The document provides a detailed overview of the anatomy, pathology, and treatment of laryngeal carcinoma, including its subdivisions (supraglottis, glottis, subglottis) and the epidemiology of laryngeal cancer. It highlights risk factors, clinical presentation, and diagnostic methods such as imaging, emphasizing the importance of computed tomography. Treatment options discussed range from radiotherapy and surgery to chemotherapy, tailored to the stage of the cancer, with varying approaches for different degrees of tumor advancement.

1. LARYNX
DR. YAMINI BISHT
JUNIOR RESIDENT
DEPARTMENT OF RADIOTHERAPY
AIIMS GORAKHPUR

2. ANATOMY

3. SUBDIVISIONS OF LARYNX
PARTS
• SUPRAGLOTTIS
• GLOTTIS
• SUBGLOTTIS

4. Source: Perez and Brady

5. INCLUDES: epiglottis, false vocal cords,
ventricles, aryepiglottic folds, and the
arytenoids.
SUPRAGLOTTIS
• The axial line of demarcation
between the glottic and supraglottic:
apex of the ventricle.
• LYMPHATIC DRAINAGE:
Jugulodigastric (level II) lymph nodes
• Middle internal jugular chain (level III)
lymph nodes.
Source: Radiopaedia
Coronal CT

6. Source: Radiopaedia
Coronal CT

7. Includes: the floor of the ventricle,
interarytenoid area, true vocal cords,
and the anterior commissure.
GLOTTIS
• The posterior commissure is the
mucosa between the arytenoids
(interarytenoid area).
• There are essentially no capillary
lymphatics of the true vocal cords
Source: Perez and Brady

8. Axial CECT at the level of Glottis

9. Located below the vocal cords
SUBGLOTTIS
• Subglottis is extends from a point 5
mm below the free margin of the
vocal cord to the inferior border of
the cricoid cartilage or 10 mm below
the apex of the ventricle.
• LYMPHATIC DRAINAGE:
• The lymphatic trunks pass through the
cricothyroid membrane to the
pretracheal (delphian) lymph nodes in
the region of the thyroid isthmus.
• The subglottic area also drains to
paratracheal (level VI) lymph nodes and
inferior jugular (level IV) chain.
Source: Perez and Brady

10. Formed by the hyoid bone, thyroid
cartilage, and cricoid cartilage
SHELL OF LARYNX
• Cricoid cartilage: complete ring of
the upper airway.
• The more mobile interior framework
is composed of : heart-shaped
epiglottis and the arytenoid,
corniculate, and cuneiform
cartilages.

11. • The external laryngeal framework is
linked together by:
• Thyrohyoid, Cricothyroid, and
Cricotracheal ligaments or
membranes
• The epiglottis is joined superiorly to
the hyoid bone by the hyoepiglottic
ligament.
Source: Perez and Brady

12. Axial CECT of larynx. C: carotid artery E: epiglottis J:
Jugular vein PES: Periepiglottis space. T: thyroid
cartilage, TAM: Thyroarytenoid muscle
Coronal MDCT of larynx. C: carotid artery H: Hyoid
bone. T: Thyroid Gland (below) cartilage (above), TAM:
Thyroarytenoid muscle

13. CARCINOMA
LARYNX

14. Cancer of the larynx represents about 2%
of the total cancer burden and accounts
for 0.3% of all cancer deaths
EPIDEMIOLOGY AND
RISK FACTORS
• Smoking
• Alcohol Consumption
• Asbestos
• Cement Dust
• Paint Fumes
• HPV (Human papillomavirus)

15. NEW CASES:
35,855
13TH
MOST COMMON
DEATHS:
22,467
INCIDENCE (PER 100,000):
6.9
5 YEAR PREVALENCE:
97,099

16. New Cases Deaths
0
7200
14400
21600
28800
36000
43200
28,721
17,641
35,855
22,467
2018 2022

17. PATTERNS
OF SPREAD

18. LOCAL SPREAD
• The fat space is an important avenue
of submucosal tumor spread for
infrahyoid epiglottis, false cord, and
true vocal cord lesions.
• Thyroid cartilage invasion usually
occurs in the ossified section of the
cartilage, commonly in the region of
the anterior commissure tendon or the
junction of the anterior one-fourth
and the posterior three-fourths of
the thyroid lamina.
• Fixation of the vocal cord from
laryngeal cancer is usually caused by
invasion or destruction of the vocal
cord muscle, invasion of the
cricoarytenoid muscle or joint, or,
rarely, invasion of the recurrent
laryngeal nerve.
Glottic-subglottic carcinoma invading and enveloping the crico-arytenoid joint. The
tumor shows medial to lateral growth through the conus elasticus: (A) Sagittal
scheme; (B) Coronal scheme; (C) Axial T2-weighted MR image obtained at vocal
process level demonstrates a right-sided true vocal cord tumor involving the inferior
paraglottic space (arrowhead). The right arytenoid cartilage shows intermediate
signal intensity alteration (asterisk) indicative of invasion; crico-arytenoid unit
involvement is observed (arrow); (D) Axial T2-weighted sequence shows the
subglottic spread of the neoplastic mass >10 mm; (E) Endoscopy at vocal cord
level; (F) Endoscopy at subglottic level

19. Suprahyoid Epiglottis
Supraglottic Larynx
• The destructive lesions tend to
invade:
• The vallecula and preepiglottic space,
• The lateral pharyngeal walls
• The remainder of the supraglottic
larynx.
Source: Radiopaedia

20. Infrahyoid
Epiglottis
• Lesions of the infrahyoid epiglottis invade
the porous epiglottic cartilage and
thyroepiglottic ligament into the
preepiglottic fat space and extend toward
the vallecula and base of the tongue.
• Lesions of the infrahyoid epiglottis grow
circumferentially to involve the false
cords, aryepiglottic folds, medial wall
of the pyriform sinus, and the
pharyngoepiglottic folds.
• Invasion of the anterior commissure and
cords and anterior subglottic extension
usually occur only in advanced lesions.
• Infrahyoid epiglottic lesions that extend
onto or below the vocal cords are at a
high risk for thyroid cartilage invasion,
even if the cords are mobile.
Source: Radiopaedia

21. False Cord
• They involve the paraglottic fat space early in
their development and may spread a
considerable distance beneath the mucosa
without producing physical signs.
• These carcinomas extend to the
perichondrium of the thyroid cartilage quite
early, but cartilage invasion is a late
phenomenon.
• Extension to the lower portion of the infrahyoid
epiglottis and invasion of the preepiglottic
space are common.
• Submucosal extension involves the true vocal
cord, which may appear normal.
• Vocal cord invasion is often associated with
thyroid cartilage invasion. Submucosal
extension to the medial wall of the pyriform
sinus occurs early.
CT scan: heterogeneously enhancing mass lesion on the false
vocal cords.

22. Aryepiglottic
Fold/Arytenoid
• Lesions extend to adjacent sites and
eventually cause fixation of the larynx,
which is usually a result of involvement
of the cricoarytenoid muscle or joint or,
rarely, invasion of the recurrent
laryngeal nerve.
• Computed tomography (CT) may
distinguish the cause of fixation.
• Advanced lesions invade the thyroid,
epiglottic, and cricoid cartilages and
eventually invade the pyriform sinus
and postcricoid area.
Supraglottic carcinoma encasing the arytenoid from above with fixation due
to weight effect, without direct invasion of the CAU: (A) sagittal scheme. (B)
Coronal T2-weighted MR image shows a supraglottic tumor that involves
the superior paraglottic space on the right side (arrow) and invades the
glottis. (C) Sagittal T2-weighted image demonstrates that the lesion
encases the right arytenoid that appears diffusely hypointense because of
sclerosis suspicious for invasion (arrowhead), without clear evidence of
CAU involvement

23. Glottic Larynx
• Most lesions of the true vocal cord begin on the
free margin and upper surface of the cord.
• The anterior portion of the cord is the most
common site.
• If the lesion crosses to the opposite cord, anterior
commissure invasion is certain
• Tumors at the anterior commissure may extend
anteriorly via the anterior commissure tendon
(Broyles ligament)
• Subglottic extension may occur by simple
mucosal surface growth, but it more commonly
occurs by submucosal penetration beneath the
conus elasticus.
• Advanced glottic lesions eventually penetrate
through the thyroid cartilage or via the
cricothyroid space to enter the neck, where they
may invade the thyroid gland.
Glottic carcinoma invading the inferior paraglottic space and extending down to the
CAU, limited medially by the conus elasticus and laterally by thyroid cartilage: (A)
Coronal scheme; (B) Axial scheme; (C) Axial CE-CT at vocal process level:
enhanced neoplastic tissue involves the left true vocal cord and anterior
commissure; the inferior paraglottic space is obliterated (asterisk). Posteriorly, the
lesion is close to the left arytenoid cartilage which shows slight sclerosis (arrow);
(D) CE-CT reconstruction on the coronal plane: the lesion partially invades the left
superior paraglottic space becoming a so-called transglottic tumor (arrowhead).
Subglottic neoplastic spread > 10 mm is not present; (E) Endoscopic view

24. Subglottic Larynx
• Most involve the inferior surface of the
vocal cords by the time they are
diagnosed, so it is difficult to know
whether the tumor started on the
undersurface of the vocal cord or in the
true subglottic larynx.
• They involve the cricoid cartilages in the
early stage because there is no
intervening muscle layer.
• Partial or complete fixation of one or
both cords is common; misdiagnosis or
diagnostic delay is frequent.
Transglottic-hypoglottic carcinoma with massive invasion of the crico-arytenoid unit
and involvement of the posterior crico-arytenoid muscle, reaching the
hypopharyngeal submucosa: (A) Axial scheme; (B) Axial CE-CT image at the level
of the cricoid lamina shows a right-side neoplastic mass with homogeneous
enhancement (asterisk). The right cricoid cartilage demonstrates sclerosis
suspicious for neoplastic invasion (arrow); (C) Axial T2-weighted MR image at the
same level: right cricoid cartilage shows signal alteration (arrowhead) similar to
intermediate tumor signal intensity, indicative of invasion. The lesion extends to the
right crico-thyroid space which appears enlarged (asterisk). Thyroid cartilage is
invaded and extra-laryngeal neoplastic spread is observed (arrow);

25. Lymphatic Spread
• The disease spreads mainly to the level II
nodes.
• The incidence of clinically positive nodes is
55% at the time of diagnosis; 16% are
bilateral
• Spread to the pyriform sinus, vallecula,
and base of the tongue increases the risk
of lymph node metastases
• Glottic spread is typically associated with
metastasis to the level II nodes.
• Anterior commissure and anterior
subglottic invasion are also associated
with involvement of the midline
pretracheal lymph node (level VI)

26. Clinical
presentation and
Diagnosis

28. Clinical Presentation
• Hoarseness of Voice (early stage).
• Odynophagia, otalgia, pain localized to the
thyroid cartilage, and airway obstruction are
features of advanced lesions.
• Odynophagia, is the most frequent initial
symptom, often described as a sore throat.
• Sensation of a “lump in the throat.”
• Pain is referred to the ear by way of the
Arnold branch of the vagus nerve.
• A neck mass may be the first sign of a
supraglottic cancer.
• Late symptoms: weight loss, halitosis,
dysphagia, and aspiration.

29. Physical Examination
• Flexible fiberoptic endoscopes provide the
best view of the larynx, hypopharynx, and
posterior oropharynx.
• The scope is inserted through the nasal
passage and passed over the
nasopharyngeal side of the soft palate to
provide a “bird’s-eye” view of the larynx
• The mucosal surfaces of the base of the
tongue, posterior pharyngeal wall, vallecula,
hypopharynx, supraglottis, glottis, and
subglottis are examined.
• Vocal cord mobility is determined by
asking the patient to say “ee” (adduction)
and sniff in (abduction). Subtle distinctions
between paresis and paralysis may require
multiple examinations or stroboscopy.

30. Normal DL scopy Findings

31. • Ulceration of the infrahyoid epiglottis
or fullness of the vallecula is an
indirect sign of preepiglottic space
invasion.
• Palpation of diffuse, firm fullness
above the thyroid notch with
widening of the space between the
hyoid and the thyroid cartilages
signifies invasion of the
preepiglottic space.
• The preepiglottic fat space is a low-
density area on the CT scan, and
changes resulting from tumor
invasion are easily seen.
• Postcricoid extension may be
suspected when the laryngeal click
disappears on physical examination.
• Postcricoid tumor may cause the
thyroid cartilage to protrude
anteriorly, producing a fullness of
the neck.
• Localized pain or tenderness to
palpation or a small bulge over one
ala of the thyroid cartilage is
suggestive of thyroid cartilage
invasion.
Physical Examination

32. Imaging
• CT scan with contrast enhancement
(method of choice)
• Should be performed before biopsy so
that abnormalities that may be caused by
the biopsy are not confused with tumor.
• CT slices 1 to 2 mm thick are obtained at
1- to 2-mm intervals through the larynx and
at 3-mm intervals for the remainder of the
study.
• The gantry is angled so that the scan slices
are parallel to the plane of the true vocal
cords.
• It is also necessary to obtain a CT scan of
the entire neck to detect positive,
nonpalpable lymph nodes..
Source: Radiopaedia

33. CT vs MRI
Imaging
• CT is preferred to magnetic resonance (MR) imaging because the longer scanning
time for MR results in motion artifact.
• The value of MR imaging includes:
• Defining subtle exolaryngeal spread or early cartilage destruction
• Extent of tracheal invasion and esophageal invasion.
• Sagittal MR may also be useful in detecting early invasion of the base of the
tongue.

34. AJCC 2017
STAGING

48. PROGNOSTIC FACTORS
• The extent of the primary lesion and neck disease are the major determinants
of prognosis.
• AJCC stage and N stage are the major determinants of cause-specific survival.
• In addition, within each N stage, patients with positive nodes in the low neck
below the level of the thyroid notch tend to have a lower cause-specific
survival rate than do those with disease confined to the upper neck.
• Women have a better prognosis than men.

49. RADIOTHERAPY
SURGERY
CHEMOTHERAPY
TREATMENT

50. VOCAL CORD CARCINOMA
STAGE RECOMMENDED TREATMENT
CARCINOMA IN SITU
RADIOTHERAPY> TLM (Transoral laser
Microsurgery)
EARLY STAGE (T1 & T2) RADIOTHERAPY WITH SALVAGE SURGERY
MODERATELY ADVANCED (T3) (FAVOURABLE)
RT with surgical salvage or immediate total
laryngectomy
ADVANCED (T3,T4) (UNFAVOURABLE)
Total laryngectomy, with or without adjuvant RT
and neck dissection
Definitive RT (medically unfit )

51. SURGERY
SURGICAL MANGEMENT INDICATION DEFINITION
Cordectomy (TLM or TORS) CARCINOMA INSITU Excision of the vocal cord
Vertical partial laryngectomy (i.e.,
hemilaryngectomy)
The maximum subglottic extension
suitable for hemilaryngectomy is 8 to
9 mm anteriorly and 5 mm
posteriorly
Removal of limited cord lesions with
preservation of voice
Supracricoid partial laryngectomy T2 and T3 glottic carcinomas
Removal of both true and false cords
as well as the entire thyroid cartilage.
Total laryngectomy with or without
neck dissection
ADVANCED STAGE
The entire larynx is removed, and the pharynx is
reconstructed. A permanent tracheostomy is
required. Speech may be reconstituted with a
prosthesis or with an electrolarynx

52. RADIATION THERAPY TECHNIQUES
• For T1 lesions, RT portals extend from the thyroid
notch superiorly to the inferior border of the cricoid
and fall off anteriorly.
• For T2 tumors, the field is extended depending on the
anatomic distribution of the tumor
• The field size ranges from 4 × 4 cm to 5 × 5 cm (plus an
additional 1.0 cm of “flash” anteriorly) and is
occasionally 6 × 6 cm for a large T2 lesion.
• Portals larger than this increase the risk of edema
without improving the cure rate.
Source: Perez and Brady

53. • RT of T3 and T4 lesions requires
larger portals, which include the
levels II and III lymph nodes.
• The level IV lymph nodes are included
in a separate low-neck portal.
Source: Perez and Brady

54. • Treatment technique for
postoperative RT after
laryngectomy
Source: Perez and Brady

55. Intensity modulated radiotherapy
IMRT
• IMRT may be considered for T1, T2 glottic
cancers to reduce the dose to carotid arteries
• Disadvantages: increased dose inhomogeneity,
increased total body dose, and increased labor
and expense.
• The most common indications for IMRT for
laryngeal cancers is a node-positive T3–T4
cancer, where the retropharyngeal nodes would
be electively irradiated and the dose to the
contralateral parotid gland reduced, and/or a
difficult low match between the lateral fields used
to treat the primary site and upper neck and the
anterior lowneck field in a patient with a short
neck and large shoulders. .
• IMRT is especially useful for patients with
extensive subglottic invasion, where achieving
an adequate inferior margin with conventional
lateral portals may not be possible.
Source: Perez and Brady

56. DOSE FRACTIONATION
• 66 Gy for T1 lesions and 70 Gy for T2 cancers given in 2-Gy fractions.
• Evidence suggests that increasing the dose per fraction may improve the
likelihood of local control
• Concomitant weekly cisplatin 30 mg/m2
is considered for patients with T2B
cancers.

57. SUPRAGLOTTIC CARCINOMA
STAGE RECOMMENDED TREATMENT
EARLY AND MODERATELY ADVANCED
RT or supraglottic laryngectomy, with or without
adjuvant RT.
ADVANCED
Total laryngectomy with or without adjuvant RT
EXOPHYTIC ADVANCED LESIONS RT and concomitant chemotherapy,

58. SURGERY
SURGICAL MANGEMENT INDICATION DEFINITION
Supraglottic laryngectomy
lesions involving the epiglottis, a
single arytenoid, the aryepiglottic
fold, or the false vocal cord
Voice sparing laryngectomy with
increased tendency to aspirate
Supracricoid laryngectomy
lesions extending from the
supraglottis into one or both vocal
cords.
At least one arytenoid must be
preserved for successful
decannulation and phonation
Total laryngectomy with or without
neck dissection
ADVANCED STAGE
The entire larynx is removed, and the pharynx is
reconstructed. A permanent tracheostomy is
required. Speech may be reconstituted with a
prosthesis or with an electrolarynx

59. • The primary lesion and both sides of the neck are
treated with opposed lateral portals
• Wedges are used to compensate for the contour of
the neck.
• The lower neck nodes are irradiated through a
separate anterior portal
• IMRT may be employed to spare one or both parotids
and to avoid a low match line in the occasional patient
with a short neck and large shoulders
RADIATION THERAPY TECHNIQUES
Source: Perez and Brady

60. Dose Fractionation
• Currently either hyperfractionation or simultaneous integrated boost (SIB) is used.
• SIB: 70 Gy in 35 fractions over 30 treatment days in 6 weeks with 1 twice-daily fraction
during the last 5 weeks (with a minimum 6-hour interfraction interval).
• The high-risk clinical target volume (CTV) encompasses the gross disease
• The intermediate-risk CTV receives 63 Gy at 1.8 Gy per fraction
• The standard-risk CTV receives 56 Gy at 1.65 Gy per fraction.
• In the case of clinically positive nodes, an electron beam portal may be used to increase the
dose to the posterior cervical nodes after the fields are reduced to avoid the spinal cord at
45 Gy if parallel opposed fields are employed.

61. Post Radiation Sequelae
• Sore throat, loss of taste, and moderate dryness during RT.
• Edema of the arytenoids may occur and give a sensation of a lump in the throat.
• Tracheostomy is rarely necessary, even for bulky lesions.
• Edema of the larynx may persist for several months to a year. (Most Common).
• Corticosteroids such as dexamethasone have been used to reduce RT-induced edema
after recurrence has been ruled out by biopsy.
• Approximately 30% treated with twice-a-day RT require temporary gastrostomy feeding
tubes because they have difficulty in swallowing.

62. Follow Up
• Follow-up of patients with early lesions is planned for every 4 to 8 weeks for 2 years,
every 3 months for the 3rd year, and every 6 months for years 4 and 5, and then
annually for life.
• If recurrence is suspected but the biopsy is negative, patients are re-examined at 2-
to 4-week intervals.
• Annual Chest Xrays to rule out lung metastasis
• TSH every 6-12 months
• CT is obtained 4 weeks after completing RT
• A neck dissection is added if the residual cancer in the nodes is believed to exceed 5%;
otherwise, the patient is observed and a CT is repeated in 3 months.
• PET-CT is obtained at 3 months, and a neck dissection is added if persistent positive
nodes are observed.

63. THANK YOU