Otolaryngology
Laryngology
د حيدر السرحان
ا م
Tumors of the larynx
Benign tumors:
1. hemangioma
2. chondroma
3. Leomyoma
4. Rhabdomyoma
5. Paraganglioma
6. Papilloma
Malignant tumors:
1. squamous cell carcinoma 85%
2. undifferentiated carcinoma 5%
3. verrucous Carcinoma 3%
4. carcinoma insitu 3%
5. sarcoma 2%
6. Adenocarcinoma 0.5%
7. others( miscellaneous:adenoid cystic carcinoma , Lymphoma ,..) 1.5%
Epidemiology
Squamous cell carcinoma of the larynx is the commonest head and neck
cancer in the Western world and represents approximately 1% of all
malignancies in men, it is the disease of urban societies,
the cause of cancer
of the larynx is not known, but persons who smoke tobacco and drink
alcohol are predisposed to the disease. It is very rare in non-smokers.
Alcohol on its own is probably not a cause of laryngeal cancer but it is
highly synergistic with smoking, chronic laryngitis , radiation, Asbestosis
and other occupational pollutions may predispose to this disease.
Surgical Anatomy:
The larynx is divided into three regions which each include a number of
sites:
1.Supraglottis. This comprises the larynx superior to the apex of the
ventricle. It includes the ventricle, vestibular folds, arytenoids, aryepiglottic
folds and the epiglottis.
2. Glottis. This comprises the vocal cords and the anterior and posterior
commissures.
3. Subglottis. This extends from the inferior border of the glottis to the
lower border of the cricoid cartilage.
Clinical features:
Malignant tumors of the larynx are about five times commoner in males than
females. The incidence increases with age, but the peak age of presentation
is in the seventh decade.
Hoarseness is the commonest and often the only presenting symptom,
Dyspnoea and stridor are late symptoms and almost invariably indicate an
advanced tumour. Pain is an uncommon symptom but is most typical in
supraglotic tumours. Patients with a cancer in this site may complain of a
unilateral sore throat. There maybe referred otalgia. Dysphagia indicates
invasion of the pharynx.
Swelling of the neck may be due to direct penetration of the tumour outside
the larynx or to lymph node metastases. Cough and irritation of the throat
are occasional symptoms. The general symptoms of norexia, cachexia and
fetor are usually associated with advanced disease.
Laryngeal tumours usually metastasize to the upper deep cervical lymph
nodes, but supraglottic tumours may cause bilateral nodes, and some
subglottic tumours may spread to the upper mediastinal nodes.
Investigations:
1.A chest radiograph, full blood count and serum analysis are baseline
investigations prior to a general anaesthetic, The chest radiograph should be
carefully examined to exclude metastases or to assess intercurrent lung
disease.
2.Hypoproteinaemia, which may indicate malnourishment and a possibility
of poor wound healing.
3. MRI or CT scans of the larynx and neck provide further information about
the primary tumour. Imaging may also uncover the presence of impalpable
or occult nodes.
4.Direct laryngoscopy under general anaesthesia is mandatory. In addition,
the patient should have a full panendoscopy including bronchoscopy. The
incidence of a synchronous second primary tumour in the head, neck or lung
is in the region of 1-5%.Biopsy material should include an adequate amount
of representative tissue to obtain a definitive diagnosis of malignancy,
identification of the tumour type and tumour differentiation.
Staging:
T (tumor mass)
Supraglottis.
T1 Tumour limited to one subsite of the supraglottis.
T2 Invasion of more than one subsite of the supraglottis or glottis
T3 Confined to larynx with a fixed vocal cord or invades the postcricoid
area, preepiglottic tissues, base of tongue.
T4 Extends beyond the larynx.
Glottis.
T1(a) Tumour limited to one vocal cord.
T1(b) Involves both vocal cords.
T2 Tumour extends to supraglottis and/or subglottis, or impaired cord
mobility.
T3 Confined to the larynx with a fixed vocal cord.
T4 Extends beyond the larynx.
Subglottis.
T1 Tumour limited to subglottis.
T2 Extends to vocal cords with normal or impaired mobility.
T3 Vocal cord fixed.
T4 Extends beyond the larynx
N (lymph node metastasis)
N0 no lymph node metastasis
N1 Iipsilateral single LN less than 3 cm in size
N2
A Ipsilateral LN 3-6 cm in size
B Ipsilateral multiple less than 6 cm in size
C CotraLATERAL OR bilateral LN less than 6 cm size
N3 LN more than 6 cm size
M (distant metastasis)
M 0 no distant metastasis
M1 distant metastasis
Management:
Treatment of benign tumors :
Usually by surgical resection , usually enolaryngeal surgeries is sufficient
for small tumors , open surgeries is recommended for late large tumors.
Treatments of the malignant tumors :
Each patient will fall into one of the following treatment categories
depending their age, general condition, and stage of the tumour: curative
treatment or palliative treatment.
1. Curative treatment may involve radiotherapy, surgery or a combination of
these two modalities.
A/ small tumors are treated by radical Radiotherapy in the first instance,
with surgery reserved for recurrence. Preservation laryngeal surgery (partial
Laryngectomy) is also an option with small tumors.
B/Larger tumors tend to be treated with primary surgery, usually with
postoperative radiotherapy.
2. Palliative treatment includes pain relief, tracheostomy, insertion of a
percutaneous gastrostomy, palliative radiotherapy, chemotherapy and
occasionally surgery.
General roles of treatment :
T1 N0 M0 Radiotherapy
T2 N0 M0 partial laryngectomy
T3 N0 M0 Total laryngectomy
T3 Nx M0 Total laryngectomy with radical neck dissection
T4 palliative
M1 Palliative