The document discusses laryngeal cancer including epidemiology, risk factors, clinical presentation, diagnosis, staging, treatment options and management. Key points include: - Laryngeal cancer accounts for 2.6% of cancers and most commonly presents between ages 40-70. - Main risk factors are smoking, alcohol consumption and HPV infection. - Diagnosis involves laryngoscopy and biopsy to determine tumor extent and staging. - Treatment depends on tumor stage but may include radiation therapy, surgery such as laryngectomy, or chemotherapy. Preservation of the larynx is prioritized when possible.

1. Dr Manpreet Singh Nanda
Associate Professor ENT
MMMC&H Solan

2.  2.6% of all cancers
 AGE – 40 to 70 yrs
 SEX – M:F 10:1
 MC –SCC (>90-95%)
 MC – glottic (70%)
 Others ca – verrucous ca, spindle cell ca,
sarcomas, malignant salivary gland tumours

3.  Alcohol – supraglottic ca
 Smoking – Benzopyrene is carcinogenic
 Alcohol + Smoking – 15 times higher
 Radiation exposure
 Familial/genetic
 Occupational – exposure to asbestos, nickel,
petroleum products, wood products,
construction workers
 Racial – black>white
 HPV-16
 Diet – high dietary fibres, salt preservation meat
 GERD

4.  Pre malignant disorders – ca in situ,
leukoplakia, solitary papillomas,
hyperkeratosis
 PREVENTION
 - smoking cessation
 - reduce alcohol
 - healthy diet (green leafy veg)

5.  Clinical Evaluation
 Adult with hoarseness presisting longer than 3-4
weeks and not responding to treatment
 Diagnostic Laryngoscopy – IDL/Fibreoptic rigid/
nasal flexible
 vc – fixed/immobile (infiltration)
 Exophytic/ulcerative lesion
 Extent of disease
 Neck Examination –
 Extra laryngeal spread, nodal metastasis,
perichondritis
 Lump neck, broadening/tenderness of larynx,loss
of crepitations

6.  Routine investigations – blood/urine/RBS/ECG
 Imaging –
 X Ray Neck – patency of airway, extent
 Chest X Ray – TB, Pulmonary metastasis,
mediastinal nodes, bronchopneumonia
 CT/MRI – extent of tumour, cartilage destruction,
nodal metastasis
 PET Scan – for recurrent (after 4
months)/residual disease (within 4 months)
 Stroboscopy
 Panendoscopy/Barium Swallow – for
secondaries/ spread
 DL Scopy and biopsy/Microlaryngoscopy

7.  For hidden areas of larynx – infrahyoid
epiglottis, ventricle,.. Subglottis
 GA
 Take a excisional biopsy for suspected lesion
with border of healthy mucosa
 Under operating microscope for more
accurate biopsy
 Supravital staining with toluidine blue –
apply to the lesion, wash after 20 sec, dry
 Dye taken up (deep blue colour) – CIS/sup ca
 Not taken up - Leukoplakia

8.  Gross – exophytic (cauliflower) – suprahyoid
epiglottis. Ulcerative – infrahyoid epiglottis
 H.P.E grading (Border’s classification)
 I – well differentiated - >75% cells are normal
– glottic ca
 II – moderately differentiated – 50-75% cells
are normal
 III – poorly differentiated – 25-50% cells are
normal – subglottic ca
 Anaplastic - <25% cells are normal –
supraglottic ca

9.  Supraglottis – Epilarynx(supraglottic
epiglottis, aryepiglottic folds, arytenoids)
 Infrahyoid epiglottis
 Ventricular bands/false cords
 Ventricle/saccule
 Glottis – true vc
 Ant commissure
 Post commissure
 Subglottis – walls of subglottis to lower
border of cricoid cartilage

10.  T – Primary tumour
 Tx – cant be assessed
 T0 – no tumour
 Tis – ca in situ
 T1, T2, T3, T4a, T4b

11.  N – Regional lymph node size in greatest
diameter
 Nx – cant be assessed
 N0 – no regional ln metastasis
 N1 – single I/L LN upto 3 cm
 N2a – single I/L LN >3 cm upto 6 cm
 N2b – multiple I/L LN upto 6 cm
 N2c – B/L or C/L LN upto 6 cm
 N3 – LN>6 cm
 M – Distant Metastasis – Mx – cant be assessed/
M0 – no distant metastasis/ M1 – distant
metastasis

12.  0 – Tis N0 M0 GOOD PROGNOSIS
 I – T1 N0 M0
 II – T2 N0 M0
 III – T3 N0 M0/T1-3 N1 M0 POOR PROGNOSIS
 IV a – T4a N0-1 M0/T1-4a N2 M0
 IV b – T4b N0-2 M0/T1-4b N3 M0
 IV c – T1-4 N0-3 M1

13.  R0 – no residual disease
 R1 – microscopic residual disease
 R2 – macroscopic residual disease

14.  MC laryngeal cancer
 Good prognosis as early presentation and late
metastasis
 Spread – 1st to reinke’s space, anterior and posterior
commissure, opposite vc, supraglottic and
subglottic..
 Nodal metastasis – rare ant commissure – delphian ln
 C/F – hoarseness of voice – early mc
 Airway obstruction/ stridor/ dyspnoea
 Cough due to aspiration
 Hemoptysis if sublottis involved....
 Vc thickening/ulcerative/exophytic growth at
anterior 2/3 rd of vc, ant commissure (granulations)
and post commissure

15.  T Staging
 T1 – Tumour involves only vocal cords, ant
commissure or post commissure with normal vc
mobility. T1a – one cord, T1b – both cords
 T2 – Tumour spreads to subglottis or supraglottis with
normal/impaired vc mobility
 T3 – Tumour limited to larynx with vc
fixation/involvement of paraglottic space, inner
cortex of thyroid cartilage
 T4a – Tumour involves thyroid cartilage or cricoid
cartilage or involves
esophagus,trachea,thyroid,tongue muscles or stap
muscles
 T4b – Tumour involves prevertebral space,
mediastinum or encasses the carotid artery

16.  2nd mc
 MC sites – epiglottis (mc), false cords, aryepiglottic
folds
 Anaplastic
 Present late – poor prognosis
 Spread
 Local – other subsites of supraglottis, vallecula, base
of tongue, pre epiglottic space, glottis, thyroid
cartilage, ant commissure
 Nodes – early involvement of level II and III. Epiglottis
– B/L metastasis
 Marginal zone tumours – tumours of aryepiglottic
folds as they behave similar to pyriform fossa
tumours..

17.  Distant metastasis – through blood to lungs,
liver and bone
 C/F
 Throat pain referred to ear
 Dysphagia/odynophagia/ FB sensation throat
 Muffled (hot potato) voice
 Aspiration
 Stridor
 Hoarseness (late symptom)
 Halitosis

18.  O/E
 LN mass neck II/III
 Exophytic (suprahyoid epiglottis) or
ulcerative growth, can obscure the glottis
 Fullness of ventricle banda
 Pooling of saliva
 Neck metastasis 40%, can be B/L
 Tender laryngeal cartilage
 Widening (splaying) of larynx

19.  T Staging
 T1 – Tumour limited to one subsite of subglottis with normal vc
mobility
 T2 – Tumour involving more than one subsite without vc fixation
or involvement of glottis, vallecula, base of tongue, pyriform
fossa
 T3 – Tumour limited to larynx with vc fixation/involvement of
post cricoid area,paraglottic space, pre epiglottic space or inner
cortex of thyroid cartilage
 T4a – Tumour involves thyroid cartilage or involves esophagus,
trachea,thyroid,tongue muscles or stap muscles
 T4b – Tumour involves prevertebral space, mediastinum or
encasses the carotid artery


20.  Rarest (1-5%)
 Prognosis – poor, high incidence of metastasis
 Poorly differentiated
 Spread
 Opposite side, trachea, vocal cords, thyroid
gland, cricothyroid membrane
 Nodes – IV, VI
 C/F – stridor (mc early symptom), dyspnoea,
cough, hemoptysis
 O/E – Diffuse proliferative growth or ulcer
involving anterior half of subglottis

21.  T Staging
 T1 – Tumour limited to subglottis with normal
vc mobility
 T2 – Tumour spread to glottis with normal/
impaired vc mobility
 T3 – Tumour limited to larynx with vc fixation
 T4a – Tumour involves thyroid cartilage or
cricoid cartilage or involves
esophagus,trachea,thyroid, or strap muscles
 T4b – Tumour involves prevertebral space,
mediastinum or encasses the carotid artery

22.  Tumours involving supraglottis, glottis and
subglottis along with involvement of
paraglottic space
 High incidence of laryngeal cartilage invasion
and destruction
 High incidence of extralaryngeal spread

23.  Factors
 Site and extent of lesion
 Status of lymph node metastasis
 Status of distant metastasis
 Stage I/II – Organ preservation therapy
 Radiotherapy
 Laser excision
 Conservative laryngectomy
 Stage III/IV – Combined therapy – surgery
(Total -laryngectomy +/- ND , pre op or post
op radical radiotherapy

24.  Curative radiotherapy
 6500 grays/ 30 fractions/ 5-6 weeks
 For early lesions – T1, T2
 Glottic ca – 90% cure rate
 Supraglottic ca – 70-90% cure rate
 Preserves the larynx function, retain voice
and normal air passage
 Not indicated for fixed cords, cartilage
invasion, advanced lesions

25.  Cordectomy – endoscopic/external
 - Partial CO2 laser cordectomy – T1 lesions
not involving ant commissure (glottic ca)
 - Total cordectomy – T2 lesions
 Partial vertical laryngectomy
 - Partial frontolateral laryngectomy –
excision of vc and ant commissure
 - Vertical hemilaryngectomy – removal of half
(I/L) true and false vc, thyroid, arytenoid
 - Partial lateral laryngectomy

26.  Partial horizontal laryngectomy
 - Supraglottic partial laryngectomy – excision
of supraglottis, aryepiglottic folds, false
cords, ventricles
 - Epiglottectomy
 Near total laryngectomy
 C/L (normal) side functional arytenoids, RLN,
short segment of cricoid forming
cricoarytenoid joint, healthy subglottic
mucosa and a strip of post tracheal wall are
left behind for reconstruction

27.  Neoadjuvant chemotherapy
 Concomittant RT + CT
 Indication – for advanced lesion with nodal
metastasis to preserve larynx function and voice
 Steps – first give CT
 If response – give complete RT
 If no response – salvage surgery followed by post
op RT
 Cisplatin (100mg/m2) and 5 FU – 3 cycles at
interval of 15-21 days
 Cisplatin, 5 FU and Bleomycin

28.  Indications - T3,T4, failure after RT or conservative
surgery
 C/I – distant metastasis
 Removal of entire larynx along with hyoid bone, strap
muscles, one or more rings of trachea and pre
epiglottic space. Pharyngeal wall is closed primarily.
Lower laryngeal stump is sutured to skin
 Types
 Wide field laryngectomy – removal of larynx, strap
muscles, thyroid gland and lymph nodes
 Narrow field laryngectomy – if tumour confined to
larynx – removal of larynx and strap muscles
 Disadvantages – loss of function of larynx and voice,
permanent tracheal opening

29.  Surgery with preop or post op RT
 Pre op RT
 - To make fixed nodes/tumour resectable
 Post op RT
 - To prevent recurrence
 - Multiple positive nodes
 - Positive margins – microscopic or gross
tumour on superficial margins on HPE

30.  Attempt to suppress the carcinoma and its
symptoms without curing it
 Indication – advanced ca with extensive
extra laryngeal spread, distant metastasis
 Procedures –
 Chemotherapy/radiotherapy
 Tracheostomy
 Gastrostomy/ RT feed
 Analgesics/ antibiotics
 Surgical debulking of tumour

31.  IV DHE (Di Hematoporphyrin Ether)
 Uptaken by malignant cells leading to
mitochondrial damage and apoptosis,
ischaemic necrosis of tumour tissue
 Indications – laryngeal ca, oesophageal ca,
bronchial tumours
 S/E – skin photosensitization

32.  Tis – endoscopic CO2 laser/ RT
 T1 – RT (preferred)/ endoscopic CO2 laser
 If ant commissure involved – RT/ partial
frontolateral laryngectomy. If fails – total
laryngectomy
 T2 – Normal vc mobility – RT, if fails – partial
vertical laryngectomy
 Fixed vc – partial vertical laryngectomy, if fails
total laryngectomy
 T3/T4 – total laryngectomy with neck dissection
 Advanced T4 – combined therapy/ palliative
therapy

33.  T1 – RT/CO2 laser excision
 Epilarynx – supraglottic laryngectomy
 T2 –
 Good lung function – supraglottic
laryngectomy
 Poor lung function – RT
 T3/T4 – total laryngectomy with neck
dissection and post op RT..

34.  Subglottic ca – T1/T2 – RT
 T3/T4 – total laryngectomy with post op RT
including superior mediastinum
 Transglottic tumours – Total laryngectomy
with neck dissection and post op RT....
 Inoperable – CT+RT
 Note – partial or total resection of pharynx,
oesophagus, base of tongue should be done
if involved along with total laryngectomy

35.  To visualise larynx,hypopharynx and oropharynx
 INDICATIONS
 Diagnostic
 IDL not successful – infants and young children,
strong gag reflex, overhanging epiglottis
 Hidden areas of larynx – vallecula, pyriform
fossa, ventricles, infrahyoid epiglottis, ant
commissure, subglottis
 As a part of bronchoscopy and oesophagoscopy
 To know the site and extent of tumour
 Persistent hoarseness
 Dyspnoea, stridor
 To evaluate vc palsy

36.  Biopsy
 Base of tongue, vallecula, laryngopharynx,
larynx
 Therapeutic
 Removal of benign lesions, early malignant
lesions, FB larynx, stricture dilatational of
laryngeal strictures
 CONTRAINDICATIONS
 Stridor (1st do tracheostomy)
 Trismus, # mandible, TM joint ankylosis
 Lesions of cervical spine
 Aneurysm of aorta, recent coronary occlusion

37.  ADVANTAGES OVER IDL
 Hidden areas can be imagined
 3 D image (2 D image in IDL)
 Biopsy/therapeutic
 No inverted image
 Overhanging epiglottis
 TYPES OF LARYNGOSCOPE
 Chevalier Jackson’s direct laryngoscope with
sliding blade
 Ant commissure laryngoscope with bevelled end
 Negus laryngoscope with proximal illumination

38.  ANAESTHESIA
 GA
 Preferred in adults
 C/I – croup, diptheria
 LA
 Sup LN block – 1-2 cc inj 2% lignocaine 1cm
below the greater cornu of hyoid bone on both
sides of neck
 Topical
 10% xylocaine spray, xylocaine viscus, few drops
of xylocaine into larynx by IDL, xylocaine soaked
swabs in pyriform fossa
 No anaesthesia – diagnostic in infants

39.  PRE OPERATIVE
 Do IDL
 NBM 6 hrs
 Rule out any loose teeth
 Take consent for tracheostomy if needed
 Inj atropine ½ hour before to reduce
pharyngeal secretions and prevent sinus
bradycardia
 Investigations – X Ray Neck (airway
patency), X Ray Chest (lung infections,
metastasis), barium swallow, CT Scan, MRI,
blood and urine investigations

40.  POSITION
 Supine with head extended at atlanto
occipital joint (head ring), neck flexed on
thorax (pillow under shoulders) – Boyce
position or barking dog position
 Head, neck and upper ½ of shoulder
projected beyond the table with head
supported by assistant
 Protect eyes with shield
 Protect teeth with gauze piece
 Lubricate laryngoscope with xylocaine jelly
or liquid paraffin

41.  PROCEDURE
 Hold scope in left hand and guide through right hand
into right side of tongue (right hand for manipulation)
-> when post 1/3rd of tongue reached, move to
midline to bring epiglottis in view
 1st look for uvula (1st landmark), then lift the
epiglottis forward by lifting the dorsum of tongue (2nd
landmark) – engagement of epiglottis and look in the
interior of larynx
 Tip advanced between the vestibular folds to
examine vc, ventricle
 Tip advanced beyond vc to examine subglottis
 Press the thyroid cartilage from external surface to
examine anterior commissure

42.  Check for mobility of vc and arytenoids
 Take biopsy (never b/l as web formation)
 POST OP CARE
 Place in lateral (coma) position to prevent
aspiration of blood and secretions
 Look for laryngeal oedema and spasm by
looking for resp distress, cyanosis
 INJ steroid
 COMPLICATIONS – Bleeding, Laryngeal spasm
and oedema, injury

43.  ON TABLE
 Anaesthesia complications like resp and
cardiac arrest, bradycardia, syncope
 Bleeding
 Dislocation, # teeth
 Laceration of epiglottis, soft palate
 Damage to cervical spine
 EARLY POST OP
 Bleeding, oedema of larynx (steroids,
tracheostomy, intubation
 LATE POST OP – scars, adhesions, granulomas

44.  Procedure for viewing and recording the
anatomical structures of larynx and their
function using special instruments for
exposure and lighting
 Instruments
 Microlaryngoscope (Kleinsasser’s)
 Chest support
 Operating microscope 10X magnification, 400
mm focal length objective lens
 Microlaryngeal instruments

45.  Advantage over DL Scopy
 Both hands free
 Better illumination
 Binocular vision
 Magnification and precision
 Documentation
 Indications
 Excision of benign lesions, leukoplakia,
papillomas, haemangiomas, lymphangiomas
 Laser treatment of early malignancy
 Endoscopic inj teflon paste, other vc
medialization, lateralization
 Supravital staining of vc

46.  Not indicated as a procedure along with
oesophagoscopy, bronchoscopy
 Anaesthesia – GA
 Procedure – here once vc visualised fix the
telescope with chest support (rest same)
 Investigations, preoperative, complications same
 Post op care
 NBM FOR 6 HOURS
 Voice rest – first 1-2 weeks complete voice rest,
next 1-2 weeks graduated voice rest (speak 5
min a day, doubled each day), next 2-3 months
avoid maladaptive voice, after 3 months normal
voice

47.  Antibiotics, steroids, steam inhalation
 Lateral position
 Speech therapy
 Anti reflux treatment
 Increased water intake
 Avoid voice abuse
 Avoid caffeine, diuretics, dairy products,
tobacco

48.  Nasopharyngoscopy
 OPD Procedure under Topical anaesthesia
providing greater magnification and better
visualisation of movement of vc........
 Documentation
 Pass via nose nasopharynx into larynx
 Indications
 Trismus
 Unconscious patient
 Difficult DL Scopy

49.  En block resection of entire laryngeal skeleton
including thyroid to 3rd tracheal ring, strap muscles,
lateral neck dissection (levelII,III,IV,VI LN) including
pharynx and upper oesophagus if required and
creating permanent tracheal stoma....
 Indications
 T3,T4 CA LARYNX, PYRIFORM FOSSA, POST CRICOID
AREA, POST PHARYNGEAL WALL
 If positive LN do RND/MRND
 PRE OP – take consent explaining need for
tracheostomy, loss of voice, quality of life
 Do preop tracheostomy
 Look for any foci of infection in nose, PNS, oral cavity
and general patient health

50.  STEPS
 Incision – Modified Sorenson’s incision (U shaped) one
mastoid process to another along SCM and to opp side 2
finger breadth above suprasternal notch or site of
tracheostoma
 Gluck’s incision
 Skin along with platysma flap elevation
 Separation of investing layer of deep cervical fascia
 Omohyoid muscle dissected
 Identify carotid sheath and clear level II, III, IV, VI LN
 Divide strap muscles
 RLN identified and divided
 Hyoid skeletonized
 Thyroid isthmus resected
 Larynx, trachea and vallecula exposed

51.  Pyriform fossa and post cricoid area
separated
 Trachea separated from oesophagus till
tracheostoma and divided
 Specimen removed
 Wound irrigated with hydrogen peroxide,
betadine and saline
 Pharyngeal defect sutured
 Trachea connected to skin creating a
permanent tracheostoma
 Close the neck in layers and place drains

53.  POST OPERATIVE CARE
 ICU 24 hrs
 NBM week in non radiated neck, 2-3 weeks in
radiated neck
 IV fluids
 Antibiotics
 Tracheostomy care
 Daily dressing
 Stitch removal after 7-10 days
 Encourage patient to sit and cough
 Serum calcium levels

54.  COMPLICATIONS
 Local
 Wound infection and dehiscence
 Pharyngo cutaneous fistula – improper closure,
post RT, infection, early feeding
 Carotid blowout – post RT
 Chylous fistula – thoracic duct
 Tracheostomal stenosis – improper technique
 Pharyngeal stenosis – inadequate pharyngeal
mucosa
 Stomal recurrence – subglottic extension,
inadequate dissection

55.  Systemic
 CVS – cardiac arrest
 LRTI
 Pulmonary embolism, pneumonia
 Anaemia
 Septicaemia
 Hypothyroidism
 hypoparathyroidism

56.  Tracheo esophageal fistula (Neoglottic
speech)
 Esophageal speech
 Artificial larynx

57.  Neoglottic speech
 Fistula created between trachea and
oesophagus/hypopharynx by puncturing the
post wall of trachea on its upper pasrt
 Primary TE puncture – at time of surgery
 Secondary TE puncture – 2-4 weeks
later/post RT
 Air carried from trachea to esophagus
through fistula -> vibrating column of air
along PE segment -> modulated into speech
by closure of tracheostome with finger

58.  Advantages
 Safe and simple
 High success
 Cost effective
 Can be performed years later
 Disadvantages
 Need for finger occlusion
 Involve 2nd surgery
 Aspiration
 Fungal infection

59.  Shunt the air from trachea into oesophagus
with inbuilt one way valve (unidirectional
valve)
 Advantages – no aspiration, no need for
finger occlusion
 Disadvantage – costly
 Types
 Non indwelling devices – inserted 1-2 weeks
after TEP, can be removed daily for cleaning
 Blom Singer Duck hill prosthesis, Panje voice
prosthesis

60.  Indwelling devices
 Placed at time of TEP, can be replaced only
by surgeon
 Blom Singer Indwelling voice prosthesis
 Latest – indigenous HRA VOICE PROSTHESIS –
made up of silicone, economical

61.  Patient taught to swallow air and hold it in
upper esophagus and save in stomach -> then
slowly ejects air from upper esophagus ->
sound produced from vibration along PE
juntion ->modulated into speech by lips,
teeth, palate
 Sound is rough but loud and understandable,
can speak 6-10 words at a time
 Inexpensive
 Needs motivation

62.  Types
 ELECTROLARYNX
 Battery operated electronic vibrator placed
externally on the neck
 TRANS ORAL PNEUMATIC DEVICE
 Plastic tube placed in back of oral cavity
 Expired air from tracheostome vibrates the
rubber diaphragm -> carried by plastic tube into
oral cavity -> modulated into speech
 Monotonous metallic voice
 Expensive
 Unwanted attention