Which surgery for laryngeal cancer?

You can have radiotherapy or surgery if you have a cancer diagnosed at an early stage. For very small, early cancers, you may have laser treatment or surgery through your mouth (endoscopic surgery).

If you had radiotherapy that did not kill off all the cancer, you may have surgery after your radiotherapy to remove the cancer that is left. In many cases, this will cure the cancer.

For larger cancers, or those diagnosed at a later stage, surgery may be the best treatment option if

• One of your vocal cords does not move any more
• Your cancer has spread beyond the vocal cords
• Your cancer has come back some time after having radiotherapy

If the cancer has spread upwards from the vocal cords (called supraglottic extension), you may still be able to have radiotherapy instead of surgery.

The amount of surgery you need to have depends on the stage of your cancer. The tests you have beforehand will help your specialist decide if surgery is an option. But your doctor may not be able to tell you exactly what stage your cancer is until after surgery. Surgery can be used to

• Remove the cancer and try to cure it
• Relieve symptoms (palliative surgery)

There are a number of different operations to remove cancer of the larynx. You may have

• Just the affected tissues taken away
• Part of your larynx removed
• All of your larynx removed

Some of these operations are major surgery. They are all done under general anaesthetic. So you will be asleep for the whole operation. How much of your larynx the surgeon takes away will depend on where the cancer is in the larynx.

This operation is done to remove early cancer of the larynx or to control symptoms of advanced cancer. When you are under general anaesthetic, your surgeon puts a rigid tube, with a camera and light inside it (an endoscope) down your throat. With this type of surgery you don't have a wound in your neck afterwards.

The surgeon can use surgical instruments through the endoscope to remove your cancer. Or they can use a type of laser to cut away the affected tissues. A laser is an extremely fine and hot beam of light. It can cut through tissue in much the same way as a surgical knife (scalpel), but causes less bleeding. 

If the tumour is very small, or the laser is used to treat symptoms caused by the tumour (palliative treatment), doctors may use a different type of laser as part of a treatment called photodynamic therapy (PDT). With photodynamic therapy you first have an injection of a drug that makes laryngeal cancer cells sensitive to the laser light. PDT is not a common treatment for laryngeal cancer.

You may have a partial laryngectomy for early laryngeal cancer. Or you may have it for cancer that has come back after earlier treatment (recurrent cancer). The surgeon makes a cut in your neck to remove the tumour. This is called an open partial laryngectomy. It is not a common operation in the UK now, because surgery through the mouth (endoscopic resection) is used more often.

With partial laryngectomy, your surgeon removes part of your voice box (larynx). You will keep at least part of one vocal cord and will usually still be able to speak afterwards. But your voice may be quite hoarse or weak.

During the operation the surgeon also makes a hole in your neck, which you breathe through. The hole is called a stoma (tracheostomy). The tracheostomy (pronounced trak-ee-os-stoh-mee) allows your voice box to heal after the surgery. Most people who have a partial laryngectomy will have a temporary tracheostomy. After a brief recovery time, your surgeon will ask your nurse to remove your tracheostomy tube and your stoma will gradually close up. Once it has closed, you will be able to speak normally again. Some people need a permanent tracheostomy but this is rare.

To get rid of the cancer completely, your surgeon may remove the whole of your voice box. This is a total laryngectomy. Part of the pharynx may also be removed.

Your larynx is the connection between your mouth and your lungs. After it is removed, that connection is no longer there. So your surgeon attaches the end of your windpipe to a hole in your neck, which you will now breathe through. This is called a stoma. If you have a total laryngectomy, this stoma is permanent. You will now always breathe through your stoma.

Without your vocal cords and with a stoma, you will not be able to speak in the normal way. This is often the greatest loss for people who have this operation. But there are now several ways to help you make sound and learn to speak again. In this section we have information about the different ways of speaking after laryngectomy. A speech therapist will visit you before your operation to discuss the different ways of communicating after surgery.

During your operation, your surgeon examines your larynx and surrounding area. They may remove some of the lymph nodes from around your larynx. This might be a big operation – it depends on what exactly is done. But it reduces the chance of the cancer coming back. The lymph nodes are in groups.

Your surgeon will remove

• The nearest group of lymph nodes to your cancer, to see if they contain cancer cells
• Any lymph nodes that look as if they contain cancer, together with all the other nodes in that group

In a selective neck dissection, some nodes are removed from one side of the neck. In a radical neck dissection all of the nodes are removed from that side of the neck. And the surgeon will need to remove the muscle, main vein and nerve from the same side of your neck. Sometimes they can remove the lymph nodes without having to remove the muscle, main vein or nerve. This is called a modified radical dissection. 

Even if there is no sign of cancer in the nodes, there is still a chance that some cells have spread into the nearest lymph nodes. There may be too few to see. So the surgeon sends these lymph nodes to the laboratory to check for cancer cells. This helps your doctor to find out the stage of your cancer. If there is cancer in these nodes, you may need to have the rest of the nodes in your neck removed or treated with radiotherapy.

After neck dissection, your neck will look different on that side. There is more detail about this in the paragraph below. If your surgeon thinks you need to have the muscle taken away, your neck will look thinner and a little sunken on that side.

If you have radiotherapy to treat the cancer in your voice box, your specialist will also treat any lymph nodes in your neck that have a high risk of containing cancer cells. Your surgeon may also have to remove some other structures if the lymph nodes next to them contain cancer cells. These structures may include

• The sternocleidomastoid muscle, which is one of a pair of muscles that run down the side of your neck and help you to move your head
• The internal jugular vein, which is one of a pair of veins on either side of your neck that drain blood from your brain, face and neck towards your heart
• The accessory nerve, which is one of a pair of nerves that control some muscles in the neck and shoulder

Removing these structures is vital to give the best chance of stopping the cancer from coming back. Because the accessory nerve controls your shoulder movement, your shoulder will be stiff and more difficult to move after the operation. If your muscle is removed, your neck will look thinner and sunken on that side.

It takes time to get over surgery to the larynx. It can be a big operation. And it can affect you emotionally as well as physically. If you have had your whole larynx removed, it can be difficult to come to terms with learning to speak in a different way and breathing through a stoma. You will need to give yourself time to adjust to these major changes. There is information about coping, speaking after laryngectomy and life with a breathing stoma in the section about living with cancer of the larynx. Before or after your operation you may find it useful to speak to someone who has been through the same treatment as you. This can be very reassuring. It can give you confidence and help you to realise that things will get easier. Most hospitals will arrange this for you before your surgery.

Even if your laryngeal cancer cannot be cured, your doctor may suggest surgery to relieve symptoms. This can give you a better quality of life for longer. You are most likely to need this type of treatment if your cancer is blocking your larynx and making it difficult for you to breathe and swallow.