(January 9, 2009 - Insidermedicine) On a recent trip to Boston, we caught up with Dr. Daniel Deschler, MD, FACS, who is an Associate Professor in Otology and Laryngology at Harvard Medical School, Director of the division of Head and Neck Surgery at Massachusetts Eye and Ear Infirmary and Director of the Norman Knight Hyperbaric Medicine Center at Massachusetts Eye and Ear Infirmary.  Dr. Deschler's research interests include voice after laryngeal cancer surgery, and prevention of microvascular thrombosis.

If I had a hoarse voice...

A common complaint that a person will often present with in our office is that of hoarseness, a change in their voice, and it’s challenging because people will often have that at some point in their life, and when do you worry and when do you not? A simple way to break that down that we try to utilize is if an individual has hoarseness or voice change that’s been persistent over a three week period or worsening, that makes us a little more concerned, and at that point they should undergo a formal evaluation by someone who can fully evaluate the region, as well as the voicebox itself. That would be an otolaryngologist, head-neck surgeon.

What questions should be asked during the assessment?

When someone sees and otolaryngologist for the complaint of hoarseness, they’ll ask you how long it has been going on, are there certain things that make it better or worse, they’ll ask you questions about risk factors for cancer of that region, that would include the use of tobacco or other inhaled agents, but mainly cigarette smoking, other things include alcohol use which is also a risk factor for a cancer of the region, and then finally they would examine you, and the examination involves looking through the mouth and feeling the neck, and things like that, but it usually also involves looking at the voicebox itself. Sometimes they can do that with a little mirror in the office, or tiny scopes that can be placed through the nose and allow a really nice view of the voicebox but can be tolerated very easily by patients in the office.

At that time of examination, the physician may find that there just looks like there’s irritation of the region which can get better with some conservative measures. If there is a specific lesion that’s there that the physician sees, one that may cause the mobility or the movement of the voicebox to be impaired or growing extensively in that area , that really raises the risk of a cancer in that area, and at that point further workup and evaluation is necessary, and it can include a CT scan, or sometimes other types of imaging, but ultimately it may require the physician taking a look at the voicebox in the operating room and obtaining a small biopsy of the area to define the diagnosis, because that becomes the critical element in the treatment of cancer – defining where it is, how advanced it is, and how extensive it is. At that point we can apply the tools we have that give us a very high cure rate of cancers of the voicebox if applied at the right time and in the right manner.

How quickly does the cancer develop?

A voice that does not improve over a three-week period needs to be evaluated. It may still be, and most likely is a benign or not cancerous process, but you don’t want to miss that period of time when you can find a cancer when it’s small as opposed to when it’s larger. If a cancer is small, what we say are stage 1 or 2, the cure rates are very high, greater than 80%, but once it becomes advanced, what we say are stage 3 or 4, those cure rates drop into the 50 - 65% cure rate, and you’d much rather find them when they’re early than when they’re more advanced, because that allows us to apply our tools in a directed fashion and in a fashion that may have less morbidity to the patient.

How is head and neck cancer treated?

The treatment of head and neck cancer has undergone a great revolution over the last two decades and specifically the treatment of a cancer of the voicebox or the larynx. What we found is over the last two decades that there has been a high success rate in being able to fully treat these cancers even when they’re advanced by not utilizing surgery to remove the voicebox but a combination of chemotherapy and radiation therapy. Now there are certain cases where removal of or surgery on the voicebox may be necessary,  and if that’s the case then we do everything possible to maximize function afterwards, because we feel it is more important that we first of all make the patient cancer-free and then focus on rehabilitation, because if you don’t achieve the first end, all the rehabilitation in the world isn’t going to help them.

In summary

If an individual has hoarseness that has persisted for over 3 weeks without improvement or has worsened, then they need to be evaluated by a professional, such as an otolaryngologist-head-neck surgeon. Other workup may be necessary, but it is imperative to rule out a potential malignancy, and often that requires a biopsy of the area and a short procedure. At that point once the diagnosis is established either benign or malignant, appropriate therapy can be undertaken.