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E.N.T,Tumors of larynx.(dr.usif chalabe)


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Published in: Health & Medicine

E.N.T,Tumors of larynx.(dr.usif chalabe)

  1. 1. Tumours of the larynx
  2. 2. Introduction <ul><li>Benign or malignant </li></ul>
  3. 3. Benign tumours Pseudotumours Mesodermal tumours Ectodermal tumours
  4. 4. Ectodermal tumours Adenoma Neurilemmoma Paraganglioma Papilloma
  5. 5. Papilloma Single papilloma Multiple papillomas
  6. 6. <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
  7. 7. Laryngeal papilloma Squamous papilloma of the Lt. aryepiglottic fold
  8. 8. 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
  9. 9. Juvenile laryngeal papillomas
  10. 10. Juvenile papillomas Before and after removal
  11. 11. 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>
  12. 12. <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
  13. 13. 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>
  14. 14. 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>
  15. 15. Chondroma <ul><li>Indirect laryngoscopy reveals a smooth mass covered by intact mucosa </li></ul>Cricoid chondroma
  16. 16. <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
  17. 17. Malignant tumours
  18. 18. Introduction <ul><li>1-2% of all malignancies In Iraq </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>
  19. 19. 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>
  20. 20. <ul><li>The International Union against Cancer (UICC) classified Ca larynx on anatomical bases </li></ul>Classification 20% 10% 70%
  21. 21. 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>
  22. 22. 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>
  23. 23. 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>
  24. 24. 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>
  25. 25. History Small lesion + long history slowly growing lesion Massive cancer + short history Aggressive lesion poor outlook
  26. 26. Cancer can coexists or supervene in leucoplakia, chronic laryngitis & TB Leucoplakia Chronic laryngitis
  27. 27. 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. 
  28. 28. 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>
  29. 29. subglottis ventricle posterior surface of epiglottis Difficult areas to be seen
  30. 30. 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><ul><li>Regional lymph nodes metastasis </li></ul><ul><li>Enlarged thyroid lobe which suggest invasion </li></ul>
  31. 31. 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 level II & III & prelaryngeal nodes) </li></ul><ul><li>Subglottis to level III & IV (mediastinal) LN </li></ul>
  32. 32. 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>
  33. 33. 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
  34. 34. X-ray Supraglottic tumour Tomography AP Lateral
  35. 35. Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion CT scan
  36. 36. Axial CT scan showing a soft tissue mass with several punctuate calcifications (Chondrosarcoma) CT scan
  37. 37. Epiglotic tumor ( laryngeal Ca. supraglotic type ) MRI
  38. 38. 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)
  39. 39. 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
  40. 40. Axial MRI showing tumour of the Rt. VC MRI
  41. 41. MRI Coronal view of MRI showing subglottic extension
  42. 42. Sagittal view showing transglottic tumour MRI
  43. 43. 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>
  44. 44. 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>
  45. 45. 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>
  46. 46. Spread of laryngeal carcinoma
  47. 47. 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>
  48. 48. Cancer of the Lt true vocal cord
  49. 49. glottic CA
  50. 50. cancer involving the true vocal cords and arytenoid .  The cancer also extends onto the supraglottis
  51. 51. <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
  52. 52. 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>
  53. 53. <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
  54. 54. Supraglottic Ca Epiglottic tumpur Tumour of Lt aryepiglottic fold Tumour of Rt false cord
  55. 55. <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
  56. 56. Subglottic Ca
  57. 57. 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>
  58. 58. <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
  59. 59. TNM classificaiton T : Primary tumour N: Nodal deposits M: Metastasis
  60. 60. T : Primary tumour TX T0 Tis Primary tumour can not be assesed No evidence of primary tumour Carcinoma in situ
  61. 61. 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>
  62. 62. T1a Rt.VC Ca with normal mobility Glottic
  63. 63. T1b Limited mobile both cords Glottic
  64. 64. 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)
  65. 65. cancer involving the true vocal cords and arytenoid . The cancer also extends onto the supraglottis T2 Glottic
  66. 66. Glottic <ul><li>T3 cord fixation </li></ul><ul><li>T4 extends beyond the larynx </li></ul>Lt VC Ca with fixation
  67. 67. Subglottic <ul><li>limited / mobile cords </li></ul>T1 T1 subglottis
  68. 68. Subglottic <ul><li>extends to glottis/mobile </li></ul>T2 Subglottic tumour extends to glottis
  69. 69. Subglottic T3 T4 cord fixation extends beyond the larynx
  70. 70. Lt false cord tumour Supraglottic T1 limited / mobile cords
  71. 71. T2 Supraglottic Ca of the Rt. aryepiglottic fold Extends to glottis Moblie cords
  72. 72. <ul><li>cord fixation </li></ul>extends beyond the larynx Supraglottic T3 T4 Ca of the Lt. arytenoid
  73. 73. 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
  74. 74. M : Metastasis <ul><li>M0 no metastasis </li></ul><ul><li>M1 metastasis </li></ul>
  75. 75. 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>
  76. 76. Treatment
  77. 77. Rehabilitation Treatment curative No treatment Palliation
  78. 78. No treatment <ul><li>Those presenting in extremes </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>
  79. 79. 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>
  80. 80. 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>
  81. 81. 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>
  82. 82. Curative treatment Radiotherapy Surgery Chemotherapy
  83. 83. <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
  84. 84. CA larynx for radiotherapy
  85. 85. Surgery Microendolaryngeal and laser surgery Excisional surgery
  86. 86. 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>
  87. 87. Microendolaryngeal and laser surgery
  88. 88. <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
  89. 89. Total laryngectomy Removed specimen
  90. 90. Thank you