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

Benign Tumors • Ectodermal • Mesodermal • pseudotumours Benign Tumors • Ectodermal • Mesodermal • pseudotumours

Ectodermal Tumours • • Papilloma: single or multiple Adenoma Paraganglioma Neurilemmoma Ectodermal Tumours • • Papilloma: single or multiple Adenoma Paraganglioma Neurilemmoma

Single papilloma • Common in adults, rare in children • Sessile or pedunculated • 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

Squamous papilloma of the aryepiglottic fold Laryngeal papilloma Squamous papilloma of the aryepiglottic fold Laryngeal papilloma

Multiple papillomas • • Infants and young children, rare in adults A virus may 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 CO 2 laser Spontaneous recovery in puberty may occur

Juvenile laryngeal papillomas Juvenile laryngeal papillomas

Juvenile papillomas Before and after removal Juvenile papillomas Before and after removal

Mesodermal tumours 1. 2. 3. 4. 5. Vascular neoplasms Chondroma Myogenic tumours Fibroma Lipoma Mesodermal tumours 1. 2. 3. 4. 5. Vascular neoplasms Chondroma Myogenic tumours Fibroma Lipoma

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

Chondroma • Arise from cartilages (Mostly cricoid) • More in men (40 -70 years) 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)

Chondroma • Indirect laryngoscopy reveals a smooth mass covered by intact mucosa • Radiology 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

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

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

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

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

Glottis true cords anterior commissure posterior commissure Glottis true cords anterior commissure posterior commissure

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

Examination and diagnosis • 1. 2. 3. 4. 5. 6. 7. Diagnosis will be Examination and diagnosis • 1. 2. 3. 4. 5. 6. 7. 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

1 -Symptoms • Dysphonia progressive and unremitting • Cough and irritation in the throat 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

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

3 -Examination of the neck A palpable neck mass could be due to: 1. 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

4 -General examination • To identify metastasis e. g. to the liver • To 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

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

AP Supraglottic tumour Tomography Lateral AP Supraglottic tumour Tomography Lateral

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

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

MRI l Sagittal T 2 image of l l l supraglottic Ca Extension involves MRI l Sagittal T 2 image of l l l supraglottic Ca Extension involves the epiglottis : E Loss of normal pr-epiglottic fat plane: solid arrows Tongue base involvement : open arrow

Axial MRI showing tumour of the Rt. VC Axial MRI showing tumour of the Rt. VC

MRI Coronal view of MRI showing subglottic extension MRI Coronal view of MRI showing subglottic extension

MRI Sagittal view showing transglottic tumour MRI Sagittal view showing transglottic tumour

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

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

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

Pathology 1. Squmous cell carcinoma: The vast majority of laryngeal malignant tumours. • Verrucous Pathology 1. 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

Glottic Ca Origin : the free margin of the vocal cords Invasion & extension 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

Cancer of the Lt true vocal cord Cancer of the Lt true vocal cord

glottic CA glottic CA

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

Glottic Ca Impaired mobility : superficial invasion of the thyroarytenoid muscle Fixation of the 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

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

Supraglottic Ca Invasion • thyroid cartilage • pre-epiglottic space occur in 40% of supraglottic 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

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

Subglottic Ca • Primary are rare • Grow circumferentially and extensively • Invasion of 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

Subglottic Ca Subglottic Ca

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

Distant metastasis • Few present with distant metastasis at the time of diagnosis • Distant metastasis • Few present with distant metastasis at the time of diagnosis • 11% have distant metastasis, mostly in the lung ( 6. 8% )

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

T : Primary tumour TX Primary tumour can not be assesed T 0 No T : Primary tumour TX Primary tumour can not be assesed T 0 No evidence of primary tumour Tis Carcinoma insitu

T : Primary tumour Glottic T 1 limited / mobile a: one cord b: T : Primary tumour Glottic T 1 limited / mobile a: one cord b: both cords Supra & subglottic T 1 limited / mobile cords T 2 extends to T 2 extends to supra or glottis/mobile subglottic /mobile T 3 cord fixation T 3 cord fixation T 4 extends beyond T 4 extends beyond the larynx

Glottic T 1 a Rt. VC Ca with normal mobility Glottic T 1 a Rt. VC Ca with normal mobility

Glottic T 1 b Limited mobile both cords Glottic T 1 b Limited mobile both cords

Glottic T 2 extends to supra or subglottic /mobile large tumor on the left Glottic T 2 extends to supra or subglottic /mobile large tumor on the left true vocal cord anterior false vocal cords (T 2 Cancer)

Glottic cancer involving the true vocal cords and arytenoid. The cancer also extends onto Glottic cancer involving the true vocal cords and arytenoid. The cancer also extends onto the supraglottis T 2

Subglottic T 1 limited / mobile cords Subglottic T 1 limited / mobile cords

Subglottic extends to glottis/mobile T 2 Subglottic extends to glottis/mobile T 2

Supraglottic T 1 limited / mobile cords Lt false cord tumour Supraglottic T 1 limited / mobile cords Lt false cord tumour

Supraglottic T 2 Extends to glottis Moblie cords Ca of the Rt. aryepiglottic fold Supraglottic T 2 Extends to glottis Moblie cords Ca of the Rt. aryepiglottic fold

Supraglottic T 3 cord fixation Ca of the Lt. arytenoid Supraglottic T 3 cord fixation Ca of the Lt. arytenoid

N: Nodal deposits N 0 No LN deposits N 1 ipsilateral movable N 2 N: Nodal deposits N 0 No LN deposits N 1 ipsilateral movable N 2 contra or bilateral movable N 3 Fixed

M: Metastasis M 0 no metastasis M 1 metastasis M: Metastasis M 0 no metastasis M 1 metastasis

Staging Stage 0 : Tis, N 0 , M 0 Stage 1 : T Staging Stage 0 : Tis, N 0 , M 0 Stage 1 : T 1, N 0 , M 0 Stage 2 : T 2, N 0 , M 0 Stage 3 : T 3, N 0 , M 0 T 1 -T 3, N 1 , M 0 Stage 4 : T 4, N 0/N 1 , M 0 Any T, N 2/N 3 , M 0 Any T, Any N , M 1

Treatment No treatment curative Palliation Rehabilitation Treatment No treatment curative Palliation Rehabilitation

No treatment • Those presenting in extremis • who are no longer conscious of 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

Palliation • The attempt to suppress the Ca and its symptoms without expectation or 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

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

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

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

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

Chemotherapy • • No Ca larynx has been cured by drugs Complete regression is 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

Curative treatment • Radiotherapy • Surgery • Chemotherapy Curative treatment • Radiotherapy • Surgery • Chemotherapy

Radiotherapy • Radiation is most effective where the tissues are well oxygenated. • So 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

Radiotherapy • Selection of cases: 1. When cure is likely with preservation of function. Radiotherapy • Selection of cases: 1. When cure is likely with preservation of function. 2. When surgery is contraindicated or refused. Chemotherapy before radiation increases the response.

Radiotherapy • Contraindicaitons 1. Active perichondritis 2. Cartilage invasion 3. Previous radiotherapy Radiotherapy • Contraindicaitons 1. Active perichondritis 2. Cartilage invasion 3. Previous radiotherapy

Radiotherapy • Interstitial radiation radioactive gold-198 grains can be inserted using a special gun 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

Radiotherapy • Radiation reactions 1. Erythema or moist desquamation of the skin, may progress Radiotherapy • Radiation reactions 1. Erythema or moist desquamation of the skin, may progress to necrosis 2. Perichondritis 3. Mucositis (Painful erythematous reaction) reactions are minimized by the avoidance of smoking and alcohol.

Recurrence after radiotherapy Recurrence after radiotherapy

Surgery • • • Microlaryngeal Surgery Laser Surgery Excisional Surgery • • • Microlaryngeal Surgery Laser Surgery Excisional

Microendolaryngeal and laser surgery • Carcinoma in situ can by treated by microsurgical excision 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

Excisional surgery • Used with or without radiotherapy • Has risk of loss of 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

Selection of treatment Selection of treatment

Microendoscopic removal with or without laser 1. Keratosis & Carcinoma in situ in the Microendoscopic removal with or without laser 1. Keratosis & Carcinoma in situ in the glottis and supraglottis 2. Small tumours in the marginal zones (suprahyoid epiglottis, aryepiglottic folds, false cords)

Radiotherapy 1. T 1 & T 2 lesions (Supraglottis and glottis ) 2. T Radiotherapy 1. T 1 & T 2 lesions (Supraglottis and glottis ) 2. T 3 glottis 3. Subglottic tumours 4. Small or subclinical nodes

Surgery 1. Supraglottic lesions arising from the base of the epiglottis and the false Surgery 1. Supraglottic lesions arising from the base of the epiglottis and the false cords. 2. T 2 lesions as alternative to radiotherapy 3. T 3 & T 4 4. Subglottic lesion as alternative to radiotherapy 5. Secondary nodal deposits 6. Other malignancies apart from squamous type all are treated by laryngectomy

Emergency laryngectomy • This is to avoid tracheostomy when there is airway obstruction in 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

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

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

cordectomy Thyroid cartilage Skin incision Cricoid cartilage cordectomy Thyroid cartilage Skin incision Cricoid cartilage

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

cordectomy The perichondrium is exposed retracting the strap muscles cordectomy The perichondrium is exposed retracting the strap muscles

cordectomy Elevation of the edges of external perichondrium cordectomy Elevation of the edges of external perichondrium

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

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

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

cordectomy Rt. VC tumour Retraction of supraglottic larynx cordectomy Rt. VC tumour Retraction of supraglottic larynx

cordectomy Line of incision Excision with scissors cordectomy Line of incision Excision with scissors

cordectomy Reapproximated thyroid cartilage cordectomy Reapproximated thyroid cartilage

cordectomy Suturing of the perichondrium cordectomy Suturing of the perichondrium

cordectomy Suturing of sternohyoid cordectomy Suturing of sternohyoid

cordectomy Suturing of platysma cordectomy Suturing of platysma

cordectomy Closure of skin cordectomy Closure of skin

cordectomy The surgical specimen 1 year after surgery cordectomy The surgical specimen 1 year after surgery

Management of LN metastasis 1. Observation for limited cancers 2. Palpable LN at presentation—Neck Management of LN metastasis 1. Observation for limited cancers 2. Palpable LN at presentation—Neck disection with/without Radiotherapy. 3. Prophylactic treatment—Neck dissection or radiotherapy. 4. Treatment of postoperative and post- irradiation LN

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