What is the evaluation and management approach for a patient with a laryngeal mass?

Evaluation and Management of Laryngeal Masses

The evaluation of a laryngeal mass requires direct visualization through laryngoscopy as the essential first step, followed by appropriate imaging and possible biopsy for definitive diagnosis. 1

Initial Assessment

Presenting Symptoms

• Hoarseness (most common symptom)
• Stridor
• Dysphagia
• Throat pain
• Foreign body sensation
• Cough
• Neck mass
• Voice changes
• Trouble swallowing
• Ear pain on the same side as the mass

Risk Factors to Assess

• Tobacco use history
• Alcohol consumption
• Voice use patterns (professional voice users)
• Prior radiation exposure
• Family history of head and neck cancer

Diagnostic Approach

Step 1: Visualization of the Larynx

• Laryngoscopy is mandatory and should be performed at the initial evaluation for any patient with suspected laryngeal mass 1
• Options include:
  • Flexible fiberoptic laryngoscopy (most common initial approach)
  • Mirror laryngoscopy
  • Rigid laryngoscopy
  • Videostroboscopy (particularly valuable for vocal fold lesions)

Step 2: Imaging Studies

• Contrast-enhanced CT scan and/or MRI are essential for assessing:
  • Primary tumor extent
  • Regional lymph node involvement
  • Cartilage invasion (critical for treatment planning) 2
• CT is particularly valuable for submucosal masses that may not be fully appreciated on endoscopy 3, 4
• For suspected malignancy, chest imaging (minimum chest CT) should be performed to assess for distant metastases 2
• FDG-PET/CT is recommended for evaluation of suspected recurrence or work-up of unknown primary 2

Step 3: Biopsy

• Direct laryngoscopy with biopsy is required for definitive diagnosis
• For submucosal masses, deep or wedge biopsy is often necessary as superficial biopsies may be negative 4
• Pathological confirmation is mandatory for suspected malignancy 2

Management Approach

For Benign Lesions

• Common benign lesions include vocal polyps, nodules, cysts, laryngoceles, and papillomas 5
• Treatment options:
  • Microlaryngeal surgery (most common approach)
  • Voice therapy
  • Voice rest
  • Observation for small, asymptomatic lesions

For Malignant Lesions

Early Stage (T1-T2)

• All patients should be treated with intent to preserve the larynx 1
• Options include:
  • Radiation therapy
  • Larynx-preserving surgery (endoscopic resection preferred when feasible) 1
  • Selection depends on tumor characteristics, patient factors, and local expertise

Advanced Stage (T3-T4)

• Multidisciplinary evaluation is essential 1
• Treatment options:
  • Organ-preservation surgery (for selected patients)
  • Concurrent chemoradiotherapy (offers higher chance of larynx preservation than RT alone) 1
  • Radiation therapy alone (with surgery reserved for salvage)
  • Total laryngectomy (may be preferred for extensive T3 or large T4a lesions with poor pretreatment laryngeal function) 1

Functional Assessment

• Pre-treatment voice and swallowing assessments should be performed to:
  • Establish baseline function
  • Guide treatment selection
  • Counsel patients on expected outcomes 1
• Assessment tools include:
  • Self-recorded and expert-rated voice quality measures
  • Voice-related quality-of-life tools
  • Videostroboscopy
  • Videofluoroscopic or fiber-optic laryngoscopic evaluation of swallowing 1

Important Considerations

• Patients with large-volume, deeply infiltrative lesions (large T3, T4a) with significant pretreatment dysfunction may have better outcomes with total laryngectomy rather than organ preservation approaches 1
• Submucosal masses may require multiple biopsies for diagnosis, and negative initial biopsies should not exclude further investigation if clinical suspicion remains high 4
• Continued smoking is associated with worse outcomes; patients should be encouraged to abstain from smoking 1
• Patients with a nonfunctional larynx or tumor penetration through cartilage into surrounding soft tissues are poor candidates for larynx-preservation approaches 1

Follow-up

• Regular post-treatment assessments are necessary to evaluate:
  • Disease control
  • Voice and swallowing function
  • Late toxicities
  • Potential recurrence

Early specialist assessment of persistent laryngeal symptoms is critical, as it enables accurate diagnosis and appropriate management, particularly for detecting laryngeal cancer at an early stage 6.