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