Tumors of Larynx

Prepared by Dr.Hiwa Asad

Benign Tumors

• Ectodermal

• Mesodermal

• pseudotumours

Ectodermal Tumours

• Papilloma: single or multiple

• Adenoma

• Paraganglioma

• Neurilemmoma

• Common in adults, rare in children• Sessile or pedunculated• Usual sites anterior commissure, anterior half of

the vocal cords• Men : women ratio 2:1• Present with hoarseness• If small removed endoscopically• If large by laryngofissure• Biopsy to exclude malignancy specially if recurrent

Single papilloma

Laryngeal papillomaLaryngeal papilloma

Squamous papilloma of Squamous papilloma of

the aryepiglottic foldthe aryepiglottic fold

Multiple papillomas

• Infants and young children, rare in adults

• A virus may be responsible (HPV)

• Vocal cords are the usual site

• Hoarsness if vocal cords affected

• Dyspnoea may occur ---- tracheostomy

• Removed endoscopically by CO2 laser

• Spontaneous recovery in puberty may occur

Juvenile laryngeal papillomasJuvenile laryngeal papillomas

Juvenile papillomasBefore and after removal

1. Vascular neoplasms

2. Chondroma

3. Myogenic tumours

4. Fibroma

5. Lipoma

Mesodermal tumoursMesodermal tumours

Vascular neoplasms

• Arise from blood or lymphatic vessels

Haemangioma

• Rare in adults• Telangiectatic vocal cord polyp

Chondroma• Arise from cartilages (Mostly cricoid)• More in men (40-70 years)

Clinical features

• Hoarsness and dyspnoea• Stridor (extention into subglottic space) • Dysphagia (extension into hypopharynx) • External swelling (cricoid ring or thyroid

cartilage)

• Indirect laryngoscopy reveals a smooth mass covered by intact mucosa

• Radiology shows calcific stippling or coarse irregular calcificatuon

• Biopsy specimens is unrepresentative, the tumour is hard and difficult to penetrate

• Surgery is the treatment of choice • Radiptherapy is of little value

Chondroma

Malignant Tumors

• 1% of all malignancies In UK

• More in men

• Predominantly of squamous pathology

• Interfere with function and emotion

• High cure rate 85%

Incidence

• Higher in urban than rural population

• Social and racial differences reflect different habits (tobacco and alcohol)

The International Union against Cancer (UICC) classified Ca larynx on anatomical bases

ClassificationClassification

20% 10% 70%

1 cm1 cm

Su

pra

glo

ttis

Su

pra

glo

ttis

EpilarynxEpilarynxSuprahyoid epiglottisSuprahyoid epiglottis

Aryepiglottic foldsAryepiglottic folds

SupraglottisSupraglottis infrahyoid epiglottis infrahyoid epiglottis

false cordsfalse cords

ventriclesventricles

Glottis Glottis True cord,ant&post comissureTrue cord,ant&post comissure

SubglottisSubglottis

UICC classification of Ca larynxUICC classification of Ca larynx

Glottis Glottis true cords true cords

anterior anterior commissure commissure

posterior posterior commissurecommissure

Aetiology • Unknown • Possibly related factors genetic and social factors male predominance racial predilection urban pollution tobacco and alcohol radiation asbestos occupational factors

Examination and diagnosis• Diagnosis will be made after consideration of:

1. History

2. Examination of the larynx

3. Examination of the neck

4. General examination of the patient

5. Radiology

6. Clinical investigations

7. Histological examination

1-Symptoms • Dysphonia progressive and unremitting• Cough and irritation in the throat (early) • Dyspnoea & stridor in advanced tumour,

specially in subglottic Ca • Pain more typical of supraglottic Ca, late and

uncommon • Referred otalgia may occur• Swelling of the neck or larynx (tumour or LN)• Haemoptysis (rare ,in lesions of the margin of

epiglottis) • Anorexia, cachexia or fetor are late symptoms• Progress of the disease

2-Examination of the larynx

examine for

• Focal abnormality • Vocal cord lesion • Mass • Mobility

examine by

• Indirect laryngoscopy (LA)• Flexible laryngoscopy (LA)• Direct laryngoscopy (GA) • Microlaryngoscopy (GA)

3-Examination of the neckA palpable neck mass could be due to:

1.Direct spread of the tumour.

2.Regional lymph nodes 2.Regional lymph nodes

metastasis. metastasis.

3.Enlarged thyroid lobe3.Enlarged thyroid lobe

which suggest which suggest invasioninvasion

4-General examination

• To identify metastasis e.g. to the liver

• To assess the overall physical status of the individual who is likely to need GA and biopsy, surgery, radiotherapy or chemotherapy

5-Radiological examination

• Chest X-ray

• Larynx Tomography

• CT and MRI of neck and larynx

Supraglottic tumourSupraglottic tumour

TomographyTomographyAPAP LateralLateral

Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarionAxial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion

CT scan

Epiglotic tumorEpiglotic tumor （（ laryngeal Ca. supraglotic typelaryngeal Ca. supraglotic type ））

MRI

MRI

Sagittal T2 image of Sagittal T2 image of supraglottic Casupraglottic Ca

Extension involves Extension involves the epiglottis :Ethe epiglottis :E

Loss of normal Loss of normal pr-epiglottic fat plane: pr-epiglottic fat plane: solid arrowssolid arrows

Tongue base Tongue base involvement : open involvement : open arrowarrow

Axial MRI showing tumour of the Rt. VCAxial MRI showing tumour of the Rt. VC

MRI

Coronal view of MRI showing subglottic extensionCoronal view of MRI showing subglottic extension

Sagittal view showing transglottic tumourSagittal view showing transglottic tumour

MRI

6-Clinical investigations

• Full hematological screen

• Biochemical profile including liver function tests and serum protein

• A urine screen for diabetes

• ECG

7-Histological examination

• Proof diagnosis of malignancy

• Type of the tumor

• Degree of differentiation

Diagnostic difficulties

• Negative biopsy

• Keratosis

• Previous radiation

• Miscellaneous conditions: chronic laryngitis, TB, Syphilis…

Pathology

1. Squmous cell carcinoma:

The vast majority of laryngeal malignant tumours.

• Verrucous carcinoma (Ackerman’s tumour):

A distinct variant of well differentiated squamous cell Ca is the

Glottic Ca

Origin :Origin : the free margin of the vocal cordsthe free margin of the vocal cords

Invasion & extensionInvasion & extension

anterior commissureanterior commissure

cartilage (Ossified more prone)cartilage (Ossified more prone)

arytenoid & posterior cricoarytenoid musclearytenoid & posterior cricoarytenoid muscle

vertical extension to the subglottis &/orvertical extension to the subglottis &/or supraglottis supraglottis

is more frequent than to the opposite sideis more frequent than to the opposite side

Cancer of the Lt true vocal cordCancer of the Lt true vocal cord

glottic CAglottic CA

cancer involving the true vocal cords and arytenoid.  The cancer also extends onto the supraglottis

Impaired mobility :

superficial invasion of the thyroarytenoid muscle

Fixation of the vocal cords: by invasion of: - thyroarytenoid muscle - arytenoid cartilage - cricoid cartilage -cricoarytenoid joint

Glottic Ca

Supraglottic Ca

• Often involving both sides

• Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies

• thyroid cartilage

• pre-epiglottic space occur in 40% of supraglottic Ca and 70% of epiglottic Ca

• vallecula & base of the tongue

• Arytenoid

• Pyriform sinus

Supraglottic Ca

InvasionInvasion

Supraglottic CaSupraglottic Ca

Epiglottic tumpur

Tumour of Lt aryepiglottic fold

Tumour of Rt false cord

• Primary are rare

• Grow circumferentially and extensively

• Invasion of the vocal cords may lead to impairment of mobility and hoarsness

• Can spread through the cricothyroid membrane anteriorly or cricotracheal membrane posteriorly or invade the trachea caudally

Subglottic Ca

Subglottic CaSubglottic Ca

Lymph node involvement

• 18% had LN metastasis at the time of referral

Supraglottic ( 40% )

Glottic Ca ( 5% )

Subglottic Ca ( 13% )

• Few present with distant metastasis at the time of diagnosis

• 11% have distant metastasis, mostly in the lung ( 6.8% )

Distant metastasis

TNM classification

T:T: Primary tumourPrimary tumour

N: Nodal depositsN: Nodal deposits

M: MetastasisM: Metastasis

T T : : Primary tumourPrimary tumour

TXTX

T0T0

TisTis

Primary tumour can not be assesed

No evidence of primary tumour

Carcinoma insitu

T : Primary tumour

GlotticT1 limited / mobile a: one cord b: both cords

T2 extends to supra or subglottic /mobile

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

T1aT1a

Rt.VC Ca with normal mobilityRt.VC Ca with normal mobility

Glottic

T1bT1b Limited mobile both cordsLimited mobile both cords

Glottic

Glottic

T2 extends to supra or subglottic /mobile

large tumor on the left true vocal cord

and anterior false vocal cords (T2 Cancer)

cancer involving the true vocal cords and arytenoid.

The cancer also extends onto the supraglottis T2

Glottic

Subglottic

limited / mobile cords

T1T1

Subglottic

extends to glottis/mobileT2T2

Lt false cord Lt false cord tumourtumour

SupraglotticSupraglottic

T1T1 limited / mobile cords

T2T2

SupraglotticSupraglottic

Ca of the Rt. aryepiglottic foldCa of the Rt. aryepiglottic fold

Extends to glottisExtends to glottis

Moblie cordsMoblie cords

cord fixation

SupraglotticSupraglottic

T3T3

Ca of the Lt. arytenoidCa of the Lt. arytenoid

N: Nodal deposits

N1 ipsilateral movable

N2 contra or bilateral movable

N3 Fixed

No LN depositsNo LN depositsN0N0

M: Metastasis

M0 no metastasis

M1 metastasis

Stage 0 : Tis, N0 , M0Stage 1 : T1, N0 , M0Stage 2 : T2, N0 , M0Stage 3 : T3, N0 , M0 T1-T3, N1 , M0

Stage 4 : T4, N0/N1 , M0 Any T, N2/N3 , M0 Any T, Any N , M1

Staging

RehabilitationRehabilitation

TreatmentTreatment

curativecurative

No treatmentNo treatment PalliationPalliation

No treatment

• Those presenting in extremis

• who are no longer conscious of pain or distress

• Disseminated tumours cause their death without the primary tumour or regional disease causing symptoms

• 7-8% recieve no treatment

Palliation • The attempt to suppress the Ca and its

symptoms without expectation or intent to cure

• Palliation is used in late stages

• Includes: pain relief tracheostomy other surgery radiotherapy chemotherapy

Pain relief

• Pain is not common in Ca larynx

• combination methods including analgesics, radiation, surgery, and chemotherapy used for pain relief

Tracheostomy

• To relieve airway obstruction

It often provide a dilemma, as it just delay the inevitable death in a patient with incurable cancer

Other surgeries

Total laryngectomy

For pain control occasionally

Radical neck dissection

may remove a fungating or painful local lesion

Radiotherapy

• Commonly used for palliation• Can be applied locally and selectively• Radioactive implants of gold are useful for

local treatment

Chemotherapy

• No Ca larynx has been cured by drugs• Complete regression is rare• Partial response in 20%• In no way can be compared to

radiotherapy or surgery• Rather it is an alternative to analgesics• Has significant side effects and leads to

more suffering

Curative treatment

• Radiotherapy

• Surgery

• Chemotherapy

• 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 has not preceded by surgery

• Radiation is more applicable on the oxygenated periphery, while surgery could deal with the mass

RadiotherapyRadiotherapy

• Selection of cases:1. When cure is likely with preservation of function.2. When surgery is contraindicated or refused.

Chemotherapy before radiation increases the response.

RadiotherapyRadiotherapy

• Contraindicaitons

1. Active perichondritis

2. Cartilage invasion

3. Previous radiotherapy

RadiotherapyRadiotherapy

• Interstitial radiation

radioactive gold-198 grains can be inserted using a special gun in a pattern which can give a very high dose localized to nodes or nodules in the neck, with little damage to normal structures

RadiotherapyRadiotherapy

• Radiation reactions

1. Erythema or moist desquamation of the skin, may progress to necrosis

2. Perichondritis

3. Mucositis (Painful erythematous reaction)

reactions are minimized by the avoidance of smoking and alcohol.

RadiotherapyRadiotherapy

Recurrence after radiotherapyRecurrence after radiotherapy

Surgery

• Microlaryngeal Surgery

• Laser Surgery

• ExcisionalExcisional Surgery

Microendolaryngeal and laser surgery

• 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

• Used with or without radiotherapy• Has risk of loss of voice, and protection of the

airway• Is more effective than radiotherapy in large

tumours and when there are secondary deposits in LN in the neck

• Partial resection of the larynx may maintain a near normal funcion with high cure rate

• Used after failure of radiotherapy

Excisional surgery

Selection of treatment

1. Keratosis & Carcinoma in situ in the glottis and supraglottis

2. Small tumours in the marginal zones (suprahyoid epiglottis, aryepiglottic folds, false cords)

Microendoscopic removal with or without laser

1. T1 & T2 lesions (Supraglottis and glottis )

2. T3 glottis

3. Subglottic tumours

4. Small or subclinical nodes

Radiotherapy

1. Supraglottic lesions arising from the base of the epiglottis and the false cords .

2. T2 lesions as alternative to radiotherapy

3. T3 & T4

4. Subglottic lesion as alternative to radiotherapy

5. Secondary nodal deposits

6. Other malignancies apart from squamous type all are treated by laryngectomy

Surgery

• This is to avoid tracheostomy when there is airway obstruction in laryngeal Ca

• Peristomal recurrence is more in those with tracheostomy who undergone laryngectomy

Emergency laryngectomy

Surgical techniques

• Vertical partial resectionVertical partial resection

• Horizontal partial resectionHorizontal partial resection

• Total resectionTotal resection

-With or without neck dissection-With or without neck dissection

Skin incision for laryngofissureSkin incision for laryngofissureRunning over the midportion of thyroid cartilage between st.cl.mastoid Running over the midportion of thyroid cartilage between st.cl.mastoid

musclesmuscles

Skin incisionSkin incision

Thyroid cartilageThyroid cartilage

Cricoid cartilageCricoid cartilage

cordectomycordectomy

Exposure of thyroid cartilage & cricothyroid membrane in the midlineExposure of thyroid cartilage & cricothyroid membrane in the midline

cordectomycordectomy

The perichondrium is exposed retracting the strap musclesThe perichondrium is exposed retracting the strap muscles

cordectomycordectomy

Elevation of the edges of external perichondriumElevation of the edges of external perichondrium

cordectomycordectomy

Midline Midline thyrotomythyrotomy

Division of the thyroid cartilae in the midline with a power sawDivision of the thyroid cartilae in the midline with a power saw

cordectomycordectomy

Thyroid alae retractedThyroid alae retracted

Endolarynx inspectedEndolarynx inspected

Extent of the tumour assesedExtent of the tumour assesed

VC removed from ventricle to VC removed from ventricle to

subglottis, lateral boundary of subglottis, lateral boundary of

resection is the internal perichondrium resection is the internal perichondrium

of tyroid ala of tyroid ala

cordectomycordectomy

Tumour of the Rt. VC is seen by retraction of thyroid laminaTumour of the Rt. VC is seen by retraction of thyroid lamina

Rt.VC tumourRt.VC tumour

cordectomycordectomy

Retraction of supraglottic larynxRetraction of supraglottic larynx

Rt.VC tumourRt.VC tumour

cordectomycordectomy

Line of incisionLine of incision

Excision with scissorsExcision with scissors

cordectomycordectomy

Reapproximated thyroid cartilageReapproximated thyroid cartilage

cordectomycordectomy

Suturing of the perichondriumSuturing of the perichondrium

cordectomycordectomy

Suturing of sternohyoid Suturing of sternohyoid

cordectomycordectomy

Suturing of platysmaSuturing of platysma

cordectomycordectomy

Closure of skinClosure of skin

cordectomycordectomy

The surgical specimenThe surgical specimen 1 year after surgery1 year after surgery

cordectomycordectomy

Management of LN metastasis

1. Observation for limited cancers

2. Palpable LN at presentation—Neck disection with/without Radiotherapy.

3. Prophylactic treatment—Neck dissection or radiotherapy.

4. Treatment of postoperative and post- irradiation LN

Thanks