Cancer
Cancer is a malignant growth or tumor caused by abnormal and uncontrolled cell division. The hallmark of cancer is its potential ability to invade neighboring tissue or to spread (metastasize) to other parts of the body through the lymphatic system or the bloodstream.
Early cancers may have done neither, remaining localized to the tissue of origin. The majority of cancers in the head and neck are classified as carcinomas.
Saving an Elderly Man from Repeated Trips to the Operating Room
A 74-year-old man presented with unexplained hoarseness. He had a history of heavy tobacco use earlier in life but had stopped smoking 25 years prior. Laryngeal examination demonstrated stippled vascularity resembling that seen in recurrent respiratory papillomatosis, and the differential diagnosis included early laryngeal carcinoma versus HPV-related papilloma.
He was taken to the operating room for definitive excisional biopsy. Pathology revealed invasive carcinoma; however, excision margins were deemed adequate, and observation was elected rather than adjuvant radiotherapy. Early postoperative healing was excellent, and voice quality was well preserved
At eight months’ follow-up, a small white patch was noted at the prior site. Given his history of carcinoma, this finding required treatment. Instead of returning to the operating room, office-based laser coagulation was performed. Over subsequent years, several additional office laser treatments were required for small areas of recurrent leukoplakia.
This approach proved highly effective. It avoided radiotherapy and repeated operative interventions, preserved vocal function, and allowed the patient to attend treatments independently without the need for anesthesia or accompaniment.
T1 Laryngeal Cancer (1 of 15)
At first examination. Note the combination of leukoplakia and vascular abnormality of the right vocal cord (left of photo).
Narrow band imaging (2 of 15)
At closer range using narrow band imaging, the vascular abnormalities are accentuated.
Inverted view in the operating room (3 of 15)
There is a small amount of bleeding due to the process of intubation.
Excision in progress (4 of 15)
The mucosal flap containing the abnormality has been elevated from close to the underlying ligament.
Excision complete (5 of 15)
The vocal ligament has been exposed by nearly full-thickness excision of all visible abnormality, whether leukoplakia, or areas of aberrant capillaries.
Office exam, one week after excision (6 of 15)
Here the area of excision is seen clearly and not yet mucosalized.
During phonation (7 of 15)
Because the match is relatively good, voice quality is already remarkably functional.
Six weeks after surgery (8 of 15)
The area of excision is remucosalized.
Match during voicing (9 of 15)
While not a perfect match, it is good enough that the speaking (though not singing) voice can pass for normal.
Recurrent abnormality (10 of 15)
At intervals, small white patches appeared. Though this appears bland and benign, with his history of cancer of the same vocal cord, this needed removal. Rather than go to the operating room, the office thulium laser was suggested each time.
Before laser coagulation (11 of 15)
The smaller chip operating scope that will accommodate a laser fiber is in use to see the same lesion as in photo 10.
Coagulation (12 of 15)
The 0.5 mm fiber is seen and the lesion has been coagulated.
An example of his longterm result (13 of 15)
In summary, he has gone to the operating room just once, for excisional biopsy that resolved his disease other than a few instances over time of small white patches managed in an office setting.
Under narrow band light (14 of 15)
Reoriented capillaries of the right cord (left of photo) provide evidence of the surgical procedure years earlier.
At the moment of voicing (15 of 15)
While the right cord (left of photo) does not oscillate as well at high pitch as the left, the match between the cords is sufficiently good that voice can pass for normal.
Early Vocal Cord Cancer at Diagnosis, After Excision and Final Result
This middle-aged man became hoarse after an upper respiratory infection, and the hoarseness persisted. Examination revealed a right vocal cord lesion, and the leading diagnosis was early vocal cord cancer.
He was offered a simple biopsy for diagnosis only, with the understanding that if cancer were confirmed, a second trip to the operating room would be required should he choose laser excision rather than radiation therapy.
Given the strong likelihood of early cancer—but the possibility of a benign condition such as papilloma—the usual option was also offered: a biopsy via definitive excision, allowing both diagnosis and treatment in a single procedure, even though this might be slightly more aggressive than ideal for a benign lesion.
He chose the latter—a one-step diagnostic and therapeutic excision. The tumor was removed with “the width of the laser beam” as the margin. This approach succeeds almost always when the tumor is non-infiltrative, as it did in his case. Under operative magnification, the experienced surgeon can clearly discern the layered structure of the vocal cord and encompass a very narrow but complete margin around the tumor.
The concept parallels Mohs micrographic surgery in dermatology, with one key difference: while a thin secondary excision could be performed to verify margins, the seasoned laryngologist often trusts the visual completeness of excision, employing a “trust-but-verify” strategy through close postoperative surveillance.
After healing, the expected medial-to-lateral capillary reorientation was observed, and the patient’s voice—entirely functional though faintly rough—has remained stable and serviceable for more than ten years.
At initial evaluation (1 of 11)
Under standard light, the right vocal cord lesion (left of photo) is clearly visible.
Narrow-band imaging refines the working diagnosis of early cancer (2 of 11)
At closer range and under narrow-band (blue-green) light, the leukoplakia appears more clearly mottled and exophytic, with capillary patterns suggestive of malignancy. This finding supported the decision to offer definitive excisional biopsy rather than simple diagnostic biopsy.
Mismatch during voicing (3 of 11)
During phonation, anterior inaccurate match accounts for the patient’s persistent hoarseness.
Beginning of surgery (4 of 11)
The tumor is again seen—now on the right side of the photo, given the inverted surgical view typical of suspension microlaryngoscopy.
After complete excision (5 of 11)
Unfortunately, there are no intraoperative photos showing the meticulous dissection around the tumor, where a very thin layer of normal tissue was included as the margin on the specimen. Here, exposed muscle can be seen anteriorly; the posterior portion of the excision is obscured by blood.
One week postoperatively. (6 of 11)
As expected, the wound looks “sad” but early granulation and re-epithelialization have begun.
Phonation at one week (7 of 11)
The vocal cords still mismatch during closure, as anticipated, pending further healing—but this will improve over time.
After complete healing (8 of 11)
Note the medial-to-lateral capillary reorientation characteristic of a healed vocal cord following superficial cordectomy.
Closer view, standard light (9 of 11)
Both cords are in the phonatory position, showing a smooth, well-healed surface.
Strobe light, open phase of vibration (10 of 11)
The left vocal cord (right of photo) moves laterally, while the right cord remains relatively stationary due to post-surgical stiffness.
Strobe light, closed phase of vibration (11 of 11)
The left cord swings medially to meet the more stiff right cord. Despite asymmetry, the patient’s voice remains remarkably functional and can even “pass for normal” in everyday conversation.
Laser Removal of Vocal Cord Cancer with Bilateral Disease
For treatment of early vocal cord cancer, both laser excision and radiotherapy are in competition as good treatment modalities. See also Early Vocal Cord Cancer: Remove with a Laser, or Radiate? Often, radiation is used when disease is bilateral, in the interest of preserving voice.
This is an example of the ability to do fairly extensive laser surgery bilaterally, yet preserving good voice. This man had a friend who had severe difficulty with radiation, and he was therefore opposed to that option.
Vocal cord cancer (1 of 10)
This 70-something man is a longterm smoker. Here you see an obvious cancer of his left vocal cord (biopsy-proven), but disease on the right side as well that is more superficial.
Stippling (2 of 10)
At higher magnification and using narrow band light, some of the vascular abnormality (stippling) is better seen (arrows).
1 week after excision (3 of 10)
A week after definitive excision of his cancer. Typical early wound appearance, with a suggestion of granulation on the left side (right of photo).
Reparative Granuloma emerges (4 of 10)
Six weeks later, healing is nearly complete other than a typical reparative granuloma on the left (right of photo).
Granuloma interferes with voicing (5 of 10)
During voicing, the granuloma interferes with closure, explaining in part his ongoing severe hoarseness. Note also the typical medial-to-lateral capillary reorientation.
Granuloma fades away (6 of 10)
Now 3 months postop, the granuloma is smaller. Classic capillary reorientation is again seen.
Closer view (7 of 10)
Under strobe light, closed phase of vibration. Voice is highly functional, since the granuloma no longer interferes with closure.
Granuloma cleft (8 of 10)
Open phase of vibration under strobe light shows the bilobed, clefted nature of the granuloma, where the right vocal fold “fits into” the granuloma (arrows at cleft).
Blood tattoo (9 of 10)
At nearly 5 months postop, the granulation tissue has auto-detached, leaving only a small “blood tattoo.” Here, under strobe light and closed phase of vibration.
Voice is improved (10 of 10)
Voice is somewhat hoarse but highly serviceable, and “better than it has been in years,” according to the patient.
Vocal Cord Cancer, Before and After Surgery
Vocal cord cancer (1 of 8)
Patient from elsewhere, first seen 9 months after radiotherapy, with obvious persistent right vocal cord cancer.
Vocal cord cancer (2 of 8)
Closer view, during phonation, showing deep ulceration and rolled upper and lower border of cancer.
Vocal cord cancer, 1 week after surgery (3 of 8)
One week after aggressive cordectomy, right, including down to inner perichondrium of thyroid cartilage.
Vocal cord cancer, 1 week after surgery (4 of 8)
Phonation, showing that the left vocal cord now has no “partner” against which to vibrate, and this explains the marked breathiness.
Vocal cord cancer, 7 weeks after surgery (5 of 8)
Nearly complete healing after complete cordectomy right vocal cord. Only residual granulation.
Vocal cord cancer, 7 weeks after surgery (6 of 8)
Closer view of defect. Thin mucosa covers inner surface of thyroid cartilage, and residual exposed cartilage, not yet healed over with mucosa, at arrow.
Vocal cord cancer, 7 weeks after surgery (7 of 8)
At maximum phonatory adduction. Note that the left vocal process is turned medially (arrow), signifying maximum adductory “effort” of that side. There is no right vocal cord, and hence there is no possibility of glottic voice.
Vocal cord cancer, 7 weeks after surgery (8 of 8)
Vibration of the arytenoid apices (arrows) against the petiole of the epiglottis (line), providing a rough, voice serviceable for quiet conversation, but highly limited in noisy surroundings.
Example 2
Vocal cord cancer (1 of 4)
Squamous cell carcinoma, right vocal cord (left of image), standard light.
Vocal cord cancer, 1 week after surgery (2 of 4)
One week after laser excision. See irregular granulation especially at lower margin of excision.
Vocal cord cancer, 1 month after surgery (3 of 4)
Approximately one month after excision, healing progressing.
Vocal cord cancer, after complete healing (4 of 4)
After complete healing, patient has a voice that passes for normal. Under strobe light, right cord oscillates well except at very high vocal pitch. Note, however, the mild pseudo-bowing of the right cord due to tissue loss, and that there is a mucosal wave on the left, but not on the right.
Glottic Cancer, Laser Removal
Glottic cancer, laser removal (1 of 3)
Early right vocal fold carcinoma, operative view (OR).
Glottic cancer, laser removal (2 of 3)
Same lesion, at the start of laser removal (OR).
Glottic cancer, laser removal (3 of 3)
Same larynx, after removal is complete. With healing over the next several months, the deficit “fills in” and voice result is often surprisingly good (OR).
Glottic Cancer, After Surgery
Glottic cancer, after surgery (1 of 3)
After superficial cordectomy, right cord, for early vocal cord cancer, standard light. Note capillary reorientation from normal mostly anteroposterior direction to medial-lateral.
Glottic cancer, after surgery (2 of 3)
Strobe light. Notice excellent matching of the cords at closed phase of vibration, correlating with the patient’s excellent voice quality.
Glottic cancer, after surgery (3 of 3)
Strobe light, open phase of vibration. This view reveals that the left cord oscillates, but the right doesn’t. As long as match is good, and there is no vibratory abnormality of the left cord (e.g. flaccidity, or mucosal abnormality), then voice can be essentially normal.
Breaking Cancer “Rules” Intelligently with Use of Laser
Post radiotherapy stage (1 of 8)
This woman had completed radiotherapy elsewhere many months ago for early vocal cord cancer. Recent biopsy of these lesions shows persistent cancer. At the same time, she is under treatment for unrelated stage IV lung cancer. Standard treatment here would be total laryngectomy.
Laser surgery typically not acceptable (2 of 8)
Under narrow band light and at closer range. Not only due to failure of radiation to cure, but also because this tumor crosses the anterior commissure (where the two vocal cords meet at the bottom of the photo), the widely accepted “rule” is that she should undergo total laryngectomy. The blue lines are located in the same place in the following photo.
Laser removal of tumor with careful followup (3 of 8)
In light of the patient’s uncertain future due to advanced lung cancer, her near-refusal of total laryngectomy, and with detailed inclusion of patient in “breaking the rules” thinking, the tumor was removed with the laser. Tissue margins were negative. Still, tumor behavior is not as predictable as it would be in a previously-untreated patient. Careful followup is therefore critical. Hashmarks show area of removal, to include everything even faintly abnormal-looking and the blue lines are located in the same place in the previous photo.
Second view post laser surgery (4 of 8)
Better view of the anterior commissure, where soft tissue was removed all the way to the inner perichondrium of the thyroid cartilage at the arrow.
Six months post laser surgery (5 of 8)
Nearly 6 months after laser surgery. Healing is complete. No obvious tumor is seen. The patient has developed very serviceable false cord voice (see photos 7 and 8).
Blood vessels stable two months post surgery (6 of 8)
Narrow band light allows more intense monitoring for aberrant blood vessels that might indicate tumor regrowth before there is any visible bulk. Vessels in the area of arrows have been stable for 2 months but require careful comparison with future examination photos.
Open phase of false vocal cord phonation (7 of 8)
False cord phonation, open phase. The true cords cannot oscillate at all due to dense scarring.
Closed phase of false vocal cord phonation (8 of 8)
True vocal cords are obscured by the false cord vibratory closure.
Glottic/Vocal Cord Cancer
Glottic/vocal cord cancer (1 of 2)
Left vocal cord cancer, abducted breathing position, standard light.
Glottic/vocal cord cancer (2 of 2)
Phonation, standard light, shows that the left cord moves normally. Tumor is mostly exophytic (growing outward like broccoli, rather than inward, like an onion).
Supraglottic Cancer
Supraglottic cancer (1 of 4)
Middle-aged woman with sore throat, discovered to have a circumscribed exophytic squamous cell carcinoma at the petiole and anterior false cords.
Supraglottic cancer (2 of 4)
Closer view, showing the aberrant tumor vessels especially in the inferior half of the tumor, with less “white-out” from light overexposure.
Supraglottic cancer (3 of 4)
As is often the case, this tumor “respects” the ventricle, meaning it does not cross the plane of the ventricle (entrance at dotted line) to invade the true cords. An instrument could lift the inferior border of the tumor to show that the true cords aren’t invaded; the tumor is simply overlapping them.
Supraglottic cancer (4 of 4)
Under narrow-band lighting, the tumor’s aberrant vessels and its relationship to both the true and false cords are clearer. This is a supraglottic (not transglottic) tumor, likely amenable to outpatient endoscopic laser resection, and management of lymphatic compartments of the neck, depending on individual circumstances, via observation, radiotherapy, or selective neck dissection.
Hypopharyngeal Cancer, before and after Surgery
Hypopharyngeal cancer (1 of 10)
Years after successful radiotherapy for glottic cancer, during a routine, yearly follow-up examination, a new hypopharyngeal cancer (invasive squamous cell carcinoma) is barely seen, at arrow. (For reference, X marks the same location in the larynx throughout this series.)
Hypopharyngeal cancer (2 of 10)
Trumpet maneuver begins, to splay open the post-arytenoid part of the posterior pharyngeal wall (arrows and dotted lines), as well as the pyriform sinuses on each side. The tumor is now seen clearly. (Note the change of perspective from photo 1, using X as a reference point.)
Hypopharyngeal cancer (3 of 10)
Similar view to photo 2 (still with the trumpet maneuver), but now with the tumor outlined.
Hypopharyngeal cancer (4 of 10)
Closer view than photos 2 and 3 (again, still with the trumpet maneuver), with the tumor still outlined. Radiation is not an option for this tumor because of prior larynx irradiation; an attempt at laser surgery was selected.
Hypopharyngeal cancer: 1 week after surgery (5 of 10)
One week after laser excision of the tumor. Note the widespread redness, and the swollen arytenoid mounds, especially on the right side of the image. Compare with photo 1.
Hypopharyngeal cancer: 1 week after surgery (6 of 10)
Panoramic view, with the patient beginning the trumpet maneuver. The surgical wound is coming into view. Compare with photo 2 (again, using X as a reference point).
Hypopharyngeal cancer: 1 week after surgery (7 of 10)
Maximum trumpet maneuver. Closer view of the surgical wound. Compare with photo 4.
Hypopharyngeal cancer: 1 week after surgery (8 of 10)
View into the left pyriform sinus, where the tumor was most bulky.
Hypopharyngeal cancer: several months after surgery (9 of 10)
Months after laser resection, panoramic view, showing the swallowing “crescent” (within dotted lines), at the upper limit of where the laser resection occurred. There is surgical stenosis at the entrance to the esophagus (shown in the next photo). This stenosis affects swallowing of solid food, but the patient says this is no problem for him, if he eats a little more slowly and chews well.
Hypopharyngeal cancer: several months after surgery (10 of 10)
With the trumpet maneuver, again splaying open the hypopharynx, as in photo 2. Notice the hypopharyngeal/ postcricoid stenosis; the dotted lines represent what would be a normal-sized opening.
Verrucous Carcinoma, before and after Laser Treatment
Verrucous carcinoma (1 of 5)
Verrucous carcinoma, left vocal cord, persistent after radiotherapy elsewhere, in a patient unable to undergo general anesthesia due to severe lung disease.
During voicing (2 of 5)
Can be seen even during voicing.
After laser treatment (3 of 5)
After several Thulium Laser ablations, using topical and injected local anesthesia, with patient sitting in examination chair, thereby avoiding general anesthesia.
Mucus remains several weeks after laser treatment (4 of 5)
Approximately six weeks later, durable resolution of tumor. Yellow material is mucus.
Much improvement several weeks after laser treatment (5 of 5)
During voicing. Arytenoid moves, but much of membranous vocal cord has been ablated as intended.
Cancer, HPV Subtype 16, before and after Radiation
Cancer: HPV Subtype 16 (1 of 5)
Cancer, in a patient with HPV subtype 16. The divot and blood seen on the left vocal cord (right of image) are the result of a biopsy performed elsewhere (not by BVI physician) earlier the same day as this examination.
Cancer: HPV Subtype 16 (2 of 5)
Closer view.
Cancer: HPV Subtype 16, after radiation therapy (3 of 5)
Six weeks after the end of radiation therapy, the tumor is no longer seen. However, part of the left cord (right of image) is missing, due to sloughing of the tumor that had eaten away part of the cord’s normal tissue.
Cancer: HPV Subtype 16, after radiation therapy (4 of 5)
Phonation. Strobe light, open phase of vibration, shows that the margin of the left cord (right of image) is at a lower level than the right’s, due to loss of some of the bulk of the cord where the tumor died and sloughed away.
Cancer: HPV Subtype 16, after radiation therapy (5 of 5)
Strobe light, closed phase of vibration. The more normal right cord (left of image) unsuccessfully attempts to reach the left cord’s residual upper surface mucosa. Voice is functional but hoarse.
Vocal Cord Cancer, before, during, and after Radiation
Vocal cord cancer (1 of 12)
A 66-year-old man who complains of hoarseness. He smoked a pack a day for 50 years but quit five years ago. Note here the fullness and irregular contour especially of the left vocal cord ( right of photo). A biopsy confirmed this was cancer.
Vocal cord cancer (2 of 12)
At closer range, scattered leukoplakia and stippled vascular markings (suggestive of HPV effect, but HPV tested negative).
Vocal cord cancer (3 of 12)
During phonation.
Vocal cord cancer, 3 weeks after radiotherapy (4 of 12)
Same patient, three weeks after the end of full-course radiotherapy. Distant view shows radiation-induced mucositis on the false and true cords, seen as areas of white, superficial ulceration. General redness is also a radiation effect.
Vocal cord cancer, 3 weeks after radiotherapy (5 of 12)
Closer view, showing that the main tumor of the left vocal cord (again, right of photo) has melted away. Note that the mucositis is generalized, and not necessarily focal to the area of tumor sloughing.
Vocal cord cancer, 2 months after radiotherapy (6 of 12)
Same patient, now two months after the end of radiotherapy. All of the visible tumor is gone, and voice is very good. Small anterior web. Compare with photo 1 of this series.
Vocal cord cancer, 2 months after radiotherapy (7 of 12)
Phonation. Compare with photo 3 of this series.
4 Years after radiation therapy (8 of 12)
Distant view of post-radiation telangiectasia.
Telangiectasia (9 of 12)
At closer range, instead of just “redness” we can see vascularity.
Closer look (10 of 12)
On closer inspection exuberant post-radiation telangiectasias are seen especially on the right cord. Also, post-radiation anterior commissure web.
Anterior Web and Telangiectasia (11 of 12)
Up close inspection of impressive, yet harmless vascularity.
Narrow band lighting (12 of 12)
Under narrow-band lighting (green and blue light). Since red light is absent, the capillaries display in even higher contrast black.
Example 2
Vocal cord cancer (1 of 8)
Superficial cancer involving both vocal cords. This is stage 1 disease (T1B). The greatest bulk is on the right posterior cord (left of image), but the majority of both cords is involved with at least superficial disease. A faint dotted rectangle indicates the zoomed-in area seen in photo 2.
Vocal cord cancer (2 of 8)
Close-up view of only the anterior half of the cords. Notice the irregular surface, and areas of leukoplakia within this squamous cell carcinoma.
Vocal cord cancer, during radiation (3 of 8)
Just over midway through radiation treatment. One can see that the tumor is melting away.
Vocal cord cancer, during radiation (4 of 8)
Postcricoid / hypopharyngeal mucositis. In this view, the patient is performing a so-called trumpet maneuver to splay open the lower throat. The radiation delivered to the vocal cords (which inhabit the airway but are hidden here due to the momentary constriction of the laryngeal vestibule, at arrows) also causes superficial ulceration of the swallowing passage (upper half of the photo), directly behind the vocal cords. On occasion, if tissue reaction and mucositis are much more severe than seen here, a stricture can form, requiring dilation.
Vocal cord cancer, 2 months after radiation (5 of 8)
Two months after radiation is complete, showing that the tumor is gone, and the mucositis has resolved. There is a small anterior commissure web (at arrow) just below the free margin of the cords. The patient’s voice can nevertheless pass for normal.
Vocal cord cancer, 4 months after radiation (6 of 8)
Now four months after the end of radiation. Close-up view of the postcricoid / hypopharynx regions (compare with photo 4 in this series). Mucositis here is resolved as well, and there is no stricture.
Vocal cord cancer, 6 months after radiation (7 of 8)
Now six months after the end of radiation. Strobe illumination, open phase of vibration. Note that the contours of the vocal cords are not perfectly normal, even though voice is very good.
Vocal cord cancer, 6 months after radiation (8 of 8)
Strobe illumination, nearly closed phase of vibration. Oscillatory flexibility is preserved, but the vocal cord margins are not perfectly straight.
Radiation Induced Web
Post radiation therapy (1 of 4)
Marked laryngeal swelling and inflammation in a woman undergoing radiation therapy to the neck for recurrent thyroid cancer. The larynx is unavoidably in the radiation field. Note swelling of the left arytenoid (right of photo) as compared with right (left of photo). The X’s indicate the location of the arytenoids. In the distance, surrounded by the dotted line, is the web between the vocal cords.
Web formation (2 of 4)
At closer range, the superficial ulceration is indicated by the dotted line. Dashed line indicates where the cords should remain separated but are not, due to formation of a web.
Closer view of ulceration and web (3 of 4)
Closer view. The dotted line is yet again seen around the ulceration and web. Dashed line shows where the cords should remain separate.
Flexible scope used to separate vocal cords (4 of 4)
Using only topical anesthesia with patient in chair and not in the O.R., the flexible scope has been used several times to break the cords apart. Voice is instantly restored. The dotted line helps to see the separation of the forming scar ban.
Larynx Cancer Managed like “skin cancer”
Two years after excision (1 of 4)
Two years after successful laser excision of a right vocal cord cancer, preserving a good voice, despite stiffness of the right cord (left of photo). During this routine followup, slight mid-cord elevation, and subtle haziness catch the eye (within dotted line).
Narrow-band lighting (2 of 4)
Under narrow band light, the elevation and hazy leukoplakia are seen more clearly. Medial-to-lateral capillary reorientation is due to the prior superficial cordectomy.
During thulium laser coagulation (3 of 4)
At the conclusion of thulium laser coagulation. This turns the tissue even whiter, much like when one puts a thin layer of white icing on an already-white cake.
After thulium laser coagulation (4 of 4)
Distant view at the conclusion of laser treatment. The white area will slough off over the next several days.
A Case for Radiation Instead of Laser Resection
Long term smoker (1 of 4)
Distant view of vocal cords of long term smoker who is chronically hoarse. The tumor is at arrow.
Tumor (2 of 4)
Close-up shows obvious tumor is mostly involving immediate undersurface of the cord. The free margin of both cords is indicated by dotted lines.
Radiation therapy suggested (3 of 4)
Suspicion of submucosal fullness in the anterior subglottis. Laser is generally preferred to radiation for non-bulky tumors but undersurface and anterior subglottic suspicion suggests radiation therapy instead.
Two months later (4 of 4)
Nearly 2 months after completion of radiotherapy, the tumor appears to have melted away; the hazy granularity of the anterior subglottis (arrow) bears careful surveillance.
Scarring after Cancer Treatment but with Very Good Voice
Post laser excision (1 of 4)
Ten years after laser excision of a left vocal cord (right of photo) cancer, viewed from a distance. Voice has been extremely serviceable, if slightly husky.
Prephonatory instant (2 of 4)
Closer visualization at the prephonatory instant. Now the pseudobowing of the left cord (from tissue loss is easily seen.
Phonation (3 of 4)
Making voice, the faint blurring of the right cord margin (left of photo), but non-vibrating left cord (right of photo) can be more easily appreciated.
Close-up view (4 of 4)
At very close range, medial-to-lateral capillary reorientation—typical of superficial cordectomy after healing.
Cancer Beginning to Block Airway
Formerly heavy smoker (1 of 2)
Formerly heavy smoker with several months of deteriorating voice. Note that the dark chink where air must pass to enter the trachea is obstructed by an estimated 50% by the tumor. The remaining space remains sufficient for all normal activities without any sense of airway restriction.
Closer view (2 of 2)
At closer range.
Breaking the Rules in Larynx Cancer
Recurrent cancer (1 of 8)
Cancer, recurrent after radiotherapy. Cancer treatment ‘rules’ dictate a radical anterior commissure resection or more likely, total laryngectomy.
Closer view (2 of 8)
Closer view. The rules just invoked came about because cancer that crosses the anterior commissure is not to be trusted and especially after radiotherapy; cartilage involvement is far more likely; furthermore, laser resection might trigger radionecrosis. With careful patient involvement, an exception to these ‘rules’ was made here due to concomitant Stage 4 lung cancer of highly uncertain prognosis.
One week post laser resection (3 of 8)
A week after radical laser resection, including to the inner perichondrium of the thyroid cartilage. Wound healing/radionecrosis is a concern, as is the risk of recurrence when rules are bent.
One year postop (4 of 8)
A year post-op. There is no sign of recurrence. As expected, the vocal cords are scarred and will not vibrate. The patient has developed highly functional false vocal cord voice. (See the next four photos.)
True cord phonation (5 of 8)
Making voice, the true cords approximate but do not vibrate.
False vocal cords (6 of 8)
The false cords travel toward each other…
False vocal cord closure (7 of 8)
Here, they have come into full vibratory approximation.
True cords (8 of 8)
False cords separate, again revealing the non-vibrating true cords.
Biopsy of Early Vocal Cord Cancer
Chronic hoarseness (1 of 3)
Examination of this man for chronic hoarseness reveals diffusely abnormal-looking tissue on his vocal cords. The area on the upper surface of the right vocal cord (enclosed in dotted circle) appears to be most likely to be diagnostic. Note the bulk, and aberrant blood vessels.
Just before biopsy (2 of 3)
A 2 millimeter cup forceps has been passed through a channel scope and is planted on this area in open position, just before the biopsy.
Cancer finding (3 of 3)
Cup forceps have now been closed to encompass a small fragment of tissue. The pathologist’s answer after looking at this sample under the microscope: cancer
Tumor in Trachea
Biopsy (1 of 4)
Tumor growing through wall of trachea, from a paratracheal lymph node. Biopsy forceps are about to close to take a tissue fragment for study.
After biopsy (2 of 4)
After biopsy was taken at arrow. The result: squamous cell carcinoma thought to be an unusual metastasis from unusually aggressive larynx cancer.
Tumor gone (3 of 4)
Soon after radiation therapy, the tumor has melted away, leaving a depression in the tracheal wall.
Slow return (4 of 4)
Eighteen months later, the patient has experienced a fairly durable response, with very slow return of tumor.
HPV 31 Cancer Cure
Carcinoma in situ (1 of 4)
This man developed hoarseness spontaneously a year before this visit. He had accumulated 30 pack-years as a smoker, but had quit 7 years earlier. Removal of “polyps” elsewhere returned a diagnosis of carcinoma in situ (CIS), the earliest stage in the development of cancer.
HPV subtype 31 (2 of 4)
Under narrow band light, note some unusual “suspicious” capillaries, and the stippled “HPV effect” at the arrow. These findings triggered HPV subtyping and identification of high-risk subtype 31.
Excisions (3 of 4)
After 2 prior excisions elsewhere with positive margins, somewhat aggressive excision was performed in the operating room, attempting to avoid the need for radiotherapy in this fairly young man. The specimen showed severe dysplasia/ CIS, but with negative margins. After some months, voice became very functional.
Seven years later (4 of 4)
Seven years later, at an annual visit, there are no stippled or other abnormal vascular marks. Voice has been very acceptable to the patient, if occasionally faintly husky.
Before and after Radiation for Vocal Cord Cancer
Bilateral vocal cord cancer (1 of 4)
Bilateral vocal cord cancer in an elderly man. Laser excision is preferred for early cancer, except when, as seen in this larynx, the abnormality is bilateral and diffuse, lacking in obvious boundaries.
“Tumor vessels” (2 of 4)
Note the bulky disease on both sides, with “tumor vessels.”
After radiotherapy (3 of 4)
After radiotherapy, more normal contours are restored to the vocal cords. Voice is also much improved. The arrow points to tiny capillaries to serve as reference for the next photo.
Vascular pattern (4 of 4)
At very close range, under narrow band light, this vascular pattern can be carefully monitored for stability. Aberrant, “suspicious” vessels (none seen here) are often the earliest indication of recurrent cancer.
Small, but Dangerous!
Post radiotherapy (1 of 4)
After radiotherapy for reported early bilateral vocal cord cancer. No photos are available of the original tumor. Distant view here, showing abnormality below the vocal cords, anteriorly.
Normal voice (2 of 4)
Voice is normal, because closure of the vocal cords and their vibration is not impeded.
Persistent cancer (3 of 4)
Closer view. This is biopsy-proven persistent cancer. Note infiltrative appearance and submucosal component at arrow.
T4 tumor (4 of 4)
Why so dangerous? Radiation resistance can indicate a more aggressive tumor. And in this location, infiltration and even cartilage invasion (direction white arrow) may be present, making this a T4 tumor.
Unusual Posterior & Transglottic Epicenter for Larynx Cancer
Tumor (1 of 4)
View under standard light shows normal left vocal cord (right of photo) and tumor on right (left of photo). Main bulk is posterior; the cord is mobile, yet (unusually) the tumor is transglottic.
Accentuation of the vascularity (2 of 4)
Slightly more distant view under narrow band light; accentuation of the vascularity makes the tumor even more easily seen.
Posterior commissure (3 of 4)
Magnified posterior commissure view shows that the main bulk of tumor involves the cartilaginous glottis. This is highly unusual.
A year later (4 of 4)
Laser excision was satisfying except that the deep margin was the cricoid cartilage and therefore radiation therapy followed laser excision for added “safety.” Laser excision and radiotherapy were 9 years prior to this posting, at which point he remained free of disease.
Nice try, but on to Radiation
Vocal cord lesion (1 of 4)
Middle aged man with hoarseness and a left vocal cord lesion (right of photo) suspicious for cancer. After extensively educating the patient about options he would have if this were proven to be cancer, a single trip to the O.R. was planned for both frozen section, and possible definitive laser excision.
Closer view (2 of 4)
Though this looks bulky, some “large” tumors can be removed definitively with the laser, if they are mostly exophytic (growing outwards) rather than endophytic (deeply infiltrating).
Removal of tumor (3 of 4)
Frozen section was positive for squamous cell cancer, and much of the tumor was removed, but an endophytic (infiltrative) growth pattern diverted the plan to radiation therapy.
Nice try, but on to radiation (4 of 4)
If significantly more vocal cord were removed, voice might also have been excessively compromised.
Progressive Cricoarytenoid Joint Fibrosis / Fixation as a Late Complication of Radiation
25 years post radiotherapy (1 of 4)
During 25 years since radiotherapy for vocal cord cancer, voice had been “80%” and breathing normal. In recent years, voice is deteriorating; breathing also seems restricted during exertion. During “quiet breathing,” the vocal cords are in only partial abduction, due to fixation/ partial fixation of the crico-arytenoid joints. This glottic chink for breathing is likely less at night during sleep, explaining noisy breathing and the need for CPAP.
Fibrosis (2 of 4)
Here, the patient is sniffing, in order to reveal maximum possible abduction. Note that the right vocal cord (left of photo) seems “frozen” but not paralyzed (no atrophy) due to fibrosis of the right cricoarytenoid joint. The left vocal cord (right of photo) lateralizes incompletely. Note as well, post-radiation capillary ectasia.
Closed phase (3 of 4)
Under strobe light, closed phase of vibration. The left cord can move to the midline, and there is no sense of atrophy of either cord.
Open phase (4 of 4)
Open phase of vibration shows that only the left vocal cord mucosa (right of photo) is flexible, and is the source of all of the patient’s voice. The right cord mucosa (left of photo) is stiff and non-vibrating at all pitches. Without an examination from 25 years earlier, it is unknown where this represents early post-treatment stiffness (scarring from biopsy, etc.) or whether it is also the result of progressive fibrosis.
Progressive Radiation Fibrosis Effects on the Larynx and a Solution to some of it
Forty years post-radiation (1 of 8)
This photo is taken forty years after curative radiation for a vocal cord cancer. Four decades of progressive radiation fibrosis (“leatherization”) has taken away arytenoid movement so that this is the maximum opening. The patient is exercise-intolerant and makes loud inspiratory breathing noises while sleeping. Her voice is also very poor.
Involuntary inspiratory voice (2 of 8)
With sudden inspiration, the darker mucosa (at the arrows) indraws and vibrates, making an involuntary inspiratory voice.
Only capable of high pitch (3 of 8)
Other than a stage whisper, she can only make a very high pitch, because the only mucosa capable of vibration is the small segment indicated by the arrows.
Open phase vibration (4 of 8)
Again under strobe light, this is the open phase of vibration, with arrows again indicating the short segment of mucosa that can oscillate.
One week post-commissuroplasty (5 of 8)
A week after posterior commissuroplasty, the patient’s breathing is much improved. Despite the distant view, the “cookie bites” taken from the posterior cords are visible.
Rapid inhalation, closer view (6 of 8)
In a much closer view, the posterior vocal cord divots are seen well. The segment of flexible mucosa is indrawing here as the patient inhales rapidly (at arrows).
Three months post-surgery (7 of 8)
Three months after the laser surgery, the patient continues to say the improvement of breathing is “large.” In this distant view the full reason why is not seen.
Closer view, post-surgery (8 of 8)
In a closer view, as is always the case after complete healing, the divots are smaller than just after surgery.
Evolution of the Wound after Laser Removal of a vocal Cord Cancer: Not Pretty at First, but Voice Result can be very Good
Vocal cord cancer (1 of 8)
Bulky but superficial right vocal cord cancer (arrow, left of photo).
Voice-making with tumor (2 of 8)
Voice-making position. Notice the more lateral turning of the right vocal process (left of photo) as compared with the left (right of photo). As the remaining series shows, it is impossible to know if this is compensation for the bulk of tumor, or weakness of the LCA muscle.
One week post-removal (3 of 8)
A week after definitive removal, swelling, early granulation, and a division of the wound into upper and lower “lips” that must bind together with healing.
Voice-making, post-removal (4 of 8)
Note again the lateral turning of right vocal process (arrow, left of photo).
Six weeks post-op (5 of 8)
Six weeks after surgery, the wound is “bound together,” and there is a residual granuloma on the upper surface anteriorly (arrow).
Voice-making, post-op (6 of 8)
Making voice, there is still that peculiar lateral turning of the vocal process on the right (left of photo).
Four months post-op (7 of 8)
Now a full 4 months since laser excision, the cord is fully healed though still pink as expected. The anterior upper surface is coated with mucus.
Voice-making, four months post-op (8 of 8)
Making voice, again that lateral deviation of the right vocal process (arrow, left of photo). Voice is very functional but a little weak. Vibratory blur is greater for left than right cord.
Laser can Beat Cancer and Spare Voice even after Radiotherapy Failure
Return of cancer (1 of 4)
Eight years after radiotherapy for early vocal cord cancer, cancer has returned in a man who never stopped smoking. Radiotherapy is no longer an option. Here, we have bilateral disease.
Leukoplakia and Stippled Vascularity (2 of 4)
At closer range under narrow band light, areas of leukoplakia and stippled vascularity are seen more clearly; all of this must be removed. The options are laser excision, partial laryngectomy, and total laryngectomy. Laser excision was selected as the “next step.”
Post-laser excision (3 of 4)
10 weeks after laser excision, healing is nearly complete. Stippled vascularity is no longer seen; the medial-to-lateral reorientation of capillaries often seen after laser excision is seen especially on the right vocal cord (left of photo).
Healing post-laser excision (4 of 4)
Now at 18 weeks after laser excision, healing is truly complete. Even under narrow band light and at close range, no vascular abnormality or leukoplakia is seen. Voice is remarkably good, without audible ” effort,” or syllable dropouts. Obviously, close follow up is required.
How a Vocal Cord Heals after Laser Removal of a Cancer
squamous cell carcinoma (1 of 6)
After biopsy performed elsewhere revealed squamous cell carcinoma, this right vocal cord cancer (left of photo) is scheduled to be treated for cure via laser excision.
1 week after laser excision (2 of 6)
A week after laser excision, the typical upper and lower “lips” swell at the margins of resection will need to heal back together to re-establish a normal vocal cord contour.
Difficulty speaking (3 of 6)
As the vocal cords approach each other in preparation for producing voice, the upper and lower lips with central depression are seen more clearly.
Natural granulation after laser excision (4 of 6)
At approximately 2 months after laser excision, healing is nearly complete and voice very functional. There is a round granuloma (exuberant healing response) that will soon fall off spontaneously. Every patient is told about possible granulation of this sort, so that they do not worry that this is a tumor recurrence.
Abnormal capillary pattern (5 of 6)
A year after surgery, the patient’s voice can pass for normal. Under strobe light, this closed phase of vibration shows the good match of the vocal cord margins. The regenerated mucosa of the right (upper part of photo) vocal cord has a typically abnormal (but healthy) post-laser capillary pattern.
Stiff right vocal cord (6 of 6)
Here during the open phase of vibration, one can see that the right vocal cord is stiff (as expected after laser surgery of any depth) and does not vibrate well. Voice sounds virtually normal, however, due to the precise match of the margins and normal left vocal cord vibration (see again, photo 5). At the time of this posting, this person has remained free of disease for 8 years, and has no sense of vocal limitation.
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Early Vocal Cord Cancer
This video provides an introduction to early vocal cord cancer (stages 1 and 2) and compares the two main treatment options: laser surgery and radiation therapy.
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Early Vocal Cord Cancer Overview