Diagnosis and treatment of carcinoma of larynx by nitesh Kr.
By: Nitesh Kr. 102Mamc
DIAGNOSIS/CLINICAL FEATUREI. History collectionII. Physical examinationIII. LaryngoscopyIV. EndoscopyV. BiopsyVI. Contrast laryngogramsVII.Radiography (CT scan, x-ray, and MRI )
1. History collection• History of supraglottic , glottic and subglotticlesion vary.• it is a dictum thatAny patient in cancer age group havingpersistent or gradually increasing hoarseness x 3weeks must have laryngeal examination toexclude cancer….!
History in glottic cancerVoice changeHemoptysisDyspneaRespiratory obstuctionDysphasiaWeight lossPain
H/O SupraglotticAspiration on swallowing.Sore throatForeign body sensationDysphasiaNeck massHaemoptysisDyspnoeaPain in the throat referred to the ear
2. Physical examinationDone for :1. Extralaryngeal spread of diseasea) Anterior commissure of vocal chordb) Subglottic region through cricothyroidmembranec) Thyroid cartilage invasion (perichondritis).2. Nodal metastasisa) Metastatic L.N examined for :size,number, mobile or fixed,unilateral/bilateral/contraletral.
3. Laryngoscopy Indirect laryngoscopy Direct laryngoscopy Microlaryngoscopy
A.Indirect laryngoscopythis will show1.Lesion appearance : varyaccording to the siteSupra hyoidepiglottisExophytic lesionInfrahyoidEpiglottisUlcerative lesionVocal cord Raised nodule,ulcer or thickeningAnteriorcommisure lesionGranulation tissueSubglottic region Raaisedsubmucosal nodule
Contd..2. Vocal cord mobility :Fixation of vocal cordindicate deeper infiltration intoa. Thyroarytenoid musclesb. Cricoarytenoid jointc. Recurrent laryngealnerve invasion3.Extent of disease :a. Valleculab. Base of tonguec. Pyriform fossa can benoticed
B.Direct laryngocopy• It is done to see :a) The hidden areas oflarynx Infrahyoid epiglottis Anterior commisure Subglottis Ventricleb) Extent of disease
C.Microlaryngoscopy• This is done for small lesionof vocal cord• Laryngoscopy is done undermicroscope to bettervisualize the lesion• Accurate biopsy specimencan be taken
4.Endoscopy• Panendoscopy :combineslaryngoscopy,esophagoscopy, and (attimes) bronchoscopy.• This lets the doctorthoroughly examine theentire area around thelarynx and hypopharynx,including the esophagusand trachea (windpipe).Endoscopic view :
5.Biopsy1.Endoscopic biopsy : larynx and hypopharynx aredeep inside the neck. Biopsies of these areas aredone in the operating room rigid laryngoscope2.Fine needle aspiration (FNA) biopsy : This typeof biopsy is not used to remove samples in the larynx orhypopharynx, but it may be done to find the cause of anenlarged lymph node in the neck. A thin, hollow needle isplaced through the skin into a mass (or tumor) to getcells for a biopsy. The cells are then looked at under amicroscope.
6.Radiography• X-ray chest : this is essential for co-existent lungdisease• Soft tissue lateral view neck: extent of lesionof epiglottis, aryepiglottic fold, arytenoidsand pre-epiglottic space involvement canbe seen• CT-scan : useful for finding the extent oftumor, invasion of pre-epiglottic space,distruction of cartilage and lymph nodeinvolvement .
StagingSource: AJCC Cancer Staging Manual, 6th Ed (2002)• Supraglottis– Tis: CA in-situ– T1: limited to subsite of supraglotsw/normal cord mobility– T2: invade mucosa of > 1 subsite ofsupraglottis, glottis, or outside ofsupraglottis w/out fixation of thelarynx– T3: limited to larynx w/vocal cordfixation and/or invades postcricoidarea, pre-epiglottictissues, paraglottic space, and/orminor thyroid cartilage erosion– T4a: invades thyroid cartilageand/or tissues beyond larynx– T4b: invades prevertebralspace, encases carotid artery, orinvades mediastinal structures
• Subglottis– Tis: CA in-situ– T1: limited to subglottis– T2: extends to vocal cord withnormal or impaired mobility– T3: limited to larynx w/vocal cordfixation– T4a: invades cricoid or thyroidcartilage, and/or invades tissuesbeyond the larynx– T4b: invades prevertebral space,encases carotid artery, or invadesmediastinal structuresStagingSource: AJCC Cancer Staging Manual, 6th Ed (2002)• Glotti– Tis: CA in-situ– T1: limited to cord;T1a: one cord; T1b: two cords– T2: extends to supraglottis, and/orsubglottis, and/or w/impaired cordmobility– T3: limited to larynx w/vocal cordfixation and/or invades paraglotticspace, and/or minor thyroidcartilage erosion– T4a: invades thyroid cartilageand/or tissues beyond larynx– T4b: invades prevertebralspace, encases carotid artery, orinvades mediastinal structures
• Nodes– N0: no regional node mets– N1: single ipsilateral node, ≤ 3 cm– N2a: single ipsilateral node, > 3 cm, ≤ 6 cm– N2b: multiple ipsilateral nodes, ≤ 6 cm– N2c: bilateral or contralateral nodes, ≤ 6 cm– N3: node > 6 cm• Mets– Mx: unknown– M0: no distant mets– M1: distant metsStaging
Treatment of Ca larynxOn basis of nodal metastases , lesion and itsextent consist of :1. Radiotherapy2. Surgery (a) Conservation laryngeal surgery(b) Total laryngectomy3. Combined therapy
1.Radiotherapy radiotherapy : is reserved for early lesionswhich neither impair cord mobility norinvade cartilage or cervical nodes. Cancer ofthe vocal cord without impairment of itsmobility gives a 90% cure rateRadiotherapy : does not give good results inlesions with fixed cords, subglottic extension,cartilage invasion, and nodal metastases
Preserves voiceNo need for permanenttracheal openingSurgeryConservativeSurgeryTotalResection
A .ConservationSurgeryVertical PartialLaryngectomyCordectomyPartial FrontolateralLaryngectomyHorizontal PartialLaryngectomy
B.Total laryngectomyIn this entire larynx including the1. hyoid bone2. pre-epiglottic space3. strap muscles4. one or more rings of trachea areremoved.Indications:a)T3 or T4 unfit for partialb)Extensive involvement of thyroid and cricoid cartilagesc)Invasion of neck soft tissuesd)Tongue base involvement beyond circumvallate papillae
ComplicationsPharyngocutaneous fistulaHaemorragePulmonary and cerebral embolismTracheal crusting,granulationsThyroid insufficiency in some cases wheretotal thyroidectomy is necessaryParathyroid insufficiency usualy follows totalthyroidectomy
Disability After Total Laryngectomy• Loss of voice• Sense of smell impaired• Loss of taste• Patient must take carethat water does not entertracheostome• Heavy lifting or strenuousdigging not possible• Patient often sociallylimited
3. Combined therapy• Surgical ablation may be combined with pre-or post-operative radiation to decrease theincidence of recurrence. Pre-operativeradiation may also render fixed nodesresectable.
VOCAL REHABILITATION AFTER TOTALLARYNGECTOMY• Written language (Pen & paper)• Aphonic lip speech (By trapping air in buccal cavityoften combined with sign language)• Oesophageal speech• Electrolarynx• Transoral pneumatic device• Tracheo-oesophageal speech-Blom-Singer prosthesis-Panje prosthesis
Oesophageal speech• Air swallowed and slowly ejected fromoesophagus into the pharynx• Patient can speak 6-10 words before re-swallowing air• Voice rough but loud and understandable
Electrolarynx• Vibrating disc produce a low pitched sound inthe hypopharynx• Modulated into speech by tongue, lips, teethand palate
Tracheo-oesophageal speechAir carried from trachea to oesophagusCreation of skin lined fistulaDisadvantage: food can enter tracheaArtificial prosthesis: Blom-Singer or PanjeInbuilt valves working in single directionPreventing problems of aspirationDisadvantage: need to replace regularly andassociated cost