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E.N.T 5th year, 6th lecture (Dr. Hiwa)
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E.N.T 5th year, 6th lecture (Dr. Hiwa)

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The lecture has been given on May 23rd, 2011 by Dr. Hiwa.

The lecture has been given on May 23rd, 2011 by Dr. Hiwa.

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  • 1. Tumours of the larynx Prepared by: Dr.Hiwa As’ad Rawandzi
  • 2. Introduction
    • The term “tumour” includes space occupying lesion.
    • In the larynx interfere with function even when the lesion is miniscule.
    • Benign or malignant
  • 3. Benign tumours cyst
  • 4. Benign tumours Pseudotumours Mesodermal tumours Ectodermal tumours
  • 5. Ectodermal tumours Adenoma Neurilemmoma Paraganglioma Papilloma
  • 6. Papilloma Single papilloma Multiple papillomas
  • 7.
    • 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 hoarsness
    • If small removed endoscopically
    • If large by laryngofissure
    • Biopsy to exclude malignancy specially if recurrent
    Single papilloma
  • 8. Laryngeal papilloma Squamous papilloma of the Lt. aryepiglottic fold
  • 9. 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
    Multiple papillomas
  • 10. Juvenile laryngeal papillomas
  • 11. Juvenile papillomas Before and after removal
  • 12. Adenoma
    • Arise from seromucinous glands
    • Common site is subglottis
    • Symptoms are few until the tumour obstructs the breathing
    • Treatment is surgery depending on the site and size of the tumour
  • 13.
    • Vascular neoplasms
    • Chondroma
    • Myogenic tumours
    • Fibroma
    • Lipoma
    Mesodermal tumours
  • 14. Vascular neoplasms
    • Arise from blood or lymphatic vessels
    • Haemangioma
    • Rare in adults
    • Telengiectatic
    • vocal cord polyp
  • 15. 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)
  • 16. Chondroma
    • Indirect laryngoscopy reveals a smooth mass covered by intact mucosa
    Cricoid chondroma
  • 17.
    • Radiology shows calcific stippling
    • Biopsy specimens is unrepresentative, the tumour is hard and difficult to penetrate
    • Surgery is the treatment of choice
    • Radiotherapy is of little value
    Chondroma
  • 18. Fibroma
    • Composed of fibrillar connective tissue
    • Soft & pedunculated
    • or firm & sessile
    • Removed endoscopically
    Large pedunculated supraglottic fibroma
  • 19. Lipoma
    • Arise from adipose tissue of false cords
    • Microscopically are composed of fat cells
    • Removed endoscopically or through an external approach.
  • 20. Malignant tumours
  • 21. Introduction
    • 1% of all malignancies In UK
    • More in men
    • Predominantly of squamous pathology
    • Interfere with function and emotion
    • High cure rate 85%
  • 22. Incidence
    • Higher in urban than rural population
    • Social and racial differences reflect different habits (tobacco and alcohol)
  • 23.
    • The International Union against Cancer (UICC) classified Ca larynx on anatomical bases
    Classification 20% 10% 70%
  • 24. 1 cm Supraglottis Epilarynx 9% Suprahyoid epiglottis 2% Aryepiglottic folds 7% Supraglottis 8% infrahyoid epiglottis 2% false cords 5% ventricles 1% Glottis 76% Subglottis 5% UICC classification of Ca larynx
  • 25. Glottis 76% true cords 73% anterior commissure 2% posterior commussure 1%
  • 26. Aetiology
    • Unknown
    • Possibly related factors
    • genetic and social factors
    • male predominance
    • racial predilection
    • urban pollution
    • tobacco and alcohol
    • radiation
    • asbestos
    • occupational factors
  • 27. 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
  • 28. Symptoms
    • 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
  • 29. 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
  • 30. History Small lesion + long history slowly growing lesion Massive cancer + short history Aggressive lesion poor outlook
  • 31. Cancer can coexists or supervene in leucoplakia, chronic laryngitis & TB Leucoplakia Chronic laryngitis
  • 32. Vocal Cord Leukoplakia :   This is a condition caused by chronic irritation which results in abnormal growth of the top layer of the skin lining the vocal cords.It is often seen in smokers and is considered a pre-cancerous condition. 
  • 33. Examination of the larynx
    • examine for
    • Foccal abnormality
    • Vocal cord lesion
    • Mass
    • Mobility
    • examine by
    • Indirect laryngoscopy (LA)
    • Flexible laryngoscopy (LA)
    • Direct laryngoscopy (GA)
    • Microlaryngoscopy (GA)
  • 34. subglottis ventricle posterior surface of epiglottis Difficult areas to be seen
  • 35. Examination of the neck
    • A palpable neck mass could be due to
    • Direct spread of the tumour
  • 36. Examination of the neck
    • A palpable neck mass
    2. Regional lymph nodes metastasis
  • 37. Examination of the neck 3. Enlarged thyroid lobe which suggest invasion
    • A palpable neck mass
  • 38. Incidence of nodal metastasis
    • Supraglottis 40%
    • Glottis 5 %
    • Subglottis 13%
    • Supra & glottis to regional LN
    • (ipsilateral deep cervical chain & prelaryngeal nodes)
    • Subglottis to mediastinal LN
  • 39. 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
  • 40. Radiological investigations
    • CXR for metastasis, other disorders and as part of assessment of physical status
    • Larynx to delineate the extent of the tumour
    X-ray CT scan MRI
  • 41. X-ray Supraglottic tumour Tomography AP Lateral
  • 42. Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion CT scan
  • 43. Axial CT scan showing a soft tissue mass with several punctuate calcifications (Chondrosarcoma) CT scan
  • 44. Epiglotic tumor ( laryngeal Ca. supraglotic type ) MRI
  • 45. MRI Axial T1 image showing large supraglottic Ca extending to retropharyngeal space Abutting the Rt. carotid artery (curved open arrow) Destruction of the Rt. thyroid ala (short open arrow) Destruction of the Rt. arytenoid (short solid arrow)
  • 46. 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
  • 47. Axial MRI showing tumour of the Rt. VC MRI
  • 48. MRI Coronal view of MRI showing subglottic extension
  • 49. Sagittal view showing transglottic tumour MRI
  • 50. Clinical investigations
    • Full haematological screen
    • Biochemical profile including liver function tests and serum protein
    • A urine screen for diabetes
    • ECG
  • 51. Histological examination
    • A biopsy by direct laryngoscopy under GA
    • Fine needle aspiration
    • Importance of biopsy:
    • Definitive diagnosis (>90%)
    • Identify type of tumour
    • Differentiation
  • 52. Pathology
    • The vast majority of laryngeal malignant tumours are squmous
    • A distinct variant of well differentiated squamous cell Ca is the verrucous carcinoma (Ackerman’s tumour)
  • 53. Spread of laryngeal carcinoma
  • 54. 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
  • 55. Cancer of the Lt true vocal cord
  • 56. glottic CA
  • 57. cancer involving the true vocal cords and arytenoid .  The cancer also extends onto the supraglottis
  • 58.
    • Fixation of the vocal cords: by invasion of
    • thyroarytenoid muscle
    • arytenoid cartilage
    • cricoid cartilage
    • cricoarytenoid joint
    • contraindication to partial surgery
    • Impaired mobility
    • superficial invasion of the thyroarytenoid muscle
    • not a contraindication to partial surgery
    Glottic Ca
  • 59.
    • CT scan and MRI are valuable in diagnosis of glottic Ca & its deep invasion, cartilage destruction and extension outside the larynx
    Glottic Ca
  • 60. Supraglottic Ca
    • Often involving both sides
    • Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies
  • 61.
    • thyroid cartilage
    • pre-epiglottic space occur in 40% of supraglottic Ca and 70% of epiglottic Ca
    • vallecula & base of the tongue
    • Arytenoid
    • Pyriform sinus
    Supraglottic Ca Invasion
  • 62. Supraglottic Ca Epiglottic tumpur Tumour of Lt aryepiglottic fold Tumour of Rt false cord
  • 63.
    • 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
  • 64. Subglottic Ca
  • 65. Lymph node involvement
    • 18% had LN metastasis at the time of referral
    • Supraglottic ( 40% )
    • Glottic Ca ( 5% )
    • Subglottic Ca ( 13% )
  • 66.
    • Few present with distant metastasis at the time of diagnosis
    • 11% have distant metastasis, mostly in the lung ( 6.8% )
    Distant metastasis
  • 67. TNM classificaiton T : Primary tumour N: Nodal deposits M: Metastasis
  • 68. T : Primary tumour TX T0 Tis Primary tumour can not be assesed No evidence of primary tumour Carcinoma in situ
  • 69. T : Primary tumour
    • Glottic
    • T1 limited / mobile
    • a : one cord
    • b : both cords
    • T2 extends to supra or
    • subglottic / impaired
    • mobility
    • 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
  • 70. T1a Rt.VC Ca with normal mobility Glottic
  • 71. T1b Limited mobile both cords Glottic
  • 72. Glottic
    • T2 extends to supra or subglottic / impaired
    • mobility
    large tumor on the left true vocal cord and anterior false vocal cords (T2 Cancer)
  • 73. cancer involving the true vocal cords and arytenoid . The cancer also extends onto the supraglottis T2 Glottic
  • 74. Glottic
    • T3 cord fixation
    • T4 extends beyond the larynx
    Lt VC Ca with fixation
  • 75. Subglottic
    • limited / mobile cords
    T1 T1 subglottis
  • 76. Subglottic
    • extends to glottis/mobile
    T2 Subglottic tumour extends to glottis
  • 77. Subglottic T3 T4 cord fixation extends beyond the larynx
  • 78. Lt false cord tumour Supraglottic T1 limited / mobile cords
  • 79. T2 Supraglottic Ca of the Rt. aryepiglottic fold Extends to glottis Moblie cords
  • 80.
    • cord fixation
    extends beyond the larynx Supraglottic T3 T4 Ca of the Lt. arytenoid
  • 81. N : Nodal deposits
    • N1 ipsilateral movable
    • N2 contra or bilateral movable
    • N3 Fixed
    NO LN deposits N0
  • 82. M : Metastasis
    • M0 no metastasis
    • M1 metastasis
  • 83. Staging
    • Stage 0 : Tis, N0 , M0
    • Stage 1 : T1, N0 , M0
    • Stage 2 : T2, N0 , M0
    • Stage 3 : T3, N0 , M0
    • T1-T3, N1 , M0
    • Stage 4 : T4, N0/N1 , M0
    • Any T, N2/N3 , M0
    • Any T, Any N , M1
  • 84. Treatment
  • 85. Rehabilitation Treatment curative No treatment Palliation
  • 86. 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
  • 87. 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
  • 88. Pain relief
    • Pain is not common in Ca larynx
    • combination methods including analgesics, radiation, surgery, and chemotherapy used for pain relief
  • 89. Tracheostomy
    • To relieve airway obstruction
    • It often provide a dilemma , as it just delay the inevitable death in a patient with incurable cancer
  • 90. Other surgeries
    • Total laryngectomy
    • For pain control occasionally
    • Radical neck dissection
    • may remove a fungating or painful local lesion
  • 91. Radiotherapy
    • Commonly used for palliation
    • Can be applied locally and selectively
    • Radioactive implants of gold are useful for local treatment
  • 92. Chemotherapy
    • No Ca larynx has been cures 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
  • 93. Curative treatment Radiotherapy Surgery Chemotherapy
  • 94.
    • 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
  • 95. CA larynx for radiotherapy
  • 96. Surgery Microendolaryngeal and laser surgery Excisional surgery
  • 97. 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
  • 98. Microendolaryngeal and laser surgery
  • 99.  
  • 100.
    • Partial(vertical or horizontal), subtotal and total laryngectomy.
    • 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 on the neck.
    • Partial resection of the larynx may maintain a near normal function with high cure rate.
    • Used after failure of radiotherapy.
    Excisional surgery
  • 101. Surgical techniques
  • 102. Skin incision Thyroid cartilage Cricoid cartilage cordectomy
  • 103. Exposure of thyroid cartilage & cricothyroid membrane in the midline cordectomy
  • 104. The perichondrium is exposed retracting the strap muscles cordectomy
  • 105. Elevation of the edges of external perichondrium cordectomy
  • 106. Midline thyrotomy Division of the thyroid cartilae in the midline with a power saw cordectomy
  • 107. Tumour of the Rt. VC is seen by retraction of thyroid lamina Rt.VC tumour cordectomy
  • 108. Retraction of supraglottic larynx Rt.VC tumour cordectomy
  • 109. Line of incision Excision with scissors cordectomy
  • 110. Reapproximated thyroid cartilage cordectomy
  • 111. Suturing of the perichondrium cordectomy
  • 112. Suturing of sternohyoid cordectomy
  • 113. Suturing of platysma cordectomy
  • 114. Closure of skin cordectomy
  • 115. The surgical specimen 1 year after surgery cordectomy
  • 116. To expose the endolarynx for a vertical hemilaryngectomy, the thyroid cartilage has been slit in the midline from the thyroid notch to the cricothyroid membrane.  The left vocal cord carcinoma is visible Laryngofissure or thyrotomy
  • 117. Total laryngectomy Removed specimen
  • 118. Thank you