Cancer of the larynx
Dr, IBRAHIM H. AHMED
Incidence : 10,000 cases per year in U S A .
Most frequent upper aerodigestive tract cancer
The integration of chemotherapy and radiation
therapy has expanded organ preservation
The patient’s perspective , with emphasis on
retention of speech , swallowing , & quality of
life has affected the decision making process.
Anatomy of larynx
area extending from :
tip of epiglottis to
lower border of cricoid cartilage .
divided into 3 anatomical subsites :
Histology of glottis
Vocal cord : stratified squamous epithelium
epithelium ( sup. & inf. Aspect )
Lamina propria : superficial ( Reink’s space )
intermediate & deep ( vocal lig. *
blood vessels & lymphatics are
almost absent in Reinke’s space. *
no mucous glands on free edge
of vocal cord .
Blood supply of the larynx
Arterial supply of larynx
•1- sup. Laryngeal a.
( branch of sup. Thyroid a. )
2- inf. Laryngeal a.
( branch of inf. Thyroid a. )
1- Sup. Thyroid v .
, ends in I . J . V .
2- inf. Thyroid v .
, ends in innominate v .
Nerve supply of the larynx
Motor supply :
recurrent laryngeal nerve supplies all laryngeal muscles
except cricothyroid muscle which supplied by external
laryngeal n. ( branch of sup. Laryngeal nerve ) .
Sensory supply :
internal laryngeal n. ( branch of sup. Laryngeal n ) .
supply mucous membrane above the vocal cords .
Recurrent laryngeal n. supplies
mucous membrane below the vocal cords.
Lymphatics of larynx
1- The vocal cords & upper part of the larynx
drain into the upper deep cervical lymph
2- The lower part of the larynx drain into
the lower deep cervical lymph nodes &
prelaryngeal lymph nodes .
Cancer of the larynx
•10,000 new cases per year
in U S A
Excessive tobacco use &
alcohol consumption .
Epidemiology of cancer larynx
- 1% of all cancer related deaths in U S A .
- 10,000 new cases / year in U S A .
- 5 year survival is 65 % .
- Male to female ratio :
9,2 : 1 for glottic ca.
3-5 : 1 for supraglottic.
- Age : affect elderly . The peak incidence is 6th
& 7th decades .
< 1% in < 30 years of age .
- No rational predominance in U S A .
- tobacco .
- Synergistic effect with heavy alcohol intake in
- occupational exposure
Painter – metal working – plastic working –
diesel & gasoline fumes .wood dust & asbestos .
- G O R .
- Infectious agents especially papilloma virus .
Hot potato voice
Weight loss & dysphagia
Palpable neck lump
Dysnea & stridure
Vocal cord involvement . Progressive &
Large fungating or ulcerated lesion (epiglottic
Malnutrition . (advanced lesion _pharyngeal
Cartilage invasion .
Direct extension in soft tissue neck
1st presentation -subglottic or supraglottic ca
2nd presentation in glottic ca .
- complete history of the disease
- weight and weight loss
- performance status
- fiberoptic examination of H&N
- neck examination
- drawing of any lesions
Complete examination of
the head and neck
• oral cavity,
• indirect laryngoscopy.
• fiberoptic examination of the larynx and pharynx
- proper assessment of glottic lesion :
1- Detailed vibrator behavior of vocal cord .
- amplitude of vibration
- mucosal wave
- non vibrating portion
2- Outpatient procedure .
3- Documentation .
4- Selection of patient for biopsy .
status of the dentition,
the status of the airway,
vocal cord mobility ,
Palpation of the neck bilaterally,
1- the location (Group or Level II - IV),
- relationship of the node(s) to
2- widening of thyroid angle .
3- direct extention of the lesion .
4- Fixation of the larynx.
5- carotid pulsation .
Pattern of lymphatic spread
Primary glottic ca
Subglottic ca :
L. N. metastases 5%
L. N. metastases 6%
Mobility of larynx
Vocal cord mobility .
Arytenoid mobility .
Hemilarynx mobility .
Laryngeal mobility over prevertebral
fascia (More’s sign )
The staging of the primary
and of the cervical lymph
nodes must be documented
Radiological examination of
To reveal tumour invasion of laryngeal
cartilages & extra laryngeal tissues .
With clinical / endoscopic examination
result in proper staging accuracy .
•Chest radiographs, PA and lateral
To rule out
(1) A synchronous pulmonary tumor,
(2) Acute or chronic pulmonary
(3) Metastatic tumor.
Thickness , invasion ,
Lymph node metastasis .
Under estimate cartilage invasion .
More accurate than C T scan .
Soft tissue details & fat planes ,
Tissue edema & tumor extention .
Over estimate cartilage invasion .
Viability of a tumor .
Residual , recurrent tumor after
Radiotherapy & or chemotherapy .
Sensitive for detection of lymph node
C T scan
Spiral C T scan
M R I
P E T
a mass is seen eroding the thyroid
cartilage and spreading into the
soft tissue of the neck.
the thyroid cartilage is seen to be
eroded. The airway also appears
to be compromised.
The tumor appears to be eroding the
anterior commissure area of the thyroid
cartilage. The tumor appears large and
predominately on the right side of the
larynx. The airway also appears to be
•C .B .C , B . T . , C . T . , serum calcium.
• Pulmonary function and arterial blood
gases in the patients with COPD or who
are candidates for surgery .
•Liver & kidney function tests (optional).
ENDOSCOPIC EXAMINATION & BIOPSY UNDER
Direct laryngoscope :
1 - confirmation .
2 - site , size , extent of the tumour .
3 - vocal cord mobility .
4 - arytenoid mobility .
5 - type of lesion .
6 - neck is felt .
7 - biopsy .
8 - drawing in axial & sagittal plane .
Pan endoscopy to exclude 2nd primary .
Pathology of cancer larynx
1- keratosis :
2- dysplasia :
Keratin layer in a normally non
keratinized epithelium .
Involves true vocal cords &
interarytenoid area .
Cellular atypia , loss of maturity ,
and loss of stratification in some
cases of keratosis .
1- mild .
2- moderate .
3- severe .
In anticipation of possible need for post-operative
radiation therapy or to use radiation therapy as a
definitive primary modality of treatment in early
To assess the status of the teeth and make
recommendations considering that radiation
therapy may be indicated. The evaluating dentist
should be versed in the effects of radiotherapy on
dentition. This evaluation should be done with
knowledge of the treatment portals planned for
For pre-operative counseling regarding possible
post-operative speech and swallowing
TMN / PRIMARY TUMOR ( T )
TX : Primary tumor cannot be assessed .
To : No evidence of primary tumor .
Tis : Carcinoma in situ .
SUPRGLOTTIS ( T )
T1 : Tumor limited to one subsite of supraglottis with
normal vocal cord mobility .
T2 : Tumor invades mucosa of more than one subsite of
supraglottis 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 the larynx with vocal cord fixation
and/or invade any of the following : postcricoid area ,
pre-epiglottic tissues .
T4 : tumor invade through the thyroid cartilage and/or
extends into soft tissue of the neck , thyroid and/or
supraglottic squamous cell
carcinoma of the larynx
T1 : Tumor limited to the vocal cord(s) ( may involve
anterior or posterior commisure ) 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 occurs with impaired vocal cord mobility .
T3 : Tumor limited to the larynx with vocal cord fixation .
T4 : Tumor invades through the thyroid cartilage and/or
to other tissues beyond the larynx ( e.g., trachea , soft
tissue of neck , including thyroid and pharynx .
glottic squamous cell carcinoma of the
larynx. The tumor involves the anterior half of the left
T1 : Tumor limited to the subglottis .
T2 : Tumor extended to vocal cord(s) with
normal or impaired mobility .
T3 : Tumor limited to the larynx with vocal cord
T4 : Tumor invade through the cricoid or thyroid
cartilage and/or to other tissues beyond the
larynx ( e.g., trachea , soft tissues of neck ,
including the thyroid and pharynx )
Picture of an extensive squamous cell carcinoma of
the larynx. The tumor involves the subglottic region,
the glottis and the supraglottic area.
No : no regional node metastasis .
Nx : regional nodes cannot be assessed .
N1 : single ipsilateral node,≤3cm
N2a : single ipsilateral nodes, > 3cm and ≤ 6cm
N2b : multiple ipsilateral nodes , ≤ 6cm
N2c : controlateral or bilateral nodes , ≤ 6cm
N3 : node > 6cm
Mx: Distant metastasis can’t be assessed
M0: No distant metastasis
M1: Distant metastasis
Treatment of glottic ca.
1- carcinoma in situ .
2 - Stage 1 .
3 – stage II ..
Micro laryngeal surgery –
Partial surgery .
Trans oral co2 laser .
Chemotherapy & radiotherapy .
Partial surgery .
Trans oral laser excision ..
Immediate post operative , after biopsy & surgical
removal of leukoplakia .This patient will be treated
with full course of radiotherapy .
Pre and post biopsy views of a patient
with two T1 SCC of true vocal cords .
The patient was treated with vocal
cord stripping and radiation therapy
Treatment of glottic ca
4 – stage III .
5 – stage IV .
1 – radiotherapy . or
2 - trans oral co2 laser excision
3 - surgery .
1- total laryngectomy +
Post operative radiotherapy .
Management of neck in glottic ca.
1- No .
2 – NI , NII .
3 – N III.
1 – radiotherapy .
2 – elective neck dissection .
1 – selective neck
1 – modified or radicalneck
dissection + radiotherapy .
Treatment of supraglottic ca.
1- TI .
2- TII .
1- radiotherapy .
2- open epiglottictomy .
3- co2 laser epiglottictomy
1- radiotherapy .
2- supraglottic laryngectomy .
3- trans oral co2 laser resection .
Treatment of supraglottic ca.
3- TIII .
4- TIV .
2- co2 laser resection .
3- near total laryngectomy
4- cicohyoidopexy .
1- 1ry radiotherapy .
2- total laryngectomy &
post . op . radiotherapy
Management of neck in supraglottic ca.
2- N1 , N2 , N3 ,
Ipsilateral selective neck
dissection . IF +ve ----- contra
lateral selective neck dissection
level II , III , IV .
Radical neck dissection + post
Treatment of subglottic ca .
Radiotherapy or total laryngectomy.
Radiotherapy or total laryngectomy .
Management of neck in
Ipsilateral level VI dissection .
Iflymph node +ve ,