Laryngeal Cancer Early Detection: Hoarseness, Risk Factors and Treatment

The larynx is the voice-producing organ in the anterior neck. It is divided into three anatomical regions: supraglottis (above the vocal cords — epiglottis, aryepiglottic folds, ventricles, false cords), glottis (true vocal cords and anterior / posterior commissure) and subglottis (from the inferior cord margin to the cricoid cartilage).

Lymphatic drainage differs across the three regions. The glottis has very sparse lymphatic vessels, so early-stage glottic cancer rarely metastasises to neck nodes — the key reason it carries such a good prognosis when caught early. The supraglottic region has a rich lymphatic network; even small tumours present with neck metastasis in 30-40% of cases.

Subglottic cancer is rare (under 5% of laryngeal cancers). It is more aggressive and usually advanced at diagnosis because it spares the voice for longer. These anatomical differences directly drive treatment and prognosis. Related overview: our head and neck cancer surgery programme.

Smoking is the dominant aetiological factor. Risk is 10-15 times higher than a never-smoker; with concurrent heavy alcohol use the risk multiplies to 30-40 fold. After quitting, risk declines over years but takes 10-15 years to approach never-smoker levels.

Alcohol alone is a risk factor but less powerful than smoking. The highest-risk profile is the heavy drinker + heavy smoker — this profile is more often associated with supraglottic tumours. Occupational exposures (asbestos, cement dust, formaldehyde, chromium) add to the risk.

HPV association in laryngeal cancer is not as strong as in oropharyngeal cancer, but it is detected in rare cases. In young laryngeal cancer patients without smoking or alcohol use, HPV should be considered. This is an evolving area.

Laryngopharyngeal reflux and chronic laryngitis are not carcinogenic per se but may drive premalignant changes. Adult-type laryngeal papillomatosis and confirmed dysplasia require close surveillance.

Glottic cancer: hoarseness exceeding 3 weeks is the earliest and nearly only early sign. The voice progressively becomes coarser, with vocal fatigue and intermittent loss. Breathing difficulty and dysphagia are late-stage findings.

Supraglottic cancer: a "lump" sensation when swallowing, ear pain referred via the superior laryngeal nerve, globus, haemoptysis, and halitosis (in advanced cases with necrotic tissue). Hoarseness appears late.

Subglottic cancer: breathing difficulty is often the first symptom — as the airway narrows, stridor (especially inspiratory) appears. Hoarseness occurs once the tumour reaches the cords. Diagnosis is usually late-stage.

Neck node: some supraglottic tumours are noticed first as a neck mass. A painless, firm, ≥2-3 cm lymph node with reduced mobility — especially in a smoker over 40 — needs work-up. In such cases the head and neck is examined for a primary site.

The first step is a detailed ENT examination. Videolaryngoscopy (flexible or rigid) evaluates vocal cord morphology and mobility. With a suspicious lesion, stroboscopy shows mucosal-wave behaviour — an important clue to invasion depth. White-light plus Narrow-Band Imaging (NBI) can pick up low-grade dysplasia.

Neck palpation and ultrasound assess nodal disease. Suspicious nodes may be sampled by fine-needle aspiration. Contrast-enhanced neck CT and / or MRI define local extension. Chest CT and, when indicated, PET-CT screen for lung and distant metastases.

Definitive diagnosis is by biopsy. This is taken at microlaryngoscopy under general anaesthesia — direct visual inspection, lesion mapping and adequate tissue sampling together. Pathology returns in 5-7 working days; most lesions are squamous cell carcinoma.

All findings are reviewed in a multidisciplinary tumour board (ENT, radiation oncology, medical oncology, radiology, pathology). TNM staging is performed and the treatment plan is finalised in that meeting. Step-by-step details: larynx cancer page.

T1 glottic cancer (confined to one cord, mobile vocal fold) has two primary options: transoral laser microsurgical cordectomy (TLM) or radiotherapy alone. Oncological results (local control, cure) are similar — 5-year local control 85-90% with either.

Surgery advantages: single-session treatment, fast recovery (2-3 weeks), avoidance of late radiation effects (xerostomia, fibrosis, thyroid dysfunction, second malignancy risk). Disadvantage: in selected cases permanent voice change (a comparable-depth cordectomy may yield poorer voice than equivalent radiotherapy).

Radiotherapy advantages: no anaesthesia, voice quality often slightly better preserved than after surgery (the gap widens at Type III or deeper cordectomy). Disadvantages: 6-week course, late effects, no re-irradiation if a second primary develops.

T2 (impaired cord mobility or extension) requires partial laryngectomy options (supraglottic, hemilaryngectomy) or chemoradiotherapy. T3-T4 lesions are discussed as organ-preservation protocols (cisplatin + radiotherapy) or total laryngectomy.

In T3 and T4 laryngeal cancer treatment forks into two paths: organ preservation (concurrent chemoradiotherapy, usually cisplatin-based) or surgery (total laryngectomy) with adjuvant radiotherapy if indicated. The decision rests on the tumour board: tumour volume, cartilage invasion, performance status, renal-auditory reserve.

After total laryngectomy a permanent tracheostoma remains — breathing is through the stoma. Three main options for voice: tracheo-oesophageal puncture prosthesis (TEP) — most common, most natural sound; electrolarynx; oesophageal speech. Pulmonary rehabilitation (HME filters) is critical to quality of life.

The organ-preservation protocol is cisplatin (100 mg/m² days 1/22/43) + 70 Gy radiotherapy. In elderly or cisplatin-unfit patients, cetuximab + radiotherapy is an alternative. After treatment 30-40% retain full voice; long-term swallowing may suffer. Salvage surgery (total laryngectomy for residual disease) must be pre-planned.

Survival closely follows stage. In T1 glottic cancer, 5-year survival exceeds 90%. T2 75-85%, T3 50-65%, T4 30-50%. Supraglottic cancers at the same stage have somewhat worse prognosis because of higher nodal involvement.

Standard follow-up: every 1-3 months for the first 2 years, every 4-6 months in years 3-5, then annually. Every visit includes a full ENT exam and videolaryngoscopy. Annual neck ultrasound, annual chest imaging (CT or low-dose lung CT to screen for second primaries). Thyroid function is checked yearly in irradiated patients.

Smoking cessation reduces both recurrence and second primary cancer risk. Without cessation, the 5-year risk of a second primary in the same or another head-and-neck site can be 15-25%. Cessation support (nicotine replacement, varenicline, behavioural counselling) is integral to treatment — as important as the oncologic intervention. Related reading: our multidisciplinary tumour board.