The larynx is small but very important: we need to use the larynx to pronounce words; air passes through the larynx to enter the lungs to breathe; the larynx closes when eating to avoid choking and coughing when food enters the trachea. It is really a “throat”. Therefore, if laryngeal lesions occur, especially malignant tumors, it will seriously affect people’s quality of life. Statistics worldwide show that the incidence of laryngeal cancer is on the rise. The incidence rate of laryngeal cancer in the United States is 4.2/100,000 people; in China, it is 3/100,000 in Shanghai and 5/100,000 in some cities of Liaoning Province. This shows that laryngeal cancer poses a threat to the health and quality of life of more and more people. So how to prevent the occurrence of laryngeal cancer and how to diagnose and treat it early?
Although the cause of laryngeal cancer is not well understood, the relationship between laryngeal cancer and smoking has been largely confirmed. From world studies, most laryngeal cancer patients have a long history of smoking. It is generally estimated that the risk of laryngeal cancer in smokers is 3 to 39 times higher than that in non-smokers. According to foreign data, the death rate of non-smokers from laryngeal cancer is 0.86/100,000, while the death rate of smokers who smoke 40 cigarettes per day is 15/100,000, which is 20 times higher than that of non-smokers. Drinking alcohol is also related to the occurrence of laryngeal cancer. However, compared with smoking, alcohol consumption is only a weak carcinogenic factor, but it plays a role in promoting the carcinogenicity of cigarettes. Therefore, people who smoke for a long time and drink liquor have more chances to develop laryngeal cancer. In addition, the occurrence of laryngeal cancer also has different correlations with various occupational factors, and the incidence of exposure to asbestos, mustard gas, and nickel is also higher. Therefore, the prevention of laryngeal cancer should start from the above factors. We should stop smoking and drinking, and pay attention to labor protection when working in the environment with risk factors. The most important of them is to quit smoking and drink less alcohol.
According to the part of the larynx where the tumor occurs, laryngeal cancer can be divided into three types: supraglottic laryngeal cancer, glottic laryngeal cancer and subglottic laryngeal cancer. The early symptoms of these cancers are different from each other.
In early stage, supraglottic laryngeal cancer may cause discomfort and foreign body sensation in the throat, and some patients may have mild pain in the throat. In the advanced stage, blood in sputum, difficulty in breathing and even difficulty in swallowing may occur. Supraglottic laryngeal cancer also has more lymph node metastasis in the neck and occurs earlier. The lymph nodes are mostly found in the back and lower part of the jaw angle, which are painless, hard and grow gradually.
The early symptom of laryngeal cancer is hoarseness. At the beginning, hoarseness is sometimes light and heavy, and it will be better with anti-inflammatory drugs; later on, it gradually worsens, and it is not easy to be relieved even with anti-inflammatory drugs. As the disease progresses, cough and blood in sputum appear, and dysphagia and dysphagia appear in the late stage. Lymph node metastasis in the neck is not easy to occur in vocal laryngeal cancer.
Subglottic laryngeal cancer is more insidious and often asymptomatic in early stage. In the middle and late stage of the disease, symptoms such as cough, blood in sputum and hoarseness may appear. If the tumor continues to grow, it may cause difficulty in breathing.
Thus, the main symptoms of early stage laryngeal cancer are discomfort in the throat and mild hoarseness. These two symptoms are not specific and can also appear when smoking, drinking and cold. They are often overlooked by patients and doctors, resulting in missed diagnosis and misdiagnosis of early laryngeal cancer. Therefore, for those who are over 40 years old and have a history of smoking and drinking, once they have throat discomfort and hoarseness, especially if they are accompanied by a lump below the back of the jaw angle, neither the patient nor the doctor should take it lightly and be alert to the possibility of early laryngeal cancer, and should be examined carefully to make a clear diagnosis.
The larynx is a deep organ and once a tumor occurs, it is not easy to be detected by patients themselves unlike surface or superficial tumors. Special medical equipment is needed to examine it in order to be detected.
Patients visit the otolaryngology department of a hospital. After listening to the patient’s complaints of discomfort, the doctor will use an indirect laryngoscope (a small round mirror with a long stem, about 2 cm in diameter) to look at the lesion in the larynx from the patient’s mouth. This test is a routine ENT examination and is included in the registration fee, usually at no extra charge. If the doctor finds a tumor in the larynx or if the results of the indirect laryngoscopy are unsatisfactory, further fiberoptic laryngoscopy will be performed. After the nasal and laryngeal cavities are sprayed with anesthesia, a pencil-thin fiberoptic scope is used to look at the lesions in the larynx from the nasal cavity down to the larynx. This method provides a detailed and comprehensive examination of the larynx, and it is usually possible to identify lesions in the larynx with this examination and to biopsy them to clarify the pathology. The cost of this test is about $80 to $100. After the diagnosis of laryngeal cancer is confirmed, the doctor will perform radiography to understand the depth and extent of the lesion in the larynx to guide the patient for further treatment.
X-ray examination: conventional X-ray photography has basically solved the observation of laryngeal cancer invasion site in the larynx for decades, of course, it is not as clear as CT in some aspects, but it is more economical and practical. Especially, the posterior anterior body layer phase can observe the whole larynx, which is unmatched by CT phase, even after reorganization. There are two positions of laryngeal radiography: lateral cervical phase – to observe the laryngeal structure from the lateral side; posterior anterior laryngeal body layer – usually take four phases, including calm breathing and vocal phase, through the vocal folds vocal phase of different tenses, you can dynamically observe the vocal folds activity, whether there is swelling or paralysis.
CT or MRI imaging: For the diagnosis of laryngeal cancer, CT or MRI each has its own focus. If CT can be reconstructed into posterior-anterior position, it is more favorable for observation.
The treatment effect of early laryngeal cancer is better, the control rate can reach 70% to 90%, and the laryngeal function of most patients can be preserved. The choice of treatment modality is mainly based on which treatment modality can better preserve the patient’s articulation effect, less complications, shorter hospitalization time and less cost. At present, there are three types of treatments available, such as laser treatment, radiotherapy and surgery.
Laser treatment: CO2 laser is mainly used, because the tissues absorb CO2 laser energy rapidly and completely, a few milliseconds to produce evaporation, so as to achieve the effect of vaporization, cutting, coagulation. CO2 laser has good hemostatic effect on blood vessels less than 0.5mm. Postoperative edema is light and tracheotomy is avoided. It is applied to early laryngeal cancer, which is time-saving and economical, and is in line with the modern principle of “minimally invasive” surgery, so it is getting more and more attention, and the indications are gradually expanding. After laser treatment, patients have higher quality of life, no need for tracheotomy and nasogastric tube placement, no surgical scar, and good pronunciation quality. Compared with radiotherapy alone, it saves time and cost, eliminates the damage and complications of radiotherapy, and the quality of pronunciation is not significantly different from that of patients after radiotherapy. The disadvantage is that the treatment effect is affected by the experience of the surgical operator, and improper treatment may easily cause recurrence. Laser treatment is mainly applicable to early-stage acoustic laryngeal cancer and some early supraglottic laryngeal cancers.
Radiation therapy: Most laryngeal cancers belong to squamous cell carcinoma with different degrees of differentiation, and these tumors have more than moderate radiosensitivity, and the effect of radiation therapy is better and can still maintain the patient’s articulatory function. It is mainly used for the treatment of laryngeal lesions in early stage of laryngeal cancer of the vocal fold type. For cervical lymph node metastasis of laryngeal cancer, most of the treatment effects are poor except for smaller and less differentiated lymph nodes. The advantages of radiotherapy are that it saves the patient from surgery and can achieve similar therapeutic effects as laser treatment and surgery. However, the hospital stay is longer and more expensive, and there are certain complications.
Surgery: In recent years, due to the improvement of surgical level and continuous improvement, partial laryngectomy has been promoted, which can preserve laryngeal function while maintaining good therapeutic effect. Therefore, except for very early laryngeal cancer lesions of vocal hilar type, which should be treated with radiotherapy or laser therapy alone, surgery can be preferred for lesions of other stages of disease. Its advantages are shorter hospitalization time, less cost than radiotherapy, and slightly better treatment effect than laser treatment and radiation therapy. The disadvantage is that the pronunciation effect after surgery is slightly worse than the above two treatment methods, and the pain of surgery has to be endured.
It should be pointed out that for early stage laryngeal cancer, the treatment effects of the above three treatment modalities are roughly equal. The doctor should inform the patient of the therapeutic effects, advantages and disadvantages of these three treatment modalities for the patient’s lesion and seek the patient’s opinion. Under the guidance of the doctor, the patient should choose a practical treatment option.
Surgery is the main treatment method for laryngeal cancer, and there are various types of surgery depending on the extent of the lesion, such as partial laryngectomy, near-total laryngectomy and total laryngectomy. Surgery can cause different degrees of damage to laryngeal function while treating laryngeal cancer. Therefore, the postoperative rehabilitation of laryngeal cancer focuses on restoring laryngeal function as much as possible.
After total laryngectomy, the cervical trachea is permanently fistulized so that the digestive and respiratory tracts are no longer connected, ensuring no choking and coughing when swallowing, but at the same time, the function of articulation is lost. In order to enable all laryngeal cancer patients to speak, there are two main methods, surgical and non-surgical. Among the non-surgical methods, there are esophageal articulation, electronic larynx, and artificial larynx. The basic principle of esophageal articulation is to use the esophagus to store a certain amount of air and force the air out of the esophagus with the help of the pressure in the lungs, just like burping, and then impact the upper end of the esophagus or the mucous membrane of the pharynx to articulate. From the experience of Cancer Hospital of Chinese Academy of Medical Sciences this is a more satisfactory method. Most patients can learn it after 1 to 2 weeks of learning, and the pronunciation is closer to the sound made by human larynx than the last two methods, without strange sound; it is easy to apply, without special equipment and tools.
In addition, due to the loss of laryngeal warming and moistening of dry and cold air, and the loss of more water than normal through the airway, it causes an increase in airway secretions, dryness and stickiness. In addition, the loss of breath-holding function makes it impossible to cough hard, and sputum is more difficult to cough out. Therefore, attention should be paid to keep the air in the room warm and moist; increase the daily water intake so that the airway secretions remain thin and easy to cough out. If necessary, expectorant drugs can be used.
Near total laryngectomy is an operation that partially preserves the function of the larynx. It preserves the function of articulation and swallowing by using a tiny articulatory tube formed by the remnant larynx to articulate. Breathing is performed through a permanent tracheostomy in the neck. Its rehabilitation is similar to that of total laryngectomy in terms of protection of the airway.
Both of these procedures leave a permanent tracheostomy in the neck and most patients do not have to wear a tracheal tube. If a tracheal tube is worn, it should not be removed for a prolonged period of time unless the surgeon confirms that it is no longer necessary to wear a tracheal tube, to prevent scarring of the fistula from causing stenosis. Whether a tracheal tube is worn or not, care should be taken to maintain the cleanliness of the fistula to prevent sputum crusts from obstructing the fistula and causing respiratory distress.
There are several types of partial laryngectomy, but the common feature is that all the functions of the larynx, especially the articulatory functions, are preserved. Most patients have the tracheal tube removed after blocking the tube for breathing and eating without choking and coughing, and the larynx function is completely restored. A few patients were unable to remove the tracheal tube due to choking and coughing after eating. The aim of postoperative rehabilitation for these patients is to restore laryngeal assisted swallowing function. Mainly through multiple daily meals in small amounts, patient and persistent efforts and practice, the majority of patients can resume a normal diet and have their tracheal cannula removed. Because water is more likely to cause choking than solid food, practice should start with semi-solid and gummy-like foods. Using the unoperated side to eat and swallowing with the hand blocking the tracheal tube is helpful to reduce choking.
Another important aspect of rehabilitation is psychological rehabilitation. This requires the help of the whole society and the patient’s own efforts, the understanding and cooperation of colleagues and family members, the patient’s ability to understand and actively cooperate with the doctor’s treatment, and the patient’s confidence to overcome the disease and overcome postoperative discomfort.
However, while building up the confidence to overcome the disease, the disease should not be taken lightly. Attention should be paid to regular review and frequent self-examination. In case of abnormalities, such as: inability to pronounce again, difficulty in breathing, obstruction in eating or new masses in the neck, patients should seek medical attention for consultation and treatment.