184 THE LARYNX, BRONCHI AND OESOPHAGUS
regurgitating air in the form of a kbelch\ Speech is produced by coordinated
movements of lips, tongue, teeth and palate.
If the patient feels strongly about losing his larynx, radiotherapy can be
offered as the primary treatment with total laryngectomy being reserved for
the recurrences. This form of treatment gives poorer results and a higher
complication rate especially with regard to fistula formation.
This usually presents as a leucoplakia of the cord (p. 162). Unless there are
signs of invasion, it is unwise to use radiotherapy for this tumour as it can
be kept under control perfectly safely with vocal cord stripping repeated as
often as required at microlaryngoscopy.
PATHOLOGY. Again, this is predominantly a squamous-cell cancer and is more
common in males who smoke. The subglottis is by far the rarest region to be
affected by laryngeal cancer and this is fortunate because the results are so
much poorer than in cancer of the glottis and supraglottis. The subglottis is a
small area extending from the lower border of the cricoid to the under surface
of the vocal cords. Cancer of the thyroid gland and the trachea can spread to
involve the subglottis and cancers of the subglottis spread to the thyroid
gland, in 20 per cent of cases, and to the trachea. Twenty per cent also involve
the strap muscles of the neck and the same percentage gives rise to cervical
node metastases. There are 6-8 paratracheal nodes in the mediastinum and
these, too, may be involved by spread of subglottic cancer.
SYMPTOMS. If the vocal cord is involved early the presenting symptom is
hoarseness but if the tumour is lower in the subglottis the patient will present
with respiratory obstruction and a normal voice. These latter usually present
as surgical emergencies.
INVESTIGATION. Examination must be made for cervical node metastases
and to ascertain the extent of spread of the tumour. Since subglottic tumours
may involve the thyroid gland this should be scanned. There is a higher
proportion of second primary tumours in these cases and so particular
attention should be paid to the chest X-ray to see if the patient has a second
chest primary tumour.
TREATMENT. Neither radiotherapy nor surgery in the form of total laryngec-
tomy gives good results in this tumour. As things stand at the moment it is
advisable to give the patient primary radiotherapy and to reserve a total
laryngectomy for any recurrence. At the same time the paratracheal nodes
should be removed. In the future use will perhaps be made of planned
combined radiotherapy and total laryngectomy, the patient receiving about
3500 r over a 2-week period, and then 2 weeks later having a total laryngec-
tomy. In the case of a large subglottic tumour presenting with respiratory
obstruction a case could be made for doing an emergency laryngectomy. If a
tracheostomy is done as the emergency procedure, it will have to be placed so
near tumour that there is a 60 per cent chance of the tumour implanting in
the tracheal stoma unless the area is removed within 72 hours.