The document discusses malignancies of the larynx and hypopharynx. It covers the etiology, which includes tobacco, alcohol, HPV, and radiation exposure. The larynx has three subsites - supraglottis, glottis, and subglottis. The hypopharynx also has three subsites - pyriform sinus, postcricoid region, and posterior pharyngeal wall. Diagnostic workup involves endoscopy, biopsy, and imaging. Treatment depends on staging and may include chemotherapy, radiation therapy, or surgery like laryngectomy. Prognosis and rehabilitation after laryngectomy is also reviewed.

1. Malignancies of Larynx
and Hypopharynx
Dr.R.Malarvizhi MS(ENT), DLO
Senior Resident
Department of Otorhinolaryngology
MAHER

2. Malignancy
 Robbins and Cotram (1979a) suggest that
“a neoplasia is a new growth, comprising an
abnormal collection of cells the growth of which
exceeds and is uncoordinated with that of the
normal tissue.”

3. Histopathology
 90-95% Squamous
cell carcinoma
 5-10%
 Verrucous carcinoma
 Spindle cell carcinoma
 Adenocarcinoma
 Sarcomas

4. Etiology
 Tobacco and Alcohol
 Combination increases risk by 15%
 Previous radiation to neck
 HPV (oropharynx more common than neck
tumours)
 Occupational exposure
 Asbestos, Mustard gas, chemical and petroleum
vapours

5. Larynx
 Supra-glottis
 Arytenoids, Ary-epiglottic folds, vestibular folds,
Epiglottis
 Glottis
 Vocal folds including anterior and posterior
commissures
 Subglottis
 Inferior surface of vocal folds to lower border of
cricoid cartilage

7. Hypopharynx
 Pharynx is
 Nasopharynx
 Oropharynx
 Hypopharynx
 Hypopharynx
 Pyriform sinus/fossa
 Postcricoid region
 Posterior pharyngeal
wall

9. Overlap
 Malignancies of larynx and hypopharynx
overlap during spread of tumor
 Only the symptomatology hierarchy points to
the primary cause
 Nodal metastasis another clue to point of
origin

10. Larynx-Glottis
 More common laryngeal sub-site
 Gender- male> female
 Cause- tobacco, alcohol
 Primary symptoms
 Voice change- hoarse
 Dyspnoea
 Spread- to other sub-sites and hypopharynx,
lungs
 Lymphatic – late- as avascular and watershed
area region. Only on spread to another laryngeal
sub-site or other regions

12.  Classification
 TNM

13. Larynx- Supraglottis
 Gender- Male>Female
 Cause- Tobacco, Alcohol
 Primary symptoms
 Often silent- hoarseness late
 Early – throat pain, dysphagia, referred otalgia
 Nodal presentation
 Spread
 Glottic and pyriform sinus
 Lymphatic- bilateral
 Oropharynx

15.  Classification
 TNM

16. Larynx- Subglottis
 Incidence- rare
 Gender- male> female
 Cause- tobacco, alcohol
 Primary symptoms
 Dyspnoea- early
 Hoarse voice late
 Spread
 Glottic, supraglottic, tracheal,

17.  Classification
 TNM

19.  M 0- No metastasis
 M 1- Metastasis present

21.  Investigation
 IDL, ENDOSCOPY
 CT/MRI Neck with contrast
 Microlaryngeal examination and Biopsy
 Supravital staining- toulidene blue
 Treatment
 Voice sparing- CCRT, Conservative- partial
laryngectomy
 Laryngectomy

23. Recap
 Larynx
 Voice, dyspnoea, swallowing, foreign body sensation, referred
otalgia
 3 subsites
 TNM N, M , T3,4 same
 T1,2 varies based on subsite
 Staging basis
 I-II – CCRT or stripping of cords – cordectomy (partial
laryngectomy is an option)
 III -CCRT with laryngectomy
 IVA – Laryngectomy with CCRT
 IV B – CCRT, Debulking surgery
 IV C – Palliative CCRT

24. Hypopharynx- Pyriform sinus
 Incidence – 60% of hypopharyngeal ca
 Gender- male > female
 Cause- tobacco, alcohol
 Primary symptoms
 Metastatic nodes first symptom in many, initially unilateral-
once other sub-sites are involved bilateral
 Remain asymptomatic in-spite of large growth
 Sticky/ pricky sensation in throat
 Referred otalgia
 Odynophagia
 Dysphagia
 Hoarse voice due to mass obstructing larynx

26.  Spread
 Local- commonly post cricoid and ppw,
esophagus
 Lymphatic
 Distant

27. Hypopharynx- Post-cricoid
region
 Incidence -40% of hypopharyngeal ca
 Gender- Female > Male
 Cause
 Patterson Brown Kelly (Plummer vinson) in 1/3rd
patients
 Alcohol, Tobacco
 Primary symptoms
 Early 20s female
 Progressive dysphagia
 Progressive malnutrition and weight loss
 On local spread aphonia

28.  Post cricoid maligancy- characteristic feature
 ABSENT Laryngeal crepitus (Bocca sign
negative, Muir’s crackle sign positive)
 Spread- exophytic, ulcerative
 Lymphatic- bilateral, retropharyngeal, mediastinal
 Pyriform sinus, ppw
 Esophagus – contiguous, skip lesions

30. Hypopharynx- Posterior
pharyngeal wall
 Incidence- 10% of hypopharyngeal ca
 Gender- males > 50yrs age
 Cause- tobacco, alcohol, HPV
 Primary symptoms
 Dysphagia
 Spitting blood
 Neck nodes as palpable mass before any other
symptom
 Spread
 Lymphatic- bilateral nodes, retropharyngeal

31. TNM
 Uniform for all Subsites

38.  Investigation
 IDL, Endoscopy, Barium swallow
 CT/MRI Neck
 Biopsy

40.  Treatment
 Chemoradiotherapy
 Laryngopharyngectomy

41. Recap
 Hypopharynx
 Swallowing, malnutrition, pain, referred
otalgia
 3 subsites
 Staging basis
 I-II - CCRT
 III – Laryngectomy/laryngopharyngectomy with CCRT
 IVA – surgery with CCRT
 IV B - CCRT
 IV C - CCRT

42. Unknown primary
 Clinical features
 Cervical nodes
 Investigation
 CT/MRI- skull base to mediastinum
 PET CT/MRI
 Pan endoscopy and biopsy from all sites of pharynx
 Treatment- CCRT, Debulking surgery (Neck
dissection)
 Prognosis- Poor

43. Role of HPV
 HPV 16
 Better prognosis than non-HPV ca
 CCRT
 Common in Tonsil, Tongue than other sub-
sites
 Vaccination in adolescence for HPV

44. Radiotherapy
 Types
 Interstitial- no longer- implanting radioactive rods
 External Beam-Linear accelerator- Gamma knife- exposure to
Cobalt 60 waves
 Commonly used
 Newer – proton therapy, stereotactic radiosurgery
 Duration – 4-6 weeks
 Exposure 2 fractions a day, 5 days per weeks, 2Gy per day
(6000-8000 Gray total dose)
 Mechanism- all cells exposed are arrested at replication
stage.
 Adverse effects- mucositis, normal tissues also affected
 Radiosensitizers- chemotherapeutic agents, Hyperbaric
oxygen, Blood products

45. Chemotherapy
 Mechanism
 Targeted at cell replication cycle (G2M, S phases)
 For head and neck- cisplatin, 5-fluorouracil
 Recurrent cases- Monoclonal antibodies- Cetuximab
 Types- based on – prior to actual treatment or
along with radiotherapy or after surgery
 Dose based on surface area to be covered,
duration- once a week for 4-6 weeks
 Adverse effects- mucositis

46. Surgery
 Laryngectomy
 Laryngo-pharyngectomy
 Laryngo-pharyngectomy- esophagectomy

48. Vocal rehabilitation after
laryngectomy
 Written
 Aphonic lip speech
 Esophageal speech
 Electrolarynx
 Trans-oral –pnematic device
 Trans-Esophageal speech
 Bloom-singer prosthesis
 Panje prosthesis

49. Supportive
 Tracheostomy- temporary/ permanent(Laryngectomy)
 Esophageo-gastric /Gastrojejunal feeding
 Radio-sensitisers
 Pre- and Pro – biotics
 Multivitamins, parenteral nutrition
 Hydration, high protein diet
 Hygiene – oral, general
 Precautions – no washing radiation area as skin will be
fragile and slough off, separate rooms, neuro-oto-
nephro-cardio-toxicity
 Emotional support

50. Tracheostomy
 Opening of trachea to the exterior
 Types – high, MID, low
 Indication- stridor, anticipated or on episode
 Types of tubes
 Cuffed, uncuffed, metal, silastic, flexible
 Procedure steps
 Complications- pneumothorax, bleeding, emphysema
(early, intermediate and late)
 Post- op care- keep airway humidified, suctioning to
remove dried crusts, wound care

51. Other Malignancies of neck
 Oropharyx- Tonsil, Posterior wall of
oropharynx, Vallecula, posterior 1/3rd tongue
 Oral part of tongue, Mandible, Buccal
mucosa,
 Thyroid and para-thyroid
 Salivary glands
 Cervical lymph nodes
 Secondary metastasis
 Leukemia and Lymphomas