The document discusses tumours of the larynx. It defines benign and malignant laryngeal tumours and describes common benign tumours like vocal nodules, vocal polyps, Reinke's edema, papillomas, and laryngoceles. It also discusses malignant tumours like squamous cell carcinoma. It provides details on the diagnosis, staging, and management of laryngeal cancer including surgery, radiotherapy, and chemotherapy. The document emphasizes that hoarseness is often the earliest symptom of glottic carcinoma and smoking is a major risk factor.

1. Tumours of Larynx
Dr. Abdur Rehman
Associate Professor ENT

2. Learning Objectives
 At the end of this lecture, student of fourth year
MBBS should be able to;
a) Enumerate common benign and malignant
laryngeal tumours
b) Differentiate between common benign and
malignant laryngeal tumours
c) Describe the aetiology and risk factors for
common laryngeal tumours
d) Describe the management of common laryngeal
tumours

3. Introduction
• Benign Or Malignant

4. Question
 36 year old female mother of two with a 4-year history of
intermittent hoarseness. Non-smoker, generally very healthy,
regular exercise. Very talkative person with outgoing
personality and work which requires constant talking both to
groups and on a one-to-one basis. Reports that her family is
also very loud in general. Gradual deterioration of voice over
the past few years.
 Laryngoscopic examination reveals bilateral vocal cord
masses 2mm in size.
 What is the diagnosis?
 How will you manage this patient?

5. Benign tumours of larynx
SOLID CYSTIC
VOCAL NODULE DUCTAL CYSTS
VOCAL POLYP SACCULAR CYSTS
REINKE’S OEDEMA LARYNGOCELE
CONTACT ULCER
INTUBATION GRANULOMA
LEUKOPLAKIA OR KERATOSIS
AMYLOID TUMOR
SQUAMOUS PAPILLOMA
JUVENILE PAPILLOMA
ADULT ONSET PAPILLOMA
GRANULAR CELL TUMOR
CHONDROMA GLANDULAR TUMOR
HAEMANGIOMA

6. • Synonyms:
Singer’s /Screamer’s /Teacher’s
/Hawker’s Node
• Benign, bilateral small swellings
• < 3mm that develop at the junction
of anterior 1/3rd and posterior 2/3rd
of vocal cord
• Aetiology: voice abuse
• Mostly seen in teachers, actors,
singers, vendors.
Vocal nodule

7. Vocal nodule
 Repeated Trauma -
oedema and haemorrhage
in the submucosal space,
hyalinization and fibrosis.
Thickening of overlying
epithelium.
 SYMPTOMS:
 Hoarseness,
 Vocal fatigue and pain in
neck on prolonged
phonation
 SIGNS:
 Pinkish to whitish swellings
 At the junction of anterior 1/3rd
and posterior 2/3rd of vocal cord
 Size < 3mm
 Normal vocal cord mobility

8. Treatment Of Vocal Nodule
 MEDICAL
May resolve spontaneously- voice
rest
Treat the aggravating factors-
allergies, infections, reflux
Speech therapy-lifestyle
modification, voice care, less strain
on voice
 SURGICAL
Excised by Microlaryngeal surgery
Postoperative Speech therapy

9. • Benign unilateral swellings >3mm,
on the free edge of vocal cord, at
the junction of anterior 1/3rd and
posterior 2/3rd of vocal cord
• Common structural abnormality of
vocal cord that causes
hoarseness
• Aetiology: phonotrauma
(shouting)
Vocal Polyp

10. Predisposing factors:
• Male, smoker, 30-50 years
Pathology:
• Haemorrhage in vocal cord,
fibrin exudation and
subsequent submucosal
oedema.
Symptoms:
• Sudden onset of hoarseness
of voice/loss of voice after
shouting
• Diplophonia (double voice)
Vocal Polyp
 Signs:
 Unilateral swelling at the
junction of anterior 1/3rd
and posterior 2/3rd of
vocal cord
 Haemorrhagic in
appearance.

11. Treatment of vocal polyp
 Polyps may shrink spontaneously
 Medical
Voice therapy
Unlikely to cause resolution
 Surgical treatment of vocal polyp
Removal under G.A.
Excised by microlaryngeal
surgery
 Voice rest for 48 hrs after surgery

12. • An air filled cystic dilatation of the
saccule.
• Predisposed by activities which
increase the intralaryngeal pressure,
like straining (weight lifters), glass
blowers and trumpet players.
• Pathological types:
• External-swelling lateral to
thyrohyoid membrane
• Internal -swelling of false cords and
aryepiglottic folds
• Combined/Mixed
Laryngocele

13. InternalExternal Combined

14. • Symptoms:
• Internal & Mixed:
Hoarseness and cough.
Stridor if large.
• External:
• Compressible mass in the neck,
• Increases on coughing or
Valsalva manoeuvre.
• Investigations:
• X-Ray neck during Valsalva, CT
scan neck.
• Laryngoscopy to rule out
malignancy.
Laryngocele

15. • Treatment:
• External/mixed:
• Surgical excision through an
external neck incision with
removal of part of thyroid
lamina
• Internal
• Marsupialisation

16. The most common (80%) benign tumour of larynx.
Juvenile Papilloma
• Seen in children
• Associated with Human Papilloma Virus types 6 and 11
• Usually multiple
• Recurrence is common after removal
• Symptoms: Hoarseness and stridor
Adult Papilloma
• They are single, less aggressive, and less prone for recurrence.
Squamous papilloma

17. • Signs:
Warty masses
sessile/pedunculated,
friable to touch.
• Treatment:
• Medical:
Interferon therapy;
anti-virals; like acyclovir and ribavirin.
• Surgical:
Endoscopic removal using KTP-
532/CO2 LASER, forceps, cryotherapy
or electro-cautery.
• Followed by interferon therapy.
Papilloma

18. Haemangioma larynx
 Commonly seen in
children
 Usually involve sub-
glottis
 Presents with stridor
 Treatment is excision
with CO2 LASER.

20. Question
 A 60 year old heavy smoker has been complaining
of hoarseness of voice for 3 years. Lately he
noticed worsening of his voice and a mild
respiratory distress on exertion. There was also
cough and some blood tinged sputum. On
laryngeal examination a whitish irregular mass was
found on the right vocal cord that was found also
paralyzed.
 What is the diagnosis?
 How will you manage this patient?

21. Laryngeal Cancer
 INCIDENCE
Most common head & neck cancer.
 Gender. Male: Female = 4:1
 >90% squamous cell cancer.
 Age. most often in people over the age of 55.
 Race. African Americans are more likely than
whites.

22. Laryngeal Cancer
Etiology and risk factors
 Cigarette smoking
 Synergistic effect with heavy
alcohol intake in Smokers.
 Alcoholism
 Occupational risk factors :
asbestos, mustard gas &
petroleum products.

23. Laryngeal Cancer
Classification
 Glottic tumour: Tumour in
the glottis.
 Supra-glottic tumour:
Tumour in the supra-glottic
area.
 Sub-glottic tumour: Tumour
in the sub-glottic area.

24. Laryngeal Cancer
1- Supraglottic cancer : 40%
2- Glottic cancer : 59%
3- Subglottic cancer: 1%

25. Laryngeal Cancer Clinical Presentation
 Signs and symptoms
 Mass effect:
Hoarseness, hemoptysis, neck mass, dysphagia, airway
compromise (difficulty breathing), aspiration.
 Throat pain, ear pain (referred through CN X branch)
Suggests advanced stage
 Hoarseness = allow for early detection of glottic carcinoma
 Supraglottic Carcinoma = tend to present later
Usually present with bulkier tumors
More likely to present with neck node due to richer lymphatics
 Weight loss

26. Laryngeal Cancer Clinical Presentation
 Physical Exam
 Complete head and neck
examination
Palpation for nodes
 Laryngoscopy
Laryngeal mirror
Fibreoptic examination
Note: contour, color,
vibration, cord mobility,
lesions.

27. Laryngeal Cancer
Diagnosis
History
Physical examination
Indirect laryngoscopy
Examination Of Neck

28. Laryngeal Cancer
Diagnosis
 Direct laryngoscopy
 Radiology:
Chest X Ray
CT Scan
MRI
 Biopsy and Histological
examination

29. Question
 The most common and earliest manifestation of
carcinoma of the glottis is:
A. Hoarseness
B. Haemoptysis
C. Cervical lymph nodes
D. Stridor
E. Dysphagia

30. Laryngeal Cancer Staging
TNM classificaiton
T : Primary tumour
N: Nodal deposits
M: Metastasis

31. T : Primary tumour
TX Primary tumour can not be assesed
T0 No evidence of primary tumour
Tis Carcinoma in situ

32. Carcinoma of the left vocal cord

33. Glottic squamous cell carcinoma

34. Glottic squamous cell carcinoma

35. Supraglottic squamous cell carcinoma

36. Subglottic Carcinoma

37. T : Primary tumour
Glottic
T1 limited / mobile
a: one cord
b: both cords
T2 extends to supra or
subglottic / impaired
mobility
T3 cord fixation
T4 extends beyond
the larynx
Supra & subglottic
T1 limited / mobile
cords
T2 extends to
glottis/mobile
T3 cord fixation
T4 extends beyond
the larynx

38. Glottic
T1a
VC Carcinoma with normal mobility

39. Glottic
T1b Limited; mobile both cords

40. GlotticT2
extends to supra or subglottic / impaired
mobility
large tumor on the left true
vocal cord
and anterior false vocal cords
(T2 Cancer)

41. Glottic
T3 cord fixation
T4 extends beyond the larynx
Lt VC Ca with fixation

42. Supraglottic
T1 limited / mobile
cords
Lt false cord tumour

43. Supraglottic
Extends to glottis
Mobile cords
Ca of the Rt. aryepiglottic
fold
T2

44. Supraglottic
T3
cord fixation
Ca of the Lt. arytenoid
T4 extends beyond the larynx

45. Subglottic
T1 subglottis
T1
limited / mobile
cords

46. Subglottic
Subglottic tumour extends to
glottis
T2 extends to glottis/mobile

47. Subglottic
T3
T4
cord fixation
extends beyond the larynx

48. N: Nodal deposits
No Lymph Node depositsN0
N1
N2
N3
ipsilateral movable,= or < 3 cm
contra or bilateral movable > 3
cm but = or < 6 cm
Fixed, > 6 cm

49. M: Metastasis
M0 No Metastasis
M1 Metastasis

50. Staging
Stage 0 : Tis, N0 , M0
Stage 1 : T1, N0 , M0
Stage 2 : T2, N0 , M0
Stage 3 : T3, N0 , M0
T1-T3, N1 , M0
Stage 4 : T4, N0/N1 , M0
Any T, N2/N3 , M0
Any T, Any N , M1
Early
stage
Advanced
stage

52. Treatment
Rehabilitationcurative
Palliation

53. Palliation
• The attempt to suppress the Carcinoma and its
symptoms without expectation or intent to cure
• Palliation is used in late stages
• Includes:
pain relief
tracheostomy
other surgery
radiotherapy
chemotherapy

54. Radiotherapy Surgery Chemotherapy
Curative treatment

55. • Radiation is most effective where the tissues are
well oxygenated.
• So it is most valuable in small lesions and when
the vascular supply is undamaged, where it’s not
preceded by surgery
• Radiation has the advantage of preservation of
voice
Radiotherapy

56. CA larynx for radiotherapy

57. Surgery
Microendolaryngeal and laser surgery
Excisional surgery

58. • Carcinoma in situ can by treated
by microsurgical excision and laser
makes this easier
• Certain localized supraglottic
lesions may be excised using a
laser
Carbon dioxide laser is used
Microendolaryngeal and laser
surgery

59. Microendolaryngeal and laser
surgery

60. • Partial(vertical or horizontal), subtotal and total
laryngectomy.
• Used with or without radiotherapy.
• Has risk of loss of voice, and loss of protection of the
airway.
• Is more effective than radiotherapy in large tumours
and when there are secondary deposits in LN on the
neck.
• Partial resection of the larynx may maintain a near
normal function with high cure rate.
• Used after failure of radiotherapy.
Excisional surgery

61. Total laryngectomy
Removed specimen

62.  Carcinoma in situ .
 Stage 1 .
 Stage II ..
 Micro laryngeal surgery
 Transoral CO2 laser. .
 Radiotherapy .
 Partial surgery .
 Trans oral co2 laser .
 Radiotherapy .
 Partial surgery .
 Trans oral laser excision .
Treatment of glottic
carcinoma

63. Treatment of glottic carcinoma
 Stage III .
 Stage IV .
 Total laryngectomy +
Neck dissection if
neck nodes palpable
 Total laryngectomy +
Neck dissection +
Post operative
radiotherapy .

64. Management of neck in glottic carcinoma
 No .
 NI , NII .
 N III.
 1 –radiotherapy .
 2 –elective neck dissection.
 1 –selective neck dissection.
 1 –modified or radical neck
dissection + radiotherapy .

65. Question
 A 60 year old heavy smoker has been complaining
of hoarseness of voice for 3 years. Lately he
noticed worsening of his voice and a mild
respiratory distress on exertion. There was also
cough and some blood tinged sputum. On
laryngeal examination a whitish irregular mass was
found on the right vocal cord that was found also
paralyzed.
 What is the diagnosis?
 How will you manage this patient?

66. Question
 A patient is diagnosed as a case of squamous cell
carcinoma right vocal cord. Stage is T1 N 0 M 0.
Treatment is
a) Monthly follow up
b) Surgery
c) Surgery followed by Radiotherapy
d) Radiotherapy and follow up
e) Chemotherapy

67. Question
 A patient is diagnosed as of squamous cell
carcinoma larynx with involvement of thyroid
cartilage. Stage is T4 N 0 M 0. Treatment is
a) Radiotherapy
b) Chemoradiotherapy
c) Total laryngectomy
d) Total laryngectomy & Radiotherapy
e) Neck dissection

69. Post total laryngectomy

70. Voice Rehabilitation
• Esophageal speech
• Tracheo-esophageal puncture
• Electrolarynx

71. Esophageal speech

72. Tracheo-esophageal puncture
(TEP)

74. Electrolarynx

75. Question
 A 25 year old man is a teacher by profession. He
complains of persistent hoarseness for the last 03
months. Most likely diagnosis is:
A. Vocal cord carcinoma
B. Recurrent laryngeal nerve paralysis
C. Vocal nodule
D. Hypothyroidism
E. Laryngeal tuberculosis

76. Take Home message
 Hoarseness of voice with bilateral nodules at the
junction between anterior 1/3rd & posterior 2/3rd in
voice abuser  Vocal cord nodules.
 Hoarseness of voice with unilateral polyp in the
vocal cord in voice abuser  laryngeal polyp.
 Old Male, chronic heavy smoker, with progressive
or persistent hoarseness of voice more than 2
weeks  may be Cancer larynx.