 About 90-95% of laryngeal malignancies are squamous
cell carcinoma with various grades of differentiation
Squamous cell ...
 The larynx is divided into the following three
anatomical regions:
 The Supraglottic larynx includes the epiglottis, fa...
 Most common- 59%
 Spread: Anteriorly- anterior commisure
Posteriorly- vocal process and arytenoid process
Upward- ventr...
 There are few lymphatics in vocal cords and
nodal metastasis are never seen unless the
disease spreads beyond the region...
Picture of glottic squamous cell carcinoma of
the larynx. The tumor involves the anterior
half of the left vocal cord.
 Less frequent than glottic cancer
 Majority of lesion are seen on epiglottis,false cord
followed by aryepiglottic fold,...
 Symptoms: Often silent, Hoarseness is a late
symptom. May present with throat pain, dysphagia
and referred pain in ear, ...
 Preepiglottic space
involvement through
foramen in infrahyoid
epiglottis.
 Paraglottic space
involvement through
mucosa...
 Lesions rare( 1 - 2%)
 Spread: Anterior wall, to the opposite side or
downwards to the trachea
 May invade cricothyroi...
Hoarseness is a late symptom as upward spread
to the vocal cords is late.
Hoarseness of voice indicates :
 Spread of dise...
1. History :
Symptomatology of glottic, subglottic, supraglottic is
different as explained earlier.
2. Indirect Laryngosco...
C) Extent of the disease.
3. Direct Laryngoscopy :
It is done to see the-
a) Hidden areas of larynx
b) Extent of disease.
...
5. Radiography :
Chest X Ray – Essential for co-existent lung
diseases,pulmonary metastasis and mediastinal
nodes.
CT Scan...
6. Microlaryngoscopy:
For smaller lesions, laryngoscopy is done
under microscope for better visualisation.
7. Supravital s...
 The staging system for laryngeal cancer is
clinical and based on the best possible estimate
of the extent of disease bef...
Tx - Primary tumor cannot be assessed.
T0 - No evidence of primary tumor.
Tis - Carcinoma in situ.
Supraglottis
T1 Tumor l...
T4a Moderately advanced local disease.Tumor invades through the
thyroid cartilage and/or invades tissues beyond the larynx...
T2 Tumor extends to supraglottis and/or subglottis and/or with
impaired vocal cord mobility.
T3 Tumor limited to the laryn...
• Subglottis
– T1: limited to subglottis
– T2: extends to vocal cord with
normal or impaired mobility
– T3: limited to lar...
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III
T3 N0 M0
T1-3 N1 M0
Stage IVA
T4a N0-1 M0
T1-4a N2 M0
Stage...
 Carcinoma in situ(Tis):if b/l staged procedure
/web formation
•Complete mucosal cord
stripping with co2 laser
•Quit smok...
T1 Carcinoma
• RT or CO2 laser
• Laryngofissure
and cordectomy
T1 Carcinoma with
ext. to anterior
commissure
• RT
• Partia...
CO2 laser
Transoral endoscopic CO2 laser cordectomy
 Cure rates are uniformly above 90%
 Quality of voice depents on extend of res...
 Tumor limited to the
glottis (T1/T2/early
T3)normal vocal cord
mobility
 localised residual /recurrent
disease followin...
- Radiotherapy to the primary including radiation
to upper neck nodes.
If failure occurs, Conservative laryngectomy or
Tot...
RT is avoided bcoz of the possibility of
developing perichondritis. Also impaired
mobility indicates deeper invasion and t...
 Best treated by total laryngectomy combined
with neck dissection if lymph nodes are
palpable.
 Can also be combined wit...
Subglottic carcinoma
T1 & T2 are treated by RT.
T3 & T4 require total laryngectomy and post-op. RT
(radiation should also ...
T1 lesions are treated by Rt or CO2 Laser.
T2 lesions require consideration of pulmonary function.
If pulmonary function i...
1. Oesophageal Speech :
The patient is taught to swallow air in the oesophagus and to
release it slowlyfrom oesophagus to ...
Tracheo-oesophageal Speech
Here attempt is made to carry air from trachea to oesophagus or
hypopharynx by the creation of ...
CA larynx Presentation - diag. & treatment
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CA larynx Presentation - diag. & treatment

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CA larynx Presentation - diag. & treatment

  1. 1.  About 90-95% of laryngeal malignancies are squamous cell carcinoma with various grades of differentiation Squamous cell subtypes include keratinizing and nonkeratinizing and well-differentiated to poorly differentiated grade  The rest 5-10% of lesions include verrucous carcinoma, spindle cell carcinoma, malignant salivary gland tumor and sarcomas.  Glottic (59%)> Supraglottic (40%)> Subglottic (1%)..  Widely prevalent in the Indian Sub-continent in comparison to the west
  2. 2.  The larynx is divided into the following three anatomical regions:  The Supraglottic larynx includes the epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids.  The Glottis includes the true vocal cords and the anterior and posterior commissures.  The Subglottic region begins about 1 cm below the true vocal cords and extends to the lower border of the cricoid cartilage or the first tracheal ring. Ref. American Cancer Society.: Cancer Facts and Figures 2012. Atlanta, Ga: American Cancer Society, 2012. Last accessed January 5, 2012
  3. 3.  Most common- 59%  Spread: Anteriorly- anterior commisure Posteriorly- vocal process and arytenoid process Upward- ventricle and false cord Downward- Subglottic region Symptoms: Hoarseness of voice is an early sign bcoz lesions of cord affect its vibratory capacity, stridor when growth becomes larger in size.
  4. 4.  There are few lymphatics in vocal cords and nodal metastasis are never seen unless the disease spreads beyond the region of membranous cords.  Good Prognosis : Bcoz of early presentation and late spread, it has good prognosis.
  5. 5. Picture of glottic squamous cell carcinoma of the larynx. The tumor involves the anterior half of the left vocal cord.
  6. 6.  Less frequent than glottic cancer  Majority of lesion are seen on epiglottis,false cord followed by aryepiglottic fold, in that order  May spread locally and invade the adjoining areas (vallecula, base of tounge and pyriform fossa)  Nodal metastases occur early(T1- 20%,T2-35%,T3- 50%,T4-65%)  Upper and middle jugular nodes are often involved  Bilateral metastases may be seen in cases of epiglottic cancer.
  7. 7.  Symptoms: Often silent, Hoarseness is a late symptom. May present with throat pain, dysphagia and referred pain in ear, mass of lymph node in the neck.  Bad Prognosis : Due to early spread and late presentation.
  8. 8.  Preepiglottic space involvement through foramen in infrahyoid epiglottis.  Paraglottic space involvement through mucosa of the ventricle.
  9. 9.  Lesions rare( 1 - 2%)  Spread: Anterior wall, to the opposite side or downwards to the trachea  May invade cricothyroid membrane, thyroid gland and muscles of neck  Paratracheal LN involved  Symptoms: Stridor is the Earliest presentation.
  10. 10. Hoarseness is a late symptom as upward spread to the vocal cords is late. Hoarseness of voice indicates :  Spread of disease to undersurface of vocal cords.  Infiltration of thyroarytenoid muscle.  Involvement of recurrent laryngeal nerve.
  11. 11. 1. History : Symptomatology of glottic, subglottic, supraglottic is different as explained earlier. 2. Indirect Laryngoscopy : It is done to see the- A) Appearance of lesion- which vary according to the site of origin. B) Vocal Cord Mobility – Fixation of vocal cords indicate deeper infiltration.
  12. 12. C) Extent of the disease. 3. Direct Laryngoscopy : It is done to see the- a) Hidden areas of larynx b) Extent of disease. 4. Examination Of Neck : It is done to find the- a) Extralaryngeal spread of the disease. b) Nodal metastasis.
  13. 13. 5. Radiography : Chest X Ray – Essential for co-existent lung diseases,pulmonary metastasis and mediastinal nodes. CT Scan – Useful investigation to find the extent of the tumour,invasion of pre and para epiglottic space,destruction of cartilage and lymph node involvement. Laryngograms using dionosil are obsolete.
  14. 14. 6. Microlaryngoscopy: For smaller lesions, laryngoscopy is done under microscope for better visualisation. 7. Supravital staining and biopsy: Toluidine blue is applied to the laryngeal lesion and then washed and examined. CIS and superficial carcinomas take up dye while leukoplakia does not and thus helping in selecting the area for biopsy.
  15. 15.  The staging system for laryngeal cancer is clinical and based on the best possible estimate of the extent of disease before treatment.  Staging of disease is very important  it influences the choice of therapy and  helps in predicting the overall prognosis,  it provides confirmity amongst clinicians thereby helping in comparing the efficacy of various forms of therapy.
  16. 16. Tx - Primary tumor cannot be assessed. T0 - No evidence of primary tumor. Tis - Carcinoma in situ. Supraglottis T1 Tumor limited to one subsite of supraglottis with normal vocal cord mobility. T2 Tumor invades mucosa of more than one adjacent subsite of supraglottis or glottis or region outside the supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx. T3 Tumor limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic space, paraglottic space, and/or inner cortex of thyroid cartilage.
  17. 17. T4a Moderately advanced local disease.Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b Very advanced local disease.Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures GLOTTIS T1 Tumor limited to the vocal cord(s) (may involve anterior or posterior commissure) with normal mobility. T1a Tumor limited to one vocal cord. T1b Tumor involves both vocal cords.
  18. 18. T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility. T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or inner cortex of the thyroid cartilage. T4a Moderately advanced local disease.Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus). T4b Very advanced local disease.Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures.
  19. 19. • Subglottis – T1: limited to subglottis – T2: extends to vocal cord with normal or impaired mobility – T3: limited to larynx w/vocal cord fixation – T4a: invades cricoid or thyroid cartilage, and/or invades tissues beyond the larynx – T4b: invades prevertebral space, encases carotid artery, or invades mediastinal structures Staging • Nodes – Nx: regional LN can’t be assessed – N0: no regional node mets – N1: single ipsilateral node, ≤ 3 cm – N2a: single ipsilateral node, > 3 cm, ≤ 6 cm – N2b: multiple ipsilateral nodes, ≤ 6 cm – N2c: bilateral or contralateral nodes, ≤ 6 cm – N3: node > 6 cm • Mets – Mx: unknown – M0: no distant mets – M1: distant mets
  20. 20. Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage II T2 N0 M0 Stage III T3 N0 M0 T1-3 N1 M0 Stage IVA T4a N0-1 M0 T1-4a N2 M0 Stage IVB T4b any N M0 any T N3 M0 Stage IVC any T any N M1 Early stage Advanced stage
  21. 21.  Carcinoma in situ(Tis):if b/l staged procedure /web formation •Complete mucosal cord stripping with co2 laser •Quit smoking/no RT •Vigilant follow up Diffuse lesion • Excision of leukoplakia with microscissors/forceps • Quit smoking/ no RT • Vigilant f/u Localised lesion
  22. 22. T1 Carcinoma • RT or CO2 laser • Laryngofissure and cordectomy T1 Carcinoma with ext. to anterior commissure • RT • Partial frontolateral laryngectomy T1 with ext. to arytenoid • Endoscopic laser resection • Laryngofissure & cordectomy (surgery preferred) • RT
  23. 23. CO2 laser
  24. 24. Transoral endoscopic CO2 laser cordectomy  Cure rates are uniformly above 90%  Quality of voice depents on extend of resection Laryngofissure and cordectomy.. rarely used now  When endoscopic exposure is very poor
  25. 25.  Tumor limited to the glottis (T1/T2/early T3)normal vocal cord mobility  localised residual /recurrent disease following failure of RT for early cancer  debulking of tumour for stridor
  26. 26. - Radiotherapy to the primary including radiation to upper neck nodes. If failure occurs, Conservative laryngectomy or Total laryngectomy +/- neck dissection is done.
  27. 27. RT is avoided bcoz of the possibility of developing perichondritis. Also impaired mobility indicates deeper invasion and thus poorer response to radiation. - Conservative laryngectomy is done, if failure occurs Total laryngectomy is done.
  28. 28.  Best treated by total laryngectomy combined with neck dissection if lymph nodes are palpable.  Can also be combined with post operative RT.
  29. 29. Subglottic carcinoma T1 & T2 are treated by RT. T3 & T4 require total laryngectomy and post-op. RT (radiation should also include superior mediastinum)
  30. 30. T1 lesions are treated by Rt or CO2 Laser. T2 lesions require consideration of pulmonary function. If pulmonary function is good, supraglottic laryngectomy is done. If pulmonary function is poor, RT can be given with follow up. T3 & T4 lesions require total laryngectomy with neck dissection and post-op RT.
  31. 31. 1. Oesophageal Speech : The patient is taught to swallow air in the oesophagus and to release it slowlyfrom oesophagus to pharynx. Patient can speak upto 6-10 understandable words. 2. Artificial Larynx : a) Electrolarynx – It has a vibrating disc which is held against the soft tissues of the neck. b) Transoral Pneumatic Device – Here vibrations produced in a rubber diaphragm is carried by a plastic tube into the back of oral cavity where sound is converted to speech by modulators.
  32. 32. Tracheo-oesophageal Speech Here attempt is made to carry air from trachea to oesophagus or hypopharynx by the creation of skin lined fistula or nowdays, prosthesis (Blom-Singer or Panje) are used which prevent the risk of aspiration. Thank You!!!

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