tumorsoflarynx-111128145849-phpapp02

7/25/2019 tumorsoflarynx-111128145849-phpapp02

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Tumours of theTumours of the

larynxlarynx


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IntroductionIntroduction

Benign or malignantBenign or malignant


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Benign tumoursBenign tumours

PseudotumoursPseudotumours

Mesodermal tumoursMesodermal tumoursEctodermal tumoursEctodermal tumours


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Ectodermal tumoursEctodermal tumours

AdenomaAdenoma

NeurilemmomaNeurilemmomaParagangliomaParaganglioma

PapillomaPapilloma


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PapillomaPapilloma

Single papillomaSingle papilloma Multiple papillomasMultiple papillomas


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Common inCommon in adultsadults, rare in children, rare in children

Sessile or pedunculatedSessile or pedunculated

Usual sitesUsual sites anterior commissure, anterior half ofanterior commissure, anterior half ofthe vocal cordsthe vocal cords

Men:omen ratioMen:omen ratio !:"!:"

Present ithPresent ith hoarsnesshoarsness

If small removedIf small removed endoscopicall#endoscopicall#If large $#If large $# lar#ngofissurelar#ngofissure

Biops#Biops#to e%clude malignanc# speciall# ifto e%clude malignanc# speciall# if recurrentrecurrent

Single papillomaSingle papilloma


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&ar#ngeal papilloma&ar#ngeal papilloma

S'uamous papilloma ofS'uamous papilloma of

the &t( ar#epiglottic foldthe &t( ar#epiglottic fold


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Multiple papillomasMultiple papillomas

InfantsInfantsand #oung children, rare in adultsand #oung children, rare in adults

AA virusvirusma# $e responsi$le )*P+ma# $e responsi$le )*P+

+ocal cords+ocal cordsare the usual siteare the usual site*oarsness*oarsnessif vocal cords affectedif vocal cords affected

-#spnoea-#spnoeama# occur ....ma# occur .... tracheostom#tracheostom#

/emoved endoscopicall# $#/emoved endoscopicall# $# C0! laserC0! laser

Spontaneous recover#Spontaneous recover#in pu$ert# ma# occurin pu$ert# ma# occur

Multiple papillomasMultiple papillomas


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1uvenile lar#ngeal papillomas1uvenile lar#ngeal papillomas


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1uvenile papillomas

Before and after removal


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AdenomaAdenoma

Arise fromArise from seromucinous glandsseromucinous glands

Common site isCommon site is su$glottissu$glottisS#mptoms areS#mptoms are fefeuntil the tumouruntil the tumour

o$structs the $reathingo$structs the $reathing

2reatment2reatmentis surger# depending on theis surger# depending on thesite and si3e of the tumoursite and si3e of the tumour


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"("( +ascular neoplasms+ascular neoplasms

!(!( ChondromaChondroma

4(4( M#ogenic tumoursM#ogenic tumours

5(5( 6i$roma6i$roma

7(7( &ipoma&ipoma

Mesodermal tumoursMesodermal tumours


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+ascular neoplasms+ascular neoplasms

Arise from $lood or l#mphatic vesselsArise from $lood or l#mphatic vessels

HaemangiomaHaemangioma

/are in adults/are in adults

2elengiectatic2elengiectatic

vocal cord pol#pvocal cord pol#p


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ChondromaChondroma

Arise from cartilages )Mostl# cricoidArise from cartilages )Mostl# cricoid

More in men )58.98 #earsMore in men )58.98 #ears

Clinical featuresClinical features

*oarsness and d#spnoea*oarsness and d#spnoea

StridorStridor)e%tention into su$glottic space)e%tention into su$glottic space-#sphagia-#sphagia)e%tension into h#pophar#n%)e%tension into h#pophar#n%

E%ternal sellingE%ternal selling)cricoid ring or th#roid)cricoid ring or th#roidcartilagecartilage


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ChondromaChondroma

Indirect laryngoscopyIndirect laryngoscopyreveals a smoothreveals a smooth

mass covered $# intact mucosamass covered $# intact mucosa

Cricoid chondromaCricoid chondroma


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RadiologyRadiologyshos calcific stipplingshos calcific stippling

BiopsyBiopsyspecimens is unrepresentative,specimens is unrepresentative,

the tumour is hard and difficult tothe tumour is hard and difficult topenetratepenetrate

SurgerySurgeryis the treatment of choiceis the treatment of choice

RadiotherapyRadiotherapyis of little valueis of little value

ChondromaChondroma


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IntroductionIntroduction

".!".!of all malignancies In Ira'of all malignancies In Ira'

More inMore in menmenPredominantl# ofPredominantl# of s'uamouss'uamouspatholog#patholog#

InterfereInterfereith function and emotionith function and emotion

*igh cure rate*igh cure rate ;7;7


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IncidenceIncidence

*igher in*igher inur$anur$anthan rural populationthan rural population

Social and racial differences reflectSocial and racial differences reflect

different ha$itsdifferent ha$its )to$acco and alcohol)to$acco and alcohol


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2he International Union against Cancer2he International Union against Cancer)UICC)UICCclassified Ca lar#n% onclassified Ca lar#n% on anatomicalanatomical

$ases$ases

ClassificationClassification

20% 10% 0%


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Aetiolog#Aetiolog#

UnknownUnknown

Possibly related factorsPossibly related factors genetic and social factorsgenetic and social factors

male predominancemale predominance racial predilectionracial predilection

ur$an pollutionur$an pollution

to$acco and alcoholto$acco and alcohol

radiationradiation

as$estosas$estos

occupational factorsoccupational factors


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SymptomsSymptoms

DysphoniaDysphoniaprogressive and unremittingprogressive and unremitting

Cough and irritationCough and irritationin the throat )earl#in the throat )earl#

Dyspnoea & stridorDyspnoea & stridorin advanced tumour,in advanced tumour,

speciall# in su$glottic Caspeciall# in su$glottic Ca

PainPainmore t#pical of supraglottic Ca, latemore t#pical of supraglottic Ca, late

and uncommonand uncommon

Referred otalgiaReferred otalgiama# occurma# occur


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SymptomsSymptoms

SellingSellingof the nec< or lar#n% )tumour or &Nof the nec< or lar#n% )tumour or &N

*aemopt#sis*aemopt#sis)rare ,in lesions of the margin)rare ,in lesions of the marginof epiglottisof epiglottis

Anore%ia, cache%ia or fetorAnore%ia, cache%ia or fetorare lateare late

s#mptomss#mptoms


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E%amination and diagnosisE%amination and diagnosis

Diagnosis will be made after consideration of:Diagnosis will be made after consideration of:

"("( *istor#*istor#

!(!( E%amination of the lar#n%E%amination of the lar#n%

4(4( E%amination of the nec(>( Clinical investigationsClinical investigations

9(9( *istological e%amination*istological e%amination


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*istor#*istor#

Small lesionSmall lesion

!!

long histor#long histor# slol# groing lesionslol# groing lesion

Massive cancerMassive cancer

!!short histor#short histor#

Aggressive lesionAggressive lesion

poor outloo


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Cancer can coe%ists or supervene inCancer can coe%ists or supervene in

leucopla


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"ocal Cord #eu$opla$ia 2his is a condition caused $#chronic irritation hich results in a$normal groth of the top

la#er of the s


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E%amination of the lar#n%E%amination of the lar#n%

examine forexamine for

6occal a$normalit#6occal a$normalit#

+ocal cord lesion+ocal cord lesion

MassMass

Mo$ilit#Mo$ilit#

examine byexamine by

Indirect lar#ngoscop# )&AIndirect lar#ngoscop# )&A

6le%i$le lar#ngoscop# )&A6le%i$le lar#ngoscop# )&A

-irect lar#ngoscop# )=A-irect lar#ngoscop# )=A

Microlar#ngoscop#Microlar#ngoscop# )=A)=A


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su$glottissu$glottis

ventricleventricle

posterior surfaceposterior surface

of epiglottisof epiglottis

-ifficult areas to $e seen-ifficult areas to $e seen


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E%amination of the nec


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Incidence of nodal metastasisIncidence of nodal metastasis

Supraglottis 58Supraglottis 58

=lottis 7 =lottis 7

Su$glottis "4Su$glottis "4

Supra ? glottisSupra ? glottisto regional &Nto regional &N

)ipsilateral deep cervical chain level II ? III ?)ipsilateral deep cervical chain level II ? III ?

prelar#ngeal nodesprelar#ngeal nodes

Su$glottisSu$glottisto level III ? I+ )mediastinal &Nto level III ? I+ )mediastinal &N


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=eneral e%amination=eneral e%amination

2o identif#2o identif# metastasismetastasise(g( to the livere(g( to the liver

2o2o assessassessthe overallthe overall ph#sical statusph#sical statusofof

the individual ho is li


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/adiological investigations/adiological investigations

C@/C@/ for metastasis, other disorders andfor metastasis, other disorders and

as part of assessment of ph#sical statusas part of assessment of ph#sical status

&ar#n%&ar#n%to delineate the e%tent of theto delineate the e%tent of the

tumourtumour

@.ra#@.ra# C2 scanC2 scan M/IM/I


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Supraglottic tumourSupraglottic tumour

2omograph#2omograph#

@.ra#@.ra#

&P&P #ateral#ateral


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A%ial C2 shos loss of pre.epiglottic fat $# carcinomatous infiltrarionA%ial C2 shos loss of pre.epiglottic fat $# carcinomatous infiltrarion

C2 scanC2 scan


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A%ial C2 scan shoing a soft tissue mass ith severalA%ial C2 scan shoing a soft tissue mass ith several

punctuate calcifications )Chondrosarcomapunctuate calcifications )Chondrosarcoma

C2 scanC2 scan


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Epiglotic tumorEpiglotic tumor lar#ngeal Ca( supraglotic t#pelar#ngeal Ca( supraglotic t#pe

M/IM/I


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M/IM/I

A%ial 2" image shoing large supraglottic Ca e%tending to retrophar#ngeal spaceA%ial 2" image shoing large supraglottic Ca e%tending to retrophar#ngeal space

A$utting the /t( carotid arter# )curved open arroA$utting the /t( carotid arter# )curved open arro

-estruction of the /t( th#roid ala )short open arro-estruction of the /t( th#roid ala )short open arro

-estruction of the /t( ar#tenoid )short solid arro-estruction of the /t( ar#tenoid )short solid arro


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M/IM/I

Sagittal 2! image of supraglottic CaSagittal 2! image of supraglottic Ca

E%tension involves the epiglottis :EE%tension involves the epiglottis :E

&oss of normal pr.epiglottic fat plane: solid arros&oss of normal pr.epiglottic fat plane: solid arros

2ongue $ase involvement : open arro2ongue $ase involvement : open arro


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&'ial MRI sho(ing tumour of the Rt) "C&'ial MRI sho(ing tumour of the Rt) "C

M/IM/I


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M/IM/I

Coronal *ie( of MRI sho(ing su+glottic e'tensionCoronal *ie( of MRI sho(ing su+glottic e'tension


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Sagittal *ie( sho(ing transglottic tumourSagittal *ie( sho(ing transglottic tumour

M/IM/I


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Clinical investigationsClinical investigations

6ull haematological screen6ull haematological screen

Biochemical profile including liverBiochemical profile including liverfunction tests and serum proteinfunction tests and serum protein

A urine screen for dia$etesA urine screen for dia$etes

EC=EC=


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*istological e%amination*istological e%amination

A $iops# $# direct lar#ngoscop# under =AA $iops# $# direct lar#ngoscop# under =A

6ine needle aspiration6ine needle aspiration

Importance of biopsy:Importance of biopsy:

"("( -efinitive diagnosis )8-efinitive diagnosis )8!(!( Identif# t#pe of tumourIdentif# t#pe of tumour

4(4( -ifferentiation-ifferentiation


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Patholog#Patholog#

2he vast maorit# of lar#ngeal malignant2he vast maorit# of lar#ngeal malignant

tumours aretumours are s'umouss'umous

A distinct variant of ell differentiatedA distinct variant of ell differentiated

s'uamous cell Ca is thes'uamous cell Ca is the verrucousverrucous

carcinomacarcinoma)Ac


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Spread of lar#ngeal carcinomaSpread of lar#ngeal carcinoma


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=lottic Ca=lottic Ca

0rigin0rigin the free margin of the vocal cordsthe free margin of the vocal cords

Invasion ? e%tensionInvasion ? e%tension

anterior commissureanterior commissure

cartilage )0ssified more pronecartilage )0ssified more prone

ar#tenoid ? posterior cricoar#tenoid musclear#tenoid ? posterior cricoar#tenoid muscle

vertical e%tension to the su$glottis ?orvertical e%tension to the su$glottis ?orsupraglottissupraglottis

is more fre'uent than to the opposite sideis more fre'uent than to the opposite side


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Cancer of the &t true vocal cordCancer of the &t true vocal cord


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glottic CAglottic CA


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cancer involving the true *ocal cords and arytenoid( 2he

cancer also e%tends onto the supraglottis


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C2 scan and M/IC2 scan and M/Iare valua$le inare valua$le in

diagnosis of glottic Ca ? its deep invasion,diagnosis of glottic Ca ? its deep invasion,cartilage destruction and e%tensioncartilage destruction and e%tension

outside the lar#n%outside the lar#n%

=lottic Ca=lottic Ca


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Supraglottic CaSupraglottic Ca

0ften involving0ften involving $oth sides$oth sides

Seldom e%tend to the glotticSeldom e%tend to the glotticregion due toregion due todifferent em$r#ological derivations anddifferent em$r#ological derivations and

various l#mphatic suppliesvarious l#mphatic supplies


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th#roid cartilageth#roid cartilage

pre.epiglottic spacepre.epiglottic spaceoccur in 58 ofoccur in 58 of

supraglottic Ca and 98 of epiglottic Casupraglottic Ca and 98 of epiglottic Ca

vallecula ? $ase of the tonguevallecula ? $ase of the tongue

Ar#tenoidAr#tenoid

P#riform sinusP#riform sinus


InvasionInvasion

Epiglottic tumpur


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Epiglottic tumpur

2umour of &t ar#epiglottic fold

2umour of /t false cord


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Primar# arePrimar# are rarerare

=ro=rocircumferentiall# and e%tensivel#circumferentiall# and e%tensivel#

InvasionInvasionof the vocal cords ma# lead toof the vocal cords ma# lead toimpairment of mo$ilit# and hoarsnessimpairment of mo$ilit# and hoarsness

CanCanspreadspreadthrough the cricoth#roid mem$ranethrough the cricoth#roid mem$rane

anteriorl# or cricotracheal mem$raneanteriorl# or cricotracheal mem$raneposteriorl# or invade the trachea caudall#posteriorl# or invade the trachea caudall#

Su$glottic CaSu$glottic Ca


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Su$glottic CaSu$glottic Ca


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mph node involvementmph node involvement

1,%1,%had &N metastasis at the time ofhad &N metastasis at the time of

referralreferral

Supraglottic ) 58 Supraglottic ) 58

=lottic Ca ) 7 =lottic Ca ) 7

Su$glottic Ca ) "4 Su$glottic Ca ) "4


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6e6e present ith distant metastasis at thepresent ith distant metastasis at the

time of diagnosistime of diagnosis

""""have distant metastasis, mostl# in thehave distant metastasis, mostl# in the

lung ) >(; lung ) >(;

-istant metastasis-istant metastasis


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-.M-.Mclassificaitonclassificaiton

--:: Primary tumourPrimary tumour

.. .odal deposits.odal deposits

MM MetastasisMetastasis


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--:: Primary tumourPrimary tumour

-/-/

-0-0

-is-is

Primar# tumour can not $e assesed

No evidence of primar# tumour

Carcinoma in situ


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--: Primar# tumour: Primar# tumour

GlotticGlottic

-1-1 limited mo+ile limited mo+ile aa one cord one cord

++ +oth cords +oth cords-2-2 e'tends to supra ore'tends to supra or

su+glottic impairedsu+glottic impaired

mo+ilitymo+ility

-- cord fi'ationcord fi'ation-- e'tends +eyonde'tends +eyond

the laryn'the laryn'

Supra & subglotticSupra & subglottic

-1-1 limited mo$ilelimited mo$ile

cordscords

-2-2 e%tends toe%tends to

glottismo$ileglottismo$ile

-- cord fi%ation cord fi%ation-- e%tends $e#onde%tends $e#ond

the lar#n%the lar#n%

3l tti3lottic


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-1a-1a

/t(+C Ca ith normal mo$ilit#/t(+C Ca ith normal mo$ilit#

3lottic3lottic

3l tti3lottic


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-1+-1+ &imited mo$ile $oth cords&imited mo$ile $oth cords

3lottic3lottic


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3lottic3lottic

-2-2 e%tends to supra or su$glottic impairede%tends to supra or su$glottic impaired

mo$ilit#mo$ilit#

large tumor on the left true *ocal cord

and anterior false *ocal cords )2! Cancer

3lottic3lottic


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cancer involving the true *ocal cords and arytenoid(

2he cancer also e%tends onto the supraglottis -2

3lottic3lottic


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3lottic3lottic

-- cord fi%ationcord fi%ation

-- e%tends $e#ond the lar#n%e%tends $e#ond the lar#n%

&t +C Ca ith fi%ation&t +C Ca ith fi%ation


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Su+glotticSu+glottic

-1-1

2" su$glottis2" su$glottis


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e%tends to glottismo$ilee%tends to glottismo$ile-2-2

Su$glottic tumour e%tends to glottisSu$glottic tumour e%tends to glottis


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--

--

cord fi%ationcord fi%ation

e%tends $e#ond the lar#n%e%tends $e#ond the lar#n%


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#t false cord tumour#t false cord tumour

SupraglotticSupraglottic

-1-1 limited mo$ile cordslimited mo$ile cords

S praglotticSupraglottic


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-2-2


Ca of the Rt) aryepiglottic foldCa of the Rt) aryepiglottic fold

E%tends to glottisE%tends to glottis

Mo$lie cordsMo$lie cords



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cord fi%ationcord fi%ation

e%tends $e#ond the lar#n%e%tends $e#ond the lar#n%


--

--

Ca of the #t) arytenoidCa of the #t) arytenoid


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..: Nodal deposits: Nodal deposits

.1.1 ipsilateral mo*a+leipsilateral mo*a+le

.2 contra or +ilateral mo*a+le.2 contra or +ilateral mo*a+le

.. 4i'ed4i'ed

.5 #. deposits.5 #. deposits.0.0


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MM: Metastasis: Metastasis

M0M0 no metastasis no metastasis

M1M1 metastasis metastasis


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StagingStaging

Stage 0Stage 0: 2is, N8 , M8: 2is, N8 , M8

Stage 1Stage 1: 2", N8 , M8: 2", N8 , M8

Stage 2Stage 2: 2!, N8 , M8: 2!, N8 , M8Stage Stage : 24, N8 , M8: 24, N8 , M8 2".24, N" , M82".24, N" , M8

Stage Stage : 25, N8N" , M8: 25, N8N" , M8 An# 2, N!N4 , M8An# 2, N!N4 , M8

An# 2, An# N , M"An# 2, An# N , M"


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2 t t2 t t


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Reha+ilitationReha+ilitation

2reatment2reatment

curati*ecurati*e

.o treatment.o treatment PalliationPalliation


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No treatmentNo treatment

2hose presenting in2hose presenting in e%tremese%tremes

ho areho are no longer consciousno longer consciousof pain orof pain or

distressdistress

-isseminated tumours-isseminated tumourscause their deathcause their death

ithout the primar# tumour or regionalithout the primar# tumour or regional

disease causing s#mptomsdisease causing s#mptoms

9.;9.;recieve no treatmentrecieve no treatment


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PalliationPalliation

2he attempt to2he attempt to suppresssuppressthe Ca and itsthe Ca and itss#mptomss#mptoms ithout e%pectationithout e%pectationor intent to cureor intent to cure

Palliation is used inPalliation is used in late stageslate stages

Includes:Includes:

pain reliefpain relief

tracheostom#tracheostom# other surger#other surger#

radiotherap#radiotherap#

chemotherap#chemotherap#


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2racheostom#2racheostom#

2o2o relieverelieveaira#aira#o$structiono$struction

It often provide aIt often provide adilemmadilemma, as it ust dela#, as it ust dela#

the inevita$le death in athe inevita$le death in apatient ith incura$lepatient ith incura$lecancercancer

/ di h


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/adiotherap#/adiotherap#

Commonl# used for palliationCommonl# used for palliation

Can $e applied locall# andCan $e applied locall# andselectivel#selectivel#

/adioactive implants of gold/adioactive implants of goldare useful for local treatmentare useful for local treatment


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Curative treatmentCurative treatment

/adiotherap#/adiotherap# Surger#Surger# Chemotherap#Chemotherap#


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/adiation is most effective here the/adiation is most effective here thetissues aretissues are ell o%#genatedell o%#genated((

So it is most valua$le inSo it is most valua$le in small lesionssmall lesionsandandhen the vascular suppl# is undamaged,hen the vascular suppl# is undamaged,here it hashere it has not preceded $# surger#not preceded $# surger#

/adiation is more applica$le on the/adiation is more applica$le on theo%#genated peripher#o%#genated peripher#, hile surger# could, hile surger# coulddeal ith the massdeal ith the mass

/adiotherap#/adiotherap#


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CA lar#n% for radiotherap#CA lar#n% for radiotherap#


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Surger#Surger#

Microendolar#ngeal and laser surger#Microendolar#ngeal and laser surger#

E%cisional surger#E%cisional surger#

Mi d l l d lMi d l l d l


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Microendolar#ngeal and laserMicroendolar#ngeal and laser

surger#surger#

Carcinoma in situCarcinoma in situcan $# treatedcan $# treated

$# microsurgical e%cision and$# microsurgical e%cision and

laser ma


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Microendolaryngeal and laserMicroendolaryngeal and lasersurgerysurgery

E i i lE i i l


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Partial)vertical or hori3ontal, su$total and totalPartial)vertical or hori3ontal, su$total and totallar#ngectom#(lar#ngectom#(

Used ith or ithout radiotherap#(Used ith or ithout radiotherap#(

*as ris< of loss of voice, and protection of the aira#(*as ris< of loss of voice, and protection of the aira#(

Is more effective than radiotherap# in large tumoursIs more effective than radiotherap# in large tumoursand hen there are secondar# deposits in &N on theand hen there are secondar# deposits in &N on thenec


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# g ## g #

/emoved specimen/emoved specimen


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