Alarming triad of progressive hoarseness in a male smoker

Discussion Laryngeal cancer is the second most common head and neck cancer in Malaysia, more commonly seen in patients of advanced age, with a mean of 59 years.2 Principally laryngeal cancer is a disease of men, and is highly associated with smoking and alcohol consumption.2,3 In Malaysia, the majority of laryngeal cancer patients are Chinese, who account for 54% of cases, followed by Indians (23%) and Malays (19%).3 The reported gender distribution is 7.6:1 male to female, with an obvious predilection to the male gender.3 Population-based studies of laryngeal cancer in other parts of the world have reported similar predilections to men, with male to female ratios between 8.4:1.6 and 30:1.3'4 The higher risk of developing laryngeal cancer is directly related to the increased prevalence of unhealthy habits like tobacco smoking and alcohol consumption among males. Various studies have shown that these factors have a synergistic effect on the development of laryngeal cancer.2-5 It is well documented that derivatives from commercially prepared tobacco act as carcinogens in the epithelium of the larynx and disrupt division and proliferation of cells, triggering carcinogenesis.6 Examples of these carcinogenic derivatives include polycyclic aromatic hydrocarbons, N-nitrosamines, aromatic amines, aldehydes and volatile organic hydrocarbons. Studies have shown that the tobacco-specific nitrosamine 4-(methylnitrosamino)-1-(3-pyridyl)-1butanone upregulates oncogenic pathways linked to head and neck cancer.6 The past decade has seen the emergence of electronic cigarettes (e-cigarettes), which 13 - 50% of tobacco smokers have been found to also use.7 Although e-cigarettes are safer than tobacco products because they do not contain nitrosamines, scientific evidence regarding their carcinogenic effect is limited due to a lack of long-term data and heterogeneity in the chemical compounds found in e-cigarettes.7 Other risk factors for laryngeal cancer include gastroesophageal reflux disease8 and certain professions. Exposure to carcinogenic agents like asbestos, textile dust and strong acid mist is associated with laryngeal cancer among miners, textile workers and workers in metal industries.9 Glottic cancer, which presents in its early stage with hoarseness, accounts for nearly 90% of laryngeal cancer.2.3 A study in the United States reported that 2.2% of individuals with persistent hoarseness lasting more than four weeks were found to have laryngeal cancer.1 Another loca