Case
This 69-year-old woman presented with a sore throat, hoarseness and a painless mass on the left side of her neck. The sore throat had been present for about three months and she had already been prescribed two courses of antibiotics. She had only noticed the swelling two months ago, but it had grown since.
She also mentions that she has had increasing difficulty and some pain swallowing, and has been eating less and less solid food.
She is being treated for hypertension and COPD, and the practice nurse who last saw her in the COPD clinic says she is noticeably thinner.
The patient smoked around 20 cigarettes a day until she was diagnosed with COPD nine years ago, and now smokes four or five a day.
Examination finds a 2cm firm, mobile and non-tender mass with no overlying erythema or induration. The oral cavity and oropharynx are normal. She is referred urgently and laryngoscopy reveals an ulcerated, necrotic mass on the laryngeal surface of the epiglottis that extends to the false vocal folds. The true vocal folds appear normal.
Histology shows a squamous cell carcinoma and a partial laryngectomy is carried out.
The problem
• Cancer of the larynx is the second most common head and neck cancer after cancer of the oral cavity.1
• It is much more common in males, with a male:female ratio of almost 5:1.
• It is rarely seen in those people younger than 40 years of age, but incidence rises steeply thereafter – with 73% of cases occurring in people over the age of 60.2
• Most laryngeal cancers originate in the glottis. Supraglottic cancers are less common, and subglottic tumours the most rare.
• Smoking is the most important risk factor. Death from laryngeal cancer is 20 times more likely for the heaviest smokers than for non-smokers.
• Heavy alcohol consumption – particularly spirits – is also significant. The two risk factors of smoking and drinking combined appear to act synergistically.
• Poor dentition is also a risk factor.
Features
• The symptoms of laryngeal cancer depend on the size and location of the tumour.
• Chronic hoarseness is the most common early symptom, but any of the following can be seen alone or in combination: a neck lump, sore throat, dysphagia, pain, ear ache or persistent cough.3
• Patients may also complain of breathlessness, weight loss or haemoptysis.
Diagnosis
• A full head and neck examination should be carried out, including inspection and palpation of the oral cavity and oropharynx – to rule out second primary tumours or other lesions – and an assessment of dentition.
• Palpation of the neck – looking for lymphadenopathy – is essential and an evaluation of the cranial nerves should also be carried out.
• Urgently refer any patient with hoarseness persisting for more than three weeks for a chest X-ray to exclude lung cancer – particularly smokers older than 50 years of age and heavy drinkers.4
• No other investigation is recommended in primary care.
• A normal chest X-ray should prompt the patient to be referred urgently to a head and neck cancer team.
• Flexible laryngoscopy allows the whole larynx to be examined and allows accurate staging of any tumour.
• Other investigations include fine-needle aspiration and CT, MRI or PET scans.
Management
• Total and partial laryngectomy are the main surgical procedures.
• Where possible, the goal of treatment is to remove the tumour and prevent recurrence while maintaining laryngeal function.
• Chemoradiation with preservation of the larynx has shown survival rates similar to total laryngectomy plus radiation therapy.5
• Outcome depends on the initial staging and is relatively good in early disease, with over 90% achieving five-year survival rates.1
Dr Raj Singh is a ENT GPSI in Manchester
References
1 Cancer Research UK. Laryngeal (larynx) cancer – UK incidence statistics. cancerresearchuk.org (accessed 10 August 2012)
2 Ridge J, Glisson B, Lango M et al. Head and neck tumours. In: Pazdur R, Wagman L, Camphausen K et al (eds). Cancer Management: A Multidisciplinary Approach (11th edition). Manhasset – NY:CMP Medica 2008
3 NICE. Service guidance on improving outcomes in head and neck cancers. 2004;CSGHN
4 NICE. Referral guidelines for suspected cancer. 2005;CG27
5 Ah-See K. The evidence for different management strategies for laryngeal cancer: summaries of systematic reviews commissioned for an educational meeting. Clin Otolaryngol 2008;33:90-3
