1. Prepared by Dr.Hiwa Asad
Tumors of Larynx
Prepared by Dr.Hiwa Asad

2. Benign Tumors
Ectodermal
Mesodermal
pseudotumours

3. Ectodermal Tumours Papilloma: single or multiple Adenoma Paraganglioma
Neurilemmoma

4. Single papilloma Common in adults, rare in children
Sessile or pedunculated
Usual sites anterior commissure, anterior half of the vocal cords
Men : women ratio 2:1
Present with hoarseness
If small removed endoscopically
If large by laryngofissure
Biopsy to exclude malignancy specially if recurrent

5. Squamous papilloma of
the aryepiglottic fold
Laryngeal papilloma

6. Multiple papillomas Infants and young children, rare in adults
A virus may be responsible (HPV)
Vocal cords are the usual site
Hoarsness if vocal cords affected
Dyspnoea may occur ---- tracheostomy
Removed endoscopically by CO2 laser
Spontaneous recovery in puberty may occur

7. Juvenile laryngeal papillomas

8. Juvenile papillomas
Before and after removal

9. Mesodermal tumours Vascular neoplasms Chondroma Myogenic tumours
Fibroma
Lipoma

10. Vascular neoplasms Haemangioma Arise from blood or lymphatic vessels
Rare in adults
Telangiectatic
vocal cord polyp

11. Chondroma Arise from cartilages (Mostly cricoid)
More in men (40-70 years)
Clinical features
Hoarsness and dyspnoea
Stridor (extention into subglottic space)
Dysphagia (extension into hypopharynx)
External swelling (cricoid ring or thyroid cartilage)

12. Chondroma
Indirect laryngoscopy reveals a smooth mass covered by intact mucosa
Radiology shows calcific stippling or coarse irregular calcificatuon
Biopsy specimens is unrepresentative, the tumour is hard and difficult to penetrate
Surgery is the treatment of choice
Radiptherapy is of little value

13. Malignant Tumors 1% of all malignancies In UK More in men
Predominantly of squamous pathology
Interfere with function and emotion
High cure rate 85%

14. Incidence Higher in urban than rural population
Social and racial differences reflect different habits (tobacco and alcohol)

15. Classification
The International Union against Cancer (UICC) classified Ca larynx on anatomical bases
20%
10%
70%

16. UICC classification of Ca larynx
Epilarynx
Suprahyoid epiglottis
Aryepiglottic folds
Supraglottis
infrahyoid epiglottis
false cords
ventricles
Supraglottis
Glottis True cord,ant&post comissure
1 cm
Subglottis
UICC classification of Ca larynx

17. Glottis true cords
anterior commissure
posterior commissure

18. Aetiology Unknown Possibly related factors genetic and social factors
male predominance
racial predilection
urban pollution
tobacco and alcohol
radiation
asbestos
occupational factors

19. Examination and diagnosis
Diagnosis will be made after consideration of:
History
Examination of the larynx
Examination of the neck
General examination of the patient
Radiology
Clinical investigations
Histological examination

20. 1-Symptoms Dysphonia progressive and unremitting
Cough and irritation in the throat (early)
Dyspnoea & stridor in advanced tumour, specially in subglottic Ca
Pain more typical of supraglottic Ca, late and uncommon
Referred otalgia may occur
Swelling of the neck or larynx (tumour or LN)
Haemoptysis (rare ,in lesions of the margin of epiglottis)
Anorexia, cachexia or fetor are late symptoms
Progress of the disease

21. 2-Examination of the larynx
examine for
Focal abnormality
Vocal cord lesion
Mass
Mobility
examine by
Indirect laryngoscopy (LA)
Flexible laryngoscopy (LA)
Direct laryngoscopy (GA)
Microlaryngoscopy (GA)

22. 3-Examination of the neck
A palpable neck mass could be due to:
1.Direct spread of the tumour.
2.Regional lymph nodes
metastasis.
3.Enlarged thyroid lobe
which suggest invasion

23. 4-General examination To identify metastasis e.g. to the liver
To assess the overall physical status of the individual who is likely to need GA and biopsy, surgery, radiotherapy or chemotherapy

24. 5-Radiological examination
Chest X-ray
Larynx Tomography
CT and MRI of neck and larynx

25. Supraglottic tumour
Tomography AP
Lateral

26. CT scan
Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion

27. MRI
Epiglotic tumor（laryngeal Ca. supraglotic type）

28. MRI Sagittal T2 image of supraglottic Ca
Extension involves the epiglottis :E
Loss of normal pr-epiglottic fat plane: solid arrows
Tongue base involvement : open arrow

29. Axial MRI showing tumour of the Rt. VC

30. MRI
Coronal view of MRI showing subglottic extension

31. MRI
Sagittal view showing transglottic tumour

32. 6-Clinical investigations
Full hematological screen
Biochemical profile including liver function tests and serum protein
A urine screen for diabetes
ECG

33. 7-Histological examination
Proof diagnosis of malignancy
Type of the tumor
Degree of differentiation

34. Diagnostic difficulties
Negative biopsy
Keratosis
Previous radiation
Miscellaneous conditions: chronic laryngitis, TB, Syphilis…

35. Pathology Squmous cell carcinoma:
The vast majority of laryngeal malignant tumours.
Verrucous carcinoma (Ackerman’s tumour):
A distinct variant of well differentiated squamous cell Ca is the

36. Glottic Ca Origin : the free margin of the vocal cords
Invasion & extension
anterior commissure
cartilage (Ossified more prone)
arytenoid & posterior cricoarytenoid muscle
vertical extension to the subglottis &/or supraglottis
is more frequent than to the opposite side

37. Cancer of the Lt true vocal cord

38. glottic CA

39. cancer involving the true vocal cords and arytenoid
cancer involving the true vocal cords and arytenoid.  The cancer also extends onto the supraglottis

40. Glottic Ca Impaired mobility :
superficial invasion of the thyroarytenoid muscle
Fixation of the vocal cords:
by invasion of:
- thyroarytenoid muscle
- arytenoid cartilage
- cricoid cartilage
-cricoarytenoid joint

41. Supraglottic Ca Often involving both sides
Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies

42. Supraglottic Ca Invasion thyroid cartilage
pre-epiglottic space occur in 40% of supraglottic Ca and 70% of epiglottic Ca
vallecula & base of the tongue
Arytenoid
Pyriform sinus

43. Supraglottic Ca Epiglottic tumpur Tumour of Lt aryepiglottic fold
Tumour of Rt false cord

44. Subglottic Ca Primary are rare Grow circumferentially and extensively
Invasion of the vocal cords may lead to impairment of mobility and hoarsness
Can spread through the cricothyroid membrane anteriorly or cricotracheal membrane posteriorly or invade the trachea caudally

45. Subglottic Ca

46. Lymph node involvement
18% had LN metastasis at the time of referral
Supraglottic ( 40% )
Glottic Ca ( 5% )
Subglottic Ca ( 13% )

47. Distant metastasis
Few present with distant metastasis at the time of diagnosis
11% have distant metastasis, mostly in the lung ( 6.8% )

48. TNM classification
T: Primary tumour
N: Nodal deposits
M: Metastasis

49. T : Primary tumour TX T0 Tis Primary tumour can not be assesed
No evidence of primary tumour
Tis
Carcinoma insitu

50. T : Primary tumour Glottic T1 limited / mobile T2 extends to supra or
a: one cord
b: both cords
T2 extends to supra or
subglottic /mobile
T3 cord fixation
T4 extends beyond
the larynx
Supra & subglottic
T1 limited / mobile
cords
T2 extends to
glottis/mobile
T3 cord fixation
T4 extends beyond
the larynx

51. Glottic
T1a
Rt.VC Ca with normal mobility

52. Glottic
T1b
Limited mobile both cords

53. Glottic T2 extends to supra or subglottic /mobile
large tumor on the left true vocal cord
and anterior false vocal cords (T2 Cancer)

54. Glottic cancer involving the true vocal cords and arytenoid.
The cancer also extends onto the supraglottis T2

55. Subglottic T1
limited / mobile cords

56. Subglottic
extends to glottis/mobile T2

57. Supraglottic
limited / mobile cords T1
Lt false cord tumour

58. Supraglottic T2 Extends to glottis Moblie cords
Ca of the Rt. aryepiglottic fold

59. Supraglottic T3
cord fixation
Ca of the Lt. arytenoid

60. N: Nodal deposits N0 No LN deposits N1 ipsilateral movable
N2 contra or bilateral movable
N3 Fixed

61. M: Metastasis
M no metastasis
M metastasis

62. Staging Stage 0 : Tis, N0 , M0 Stage 1 : T1, N0 , M0
T1-T3, N1 , M0
Stage 4 : T4, N0/N1 , M0
Any T, N2/N3 , M0
Any T, Any N , M1

63. Treatment
No treatment
Palliation
curative
Rehabilitation

64. No treatment Those presenting in extremis
who are no longer conscious of pain or distress
Disseminated tumours cause their death without the primary tumour or regional disease causing symptoms
7-8% recieve no treatment

65. Palliation
The attempt to suppress the Ca and its symptoms without expectation or intent to cure
Palliation is used in late stages
Includes: pain relief
tracheostomy
other surgery
radiotherapy
chemotherapy

66. Pain relief Pain is not common in Ca larynx
combination methods including analgesics, radiation, surgery, and chemotherapy used for pain relief

67. Tracheostomy To relieve airway obstruction
It often provide a dilemma, as it just delay the inevitable death in a patient with incurable cancer

68. Other surgeries Total laryngectomy For pain control occasionally
Radical neck dissection
may remove a fungating or painful local lesion

69. Radiotherapy Commonly used for palliation
Can be applied locally and selectively
Radioactive implants of gold are useful for local treatment

70. Chemotherapy No Ca larynx has been cured by drugs
Complete regression is rare
Partial response in 20%
In no way can be compared to radiotherapy or surgery
Rather it is an alternative to analgesics
Has significant side effects and leads to more suffering

71. Curative treatment
Radiotherapy
Surgery
Chemotherapy

72. Radiotherapy
Radiation is most effective where the tissues are well oxygenated.
So it is most valuable in small lesions and when the vascular supply is undamaged, where it has not preceded by surgery
Radiation is more applicable on the oxygenated periphery, while surgery could deal with the mass

73. Radiotherapy Selection of cases:
When cure is likely with preservation of function.
When surgery is contraindicated or refused.
Chemotherapy before radiation increases the
response.

74. Radiotherapy Contraindicaitons Active perichondritis
Cartilage invasion
Previous radiotherapy

75. Radiotherapy Interstitial radiation
radioactive gold-198 grains can be inserted using a special gun in a pattern which can give a very high dose localized to nodes or nodules in the neck, with little damage to normal structures

76. Radiotherapy Radiation reactions
Erythema or moist desquamation of the skin, may progress to necrosis
Perichondritis
Mucositis (Painful erythematous reaction)
reactions are minimized by the avoidance of smoking and alcohol.

77. Recurrence after radiotherapy

78. Surgery
Microlaryngeal Surgery
Laser Surgery
Excisional Surgery

79. Microendolaryngeal and laser surgery
Carcinoma in situ can by treated by microsurgical excision and laser makes this easier
Certain localized supraglottic lesions may be excised using a laser
Carbon dioxide laser is used

80. Excisional surgery Used with or without radiotherapy
Has risk of loss of voice, and protection of the airway
Is more effective than radiotherapy in large tumours and when there are secondary deposits in LN in the neck
Partial resection of the larynx may maintain a near normal funcion with high cure rate
Used after failure of radiotherapy

81. Selection of treatment

82. Microendoscopic removal with or without laser
Keratosis & Carcinoma in situ in the glottis and supraglottis
Small tumours in the marginal zones (suprahyoid epiglottis, aryepiglottic folds, false cords)

83. Radiotherapy T1 & T2 lesions (Supraglottis and glottis ) T3 glottis
Subglottic tumours
Small or subclinical nodes

84. Surgery
Supraglottic lesions arising from the base of the epiglottis and the false cords .
T2 lesions as alternative to radiotherapy
T3 & T4
Subglottic lesion as alternative to radiotherapy
Secondary nodal deposits
Other malignancies apart from squamous type all are treated by laryngectomy

85. Emergency laryngectomy
This is to avoid tracheostomy when there is airway obstruction in laryngeal Ca
Peristomal recurrence is more in those with tracheostomy who undergone laryngectomy

86. Surgical techniques Vertical partial resection
Horizontal partial resection
Total resection
-With or without neck dissection

88. Skin incision for laryngofissure
Running over the midportion of thyroid cartilage between st.cl.mastoid muscles

89. cordectomy
Thyroid cartilage
Skin incision
Cricoid cartilage

90. cordectomy
Exposure of thyroid cartilage & cricothyroid membrane in the midline

91. cordectomy
The perichondrium is exposed retracting the strap muscles

92. cordectomy
Elevation of the edges of external perichondrium

93. cordectomy
Midline thyrotomy
Division of the thyroid cartilae in the midline with a power saw

94. cordectomy Thyroid alae retracted VC removed from ventricle to
Endolarynx inspected
Extent of the tumour assesed
VC removed from ventricle to
subglottis, lateral boundary of
resection is the internal perichondrium
of tyroid ala

95. cordectomy
Rt.VC tumour
Tumour of the Rt. VC is seen by retraction of thyroid lamina

96. cordectomy
Rt.VC tumour
Retraction of supraglottic larynx

97. cordectomy
Line of incision
Excision with scissors

98. cordectomy
Reapproximated thyroid cartilage

99. cordectomy
Suturing of the perichondrium

100. cordectomy
Suturing of sternohyoid

101. cordectomy
Suturing of platysma

102. cordectomy
Closure of skin

103. cordectomy
The surgical specimen
1 year after surgery

104. Management of LN metastasis
Observation for limited cancers
Palpable LN at presentation—Neck disection with/without Radiotherapy.
Prophylactic treatment—Neck dissection or radiotherapy.
Treatment of postoperative and post- irradiation LN

105. Thanks