Laryngeal cancer is the second most common head and neck cancer. The most common type is squamous cell carcinoma (SCC)
It peaks between 40 and 70 years of age. The 5-year survival rate is 65%.
Regions of the larynx
| Site | Anatomical boundaries | Histology |
|---|---|---|
| Supraglottic Site | From the epiglottis to the junction of the ventricle and the true vocal cord | Respiratory epithelium |
| Glottic Site | From the superior surface of the true vocal fold to 1 cm below the true vocal folds | Stratified squamous epithelium |
| Subglottic Site | From 1cm below the true vocal folds to the inferior cricoid cartilage | Respiratory epithelium |
Histological subtypes of laryngeal cancer
| Histology | Description |
|---|---|
| Squamous Cell Carcinoma | >95% of Laryngeal Cancer. Basaloid SCC is the most aggressive high-grade variant. |
| Verrucous Carcinoma (Ackerman’s Tumor) | Slow-growing and locally destructive. Appears exophytic (warty), fungating, and grey-white in color. It rarely metastasizes and has an excellent prognosis. |
| Adenocarcinoma | 1% of laryngeal cancer. Primarily in the supraglottic and subglottic regions. More aggressive than SCC. |
| Adenoid Cystic Carcinoma | Perineural spread, an indolent course, and may present with distant metastasis years after primary treatment |
| Spindle Cell Carcinoma | Poorly differentiated variant of SCC with spindle cell stroma component |
| Neuroendocrine Tumors | Paragangliomas, Carcinoid tumors, Small cell carcinoma |
| Sarcomas | Fibrosarcoma, chondrosarcoma, malignant fibrous histiocytoma, rhabdomyosarcoma |
| Metastatic | Rare. Primaries from the kidney, prostate, breast, stomach, and lung. |
Premalignant glottic lesions
| Histology | Description |
|---|---|
| Hyperplasia and Hyperkeratosis | An increase in the number of cells and keratin production |
| Mild Dysplasia | Mild atypia |
| Moderate Dysplasia | Moderate atypia |
| Severe Dysplasia (Carcinoma in Situ) | Full-thickness features of malignancy without invasion of the basement membrane |
| Microinvasive Carcinoma | Discrete foci invade beyond the basement membrane |
| Invasive Carcinoma | Invasion through the basement membrane |
Subsites of laryngeal cancer
| Feature | Supraglottic | Glottic | Subglottic |
|---|---|---|---|
| Frequency | ~40% | ~60% (most common) | Rare |
| Prognosis | Poor (early spread, late detection) | Best (early symptoms) | Poor |
| Lymphatic Spread | Rich → early, bilateral nodal spread (II–IV) | Poor → late, ipsilateral spread | To paratracheal nodes (Level VI) |
| Tumor Spread Pattern | Superior → base of tongue | Limited initially (ligament barriers) | Inferior → cricoid, trachea |
| Special Feature | The fusion plate limits the spread between regions | Barriers (vocal ligament, conus elasticus) | Silent progression |
| Key Early Symptom | Sore throat, dysphagia | Hoarseness | Stridor |
| Other Symptoms | Hemoptysis, aspiration, odynophagia, otalgia, weight loss | Stridor (late), dysphagia, weight loss | Late hoarseness, hemoptysis, dysphagia |
| Unique Entity | Marginal tumor (aggressive, basaloid SCC) | — | — |
- Risk factors
- Smoking and alcohol use
- The highest risk is in current smokers
- Risk increases with the number of cigarettes
- Risk reduces to the level of an individual who has never smoked approximately 20 years after cessation
- History of Recurrent Respiratory Papillomatosis (HPV)
- Previous head and neck Radiation
- Plummer-Vinson Syndrome
- Premalignant lesions
- Leukoplakia
- Hyperkeratosis with atypia
- Carcinoma in Situ
- Genetic mutations in p53, p16, and cyclin D1
- Occupational toxins
- Asbestos
- Wood dust
- Coal dust
- Cement dust
- Polycyclic aromatic hydrocarbons
- Fanconi’s anemia
- Congenital dyskeratosis
- Low socioeconomic status
- Smoking and alcohol use
- Signs and symptoms
- Hoarseness
- Persistent
- Stridor (Airway obstruction)
- Dysphagia
- Odynophagia
- Throat pain
- Haemoptysis
- Referred Otalgia
- Globus sensation
- Weight loss
- Hoarseness
- Differentials
- Fungal laryngitis
- Sarcoidosis
- Tuberculosis
- Wegener’s granulomatosis
- Benign vocal cord tumors
- Polyps
- Cysts
- Hemangioma
- Papilloma
- Investigations
- Indirect laryngoscopy
- Flexible nasolaryngoscopy to visualize cord mobility
- Rigid endoscopy of the larynx
- Direct laryngoscopy under general anaesthesia and biopsy
- Chest X-ray for chest metastasis, mediastinal nodes, and co-existing lung disease
- CT scan of the base of the skull to the thoracic inlet
- PET scan for follow-up and detection of distant metastases
- Pulmonary function tests
- Liver function tests
- Urea and Creatinine
- Electrolytes
- Full Hemogram
- Treatment of Carcinoma in Situ and Micro-Invasive Carcinoma
- Treatment of Laryngeal Carcinoma
- Primary radiation to the primary site
- CO2 laser
- Conservative Laryngeal Surgery
- Total Laryngectomy and neck dissection
- Organ Preservation
- Induction chemotherapy, then Chemoradiation
- Chemoradiation only
- Palliation
- Tracheostomy
- Gastrotomy
- Post-operative complications
- Fistula
- Tracheotomy Complications:
- Pneumothorax
- Haemorrhage
- Subcutaneous emphysema
- Speech alterations
- Swallowing problems
- Persistent aspiration
- Bronchopneumonia
- Esophageal or pharyngeal stenosis
- Perichondritis and shondritis
- Stomal stenosis
- Post-operative voice management
- Writing
- Artificial larynx (electrolarynx)
- Esophageal speech
- Tracheoesophageal Puncture
AJCC T Staging comparison
| Stage | Supraglottic | Glottic | Subglottic |
|---|---|---|---|
| T1 | Limited to 1 subsite, normal cords | Limited to the vocal folds | Limited to the subglottis |
| T2 | >1 subsite or adjacent spread, no fixation | Extends the supra/subglottis or ↓ mobility | Extends to the vocal cords |
| T3 | Cord fixation or invasion (pre-epiglottic/paraglottic space, thyroid cartilage) | Cord fixation or paraglottic invasion | Cord fixation or paraglottic invasion |
| T4 | Invades beyond the larynx / major structures | Advanced invasion | Advanced invasion |