Laryngeal (larynx) cancer

Cancer of the larynx, also known as laryngeal cancer, is an uncommon type of cancer that develops inside the tissue of the larynx (see below).

Introduction

Cancer of the larynx, also known as laryngeal cancer, is an uncommon type of cancer that develops inside the tissue of the larynx (see below).

Common symptoms of laryngeal cancer include:

  • unexplained changes in the voice, such as sounding hoarse or husky
  • pain when swallowing
  • sore throat

When to seek medical advice

You should visit your doctor if you have any of the symptoms listed above and they've lasted for more than three weeks.

As these symptoms are the same as those for many other conditions, it's unlikely that they're caused by cancer. However, it's a good idea to rule out all possible causes of your symptoms by visiting your doctor.

See Laryngeal cancer - symptoms for more information.

The larynx

The larynx, also known as the voice box, is found at the back of the throat, in front of the windpipe (trachea). The larynx has three main functions. It:

  • channels oxygen into the windpipe during breathing
  • acts like a valve by closing off the trachea and preventing food or drink falling down into the lungs when eating or drinking
  • produces the sound of your voice; the larynx contains two folds of tissue (vocal cords) that vibrate as air passes through them

Who is affected by laryngeal cancer?

Laryngeal cancer is an uncommon type of cancer.

Laryngeal cancer is five times more common in men than in women. Most cases develop in older adults who are 40 years old. Three quarters of cases affect people who are 60 years old or over.

Smoking is the single biggest risk factor for laryngeal cancer. Drinking alcohol when smoking increases the risk further. It's unclear whether drinking alcohol but not smoking also increases a person’s chances of developing laryngeal cancer.

See Laryngeal cancer - causes for more information.

Treatment and outlook

If diagnosed in its early stages, there's a good chance that people with laryngeal cancer will achieve a complete cure. However, the more advanced the cancer is at the time of diagnosis, the less favourable the outlook and the chances of achieving a complete cure.

The main treatment option for laryngeal cancer is to surgically remove any cancerous tissue. Radiotherapy, chemotherapy and a type of medication called cetuximab can also be used to increase the chances of surgery being successful.

Survival rates

The survival rates for laryngeal cancer depend on the stage that the condition is diagnosed.
There are four stages of laryngeal cancer – stage one is the earliest stage and stage four is the most advanced stage.

See Laryngeal cancer - diagnosis for more information.

According to the leading cancer charity, Cancer Research UK:

  • more than 9 out of 10 people with stage one laryngeal cancer will live at least five years after diagnosis
  • more than 7 out of 10 people with stage two laryngeal cancer will live at least five years after diagnosis
  • more than 6 out of 10 people with stage three laryngeal cancer will live at least five years after diagnosis
  • around 1 in 4 people with stage four laryngeal cancer will live at least five years after diagnosis

Symptoms

Most laryngeal cancers develop near the vocal cords, so the first noticeable symptom is often a change in the sound of your voice. For example, your voice may be unusually hoarse or husky.

Other symptoms include:

  • pain when swallowing or difficulty swallowing
  • a lump or swelling in your neck
  • sore throat
  • ear pain
  • persistent coughing
  • unexplained weight loss
  • difficulty breathing
  • spitting or coughing up blood-stained saliva
  • bad breath
  • fatigue and weakness

When to seek medical advice

You should visit your doctor if you have any of the symptoms listed above and they've lasted for more than three weeks.

As these symptoms are the same as those for many other conditions, it's unlikely that they're caused by cancer. However, it's a good idea to rule out all possible causes of your symptoms by visiting your doctor.

Causes

Cancer begins with a change in the structure of DNA. DNA provides our cells with a basic set of instructions, such as when to grow and reproduce.

A change in DNA structure is known as a mutation, and it can alter the instructions that control cell growth. This means that the cells continue to grow instead of stopping when they should. This causes the cells to reproduce in an uncontrollable manner, producing a lump of tissue called a tumour.

Common risk factors

It's not known why and how the DNA inside the cells of the larynx is affected in cases of laryngeal cancer. However, it appears that exposure to anything that can directly damage the cells and tissue of the larynx increases the risk of cancer developing. The most common risk factors for laryngeal cancer are outlined below.

Alcohol and tobacco

Evidence shows that alcohol and tobacco are the two biggest risk factors for laryngeal cancer. Alcohol and tobacco are thought to contain chemicals that affect the normal workings of the cells of the larynx, triggering mutations that can lead to cancer. Drinking alcohol and smoking carry individual risks, but if you do both the risks are greatly increased.

Research has shown that if you smoke 40 cigarettes a day but don't drink alcohol, you're five times more likely to develop laryngeal cancer as well as other cancers of the head and neck, such as mouth cancer, than someone who doesn't drink or smoke.

Similarly, if you don't smoke but drink the equivalent of 30 pints of beer a week, your risk of developing laryngeal cancer is five times that of someone who doesn't drink or smoke.

However, if you smoke more than 40 cigarettes a day and drink an average of 30 pints a week, you're 38 times more likely to develop laryngeal cancer than someone who doesn't drink or smoke.

The fact that only a very small minority of heavy smokers and drinkers develop laryngeal cancer has led researchers to speculate that there must be certain genetic mutations that make people more vulnerable to the harmful effects of alcohol and tobacco smoke.

A number of common genetic mutations have been found in people with laryngeal cancer. It's thought that the genetic mutations disrupt the larynx’s ability to repair itself from the damage caused by tobacco smoke and alcohol.

Human papilloma virus (HPV)

The human papilloma virus (HPV) is the name given to a family of viruses that affect the skin and moist membranes that line the body, such as those in the cervix (neck of the womb), anus, mouth and throat.

Research shows that HPV may increase your risk of getting laryngeal cancer. In one in five cases of laryngeal cancer, HPV DNA was found in cancerous tissue.

HPV is known to cause changes in the cells of the cervix, which can lead to cervical cancer. It's thought that the virus may have a similar effect on the cells of the larynx. HPV is spread during sexual intercourse, including anal and oral sex.

Diet

There's evidence to suggest that a diet high in red meat, processed food and fried food can increase your risk of developing laryngeal cancer.

Occupational exposure

Having a job where you're exposed to high levels of certain substances may also increase your risk of developing laryngeal cancer. These substances include:

  • paint fumes
  • coal dust
  • wood dust
  • diesel fumes
  • nickel
  • formaldehyde – a chemical that's used in a wide range of industrial processes, such as paint manufacturing and cosmetics
  • isopropyl alcohol, which is often used as a cleaning solvent

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Diagnosis

If you have symptoms such as pain when swallowing and persistent coughing, your doctor will ask you about your symptoms and your recent medical history.

They may also examine the inside and outside of your throat for any abnormalities, such as lumps and swellings.

If laryngeal cancer is suspected, you'll probably be referred to the ear, nose and throat (ENT) department of your local hospital for further testing.

Nasoendoscope

A nasoendoscope is a medical instrument that consists of a small tube with a light at one end. The tube can be inserted into one of your nostrils and passed into the back of your throat to enable hospital staff to get a clearer view of your larynx.

The procedure isn't painful but can sometimes feel a little uncomfortable, so an anaesthetic spray is often used to numb your nose and throat.

Panendoscope

A panendoscope is similar to a nasoendoscope but it is longer and has a camera at one end as well as a light. It's often used when the results of earlier tests have been inconclusive or have detected a possible problem. A panendoscope can be used to show more of the larynx in greater detail.

The procedure can be painful so it's usually carried out under general anaesthetic (where you will be asleep). You should be able to leave hospital as soon as you've recovered from the effects of anaesthetic, which is usually the same day as the procedure or the day after.

Biopsy

During a biopsy, a small sample of tissue is removed and sent to a laboratory so that it can be examined for cancerous cells. A biopsy can usually be done at the same time as using the nasoendoscope or panendoscope. Small instruments are passed down the tube and used to remove a tissue sample.

Alternatively, if you have a lump in your neck, a needle can be used to draw out a tissue sample. This is known as fine needle aspiration (FNA).

Further testing

If the results of the biopsy show that you have cancer and there's a risk that it may have spread, you'll probably be referred for further testing to assess how widespread the cancer is. The tests may include:

Staging

After the tests described above have been completed, the doctor in charge of your care should be able to tell you how far the cancer has spread from your larynx to other parts of your body. Healthcare professionals use a four-stage system to describe how far laryngeal cancer has advanced. The four stages are described below.

  • Stage 1 – the cancer is present in the top layers of tissue that cover the larynx. The vocal cords are usually unaffected.
  • Stage 2 – the cancer has spread deeper into the larynx, affecting the functioning of the vocal cords and making the voice hoarse. Nearby lymph nodes are unaffected.
  • Stage 3 – the cancer has spread throughout the larynx and one of the vocal cords is no longer able to move, resulting in a loss of voice. Small lymph nodes near the larynx may also contain cancerous cells.
  • Stage 4 – the cancer has spread beyond the larynx and into the larger lymph nodes. In very advanced cases, the cancer can also spread to other parts of the body, usually the lungs.

Treatment

Cancer treatment team

Many hospitals use multidisciplinary teams (MDTs) to treat laryngeal cancer. These are teams of specialists that work together to decide the best way to proceed with your treatment. See the box (left) for details of the specialists who make up MDTs.

As well as having a specialist MDT, you may also be assigned a key worker who will usually be a specialist nurse. They will be responsible for co-ordinating your care.

Deciding what treatment is best for you can often be confusing. Your cancer team will recommend what they think is the best treatment option, but the final decision will be yours.

Before visiting hospital to discuss your treatment options, you may find it useful to write a list of questions that you'd like to ask the specialist. For example, you may want to find out the advantages and disadvantages of particular treatments.

Your treatment plan

Your recommended treatment plan will depend on the stage that your laryngeal cancer is at (see Laryngeal cancer - diagnosis for more information about staging).

If you have early stage one laryngeal cancer, it may be possible to remove the cancer using radiotherapy alone (see below). Later stage one and stage two cancer will probably require a combination of surgery and radiotherapy.

In stages three and four, more extensive surgery may be needed. Radiotherapy and chemotherapy will probably be used. In particularly severe cases, the entire larynx may have to be removed.

Radiotherapy

Radiotherapy uses controlled doses of high-energy radiation to destroy cancerous cells. It can be used as a primary treatment in early-stage laryngeal cancer. It's also often used as a secondary treatment before or after surgery to stop cancerous cells returning.

The energy beams that are used during radiotherapy have to be precisely targeted to your larynx. In order to ensure that the beams are directed to the exact area, a special plastic mask will be made to hold your head in the right position. During your first visit to the radiotherapist, a mould of your face will be taken to make the mask.

Radiotherapy is usually given in short daily sessions from Monday to Friday, with a break from treatment at the weekend. As well as killing cancerous cells, radiotherapy can affect healthy tissue and has a number of associated side effects, including:

  • sore, red skin (similar in appearance to sunburn)
  • mouth ulcers
  • sore mouth and throat
  • dry mouth
  • loss of taste
  • loss of appetite
  • tiredness
  • feeling sick

Your MDT will monitor any side effects and, where possible, provide treatment for them. For example, protective gels can be used to treat mouth ulcers, and medicines are available if you have a dry mouth.

Radiotherapy can sometimes cause your throat tissue to become inflamed. Severe inflammation can cause breathing difficulties. Contact your MDT as soon as possible if you have difficulty breathing.

Most side effects should pass after your course of radiotherapy has been completed, although symptoms such as tiredness and dry mouth can last for several months following treatment.

See the Health A-Z topic about Radiotherapy for more information.

Surgery

There are four types of surgery that are used to treat laryngeal cancer. They are:

  • laser surgery
  • endoscopic resection
  • partial laryngectomy
  • total laryngectomy

These are discussed below.

Laser surgery

Laser surgery will be used if the tumour in your larynx is still very small. A fibre-optic cable is placed into your larynx and a laser is passed through the cable to destroy the cancerous cells.

The operation is carried out under general anaesthetic. Most people who have laser surgery are able to leave hospital the day after their operation.

Endoscopic resection

Endoscopic resection can be used to treat stage one and stage two laryngeal cancer. The surgeon uses an endoscope, which is a small flexible tube with a light and a camera on one end. Tiny surgical instruments can also be passed down through the endoscope.

During an endoscopic resection, the surgeon will guide the endoscope into your larynx. The camera will be used to relay images to a screen in the operating theatre so that the surgeon is able to see your larynx in detail. They will remove any cancerous cells either using a laser or surgical instruments.

An endoscopic resection is carried out under general anaesthetic and doesn't cause any long-lasting side effects. However, you may feel some soreness in your mouth and throat for a few weeks afterwards.

Partial laryngectomy

A partial laryngectomy is usually used to treat stage three laryngeal cancer. The operation involves surgically removing the affected part of your larynx. Some of your vocal cords will be left in place so that you will still be able to talk, but your voice may be quite hoarse or weak.

While your larynx is healing, you may find breathing difficult. If this is the case, the surgeon will create a temporary hole in your neck, which will be attached to a tube that you can breathe through. This is known as a temporary tracheostomy.

Once your larynx has healed, the tube can be removed and the hole will heal. You may have a small scar.

Total laryngectomy

A total laryngectomy is usually used to treat advanced stage three or stage four laryngeal cancer. The operation involves removing your entire larynx. Nearby lymph nodes may also need to be removed if the cancer has spread to them.

As your vocal cords will be removed, you won't be able to speak in the usual way. There are several ways to help restore your speech. See Laryngeal cancer - recovery for more information about the different ways of restoring your speech.

If you have a total laryngectomy, you'll also need to have a permanent tracheostomy. The tube will usually be removed after a few weeks, leaving the hole. The medical term for a surgically created hole in the skin is a stoma.

You'll be given training about how to keep your stoma clean. Having a permanent tracheostomy can seem daunting and frightening at first, but most people get used to the stoma after a few months. See Laryngeal cancer - recovery for more information about adjusting to life after a laryngectomy.

Chemotherapy

Chemotherapy is often used in combination with radiotherapy before you have surgery to treat advanced laryngeal cancer. Chemotherapy uses powerful cancer-killing medicines to damage the DNA of the cancerous cells and stop them from reproducing.

Chemotherapy can often be used to shrink a tumour, which means it's not necessary to remove your entire larynx during surgery. However, the medicines that are used can sometimes damage healthy tissue as well as the cancerous tissue. Unfortunately, side effects are common and include:

  • feeling sick
  • being sick
  • hair loss
  • sore mouth
  • mouth ulcers
  • tiredness

These side effects should stop after your treatment has finished. Chemotherapy can also weaken your immune system, making you more vulnerable to infection and illness.

It's therefore important that you report any symptoms of a potential infection to your MDT, such as a high temperature, persistent cough or reddening of the skin. Also avoid close contact with people who are known to have an infection.

Targeted therapies

Targeted therapies refer to a group of medicines that are designed to target and disrupt one or more of the biological processes that cancerous cells use to grow and reproduce.

A targeted therapy called cetuximab can be used to treat cases of stage three or stage four laryngeal cancer where it's not possible to use chemotherapy. For example, people with kidney disease or people with an ongoing infection can't have chemotherapy because it could make them very ill.

Cetuximab targets special proteins called epidermal growth factor receptors (EGFRs), which are found on the surface of cancerous cells. EGFRs help the cancer to grow, so by targeting them cetuximab can prevent the cancer from spreading.

Cetuximab is given intravenously (through a drip into your vein) which slowly delivers the first dose over the course of a few hours. Further doses should take about an hour and are given weekly.

The side effects of cetuximab are usually mild and include:

  • skin rashes
  • feeling sick
  • diarrhoea
  • breathlessness
  • eye inflammation (conjunctivitis)

Cetuximab can trigger allergic reactions in some people, such as a swollen tongue or throat.
Occasionally, the allergic reaction can be severe and life-threatening. This is known as an infusion reaction and it occurs in about 1 in 35 people who take cetuximab.

Most infusion reactions occur within 24 hours of treatment starting, so you'll be closely monitored once your treatment begins. If you have symptoms of an infusion reaction, such as a rapid heartbeat or breathing problems, anti-allergy medicines can be used to relieve them – for example, corticosteroids.

These measures mean that deaths resulting from infusion reactions in people taking cetuximab are very rare, occurring in less than 1 out of every 1,000 cases.

Recovery

If you have had some, or all, of your larynx removed (laryngectomy), it's likely that you'll need to spend one or two days in an intensive care unit (ICU) until your body has recovered from the effects of the surgery.

You won't be able to eat until your throat has healed, which for most people is between 7 and 14 days. During this time, you'll need to be fed with a tube that's placed down your nose and into your stomach. However, in a small number of people, recovery can take several months.

If you've had all of your larynx removed, you won't be able to speak normally because you will no longer have any vocal cords (the tissue that's used to generate sound). A number of techniques can be used to replicate the functions of your vocal cords (see below), although they can take several weeks or months to learn.

Therefore, it's likely that you'll need to use alternative methods of communicating during the first few weeks or months after surgery. For example, using a pen and paper or lip reading. This can be a frustrating experience and the loss of an ability that you've previously taken for granted can be difficult to cope with.

Prepare yourself for people who you don't know reacting to you in unpredictable or sometimes upsetting ways. For example, many people who have had a laryngectomy have reported that people sometimes assume that they're deaf or have a learning difficulty due to their inability to speak.

Emotional impact

The emotional impact of living with a laryngectomy can be significant. Many people report experiencing a kind of roller-coaster effect.

For example, you may feel down when laryngeal cancer is diagnosed, then feel up after the cancer has been removed, then feel down again as you try to come to terms with the practicalities of living with a laryngectomy. This type of emotional disruption can sometimes trigger feelings of depression. You may be depressed if:

  • you have felt very down during the past month
  • you no longer take pleasure in doing the things that you enjoy

Contact your doctor for advice if you think that you may be depressed. There are a range of effective treatments for depression, such as antidepressant medication and talking therapies, such as cognitive behavioural therapy.

Stoma care

If you've had all of your larynx removed (total laryngectomy) the surgeon will need to create a permanent hole in your throat through which you will breathe (a stoma). During the first few months after surgery, it's likely that your stoma will produce a lot of mucus, particularly if you've had radiotherapy.

Excessive mucus can cause breathing difficulties, so a tube may be attached to your stoma to help you breathe more easily. Once the production of mucus has settled down the tube can be removed.

It's important to clean your stoma at least once a day otherwise it can become crusty and may become vulnerable to infection. This can be done using a cotton bud and freshly boiled water that's then cooled.

Alternatively, the ear nose and throat (ENT) department of your local hospital will be able to give you cleaning solutions. An ENT nurse will be able to train you in how to keep your stoma clean. Your ENT department also has filters that can help to keep your stoma moist and free of germs.

It's important to remember that you'll need to cover your stoma with a tissue when you cough or sneeze, rather than covering your mouth or nose. This is because mucus or saliva will come out of your stoma.

Vocal restoration

If your larynx has been completely removed as part of your treatment for laryngeal cancer, you'll need additional treatment to help restore your voice. This is because you will no longer have any vocal cords, so you won't be able to produce sound in the normal way.

Before your laryngectomy, you may meet a speech and language therapist (SLT) to discuss possible treatment options for restoring your voice. A SLT is a healthcare professional who specialises in helping people who have difficulties speaking and using language.

There are several different treatment options, which are briefly outlined below.

Voice prosthesis

A voice prosthesis is an artificial valve that can be implanted into your neck when you have a laryngectomy. When you want to speak, you cover the stoma and breathe out through the valve.

The valve produces a noise which you can use to make words by moving your lips and mouth in the usual way. The voice that's produced by the valve sounds natural although it may be lower pitched than your previous voice.

Oesophageal speech

Oesophageal speech is a technique for speaking that your SLT can teach you. It involves learning to push through your oesophagus (gullet). As the air moves through your oesophagus it vibrates and makes a noise. You can produce words by moving your lips and mouth.

Some people find it quite easy to learn oesophageal speech, whereas others find it difficult. Regular practice by yourself and with your SLT can help you to improve.

Electropharynx

An electropharynx is a small electrical device that vibrates and produces sound. You hold the device under your chin, and as you move your mouth and lips the vibrations translate into spoken words. Your SLT can train you to use an electropharynx.

Prevention

Tobacco

Using tobacco products increases your chances of developing laryngeal cancer, lung cancer and bladder cancer.

Tobacco comes in many forms, including:

  • cigarettes
  • pipe tobacco
  • cigars
  • cigarillos
  • snuff (powdered tobacco that's snorted through the nose)
  • chewing tobacco

If you smoke or use other tobacco products, giving up will have both short- and long-term health benefits. For example, if you're able to not smoke for 10 years, your risk of developing laryngeal cancer and other oral cancers will be the same as someone who has never smoked.

If you want to give up smoking but you don't want to be referred to a stop smoking service, your doctor should be able to prescribe medical treatment to help with any withdrawal symptoms that you may have after you give up.

See the Health A-Z topic about Quitting smoking - treatment for more information and advice about giving up.

Alcohol

Staying within the recommended guidelines for alcohol consumption will also reduce your risk of developing laryngeal cancer and liver cancer. The recommended daily limits of alcohol are:

  • 3-4 units of alcohol for men
  • 2-3 units of alcohol for women

A unit of alcohol is equal to about half a pint of normal-strength lager, a small glass of wine or a pub measure (25ml) or spirits.

Contact your doctor if you're finding it difficult to reduce the amount of alcohol that you drink. You may need to have additional treatment that could include counselling, group work or medication.

See the Health A-Z topic about Alcohol misuse - treatment for more information and advice.

Diet

Research shows that a diet that's high in fresh vegetables, particularly tomatoes, citrus fruit such as oranges, grapefruits and lemons, olive oil and fish oil, can reduce your risk of getting laryngeal cancer. This type of diet is sometimes known as a Mediterranean-style diet.

Eating five portions a day of a variety of fruit and vegetables will also help prevent oral cancer, as well as other types of cancer. Fruit and vegetables contain chemicals called antioxidants, which are thought to help protect cells from becoming damaged. Leafy vegetables, such as lettuce, spinach and cabbage are thought to provide the most protection against cancer.

Your diet should also be low in fat and high in starchy foods (carbohydrates), such as wholemeal bread, cereals and potatoes.

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