6. CLINICAL HINT
• 69 years male-chief complain voice change for 6 months
• Insiduous onset-gradually progressive-hoarse in character-persistent
• Without respiratory distress or noisy breathing(subglottic)/pain throat
• No h/o swallowing difficulty/pain during swallowing/cough with expectoration/aspiration/blood stained
sputum
• No h/o swelling in neck/foreign body sensation throat/soarness of throat/constant irritation of
throat(hypopharynx)
• No h/o ear pain(pyriform/hypopharyngeal growth/internal branch of sup laryngea nv/vagus
• No h/o headache(mets)/fever/loss of weight/hot potato voice(epilaryngs)
7. NEGATIVE
• Htn/DM/COPD/Tb/CAD/Epilepsy
• No significant family history/exposure to carcinogen/smoking/passive smoking/protein
deficient diet
• Predisposing factors-h/o tobacco chewing/chronic alcoholic 180ml per day –stopped for
past 2 years.
8. GEN EXAM
• Moderately built well nourished-chronic nutritional status
• Conscious oriented alert
• Vitals
• Pallor/Spo2/icterus/clubbing/bilateral pitting oedema/cyanosis –
/lymphadenopathy-absent
9. ENT EXAM
• Oral cavity –lips/dental nicotin stain/gingivo buccal & gingivolabial sulcus/floor of
mouth/vestibule/ant 2/3rd of tongue/hard palate /retromolar trigone-normal
• Soft palate/uvula/tonsillar fossa/ant & post pillars/post pharyngeal wall-normal
12. FINDINGS
• Pink proliferative growth involving entire left vocal cord extending to anterior
commissure-left hemilarynx fixed.(vocal cord and arytenoid fixed
• Right vocal cord ant 1/3rd involved in growth
• Surface of growth irregular-no ulcer/hyperkeratotic area
• Glottic chink adequate.
• Patient not in stridor
• Ventricular fold elevated/ above with fullness and not moving
13. TRANSGLOTTIC GROWTH-SPREAD
• Growth/topographic tumour extending from glottis to supraglottis or viceversa
passing /traversing through ventricle-deep seated/early nodal mets/present
late/early paraglottic space involvement
• Spread epithelium-reinke’s space –thyroarytenoid muscle-ant commissure-
broyle,s ligament-thyroid cartilage.
14. RLN PALSY AND CORD FIXITY
• Cord short/thicker/wavy margin/lower level/tone lost/probe test cricoarytenoid joint
mobile-in RLN palsy
• Causes of vocal cord fixity-CA joint fixation/RLN involvement/Thyroarytenoid muscle
involvement/mass effect/paraglottic space involvement
15. EXAMINATION OF NECK
• Trachea midline
• Laryngeal contour normal-no widening/tenderness
• Laryngeal crepitus present
• No palpable lymphadenopathy-4/14/40%(glottic/subglottic/supra)
• No scar sinus.
18. GENERAL TRIVIA
• All malignant tumour in male -2.3%
• All malignant tumour in female 0.4%
• Peak 6th-7th decade
• Malignant lesions of larynx- 95-98% SCC
• Glottis 70%-hoarseness-poor lymph drainage-less nodal mets –cure rate-
90-95%-Indians supraglottic more common.
• Adult with hoarseness more than 3 weeks -not responding to treatment
should be diagnosed as ca larynx unless proved otherwise.
• Male:female 10:1(recent increase in female)
19. AETIOLOGY
• TARGET
• Tobacco-Benzopyrene-nonsmoker –less than 5%
• Alcohol-synergistic more supraglottic
• Radiation
• Genetic –familial
• Environmental-/occupational- asbestos/petroleum/mustard gas/painter/construction worker/metal and plastic industry
• Tumour-premalignantleucoplakia/erythroplakia
• Dietary factors –salt preserved meat/high dietary fat/Lprd/GERD.
• Antioxidant protective-curcumin.
20. GROSS PATHOLOGY
• Proliferative/exophytic-cauliflower-usually well differenciated
• Ulcerative-endophytic-usually poorly differenciated
• Ulceroproliferative(UCP)
• Supraglottic-epilarynx/epiglottis &ae fold-mobile area/apex of arytenoid–
exophytic like hypopharyngeal malignancy-/supraglottis proper-infiltrative
behave like laryngeal growth
21. SITE OF LARYNX
• Supraglottis-from free border of epiglottis till laryngeal ventricle
• Glottis- from apex of ventricle to 10 mm below free border of vocal cord
• Subglottis-extend from 10 mm below free border of vocal cord upto lower border
of cricoid cartilage.
22. STAGING GLOTTIC CA
• T1-Limited to Vocal cord with normal mobility
• T1a-involving single cord
• T1b – involving both vocal cords
• T2- More than 1 subsite like supraglottis or subglottis with or without impaired mobility of vocal
cord
• T3-Vocal cord fixed restricted to larynx with minor thyroid cartilage erosion
• T4a-Moderately advanced disease-extra laryngeal spread/thyroid cartilage/ trachea /eso/deep
extrinsic muscle of tongue/thyroid/
• T4b-mediastinum/carotid encased/prevertebral muscle and fascia
23.
24.
25.
26.
27.
28. VOCAL FOLDS
• Structure between the vocal process of the arytenoids and the anterior
commissure
• Vibratory portion
epithelium
lamina propria (3 layers)
vocalis muscle
• Body cover concept (Hirano)
Cover = epithelium + gelatinous superficial layer of lamina propria
Body = elastic (intermediate) + collagenous (deep) layer of
lamina propria + vocalis muscle
• Vocal cords protected from vibratory damage by thickenings at the elastic layer
of lamina (anterior & posterior macula flava)
29.
30.
31.
32. MUSCLES OF LARYNX
Extrinsic muscles
Muscles of the laryngohyoid complex that
raise : thyrohyoid, stylohyoid, geniohyoid, mylohyoid,
stylopharyngeus, digastric
lower : omohyoid, sternothyroid, sternohyoid
stabilize : superior and inferior constrictor, cricopharyngeus
33. MUSCLES OF LARYNX
Intrinsic muscles
• Anatomically restricted to the larynx proper
• Modify length and tension of vocal cord and glottic opening
• Single abductors, multiple adductors
• All are paired, except the interarytenoids
34. MUSCLES OF LARYNX
• Acting on the vocal cords
Abductors: Posterior cricoarytenoids
Adductors: Lateral cricoarytenoids
Inter-/transverse arytenoids
Thyroarytenoid (external part)
Tensors: Cricothyroid
Vocalis (internal part of thyroarytenoids)
• Acting on laryngeal inlet
Openers: Thyroepiglottic (part of thyroarytenoid)
Closers: Interarytenoid (oblique part)
Aryepiglottic (posterior oblique part of interarytenoids)
35.
36. STAGE LIMITED
TO
SUPRAGLO
TTIS
GL
OT
TIS
SUBGL
OTTIS
FIXATIO
N OF
LARYNX
OUTSIDE LARYNX
T1 LARYNX SUBSITE X X X X
ONE
T2 LARYNX MORE
THAN ONE
SUBSITE
OR
GL
OT
TIS
mucosa of base of
tongue/vallecula/medial
wall of pfs
T3 LIMITED
TO
LARYNX
VOCAL
CORD
FIXATIO
N
invade any of the
following -post cricoid
area/paraglotticspace
/preepiglottic space
MINOR
THYROID
CARTILAG
E EROSION
T4a Invade tissue beyond
larynx,trachea,esophagu
s,deep extrinsic muscle
of tongue ,thyroid
Invade
through
thyroid
cartilage
T4b Prevertebral tissue,
encase carotid,invade
mediastinal structure
37. NX NODAL METS CAN NOT BE
ASSESSED
N0 no nodal mets
N1 single ipsilateral node 3cm or less
N2a Single ipsilateral node more than
3cm less than6cm
N2b Multiple ipsilateral node none
more than6cm
N2c Contralateral or bilateral node
none more than6cm
N3 Mets in a lympnh node more
than 6cm
38. SPREAD
• Local –mucous glands in supraglottic region/pits in cartilage facilitate spread to
preepiglottic space.
• From laryngeal surface of epiglottis spread inferiorly to petiole of epiglottis and
anterior commissure.
• Supraglottic cancer -remain above the laryngeal ventricle. Hyoepiglottic ligament and
anterior commisure tendon - a barrier for inferior spread.
• Lesion from false vocal cord spread to epiglottis, AE fold , arytenoid if paraglottic
space involved.
• Primary tumour of ventricle rare-lesion not visible-present as fullness of ventricular
band.
39. SPREAD CONTD
• AE fold lesion- biological behaviour similar to pfs ca-called marginal zone lesion
• Lymphatic spread-via thyrohyoid membrane to level –II & level- III
• Incidence-20-40%
• Clinicallly N0 neck can have occult mets.
40. SYMPTOMS-SUPRAGLOTTIC
• Supraglottic –hot potato voice-muffled rather than hoarseness.
• Hoarseness is a late phenomena.
• Foreign body sensation or lump in throat
• Dysphagia
• Soarthroat
• Referred otalgia
• Neck swelling
• stridor
41. EXAM
• IDL –UCP growth in supraglottis-larynx distorted-glottis may be obscured
• VC mobility –restricted/fixed
• Extralaryngeal spread.
• 40% with cervical mets
• Widening/splaying of larynx
• Laryngeal cartilage tenderness
42. GLOTTIC CA -FEATURES
• Most common type -50-70% of all
• Early symptom-interfere with voice
• Lymphatic spread rare &at advanced stage
• Spread early to Reinke’s space-potential space between margin of true cord and vocal
ligament
• Advanced lesion involve vocal ligament and vocalis muscle
• Can extend superiorly to ventricle and supraglottis
• Can extend postly to vocal process, arytenoid cartilage and cricoarytenoid joint
43. SPREAD OF GLOTTIC TUMOUR CONTD
• Lymphatic spread to prelaryngeal Delphian node via ant commissure
• TRANSGLOTTIC –malignant tumour involving paraglottic space-extending to supraglottis above
and subglottis beyond 10mm of free border of vocal cord-high incidence of extralaryngeal
spread.
• Clinical features- persistent and progressive hoarseness
• Cough due to aspiration
• Hemoptysis
• Dyspnoea/stridor-impaired mobility of both cords
• Rarely bulky lesion occupying subglottis
44. EXAMINATION
• IDL-irregular thickening of vocal cord-cauliflower appearance
• Surrounding erythema/ulceration
• More proliferative than ulcerative
• Glottic chink may be compromised
• Mobility of cord may be restricted
• Laryngeal splaying
• Laryngeal tenderness
45. SUB-GLOTTIC
• Rare
• 80% diagnosed as T3/T4
• Cord fixation on presentation/airway obstruction
• Present with cough,dyspnoea,hemoptysis/stridor
• Hoarseness late
• IDL diffuse proliferative growth in subglottis
• Cervical mets through cricothyroid membrane to paratracheal nodes
• Very poor prognosis
46. INVESTIGATIONS/CONFIRM DIAGNOSIS
• Xray neck lateral –asses patency of laryngeal airway/tracheal shifting
• Chest xray-to rule out mets,aspiration pneumonia, performance status
• Mediastinal widening/second primary
• CECT scan neck-cartilage erosion /extralaryngeal spread/LN status
• FNAC of nodes for mets
• Direct laryngoscopy with biopsy-rigid-can palpate and biopsy
• Flexible/FLP-lower extent can be assessed.
• PET CT for mets evaluation
• Ba swallow-post cricoid and esophageal extension
49. BENIGN OR MALIGNANT NODE
• Malignant-spherical, loss of fatty hilum, peripheral rim enhancement
• >1 cm in greatest dimension for jugulodigasrtric
• >1.5 cm for others
50. TREATMENT
• Stridor tracheostomy
• Stage I/II- Organ preservation –radiotherapy/conservative
laryngectomy/TORL/TORS
• Stage III/IV-Combind modality
• Surgery-total laryngectomy with neck dissection f/b radical radiotherapy
• Radical rt f/b salvage surgery.
• Near total laryngectomy leaves one functioning arytenoid and healthy subglottic
mucosa to reconstruct a dynamic shunt connecting the trachea that can produce
aspiration free voice.
51. • T3-CTRT/TOTAL LARYNGECTOMY
• IF Larynx functioning –CTRT
• IF Larynx nonfunctioning-total laryngectomy
• T4a –total laryngectomy/CTRT
• Stridor –tracheostomy
• T1/T2-endolaryngeal surgery laser-TLM TRANS ORAL LASER MICROSURGERY-
FOLLOWUP with CTRT
52. INDICATION FOR TOTAL LARYNGECTOMY
• Malignant-T3/T4 Advanced SCC lesion of larynx with nonfunctional larynx / CTRT
contraindicated.(residual/recurrent tumour/cartilage/skin involvement)
• In continuity resection with neck dissection if patient has a mobile node
• Non squamous sarcoma/adenocarcinoma RT not possible.
• Nonmalignant-extensive amyloidosis with nonfunctional larynx
• Aspiration/laryngeal trauma
• Tumour board or 2 surgeon opinion for laryngectomy
53. FUNCTION OF LARYNX
• Phonation
• Respiration-conduit for air passage
• Protection of lower airway and prevent aspiration
• Fixation of chest wall during lifting weight
• Help in deglutition by elevating subglottic pressure
• Help in circulation-aids venous return
• Help in maintain end expiratory pressure
• Cough and protective reflex
