.

Currently a broad spectrum of non-surgical and surgical procedures is available to treat advanced laryngeal cancer.

Towards Increased Emphasis on Laryngeal Preservation

• New studies evaluating quality of life in the treatment of advanced laryngeal cancer raise the issue of the lifestyle costs the patient and physician must consider when choosing a particular therapy.
• Both patients and physicians are currently placing a renewed emphasis on treatment approaches that preserve key functions of the larynx – breathing, protecting the airway during swallowing, and producing voice. This emphasis is influencing both surgical and non-surgical treatment approaches.

 

  Red Flag

Ultimate Survival and Tumor Control Are First Priority

While the patient and physician must consider all options, control of the tumor, and ultimately survival, are the main considerations in deciding on a treatment for advanced laryngeal cancer.

Key Functions of Larynx Can Be Addressed in Both Surgical and Non-Surgical Approaches

Along with tumor control, the preservation of laryngeal functions – breathing, protecting the airway during swallowing, and producing voice – needs to be addressed. Loss of laryngeal function occurs in both surgical and non-surgical treatment strategies.

Laryngeal Preservation Can and Should Be Addressed With Surgical Treatment Plans

• Loss of laryngeal function occurs obviously in surgical procedures that remove part of the larynx (partial laryngectomies).
• Although these procedures may seem wholly destructive to the larynx, preservation of laryngeal function can be addressed, resulting in restoration and/or rehabilitation of voice.

Loss of Laryngeal Function Can Occur in Non-Surgical Therapy

• Laryngeal function can also be lost as a result of non-surgical therapy (radiation and/or chemotherapy), even though these treatments keep the larynx intact anatomically.
• The acute and chronic side effects of radiation and/or chemotherapy affecting both the larynx and surrounding tissues can result in dysfunction of normal tissue and permanent scarring – to the point that the larynx, although structurally present, cannot function.
• Patients may experience difficulties with speaking, breathing and swallowing. Some of these effects may improve over time, while others are more permanent.

Issues in the Treatment of T2 Laryngeal Tumors

Radiation therapy, widely used for T2 tumors, can result in significant loss of larynx function.

Radiation Therapy Cannot Distinguish Cancer from Normal Tissue

T2 laryngeal tumors, particularly those that begin on the vocal folds, are likely to be treated primarily with radiation therapy alone. These tumors are often only on one side of the larynx. However, radiation, which cannot distinguish between normal and cancerous tissue, has an impact on both cancerous and normal tissues in the larynx. Thus, voice quality will be abnormal in these cases, to a greater or lesser degree depending on the patient, the size and location of the tumor, and the dose of radiation used.

Radiation Therapy for T2 Tumor Can Be a Disadvantage

More importantly, radiation therapy is not available for further use if another primary tumor grows in the same area (5 percent chance per year), since radiation can only be delivered to a particular area of the body once in a patient’s life. Thus, failure of radiation therapy more than likely results in total laryngectomy (removal of the entire larynx), with a permanent windpipe brought out through the skin of the neck.

Partial Laryngectomy Possible for T2 Tumors

Partial laryngectomies are possible for T2 laryngeal tumors. For those T2 tumors arising on the vocal folds, surgical treatment involves cutting out the tumor (surgical resection) on one or both vocal folds with either a vertical or horizontal transection (removal) of the thyroid cartilage. (See Anatomy & Physiology of Voice Production for more information and a picture of the thyroid cartilage.)

Quality of Life: Need for a Temporary Breathing Tube

A temporary plastic breathing tube placed below the tumor into the windpipe (tracheotomy) is necessary in these cases.

Tumor Control: Variable Success Rate for T2 Cancer of the Vocal Folds

The tumor control rate for T2 tumors with partial laryngectomy is somewhat variable because of slight differences between surgeons and medical centers in performing this procedure. The failure rate for tumor control is reported to range between 5 and 25 percent

Current Best Practice: Total Laryngectomy Not Recommended for T2 Cancer

According to current best practice, a total laryngectomy is usually not recommended for a T2 laryngeal cancer, unless the tumor was “unfavorable” and/or had already been treated with chemotherapy and/or radiation therapy.

 

Key Information

Multidisciplinary Approach Important for Comprehensive Care

The key to cancer therapy and recovery is a multidisciplinary approach, often found in “team-oriented” environment at an academic medical center. Results are best when speech and swallowing therapists are involved in rehabilitation of speaking and swallowing after treatment procedure(s). (For more information, see Voice Care Team.)

Combined Radiation Therapy and Chemotherapy

• Recent studies comparing radiation therapy alone with chemoradiation (chemotherapy and radiation therapy delivered at the same time rather than sequentially) have demonstrated that combined chemoradiation is the optimal non-surgical treatment for larynx preservation. However, there is no survival advantage of this technique, and those for whom chemoradiation fails usually must have a total laryngectomy.
• Quality of life studies are currently underway that compare non-surgical (chemoradiotherapy) versus partial laryngectomies or total laryngectomy.

Note: For laryngeal cancers with large and/or extensive neck nodes containing cancer (N2-N3), combination chemoradiation therapy has not been effective for tumor control in the lymph nodes, even if the laryngeal cancer is controlled.

How do I select cancer treatment options?

Patients must be educated regarding different cancer treatment options to make an informed decision. Informed decisions are depend on:

• Cooperative discussion with the treating physician otolaryngologist
• Realization that one therapy or another might be more prevalent, or preferred, by a particular physician at a particular medical center
• The treating physician should be able to accurately describe the likely success rate of a given, recommended treatment for each particular tumor at that medical center.

Selecting the most appropriate therapy for a particular cancer of the larynx depends on many factors.

Factor 1: TNM Stage of the Tumor

A patient with an early T2N0 (stage 2) tumor may choose single modality therapy, such as radiation alone or surgery alone. Chemotherapy alone in this setting has not been proven to be effective at this point in time.

• For more advanced cancers, such as T3 and T4 tumors, with or without evidence of spread to the neck, multi-modality therapy is needed to improve the chances of tumor control and survival. Additionally, patients with T3 and T4 tumors also receive treatment on one or both sides of the neck with either surgery, radiation, or both.

Note: The most appropriate treatment is chosen after a thorough discussion between the patient and the physician once an accurate diagnosis is obtained, including pathologic biopsies to confirm the tissue type of the tumor. When considering which therapy is most appropriate, the patient does play an important role in guiding the advice of the surgeon.

 

Key Information

Recently, some clinical studies have directly compared the use of surgery (total laryngectomy) and postoperative radiation therapy with non-surgical treatment (combined chemotherapy and radiation therapy). These studies suggest that although there is no survival advantage from the addition of chemotherapy to radiation therapy for T3 and T4 tumors, the number of individuals who were cured while avoiding the need for laryngectomy (surgical removal of the voice box) was significant.

• Therefore, some physicians recommend that chemoradiotherapy is a viable alternative to total laryngectomy for advanced tumors, such as T3 and T4 cancers.
• However, of the patients who avoided laryngectomy, some experienced a recurrence of the tumor and were not able to have subsequent surgery to remove the tumor after chemoradiation therapy.

Follow-Up Surveillance Is Important in Cancer Management

Response to chemoradiotherapy, either immediate or in the long-term, is currently impossible to determine. Therefore, close follow-up for tumor surveillance is necessary every month or two for the first two years after treatment.

Total Laryngectomy: A Treatment Trade-Off

Patients who wish to avoid surgery assume the risk that, if the tumor comes back after non-surgical therapy, they may no longer be a candidate for surgery and may later die from the cancer.

On the other hand, those who undergo total laryngectomy for advanced cancers of the larynx may have an equal or better survival rate than those who choose non-surgical therapy, but must learn to live without their larynx (voice box) and will need to learn new techniques for communicating through extralaryngeal speech techniques.

Other Factors

Other factors play a role in the decision made jointly by the physician and patient to maximize the benefit of the treatment.

• The general medical condition of patients affects their ability to undergo major surgery or to receive chemotherapy and radiation therapy, which can have side effects on certain organ systems such as the kidneys.
• Radiation therapy for advanced laryngeal cancer requires treatments by a radiation therapist five days per week, for approximately six weeks consecutively. Occasionally, a one-week break may be recommended by the radiation therapist.
• Surgery typically entails a stay in the hospital of between five to eight days for recovery, as well as swallowing and speech therapy.

What are the frontiers/controversies of treatment?

Emphasis on Tumor Control and Quality of Life

The goal of organ preservation is to emphasize quality of life issues, providing grounds for a healthy debate on the best treatment approaches for patients with advanced laryngeal cancer.

Combination Chemotherapy and Radiation Therapy for Larynx Preservation in Advanced Cancer Treatment

The introduction of combined chemotherapy and radiation therapy as an alternative to total laryngectomy for patients with advanced laryngeal cancer has led to a new perspective on treatment for laryngeal cancer, referred to as “larynx preservation.”

Limitations of Combination Chemotherapy and Radiotherapy for Larynx Preservation

The combination of chemotherapy and radiotherapy for organ preservation is appropriate only for patients otherwise facing total laryngectomy.

• Although the structure and the tissues of the larynx are preserved in those patients whose tumor is successfully treated by chemoradiotherapy, the function of the remaining larynx is no longer normal in terms of speaking and swallowing.

Furthermore, some patients receiving non-surgical therapy will not be successfully treated and will still need total laryngectomy.

• Because radiation therapy can only be delivered once to a particular area of the body, the use of non-surgical treatment (chemoradiotherapy) up front means that radiation cannot be used later if another primary tumor is found (5 percent chance per year).

Key Information

Patient Counseling and Education Regarding Treatment Options

Patients considering organ-preserving treatment must be adequately counseled and educated regarding all treatment options, side effects, and failure rates.

Key Role of Otolaryngologist

• The otolaryngologist assists the patient in making an appropriate decision in conjunction with the advice of a medical oncologist and radiation oncologist, whose practices are limited to head and neck cancer. Otolaryngologists have the understanding, tumor staging skills, and expertise to accurately represent both the surgical and non-surgical approaches to organ preservation.

Surgical Approaches and Larynx Preservation – Emerging Importance

• The use of organ preserving surgical approaches has the added benefit of keeping radiation therapy in reserve if a recurrence or another primary cancer in the head and neck area develop. This added benefit is significant since the chance of recurrence or development of another primary cancer in the head and neck area is not small.

Note:

Development of another cancer in the throat area in an individual with advanced laryngeal cancer is approximately 4 to 5 percent per year for the rest of that person’s life.

• The increased risk of second tumors in the larynx or other locations within the mouth, throat, swallowing tube, or lungs is most likely related to the exposure of those tissues to the same cigarette and tobacco substances that induced the first cancer.

New Research on Inherited Susceptibility to Cancer Development

Newer information is being discovered that a small fraction of patients with head and neck cancer may have some inherited problem with repairing their DNA that makes them more susceptible to cancer in general. The cancer can develop on its own and be even more likely in someone with an inherited DNA problem who also smokes and drinks heavily.

How can treatment options affect voice and swallowing?

Treatment of advanced cancer of the larynx often results in moderate to severe effects on laryngeal functions (voice, breathing, and swallowing).

Surgical Treatment for Advanced Cancer

• Surgical treatment, involving the removal of any part of the vocal folds, will cause the voice to be rough, gravelly, and hoarse. Taking a significant amount of tissue away from the larynx can also result in a breathy, quiet, and whispered voice.
• The advantage of surgery in the treatment of laryngeal cancer is that only the areas involved with tumor are subjected to treatment. Larger, more advanced laryngeal tumors (some T3 and most T4) usually are treated with total laryngectomy.

Impact of Total Laryngectomy–Removal of Entire Larynx

• Total laryngectomy involves the removal of the entire larynx (voice box). After the removal of the larynx, the breathing tube and swallowing tube are separated.

Swallowing: The swallowing portion of the throat is reconnected with the esophagus so the patient can swallow food and liquid normally.

Breathing: The breathing tube (wind pipe or trachea) is brought out to the front, lower part of the neck and will be visible. Therefore, the patient will no longer breathe through the mouth and the nose, but rather through the surgically created hole in the neck attached to the windpipe (laryngectomy stoma). Although this is somewhat discouraging for patients initially, and is often the part of a laryngectomy that patients dislike the most, this is actually a quite effective method of breathing.

However, the humidification that our mouth, nasal cavity, and sinuses give to the air we breathe no longer occurs after laryngectomy. Without this humidification, normal secretions and mucous may become crusty and difficult to care for. Therefore, after a total laryngectomy, a humidifier is often used to prevent the air breathed into the lungs from being too dry.

Impact of Partial Laryngectomy – Removal of Part of Larynx

Voice: Because some bulk of tissue has been removed during partial laryngectomy, the voice becomes gravelly, weak, or breathy. However, surgical techniques can add tissue or bulk to improve voice quality and strength.

One possibility is to push one side of the larynx over so that the other unaffected vocal fold can move to meet it and better create voice. This sort of procedure is called a thyroplasty or laryngoplasty, and it entails inserting a material – such as silastic (soft black plastic) or Gore-tex™ strips – into the larynx to restore some of the fullness and bulk to the side of the larynx where tissue was removed. Other procedures can also be combined to improve how the remaining vocal folds meet the excised side of the larynx.

Swallowing: After partial laryngectomy swallowing is different, and the cooperation of the surgeon with an experienced speech/language pathologist (SLP) is critical to providing rehabilitation, teaching new swallowing techniques, and giving voice therapy. The SLP can teach patients many different maneuvers to improve swallowing and to prevent swallowed materials from going through your larynx into the lungs (“aspiration”).

Radiation Therapy for Advanced Cancer

Radiation Therapy Side Effects Variable, but Usually Progressive

• Radiation therapy cannot distinguish normal from cancerous tissue and therefore affects all of the tissues in the treated area, including the parts of the larynx that are not involved with tumor. Radiation therapy can have variable effects on the voice and swallowing. These effects are progressive, meaning that they develop over time (up to several years after the treatment). The effects of radiation therapy include a rough, hoarse voice.

• Dryness – a Frequent Side Effect of Radiation Therapy
  The main negative effect of radiation therapy is that it destroys salivary tissues which secrete lubricating mucous. Therefore, any area that has received radiation therapy will be very dry.
• Swelling After Radiation Therapy
  Another side effect of radiation therapy is swelling and a decrease in the ability of fluid to drain out of the tissues normally and recirculate around the body. This leads to swelling in the vocal folds and swallowing areas, reducing the functions of voice and food intake.

 

Key Information

Side Effects from Radiation and Chemotherapy Can Be Severe – Making the Larynx Non-Functional

Different patients react to radiation and chemotherapy in different ways. Some individuals do quite well with this non-surgical therapy, while others have so much dryness, swelling, and scarring (fibrosis) that the larynx is essentially rendered non-functional following treatment.

Total Laryngectomy After Non-Surgical Treatment of Advanced Cancer

In large studies of patients undergoing non-surgical treatment (chemoradiotherapy) for advanced laryngeal cancer, a small fraction (5 percent) lose all functioning of the larynx, resulting in poor voice, difficulty breathing, an inability to swallow enough food to maintain nutrition, and/or an inability to protect the lungs from saliva or food that leaks through the vocal folds into the windpipe (aspiration). These patients may need to undergo a total laryngectomy, even though the tumor no longer present.

If I Lose My Voice Box (from Total Laryngectomy)- How will I talk?

Restoration of voice after laryngectomy has improved significantly over the past 10 to 20 years. There are three main ways to restore voice after total laryngectomy.

• The first way to restore speech after laryngectomy is the use of pharyngo-esophageal speech, which can be learned with the assistance of an SLP. Patients learn to swallow air and bring it back up again (similar to a belch) to vibrate throat membranes to create sound. Pharyngo-esophageal speech can be remarkably intelligible.
• The second way to restore speech is the use of a vibrating instrument that the patient holds up to the throat or places along the cheek, called an electrolarynx. This is the vibrating device that most people associate with a patient who has had a total laryngectomy.
• The third technique, called a tracheoesophageal puncture (TEP), is most effective at restoring speech after laryngectomy. Placement of a TEP prosthesis, which is a one-way valve going from the windpipe into the esophagus (swallowing tube), requires a very minor surgical procedure. Patients speak by taking a deep breath and putting their thumb over the stoma (windpipe hole in the neck) or by using a plastic valve called a stoma vent to enable air to go through the TEP valve and out through the mouth. Although this is not a normal sounding voice, many patients function quite adequately and can even talk on the telephone well. Most patients can be taught to care for their TEP prosthesis.
  • When necessary, replacement of an old prosthesis can be done in the clinic by a doctor or a speech pathologist.
  • Although the TEP is effective, the patient should know how to use an electrolarynx if the TEP ever malfunctions.

How will I breathe?

After total laryngectomy, breathing is quite easy because the windpipe comes out directly from the neck instead of being connected to the mouth and throat. Although breathing is not difficult, the air that someone breathes after a laryngectomy must have humidity added to it or the mucous will become crusty and block the windpipe. While this is frustrating to some patients, they soon realize that is just like brushing their hair or teeth or other aspects of self-care; caring for the breathing tube becomes quite routine and simple.

How will I eat?

Most patients can eat normally after a laryngectomy.

The new throat will take some time to heal (up to several weeks), but usually liquids can be started by mouth within a week or so after surgery.

A temporary tube to give nutrition directly into the stomach may be placed through the nose or directly through the abdominal skin into the stomach. This tube is removed once swallowing improves and the patient can maintain nutrition adequately. Some patients can eat a completely normal diet, while others may eat some regular food and supplement their diet with tube feeds such as Ensure or Jevity.

What can I expect for follow-up and for surveillance of recurrence?

Most surgeons and oncologists want to keep a very careful follow-up schedule with patients who have been treated for advanced laryngeal cancer.

• Typical Schedule of Follow-Up
  • Follow-up visits are generally scheduled every four to six weeks for the first year and then every six to eight weeks for the second year after treatment. This schedule is based on observations from many cases indicating that if a laryngeal cancer is going to return, there is an 85 perecent chance it will do so within two years of the definitive treatment.
• Purpose of Follow-Up
  • Follow-up for the first two years is critical to detect any recurrent or persistent laryngeal cancer as quickly as possible so that salvage treatment can be given.
  • Follow-up visits for subsequent years, which are generally every three to six months for years three, four, and five after treatment, are scheduled so that physicians can perform surveillance (detection) of a second primary tumor elsewhere in the mouth, throat, or voice box.

What to Watch Out For – Monitoring for Cancer After Treatment

Any change in symptoms of speaking, breathing, or swallowing

• If any symptoms change or there is new pain or trouble speaking, swallowing, or breathing that was not present after cancer treatment finished, a visit with the physician should be scheduled immediately.
• Changes in every possible area that might harbor a persistent, recurrent, or second primary tumor
• The patient can perform a self-directed neck examination (your doctor will show you how), similar to the monthly self-breast examination that all women should perform.
• A patient should seek medical evaluation of any new mass, lump, or nodule, preferably by the surgeon who took care of the patient initially or the doctor who made the initial diagnosis. Returning to the same doctor is necessary because after surgical or non-surgical treatment of advanced laryngeal cancer the anatomy of the breathing and swallowing tubes, as well as the appearance and feel of the neck, are quite different and can be best assessed by someone capable of comparing previous and follow-up examinations.

Key Information

85% or more of the cases of laryngeal cancer recurrence within two years of the completion of therapy.

• Follow-up for the first two years is critical to detect any recurrent or persistent laryngeal cancer as quickly as possible so salvage treatment can be given.
• Follow-up visits in later years are also important to detect other types of cancers in the mouth, throat, or voice box.

What is it like to live with advanced cancer?

Patient-Physician Partnership Important

Once you have been told that there is a tumor in your larynx, you must cooperate fully with your physicians’ advice. Therefore, you need to find a doctor or doctors you trust.

Doctors who treat laryngeal cancer are used to dealing with the issues of patients who are diagnosed with this disease. These doctors are very interested in treating the cancer as soon as possible and maximizing the quality of life before, during, and after tumor removal. Early treatment requires a partnership between the doctor and the patient; patients must have a real desire to assist and to be a part of their medical team.

A patient’s positive attitude and an energetic approach to treatment maximize the likelihood of treatment success.

Psychiatric Consultation Helpful

Studies have shown that individuals with laryngeal cancer are often depressed and may benefit from talking to a psychiatrist or receiving medication for depression. Patients should realize that this is normal and should feel comfortable bringing up these issues with their surgeon.

Near-Normal Lifestyles With Effective Talking, Breathing, and Eating Are Possible

Many patients are able to confront their cancer and, with appropriate state-of-the-art medical care, successfully undergo treatment. Frequently, these patients are able to return to normal or near-normal lifestyles, with effective talking, breathing and eating.

Key Information

Multidisciplinary Approach Gives Optimal Comprehensive Care

The key to any cancer therapy and recovery is a multidisciplinary approach, often found in team-oriented settings in academic medical centers. Treatment results are best when speech and swallowing therapists are involved in rehabilitation of speaking and swallowing after treatment procedure(s). (For more information, see Voice Care Team.)