Synopsis
Recognise glottic, supraglottic and subglottic cancer, distinguish stable hoarseness from impending obstruction, investigate safely and choose treatment that balances cure with voice, swallowing and airway function.
- Glottic cancer classically causes persistent progressive hoarseness early; supraglottic cancer more often causes sore throat, dysphagia, odynophagia, referred otalgia, aspiration or a neck node.
- First-line diagnostic assessment is flexible nasendoscopy by a trained clinician, but a severely compromised patient needs a controlled airway plan before repeated examination or transfer.
- The diagnostic reference standard is direct laryngoscopy with biopsy and histology once the airway is secure; do not biopsy a precarious obstructing lesion in an uncontrolled setting.
- Contrast CT neck and chest stages cartilage, spaces, nodes, airway and thoracic disease; MRI adds selected cartilage, soft-tissue, tongue-base or prevertebral detail.
- Early glottic disease is commonly treated with one modality, such as transoral laser microsurgery or radiotherapy, with broadly high local control and different voice trade-offs.
- Locally advanced disease may need total laryngectomy with neck and risk-adapted adjuvant therapy or organ-preserving chemoradiotherapy after realistic functional assessment.
- Dexamethasone and nebulised adrenaline may temporarily reduce oedema in selected acute cases, but neither removes tumour and neither should delay definitive airway control.
- Avoid sedatives, opioids and neuromuscular blockade before a shared difficult-airway plan when spontaneous ventilation is maintaining a critically narrow airway.
- A tracheostomy may retain an upper-airway connection; a total-laryngectomy stoma does not. In laryngectomy, apply oxygen and ventilate through the stoma only.
- Smoking cessation, nutrition, dental preparation, swallowing therapy, voice rehabilitation and emergency stoma education are integral to treatment.
Key red flags
Stridor at rest, drooling, severe recession, silent airflow, fatigue, cyanosis or reduced consciousness requires an immediate controlled airway response.
Progressive or persistent unexplained hoarseness, especially with tobacco exposure, warrants urgent laryngeal visualisation rather than repeated reflux treatment.
Odynophagia, dysphagia, referred otalgia, haemoptysis, weight loss, neck mass or aspiration suggests invasive or supraglottic disease.
A patient after total laryngectomy breathes only through the neck stoma; oral or nasal oxygen and intubation cannot ventilate the lungs.
Fresh tracheostomy or stoma bleeding, especially a pulsatile sentinel bleed, can precede major vessel haemorrhage and needs immediate surgical and major-haemorrhage support.
Stridor at rest, inability to speak normally, secretion intolerance, recession, orthopnoea, cyanosis or exhaustion requires immediate airway action.
A mature end stoma without upper-airway airflow, loss of normal voice and a neck-breather alert identifies total laryngectomy rather than simple tracheostomy.
Investigation priorities
Visualise supraglottis, glottis, subglottic inlet, pooling, tumour and vocal-cord movement and assess airway calibre.
Assess laryngeal spaces, cartilage, extralaryngeal spread, cervical nodes, airway, lung metastasis and synchronous lung cancer.
Management branches
The patient has rest stridor, severe work of breathing, secretion intolerance, hypoxaemia or exhaustion.
- Call senior ENT, anaesthesia and critical care, keep upright and calm, give oxygen, attach monitoring and prepare suction and difficult-airway equipment while identifying prior tracheostomy or laryngectomy anatomy.
- Agree the planned and rescue airway before drugs or transfer; a controlled awake approach, rigid endoscopic debulking, tracheostomy or front-of-neck access may be selected according to level and anatomy.
- Treat oedema or infection concurrently when suspected, but regard steroid, adrenaline or antibiotics as bridges and proceed to definitive airway control if clinical obstruction persists or progresses.
Persistent hoarseness or another suspicious laryngeal symptom is present without immediate compromise.
- Arrange urgent specialist head-and-neck examination and flexible nasendoscopy, documenting cord mobility, neck nodes, swallowing and airway symptoms.
- Obtain contrast CT neck and chest and selected MRI, then perform direct laryngoscopy and biopsy in a setting matched to anticipated airway difficulty.