CARCINOMA LARYNX

BY

DR TARIQUE AHMED MAKAREGISTRAR IN ENT

CARCINOMA LARYNX

PATIENT’S PROFILE

NAME XYZ

AGE 65 yrs

SEX Male

RESIDENCE Kotla Arab Ali Khan

DATE OF ADMISSION Jan 2014

PRESENTING COMPLAINTS

HOARSENESS - 6 Months

DIFFICULT - 2 weeks BREATHING

HISTORY OF PRESENT ILLNESS

Hoarseness of voice Insidious onset and progressive

Breathing Difficulty Inspiratory stridor

Past history Personal history

25 cigarettes a day

Family history Drug history Socioeconomic history

Not Contributory

GENERAL PHYSICAL EXAMINATION

PULSE 98 bpm BLOOD PRESSURE 130/80 mm of Hg TEMPERATURE 98.2 ˚F RESPIRATORY RATE 28 breaths/min

EXAMINATION (contd)

PALLOR CYANOSIS CLUBBING JAUNDICE OEDEMA KOILONYCHIA

THYROID Not enlarged JVP Not raised LYMPH NODES Not palpable

ABSENT

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

ENT EXAMINATION

THROAT No abnormality found in oral

cavity

EARS NOSE Normal NECK

UNREMARKABLE

SYSTEMIC EXAMINATION

Cardiovascular system

Respiratory system

Gastrointestinal system

Central nervous system

EMERGENCY TRACHEOSTOMY

Emergency tracheostomy was performed under local anesthesia to relieve stridor

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

NORMAL

INVESTIGATIONS (contd)

ECG ,2-D echo Serum urea & electrolytes PT, PTTK LFTs Blood Glucose levels Hepatitis Profile

INVESTIGATIONS (contd)

CT Scan Neck

PROVISIONAL DIAGNOSIS

Growth larynx

Direct laryngoscopy and biopsy under GA planned

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

HISTOPATHOLOGY

WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA

DIAGNOSIS

WELL DIFFERENTIATED SQUAMOUS

CELL CARCINOMA LARYNX

STAGE (iii) T3 N0 M0

DECISION

TOTAL LARYNGECTOMY FOLLOWED BY RADIOTHERAPY

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

OPERATIVE STEPS

GLUCK SORENSON INCISION

DRAPING

SKIN FLAPS RAISED

DISSECTION CONTINUES

LARYNX DISSECTED FROM STERNOMASTOID

AND CAROTID SHEATH

CONTRALATERAL THYRIOD FREED & SECURED

STRAP MUSCLES SECTIONED & LARYNX MOBILIZED

REMOVAL OF SPECIMEN

Larynx

mobilized

LARYNX REMOVED

NASOGASTRIC TUBE PASSED

Neopharyn

The Resected Specimen

NEOPHARYNX CONSTRUCTED

Base of tongue

Oesophagus

Tracheostome

Neopharynx

SUCTION DRAINS PLACED WITHOUT CROSSING THE NEOPHARYNX

SUCTION DRAIN

SUC

TION

DR

AIN

NEOPHARYNX

TRACHEOSTOME FASHIONED

& WOUND CLOSSED

TRACHEOSTOME

THE TRANSGLOTTIC GROWTH

The Resected Specimen

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

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

POST OP HISTOPATHOLOGY

WELL DIFFERENTIATED

SQUAMOUS CELL

CARCINOMA Clear resection margins Thyroid gland not involved

Regular follow-up

Adjuvant Radiotherapy

Voice Rehabilitation Healthy stoma

FOLLOW UP

Healthy stoma

CARCINOMA LARYNX

CASE DISCUSSION

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

Supraglottis Epiglottis Aryepiglotic Fold Arytenoids False cords and Ventricle

Glottis True vocal cords Anterior & Posterior commissures

Subglottis Upto lower border of cricoid catilage

SUBSITES

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

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

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

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

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

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

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

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)

DIAGNOSIS

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

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

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 beimpaired cord mobility

T3 Limited to larynx with cord fixation

T4 Extension beyond larynx or into cartilage

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

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

Distant Metastasis (M)Mx Distant metastasis cannot be assessedM0 No distant metastasisM1 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 GradesGrade 1 : Well-differentiatedGrade 2 : Moderately differentiatedGrade 3 : Poorly differentiated

TREATMENT OPTIONS

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

TYPES OF LARYNGECTOMY

Vertical partial laryngectomy (hemilaryngectomy)

Horizontal partial laryngectomy Supracricoid laryngectomy

(subtotal laryngectomy) Near-total laryngectomy Total laryngectomy

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

XRT COMPLICATIONS

Mucositis Odynophagia Laryngeal edema Xerostomia Stricture and fibrosis Radionecrosis Hypothyroidism

PROGNOSIS

5 YEAR SURVIVAL

STAGE I >95%

STAGE II 85-90%

STAGE III 70-80%

STAGE IV 50-60%

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

METHODS OF SPEECH RESTORATION

Electro larynx Oesophageal speech Transoral pneumatic device

Tracheo-oesophageal speech Blom-singer prosthesis Panje valve

ELECTRO LARYNX

OTHER METHODS OF COMMUNICATION

Lip reading classes for attendants

Sign language classes for patient and

attendants

OTHERS

Ca LARYNX

n= 49

37

12 LARYNGEAL CANCERS

ENT DEPT January 2012–June 2015

male female

n= 49

36

13

ENT DEPT January 2012–June 2015

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 Deptt July 2012 JUNE 2015

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

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

DEPARTMENT OF ENT, HEAD AND NECK SURGERY