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MALIGNANT TUMOURS OF
LARYNXDr Manpreet Singh Nanda
Associate Professor ENTMMMC&H Solan
EPIDEMIOLOGY 2.6% of all cancers AGE – 40 to 70 yrs SEX – M:F 10:1 MC –SCC (>90-95%) MC – glottic (70%) Others ca – verrucous ca, spindle cell ca,
sarcomas, malignant salivary gland tumours
RISK FACTORS Alcohol – supraglottic ca Smoking – Benzopyrene is carcinogenic Alcohol + Smoking – 15 times higher Radiation exposure Familial/genetic Occupational – exposure to asbestos, nickel,
petroleum products, wood products, construction workers
Racial – black>white HPV-16 Diet – high dietary fibres, salt preservation meat GERD
Pre malignant disorders – ca in situ, leukoplakia, solitary papillomas, hyperkeratosis
PREVENTION - smoking cessation - reduce alcohol - healthy diet (green leafy veg)
DIAGNOSIS Clinical Evaluation Adult with hoarseness presisting longer than 3-4
weeks and not responding to treatment Diagnostic Laryngoscopy – IDL/Fibreoptic rigid/
nasal flexible vc – fixed/immobile (infiltration) Exophytic/ulcerative lesion Extent of disease Neck Examination – Extra laryngeal spread, nodal metastasis,
perichondritis Lump neck, broadening/tenderness of larynx,loss
of crepitations
Routine investigations – blood/urine/RBS/ECG Imaging – X Ray Neck – patency of airway, extent Chest X Ray – TB, Pulmonary metastasis,
mediastinal nodes, bronchopneumonia CT/MRI – extent of tumour, cartilage destruction,
nodal metastasis PET Scan – for recurrent (after 4 months)/residual
disease (within 4 months) Stroboscopy Panendoscopy/Barium Swallow – for
secondaries/ spread DL Scopy and biopsy/Microlaryngoscopy
DL SCOPY/MICROLARYNGOSCOPY For hidden areas of larynx – infrahyoid
epiglottis, ventricle,.. Subglottis GA Take a excisional biopsy for suspected lesion
with border of healthy mucosa Under operating microscope for more
accurate biopsy Supravital staining with toluidine blue –
apply to the lesion, wash after 20 sec, dry Dye taken up (deep blue colour) – CIS/sup ca Not taken up - Leukoplakia
PATHOLOGY Gross – exophytic (cauliflower) –
suprahyoid epiglottis. Ulcerative – infrahyoid epiglottis
H.P.E grading (Border’s classification) I – well differentiated - >75% cells are
normal – glottic ca II – moderately differentiated – 50-75% cells
are normal III – poorly differentiated – 25-50% cells are
normal – subglottic ca Anaplastic - <25% cells are normal –
supraglottic ca
AJCC – DIVISIONS OF LARYNX Supraglottis – Epilarynx(supraglottic
epiglottis, aryepiglottic folds, arytenoids) Infrahyoid epiglottis Ventricular bands/false cords Ventricle/saccule Glottis – true vc Ant commissure Post commissure Subglottis – walls of subglottis to lower
border of cricoid cartilage
TNM STAGING T – Primary tumour Tx – cant be assessed T0 – no tumour Tis – ca in situ T1, T2, T3, T4a, T4b
N – Regional lymph node size in greatest diameter
Nx – cant be assessed N0 – no regional ln metastasis N1 – single I/L LN upto 3 cm N2a – single I/L LN >3 cm upto 6 cm N2b – multiple I/L LN upto 6 cm N2c – B/L or C/L LN upto 6 cm N3 – LN>6 cm M – Distant Metastasis – Mx – cant be
assessed/ M0 – no distant metastasis/ M1 – distant metastasis
STAGING 0 – Tis N0 M0 GOOD PROGNOSIS I – T1 N0 M0 II – T2 N0 M0 III – T3 N0 M0/T1-3 N1 M0 POOR
PROGNOSIS IV a – T4a N0-1 M0/T1-4a N2 M0 IV b – T4b N0-2 M0/T1-4b N3 M0 IV c – T1-4 N0-3 M1
RESIDUAL DISEASE R0 – no residual disease R1 – microscopic residual disease R2 – macroscopic residual disease
GLOTTIC CANCER MC laryngeal cancer Good prognosis as early presentation and late
metastasis Spread – 1st to reinke’s space, anterior and posterior
commissure, opposite vc, supraglottic and subglottic.. Nodal metastasis – rare ant commissure – delphian ln C/F – hoarseness of voice – early mc Airway obstruction/ stridor/ dyspnoea Cough due to aspiration Hemoptysis if sublottis involved.... Vc thickening/ulcerative/exophytic growth at anterior
2/3 rd of vc, ant commissure (granulations) and post commissure
T Staging T1 – Tumour involves only vocal cords, ant
commissure or post commissure with normal vc mobility. T1a – one cord, T1b – both cords
T2 – Tumour spreads to subglottis or supraglottis with normal/impaired vc mobility
T3 – Tumour limited to larynx with vc fixation/involvement of paraglottic space, inner cortex of thyroid cartilage
T4a – Tumour involves thyroid cartilage or cricoid cartilage or involves esophagus,trachea,thyroid,tongue muscles or stap muscles
T4b – Tumour involves prevertebral space, mediastinum or encasses the carotid artery
SUPRAGLOTTIC CANCER 2nd mc MC sites – epiglottis (mc), false cords, aryepiglottic
folds Anaplastic Present late – poor prognosis Spread Local – other subsites of supraglottis, vallecula,
base of tongue, pre epiglottic space, glottis, thyroid cartilage, ant commissure
Nodes – early involvement of level II and III. Epiglottis – B/L metastasis
Marginal zone tumours – tumours of aryepiglottic folds as they behave similar to pyriform fossa tumours..
Distant metastasis – through blood to lungs, liver and bone
C/F Throat pain referred to ear Dysphagia/odynophagia/ FB sensation
throat Muffled (hot potato) voice Aspiration Stridor Hoarseness (late symptom) Halitosis
O/E LN mass neck II/III Exophytic (suprahyoid epiglottis) or
ulcerative growth, can obscure the glottis
Fullness of ventricle banda Pooling of saliva Neck metastasis 40%, can be B/L Tender laryngeal cartilage Widening (splaying) of larynx
T Staging T1 – Tumour limited to one subsite of subglottis with
normal vc mobility T2 – Tumour involving more than one subsite without vc
fixation or involvement of glottis, vallecula, base of tongue, pyriform fossa
T3 – Tumour limited to larynx with vc fixation/involvement of post cricoid area,paraglottic space, pre epiglottic space or inner cortex of thyroid cartilage
T4a – Tumour involves thyroid cartilage or involves esophagus, trachea,thyroid,tongue muscles or stap muscles
T4b – Tumour involves prevertebral space, mediastinum or encasses the carotid artery
SUBGLOTTIC CANCER Rarest (1-5%) Prognosis – poor, high incidence of
metastasis Poorly differentiated Spread Opposite side, trachea, vocal cords, thyroid
gland, cricothyroid membrane Nodes – IV, VI C/F – stridor (mc early symptom), dyspnoea,
cough, hemoptysis O/E – Diffuse proliferative growth or ulcer
involving anterior half of subglottis
T Staging T1 – Tumour limited to subglottis with normal
vc mobility T2 – Tumour spread to glottis with normal/
impaired vc mobility T3 – Tumour limited to larynx with vc fixation T4a – Tumour involves thyroid cartilage or
cricoid cartilage or involves esophagus,trachea,thyroid, or strap muscles
T4b – Tumour involves prevertebral space, mediastinum or encasses the carotid artery
TRANSGLOTTIC TUMOURS Tumours involving supraglottis, glottis
and subglottis along with involvement of paraglottic space
High incidence of laryngeal cartilage invasion and destruction
High incidence of extralaryngeal spread
MANAGEMENT Factors Site and extent of lesion Status of lymph node metastasis Status of distant metastasis Stage I/II – Organ preservation therapy Radiotherapy Laser excision Conservative laryngectomy Stage III/IV – Combined therapy – surgery
(Total -laryngectomy +/- ND , pre op or post op radical radiotherapy
RADIOTHERAPY Curative radiotherapy 6500 grays/ 30 fractions/ 5-6 weeks For early lesions – T1, T2 Glottic ca – 90% cure rate Supraglottic ca – 70-90% cure rate Preserves the larynx function, retain
voice and normal air passage Not indicated for fixed cords, cartilage
invasion, advanced lesions
CONSERVATIVE SURGERY Cordectomy – endoscopic/external - Partial CO2 laser cordectomy – T1 lesions
not involving ant commissure (glottic ca) - Total cordectomy – T2 lesions Partial vertical laryngectomy - Partial frontolateral laryngectomy –
excision of vc and ant commissure - Vertical hemilaryngectomy – removal of
half (I/L) true and false vc, thyroid, arytenoid
- Partial lateral laryngectomy
Partial horizontal laryngectomy - Supraglottic partial laryngectomy –
excision of supraglottis, aryepiglottic folds, false cords, ventricles
- Epiglottectomy Near total laryngectomy C/L (normal) side functional arytenoids,
RLN, short segment of cricoid forming cricoarytenoid joint, healthy subglottic mucosa and a strip of post tracheal wall are left behind for reconstruction
ORGAN PRESERVATION THERAPY Neoadjuvant chemotherapy Concomittant RT + CT Indication – for advanced lesion with nodal
metastasis to preserve larynx function and voice
Steps – first give CT If response – give complete RT If no response – salvage surgery followed by
post op RT Cisplatin (100mg/m2) and 5 FU – 3 cycles at
interval of 15-21 days Cisplatin, 5 FU and Bleomycin
TOTAL LARYNGECTOMY Indications - T3,T4, failure after RT or conservative
surgery C/I – distant metastasis Removal of entire larynx along with hyoid bone,
strap muscles, one or more rings of trachea and pre epiglottic space. Pharyngeal wall is closed primarily. Lower laryngeal stump is sutured to skin
Types Wide field laryngectomy – removal of larynx, strap
muscles, thyroid gland and lymph nodes Narrow field laryngectomy – if tumour confined to
larynx – removal of larynx and strap muscles Disadvantages – loss of function of larynx and
voice, permanent tracheal opening
COMBINED THERAPY Surgery with preop or post op RT Pre op RT - To make fixed nodes/tumour resectable Post op RT - To prevent recurrence - Multiple positive nodes - Positive margins – microscopic or gross
tumour on superficial margins on HPE
PALLIATIVE THERAPY Attempt to suppress the carcinoma and
its symptoms without curing it Indication – advanced ca with extensive
extra laryngeal spread, distant metastasis Procedures – Chemotherapy/radiotherapy Tracheostomy Gastrostomy/ RT feed Analgesics/ antibiotics Surgical debulking of tumour
PHOTODYNAMIC THERAPY (PDT) IV DHE (Di Hematoporphyrin Ether) Uptaken by malignant cells leading to
mitochondrial damage and apoptosis, ischaemic necrosis of tumour tissue
Indications – laryngeal ca, oesophageal ca, bronchial tumours
S/E – skin photosensitization
TREATMENT OF GLOTTIC CANCER Tis – endoscopic CO2 laser/ RT T1 – RT (preferred)/ endoscopic CO2 laser If ant commissure involved – RT/ partial
frontolateral laryngectomy. If fails – total laryngectomy
T2 – Normal vc mobility – RT, if fails – partial vertical laryngectomy
Fixed vc – partial vertical laryngectomy, if fails total laryngectomy
T3/T4 – total laryngectomy with neck dissection Advanced T4 – combined therapy/ palliative
therapy
TREATMENT OF SUPRAGLOTTIC CANCER T1 – RT/CO2 laser excision Epilarynx – supraglottic laryngectomy T2 – Good lung function – supraglottic
laryngectomy Poor lung function – RT T3/T4 – total laryngectomy with neck
dissection and post op RT..
Subglottic ca – T1/T2 – RT T3/T4 – total laryngectomy with post op
RT including superior mediastinum Transglottic tumours – Total
laryngectomy with neck dissection and post op RT....
Inoperable – CT+RT Note – partial or total resection of
pharynx, oesophagus, base of tongue should be done if involved along with total laryngectomy
DIRECT LARYNGOSCOPY To visualise larynx,hypopharynx and oropharynx INDICATIONS Diagnostic IDL not successful – infants and young children,
strong gag reflex, overhanging epiglottis Hidden areas of larynx – vallecula, pyriform fossa,
ventricles, infrahyoid epiglottis, ant commissure, subglottis
As a part of bronchoscopy and oesophagoscopy To know the site and extent of tumour Persistent hoarseness Dyspnoea, stridor To evaluate vc palsy
Biopsy Base of tongue, vallecula, laryngopharynx,
larynx Therapeutic Removal of benign lesions, early malignant
lesions, FB larynx, stricture dilatational of laryngeal strictures
CONTRAINDICATIONS Stridor (1st do tracheostomy) Trismus, # mandible, TM joint ankylosis Lesions of cervical spine Aneurysm of aorta, recent coronary occlusion
ADVANTAGES OVER IDL Hidden areas can be imagined 3 D image (2 D image in IDL) Biopsy/therapeutic No inverted image Overhanging epiglottis TYPES OF LARYNGOSCOPE Chevalier Jackson’s direct laryngoscope with
sliding blade Ant commissure laryngoscope with bevelled
end Negus laryngoscope with proximal illumination
ANAESTHESIA GA Preferred in adults C/I – croup, diptheria LA Sup LN block – 1-2 cc inj 2% lignocaine 1cm below
the greater cornu of hyoid bone on both sides of neck
Topical 10% xylocaine spray, xylocaine viscus, few drops of
xylocaine into larynx by IDL, xylocaine soaked swabs in pyriform fossa
No anaesthesia – diagnostic in infants
PRE OPERATIVE Do IDL NBM 6 hrs Rule out any loose teeth Take consent for tracheostomy if needed Inj atropine ½ hour before to reduce
pharyngeal secretions and prevent sinus bradycardia
Investigations – X Ray Neck (airway patency), X Ray Chest (lung infections, metastasis), barium swallow, CT Scan, MRI, blood and urine investigations
POSITION Supine with head extended at atlanto
occipital joint (head ring), neck flexed on thorax (pillow under shoulders) – Boyce position or barking dog position
Head, neck and upper ½ of shoulder projected beyond the table with head supported by assistant
Protect eyes with shield Protect teeth with gauze piece Lubricate laryngoscope with xylocaine jelly
or liquid paraffin
PROCEDURE Hold scope in left hand and guide through right
hand into right side of tongue (right hand for manipulation) -> when post 1/3rd of tongue reached, move to midline to bring epiglottis in view
1st look for uvula (1st landmark), then lift the epiglottis forward by lifting the dorsum of tongue (2nd landmark) – engagement of epiglottis and look in the interior of larynx
Tip advanced between the vestibular folds to examine vc, ventricle
Tip advanced beyond vc to examine subglottis Press the thyroid cartilage from external surface to
examine anterior commissure
Check for mobility of vc and arytenoids Take biopsy (never b/l as web formation) POST OP CARE Place in lateral (coma) position to
prevent aspiration of blood and secretions
Look for laryngeal oedema and spasm by looking for resp distress, cyanosis
INJ steroid COMPLICATIONS – Bleeding, Laryngeal
spasm and oedema, injury
ON TABLE Anaesthesia complications like resp and
cardiac arrest, bradycardia, syncope Bleeding Dislocation, # teeth Laceration of epiglottis, soft palate Damage to cervical spine EARLY POST OP Bleeding, oedema of larynx (steroids,
tracheostomy, intubation LATE POST OP – scars, adhesions,
granulomas
MICROLARYNGOSCOPY Procedure for viewing and recording the
anatomical structures of larynx and their function using special instruments for exposure and lighting
Instruments Microlaryngoscope (Kleinsasser’s) Chest support Operating microscope 10X
magnification, 400 mm focal length objective lens
Microlaryngeal instruments
Advantage over DL Scopy Both hands free Better illumination Binocular vision Magnification and precision Documentation Indications Excision of benign lesions, leukoplakia, papillomas,
haemangiomas, lymphangiomas Laser treatment of early malignancy Endoscopic inj teflon paste, other vc medialization,
lateralization Supravital staining of vc
Not indicated as a procedure along with oesophagoscopy, bronchoscopy
Anaesthesia – GA Procedure – here once vc visualised fix the
telescope with chest support (rest same) Investigations, preoperative, complications same Post op care NBM FOR 6 HOURS Voice rest – first 1-2 weeks complete voice rest,
next 1-2 weeks graduated voice rest (speak 5 min a day, doubled each day), next 2-3 months avoid maladaptive voice, after 3 months normal voice
Antibiotics, steroids, steam inhalation Lateral position Speech therapy Anti reflux treatment Increased water intake Avoid voice abuse Avoid caffeine, diuretics, dairy products,
tobacco
FIBREOPTIC LARYNGOSCOPY Nasopharyngoscopy OPD Procedure under Topical
anaesthesia providing greater magnification and better visualisation of movement of vc........
Documentation Pass via nose nasopharynx into larynx Indications Trismus Unconscious patient Difficult DL Scopy
TOTAL/WIDE FIELD LARYNGECTOMY En block resection of entire laryngeal skeleton
including thyroid to 3rd tracheal ring, strap muscles, lateral neck dissection (levelII,III,IV,VI LN) including pharynx and upper oesophagus if required and creating permanent tracheal stoma....
Indications T3,T4 CA LARYNX, PYRIFORM FOSSA, POST CRICOID
AREA, POST PHARYNGEAL WALL If positive LN do RND/MRND PRE OP – take consent explaining need for
tracheostomy, loss of voice, quality of life Do preop tracheostomy Look for any foci of infection in nose, PNS, oral
cavity and general patient health
STEPS Incision – Modified Sorenson’s incision (U shaped) one
mastoid process to another along SCM and to opp side 2 finger breadth above suprasternal notch or site of tracheostoma
Gluck’s incision Skin along with platysma flap elevation Separation of investing layer of deep cervical fascia Omohyoid muscle dissected Identify carotid sheath and clear level II, III, IV, VI LN Divide strap muscles RLN identified and divided Hyoid skeletonized Thyroid isthmus resected Larynx, trachea and vallecula exposed
Pyriform fossa and post cricoid area separated
Trachea separated from oesophagus till tracheostoma and divided
Specimen removed Wound irrigated with hydrogen peroxide,
betadine and saline Pharyngeal defect sutured Trachea connected to skin creating a
permanent tracheostoma Close the neck in layers and place drains
MODIFIED SORENSON’S INCISION
POST OPERATIVE CARE ICU 24 hrs NBM week in non radiated neck, 2-3 weeks
in radiated neck IV fluids Antibiotics Tracheostomy care Daily dressing Stitch removal after 7-10 days Encourage patient to sit and cough Serum calcium levels
COMPLICATIONS Local Wound infection and dehiscence Pharyngo cutaneous fistula – improper
closure, post RT, infection, early feeding Carotid blowout – post RT Chylous fistula – thoracic duct Tracheostomal stenosis – improper technique Pharyngeal stenosis – inadequate pharyngeal
mucosa Stomal recurrence – subglottic extension,
inadequate dissection
Systemic CVS – cardiac arrest LRTI Pulmonary embolism, pneumonia Anaemia Septicaemia Hypothyroidism hypoparathyroidism
POST LARYNGECTOMY VOICE REHABILITATION Tracheo esophageal fistula (Neoglottic
speech) Esophageal speech Artificial larynx
TRACHEO ESOPHAGEAL FISTULA SPEECH Neoglottic speech Fistula created between trachea and
oesophagus/hypopharynx by puncturing the post wall of trachea on its upper pasrt
Primary TE puncture – at time of surgery Secondary TE puncture – 2-4 weeks
later/post RT Air carried from trachea to esophagus
through fistula -> vibrating column of air along PE segment -> modulated into speech by closure of tracheostome with finger
Advantages Safe and simple High success Cost effective Can be performed years later Disadvantages Need for finger occlusion Involve 2nd surgery Aspiration Fungal infection
PROSTHESIS Shunt the air from trachea into
oesophagus with inbuilt one way valve (unidirectional valve)
Advantages – no aspiration, no need for finger occlusion
Disadvantage – costly Types Non indwelling devices – inserted 1-2
weeks after TEP, can be removed daily for cleaning
Blom Singer Duck hill prosthesis, Panje voice prosthesis
Indwelling devices Placed at time of TEP, can be replaced
only by surgeon Blom Singer Indwelling voice prosthesis Latest – indigenous HRA VOICE
PROSTHESIS – made up of silicone, economical
ESOPHAGEAL SPEECH Patient taught to swallow air and hold it
in upper esophagus and save in stomach -> then slowly ejects air from upper esophagus -> sound produced from vibration along PE juntion ->modulated into speech by lips, teeth, palate
Sound is rough but loud and understandable, can speak 6-10 words at a time
Inexpensive Needs motivation
ARTIFICIAL LARYNX Types ELECTROLARYNX Battery operated electronic vibrator placed
externally on the neck TRANS ORAL PNEUMATIC DEVICE Plastic tube placed in back of oral cavity Expired air from tracheostome vibrates the
rubber diaphragm -> carried by plastic tube into oral cavity -> modulated into speech
Monotonous metallic voice Expensive Unwanted attention
ELECTROLARYNX
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