Malignant tumours of larynx

MALIGNANT TUMOURS OF

LARYNXDr Manpreet Singh Nanda

Associate Professor ENTMMMC&H Solan

EPIDEMIOLOGY 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

RISK FACTORS 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

Pre malignant disorders – ca in situ, leukoplakia, solitary papillomas, hyperkeratosis

PREVENTION - smoking cessation - reduce alcohol - healthy diet (green leafy veg)

DIAGNOSIS 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

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

DL SCOPY/MICROLARYNGOSCOPY 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

PATHOLOGY 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

AJCC – DIVISIONS OF LARYNX 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

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

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

STAGING 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

RESIDUAL DISEASE R0 – no residual disease R1 – microscopic residual disease R2 – macroscopic residual disease

GLOTTIC CANCER 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

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

SUPRAGLOTTIC CANCER 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..

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

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

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

SUBGLOTTIC CANCER 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

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

TRANSGLOTTIC TUMOURS 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

MANAGEMENT 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

RADIOTHERAPY 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

CONSERVATIVE SURGERY 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

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

ORGAN PRESERVATION THERAPY 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

TOTAL LARYNGECTOMY 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

COMBINED THERAPY 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

PALLIATIVE THERAPY 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

PHOTODYNAMIC THERAPY (PDT) 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

TREATMENT OF GLOTTIC CANCER 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

TREATMENT OF SUPRAGLOTTIC CANCER 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..

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

DIRECT LARYNGOSCOPY 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

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

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

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

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

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

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

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

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

MICROLARYNGOSCOPY 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

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

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

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

tobacco

FIBREOPTIC LARYNGOSCOPY 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

TOTAL/WIDE FIELD LARYNGECTOMY 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

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

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

MODIFIED SORENSON’S INCISION

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

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

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

POST LARYNGECTOMY VOICE REHABILITATION Tracheo esophageal fistula (Neoglottic

speech) Esophageal speech Artificial larynx

TRACHEO ESOPHAGEAL FISTULA SPEECH 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

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

PROSTHESIS 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

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

ESOPHAGEAL SPEECH 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

ARTIFICIAL LARYNX 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

ELECTROLARYNX