For medical students

1. Laryngeal Cancer
It is the most common cancer of
the head and neck malignancies.

2. Etiology

3. Etiology
 Smoking
• The incidence of laryngeal tumors is closely
correlated with smoking, as head and neck
tumors occur 6 times more often among
cigarette smokers than among
nonsmokers.
.

4. Etiology
Alcohol
• Although alcohol is a less potent
carcinogen than tobacco, alcohol
consumption is a risk factor for laryngeal
tumors.
• In individuals who use both tobacco and
alcohol, these risk factors appear to be
synergistic, and they result in a
multiplicative increase in the risk of
developing laryngeal cancer.

5. Other Risk Factors
• Previous history of head and neck
irradiation
• Chronic Gastric Reflux
• Occupational exposures
• Human Papilloma Virus 16 &18

6. Sex & Age Incidence
• The male-to-female ratio in patients with
laryngeal cancer was 5:1.
• Laryngeal cancer most commonly affects
men middle-aged or older. The peak
incidence is in those aged 50-60 years.

7. Subtypes of Ca larynx
• Glottic Cancer: 59%
• Supraglottic Cancer: 40%
• Subglottic Cancer: 1%
• Most subglottic masses are extension from
glottic carcinomas

8. Histological Types
 85-95% of laryngeal tumors are
squamous cell carcinoma.
Cordal lesions are often well-differentiated
SCC while supraglottic lesions are usually
anaplastic.

9. Histological Types
The rest 5 – 10 % of laryngeal cancers
types may be
• Verrucous Carcinoma
• Sarcomas
• Adenoid cystic carcinoma
• Adenocarcinoma
• Lymphoma
• Spindle cell carcinoma

10. Anatomy

11. The supraglottic larynx
• It consists of
epiglottis, false vocal
cords, ventricles,
aryepiglottic folds,
and arytenoids

12. The glottic larynx
• It consists of the true
vocal cords and
anterior commissure
and the posterior
commissure

13. The subglottic larynx
• It consists of the
region between the
true vocal cords
and lower border of
cricoid cartilage.

14. Pre-epiglottic space & Para-glottic space
• Pre-epiglottic space
 Anterior : thyrohyoid membrane
& thyroid cartilage
 Posterior: : epiglottis elastic
cartilage
 Inferior : Petiole attachment to
thyroid cartilage
• Paraglottic space
 quadrangular membrane inferiorly
 conus elasticus anteriorly and
medially
 thyroid cartilage laterally Myers: Laryngoscope, Volume 106(5).May 1996.559-567
Cummings: otolaryngology, 4th ed- 2005 - Mosby, Inc.

15. Staging: Primary Tumor of Larynx (T)
Tx Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ

16. Staging (T) : Supraglottis CA
T1 Tumor limited to one subsite of the supraglottis with normal vocal
cord mobility
T2 Tumor invades mucosa of more than one adjacent subsite of the
supraglottis or glottis or region outside the supraglottis (eg. mucosa
of base of tongue, vallecula, medial wall of pyriform sinus)without
fixation of the larynx
T3 Tumor limited to the larynx with vocal cord fixation and/or invades any
of the following: postcricoid area, pre-epiglottic tissues, paraglottic
space and/or minor thyroid cartilage invasion
T4a Tumor invades through thyroid cartilage and/or invades tissues
beyond the larynx ( eg. Trachea, soft tissues of neck including deep
extrinsic muscles of tongue , strap muscles , thyroid or oesophagus)
T4b Tumor invades prevertebral space, encases carotid artery or
invades mediastinal structures

17. Staging (T) : Glottis CA
T1 Tumor limited to vocal cord(s) (may involve anterior or posterior
commisures) with normal mobility
T1a Tumor limited to one vocal cord
T1b Tumor involves both vocal cords
T2 Tumor extends to supraglottis and / or subglottis , and /or with
impaired vocal cord morbility
T3 Tumor limited to the larynx with vocal cord fixation and/or invades
paraglottis space and / or minor thyroid cartilage erosion
T4a Tumor invades through thyroid cartilage and/or invades tissues
beyond the larynx ( eg. Trachea, soft tissues of neck including deep
extrinsic muscles of tongue , strap muscles , thyroid or oesophagus)
T4b Tumor invades prevertebral space, encases carotid artery or
invades mediastinal structures

18. Staging (T) : Subglottis CA
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to the larynx with vocal cord fixation
T4a Tumor invades cricoid or thyroid cartilage and/or invades tissues
beyond the larynx ( eg. Trachea, soft tissues of neck including deep
extrinsic muscles of tongue , strap muscles , thyroid or oesophagus)
T4b Tumor invades prevertebral space, encases carotid artery or
invades mediastinal structures

19. Staging (N) : Regional Lymph Nodes
N0 No cervical lymph nodes positive
N1 Single ipsilateral lymph node ≤ 3cm
N2a Single ipsilateral node > 3cm and ≤6cm
N2b Multiple ipsilateral lymph nodes, each ≤
6cm
N2c Bilateral or contralateral lymph nodes, each
≤6cm
N3 Single or multiple lymph nodes > 6cm

20. Staging (M) : Distant Metastasis
• Mx : Distant metastasis cannot be assessed
• M0 : No distant metastasis
• M1 : Distant metastasis

21. Stage Grouping
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IV A T4a N0 M0
T4a N1 M0
T1 N2 M0
T2 N2 M0
T3 N2 M0
T4a N2 M0
IV B T4b Any N M0
Any T N3 M0
IV C Any T Any N M1

22. Supraglottic carcinomas
• Supraglottis cancer is less frequent than glottic cancer.
• The epiglottis is the most frequent location for cancers
that arise in the supraglottic larynx. These lesions are
often exophytic and circumferential masses. They can
extend into pre-epiglottis space and penetrate thyroid
cartilage.
• Growth from aryepiglottic fold, false cords and ventricle
can extend to paraglottic space and to true vocal cords.
And this may lead to fixation of supraglottic larynx.

23. Supraglottic carcinomas
• Nodal metastasis occur early. Upper and middle jugular
nodes are often involved. Bilateral nodal metastasis is
seen in cases of epiglottic cancer
• Supraglottic growth are often silent in symptoms in early
stage.
• Presenting symptoms may be throat pain, dysphagia
and referred ear pain and cervical lymphadenopathy..
• Hoarseness and stridor are late symptoms.

24. Glottic carcinomas
• The true vocal cords are the most common site of
laryngeal carcinomas.
• Free edge and upper surface of vocal cord in its
anterior and middle third are the most frequent sites
of glottic carcinomas.
• Anteriorly, the tumor may extend to anterior commissure,
where it may involve the contralateral true vocal cord.

25. Glottic carcinomas
• There are few lymphatics in true vocal cords.
• So lymphatic metastasis is practically rarely seen in
confined cordal lesions , unless the disease spreads
beyond the region of true vocal cords.
• The incidence of lymph node metastasis in T1 lesions is
2%. It increases to 20% in T3 and T4 lesions.
• Hoarseness is an early symptom and thus glottic cancers
can be detected early. Increase in size of glottic cancers
may cause stridor and laryngeal obstruction.

26. Subglottic carcinomas
• Subglottic carcinomas are rare and account for only 1 -2%
of all laryngeal carcinomas.
• Subglottic tumors are characteristically circumferential and
often extend to involve the undersurface of the true vocal
cords .
• Subglottic growth can invade the cricoid cartilage and
extends through the cricothyroid membrane, thyroid
cartilage and strap muscles of neck.
• Lymphatic metastasis go to prelaryngeal , pretracheal ,
paratracheal and lower jugular nodes.

27. Subglottic carcinomas
• The presentation symptom of subglottic carcinoma
may be stridor or laryngeal obstruction but it is
often late.
• Hoarseness of voice is not an early symptom.
• Hoarseness usually indicates that there is spread
of tumor to undersurface of vocal cords , infiltration
of thyroarytenoid muscle or involvement of
recurrent laryngeal nerve at the cricoarytenoid
joint.

28. Diagnosis of Laryngeal Cancers
 Detection of presenting Symtoms
Hoarseness
• Most common symptom
• Small irregularities in the vocal fold result in
voice changes
 any patient in cancer age group having
persistent or gradually increasing
hoarseness of voice for 3 weeks must
have laryngeal examination to exclude
cancer.

29. • Other symptoms include:
Stridor or laryngeal obstruction
Dysphagia
Hemoptysis
Throat pain
Ear pain
Aspiration
Neck mass

30.  (IDL ) or (MPL) or Flexible Laryngoscopy
Examination to detect :
1. Appearance of lesion:
. Vocal cord lesion :
raised nodule or ulcer or thickening
lesions
.Supraglottic/ subglottic lesion :
fungating growth or exophytic or
ulcerative growth
2. Vocal cord mobility
3. Extent of disease

32. Examination of neck
• Proper neck examination for cervical lymphadenopathy
(size, neck node level, numbers, mobility , fixation
and unilateral/ bilateral/ contralaterl) is essential.
• Awareness of midline swelling is needed as growth of
anterior commissure and subglottic growth can spread
through cricothyroid membrane and may produce a
midline neck swelling.
• Restricted laryngeal crepitus may be a sign of post
cricoid or retropharyngeal invasion

33. Radiographic examinations
• X-ray Chest : essential for co-existent lung disease /
pulmonary metastasis / mediastinal nodes
• Lateral neck X-ray: destruction of thyroid cartilage / soft
tissue mass may be seen
• CT scan :
 very useful to find extent of tumor, invasion of pre- epiglottic
or paraglottid space , destruction of cartilage and lymph
node involvement
 important for staging of laryngeal carcinomas

34. Direct Laryngoscopy and Biopsy
• Biopsy is essential for diagnosis
• Performed in operation theatre with patient
under anesthesia

35. Management of Laryngeal carcinomas
Curative Treatment
 Radiotherapy ( organ preservation) with or
without chemotherapy
 Surgery : (a) conservative laryngeal surgery
: (b) total laryngectomy
 Combined : surgery with postoperative
radiotherapy or chemoradiotherapy

36. Management of Laryngeal carcinomas
Palliative treatment
 tracheostomy
 palliative surgery
 palliative radiotherapy and chemotherapy
 general palliative care :
pain control , symptom control and
nutritional support

37. Curative Radiotherapy
• It is used for early stages of ca larynx with normal
vocal cord mobility, or no invasion of cartilage, or no
cervical lymph node metastasis.
• It has a significant advantage of functional
preservation of voice.
• Glottic cancers with normal cord mobility gives 90%
cure rate after radiotherapy.
• Superficial exophytic lesions especially at epiglottic and
AE fold give 70-90% cure rate.

38. Surgery
• Radiotherapy does not give good results in
lesions with fixed cords, subglottic extension ,
cartilage invasion and lymphatic nodal
metastasis. These conditions require surgery.
 conservative laryngeal surgery
 total laryngectomy with or without neck
dissection

39. Conservative Surgery Types
 Cordectomy via laryngofissure
( excision of vocal cord after splitting larynx)
 Partial frontolateral laryngectomy
(excision of vocal cord and anterior commisure region)
 Partial horizontal laryngectomy/ supraglottic laryngectomy
(excision of supraglottis including epiglottis, AE folds,
false cords and ventricle)

40. Total laryngectomy
The entire larynx including hyoid bone,thyroid and cricoid
cartilages , pre-epiglottic space, strap muscles ,proximal trachea
and ipsilateral thyroid lobe or both thyroid lobes are removed. .
Pharyngeal wall is repaired and lower tracheal stump sutured to
the skin.
It is indicated in conditions as :
• T3 and T4 lesions of ca larynx
• Tumor invasion to thyroid or cricoid cartilage
• Transglottic cancers : tumor involving supraglottis , glottis and
subglottis
• Treatment failure after radiotherapy or conservative surgery
Total laryngectomy is contraindicated in patients with distant
mestastasis

41. Management Options for Glottic Ca
 Glottic carcinoma T1 :
Radiotherapy is the treatment of choice.
Excision of cord by CO2 laser can also be useful.
 Glottic ca T2N0 :
Radiotherapy gives good result.
But if disease recurs, total laryngectomy is preferred.
 Glottic ca T3 &T4:
It is best treated by total laryngectomy.
If cervical lymph node metastasis is palpable , total
laryngectomy may be combined with neck dissection.
Post-operative radiotherapy is used after total layrngectomy.

42. Management Options for Supraglottic Ca
 T1 lesion : It responds well to radiotherapy.
It can also be excised with CO2 laser.
 T2 lesion : It can be treated by supraglottic
laryngectomy if lung function is good.
Curative radiotherapy can also be used.
 T3&T4 lesion : requires total laryngectomy with or
without neck dissection and
postoperative radiotherapy.

43. Management Options for Subglottic ca
• Early lesion T1 &T2 can be treated by curative
radiotherapy.
• T3&T4 lesions require total laryngectomy with or
without neck dissection and postoperative
radiotherapy.

44. Voice rehabilitation after total laryngectomy
• Oesophageal Speech
• Tracheo-oesophageal
speech
• Electrolarynx

45. Conclusion
• The prognosis for small laryngeal cancers that do not
have lymph node metastasis (which mean early
detected Ca) is good, with cure rates of 75-95%.
• Advanced disease has a worse prognosis.
• Supraglottic cancers usually manifest late and have a
poorer prognosis.
• Preoperative Informed Consent of consequences,
complications and rehabilitation is essential to
patients who are selected for total laryngectomy.

46. Thanks You