This document describes a case of carcinoma of the larynx in a 65-year-old male patient who presented with hoarseness of voice for 6 months and breathing difficulty for 2 weeks. Examination revealed a growth on the left vocal cord. The patient underwent an emergency tracheostomy followed by a total laryngectomy and biopsy, which showed well-differentiated squamous cell carcinoma. The patient recovered well post-operatively and was discharged on adjuvant radiotherapy and voice rehabilitation.

2. CARCINOMA LARYNX
BY
DR TARIQUE AHMED MAKA
REGISTRAR IN ENT

3. CARCINOMA LARYNX

4. PATIENT’S PROFILE
 NAME XYZ
 AGE 65 yrs
 SEX Male
 RESIDENCE Kotla Arab Ali Khan
 DATE OF ADMISSION Jan 2014

5. PRESENTING COMPLAINTS
 HOARSENESS - 6 Months
 DIFFICULT - 2 weeks
BREATHING

6. HISTORY OF PRESENT ILLNESS
 Hoarseness of voice
 Insidious onset and progressive
 Breathing Difficulty
 Inspiratory stridor

7.  Past history
 Personal history
25 cigarettes a day
 Family history
 Drug history
 Socioeconomic history
Not Contributory

8. GENERAL PHYSICAL EXAMINATION
 PULSE 98 bpm
 BLOOD PRESSURE 130/80 mm of Hg
 TEMPERATURE 98.2 ˚
F
 RESPIRATORY RATE 28 breaths/min

9. EXAMINATION (contd)
 PALLOR
 CYANOSIS
 CLUBBING
 JAUNDICE
 OEDEMA
 KOILONYCHIA
 THYROID Not enlarged
 JVP Not raised
 LYMPH NODES Not palpable
ABSENT

10. ENT EXAMINATION
 THROAT
No abnormality found in oral cavity
 INDIRECT LARYNGOSCOPY
 Exophytic growth arising from left vocal cord
involving supraglottis and anterior commissure with
narrow glottic chink
 Fixed Lt vocal cord

11. ENT EXAMINATION
 THROAT
No abnormality found in oral
cavity
 EARS
 NOSE Normal
 NECK

12. UNREMARKABLE
SYSTEMIC EXAMINATION
 Cardiovascular system
 Respiratory system
 Gastrointestinal system
 Central nervous system

13. EMERGENCY TRACHEOSTOMY
 Emergency tracheostomy was performed
under local anesthesia to relieve stridor

14. Normal study
INVESTGATIONS
 Blood complete picture
 Haemoglobin: 13g/dl
 Platelets: 291x109
/L
 X Ray Neck Lat view
 X Ray Chest PA
 USG Neck
 USG Abdomen
Narrowed airway in
supraglottis & glottis

15. NORMAL
INVESTIGATIONS (contd)
 ECG ,2-D echo
 Serum urea & electrolytes
 PT, PTTK
 LFTs
 Blood Glucose levels
 Hepatitis Profile

16. INVESTIGATIONS (contd)
 CT Scan Neck

17. PROVISIONAL DIAGNOSIS
 Growth larynx
 Direct laryngoscopy and biopsy under GA
planned

18. DIRECT LARYNGOSCOPY
 Exophytic growth on left vocal cord involving
left supraglottis and anterior commissure
 Pyriform fossae, Posterior pharyngeal wall
and Post-cricoid region - Normal
 Biopsy

19. HISTOPATHOLOGY
 WELL DIFFERENTIATED
SQUAMOUS CELL CARCINOMA

20. DIAGNOSIS
WELL DIFFERENTIATED SQUAMOUS
CELL CARCINOMA LARYNX
STAGE (iii) T3 N0 M0

21. DECISION
TOTAL LARYNGECTOMY FOLLOWED
BY RADIOTHERAPY

22. MANAGEMENT
 PRE-OP WORK UP
 Counseling

Details of the nature and severity of the disease

Treatment options available

Specific risk of surgery and GA

Understanding the total laryngectomy state & life
style after surgery
 Informed written consent
 Pre-anesthesia assessment: ASA-II
 2 Unit RCC arranged

23. OPERATIVE STEPS

24. GLUCK SORENSON INCISION

25. DRAPING

27. SKIN FLAPS RAISED

28. DISSECTION CONTINUES

29. LARYNX DISSECTED FROM STERNOMASTOID
AND CAROTID SHEATH

30. CONTRALATERAL THYRIOD FREED
& SECURED

31. STRAP MUSCLES SECTIONED
& LARYNX MOBILIZED

32. REMOVAL OF SPECIMEN
Larynx
mobilized

33. LARYNX REMOVED

34. NASOGASTRIC TUBE PASSED

35. Neopharyn
The Resected
Specimen
NEOPHARYNX CONSTRUCTED
Base of tongue
Oesophagus
Tracheostome
Neopharynx

36. SUCTION DRAINS PLACED WITHOUT
CROSSING THE NEOPHARYNX
SUCTION DRAIN
SUCTION
DRAIN
NEOPHARYNX

37. TRACHEOSTOME FASHIONED
& WOUND CLOSSED
TRACHEOSTOME

38. THE TRANSGLOTTIC GROWTH
The Resected Specimen

39. POST OP MANAGEMENT
 Tracheostomy care
 Antibiotics :
 Inj ceftriaxone 1g I/V 12 hourly (ATD)
 Inj metronidazole 500mg I/V 8 hourly
 Inj coamoxiclav 1.2g I/V 8 hourly (ATD)
 Inj Diclofenac Sodium 75mg I/M 12 hourly
 Omeprazole infusion 40mg I/V HS
 Intra venous fluids

40. RECOVERY
 1st
Post operative day

Folley catheter removed

Patient mobilized
 3rd
Post op day

Neck drains removed

N/G feed started with clear water
 7th
Post op day

Neck stitches removed
 10th
Post op day

Oral sips started with clear water

41. POST OP HISTOPATHOLOGY
 WELL DIFFERENTIATED
SQUAMOUS CELL
CARCINOMA
 Clear resection margins
 Thyroid gland not involved

42.  Regular follow-up
 Adjuvant Radiotherapy
 Voice Rehabilitation Healthy stoma
FOLLOW UP
Healthy stoma

43. CARCINOMA LARYNX
CASE DISCUSSION

44. THE ANATOMY
 Extends from pharynx to trachea in front of 3 to 6
cervical vertebrae
 Acts as a compound sphincter

Prevents aspiration

Glottic closure for pressure build-up
 Phonation
 Provides attachment to ligaments & muscles
 Cartilages
Unpaired Paired
Thyroid Arytenoids
Cricoids Corniculate
Epiglottis Cuneform

45.  Supraglottis
 Epiglottis
 Aryepiglotic Fold
 Arytenoids
 False cords and Ventricle
 Glottis
 True vocal cords
 Anterior & Posterior commissures
 Subglottis
 Upto lower border of cricoid catilage
SUBSITES

46. LYMPHATIC DRAINAGE
 Supraglottic Larynx
 Upper deep cervical nodes (level ll & lll)

Infraglottic larynx
 Lower deep cervical and mediastinal nodes
(level IV &VI)

Glottis
 Lymphatic watershed

47. EPIDEMIOLOGY
 6th
commonest cancer world wide.
 Incidence in UK is 1% of all malignancies
 Male & female ratio 4:1
 Peak incidence 55 to 65 years
 Laryngeal cancer is approximately 4/100,000
 Incidence in females has increased in the western world

48.  Wide prevalence
 Mean age at presentation 40-70 years
 Male Female ratio 10:1
 Incidence in India 10/10,000
 Incidence in Pakistan 8.6/10,000
REGIONAL STATISTICS

49. AETIOLOGY
 Tobacco and alcohol
 Benzopyrine and other hydrocarbons
 Alcohol and smoking increases the risk 15 folds
 Previous radiation to neck for benign
lesions
 Genetic factor
 Occupational exposure
 Asbestos,mustard gas and petroleum products

50. HISTOPATHOLOGY
 90-95% are squamous cell
carcinoma with various grades
of differentiation
 5-10% lesion includes
 Verrucous carcinomas
 Spindle cell carcinomas
 Malignant salivary gland tumors
 Sarcomas

51. SUPRAGLOTTIC CARCINOMA
 Less frequent than the glottic cancer
 Spreads locally and invades
adjoining areas
 Nodal metastasis occurs early
 Symptoms
 Hoarseness, throat pain, dysphagia, neck nodes,
referred pain in ear, wt loss, and respiratory obstruction

52. GLOTTIC CARCINOMA
 More frequent
 Spreads locally
 Few lymphatics with no nodal
metastasis
 Symptoms
 Hoarseness of voice (early sign)
 Cord fixation leads to stridor and laryngeal
obstruction

53. SUBGLOTTIC CARCINOMA
 Rare (1-2%)
 Invades cricothyriod membrane, thyroid gland and strap
muscles of neck
 Lymphatic metastasis
 Prelaryngeal
 Paratracheal
 Lower jugular nodes
 Symptoms
 Stridor or laryngeal obstruction
 Hoarseness (late feature)

54. DIAGNOSIS
 History
 Indirect laryngoscopy
 Examination of neck
 Soft tissue x-ray of neck
 CT & tomography
 Direct laryngoscopy & biopsy - confirms

55. TNM Classification of cancer larynx
(American joint committee on cancer)
SUPRAGLOTTIS
T1 Tumor confined to one subsite of larynx; normal mobility
(i.e., ventricular bands; arytenoids; epiglottis)
T2 Involving more than one subsite (supraglottis or glottis;
normal mobility)
T3 Tumour limited to larynx with vocal cord fixation and/or
invades
any of the following: postcricoid area, pre-epiglottic tissues
T4 Tumor invasion of cartilage or tissue beyond larynx

56. TNM Classification of cancer larynx
(American joint committee on cancer)
GLOTTIS
T1 Tumor limited to vocal cords, normal mobility
T1a Tumour limited to one vocal cord
T1b Tumour involves both vocal cords
T2 Extension to supraglottis and/or subglottis; may be
impaired cord mobility
T3 Limited to larynx with cord fixation
T4 Extension beyond larynx or into cartilage

57. TNM Classification of cancer larynx
(American joint committee on cancer)
SUBGLOTTIS
T1 Tumour limited to the subglottis
T2 Tumour extends to vocal cord(s) with normal or impaired
mobility
T3 Tumour limited to larynx with vocal cord fixation
T4 Extension beyond larynx or into cartilage

58. Regional Lymph Nodes (N)
Nx Cannot be assessed
N0 No regional metastasis
N1 Single positive ipsilateral node, less than 3 cm
N2 Nodes less than 6 cm
N2a Single ipsilateral node 3-6 cm
N2b Many ipsilateral nodes less than 6 cm
N2c Bilateral and contralateral node less than 6 cm
N3 Node(s) greater than 6 cm

59. Distant Metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
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
IVA T4 N0 M0
Any T N2 M0
IVB Any T N3 M0
IVC Any T Any N M1
Histopathologic Grades
Grade 1 : Well-differentiated
Grade 2 : Moderately differentiated
Grade 3 : Poorly differentiated

60. TREATMENT OPTIONS

61. TREATMENT PLAN
 For the first and second stages
 Radiation therapy and/or conservative surgery
 For the third and fourth stages
 Radical surgery

Total laryngectomy

Laryngopharyngectomy
 Combined with unilateral radical neck dissection with
or without contralatral modified neck dissection
 Post operative radiotherapy

62. TYPES OF LARYNGECTOMY
 Vertical partial laryngectomy
(hemilaryngectomy)
 Horizontal partial laryngectomy
 Supracricoid laryngectomy (subtotal
laryngectomy)
 Near-total laryngectomy
 Total laryngectomy

63. COMPLICATIONS OF SURGERY
 Infection
 Voice alterations
 Swallowing difficulties
 Loss of taste and smell
 Fistula
 Tracheostomy dependence
 Injury to cranial nerves: VII, IX, X, XI, XII
 Stroke or carotid “blowout”
 Hypothyroidism

64. XRT COMPLICATIONS
 Mucositis
 Odynophagia
 Laryngeal edema
 Xerostomia
 Stricture and fibrosis
 Radionecrosis
 Hypothyroidism

65. PROGNOSIS
5 YEAR SURVIVAL
STAGE I >95%
STAGE II 85-90%
STAGE III 70-80%
STAGE IV 50-60%

66. VOICE REHABILITATION
 The process of rehabilitation begins with
counselling before the patient undergoes
treatment
 Meeting with a fellow patient who has already
undergone the procedure
 Pre-operative visits to the speech therapist
 Booklets and websites hosted by the
laryngectomee clubs

67. METHODS OF SPEECH
RESTORATION
 Electro larynx
 Oesophageal speech
 Transoral pneumatic device
 Tracheo-oesophageal
speech
 Blom-singer prosthesis
 Panje valve

68. ELECTRO LARYNX

69. OTHER METHODS OF
COMMUNICATION
 Lip reading classes for attendants
 Sign language classes for patient and
attendants

70. OTHERS
Ca LARYNX
n= 49
37
12 LARYNGEAL CANCERS
ENT DEPT
January 2012–June 2015

71. male female
n= 49
36
13
ENT DEPT
January 2012–June 2015

72. 0
2
4
6
8
10
12
14
16
18
20
Mandibulectomy & Neck
Dissection
Maxillectomy Laryngectomy Parotidectomy Neck Dissection Glossectomy & Neck
Dissection
Laryngo-Pharyngo-
Esophagectomy
Extended Radical
Mastoidectomy
Misc Excisions
19
11
9
6
12
1 3 1
9
Summary of head and neck cases done at ENT Dept
July 2012 JUNE 2015

73. Current thought for laryngeal cancer is
organ sparing therapy for voice
preservation.Radiation therapy is ideal for
this and works well for early stages of the
disease.Surgical therapy has also evolved
organ sparing techniques.However,the older
proven technique of total
laryngectomy is still a primary
modality for advanced laryngeal cancers.
CONCLUSION

74. Nutting CM, Robinson M, Birchall M. Survival from '
laryngeal cancer in England and Wales up to 2001. British
Journal of Cancer 2008; 99(5uppl 1): S38-9.
Lauder E. The laryngectomee and the artificial larynx—a second look.
J Speech Hear Disord 1970;35:62–5.
list MA, Ritter-Sterr CA , Baker TM et ai. Longitudinal assemsment of quility of life
in laryngeal cancer patients 1996; 18: 1-10
Cancer research UK website, accessed Oct 5, 2009
Silver SE . Surgery for of the larnyx and related structures, 2nd
edn. Philadelphia: WB
Saunders 1996
REFERENCES

75. DEPARTMENT OF ENT,
HEAD AND NECK SURGERY