The larynx is eloquent, and even a tiny tumor can produce dramatic vocal changes that frequently allow for very early detection of disease. The American Cancer Society estimated that in 2013, there would be 12,260 laryngeal cancers and 3630 laryngeal cancer deaths. This progress that has been made for laryngeal cancer therapy has been one of the real success stories in head and neck cancer.1 Improved cure rates have allowed us to better tailor the treatment to the patient and, in doing so, to improve quality of life.
With surgery and radiation each progressing, there has been a near reversal of the definitive roles for each modality. Thirty years ago, many early laryngeal lesions were treated with radiation whereas many advanced lesions were treated with open surgery. Transoral laser surgery, better reconstructive surgery, Intensity Modulated Radiation Therapy (IMRT), concurrent chemotherapy, different fractionation schedules, improved imaging, speech pathology involvement are all factors that have all converged to improve preservation of function.
Treatment paradigms for advanced laryngeal cancer have evolved from a default position of total laryngectomy to careful consideration of laryngeal conservation when anatomically and medically possible. Carcinoma-in-situ (CIS) and T1/T2 disease are frequently handled with transoral laser surgery, and patients with T3 disease who have adequate laryngeal function are usually treated definitively with concurrent chemotherapy and radiation. For patients with bulky T4 disease or laryngeal cancers that cause aspiration, the standard management strategy is total laryngectomy followed by appropriate adjuvant therapy. On the other hand, for patients with T4 disease and functional larynxes, some centers are offering trials of nonsurgical management. Because those T4 patients who are either unresectable or medically inoperable are also treated with concurrent chemotherapy and external radiation retrospective comparisons of nonoperative versus operative approaches to T4 laryngeal disease are inherently suspect.
Understanding the anatomy of the region is crucial to designing the most appropriate treatment for each patient, and much of this chapter will be so focused.
Tumors of hypopharynx are far less “vocal” and large tumors or advanced stage at presentation are the rule rather than the exception. Partly due to their greater size and partly due to an overall worse prognosis, the outlook for patients with hypopharyngeal cancers remains suboptimal. CIS of the hypopharynx is very rarely detected, and most patients with a functional larynx and T1-T3 hypopharyngeal disease are offered concurrent chemoradiation. Assuming that the patients are medically fit and surgically resectable, laryngopharyngectomies are used for salvage or when patients have poor laryngeal function at presentation.
The larynx is divided into three regions: supraglottis, glottis, and subglottis (Figs. 55-1 to 55-8). The organ is inferior to the oropharynx, anterior to the hypopharynx, and sits astride the trachea. Compared to laryngeal cancers, hypopharyngeal tumors of the lateral and posterior pharyngeal walls, the postcricoid region, and the pyriform sinus ...