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Department of Surgery

 
CANCER OF THE THROAT AND LARYNX
General Information

Cancer of the Larynx (Voice Box) and Pharynx (Swallowing Passage)
The MGH Center for Laryngeal Surgery and Voice Rehabilitation is recognized nationally and internationally for their highly-successful pioneering surgical techniques to preserve voice, swallowing and breathing function in those patients who develop throat cancer.  They have published this work extensively in the peer-reviewed literature and in many textbooks.  They have taught these techniques in medical centers throughout the USA and abroad.  For this reason, doctors themselves, from the USA and overseas with throat cancer often seek care at the MGH Voice Cente

BEFORE
AFTER

Cancer of the throat typically starts in surface membranes (mucosa) of the air and food passages and as it enlarges can spread to adjacent locations.  Although most tumors of this region are cancerous (malignant), occasionally benign (nonmalignant) tumors of the throat are encountered.  When malignant (cancerous) tumors invade (grow into) the deeper underlying soft tissues such as muscle, the patient may also develop a neck lump or swelling, which represents spread of the cancer to the lymph nodes in the neck. 

BEFORE
AFTER

This must be distinguished from enlarged and swollen lymph nodes in the neck that can occur as a result of infections in the mouth, throat or tonsils.  Although most patients who get throat cancer have smoked at some point in their lives, in recent years there are increasing numbers of patients who have not smoked.

BEFORE
AFTER
Symptoms

Patients may have more than one symptom, however, specific complaints usually relate to the site where the cancer starts and is largest. This may include voice changes (dysphonia) or hoarseness if the cancer is near or in the vocal cords.  There may be a general feeling of a lump in the throat (globus sensation). 

BEFORE
AFTER

Difficulty swallowing (dysphagia) and/or painful swallowing (odynophagia) are common symptoms with cancer of the pharynx in including the palate, tonsil, tongue, and hypopharynx as well as the supraglottic larynx (upper voice box).  Difficulty breathing often associated noisy breathing (stridor) occurs with airway obstruction and usually occurs with more advanced and larger cancers/tumors.

Location of the Cancer
Larynx

Cancer of the larynx (voice box) can arise in the upper (supraglottis), middle (glottis: vocal cords) or lower (subglottis) regions.  While glottic and supraglottic cancer are equally common, subglottic cancer is rare.  The MGH laryngeal surgery group is well recognized for creating and establishing the state of the art in voice-preserving and voice-restoring treatment for larynx (voice box) cancer.

BEFORE
AFTER
Glottis
Supraglottis

The glottis is the area that contains the vocal cords (vocal folds).  The most common and first symptom with vocal cord cancer is typically voice loss, hoarseness, or dysphonia.  Larger tumors can cause breathing difficulties that can lead to noisy breathing (stridor) when especially during sleep. 

In fact, many patients have been noted to have precancerous (premalignant) mucosal membrane dysplasia (atypia) prior to developing vocal cord cancer and others will develop vocal cord dysplasia after successful treatment of cancer. 

The supraglottis is the area of the larynx (voice box) that contains the epiglottis, false vocal cords (vocal folds) and aryepiglottic folds.

The most common symptoms with supraglottic cancer include throat discomfort/pain or a lump in the neck.  Patients may also have voice changes, swallowing difficulties, ear pain or breathing problems especially when sleeping.

Diagnosis
Diagnosis

Precise office examination with both a rigid telescope through the mouth and a specialized distal-chip flexible laryngoscope passed through the nose will provide key information about the size, location, and extent of the cancer.

These larynx examinations should be done with stroboscopy to identify which areas of the vocal cords are still vibrating.

If laryngeal stroboscopy is not done with the rigid telescope or flexible laryngoscope, the examiner is unlikely to be a skilled voice expert.  If a lesion/tumor is suspicious for being cancer or dysplasia, the patient is scheduled to go to the operating room to examine the larynx with a surgical microscope (microlaryngoscopy) with the patient asleep under general anesthesia. 

During that diagnostic procedure, the cancer is typically biopsied and treated.  A CT-scan may be obtained if a large vocal cord cancer is seen.

Precise office examination with both a rigid telescope through the mouth and a specialized distal-chip flexible laryngoscope passed through the nose will provide key information about the size, location, and extent of supraglottic (epiglottis, false vocal cord, aryepiglottic fold) cancer.

These laryngeal examinations should be done with stroboscopy to determine whether there has been extension of the disease to the vocal cords and whether the vocal cords are vibrating normally.  If a lesion/tumor is suspicious for being cancer, the patient is scheduled to go to the operating room to examine the larynx with a surgical microscope (microlaryngoscopy) with the patient asleep under general anesthesia. 

During that diagnostic procedure, the cancer is typically biopsied to confirm the diagnosis and treated.  A CT-scan is obtained prior to the microlaryngoscopy and biopsy to help determine the extent of the cancer in the larynx and pharynx as well as to identify whether there are lymph nodes that suspicious for cancer.

Treatment
Treatment

Members of the MGH team have likely created more developments for optimally treating vocal cord cancer than any other group. The two conventional treatments for vocal cord cancer are surgery and radiotherapy. 

Because of the development of highly-effective function-sparing endoscopic transoral (through the mouth) minimally-invasive laser surgery, we seldom employ chemotherapy for laryngeal cancer.

In most circumstances, vocal cord cancer that has not been previously treated by radiation (radiotherapy), can be treated with endoscopic laser management preserving the patient’s ability to speak, swallow, and breathe.

As necessary, larger cancers may require radiotherapy and may need to be removed by open external surgery through the neck.

Pulsed KTP (Angiolytic) Laser treatment of vocal cord cancer: This latest pioneering breakthrough research is a new cancer treatment for vocal cords that has been highly successful and has resulted in the best voice results to date.  This work was based an extensive basic science research and clinical experience with precancerous (premalignant) dysplasia (atypia).

Thus far, no patients have needed radiation and no patients have required resection (removal) of their vocal cord.

This new and highly effective cancer treatment has been used for over 5 years exclusively by the MGH team and was recently presented at the annual meeting of the American Broncho-Esophagological Association. 
The groundbreaking success has also led to national television and newspaper coverage and patients from throughout the seeking this unique.

The MGH laryngeal surgery team has been reporting on the endoscopic carbon dioxide (CO2) laser treatment of supraglottic cancer for ~20 years. The two conventional treatments for vocal cord cancer are surgery and radiotherapy. 

Because of the development of highly-effective function sparing endoscopic transoral (remove through the mouth) minimally-invasive laser surgery, we seldom employ chemotherapy for laryngeal cancer.  In most circumstances, supraglottic cancer that has not been previously treated by radiation (radiotherapy) can be treated with endoscopic laser management thereby preserving the patient’s ability to swallow, breathe and speak.

Most supraglottic cancers will require endoscopic and at times open surgery through the neck as well radiation (radiotherapy) to optimize cure rates.  If patients present with evidence of lymph node spread (metastasis), they should undergo removal of the lymph nodes, which is called a neck dissection.

Thulium Laser treatment of supraglottic cancer: This new laser was introduced to Otolaryngology - Head and Neck Surgery by the MGH team who were likely the first to resect cancer with this unique innovative fiber-based laser technology. 

The Thulium laser has been highly effective in endoscopically resecting supraglottic and pharynx cancer in a minimally-invasive fashion is has been demonstrated to be a significant technological advancement in surgery of the upper air and food (aerodigestive) passages.

Pharynx
Cancer of the pharynx can arise in the upper (nasopharynx), middle (oropharynx) or lower (hypopharynx) regions.  Oropharynx and hypopharynx cancera are more commonly encountered in the USA while nasopharynx cancer is more commonly seen in many parts of Asia.  The MGH laryngeal surgery group has made a number of substantive function sparing advances in the successful management pharyngeal cancer.
Oropharynx
Hypopharynx

The oropharynx is comprised of the soft palate, tonsil region, tongue base and posterior pharyngeal wall.  Cancer of the oropharynx often involves more than one of these areas.  These structures are critical for normal swallowing so that cancer of the oropharynx frequently causes difficult or painful swallowing.

If the tumor is large, it may change the resonance of the voice.  Tumors of the tonsil or soft palate may even be visible to patients and noticed while brushing their teeth. Occasionally, blood will be noted in saliva.

The hypopharynx is the lowest part of the swallowing passage in the neck just before food enters the esophagus, which travels through the chest into the stomach. 

The hypopharynx is comprised of right and left pyriform (piriform) sinus, post-cricoid (behind the voice box) and posterior pharyngeal wall.

Cancer of the hypopharynx often involves more than one of these areas and possibly the larynx (voice box) as well.  These structures are critical for normal swallowing so that cancer of the oropharynx frequently causes difficult or painful swallowing and may be associated with weight loss.

If the tumor is large, it may change the voice and/or breathing.  Tumors of the hypopharynx may grow into the larynx (voice box) and immobilize a vocal cord.  It may grow north (superior) into the oropharynx or south (inferior) into the esophagus.  Occasionally, blood will be noted in saliva.

Diagnosis
Diagnosis

Precise office examination with direct viewing through the oral cavity as well as with a rigid telescope through the mouth and a specialized distal-chip flexible laryngoscope passed through the nose will provide key information about the size, location, and extent of oropharynx (soft palate, tonsil region, tongue base and posterior pharyngeal wall) cancer.

Since these tumors can spread under the surface of the membranes (mucosa), it is important for the surgeon to manually feel the tumor if possible. 

A CT-scan is obtained prior to the micro-pharyngoscopy / laryngoscopy and biopsy to help determine the extent of the cancer to other areas of the pharynx and larynx as well as to identify whether there are lymph nodes that suspicious for cancer.  If a lesion/tumor is suspicious for being cancer, the patient is scheduled to go to the operating room to examine the pharynx endoscopically with a surgical microscope (micro-pharyngoscopy/laryngoscopy) with the patient asleep under general anesthesia.

During that diagnostic procedure, the cancer is typically biopsied to confirm the diagnosis and treated during the same procedure. 

Precise office examination with a rigid telescope through the mouth and a specialized distal-chip flexible laryngoscope passed through the nose will provide key information about the size, location, and extent of hypopharynx (pyriform (piriform) sinus, post-cricoid (behind the voice box) and posterior pharyngeal wall) cancer. 

A CT-scan is obtained prior to the micro-pharyngoscopy/laryngoscopy and biopsy to help determine the extent of the cancer to other areas of the pharynx and larynx as well as to identify whether there are lymph nodes that suspicious for cancer.

If a lesion/tumor is suspicious for being cancer, the patient is scheduled to go to the operating room to examine the pharynx endoscopically with a surgical microscope (micro-pharyngoscopy/laryngoscopy) with the patient asleep under general anesthesia.  During that diagnostic procedure, the cancer is typically biopsied to confirm the diagnosis and treated during the same procedure. 

Treatment
Treatment

The MGH laryngeal surgery team has been reporting on the treatment of oropharynx (soft palate, tonsil region, tongue base and posterior pharyngeal wall) cancer for ~20 years and authored a number of academic manuscripts describing innovative surgical methods to preserve full swallowing, breathing and voice function including the official monograph for the American academy of Otolaryngology -  Head and Neck Surgery.

Because of these unique and proven surgical techniques, in a majority of cases, the tumor can be removed without cutting the jaw bone (mandible) or performing a tracheotomy (breathing tube in the neck), which is substantially different from most other institutions.

Given the nature of oropharynx cancer, most patients will undergo radiation treatment (radiotherapy) after the surgical removal of the cancer.

The MGH laryngeal surgery team has developed novel laser endoscopic and laser technology to treat hypopharynx cancer in a minimally-invasive manner when appropriate.

In addition, the novel methods to remove oropharynx cancer and perform partial removal of the voice box are critically valuable for saving patients’ voice, breathing, and swallowing function.

Large hypopharynx cancers often require removal of the entire voice box (total laryngectomy) or swallowing passage in the chest (esophagectomy).

  Given the nature of oropharynx cancer, most patients will undergo radiation treatment (radiotherapy) after the surgical removal of the cancer and may also receive chemotherapy.