This document provides information on the diagnosis and treatment of laryngeal carcinoma. Key points include:
- Diagnosis involves laryngeal examination using indirect laryngoscopy, radiography like CT scans, and biopsies to determine the site, extent, and involvement of lymph nodes.
- Treatment depends on the site and extent of the lesion, and may involve radiotherapy, surgery like cordectomy or laryngectomy, or combined therapy.
- Surgical options aim to preserve voice if possible, while total laryngectomy results in loss of natural voice requiring rehabilitation methods.
2. DIAGNOSIS
• HISTORY
“Any patient in cancer age group having persistent
or gradually increasing hoarseness for 3 weeks must
have laryngeal examination to exclude cancer.”
3. INDIRECT LARYNGOSCOPY
Appearance of lesion
• Suprahyoid epiglottis : exophytic lesion
• Infrahyoid epiglottis : ulcerative lesion
• Vocal cord : raised nodule, ulcer or thickening
• Anterior commissure : granulation
• Subglottic region :raised sub mucosal nodule
Vocal cord mobility
• Impairment or fixation
• deeper infiltration
• Invasion of recurrent laryngeal nerve
Extent of the disease
4. • Flexible fibreoptic or rigid laryngoscopy or
video laryngoscopy
• Examination of neck
– Extralaryngeal spread
– Nodal metastasis
5. RADIOGRAPHY
X RAY chest
• Coexistent lung disease
• Pulmonary metastasis
• Mediastinal nodes
Soft tissue lateral view neck
• Extent of lesion
• Destruction of thyroid cartilage
CT scan
• Extent of tumor
• Invasion to pre epiglottic and paraglottic space
• Destruction of cartilage
• Cervical node involvement
MRI
• Recurrent cancer after radiotherapy
6. Direct laryngoscopy
• Visualise hidden areas of larynx
• Infrahyoid epiglottis, anterior commissure,
subglottis and ventricles
• Extent of the disease
Microlaryngoscopy
• Small lesions of vocal cord
• Taking biopsy without damaging the vocal cord
7. • Supravital staining and biopsy
– Selection of site for biopsy in leukoplakic lesion
– Carcinoma in situ and superficial carcinoma take
up the stain
– Leukoplakic lesion will not
Toluidine blue is
applied to
laryngeal lesion
Washed with
saline
Examined under
microscope
10. RADIOTHERAPY
• Curative radiotherapy
– Neither impairment of vocal cord mobility nor invasion of
cartilage or cervical nodes
• Advantage
– Voice is preserved
• Not suitable when
– Fixed cord
– Subglottic extension
– Cartilage invasion
– Nodal metastasis
CURE RATE
Vocal cord mobility not impaired 90%
Superficial exophytic lesion of tip of
epiglottis and aryepiglottic folds
70-90%
11. SURGERY
• CONSERVATION SURGERY
– Conservation surgery include
• Excision of vocal cord after splitting the larynx
– Cordectomy via laryngofissure
• Excision of vocal cord and anterior commissure region :
– Partial frontolateral laryngectomy
• Excision of supraglottis : partial horizontal
laryngectomy
– Advantages
• Voice is preserved
• No need of permanent tracheal opening
12. TOTAL LARYNGECTOMY
• Pharyngeal wall repaired
• Lower tracheal stump sutured to the skin for
breathing
• Laryngectomy + block dissection : nodal
metastasis
• Contraindicated
– Distant metastasis
Larynx
Hyoid
bone
Pre
epiglottic
space
Strap
muscles
Tracheal
rings 1 or
more
13. Indications
• T3 lesion ( vocal cord fixed)
• All T4 lesions
• Invasion of thyroid and cricoid cartilage
• B/L arytenoid cartilage involvement
• Lesion of posterior commissure
• Failure after radiotherapy or conservation therapy
• Transglottic cancers
Disadvantages
• Voice not preserved
• Permanent tracheostome
14. Combined therapy
• Decreases incidence of recurrence
• Helps to resect fixed nodes
Endoscopic resection with CO2 laser
• Ca of mobile membranous vocal cord
• T1 lesion of supra or infrahyoid epiglottis with or
without neck nodule
• Advantages
• Low cost
• Lower duration of treatment
• Low morbidity
16. Carcinoma in situ
• Transoral endoscopic CO2 laser
• Stripping of vocal cord under microscope
• Tissue subjected to biopsy
Biopsy
Invasive
carcinoma
Radiotherapy
Carcinoma insitu
Regular follow
up
17. Invasive carcinoma
T1 carcinoma
• Radiotherapy
• Excision of cord by endoscopic CO2 laser or laryngofissure.
T1 carcinoma with extension to anterior commissure
• Radiotherapy
• Frontolateral partial laryngectomy
• Total laryngectomy
T1 carcinoma with extension to arytenoids
• Surgery is preferred
18. T2N0 CANCER
Cord mobility Cord mobility impaired
or
Involvement of anterior
Commissure or arytenoid
Radiotherapy to the
Primary including
Radiation to upper
Neck nodes
Failure
Conservation
Laryngectomy
Failure
Total laryngectomy
+/- neck dissection
failure
Conservation
laryngectomy
Failure
Total laryngectomy
+/- neck dissection
ALGORITHM FOR TREATMENT OF T2N0 GLOTTIC CANCER
19. • Subglottic cancers
– T1 and T2 : radiotherapy
– T3 and T4 : total laryngectomy
– Radiation portal should also include superior
mediastinum
20. Supraglottic cancers
• Status of cervical lymph node
• Mobility of cord
• Age
• Lung function
• Cartilage invasion
• Subsites involved
• Pre epiglottic space involvement
Factors influencing
treatment
T1 LESION
• Radiation
• Excised with co2laser
T2 LESION
• Lung function good : supraglottic laryngectomy with or without nock dissection
• Lung function poor : radiation to primary and nodes
T3 AND T4
• Total laryngectomy with neck dissection
• post operative radiation
21. Vocal rehabilitation after total
larygectomy
Methods of communication in laryngectomized patient
• Written language
• Aphonic lip speech
• Oesophageal speech
• Electrolarynx
• Transoral pneumatic device
• Trancheo oesophageal speech
• Blom Singer prosthesis
• Panje prosthesis
22. OESOPHAGEAL SPEECH
• Swallow air
• Hold it in upper oesophagus
• Slowly eject it from upper oesophagus into the pharynx
• 6-10 words before reswallowing air
• Voice is rough loud understandable
ARTIFICIAL LARYNX
• Electrolarynx
• Transistorized battery operated potable device
• Vibrating disc held against soft tissue of neck
• Low pitched sound produced in the hypopharynx modulated to speech by lips
tongue teeth palate
• Transoral pneumatic device
• Vibration produced in rubber diaphragm
• Carried by tube into the back of oral cavity
• Sound and converted to speech by modulators
• Use air from tracheostome
23. • Tracheo oesophageal speech
– Air is carried away from trachea to oesophagus or
hypopharynx by creation of a skin lined fistula or
placement of anterior prosthesis
– Vibrating column of air entering the pharynx is
then modulated into speech
– Disadvantage
• Entry of food into trachea