HEAD AND NECK

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In the last few decades, there has been great progress in both the diagnosis and the treatment of the malignant diseases of the larynx.  The application of endoscopes and stroboscopy for the examination of the larynx, but also of techniques which are still developing, such as the fluorescence of the mucosa, have immensely helped in the prompt diagnosis.  New methods in Pathology, like immunochemistry, have led to more prompt diagnoses and, as such, to more correct treatment decisions.

Developments in radiotherapy, like the linear accelerator, contributed to a much more effective treatment of malignant cells and, at the same time, to a lesser harm of the normal tissues.  The application of the laser in the surgery of the malignant diseases of the larynx allowed the removal of the diseased tissues of the organ, without breaching of the cartilage framework or the total removal of the larynx.

The most important, however, is the growing understanding of the predisposition factors which may lead to the development of a malignant disease in the larynx, the increasing public awareness towards health matters and the better grounding of doctors in diagnostic matters, as well as the treatment of these diseases.  So, today, we rarely need to resort to amputating, but lifesaving, solution of total laryngectomy.

The typical case of a patient whom we suspect of having a malignant disease of the larynx is an average to heavy smoker, who also often drinks alcohol.   He/She is of a middle or older age and is complaining for a hoarse voice which insists for several days.  Some other times, he/she may mention difficulty or pain in swallowing, pain which may oddly reflect to the ear area, or he may believe that he/she has a sore in the pharynx, caused by a fish bone which he/she has swallowed.  As he/she is a smoker, his/her voice may have been already hoarse for a long time.  Because of this, he/she misses the important warning signal of an alteration to his/her voice due to the development of a neoplasia.  Fortunately, only in rare cases will he/she visit the doctor, because of breathlessness, inhale wheezing or because he/she has felt a bulge in his/her neck.

From the history of the patient, the doctor should look for possible previous radiotherapy for the same or an irrelevant reason, as well as previous operations in the larynx and the results of the histological tests.  The clinical examination always includes palpation of the neck.  We check the oral cavity, the state of the denture and we take into consideration the difficulties in case of intubation.  The main method of examination is the endoscopy of the larynx with the rigid endoscope.  In patients with strong reflexes, the flexible endoscope through the nose gives the solution in most cases. The recording of the examination on DVD makes it possible to better study the picture of the larynx, in order to explain to our patient his/her condition, but also to store the picture in the patient’s history for reference in future examinations.

During the endoscopy of the larynx we check the mobility of the vocal cords and we look for alterations of the mucosa, potentially indicative of malignance.  Stroboscopy is a development of the simple endoscopy.  With stroboscopy we can check the mobility of the mucosa of the free border of the vocal cords.  Lack of mobility in the area of the lesion may mean invasion of the underlying layers, which strengthens the possibility for malignancy.

Some alterations of the mucosa may have a pathological origin, but look similar to those of malignant diseases.  If we suspect such cases, like syphilis or tuberculosis, we should do the related lab examination in cooperation with our colleague internist.

The malignant diseases of the larynx spread to the lymph nodes of the neck in a rather advanced stage.  A special examination for the tracing of lymphatic metastases is the ultrasonography of the neck.  In addition, because such patients are prone to malignant diseases of other organ as well, the diagnostic workup may be accompanied by a CT of the thorax, gastroscopy etc.  Finally, if we suspect that the disease may have ruptured the cartilage framework of the larynx, it will be necessary to run a CT or an MRI of the neck.

No treatment, either in the form of radiotherapy or surgery, is to be undertaken before we have the histological confirmation of the diagnosis.  If the suspicious lesion is thought to be at an early stage of dysplasia and has not turned malignant, the patient is placed under medical surveillance being given firm instructions to quit smoking and alcohol and medical treatment with antacids or vitamins which help in the regeneration of the mucosa.  However, if there are strong indications that the lesion is of a malignant nature, then the patient has to undergo biopsy.

Biopsy is not an independent event in the whole process.  It has to be done having in mind the next stage of the patient’s treatment.  With very few exceptions, biopsy is done under general anesthesia.  If the lesion is small, let’s say few millimeters, it is logical to be removed among healthy tissue, as when we are certain about its malignant character, especially if our patient is not a professional singer.  This will relieve the patient from the need for a second general anesthesia, in order for the lesion to be removed, provided that histology proves to be malignant.

If, however, the lesion is extensive, the procedure of biopsy consists a rehearsal for the total removal of the tumor in the case the use of the laser has been selected for its treatment.  Thus, in addition to the taking of material for histological examination, biopsy allows the complete mapping of the tumor and the study of the possibility of the total removal via laser.  Our operation has to be carried out very delicately, so that we do not become the reason for the implantation of the disease into other parts of the larynx and in order not to alter the borders of the lesion so that its subsequent total removal is possible. Parallel to this, we also take into consideration the general anatomic conditions, the opening of the mouth, the condition of the denture, the anatomic parameters of the neck and if these allow a total review of the tumor and, hence, its imminent removal with the use of the laser.

The biopsy material is sent for histological examination and, in a few days, we will know whether it is malignant, the histological type and the degree of aggressiveness of the disease.  If it is a usual histological type, then we are ready to discuss with our patient the treatment choices.  If, however, we have to do with any unusual types of the malignant disease, then our patients will most likely appreciate the fact that we first have to consult international bibliography before we suggest any method of treatment.

Our scientific team studies and uses the laser in particular cases of malignant diseases of the larynx.  The laser enables us to cut through the tumor, something which allows its total removal in pieces.  These pieces of tissue are sent to the pathologist with a special notice concerning their orientation.  All the work is done within the larynx lumen, paying special attention to its cartilage framework which works as a barrier against the spreading of the tumor to the neck tissues.  This fact presents a great advantage to the traditional access by partial laryngectomy.

If the removal of the tumor, despite our effort, is not performed satisfactorily enough, then the patient is sent for radiation. Radiotherapy is an old and tested therapeutic method.  The removal of the main mass of the malignant disease makes it even more effective as far as the sterilization of the tissues as far as the malignant cells is concerned.  In addition, it has the advantage of simultaneously sterilizing the rest of the neck against possible microscopic spread to the lymph nodes.  Drawbacks of radiotherapy are that it can be administered only once in therapeutic dose for a specific area, while the laser theoretically has unlimited applications. Also, radiotherapy harms the integrity of the healthy tissues and that, in the long-run, it can cause post-radiation development of a malignant neoplasia in the area.  Chemotherapy is not particularly effective on malignant diseases of the neck and it is used complementarily in some chosen cases.

With the application of the laser and radiotherapy, total laryngectomy may be postponed for many years or, for some patients, even not be necessary.  Total laryngectomy is an amputating operation, repulsive to the patient, because of permanent tracheostomy.  It is, however, life saving for the patient.  With the modern methods of speech rehabilitation, the problem of communication is also corrected.

Some patients, whose disease is diagnosed as already advanced during the first examination, the application of the laser or radiotherapy may be just a waste of time or to hinder the operation for total laryngectomy.  For those patients, total laryngectomy may be the only realistic solution.  The operation requires a one-week hospitalization, until the natural healing process is complete.

As it happens with every malignant disease, prevention is better than cure.  In the case of larynx, as well, the connection of smoking with the development of malignant disease is so well established that it necessitates the effort towards this direction not only of the general population but also of the medical world.