Laryngeal cancers are of diverse histology but by far the commonest is squamous cell carcinoma, making 85% of all laryngeal malignancy. This section will concentrate on this disease due to its prevalence.

 

Squamous carcinoma is four times more common in men than women and peak incidence is between 55 and 65 years.

 

Risk factors for the disease are:

 

1. Smoking

2. Dark spirits

3. Asbestos exposure

4. Formaldehyde exposure

5. Radiation (for thyroid disease)

 

Hoarseness and airway compromise are symptoms common to all laryngeal tumours eventually but other symptoms and signs occur as the tumour extends:

 

1. Pain on swallowing

2. Dysphagia

3. Referred otalgia

4. Haemoptysis

5. Halitosis

6. Neck mass

 

Remember that the risk factors for laryngeal cancer are the same as for lung cancer and it is not infrequent that the patient will have a laryngeal tumour and a lung primary.

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Diagnosis

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• History & examination

   The old saying goes 70% of diagnosis are made from the history alone. 

 

• Flexible nasendoscopy

   Direct visualisation of the larynx allows views of potential lesions to be made.

 

• CT/ MRI aerodigestive tract 

   - as part of staging and quantifying the size of any lesion

 

• Panendoscopy + biopsies

   Allows the collection of specimens for histology.

 

• US neck +/- biopsies

   Assess lymph node spread

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Management

 

The factors to consider in deciding on a treatment plan are as follows:

 

1. Performance status of the patient

2. Patient preference is important

3. Patient’s distance from the treatment facility

4. Follow-up reliability

5. Physician’s preference

6. Availability of good quality imaging, pathology and surgeon

 

All of these must be weighed up before a decision can be arrived at. The options for treatment depend on the site of the tumour, the extent of the tumour and whether there are metastases or lung primaries or not. A combination of surgery and radiotherapy are usually opted for.

 

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Pharyngeal Cancer

 

The pharynx has three sub-sites: the nasopharynx, the oropharynx, and the laryngopharynx. Tumours may occur in any of these and the symptoms that they produce will vary accordingly.

 

Oropharyngeal

 

The base of the tongue and the tonsils are the commonest place for oropharyngeal cancer. Histologically squamous cell carcinoma is by far the most common with HPV being implicated in many. Lymphomas are the second most common tumour of the tonsil.

 

Ulceration or asymmetry of the tonsil should raise the suspicion of malignancy especially if there are other symptoms and signs. Pain, referred otalgia, bleeding, and neck nodes may all be present and trismus may arise through extension into the underlying pterygoid muscles.

 

Tongue base tumours may present late to the surgeon because they are easily confused with simple chronic infection. A neck node may be the first sign of disease.

 

Diagnosis is made by history, examination and palpation of the oropharyngeal structures. It is confirmed by biopsy. Other investigations to assess stage of the disease include chest X-ray, CT and MRI and Ultrasound of the neck.

 

Treatment is by surgery and radiotherapy.

 

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Nasopharyngeal

 

Nasopharyngeal carcinoma is uncommon except in Cantonese patients, especially in Hong Kong. There are several risk factors that appear to act synergistically:

 

1. Positive family history

2. Epstein Barr virus infection

3. Diet rich in salt and Vit C deficiency

 

Lymphoma does also occur (Non-Hodgkin).

 

The symptoms are related to obstruction of the nasal airway and to extension of the tumour into adjacent structures. Thus the possibilities are:

 

1. Blocked nose

2. Epistaxis

3. Neck node

4. Extension into the Cavernous sinus with diplopia due to cranial nerve palsy

5. Facial pain / numbness

6. Otitis media with effusion – unilateral

 

Surgery has a limited role and radiotherapy with chemotherapy are the mainstays of management.

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Hypopharyngeal

 

Squamous carcinoma of the hypopharynx is commonest in the piriform sinus and over half of patients will have lymph node metastasis at presentation. The other two sub-sites of the hypopharynx, the post cricoid and posterior pharyngeal wall, also often present with a lymph node.

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Symptoms include dysphagia, odynaphagia, referred otalgia, and laryngeal symptoms. 

 

Prognosis is poor if there are laryngeal palsy and nodal metastasis present. Tumour size and distant metastasis also contribute to this.

 

About a quarter of patients are untreatable at presentation. Surgery with radiotherapy and chemotherapy.

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Oral Cancer

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By far the commonest histological type is squamous carcinoma but adenocarcinoma from salivary tissue, lymphomas in lymphoid tissue and mucosal melanomas are all seen.

 

Smoking and excessive alcohol consumption are the commonest causes but dental disease, poor nutrition and some chronic infections can predispose to it and work synergistically with smoke and alcohol to stimulate cancer genesis.

 

The human papilloma virus (subtype 16) is also relevant in cancer genesis. This is the same virus implicated in cervical cancer and is a common sexually transmitted pathogen.

 

Signs and symptoms

 

In the early stage small lesions may go unnoticed. As they enlarge a non-healing ulcer may be noticed. White or red patches may be visible and there may be bleeding from the lesion. Later in the disease induration, pain, bleeding, infection and halitosis, dysphagia, referred otalgia, trismus, and neck nodes appear.