2. Topics to be covered
Anatomy
Radiological anatomy
Epidemiology
Routes of spread
Clinical Presentation
Examination
3. Introduction :-
The larynx is an air passage,
a sphincter and an organ of
phonation
Extends from the root of
tongue to the trachea.
Projects ventrally between
the great vessels of the neck
Lies in anterior midline of
neck
Infront of C3 to C6 vertebrae
4. Contd…
Covered anteriorly by skin,
fasciae and the hyoid depressor
muscles
Above, it opens into the
laryngopharynx and forms its
anterior wall
Below, it continues into the
trachea
mobile on deglutition.
5. Constituents of Larynx
CARTILAGES –
3 Unpaired - thyroid
- cricoid
- epiglottis
3 paired cartilages –
• arytenoid
• corniculate
• cuneiform
All cartilages are hyaline except epiglottis ,corniculate,
cuneiform, vocal process and apex of arytenoid
9. Membranes and Ligaments
Extrinsic:
connect thyroid cartilage with epiglottis and hyoid
bone ;cricoid cartilage with trachea
Intrinsic:
connect cartilages of larynx to each other
10. LIGAMENTS AND MEMBRANES
EXTRINSIC
LIGAMENTS AND
MEMBRANES
Thyrohyoid membrane
Hyo- and
thyroepiglottic
ligaments
Cricotracheal ligament
14. Muscles of Larynx and their function
Abductor Adductors
Cricothyroid is
the only intrinsic
laryngeal muscle
lying outside the
larynx
Transverse
arytenoid is the
only unpaired
intrinsic muscle
17. Supraglottic Larynx
Extend from tip of the
epiglottis to superior
surface of true vocal cord .
Composed of –
Epiglottis
Arytenoid
Aryepiglottic fold
False vocal cord
Posterior tapering shape
reduces area of mucosa in
posterior region
Majority of Supraglottic
tumors are epiglottic
The inferior boundary of the
supraglottis is a horizontal plane
passing through the lateral margin of
the ventricle at its junction with the
superior surface of the vocal cord.AJCC 2010
18. Glottis
o upper border started from superior
surface of true vocal cords
o Lower border is 0.5 cm below the
free edge of true vocal cord.
o Glottis consists of true vocal cords
and the ant and post
commisures(mucosa between the
arytenoids)
o True vocal cord are 2 cm long and
are thinnest anteriorly and
posteriorly
o Most lesions arise from free edge
and upper surface of ant 2/3
Anterior
Commisure
Posterior
Commisure
20. Subglottic Larynx
It extends from the lower border of glottis to lower border of cricoid cartilage .
Consists of a mobile upper and fixed lower part.
21. Mucosa
Mucosa of glottic and Supraglottic regions is
stratified squamous epithelium.
Mucosa of ventricles and sub-glottic regions is
pseudo-stratified ciliated epithelium
Supra and sub glottic regions particularly
ventricles are rich in submucosal mucous or minor
salivary glands while glottis is not.
27. Reinke’s Space
Mucosa over the vocal
ligament loosely attached
to ligaments.
Under the epithelium of
vocal cord is a potential
space with subepithelial
connective tissues.
38. Lymphatics
Glottic and supraglottic to levels 2-3, subglottic to
level 4
Very sparce lymphatics in TVC, therefore glottic
CA usually better prognosis (although also usually
detected earlier)
Glottic and subglottic tumors metastasize to
ipsilateral lymph nodes, but supraglottic tumors
often spread to nodes on both sides of the neck.
39. Supraglottic lymphatics
Supraglottis has a rich lymphatic network.
High propensity for b/l LN mets due to midline
location.
Primary drainage pattern of supraglottic cancers is the
jugular lymph chain.
Level 2 nodes mc involved followed by level 3 and 4.
Level 5 seldom involved.
Level 1b and 1a almost never involved
40. The risk of clinically involved lymph nodes is
approx. 40% for T 1 and T 2 tumors
approx . 60 % for T 3 and T 4 tumors
41. Lymphatics of subglottis
The first-echelon lymphatics for the subglottic larynx are
the Delphian node.
The lymphatics in subglottis is less developed.
Incidence of lymph node mets varies from 20% to 50%.
Lymphatics from subglottis form 3 pedicles:
1 anteriorly and 2 posteriorly
The anterior channels pass through the cricothyroid
membrane and drain into the middle and lower jugular
nodes to terminate in the prelaryngeal node(Delphian
node),from which lymphatics drain into pretracheal and
supraclavicular nodes.
42. The posterolateral lymphatic
channels pass through cricotracheal
membrane and terminate in high
paratracheal nodes.
Mediastinal involvement can
occur,if present is considered a
metastasis ( unless it is a level VII
mets in which case it is considered
regional lymph node metastasis ).
Path of Subglottic
Tumor spread
43. Lymphatics of glottis
True vocal cords are almost devoid of lymphatics.
Incidence of LN mets at diagnosis approaches
zero for T1 ,
2% for T2 ,
15 to 20% for T3 ,
20 to 30% for T4.
Lymphatic spread occurs when tumor extends to
subglottis or supraglottis.
44.
45. Lymphatic Drainage contd..
With a single lymph node involved by metastatic disease,
the prognosis is said to be reduced by half.
Criteria that suggest metastatic involvement of a lymph
node include enlarged size, abnormal shape, necrosis, and
extracapsular spread.
Nodal metastasis at the time of presentation is much more
common from supraglottic carcinomas when compared
with glottic and infraglottic tumors because of the rich
supraglottic lymphatic network.
The sensitivity of CT and MRI in detecting nodal
metastasis is higher than clinical examination and lower
than PET.
Surg Oncol Clin N Am 23 (2014) 685–707
46. Supra glottis Carcinoma
Sore throat and odynophagia are the most common
presenting symptoms of carcinoma of the supraglottis.
Patients often describe the sensation of foreign body and
can have difficulty swallowing.
Hoarseness occurs in advanced lesions, but is typically
absent in early stages.
Because of the high incidence of lymph nodes metastasis,a
neck mass can be the first sign of carcinoma of the
supraglottis.
47. Supraglottic Carcinomas
The epiglottis is the most
frequent location for cancers
that arise in the supraglottic
larynx. These lesions are often
exophytic and circumferential
masses
Tumors of the aryepiglottic fold
are typically exophytic lesions
that, when detected early, are
confined laterally along the
aryepiglottic fold.
-Advanced lesions may
extend laterally to involve
the adjacent wall of the
pyriform sinus or medially
to invade the epiglottis.
48.
49. Glottic Carcinomas
The true vocal cords are the most common site of
laryngeal carcinomas; the ratio of glottic carcinomas to
supraglottic carcinomas is approximately 3:1.
The anterior portion of the true vocal cord is the most
common location of squamous cell cancer.
Most lesions occur along the free margin of the vocal
cord.
50. CONTD..
Anteriorly, the tumor may extend to
anterior commissure, where it may
involve the contralateral true vocal
cord.
Hoarseness is the most common
presenting symptom of early vocal
cord cancer.Thus glottis tumours
are most commonly diagnosed at
early stage.
Sore throat.otalgia,localized pain result
from cartilage invasion , and dyspnea
are symptoms of advanced disease
51. Sub-glottis Carcinomas
Subglottic carcinomas are rare and account for only 5%
of all laryngeal carcinomas.
When present, these lesions are characteristically
circumferential and often extend to involve the
undersurface of the true vocal cords
They have a tendency for early invasion of the cricoid
cartilage and extension through the cricothyroid
membrane.
53. Trans-glottic Carcinomas
Usually initiate as
supraglottic or
glottic cancers
As for example
Glottic cancers more
commonly spread to
spraglottic areas.
54.
55. Epidemiology
MC malignancies of upper aerodigestive tract
Approx 25% of head and neck tumors
2.63 % of all body cancer.
Primary glottic cancers 3times more common than
supraglottic
Subglottic cancers are rare
80% occur in men.
Age group 40- 70 yrs.
Most curable of upper aerodigestive tract cancers
56. GLOBOCAN 2012 (data for ca larynx)
INCIDENCE MORTALITY 5- YEAR
PREVALENCE
Men 4.8 (22900) 4.4 6.8
Women 0.5 0.5 0.4
Both sexes 2.5 (25446) 2.6 2.8
INCIDENCE MORTALITY 5-YEAR
PREVALENCE
Men 1.9 1.6 2.5
Women 0.3 0.3 0.3
Both sexes 1.1 1.1 1.4
INDIA
WORLD
59. Risk Factors
Smoking and alcohol are two main risk factors
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.
Human Papilloma Virus 16 & 18
Chronic Gastric Reflux
Prior history of head and neck irradiation
60. Occupational exposure to asbestos , diesel fumes ,
rubber ,wood dust
Vitamin and nutrient deficiency(subglottic ca)
Mutations in p53,ki-67,EGFR,TGF beta,cyclin D1
P53 mutation seen nearly in 50% smokers and 55%
drinkers
Telomerase present in high levels
61. Routes of spread
LOCAL SPREAD
No anatomical barrier to growth from one area to another.
Involvement of vocal cords on the external epithelial
surface is a late phenomenon but sub mucosal extension by
way of para glottic space occur early.
Fat space is an important venue for submucosal spread of
infrahyoid epiglottis ,false cord and true cord lesions.
62. Distant Metastasis
• Incidence is very low.
• Identified in appro 10 to 20% cases majority have
supraglottic or subglottic primary.
• Lung(60%) is mc site followed by bones(20%) and
liver(10%).
• Brain mets very rare.
63. Histological Types
95% of laryngeal tumors are squamous cell carcinoma
Histologic type linked to tobacco and alcohol abuse
Characterized by epithelial nests surrounded by
inflammatory stroma
Keratin Pearls are pathognomonic
65. Presentation
Hoarseness
Most common symptom
Small irregularities in the vocal fold result in voice
changes
Changes of voice in patients with chronic hoarseness
from tobacco and alcohol can be difficult to appreciate
66. Contd…
Patients presenting with hoarseness should undergo
an indirect mirror exam and/or flexible laryngoscope
evaluation
Malignant lesions can appear as friable, fungating,
ulcerative masses or be as subtle as changes in mucosal
color
Video laryngoscopy may be needed to follow up these
subtler lesions
67. Supraglottic carcinoma-
• Often silent
• throat pain
• dysphagia
• referred pain in ear
• neck mass
• respiratory obstruction
• halitosis
• hoarseness of voice – late symptom
68. Glottic carcinoma –
Hoarseness of voice (early sign)
Stridor
Weight loss ,halitosis, aspiration can occur with
locally advanced disease.
Sore throat, localized pain from cartilage invasion ,
dyspnoea are symptoms of advanced disease.
Ca subglottis rare.
Usually diagnosed late.
70. History
History-
Any patient in cancer age group having persistent or
gradually increase hoarseness of voice x 3 weeks must be
consider for further evaluation .
personal history
Family history
Occupational history
71. Examination
Good neck examination looking for cervical
lymphadenopathy and broadening of the laryngeal
prominence is required
The base of the tongue should be palpated for masses
as well
Restricted laryngeal crepitus may be a sign of post
cricoid or retropharyngeal invasion
72. Examination
See for –
Appearance of lesion –
Suprahyoid- exophytic
Infrahyoid- ulcerative
Vocal cord – nodular/ ulcer/ thickened
Ant commissure- granulation tissue
Subglottic – raised submucosal tissue
Vocal cord mobility –
Fixation indicate infiltration into
Thyroarytenoid
Cricoarytenoid
Invlovment of recurrent laryngeal nerve
Extent of disease
73. Examination of neck –
lymphnode mass
extralaryngeal spread -
• palpation of diffuse firm fullness above the thyroid notch with
widening of space between hyoid and thyroid indicate invasion of
preepiglottic space.
• growth through cricohyoid membrane may produce midline
swelling.
• thyroid cartilage invasion may cause perichondritis and on
palpation may be tender .
74. Diagnostic Evaluation
Careful history and clinical examination.
D/L scopy and biopsy is the most valuable step in
diagnosis and staging.
Rigid endoscope requires anaesthesia,better
visualisation of subglottis and ant commissure.
Assesment of vocal cord mobility
75. CT SCAN
CECT and contrast MRI are useful in diagnostic imaging.
Preferably done before biopsy.
In cancers of the larynx, cross-sectional imaging with CT
provides valuable information regarding primary tumor
staging and treatment
Malignancies of the larynx are primarily imaged with CT,
because of lower image degradation from breathing ,
swallowing and coughing during examination.
CT and MRI play a superior role, especially in evaluating
the deep spaces of the head and neck.
76. Contd…
Characteristics such as tumor volume, sclerosis of laryngeal
cartilage on CT have been found to have prognostic value.
Limitations of CT include subtle evaluation of tumor
induced cartilage and bone defects , detection of
superficial tumors.
CT evaluation is much faster than MRI and has practical
advantages as cost , speed and availability.
CT Scan is used for lymph node delineation and
radiotherapy contouring.
MRI is more resource-intensive and less available than CT.
77. MRI Scan
Staging accuracy for MRI in ca larynx is higher due to
more accurate assessment of cartilage invasion , pre
epiglotic and paraglottic extension.
Gross cartilage invasion can be detected on CT;
however, early cartilage abnormalities are detected
better on MRI.
Areas of cartilage involvement result in high signal
intensity on T2W images and contrast-enhanced T1W
images.
Surg Oncol Clin N Am 23 (2014) 685–707
78. PET Scan
The role of PET scan in the routine initial work up
remains investigational.
Useful in detection of occult nodal and distant mets.
To distinguish between recurrence and post treatment
changes.
A pretreatment standardized uptake value (SUV) of
less than 9.0 in the primary tumor has been shown to
be associated with less frequency of disease recurrence
and improved disease-free survival.
PET/CT is the modality of choice for therapy
assessment and is performed 12 weeks after
completion of chemoradiation.
Surg Oncol Clin N Am 23 (2014) 685–707
81. Indirect Laryngoscopy contd…
Patient is seated opposite the examiner.
Asked to protrude the tongue which is wrapped in
gauze
And held by examiner b/w thumb and middle finger .
Index finger is used to keep upper lip out of way.
Warm the laryngeal mirror , introduced into the
mouth and held firmly against uvula and soft palate .
To see movement of cords asked the patient to take
deep inspiration , say” Aa” (adduction ) and ” Eee” (for
adduction and tension ).
84. Metastatic Work up
Chest xray sufficient in early stages at low risk for
mets.
CT scan in locally advanced disease.
PET scan in detection of distant mets.
PFTs for patients considered for surgery.
Bronchoscopy and oesophagoscopy to rule out
synchronous tumours.
Routine lab tests include complete blood count,LFTs.
Attention to anemia.
The inferior boundary of the supraglottis is a horizontal
plane passing through the lateral margin of the ventricle
at its junction with the superior surface of the vocal