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Prepared by Dr.Hiwa Asad
Tumors of Larynx Prepared by Dr.Hiwa Asad
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Benign Tumors Ectodermal Mesodermal pseudotumours
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Ectodermal Tumours Papilloma: single or multiple Adenoma Paraganglioma
Neurilemmoma
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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
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Squamous papilloma of the aryepiglottic fold Laryngeal papilloma
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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
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Juvenile laryngeal papillomas
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Juvenile papillomas Before and after removal
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Mesodermal tumours Vascular neoplasms Chondroma Myogenic tumours
Fibroma Lipoma
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Vascular neoplasms Haemangioma Arise from blood or lymphatic vessels
Rare in adults Telangiectatic vocal cord polyp
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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)
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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
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Malignant Tumors 1% of all malignancies In UK More in men
Predominantly of squamous pathology Interfere with function and emotion High cure rate 85%
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Incidence Higher in urban than rural population
Social and racial differences reflect different habits (tobacco and alcohol)
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Classification The International Union against Cancer (UICC) classified Ca larynx on anatomical bases 20% 10% 70%
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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
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Glottis true cords anterior commissure posterior commissure
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Aetiology Unknown Possibly related factors genetic and social factors
male predominance racial predilection urban pollution tobacco and alcohol radiation asbestos occupational factors
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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
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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
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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)
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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
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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
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5-Radiological examination
Chest X-ray Larynx Tomography CT and MRI of neck and larynx
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Supraglottic tumour Tomography AP Lateral
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CT scan Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion
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MRI Epiglotic tumor(laryngeal Ca. supraglotic type)
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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
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Axial MRI showing tumour of the Rt. VC
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MRI Coronal view of MRI showing subglottic extension
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MRI Sagittal view showing transglottic tumour
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6-Clinical investigations
Full hematological screen Biochemical profile including liver function tests and serum protein A urine screen for diabetes ECG
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7-Histological examination
Proof diagnosis of malignancy Type of the tumor Degree of differentiation
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Diagnostic difficulties
Negative biopsy Keratosis Previous radiation Miscellaneous conditions: chronic laryngitis, TB, Syphilis…
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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
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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
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Cancer of the Lt true vocal cord
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glottic CA
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cancer involving the true vocal cords and arytenoid
cancer involving the true vocal cords and arytenoid. The cancer also extends onto the supraglottis
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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
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Supraglottic Ca Often involving both sides
Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies
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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
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Supraglottic Ca Epiglottic tumpur Tumour of Lt aryepiglottic fold
Tumour of Rt false cord
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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
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Subglottic Ca
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Lymph node involvement
18% had LN metastasis at the time of referral Supraglottic ( 40% ) Glottic Ca ( 5% ) Subglottic Ca ( 13% )
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Distant metastasis Few present with distant metastasis at the time of diagnosis 11% have distant metastasis, mostly in the lung ( 6.8% )
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TNM classification T: Primary tumour N: Nodal deposits M: Metastasis
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T : Primary tumour TX T0 Tis Primary tumour can not be assesed
No evidence of primary tumour Tis Carcinoma insitu
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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
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Glottic T1a Rt.VC Ca with normal mobility
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Glottic T1b Limited mobile both cords
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Glottic T2 extends to supra or subglottic /mobile
large tumor on the left true vocal cord and anterior false vocal cords (T2 Cancer)
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Glottic cancer involving the true vocal cords and arytenoid.
The cancer also extends onto the supraglottis T2
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Subglottic T1 limited / mobile cords
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Subglottic extends to glottis/mobile T2
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Supraglottic limited / mobile cords T1 Lt false cord tumour
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Supraglottic T2 Extends to glottis Moblie cords
Ca of the Rt. aryepiglottic fold
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Supraglottic T3 cord fixation Ca of the Lt. arytenoid
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N: Nodal deposits N0 No LN deposits N1 ipsilateral movable
N2 contra or bilateral movable N3 Fixed
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M: Metastasis M no metastasis M metastasis
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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
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Treatment No treatment Palliation curative Rehabilitation
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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
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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
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Pain relief Pain is not common in Ca larynx
combination methods including analgesics, radiation, surgery, and chemotherapy used for pain relief
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Tracheostomy To relieve airway obstruction
It often provide a dilemma, as it just delay the inevitable death in a patient with incurable cancer
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Other surgeries Total laryngectomy For pain control occasionally
Radical neck dissection may remove a fungating or painful local lesion
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Radiotherapy Commonly used for palliation
Can be applied locally and selectively Radioactive implants of gold are useful for local treatment
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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
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Curative treatment Radiotherapy Surgery Chemotherapy
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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
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Radiotherapy Selection of cases:
When cure is likely with preservation of function. When surgery is contraindicated or refused. Chemotherapy before radiation increases the response.
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Radiotherapy Contraindicaitons Active perichondritis
Cartilage invasion Previous radiotherapy
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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
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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.
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Recurrence after radiotherapy
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Surgery Microlaryngeal Surgery Laser Surgery Excisional Surgery
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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
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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
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Selection of treatment
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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)
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Radiotherapy T1 & T2 lesions (Supraglottis and glottis ) T3 glottis
Subglottic tumours Small or subclinical nodes
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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
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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
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Surgical techniques Vertical partial resection
Horizontal partial resection Total resection -With or without neck dissection
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Skin incision for laryngofissure
Running over the midportion of thyroid cartilage between st.cl.mastoid muscles
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cordectomy Thyroid cartilage Skin incision Cricoid cartilage
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cordectomy Exposure of thyroid cartilage & cricothyroid membrane in the midline
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cordectomy The perichondrium is exposed retracting the strap muscles
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cordectomy Elevation of the edges of external perichondrium
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cordectomy Midline thyrotomy Division of the thyroid cartilae in the midline with a power saw
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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
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cordectomy Rt.VC tumour Tumour of the Rt. VC is seen by retraction of thyroid lamina
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cordectomy Rt.VC tumour Retraction of supraglottic larynx
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cordectomy Line of incision Excision with scissors
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cordectomy Reapproximated thyroid cartilage
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cordectomy Suturing of the perichondrium
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cordectomy Suturing of sternohyoid
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cordectomy Suturing of platysma
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cordectomy Closure of skin
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cordectomy The surgical specimen 1 year after surgery
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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
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Thanks
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