Tumours of Tumours of the larynx the larynx
May 06, 2015
Tumours of the Tumours of the larynxlarynx
IntroductionIntroduction
Benign or malignantBenign or malignant
Benign tumoursBenign tumours
PseudotumoursPseudotumours
Mesodermal tumoursMesodermal tumours
Ectodermal tumoursEctodermal tumours
Ectodermal tumoursEctodermal tumours
AdenomaAdenoma
NeurilemmomaNeurilemmomaParagangliomaParaganglioma
PapillomaPapilloma
PapillomaPapilloma
Single papillomaSingle papilloma Multiple papillomasMultiple papillomas
Common in Common in adultsadults, rare in children, rare in childrenSessile or pedunculatedSessile or pedunculatedUsual sites Usual sites anterior commissure, anterior half of anterior commissure, anterior half of the vocal cordsthe vocal cordsMen:women ratio Men:women ratio 2:12:1Present with Present with hoarsnesshoarsnessIf small removed If small removed endoscopicallyendoscopicallyIf large by If large by laryngofissurelaryngofissureBiopsyBiopsy to exclude malignancy specially if to exclude malignancy specially if recurrentrecurrent
Single papillomaSingle papilloma
Laryngeal papillomaLaryngeal papilloma
Squamous papilloma of Squamous papilloma of
the Lt. aryepiglottic foldthe Lt. aryepiglottic fold
Multiple papillomasMultiple papillomas
InfantsInfants and young children, rare in adults and young children, rare in adults
A A virusvirus may be responsible (HPV) may be responsible (HPV)
Vocal cordsVocal cords are the usual site are the usual site
HoarsnessHoarsness if vocal cords affected if vocal cords affected
DyspnoeaDyspnoea may occur ---- may occur ---- tracheostomytracheostomy
Removed endoscopically by Removed endoscopically by CO2 laser CO2 laser
Spontaneous recoverySpontaneous recovery in puberty may occur in puberty may occur
Multiple papillomasMultiple papillomas
Juvenile laryngeal papillomasJuvenile laryngeal papillomas
Juvenile papillomasBefore and after removal
AdenomaAdenoma
Arise from Arise from seromucinous glandsseromucinous glands
Common site is Common site is subglottissubglottis
Symptoms are Symptoms are fewfew until the tumour until the tumour obstructs the breathingobstructs the breathing
TreatmentTreatment is surgery depending on the is surgery depending on the site and size of the tumoursite and size of the tumour
1.1. Vascular neoplasmsVascular neoplasms
2.2. Chondroma Chondroma
3.3. Myogenic tumoursMyogenic tumours
4.4. FibromaFibroma
5.5. Lipoma Lipoma
Mesodermal tumoursMesodermal tumours
Vascular neoplasmsVascular neoplasms
Arise from blood or lymphatic vesselsArise from blood or lymphatic vessels
HaemangiomaHaemangioma
Rare in adultsRare in adultsTelengiectatic Telengiectatic
vocal cord polypvocal cord polyp
ChondromaChondroma
Arise from cartilages (Mostly cricoid)Arise from cartilages (Mostly cricoid)More in men (40-70 years)More in men (40-70 years)
Clinical featuresClinical features
Hoarsness and dyspnoeaHoarsness and dyspnoeaStridorStridor (extention into subglottic space) (extention into subglottic space) DysphagiaDysphagia (extension into hypopharynx) (extension into hypopharynx) External swellingExternal swelling (cricoid ring or thyroid (cricoid ring or thyroid cartilage)cartilage)
ChondromaChondroma
Indirect laryngoscopyIndirect laryngoscopy reveals a smooth reveals a smooth mass covered by intact mucosamass covered by intact mucosa
Cricoid chondromaCricoid chondroma
RadiologyRadiology shows calcific stippling shows calcific stippling
BiopsyBiopsy specimens is unrepresentative, specimens is unrepresentative, the tumour is hard and difficult to the tumour is hard and difficult to penetrate penetrate
SurgerySurgery is the treatment of choice is the treatment of choice
RadiotherapyRadiotherapy is of little value is of little value
ChondromaChondroma
IntroductionIntroduction
1-2%1-2% of all malignancies In Iraq of all malignancies In Iraq
More in More in menmen
Predominantly of Predominantly of squamoussquamous pathology pathology
InterfereInterfere with function and emotion with function and emotion
High cure rate High cure rate 85%85%
IncidenceIncidence
Higher inHigher in urbanurban than rural population than rural population
Social and racial differences reflect Social and racial differences reflect different habits different habits (tobacco and alcohol)(tobacco and alcohol)
The International Union against Cancer The International Union against Cancer (UICC)(UICC) classified Ca larynx on classified Ca larynx on anatomical anatomical basesbases
ClassificationClassification
20% 10% 70%
AetiologyAetiology
Unknown Unknown Possibly related factorsPossibly related factors
genetic and social factorsgenetic and social factors male predominancemale predominance racial predilectionracial predilection urban pollution urban pollution tobacco and alcoholtobacco and alcohol radiation radiation asbestosasbestos occupational factorsoccupational factors
SymptomsSymptoms
DysphoniaDysphonia progressive and unremitting progressive and unremitting
Cough and irritationCough and irritation in the throat (early) in the throat (early)
Dyspnoea & stridorDyspnoea & stridor in advanced tumour, in advanced tumour, specially in subglottic Ca specially in subglottic Ca
PainPain more typical of supraglottic Ca, late more typical of supraglottic Ca, late and uncommon and uncommon
Referred otalgiaReferred otalgia may occur may occur
SymptomsSymptoms
SwellingSwelling of the neck or larynx (tumour or LN) of the neck or larynx (tumour or LN)
HaemoptysisHaemoptysis (rare ,in lesions of the margin (rare ,in lesions of the margin of epiglottis) of epiglottis)
Anorexia, cachexia or fetorAnorexia, cachexia or fetor are late are late symptomssymptoms
Examination and diagnosisExamination and diagnosis
Diagnosis will be made after consideration of:Diagnosis will be made after consideration of:
1.1. History History
2.2. Examination of the larynxExamination of the larynx
3.3. Examination of the neckExamination of the neck
4.4. General examination of the patientGeneral examination of the patient
5.5. RadiologyRadiology
6.6. Clinical investigationsClinical investigations
7.7. Histological examinationHistological examination
HistoryHistory
Small lesionSmall lesion
++
long historylong historyslowly growing lesionslowly growing lesion
Massive cancer Massive cancer
++
short historyshort history
Aggressive lesionAggressive lesion
poor outlookpoor outlook
Cancer can coexists or supervene in Cancer can coexists or supervene in leucoplakia, chronic laryngitis & TBleucoplakia, chronic laryngitis & TB
LeucoplakiaLeucoplakia
Chronic laryngitisChronic laryngitis
Vocal Cord Leukoplakia: This is a condition caused by chronic irritation which results in abnormal growth of the top layer of the skin lining the vocal cords.It is often seen in smokers and is considered a pre-cancerous condition.
Examination of the larynxExamination of the larynx
examine forexamine for
Foccal abnormality Foccal abnormality
Vocal cord lesion Vocal cord lesion
Mass Mass
MobilityMobility
examine byexamine by
Indirect laryngoscopy (LA)Indirect laryngoscopy (LA)
Flexible laryngoscopy (LA)Flexible laryngoscopy (LA)
Direct laryngoscopy (GA) Direct laryngoscopy (GA)
MicrolaryngoscopyMicrolaryngoscopy (GA) (GA)
subglottissubglottis
ventricleventricle
posterior surfaceposterior surface
of epiglottisof epiglottis
Difficult areas to be seenDifficult areas to be seen
Examination of the neckExamination of the neck
A palpable neck mass could A palpable neck mass could be due tobe due to
1.1. Direct spread of the tumourDirect spread of the tumour
2.2. Regional lymph nodes Regional lymph nodes metastasismetastasis
3.3. Enlarged thyroid lobe which Enlarged thyroid lobe which suggest invasionsuggest invasion
Incidence of nodal metastasisIncidence of nodal metastasis
Supraglottis 40%Supraglottis 40%Glottis 5 %Glottis 5 %Subglottis 13%Subglottis 13%
Supra & glottisSupra & glottis to regional LN to regional LN
(ipsilateral deep cervical chain level II & III & (ipsilateral deep cervical chain level II & III & prelaryngeal nodes)prelaryngeal nodes)
SubglottisSubglottis to level III & IV (mediastinal) LN to level III & IV (mediastinal) LN
General examinationGeneral examination
To identify To identify metastasismetastasis e.g. to the liver e.g. to the liver
To To assessassess the overall the overall physical statusphysical status of of the individual who is likely to need GA and the individual who is likely to need GA and biopsy, surgery, radiotherapy or biopsy, surgery, radiotherapy or chemotherapychemotherapy
Radiological investigationsRadiological investigations
CXR CXR for metastasis, other disorders and for metastasis, other disorders and as part of assessment of physical statusas part of assessment of physical status
LarynxLarynx to delineate the extent of the to delineate the extent of the tumourtumour
X-rayX-ray CT scanCT scan MRIMRI
Supraglottic tumourSupraglottic tumour
TomographyTomography
X-rayX-ray
APAP LateralLateral
Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarionAxial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion
CT scanCT scan
Axial CT scan showing a soft tissue mass with several Axial CT scan showing a soft tissue mass with several
punctuate calcifications (Chondrosarcoma)punctuate calcifications (Chondrosarcoma)
CT scanCT scan
Epiglotic tumorEpiglotic tumor (( laryngeal Ca. supraglotic typelaryngeal Ca. supraglotic type ))
MRIMRI
MRIMRI
Axial T1 image showing large supraglottic Ca extending to retropharyngeal spaceAxial T1 image showing large supraglottic Ca extending to retropharyngeal space
Abutting the Rt. carotid artery (curved open arrow)Abutting the Rt. carotid artery (curved open arrow)
Destruction of the Rt. thyroid ala (short open arrow)Destruction of the Rt. thyroid ala (short open arrow)
Destruction of the Rt. arytenoid (short solid arrow)Destruction of the Rt. arytenoid (short solid arrow)
MRIMRI
Sagittal T2 image of supraglottic CaSagittal T2 image of supraglottic Ca
Extension involves the epiglottis :EExtension involves the epiglottis :E
Loss of normal pr-epiglottic fat plane: solid arrowsLoss of normal pr-epiglottic fat plane: solid arrows
Tongue base involvement : open arrowTongue base involvement : open arrow
Axial MRI showing tumour of the Rt. VCAxial MRI showing tumour of the Rt. VC
MRIMRI
MRIMRI
Coronal view of MRI showing subglottic extensionCoronal view of MRI showing subglottic extension
Sagittal view showing transglottic tumourSagittal view showing transglottic tumour
MRIMRI
Clinical investigationsClinical investigations
Full haematological screenFull haematological screen
Biochemical profile including liver Biochemical profile including liver function tests and serum protein function tests and serum protein
A urine screen for diabetesA urine screen for diabetes
ECGECG
Histological examinationHistological examination
A biopsy by direct laryngoscopy under A biopsy by direct laryngoscopy under GAGA
Fine needle aspirationFine needle aspiration
Importance of biopsy:Importance of biopsy:1.1. Definitive diagnosis (>90%)Definitive diagnosis (>90%)
2.2. Identify type of tumourIdentify type of tumour
3.3. DifferentiationDifferentiation
PathologyPathology
The vast majority of laryngeal malignant The vast majority of laryngeal malignant tumours are tumours are squmoussqumous
A distinct variant of well differentiated A distinct variant of well differentiated squamous cell Ca is the squamous cell Ca is the verrucous verrucous carcinomacarcinoma (Ackerman’s tumour) (Ackerman’s tumour)
Spread of laryngeal carcinomaSpread of laryngeal carcinoma
Glottic CaGlottic Ca
OriginOrigin 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
CT scan and MRICT scan and MRI are valuable in are valuable in diagnosis of glottic Ca & its deep invasion, diagnosis of glottic Ca & its deep invasion, cartilage destruction and extension outside cartilage destruction and extension outside the larynxthe larynx
Glottic CaGlottic Ca
Supraglottic CaSupraglottic Ca
Often involving Often involving both sidesboth sides
Seldom extend to the glotticSeldom extend to the glottic region due to region due to different embryological derivations and different embryological derivations and various lymphatic suppliesvarious lymphatic supplies
thyroid cartilagethyroid cartilage
pre-epiglottic spacepre-epiglottic space occur in 40% of occur in 40% of supraglottic Ca and 70% of epiglottic Casupraglottic Ca and 70% of epiglottic Ca
vallecula & base of the tonguevallecula & base of the tongue
ArytenoidArytenoid
Pyriform sinusPyriform sinus
Supraglottic CaSupraglottic Ca
InvasionInvasion
Supraglottic CaSupraglottic Ca
Epiglottic tumpur
Tumour of Lt aryepiglottic fold
Tumour of Rt false cord
Primary are Primary are rarerare
GrowGrow circumferentially and extensively circumferentially and extensively
InvasionInvasion of the vocal cords may lead to of the vocal cords may lead to impairment of mobility and hoarsnessimpairment of mobility and hoarsness
CanCan spread spread through the cricothyroid membrane through the cricothyroid membrane anteriorly or cricotracheal membrane posteriorly anteriorly or cricotracheal membrane posteriorly or invade the trachea caudallyor invade the trachea caudally
Subglottic CaSubglottic Ca
Subglottic CaSubglottic Ca
Lymph node involvementLymph node involvement
18%18% had LN metastasis at the time of referral had LN metastasis at the time of referral
Supraglottic ( 40% )Supraglottic ( 40% )
Glottic Ca ( 5% )Glottic Ca ( 5% )
Subglottic Ca ( 13% )Subglottic Ca ( 13% )
Few Few present with distant metastasis at the present with distant metastasis at the time of diagnosistime of diagnosis
11%11% have distant metastasis, mostly in the have distant metastasis, mostly in the lung ( 6.8% )lung ( 6.8% )
Distant metastasisDistant metastasis
TNMTNM classificaiton classificaiton
TT : : Primary tumourPrimary tumour
N: N: Nodal depositsNodal deposits
M: M: MetastasisMetastasis
TT : : Primary tumourPrimary tumour
TXTX
T0T0
TisTis
Primary tumour can not be assesed
No evidence of primary tumour
Carcinoma in situ
TT : Primary tumour: Primary tumour
GlotticGlotticT1T1 limited / mobile limited / mobile
aa: one cord: one cord bb: both cords: both cords
T2T2 extends to supra or extends to supra or
subglottic / impaired subglottic / impaired mobilitymobility
T3 T3 cord fixationcord fixation
T4T4 extends beyond extends beyond
the larynxthe larynx
Supra & subglotticSupra & subglottic
T1T1 limited / mobile limited / mobile
cordscords
T2 T2 extends to extends to
glottis/mobileglottis/mobile
T3T3 cord fixation cord fixation
T4T4 extends beyond extends beyond
the larynxthe larynx
T1aT1a
Rt.VC Ca with normal mobilityRt.VC Ca with normal mobility
GlotticGlottic
T1bT1b Limited mobile both cordsLimited mobile both cords
GlotticGlottic
GlotticGlottic
T2T2 extends to supra or subglottic / impaired extends to supra or subglottic / impaired
mobilitymobility
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
GlotticGlottic
GlotticGlottic
T3 T3 cord fixationcord fixation
T4T4 extends beyond the larynx extends beyond the larynx
Lt VC Ca with fixationLt VC Ca with fixation
SubglotticSubglottic
limited / mobile cordslimited / mobile cords
T1T1
T1 subglottisT1 subglottis
SubglotticSubglottic
extends to glottis/mobileextends to glottis/mobileT2T2
Subglottic tumour extends to glottisSubglottic tumour extends to glottis
SubglotticSubglottic
T3T3
T4T4
cord fixationcord fixation
extends beyond the larynxextends beyond the larynx
Lt false cord tumourLt false cord tumour
SupraglotticSupraglottic
T1T1 limited / mobile cordslimited / mobile cords
T2T2
SupraglotticSupraglottic
Ca of the Rt. aryepiglottic foldCa of the Rt. aryepiglottic fold
Extends to glottisExtends to glottis
Moblie cordsMoblie cords
cord fixationcord fixation
extends beyond the larynxextends beyond the larynx
SupraglotticSupraglottic
T3T3
T4T4
Ca of the Lt. arytenoidCa of the Lt. arytenoid
NN: Nodal deposits: Nodal deposits
N1N1 ipsilateral movableipsilateral movable
N2 contra or bilateral movableN2 contra or bilateral movable
N3N3 FixedFixed
NO LN depositsNO LN depositsN0N0
MM: Metastasis: Metastasis
M0M0 no metastasis no metastasis
M1 M1 metastasis metastasis
StagingStaging
Stage 0Stage 0 : Tis, N0 , M0 : Tis, N0 , M0
Stage 1Stage 1 : T1, N0 , M0 : T1, N0 , M0
Stage 2Stage 2 : T2, N0 , M0 : T2, N0 , M0
Stage 3Stage 3 : T3, N0 , M0 : T3, N0 , M0 T1-T3, N1 , M0T1-T3, N1 , M0
Stage 4Stage 4 : T4, N0/N1 , M0 : T4, N0/N1 , M0 Any T, N2/N3 , M0Any T, N2/N3 , M0 Any T, Any N , M1Any T, Any N , M1
Rehabilitation Rehabilitation
TreatmentTreatment
curative curative
No treatmentNo treatment PalliationPalliation
No treatmentNo treatment
Those presenting in Those presenting in extremesextremes
who are who are no longer consciousno longer conscious of pain or of pain or distressdistress
Disseminated tumoursDisseminated tumours cause their death cause their death without the primary tumour or regional without the primary tumour or regional disease causing symptomsdisease causing symptoms
7-8%7-8% recieve no treatment recieve no treatment
Palliation Palliation
The attempt to The attempt to suppresssuppress the Ca and its the Ca and its symptoms symptoms without expectationwithout expectation or intent to cure or intent to cure
Palliation is used in Palliation is used in late stageslate stages
Includes:Includes: pain reliefpain relief tracheostomytracheostomy other surgeryother surgery radiotherapyradiotherapy chemotherapychemotherapy
TracheostomyTracheostomy
To To relieverelieve airway airway obstructionobstruction
It often provide a It often provide a dilemmadilemma, as it just delay , as it just delay the inevitable death in a the inevitable death in a patient with incurable patient with incurable cancercancer
RadiotherapyRadiotherapy
Commonly used for palliationCommonly used for palliationCan be applied locally and Can be applied locally and selectivelyselectivelyRadioactive implants of gold Radioactive implants of gold are useful for local treatmentare useful for local treatment
Curative treatmentCurative treatment
RadiotherapyRadiotherapy SurgerySurgery ChemotherapyChemotherapy
Radiation is most effective where the Radiation is most effective where the tissues are tissues are well oxygenatedwell oxygenated..
So it is most valuable in So it is most valuable in small lesionssmall lesions and and when the vascular supply is undamaged, when the vascular supply is undamaged, where it has where it has not preceded by surgerynot preceded by surgery
Radiation is more applicable on the Radiation is more applicable on the oxygenated peripheryoxygenated periphery, while surgery could , while surgery could deal with the massdeal with the mass
RadiotherapyRadiotherapy
CA larynx for radiotherapyCA larynx for radiotherapy
SurgerySurgery
Microendolaryngeal and laser surgeryMicroendolaryngeal and laser surgery
Excisional surgeryExcisional surgery
Microendolaryngeal and laser Microendolaryngeal and laser surgerysurgery
Carcinoma in situCarcinoma in situ can by treated can by treated by microsurgical excision and by microsurgical excision and laser makes this easierlaser makes this easier
Certain localized supraglottic Certain localized supraglottic lesionslesions may be excised using a may be excised using a laserlaser
Carbon dioxide laser is usedCarbon dioxide laser is used
Microendolaryngeal and laser Microendolaryngeal and laser surgerysurgery
Partial(vertical or horizontal), subtotal and total Partial(vertical or horizontal), subtotal and total laryngectomy.laryngectomy.
Used with or without radiotherapy.Used with or without radiotherapy.
Has risk of loss of voice, and protection of the airway.Has risk of loss of voice, and protection of the airway.
Is more effective than radiotherapy in large tumours Is more effective than radiotherapy in large tumours and when there are secondary deposits in LN on the and when there are secondary deposits in LN on the neck.neck.
Partial resection of the larynx may maintain a near Partial resection of the larynx may maintain a near normal function with high cure rate.normal function with high cure rate.
Used after failure of radiotherapy.Used after failure of radiotherapy.
Excisional surgeryExcisional surgery
Total laryngectomyTotal laryngectomy
Removed specimenRemoved specimen