I. What is meant by clinical manifestations?
The medical term for the discomfort and abnormalities of the body associated with a disease is clinical manifestations. Clinical manifestations include symptoms and signs. Symptoms refer to the discomfort or abnormalities perceived and expressed by patients; while signs refer to the abnormalities of the body discovered by doctors through objective physical examination.
1.What are the symptoms of early stage laryngeal cancer patients?
Early stage laryngeal cancer patients may feel discomfort in the throat or foreign body sensation in the throat, cough or cough with blood, hoarseness, voice change, pain, breath sound change or difficulty in breathing. These manifested early symptoms may not be particularly different from some other diseases, and therefore are often not easily noticed or taken seriously.
(1) Foreign body sensation in the pharynx: If the lesion occurs in the upper part of the larynx, i.e. the so-called supraglottis area, most epiglottis cancers may only have a foreign body sensation in the pharynx in the early stage. This symptom is ignored by patients; if the mass is larger in the epiglottis, there may be some changes in the voice and a “ball-like voice” when speaking.
(2) Throat pain: The ulcerated type may have slight pain, and when the tumor is ulcerated, there may be throat pain, which gradually worsens and may radiate to the ear.
(3) Hoarseness: If the tumor occurs in the supraglottis or called the vocal fold area, it is the first symptom of almost all patients with vocal fold type laryngeal cancer. When the supraglottic cancer invades the vocal cord or invades the vocal cord downward, there is often hoarseness of different degrees.
(4) Difficulty in breathing: Large tumor blocking the entrance of larynx or tumor falling down into the vocal fissure can cause difficulty in breathing.
(5) Blood in sputum: coughing or small amount of bleeding on the surface of tumor may cause blood in sputum.
These symptoms may not all be manifested in the early stage of laryngeal cancer, and the order of their appearance may be different because the tumor first occurs in different parts of the larynx.
2.What are the most common clinical symptoms of middle and late stage laryngeal cancer patients?
With the development of tumor, patients with mid- to late-stage laryngeal cancer may have the following manifestations.
(1) Hoarseness aggravation and choking cough: hoarseness continues to aggravate, and in advanced epiglottis cancer, choking cough may appear when the upper part of epiglottis has rotted away.
(2) Dyspnea: dyspnea can be caused by large tumors blocking the entrance to the larynx or tumors falling downward into the vocal fissure, or restricted or fixed movement of both vocal folds.
(3) Eustachian pain and blood in sputum: if laryngeal cancer continues to develop, it may be accompanied by local pain and may involve the head and ear in the middle and late stages, which is caused by local inflammatory stimulation and radiation from laryngeal tumor to the eustachian area. When the tumor is combined with infection and necrosis, a small amount of bleeding on the surface of the tumor may appear in the sputum with blood.
(4) Neck lump: About 1/4 to 1/3 of patients present with a neck lump. The mass is mainly located at the anterior border of the sternocleidomastoid muscle in the upper neck; in case of anterior cervical lymph node metastasis, enlarged lymph nodes can be palpated, which are painless, hard, not easy to push and gradually increase in size, and cannot be reduced by antibiotic treatment. When the laryngeal cancer tumor is enlarged or even invaded, the lump can be palpated on the laryngeal nodes.
3.What are the most common physical signs of laryngeal cancer?
In the early stage of laryngeal cancer, there are often no physical signs, but as the tumor develops, a lump in the neck may be found.
(1) Occurring in the supraglottis region, persistently aggravated sore throat, cough, blood in sputum, and its hoarseness changing from intermittent to persistent are its characteristics. On examination, a mass is found above the laryngeal nodes or on the side of the throat, or on both sides of the neck, starting from the angle of the lower jaw and down along the anterior border of the sternocleidomastoid muscle, or one or more round masses with a hard texture without pressure can be palpated.
(2) Laryngeal cancer occurring in the vocal cords, characterized by coarsening of tone and persistent worsening of hoarseness, with no obvious physical signs during physical examination.
(3) laryngeal cancer occurring in the subglottis is characterized by inspiratory respiratory effort and rarely detects obvious signs. Sometimes, when the tumor is invasive or the lymph nodes are metastatic, hard masses may be palpated in the front of the subchondral larynx or both sides of the trachea.
If these symptoms and signs persist or worsen and hoarseness exceeds 3 weeks, you should go to otorhinolaryngology or head and neck surgery for examination in time to avoid delaying the detection of early lesions, and the doctor will make a diagnosis of the disease as soon as possible according to the clinical manifestations and examination of medical history.
II. Diagnosis
Diagnosis methods of laryngeal cancer.
(1) Based on the symptoms mentioned by the patient and the signs obtained from physical examination, that is, clinical manifestations, among which, palpation of the neck is the simplest method to understand whether there is widening of the laryngeal shape, whether there is destruction of the thyroid cartilage notch, whether there are enlarged lymph nodes in the neck and the size, texture and mobility of the enlarged lymph nodes.
(2) Endoscopy: It is the most basic examination method for laryngeal cancer, including indirect laryngoscopy or fiberoptic laryngoscopy, and the diagnosis mainly relies on tumor biopsy. Endoscopy can be performed in otorhinolaryngology or head and neck surgery outpatient clinic.
①Indirect laryngoscopy: Patients who seek treatment for any of the symptoms or manifestations such as foreign body sensation in the throat, pain in the throat, hoarseness, dyspnea, blood in the sputum, swollen middle and upper cervical lymph nodes, etc. should first undergo indirect laryngoscopy to exclude laryngeal tumors. Indirect laryngoscopy is simple, intuitive and fast, and can obtain histopathology at the same time, but sometimes it may be limited by the field of view, or the examinee may not be able to lift the epiglottis or the pharyngeal reflex is sensitive and difficult to cooperate, which often leads to unsatisfactory observation or difficulty in obtaining histopathological results.
Fiberoptic laryngoscopy: For cases with symptoms of laryngeal cancer but indirect laryngoscopy cannot see the larynx clearly, or cases where new organisms in the larynx have been found or diagnosed as laryngeal cancer, fiberoptic laryngoscopy should be performed routinely. This examination can not only clarify whether there are new organisms in the larynx, but also determine the site, size and scope of the tumor in most cases. The fiberoptic laryngoscope is also intuitive and fast, and can clearly observe the structures and tumor in the larynx, especially helpful for determining the lower boundary of the tumor, and at the same time, it can acquire preserved images (Figure 1) and obtain histopathology to determine the clinical stage and treatment plan.
Figure 1 Fiberoptic laryngoscopy: image of left vocal fold mass
Of course, endoscopy is difficult to show and understand the deep submucosal structures and lesions in the laryngeal cavity and the distal part covered by tumor, so it is often necessary to complement other imaging examinations to fully understand the tumor.
Biopsy of new organisms in the larynx: In cases where new organisms are found in the larynx, biopsy of new organisms in the larynx should be performed in a timely manner, either indirect laryngoscopic biopsy under epi-anesthesia or optical fiber laryngoscopic biopsy, or direct laryngoscopic biopsy if necessary, in order to determine the diagnosis as early as possible to avoid delay in treatment. If the diagnosis cannot be confirmed after two or more biopsies, surgical methods should be considered to obtain a biopsy to avoid delaying the diagnosis. If there is already respiratory distress, the patient should undergo tracheotomy for biopsy.
(3) Imaging examinations, including laryngeal X-ray, CT, MRI, ultrasound, etc.
(1) X-ray examination: traditional X-ray examination is relatively easy to perform and economical. It mainly uses the low voltage soft tissue projection conditions and the air in the airway as a contrast, so that the soft tissue of the laryngopharynx can be displayed and its morphology and dynamic changes different from the normal structures and parts can be observed. However, due to many factors, traditional X-ray examination can only roughly observe the outline of the laryngopharynx, but not the deep tissue structure, and cannot meticulously observe the scope and structure of tumor invasion, which is not as clear as CT. Chest X-ray is still a routine preliminary examination of lung of laryngeal cancer patients to understand whether there are other combined lesions in the lung and to exclude the signs of distant metastasis, which can be used as a reference when formulating treatment plan and also as a reference for long-term follow-up after treatment.
CT examination is not significant for small and clear early lesions in the larynx, so this examination is not necessarily a routine examination. When deep invasion of laryngeal tumor or laryngeal cancer invasion is suspected, which is difficult to be observed under endoscopy, CT can help to understand whether there is destruction of cricoid cartilage of thyroid cartilage and the site and scope of invasion, lymph node metastasis and soft tissue invasion in the neck (Figure 2, 3, 4, 5).
Figure 2 CT cross-sectional view of the larynx, showing the tumor in the left vocal fold of the larynx
Figure 3 CT cross-sectional view of the larynx, showing the tumor invading the left side of the cricoid cartilage
Figure 4 CT coronal view of larynx, showing laryngeal tumor located on the left side of the supraglottis
Figure 5 CT image of laryngeal supraglottis cancer
If the patient has a history of allergy that prevents CT-enhanced scan, MR scan can be performed instead. But again, MRI examination is of little value for small tumors in the larynx. MRI can help to understand whether there is significant invasion of the anterior epiglottis and paraventricular space, and also obtain clear images of deep laryngeal infiltration and cervical lymph node metastasis, with higher resolution of soft tissues than CT. However, it should be noted that due to the long scanning time of MRI, patients are prone to claustrophobia and movement artifacts such as swallowing and coughing during the scan, which leads to examination failure or poor image quality and cannot help diagnosis, which is one of the main limitations of MRI scan.
It is mainly used to observe and understand the metastasis of lymph nodes in the neck of laryngeal cancer and the relationship of blood vessels, and sometimes it is used as an auxiliary examination to understand the status of abdominal organs or lymph nodes to provide reference for the formulation of treatment plan.
④Do I need PET-CT examination for laryngeal cancer? The glucose metabolism of tumor cells is higher than normal tissues, so PET with FDC (2-F18-2 deoxyglucose) may show small tumor lesions, identify mature scar or tumor recurrence after treatment, and make lesion localization more accurate with CT/MRI images, and sometimes it is also used to find tumor of unknown primary lesion. For the examination and diagnosis of laryngeal cancer, after the methods provided earlier, it can generally be well solved, so PET-CT examination is not too necessary, or it can be considered only for post-treatment follow-up to understand whether there is tumor recurrence that cannot be judged by other common methods. However, PET-CT examination is expensive and has certain false positive and false negative cases, so its clinical application value is still under research and observation, and it should not be used as a routine examination (Figure 6).
Figure 6a, b, c CT images of laryngeal cancer, d is PET-CT showing laryngeal tumor and cervical lymph node metastasis
Other than that, there is no laboratory test used for the diagnosis of laryngeal cancer, and no relevant antigens have been found that can be used for clinical detection of laryngeal cancer. Some of the abnormal biochemical indices or elevated tumor markers sometimes seen on the laboratory tests are not specific. Many laboratory tests may be routine examinations or tests necessary to understand or exclude other diseases before treatment, and sometimes they can only be used as reference indicators to observe the changes of laryngeal cancer after treatment.