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Larynx (voice box)

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Larynx anatomy: supraglottis, glottis, subglottis

Last reviewed: October 4, 2026

Introduction

Cancer of the larynx (voice box) is almost always squamous cell carcinoma, and most cases are caused by smoking, often together with heavy drinking. Because a growth on the vocal cords changes the voice early, many larynx cancers are found while still small and highly curable. Cancers above or below the vocal cords tend to be found later [1].

Early cancers are usually treated with a single treatment, either radiation or surgery through the mouth (often with a laser), with similar cure rates [2]. For more advanced cancers, landmark trials showed that many patients can keep their voice box by having radiation with chemotherapy, without lowering survival, while the most advanced tumors that have destroyed cartilage do better with removal of the larynx (total laryngectomy) followed by radiation [3, 4, 2, 5]. The sections below cover anatomy, evaluation, the airway, swallowing and treatment, including voice after laryngectomy. A numbered reference list is at the end of the page.

The larynx, often called the voice box, contains the vocal cords used in speech, but also acts as a valve that closes with swallowing, so that food and liquid pass to the hypopharynx and esophagus. The glottis consists of the vocal cords and their moveable attachments, the arytenoids. The supraglottis is above the glottis, including the false vocal cords, the epiglottis, and the aryarytenoid folds. The subglottis is the segment of the larynx below the glottis. The epiglottis is a flap of cartilage that covers the laryngeal airway during swallows.

The three regions behave differently. The supraglottis has a rich network of lymphatic channels, so supraglottic cancers often spread to lymph nodes on both sides of the neck. The glottis has very few lymphatic channels, so early vocal cord cancers rarely spread to the neck. The subglottis drains to nodes low in the front of the neck, around the windpipe and thyroid [1]. For this reason, the neck lymph nodes are often treated for supraglottic cancer even when scans look normal, but usually not for small glottic cancers (see lymphatics and lymph nodes).

evaluation of larynx cancer

Evaluating larynx cancer begins with a history and physical exam, including evaluation of the airway, swallowing, and the lymph nodes of the neck. Further evaluation commonly includes the following:

• Laryngoscopy in the office: Link to a page on the American Cancer Society site describing use of a scope in the office to examine the throat. This procedure is done to look at both the larynx and pharynx (laryngoscopy and pharyngoscopy, respectively) and it takes about 30-60 seconds, typically.

• CT scan with iodine contrast: This imaging study done in radiology utilizing intravenous dye provides additional anatomic detail. In individuals allergic to iodine contrast, medications may be used to curb any reacti0n, or another study may be undertaken, such as CT scan without contrast or MRI scan with gadolinium contrast.

• PET-CT scan: The combination of a Positron Emission Tomogram (PET) with a non-contrast CT scan is commonly utilized for more advanced cancers or situations in which the above studies are inconclusive. The CT component of this study provides good anatomic detail, while the PET component provides information on the metabolic activity of a tissue, which is useful in identifying probable extent of cancer.

• Videostroboscopy: a scope exam with a strobe light that shows the vibration of the vocal cords in slow motion, which helps judge how deep an early cancer goes and gives a baseline record of the voice before treatment [2].

• Direct laryngoscopy and biopsy under anesthesia: confirms the diagnosis and maps the full extent of the tumor, including areas hard to see in the office [1].

• Voice and swallowing evaluation by a speech-language pathologist before treatment is recommended for all patients [2].

Staging

Larynx cancer is staged with the AJCC TNM system (8th edition), with separate tumor (T) definitions for the supraglottis, glottis and subglottis [6]. In general terms, T1 cancers are limited to one region with normal vocal cord movement, T2 cancers extend to a neighboring region or reduce cord movement, T3 cancers fix the vocal cord in place or invade nearby spaces or the inner layer of the thyroid cartilage, and T4a cancers grow through the cartilage or outside the larynx. Stage I and II (T1 or T2 without lymph node spread) are considered early; stage III and IV are advanced [6, 1].

larynx cancer and the airway

Over time, as a larynx cancer grows, the airway gets narrower. This may have minimal effect early-on, but once the airway gets small, every additional millimeter of diameter lost can have a major effect on the ability to breathe. For this reason, when a person’s larynx cancer is causing noticeable challenge in breathing, such as with taking longer to catch one’s breath, becoming unable to breathe in certain positions, or having noisy breathing, their doctor should be notified immediately and tracheostomy should be considered.

In addition, tumors of the throat tend to have bacterial infection on their surfaces. Larynx tumors impair the normal mechanism by which food and liquid are routed to the esophagus instead of to the windpipe (trachea). Combined, larynx cancers tend to soil the lungs with bacteria, leading to infection that further limits breathing.

When a tumor already narrows the airway at diagnosis, a tracheostomy may be done before treatment to keep breathing safe, and the choice of treatment takes it into account. A larynx that has lost its function because of the tumor (for example, with a tracheostomy needed for breathing or repeated aspiration pneumonia) is one of the situations in which removing the larynx is recommended over attempts to preserve it [2]. After a total laryngectomy, the windpipe is brought out to a permanent opening in the lower neck (stoma), and breathing no longer passes through the nose or mouth (see recovery after tracheostomy).

Swallowing

Swallowing well is essential for maintaining nutrition as well as keeping the lungs free of infection. A decision faced commonly in the treatment of larynx cancer (especially advanced stages of larynx cancer) is whether to place a gastric feeding tube (G tube).

Swallowing problems are common after both surgery and chemoradiation and can appear or worsen years after treatment, as scar tissue forms. Adding chemotherapy to radiation increases the long-term risk of swallowing difficulty. The 2018 ASCO guideline recommends a swallowing evaluation before treatment, continued swallowing by mouth during radiation when it is safe, swallowing exercises, and avoiding long periods with nothing by mouth [2]. Swallowing can be measured with a modified barium swallow study. More information is on the swallowing page.

Treatment types

Three main categories of treatment used for cancer, including larynx cancer, are surgery, radiation therapy, and medication. The mainstays of treatment of a larynx cancer are surgery and radiation therapy. Medications (chemotherapy or immunotherapy) may be added to radiation for additional treatment effect. Surgery is used in certain situations, such as when the primary tumor is large enough that radiation and medical treatments without surgery are unlikely to produce a cure, or if these treatments would likely cause enough damage to the throat that larynx function (voice and protecting the lungs during swallowing) would be ineffective. Surgery may also include the removal of lymph nodes in the neck that have cancer spread to them or are at risk for that. The best treatment plan for a given individual is agreed upon by members of the tumor board conference, and this recommendation is relayed to the patient.

Early cancer: radiation or laser surgery

For early (T1 and T2) glottic cancer, radiation and transoral laser microsurgery give similar cure rates and similar voice results overall, so the choice depends on the tumor and the person's preferences [2, 1]. Laser surgery is a single outpatient or short-stay procedure that provides tissue for the pathologist and keeps radiation available for later use. Radiation avoids an operation, may give a better voice for some deeper tumors or tumors at the front junction of the vocal cords (the anterior commissure), and can treat tumors that are hard to reach through the mouth [2]. A 2025 meta-analysis found no meaningful difference in patient-reported voice handicap between the two, while noting that the quality of the studies was low [7].

Advanced cancer: keeping the larynx

Before 1991, most advanced larynx cancers were treated by removing the larynx. Three trials changed that:

  • The VA Laryngeal Cancer Study (1991) randomly assigned 332 patients with stage III or IV cancer to chemotherapy followed by radiation (with laryngectomy kept for poor responders or recurrence) or to laryngectomy and radiation. Two-year survival was 68% in both groups, and about two-thirds of the chemotherapy group kept their larynx [3].

  • RTOG 91-11 (2003) compared three non-surgical approaches. At two years the larynx was preserved in 88% of patients given radiation with cisplatin at the same time, 75% given chemotherapy before radiation, and 70% given radiation alone [4].

  • RTOG 91-11 at ten years (2013): concurrent chemoradiation still gave the best larynx preservation and control in the neck, and overall survival did not differ significantly between groups. Deaths not caused by the cancer were more frequent after concurrent chemoradiation, which is a reminder that the treatment has long-term effects [8].

The 2018 ASCO guideline concluded that, for well-selected patients, larynx-preservation treatment does not compromise survival, but that no larynx-preservation approach improves survival compared with total laryngectomy with appropriate radiation [2].

Very advanced cancer: total laryngectomy

For T4a cancers that have grown through cartilage or outside the larynx, and for larynxes that no longer work, the guidelines recommend total laryngectomy (usually with neck dissection) followed by radiation or chemoradiation [2, 1]. In the National Cancer Database, patients with T4a cancer treated with total laryngectomy lived a median of 61 months, compared with 39 months for those treated with chemoradiation [5], and a second analysis found the survival advantage of laryngectomy was concentrated in T4 disease [9]. A 2006 national study had earlier found that survival for laryngeal cancer in the United States fell from the mid-1980s to the mid-1990s as non-surgical treatment became more common, which led to closer attention to choosing the right patients for larynx preservation [10]. These are observational studies and cannot fully account for differences between patients, but they are consistent.

Voice after total laryngectomy

After a total laryngectomy the vocal cords are gone, so speech is produced in a new way [11]:

  • Tracheoesophageal voice: a small one-way valve (voice prosthesis) placed in a puncture between the windpipe and the esophagus lets air from the lungs vibrate the throat when the stoma is covered. It gives the most natural, fluent voice and is the most common method today. The prosthesis is replaced every few months, usually because of leakage.

  • Electrolarynx: a handheld battery-powered device held against the neck or cheek that produces a mechanical-sounding voice. It is easy to learn and a useful backup.

  • Esophageal speech: swallowed air is released to produce sound. It needs no device but is the hardest to learn.

In a 2023 series of 197 patients, 71% of those using tracheoesophageal voice were using it successfully as their main way of communicating at one year, compared with 49% with an electrolarynx and 19% with esophageal speech; lower socioeconomic status was the only independent predictor of failure, which points to the importance of access to speech therapy [12]. More information is on the voice and larynx treatments pages.

Smoking after the diagnosis

Stopping smoking after a diagnosis of head and neck cancer improves survival: a meta-analysis found about a 20% lower risk of death in those who quit compared with those who kept smoking [13]. In a study of laryngeal cancer specifically, those who quit before treatment were more likely to have a complete response and less likely to need a salvage laryngectomy [14]. Help with quitting is part of treatment (see how to quit tobacco).

Survival

In a large European study, five-year survival for larynx cancer was about 65% overall, and it was lower with more advanced stage, older age and continued smoking [15]. Early glottic cancers have the best outcomes. These figures describe large groups and do not predict an individual result.

Additional links

• Link to an interactive page on the American Cancer Society with information on cancer of the larynx (voice box) and hypopharynx (lowest part of the throat).

• Link to an illustrated article on the American Head and Neck Society page explaining cancer of the larynx (voice box) in detail.

Related pages on this site: throat cancers, throat tumor treatments, hypopharynx, oropharynx, neck, tracheostomy.

Summary

  • The larynx has three regions; supraglottic cancers spread to neck lymph nodes more often than glottic (vocal cord) cancers [1].

  • Evaluation includes laryngoscopy, stroboscopy, CT or MRI, biopsy under anesthesia and, for advanced cancer, PET-CT [2, 1].

  • Early cancers are treated with radiation or laser surgery, with similar cure rates and voice results [2, 7].

  • Many advanced cancers can be treated with chemoradiation while keeping the larynx, without lowering survival [3, 4, 8].

  • For T4a cancer or a non-functioning larynx, total laryngectomy followed by radiation gives better survival [2, 5]. Voice can be restored, most often with a voice prosthesis [12].

  • Quitting smoking improves the results of treatment [13, 14].

References

  1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Head and Neck Cancers. Version 2.2026. nccn.org

  2. Forastiere AA, Ismaila N, Lewin JS, et al. Use of Larynx-Preservation Strategies in the Treatment of Laryngeal Cancer: American Society of Clinical Oncology Clinical Practice Guideline Update. J Clin Oncol. 2018;36(11):1143-1169. doi:10.1200/JCO.2017.75.7385 PubMed 29172863

  3. Wolf GT, Fisher SG, Hong WK, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med. 1991;324(24):1685-90. doi:10.1056/NEJM199106133242402 PubMed 2034244

  4. Forastiere AA, Goepfert H, Maor M, et al. Concurrent chemotherapy and radiotherapy for organ preservation in advanced laryngeal cancer. N Engl J Med. 2003;349(22):2091-8. doi:10.1056/NEJMoa031317 PubMed 14645636

  5. Grover S, Swisher-McClure S, Mitra N, et al. Total Laryngectomy Versus Larynx Preservation for T4a Larynx Cancer: Patterns of Care and Survival Outcomes. Int J Radiat Oncol Biol Phys. 2015;92(3):594-601. doi:10.1016/j.ijrobp.2015.03.004 PubMed 26068492

  6. Lydiatt WM, Patel SG, O'Sullivan B, et al. Head and Neck cancers-major changes in the American Joint Committee on cancer eighth edition cancer staging manual. CA Cancer J Clin. 2017;67(2):122-137. doi:10.3322/caac.21389 PubMed 28128848

  7. Qasem M, Qasem N, Kinshuck A, et al. Long-Term Laryngeal Function and Quality of Life Following Treatment of Early Glottic Cancer: A Meta-Analysis. Otolaryngol Head Neck Surg. 2025;172(2):375-385. doi:10.1002/ohn.1011 PubMed 39403814

  8. Forastiere AA, Zhang Q, Weber RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013;31(7):845-52. doi:10.1200/JCO.2012.43.6097 PubMed 23182993

  9. Patel SA, Qureshi MM, Dyer MA, et al. Comparing surgical and nonsurgical larynx-preserving treatments with total laryngectomy for locally advanced laryngeal cancer. Cancer. 2019;125(19):3367-3377. doi:10.1002/cncr.32292 PubMed 31206637

  10. Hoffman HT, Porter K, Karnell LH, et al. Laryngeal cancer in the United States: changes in demographics, patterns of care, and survival. Laryngoscope. 2006;116(9 Pt 2 Suppl 111):1-13. doi:10.1097/01.mlg.0000236095.97947.26 PubMed 16946667

  11. van Sluis KE, van der Molen L, van Son RJJH, et al. Objective and subjective voice outcomes after total laryngectomy: a systematic review. Eur Arch Otorhinolaryngol. 2018;275(1):11-26. doi:10.1007/s00405-017-4790-6 PubMed 29086803

  12. Landry V, Christopoulos A, Guertin L, et al. Patterns of alaryngeal voice adoption and predictive factors of vocal rehabilitation failure following total laryngectomy. Head Neck. 2023;45(10):2657-2669. doi:10.1002/hed.27491 PubMed 37646494

  13. Caini S, Del Riccio M, Vettori V, et al. Post-diagnosis smoking cessation and survival of patients with head and neck cancer: a systematic review and meta-analysis. Br J Cancer. 2022;127(11):1907-1915. doi:10.1038/s41416-022-01945-w PubMed 35999273

  14. Krutz M, Acharya P, Elliott J, et al. Tobacco Cessation Following Laryngeal Cancer Diagnosis Predicts Response to Treatment and Laryngectomy-Free Survival. Otolaryngol Head Neck Surg. 2024;170(2):438-446. doi:10.1002/ohn.567 PubMed 37890055

  15. Abrahão R, Anantharaman D, Gaborieau V, et al. The influence of smoking, age and stage at diagnosis on the survival after larynx, hypopharynx and oral cavity cancers in Europe: The ARCAGE study. Int J Cancer. 2018;143(1):32-44. doi:10.1002/ijc.31294 PubMed 29405297

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