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.

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

  1. 1. Tumours of the larynx Prepared by: Dr.Hiwa As’ad Rawandzi
  2. 2. Introduction <ul><li>The term “tumour” includes space occupying lesion. </li></ul><ul><li>In the larynx interfere with function even when the lesion is miniscule. </li></ul><ul><li>Benign or malignant </li></ul>
  3. 3. Benign tumours cyst
  4. 4. Benign tumours Pseudotumours Mesodermal tumours Ectodermal tumours
  5. 5. Ectodermal tumours Adenoma Neurilemmoma Paraganglioma Papilloma
  6. 6. Papilloma Single papilloma Multiple papillomas
  7. 7. <ul><li>Common in adults , rare in children </li></ul><ul><li>Sessile or pedunculated </li></ul><ul><li>Usual sites anterior commissure, anterior half of the vocal cords </li></ul><ul><li>Men:women ratio 2:1 </li></ul><ul><li>Present with hoarsness </li></ul><ul><li>If small removed endoscopically </li></ul><ul><li>If large by laryngofissure </li></ul><ul><li>Biopsy to exclude malignancy specially if recurrent </li></ul>Single papilloma
  8. 8. Laryngeal papilloma Squamous papilloma of the Lt. aryepiglottic fold
  9. 9. Multiple papillomas <ul><li>Infants and young children, rare in adults </li></ul><ul><li>A virus may be responsible (HPV) </li></ul><ul><li>Vocal cords are the usual site </li></ul><ul><li>Hoarsness if vocal cords affected </li></ul><ul><li>Dyspnoea may occur ---- tracheostomy </li></ul><ul><li>Removed endoscopically by CO2 laser </li></ul><ul><li>Spontaneous recovery in puberty may occur </li></ul>Multiple papillomas
  10. 10. Juvenile laryngeal papillomas
  11. 11. Juvenile papillomas Before and after removal
  12. 12. Adenoma <ul><li>Arise from seromucinous glands </li></ul><ul><li>Common site is subglottis </li></ul><ul><li>Symptoms are few until the tumour obstructs the breathing </li></ul><ul><li>Treatment is surgery depending on the site and size of the tumour </li></ul>
  13. 13. <ul><li>Vascular neoplasms </li></ul><ul><li>Chondroma </li></ul><ul><li>Myogenic tumours </li></ul><ul><li>Fibroma </li></ul><ul><li>Lipoma </li></ul>Mesodermal tumours
  14. 14. Vascular neoplasms <ul><li>Arise from blood or lymphatic vessels </li></ul><ul><li>Haemangioma </li></ul><ul><li>Rare in adults </li></ul><ul><li>Telengiectatic </li></ul><ul><li>vocal cord polyp </li></ul>
  15. 15. Chondroma <ul><li>Arise from cartilages (Mostly cricoid) </li></ul><ul><li>More in men (40-70 years) </li></ul><ul><li>Clinical features </li></ul><ul><li>Hoarsness and dyspnoea </li></ul><ul><li>Stridor (extention into subglottic space) </li></ul><ul><li>Dysphagia (extension into hypopharynx) </li></ul><ul><li>External swelling (cricoid ring or thyroid cartilage) </li></ul>
  16. 16. Chondroma <ul><li>Indirect laryngoscopy reveals a smooth mass covered by intact mucosa </li></ul>Cricoid chondroma
  17. 17. <ul><li>Radiology shows calcific stippling </li></ul><ul><li>Biopsy specimens is unrepresentative, the tumour is hard and difficult to penetrate </li></ul><ul><li>Surgery is the treatment of choice </li></ul><ul><li>Radiotherapy is of little value </li></ul>Chondroma
  18. 18. Fibroma <ul><li>Composed of fibrillar connective tissue </li></ul><ul><li>Soft & pedunculated </li></ul><ul><li>or firm & sessile </li></ul><ul><li>Removed endoscopically </li></ul>Large pedunculated supraglottic fibroma
  19. 19. Lipoma <ul><li>Arise from adipose tissue of false cords </li></ul><ul><li>Microscopically are composed of fat cells </li></ul><ul><li>Removed endoscopically or through an external approach. </li></ul>
  20. 20. Malignant tumours
  21. 21. Introduction <ul><li>1% of all malignancies In UK </li></ul><ul><li>More in men </li></ul><ul><li>Predominantly of squamous pathology </li></ul><ul><li>Interfere with function and emotion </li></ul><ul><li>High cure rate 85% </li></ul>
  22. 22. Incidence <ul><li>Higher in urban than rural population </li></ul><ul><li>Social and racial differences reflect different habits (tobacco and alcohol) </li></ul>
  23. 23. <ul><li>The International Union against Cancer (UICC) classified Ca larynx on anatomical bases </li></ul>Classification 20% 10% 70%
  24. 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. 25. Glottis 76% true cords 73% anterior commissure 2% posterior commussure 1%
  26. 26. Aetiology <ul><li>Unknown </li></ul><ul><li>Possibly related factors </li></ul><ul><li>genetic and social factors </li></ul><ul><li>male predominance </li></ul><ul><li>racial predilection </li></ul><ul><li>urban pollution </li></ul><ul><li>tobacco and alcohol </li></ul><ul><li>radiation </li></ul><ul><li>asbestos </li></ul><ul><li>occupational factors </li></ul>
  27. 27. Symptoms <ul><li>Dysphonia progressive and unremitting </li></ul><ul><li>Cough and irritation in the throat (early) </li></ul><ul><li>Dyspnoea & stridor in advanced tumour, specially in subglottic Ca </li></ul><ul><li>Pain more typical of supraglottic Ca, late and uncommon </li></ul><ul><li>Referred otalgia may occur </li></ul>
  28. 28. Symptoms <ul><li>Swelling of the neck or larynx (tumour or LN) </li></ul><ul><li>Haemoptysis (rare ,in lesions of the margin of epiglottis) </li></ul><ul><li>Anorexia, cachexia or fetor are late symptoms </li></ul>
  29. 29. Examination and diagnosis <ul><li>Diagnosis will be made after consideration of: </li></ul><ul><li>History </li></ul><ul><li>Examination of the larynx </li></ul><ul><li>Examination of the neck </li></ul><ul><li>General examination of the patient </li></ul><ul><li>Radiology </li></ul><ul><li>Clinical investigations </li></ul><ul><li>Histological examination </li></ul>
  30. 30. History Small lesion + long history slowly growing lesion Massive cancer + short history Aggressive lesion poor outlook
  31. 31. Cancer can coexists or supervene in leucoplakia, chronic laryngitis & TB Leucoplakia Chronic laryngitis
  32. 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. 33. Examination of the larynx <ul><li>examine for </li></ul><ul><li>Foccal abnormality </li></ul><ul><li>Vocal cord lesion </li></ul><ul><li>Mass </li></ul><ul><li>Mobility </li></ul><ul><li>examine by </li></ul><ul><li>Indirect laryngoscopy (LA) </li></ul><ul><li>Flexible laryngoscopy (LA) </li></ul><ul><li>Direct laryngoscopy (GA) </li></ul><ul><li>Microlaryngoscopy (GA) </li></ul>
  34. 34. subglottis ventricle posterior surface of epiglottis Difficult areas to be seen
  35. 35. Examination of the neck <ul><li>A palpable neck mass could be due to </li></ul><ul><li>Direct spread of the tumour </li></ul>
  36. 36. Examination of the neck <ul><li>A palpable neck mass </li></ul>2. Regional lymph nodes metastasis
  37. 37. Examination of the neck 3. Enlarged thyroid lobe which suggest invasion <ul><li>A palpable neck mass </li></ul>
  38. 38. Incidence of nodal metastasis <ul><li>Supraglottis 40% </li></ul><ul><li>Glottis 5 % </li></ul><ul><li>Subglottis 13% </li></ul><ul><li>Supra & glottis to regional LN </li></ul><ul><li>(ipsilateral deep cervical chain & prelaryngeal nodes) </li></ul><ul><li>Subglottis to mediastinal LN </li></ul>
  39. 39. General examination <ul><li>To identify metastasis e.g. to the liver </li></ul><ul><li>To assess the overall physical status of the individual who is likely to need GA and biopsy, surgery, radiotherapy or chemotherapy </li></ul>
  40. 40. Radiological investigations <ul><li>CXR for metastasis, other disorders and as part of assessment of physical status </li></ul><ul><li>Larynx to delineate the extent of the tumour </li></ul>X-ray CT scan MRI
  41. 41. X-ray Supraglottic tumour Tomography AP Lateral
  42. 42. Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion CT scan
  43. 43. Axial CT scan showing a soft tissue mass with several punctuate calcifications (Chondrosarcoma) CT scan
  44. 44. Epiglotic tumor ( laryngeal Ca. supraglotic type ) MRI
  45. 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. 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. 47. Axial MRI showing tumour of the Rt. VC MRI
  48. 48. MRI Coronal view of MRI showing subglottic extension
  49. 49. Sagittal view showing transglottic tumour MRI
  50. 50. Clinical investigations <ul><li>Full haematological screen </li></ul><ul><li>Biochemical profile including liver function tests and serum protein </li></ul><ul><li>A urine screen for diabetes </li></ul><ul><li>ECG </li></ul>
  51. 51. Histological examination <ul><li>A biopsy by direct laryngoscopy under GA </li></ul><ul><li>Fine needle aspiration </li></ul><ul><li>Importance of biopsy: </li></ul><ul><li>Definitive diagnosis (>90%) </li></ul><ul><li>Identify type of tumour </li></ul><ul><li>Differentiation </li></ul>
  52. 52. Pathology <ul><li>The vast majority of laryngeal malignant tumours are squmous </li></ul><ul><li>A distinct variant of well differentiated squamous cell Ca is the verrucous carcinoma (Ackerman’s tumour) </li></ul>
  53. 53. Spread of laryngeal carcinoma
  54. 54. Glottic Ca Origin the free margin of the vocal cords Invasion & extension <ul><li>anterior commissure </li></ul><ul><li>cartilage (Ossified more prone) </li></ul><ul><li>arytenoid & posterior cricoarytenoid muscle </li></ul><ul><li>vertical extension to the subglottis &/or supraglottis </li></ul><ul><li>is more frequent than to the opposite side </li></ul>
  55. 55. Cancer of the Lt true vocal cord
  56. 56. glottic CA
  57. 57. cancer involving the true vocal cords and arytenoid .  The cancer also extends onto the supraglottis
  58. 58. <ul><li>Fixation of the vocal cords: by invasion of </li></ul><ul><li>thyroarytenoid muscle </li></ul><ul><li>arytenoid cartilage </li></ul><ul><li>cricoid cartilage </li></ul><ul><li>cricoarytenoid joint </li></ul><ul><li>contraindication to partial surgery </li></ul><ul><li>Impaired mobility </li></ul><ul><li>superficial invasion of the thyroarytenoid muscle </li></ul><ul><li>not a contraindication to partial surgery </li></ul>Glottic Ca
  59. 59. <ul><li>CT scan and MRI are valuable in diagnosis of glottic Ca & its deep invasion, cartilage destruction and extension outside the larynx </li></ul>Glottic Ca
  60. 60. Supraglottic Ca <ul><li>Often involving both sides </li></ul><ul><li>Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies </li></ul>
  61. 61. <ul><li>thyroid cartilage </li></ul><ul><li>pre-epiglottic space occur in 40% of supraglottic Ca and 70% of epiglottic Ca </li></ul><ul><li>vallecula & base of the tongue </li></ul><ul><li>Arytenoid </li></ul><ul><li>Pyriform sinus </li></ul>Supraglottic Ca Invasion
  62. 62. Supraglottic Ca Epiglottic tumpur Tumour of Lt aryepiglottic fold Tumour of Rt false cord
  63. 63. <ul><li>Primary are rare </li></ul><ul><li>Grow circumferentially and extensively </li></ul><ul><li>Invasion of the vocal cords may lead to impairment of mobility and hoarsness </li></ul><ul><li>Can spread through the cricothyroid membrane anteriorly or cricotracheal membrane posteriorly or invade the trachea caudally </li></ul>Subglottic Ca
  64. 64. Subglottic Ca
  65. 65. Lymph node involvement <ul><li>18% had LN metastasis at the time of referral </li></ul><ul><li>Supraglottic ( 40% ) </li></ul><ul><li>Glottic Ca ( 5% ) </li></ul><ul><li>Subglottic Ca ( 13% ) </li></ul>
  66. 66. <ul><li>Few present with distant metastasis at the time of diagnosis </li></ul><ul><li>11% have distant metastasis, mostly in the lung ( 6.8% ) </li></ul>Distant metastasis
  67. 67. TNM classificaiton T : Primary tumour N: Nodal deposits M: Metastasis
  68. 68. T : Primary tumour TX T0 Tis Primary tumour can not be assesed No evidence of primary tumour Carcinoma in situ
  69. 69. T : Primary tumour <ul><li>Glottic </li></ul><ul><li>T1 limited / mobile </li></ul><ul><li>a : one cord </li></ul><ul><li>b : both cords </li></ul><ul><li>T2 extends to supra or </li></ul><ul><li>subglottic / impaired </li></ul><ul><li>mobility </li></ul><ul><li>T3 cord fixation </li></ul><ul><li>T4 extends beyond </li></ul><ul><li>the larynx </li></ul><ul><li>Supra & subglottic </li></ul><ul><li>T1 limited / mobile </li></ul><ul><li>cords </li></ul><ul><li>T2 extends to </li></ul><ul><li>glottis/mobile </li></ul><ul><li>T3 cord fixation </li></ul><ul><li>T4 extends beyond </li></ul><ul><li>the larynx </li></ul>
  70. 70. T1a Rt.VC Ca with normal mobility Glottic
  71. 71. T1b Limited mobile both cords Glottic
  72. 72. Glottic <ul><li>T2 extends to supra or subglottic / impaired </li></ul><ul><li>mobility </li></ul>large tumor on the left true vocal cord and anterior false vocal cords (T2 Cancer)
  73. 73. cancer involving the true vocal cords and arytenoid . The cancer also extends onto the supraglottis T2 Glottic
  74. 74. Glottic <ul><li>T3 cord fixation </li></ul><ul><li>T4 extends beyond the larynx </li></ul>Lt VC Ca with fixation
  75. 75. Subglottic <ul><li>limited / mobile cords </li></ul>T1 T1 subglottis
  76. 76. Subglottic <ul><li>extends to glottis/mobile </li></ul>T2 Subglottic tumour extends to glottis
  77. 77. Subglottic T3 T4 cord fixation extends beyond the larynx
  78. 78. Lt false cord tumour Supraglottic T1 limited / mobile cords
  79. 79. T2 Supraglottic Ca of the Rt. aryepiglottic fold Extends to glottis Moblie cords
  80. 80. <ul><li>cord fixation </li></ul>extends beyond the larynx Supraglottic T3 T4 Ca of the Lt. arytenoid
  81. 81. N : Nodal deposits <ul><li>N1 ipsilateral movable </li></ul><ul><li>N2 contra or bilateral movable </li></ul><ul><li>N3 Fixed </li></ul>NO LN deposits N0
  82. 82. M : Metastasis <ul><li>M0 no metastasis </li></ul><ul><li>M1 metastasis </li></ul>
  83. 83. Staging <ul><li>Stage 0 : Tis, N0 , M0 </li></ul><ul><li>Stage 1 : T1, N0 , M0 </li></ul><ul><li>Stage 2 : T2, N0 , M0 </li></ul><ul><li>Stage 3 : T3, N0 , M0 </li></ul><ul><li>T1-T3, N1 , M0 </li></ul><ul><li>Stage 4 : T4, N0/N1 , M0 </li></ul><ul><li>Any T, N2/N3 , M0 </li></ul><ul><li>Any T, Any N , M1 </li></ul>
  84. 84. Treatment
  85. 85. Rehabilitation Treatment curative No treatment Palliation
  86. 86. No treatment <ul><li>Those presenting in extremis </li></ul><ul><li>who are no longer conscious of pain or distress </li></ul><ul><li>Disseminated tumours cause their death without the primary tumour or regional disease causing symptoms </li></ul><ul><li>7-8% recieve no treatment </li></ul>
  87. 87. Palliation <ul><li>The attempt to suppress the Ca and its symptoms without expectation or intent to cure </li></ul><ul><li>Palliation is used in late stages </li></ul><ul><li>Includes: </li></ul><ul><li>pain relief </li></ul><ul><li>tracheostomy </li></ul><ul><li>other surgery </li></ul><ul><li>radiotherapy </li></ul><ul><li>chemotherapy </li></ul>
  88. 88. Pain relief <ul><li>Pain is not common in Ca larynx </li></ul><ul><li>combination methods including analgesics, radiation, surgery, and chemotherapy used for pain relief </li></ul>
  89. 89. Tracheostomy <ul><li>To relieve airway obstruction </li></ul><ul><li>It often provide a dilemma , as it just delay the inevitable death in a patient with incurable cancer </li></ul>
  90. 90. Other surgeries <ul><li>Total laryngectomy </li></ul><ul><li>For pain control occasionally </li></ul><ul><li>Radical neck dissection </li></ul><ul><li>may remove a fungating or painful local lesion </li></ul>
  91. 91. Radiotherapy <ul><li>Commonly used for palliation </li></ul><ul><li>Can be applied locally and selectively </li></ul><ul><li>Radioactive implants of gold are useful for local treatment </li></ul>
  92. 92. Chemotherapy <ul><li>No Ca larynx has been cures by drugs </li></ul><ul><li>Complete regression is rare </li></ul><ul><li>Partial response in 20% </li></ul><ul><li>In no way can be compared to radiotherapy or surgery </li></ul><ul><li>Rather it is an alternative to analgesics </li></ul><ul><li>Has significant side effects and leads to more suffering </li></ul>
  93. 93. Curative treatment Radiotherapy Surgery Chemotherapy
  94. 94. <ul><li>Radiation is most effective where the tissues are well oxygenated . </li></ul><ul><li>So it is most valuable in small lesions and when the vascular supply is undamaged, where it has not preceded by surgery </li></ul><ul><li>Radiation is more applicable on the oxygenated periphery , while surgery could deal with the mass </li></ul>Radiotherapy
  95. 95. CA larynx for radiotherapy
  96. 96. Surgery Microendolaryngeal and laser surgery Excisional surgery
  97. 97. Microendolaryngeal and laser surgery <ul><li>Carcinoma in situ can by treated by microsurgical excision and laser makes this easier </li></ul><ul><li>Certain localized supraglottic lesions may be excised using a laser </li></ul><ul><li>Carbon dioxide laser is used </li></ul>
  98. 98. Microendolaryngeal and laser surgery
  99. 100. <ul><li>Partial(vertical or horizontal), subtotal and total laryngectomy. </li></ul><ul><li>Used with or without radiotherapy. </li></ul><ul><li>Has risk of loss of voice, and protection of the airway. </li></ul><ul><li>Is more effective than radiotherapy in large tumours and when there are secondary deposits in LN on the neck. </li></ul><ul><li>Partial resection of the larynx may maintain a near normal function with high cure rate. </li></ul><ul><li>Used after failure of radiotherapy. </li></ul>Excisional surgery
  100. 101. Surgical techniques
  101. 102. Skin incision Thyroid cartilage Cricoid cartilage cordectomy
  102. 103. Exposure of thyroid cartilage & cricothyroid membrane in the midline cordectomy
  103. 104. The perichondrium is exposed retracting the strap muscles cordectomy
  104. 105. Elevation of the edges of external perichondrium cordectomy
  105. 106. Midline thyrotomy Division of the thyroid cartilae in the midline with a power saw cordectomy
  106. 107. Tumour of the Rt. VC is seen by retraction of thyroid lamina Rt.VC tumour cordectomy
  107. 108. Retraction of supraglottic larynx Rt.VC tumour cordectomy
  108. 109. Line of incision Excision with scissors cordectomy
  109. 110. Reapproximated thyroid cartilage cordectomy
  110. 111. Suturing of the perichondrium cordectomy
  111. 112. Suturing of sternohyoid cordectomy
  112. 113. Suturing of platysma cordectomy
  113. 114. Closure of skin cordectomy
  114. 115. The surgical specimen 1 year after surgery cordectomy
  115. 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
  116. 117. Total laryngectomy Removed specimen
  117. 118. Thank you

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