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Laryngeal cancer
Laryngeal cancer is almost always squamous cell carcinoma in a smoker; its site decides everything — glottic disease is found early through hoarseness and spreads little, supraglottic disease is found late and spreads to both sides of the neck — and vocal fold mobility and invasion of the thyroid cartilage set the T stage and the choice between larynx preservation and total removal.
Why it matters in the exam
Hoarseness lasting over 4 weeks in a smoker requires laryngeal examination. The glottis has few lymphatics, so in glottic T1 to T2 tumours neck metastases are rare (less than 5%) and elective neck treatment is not needed. The supraglottis is rich in lymphatics, so even in a clinically "clean" neck both sides are treated electively (levels II to IV). The subglottis is rare and drains to the paratracheal nodes (level VI). The pre-epiglottic and paraglottic spaces, and the anterior commissure, are the important routes of spread.
Under AJCC 8, glottis: T1 — limited to one vocal fold (T1a) or both (T1b) with normal mobility; T2 — extension to the supraglottis or subglottis and/or impaired vocal fold mobility; T3 — fixed vocal fold, invasion of the paraglottic space or the inner cortex of the thyroid cartilage; T4a — through the outer cortex of the cartilage or into tissues outside the larynx; T4b — prevertebral space, carotid encasement or mediastinum. The most important prognostic factor is lymph node involvement, especially extranodal extension (ENE).
Early disease (T1 to T2) is treated with a single modality: radiotherapy or transoral laser microsurgery (TLM); contraindications to TLM are poor laryngeal exposure and deep cartilage invasion. T3 suits larynx preservation with concurrent chemoradiotherapy with cisplatin (the VA study of 1991 and RTOG 91-11), or total laryngectomy. T4a with invasion through cartilage is treated by total laryngectomy and adjuvant radiotherapy. Recurrence after radiotherapy is treated with salvage laryngectomy, with a high risk of pharyngocutaneous fistula. Voice rehabilitation after laryngectomy is mainly with a tracheoesophageal prosthesis (TEP); after laryngectomy and radiotherapy thyroid function should be checked.
Key points
- Glottic: early, few metastases.
- Supraglottic: late, bilateral metastases.
- T1 to T2: one modality — radiotherapy or TLM.
- T3: chemoradiotherapy or laryngectomy.
- T4a: total laryngectomy.
Summary table
| Site | Behaviour | Early treatment |
|---|---|---|
| Glottis | Early hoarseness, metastases rare in T1 to T2 | Radiotherapy or TLM, no elective neck treatment |
| Supraglottis | Late detection, bilateral metastases | Radiotherapy or surgery, with elective treatment of both sides of the neck |
| Subglottis | Rare, paratracheal nodes | Treat level VI |
| T3 | Fixed fold or paraglottic space | Chemoradiotherapy with cisplatin or laryngectomy |
| T4a | Through the outer cortex of the cartilage | Total laryngectomy and adjuvant radiotherapy |
In the full version for subscribers
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Sources
- AJCC Cancer Staging Manual, 8th edition (2017) — Larynx
- NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers — Cancer of the Glottic and Supraglottic Larynx, 2025 — Treatment by stage
- ASCO Guideline: Larynx Preservation in the Treatment of Laryngeal Cancer, 2018 — Organ preservation
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.