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Laryngeal Carcinoma:Laryngeal Carcinoma:An OverviewAn Overview
Ryan EricRyan Eric NeilanNeilan
MS IVMS IV
For the Dept of OtolaryngologyFor the Dept of Otolaryngology
University of Texas Medical BranchUniversity of Texas Medical Branch
JulyJuly 20, 200720, 2007
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OverviewOverview
11,000 new cases of laryngeal cancer per11,000 new cases of laryngeal cancer per
year in the U.S.year in the U.S.Accounts for 25% of head and neckAccounts for 25% of head and neck
cancer and 1% of all cancerscancer and 1% of all cancers OneOne--third of these patients eventually diethird of these patients eventually die
of their diseaseof their disease
Most prevalent in the 6Most prevalent in the 6thth and 7and 7thth decadesdecades
of lifeof life
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OverviewOverview
4:1 male predilection4:1 male predilection
Downward shift from 15:1 post WWIIDownward shift from 15:1 post WWII
Due to increasing public acceptance ofDue to increasing public acceptance of
female smokingfemale smoking More prevalent among lowerMore prevalent among lower
socioeconomic class, in which it issocioeconomic class, in which it isdiagnosed at more advanced stagesdiagnosed at more advanced stages
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SubtypesSubtypes
GlotticGlottic Cancer: 59%Cancer: 59%
SupraglotticSupraglottic Cancer: 40%Cancer: 40%
SubglotticSubglottic Cancer: 1%Cancer: 1%
MostMost subglotticsubglottic masses are extension frommasses are extension fromglotticglottic carcinomascarcinomas
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HistoryHistory
The firstThe first laryngectomylaryngectomy for cancer of thefor cancer of the
larynx was performed in 1883 bylarynx was performed in 1883 by BillrothBillroth Patient was successfully fed by mouth andPatient was successfully fed by mouth and
fitted with an artificial larynxfitted with an artificial larynx In 1886 the Crown Prince Frederick ofIn 1886 the Crown Prince Frederick of
Germany developed hoarseness as he wasGermany developed hoarseness as he was
due to ascend the throne.due to ascend the throne.
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Crown Prince Frederick of GermanyCrown Prince Frederick of Germany
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HistoryHistory
Was evaluated by SirWas evaluated by Sir MakenzieMakenzie of London,of London,
the inventor of the direct laryngoscopethe inventor of the direct laryngoscope FrederickFredericks lesion wass lesion was biopsiedbiopsied andand
thought to be cancerthought to be cancer He refusedHe refused laryngectomylaryngectomy and later died inand later died in
18881888
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HistoryHistory
Frederick wasFrederick was
succeeded by Kaisersucceeded by KaiserWilhelm II, who alongWilhelm II, who alongwith Otto vonwith Otto von BismarkBismarkmilitarized themilitarized theGerman Empire andGerman Empire andled them into WW Iled them into WW I
Could anCould anOtolaryngologistOtolaryngologist havehave
prevented WW I?prevented WW I?
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Risk FactorsRisk Factors
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Risk FactorsRisk Factors
Prolonged use of tobacco and excessiveProlonged use of tobacco and excessive
EtOHEtOH use primary risk factorsuse primary risk factors The two substances together have aThe two substances together have a
synergistic effect on laryngeal tissuessynergistic effect on laryngeal tissues 90% of patients with laryngeal cancer90% of patients with laryngeal cancer
have a history of bothhave a history of both
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Risk FactorsRisk Factors
HumanHuman PapillomaPapillomaVirus 16 &18Virus 16 &18
Chronic Gastric RefluxChronic Gastric Reflux Occupational exposuresOccupational exposures
Prior history of head and neck irradiationPrior history of head and neck irradiation
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Histological TypesHistological Types
VerrucousVerrucous CarcinomaCarcinoma
FibrosarcomaFibrosarcoma ChondrosarcomaChondrosarcoma
Minor salivary carcinomaMinor salivary carcinomaAdenocarcinomaAdenocarcinoma
Oat cell carcinomaOat cell carcinoma Giant cell and Spindle cell carcinomaGiant cell and Spindle cell carcinoma
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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AnatomyAnatomy
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Natural HistoryNatural History
SupraglotticSupraglottic tumors more aggressive:tumors more aggressive:
Direct extension into preDirect extension into pre--epiglotticepiglottic spacespace Lymph node metastasisLymph node metastasis
Direct extension into lateralDirect extension into lateral
hypopharnyxhypopharnyx
,,
glossoepiglotticglossoepiglottic fold, and tongue basefold, and tongue base
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Natural HistoryNatural History
GlotticGlottic tumors grow slower and tend totumors grow slower and tend to
metastasize late owing to a paucity ofmetastasize late owing to a paucity oflymphatic drainagelymphatic drainage
They tend to metastasize after they haveThey tend to metastasize after they have
invaded adjacent structures with betterinvaded adjacent structures with betterdrainagedrainage
Extend superiorly into ventricular walls orExtend superiorly into ventricular walls orinferiorly intoinferiorly into subglotticsubglottic spacespace
Can cause vocal cord fixationCan cause vocal cord fixation
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Natural HistoryNatural History
TrueTrue subglotticsubglottic tumors are uncommontumors are uncommon
GlotticGlottic spread to thespread to the subglotticsubglottic space is aspace is asign of poor prognosissign of poor prognosis
Increases chance of bilateral disease andIncreases chance of bilateral disease andmediastinalmediastinal extensionextension
Invasion of theInvasion of the subglotticsubglottic space associatedspace associated
with high incidence ofwith high incidence ofstomalstomal reoccurrencereoccurrence
following totalfollowing total laryngectomylaryngectomy (TL)(TL)
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PresentationPresentation
HoarsenessHoarseness
Most common symptomMost common symptom Small irregularities in the vocal fold result inSmall irregularities in the vocal fold result in
voice changesvoice changes
Changes of voice in patients with chronicChanges of voice in patients with chronic
hoarseness from tobacco and alcohol can behoarseness from tobacco and alcohol can be
difficult to appreciatedifficult to appreciate
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PresentationPresentation
Patients presenting with hoarsenessPatients presenting with hoarseness
should undergo an indirect mirror examshould undergo an indirect mirror examand/or flexible laryngoscope evaluationand/or flexible laryngoscope evaluation
Malignant lesions can appear as friable,Malignant lesions can appear as friable,fungatingfungating, ulcerative masses or be as, ulcerative masses or be as
subtle as changes in mucosal colorsubtle as changes in mucosal color
VideostrobeVideostrobe laryngoscopylaryngoscopy may be neededmay be neededto follow up these subtler lesionsto follow up these subtler lesions
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PresentationPresentation
Good neck exam looking for cervicalGood neck exam looking for cervical
lymphadenopathylymphadenopathy and broadening of theand broadening of thelaryngeal prominence is requiredlaryngeal prominence is required
The base of the tongue should beThe base of the tongue should bepalpated for masses as wellpalpated for masses as well
Restricted laryngealRestricted laryngeal crepituscrepitus may be amay be a
sign of postsign of post cricoidcricoid or retropharyngealor retropharyngealinvasioninvasion
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PresentationPresentation
Other symptoms include:Other symptoms include:
DysphagiaDysphagia HemoptysisHemoptysis
Throat painThroat pain
Ear painEar pain
Airway compromiseAirway compromise
AspirationAspiration
Neck massNeck mass
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Work upWork up
Biopsy is required for diagnosisBiopsy is required for diagnosis
Performed in OR with patient underPerformed in OR with patient underanesthesiaanesthesia
Other benign possibilities for laryngealOther benign possibilities for laryngeallesions include: Vocal cord nodules orlesions include: Vocal cord nodules or
polyps,polyps, papillomatosispapillomatosis,, granulomasgranulomas,,
granular cellgranular cell neoplasmsneoplasms,, sarcoidosissarcoidosis,,WegnerWegnerss granulomatosisgranulomatosis
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Work upWork up
Other potential modalities:Other potential modalities:
DirectDirect laryngoscopylaryngoscopy BronchoscopyBronchoscopy
EsophagoscopyEsophagoscopy
Chest XChest X--rayray
CT or MRICT or MRI
Liver function tests with or without USLiver function tests with or without US
PET ?PET ?
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StagingStaging-- Primary Tumor (T)Primary Tumor (T)
TXTX Minimum requirements to assess primaryMinimum requirements to assess primarytumor cannot be mettumor cannot be met
T0T0 No evidence of primary tumorNo evidence of primary tumor
TisTis Carcinoma in situCarcinoma in situ
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StagingStaging-- SupraglottisSupraglottis
T1T1 Tumor limited to oneTumor limited to one subsitesubsite ofofsupraglottissupraglottis with normal vocal cordwith normal vocal cord
mobilitymobility
T2T2 Tumor involves mucosa of more than one adjacentTumor involves mucosa of more than one adjacent subsitesubsite ofofsupraglottissupraglottis
or glottis, or region outside theor glottis, or region outside the supraglottissupraglottis (e.g. mucosa of base of the(e.g. mucosa of base of the
tongue,tongue, valleculavallecula, medial wall of, medial wall ofpiriformpiriform sinus) without fixationsinus) without fixation
T3T3 Tumor limited to larynx with vocal cord fixation and or invadesTumor limited to larynx with vocal cord fixation and or invades any of theany of thefollowing:following: postcricoidpostcricoid area,area, preepiglotticpreepiglottic tissue,tissue, paraglotticparaglottic space, and/orspace, and/or
minor thyroid cartilage erosion (e.g. inner cortex)minor thyroid cartilage erosion (e.g. inner cortex)
T4aT4a Tumor invades through the thyroid cartilage and/or invades tissuTumor invades through the thyroid cartilage and/or invades tissuee
beyond the larynx (e.g. trachea, soft tissues of neck includingbeyond the larynx (e.g. trachea, soft tissues of neck including deepdeepextrinsic muscles of the tongue, strap muscles, thyroid, or esopextrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)hagus)
T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, or invadesspace, encases carotid artery, or invades
mediastinalmediastinal structuresstructures
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StagingStaging-- GlottisGlottis
T1T1 Tumor limited to the vocal cord (s) (may involve anterior or posTumor limited to the vocal cord (s) (may involve anterior or posteriorterior
commissurecommissure) with normal) with normal mobiltymobilty
T1aT1a Tumor limited to one vocal cordTumor limited to one vocal cord
T1bT1b Tumor involves both vocal cordsTumor involves both vocal cords
T2T2 Tumor extends toTumor extends to supraglottissupraglottis and/orand/or subglottissubglottis, and/or with, and/or withimpaired vocal cord mobilityimpaired vocal cord mobility
T3T3 Tumor limited to the larynx with vocal cord fixation and/or invaTumor limited to the larynx with vocal cord fixation and/or invadesdes
paraglotticparaglottic space, and/or minor thyroid cartilage erosion (e.g. innerspace, and/or minor thyroid cartilage erosion (e.g. inner
cortex)cortex)T4aT4a Tumor invades through the thyroid cartilage, and/or invades tissTumor invades through the thyroid cartilage, and/or invades tissuesues
beyond the larynx (e.g. trachea, soft tissues of the neck includbeyond the larynx (e.g. trachea, soft tissues of the neck includinging
deep extrinsic muscles of the tongue, strap muscles, thyroid, ordeep extrinsic muscles of the tongue, strap muscles, thyroid, or
esophagusesophagus
T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, or invadesspace, encases carotid artery, or invades
mediastinalmediastinal structuresstructures
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StagingStaging-- SubglottisSubglottis
T1T1 Tumor limited to theTumor limited to the subglottissubglottis
T2T2 Tumor extends to vocal cord (s) with normal or impairedTumor extends to vocal cord (s) with normal or impaired
mobilitymobility
T3T3 Tumor limited the larynx with vocal cord fixationTumor limited the larynx with vocal cord fixation
T4aT4a Tumor invadesTumor invades cricoidcricoid or thyroid cartilage and/or invadesor thyroid cartilage and/or invades
tissues beyond larynx (e.g. trachea, soft tissues of the necktissues beyond larynx (e.g. trachea, soft tissues of the neckincluding deep extrinsic muscles of the tongue, strap muscles,including deep extrinsic muscles of the tongue, strap muscles,
thyroid, or esophagus)thyroid, or esophagus)
T4bT4b Tumor invadesTumor invades prevertebralprevertebral space, encases carotid artery, orspace, encases carotid artery, or
invadesinvades mediastinalmediastinal structuresstructures
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StagingStaging-- NodesNodes
N0N0 No cervical lymph nodes positiveNo cervical lymph nodes positive
N1N1 SingleSingle ipsilateralipsilateral lymph nodelymph node 3cm3cm
N2aN2a SingleSingle ipsilateralipsilateral node > 3cm andnode > 3cm and 6cm6cm
N2bN2b MultipleMultiple ipsilateralipsilateral lymph nodes, eachlymph nodes, each
6cm6cm
N2cN2c Bilateral orBilateral or contralateralcontralateral lymph nodes, eachlymph nodes, each
6cm6cm
N3N3 Single or multiple lymph nodes > 6cmSingle or multiple lymph nodes > 6cm
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StagingStaging-- MetastasisMetastasis
M0M0 No distant metastasesNo distant metastases
M1M1 Distant metastases presentDistant metastases present
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Stage GroupingsStage Groupings
00 TisTis N0N0 M0M0
II T1T1 N0N0 M0M0IIII T2T2 N0N0 M0M0
IIIIII T3T3 N0N0 M0M0
T1T1--33 N1N1 M0M0
IVAIVA T4aT4a N0N0--22 M0M0
T1T1--4a4a N2N2 M0M0
IVBIVB T4bT4b Any NAny N M0M0
Any TAny T N3N3 M0M0IVCIVC Any TAny T Any NAny N M1M1
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TreatmentTreatment
PremalignantPremalignant lesions or Carcinoma in situlesions or Carcinoma in situ
can be treated by surgical stripping of thecan be treated by surgical stripping of theentire lesionentire lesion
CO2 laser can be used to accomplish thisCO2 laser can be used to accomplish this
but makes accurate review of marginsbut makes accurate review of margins
difficultdifficult
T
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TreatmentTreatment
Early stage (T1 and T2) can be treatedEarly stage (T1 and T2) can be treated
with radiotherapy or surgery alone, bothwith radiotherapy or surgery alone, bothoffer the 85offer the 85--95% cure rate.95% cure rate.
Surgery has a shorter treatment period,Surgery has a shorter treatment period,
saves radiation for recurrence, but maysaves radiation for recurrence, but mayhave worse voice outcomeshave worse voice outcomes
Radiotherapy is given for 6Radiotherapy is given for 6
--7 weeks,7 weeks,
avoids surgical risks but has ownavoids surgical risks but has owncomplicationscomplications
TT t t
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TreatmentTreatment
XRT complications include:XRT complications include:
MucositisMucositis OdynophagiaOdynophagia
Laryngeal edemaLaryngeal edema
XerostomiaXerostomia
Stricture and fibrosisStricture and fibrosis
RadionecrosisRadionecrosis
HypothyroidismHypothyroidism
T t tT t t
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TreatmentTreatment
Advanced stage lesions often receiveAdvanced stage lesions often receive
surgery with adjuvant radiationsurgery with adjuvant radiation Most T3 and T4 lesions require a totalMost T3 and T4 lesions require a total
laryngectomylaryngectomy
Some small T3 and lesser sized tumorsSome small T3 and lesser sized tumors
can be treated with partialcan be treated with partial larygectomylarygectomy
T t tT t t
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TreatmentTreatment
Adjuvant radiation is started within 6 weeks ofAdjuvant radiation is started within 6 weeks of
surgery and with once daily protocols lasts 6surgery and with once daily protocols lasts 6--77
weeksweeks
Indications for postIndications for post--op radiation include: T4op radiation include: T4
primary, bone/cartilage invasion, extension intoprimary, bone/cartilage invasion, extension intoneck soft tissue,neck soft tissue, perineuralperineural invasion, vascularinvasion, vascular
invasion, multiple positive nodes, nodalinvasion, multiple positive nodes, nodal
extracapsularextracapsular extension, margins
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TreatmentTreatment
Chemotherapy can be used in addition toChemotherapy can be used in addition to
irradiation in advanced stage cancersirradiation in advanced stage cancers Two agents used areTwo agents used are CisplatinumCisplatinum and 5and 5--
flourouracilflourouracil
CisplatinCisplatin thought to sensitize cancer cellsthought to sensitize cancer cells
to XRT enhancing its effectiveness whento XRT enhancing its effectiveness when
used concurrently.used concurrently.
T t tT eatment
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TreatmentTreatment
Induction chemotherapy with definitiveInduction chemotherapy with definitive
radiation therapy for advanced stageradiation therapy for advanced stagecancer is another optioncancer is another option
Studies have shown similar survival ratesStudies have shown similar survival rates
as compared to totalas compared to total laryngectomylaryngectomy withwith
adjuvant radiation but with voiceadjuvant radiation but with voice
preservation.preservation. Role in treatment still under investigationRole in treatment still under investigation
T t tTreatment
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TreatmentTreatment
Modified or radical neck dissections are indicatedModified or radical neck dissections are indicated
in the presence of nodal diseasein the presence of nodal disease
Neck dissections may be performed in patientsNeck dissections may be performed in patients
with supra orwith supra or subglotticsubglottic T2 tumors even in theT2 tumors even in the
absence of nodal diseaseabsence of nodal disease N0 necks can have a selective dissection sparingN0 necks can have a selective dissection sparing
the SCM, IJ, and XIthe SCM, IJ, and XI
N1 necks usually have a modified dissection ofN1 necks usually have a modified dissection of
levels IIlevels II--IVIV
Surgical OptionsSurgical Options
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Surgical OptionsSurgical Options
HemilaryngectomyHemilaryngectomy
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HemilaryngectomyHemilaryngectomy
No more than 1cmNo more than 1cm
subglotticsubglottic extensionextension
anteriorlyanteriorly or 5mmor 5mmposteriorlyposteriorly
Mobile affected cordMobile affected cord
Minimal anteriorMinimal anteriorcontralateralcontralateral cordcord
involvementinvolvement
No cartilage invasionNo cartilage invasion No neck soft tissueNo neck soft tissue
invasioninvasion
SupraglotticSupraglottic laryngectomylaryngectomy
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SupraglotticSupraglottic laryngectomylaryngectomy
T1,2, or 3 if only byT1,2, or 3 if only bypreepiglotticpreepiglottic spacespace
invasioninvasion Mobile cordsMobile cords
No anteriorNo anterior commissurecommissure
involvementinvolvement FEV1 >50%FEV1 >50%
No tongue base diseaseNo tongue base diseasepastpast circumvallatecircumvallatepapillaepapillae
Apex ofApex ofpyriformpyriform sinussinusnotnot invlovedinvloved
SupracricoidSupracricoid LaryngectomyLaryngectomy
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SupracricoidSupracricoid LaryngectomyLaryngectomy
Resection of trueResection of true
vocal cords,vocal cords,
supraglottissupraglottis, thyroid, thyroid
cartilagecartilage
Leave arytenoids andLeave arytenoids andcricoidcricoid ring intactring intact
Half of patientsHalf of patients
remain dependent onremain dependent ontracheostomytracheostomy
TotalTotal LarygectomyLarygectomy
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TotalTotal LarygectomyLarygectomy
Indications:Indications:
T3 or T4 unfit for partialT3 or T4 unfit for partial Extensive involvement of thyroid andExtensive involvement of thyroid and cricoidcricoid
cartilagescartilages
Invasion of neck soft tissuesInvasion of neck soft tissues
Tongue base involvement beyondTongue base involvement beyond
circumvallatecircumvallate papillaepapillae
TotalTotal LaryngectomyLaryngectomy
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TotalTotal LaryngectomyLaryngectomy
TotalTotal LaryngectomyLaryngectomy
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TotalTotal LaryngectomyLaryngectomy
TotalTotal LaryngectomyLaryngectomy
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TotalTotal LaryngectomyLaryngectomy
TotalTotal LaryngectomyLaryngectomy
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TotalTotal LaryngectomyLaryngectomy
Voice RehabilitationVoice Rehabilitation
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Voice RehabilitationVoice Rehabilitation
TracheostomalTracheostomal prosthesisprosthesis
ElectrolarynxElectrolarynx
Pure esophageal speechPure esophageal speech
ComplicationsComplications
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ComplicationsComplications
Inaccurate stagingInaccurate staging
InfectionInfection
Voice alterationsVoice alterations Swallowing difficultiesSwallowing difficulties
Loss of taste and smellLoss of taste and smell
FistulaFistula TracheostomyTracheostomy dependencedependence
Injury to cranial nerves: VII, IX, X, XI, XIIInjury to cranial nerves: VII, IX, X, XI, XII
Stroke or carotidStroke or carotidblowoutblowout HypothyroidismHypothyroidism
Radiation induced fibrosisRadiation induced fibrosis
PrognosisPrognosis
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PrognosisPrognosis
After initial treatment patients are followed at 4After initial treatment patients are followed at 4--
6 week intervals. After first year decreases to6 week intervals. After first year decreases toevery 2 months. Third and fourth year everyevery 2 months. Third and fourth year everythree months, with annual visits after thatthree months, with annual visits after that
5 year survival5 year survival
Stage IStage I >95%>95%
Stage IIStage II 8585--90%90%
Stage IIIStage III 7070--80%80%
Stage IVStage IV 5050--60%60%
PrognosisPrognosis
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PrognosisPrognosis
Patients considered cured after beingPatients considered cured after being
disease free for five yearsdisease free for five years Most laryngeal cancers reoccur in the firstMost laryngeal cancers reoccur in the first
two yearstwo years
Despite advances in detection andDespite advances in detection and
treatment options the five year survivaltreatment options the five year survival
has not improved much over the last thirtyhas not improved much over the last thirtyyearsyears
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