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Tumours of the larynx

DR / Mohammed Alhouthi
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Objectives
1.To Study the benign and malignant
tumors of the larynx.
2.Identify the clinical features of
laryngeal tumors.
3. How to diagnose the laryngeal tumors.
4.Classification and treatment of
laryngeal carcinoma.
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The larynx divided anatomically in to three

parts.
• 1.Supraglottic region.
Includes
• *a. Epiglottis.
*b.False vocal cord
.* c.The ventricle.
*d.The arytenoids.
• * e. Aryepiglottic fold.
• 2.Glottic region.
Involves True vocal
cord(anterior and
posterior
commissure.)
• 3.Subglottic region
• .Extened from below
the vocal cord to the
inferior border of the
cricoid cartilage.
 BENIGN TUMORS OF THE LARYNX:

1.Papilloma. *The commonest benign laryngeal tumor

(80% ). It is of two types :

1. Recurrent (Juvenile) respiratory

papillomatosis(RRP).
* Caused by infection with Human Papilloma Virus (HPV) subtype 6
and 11,transmitted from the mother to the child in the birth canal, or in
utero.
*(50%-70%) of patients have mother with genital warts.

Site :
Commonly seen at the junction of respiratory epithelium with
squamous epithelium, generally at the glottis, although it may occur
throughout the air way.
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Clinical features:
The age of presentation is 2-6 years,
There are :
*hoarseness,*aphonia,*stridor and* dyspnea
due to airway obstruction.
It is :
1 *usually multiple, warty appearance, mainly
involved the true and false vocal cords, but
may extend to subglotic,trachea ,bronchi, and
epiglottis.
2*Has propensity to recur after local removal,
(HPV has been found consistently in the
epithelium of papilloma lesions and adjacent
normal appearing tissue; this explains the
ability of the virus to cause recurrent disease,
despite apparent surgical eradication of
lesions),
3 *may regress spontaneously after
puberty ,and
4 *not undergoes malignant changes unless
irradiated.
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Diagnosis
➢ *Direct laryngoscope and biopsy and
histopathological study.
➢ *Bronchoscopy.To exclude lung
involvement.
Treatment;
1. Avoid tracheotomy. to prevent seeding of the virus to
trachea,
2-Surgical excision.
* Best by Co2 Laser vaporization,
*Cryotherapy to reduce seeding of the virus.
* microforceps(conventional microlaryngeal surgery.)
The growths recur regularly, requiring repeat operations
3- Ajuvant medical treatment; aimed the virus and growth of
tumors. like *Alfa interferon(subcutaneously),
*Cidofovir ( intralesionally). *Indole-3-carbinol.
4- Other includes ;preventing and therapeutic vaccines,
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2.Adult type laryngeal papillomatosis .

Common in young adults (18-39 years old)presented with
hoarseness
* It is usually single.
*L•ess propensity for recurs after local excision.
* when recurs may gets malignant changes.
*no spontaneous regression.

Single adult papilloma Multiple laryngeal papillomatosis

2.Haemangioma. Juvenile and adult forms,
It is typically located in the subglottic region, but the supraglottic space, vocal
cords or upper part of the trachea may be involved.
Generally associated with cutaneous haemangioma( 63%).
* A characteristic history of rapid growth during the first 6 months of life, and then
after 12 months a slow regression takes place.
symptoms:
*stridor, *dyspnoea, *cough, and *hoarseness are present in the clinical picture
of other congenital obstructions of the airway passage.
Treatment ,
*When large tumor require a tracheotomy until their natural resolution.
*Laser surgery.
* Steroid (Dexamethazone.)
*propranolol

3.Other benign tumor ,rare

includes.Chondroma (mostly
cricoids cartilage) ,fibroma,
schwanoma,neurofibroma,

. Subglottic haemangioma presenting

cutaneously in “beard” distribution over
the face, and over the neck and chest.
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Malignant tumors of the larynx
Includes
1.Squamous cell carcinoma.
2.Lymphoma .second common malignancy of the larynx
3.Uncommon malignancy. Verrucous carcinoma, adeno ca.
,sarcoma, minor salivary gland tumors.
4.metastatic tumors. From renal, prostate, breast, lung ,stomach.(rare).
Squamous cell carcinoma.
Commonest malignant laryngeal tumor ( 94% ).
* 67% glottis,*31% supraglottic,*2%subglottic.
Risk factors;
1. Age;Old age (over the age of 55.)
2. Sex; Men are four times more than women .
3.Smoking and alcohol abuse, they increase the risk 50%.
4.Irradiation for neck ex. for thyroid .
5. Occupational like asbestos. Nickel, wood products and painters.
6. Human papilloma virus infections :Solitary respiratory papilloma (
infection with high risk subtype HPV infection (e.g.16:RR3).
7. Others like genetic ,family tendency , Gastro-esophageal reflux..
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Clinical features:
Common in male 90%, peak age incidence 55-65 year .
(usually elderly male with low socioeconomic status)
1. Progressive unremitting dysphonia(Hoarseness).
2. Stridor and dyspnea due to vocal cord paralysis, or extensive
endolaryngeal lesion in supraglottic ,Glottic,and subglottic.
3. Pain (referred otalgia) .indicate deep invasion, involvement of the
pharynx.
4. dysphagia.when the tumor involve the hypopharynx.
5. Neck mass. Metastatic node, or local spread
6. Haemoptysis.is late symptoms in ulcerative or invasive lesion
specially supraglottic lesion.
7. Cough and irritation. By the tumor it self, or associate with
pneumonia,chronic bronchitis, or lung metastasis.
8. Anemia,cachexia,an fetor due to tumor necrosis.
*Glottic cancer tends to present early with voice
changes,( Every patients with hoarseness for 2
weeks or more require to be seen by specialist.
*Supraglottic tumors delay in presentation are
common due to vagueness of symptoms such
as globus, and otalgia therefore may advanced
and have nodal disease at time of presentation
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Diagnosis :
1.--Indirect laryngoscope (Mirror.or Flexible
laryngoscopy.)
2--.Direct laryngoscopy. To assess.
a.Site and limit of the tumor.
b.See the hidden areas (Ventral surface of
epiglottis,anterior commisure,the
ventricle,subglottic region.)
c.Probing the vocal cord for fixation or
paralysis.
d.Take biopsy for histopathological study.
3-- CT scan(ComputerizaedTomography).
4-- Magnatic Resonance Imaging (MRI)
( 3&4 with enhancement use for further
evaluation of the tumor.
*MRI better for soft tissue detail evaluating
the supraglottis, subglottic ,and soft tissue
involvement (preepiglotic space,paraglottic Contrast CT scan showing bulky
space, cartilages, thyroid gland, muscles,) left supraglottic tumor (arrow)
*Lymph node involvement(Number, site, and with ipsilateral lymph node
relation to the major vessels.) metastasis (arrowhead
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The (TMN) Classification laryngeal carcinoma

The larynx divided anatomically in to three parts.
1.Supraglottic region...
2. Glottic region.
3.Subglottic region.
Generally the T classification can be applied to any region
Tis=Carcinoma in situ.
T1a= Ca. limit to on site.
T1b=Ca. in two sites, but
within one region.
T2=Ca. Affected two
regions{Transglottic}
,e.g. supraglottic and glottis, or glottis and
subglottic region.
But mobile vocal cords.
T 3=Tumor within the larynx
but fixed vocal cord.
T 4=Tumor out side the
larynx.
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Treatment of laryngeal cancer :

1. Ca. in situ : Endoscopic resection; by microlaryngeal instruments or by Carbon
dioxid (CO2) laser.
2;T1,andT2 : *Radiotherapy.
*. Partial laryngectomy.. An operations in which part of the larynx is
removed, but the trachea and pharynx remain intact.. It is Voice preservation
surgery ,includes.
A. Vertical partial laryngectomy(PL).(Hemilaryngectomy). Used for glottis tumor
with mobile vocal cord, like cordectomy,Frontal partial laryngectomy(PL).Lateral
partial laryngectomy, Extended froto-lateral PL.
B. Horizontal partial laryngectomy. Used for T1,T2 Supraglottic tumor ,remove the
portion of the larynx above the vocal cords,,Epigloectomy.*Supraglottic
laryngectomy,Exteneded supraglottic laryngectomy.
3. T3,T4,Failure of treatment of T1,andT2 : surgical treatment Total laryngectomy.
4. Nodal metastasis:
*Elective neck dissection is commonly preferred for T 2- 4 Supraglottic
cancer even with No.
*Neck dissection. It is usually done at the same time as surgery to remove an
already existing tumor. The type of surgery (Radical neck dissection or modified
radical neck dissection.) depends on the stage of cancer.
5. Combine surgery *Surgery +Radiotherapy, or chemotherapy.
*Radiotherapy+Chemotherapy.
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Total laryngectomy:
indicated in stage T3,T4 tumor, and failure of treatment of stage T1,andT2
The mainstay of treatment for advanced laryngeal carcinoma.
It is a.surgical procedure when the whole larynx (voice box)is removed, and the trachea
sutured to the skin anteriorly ( stoma) as permanent tracheotomy, the patient breathe
through the stoma. The pharynx closed and sutured to the base of the tongue .
*In total laryngectomy
Removal Of
❑ the larynx,
❑ thyroid cartilage,
❑ cricoid cartilage,
❑ epiglottis,
❑ hyoid bone,
❑ strap muscles,
❑ one or both lobs of thyroid gland,
❑ 2-3 tracheal rings.
Prognosis of ca.larynx.
5 years survival of ca.larynx
Stage 1= >95%
Stage II=85 -90%,
Stage III=70-80%
Stage IV=50-60%
*patient considered cured after being disease free for
five years
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Rehabititation after total laryngectomy

The chief problems where rehabilitation is likely to be required are:
1.Speech.(Voice restoration)
2. Swallowing
3. Tracheostomy problems.
4.Problem with loss of glottis occlusion, e.g. lifting. swimming,
bathing and shower
5. problems with airway diverging ,e . g. loss of olfaction. because the
air not pass through the nose and mouth .
6. Body image/psychological/social problems.
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Methods of voice restoration after total laryngectomy.
1.Esophageal speech.
2.Artifical (electronic) larynx
3.Tracheo-esophageal speech

• 1.Esophageal speech. The laryngectomee patient can

learn from a speech therapist . where air is injected,
then expelled in a controlled way to form voice.

A. Tongue press to inject air into

esophagus B. Air enters esophagus C.
Air released from esophagus to
produce voice D. Voice shaped into
speech
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2.Artifical (electronic) larynx ..

It is a device emits a vibrating noise and is hand-held against the
throat. By mouthing words, the laryngectomee converts the vibrations
to speech.
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3.Tracheo-esophageal speech.(preferred methods)

• .By creating a small surgical passage (TEP, or Tracheoesophageal
Puncture (fistula)), inside the stoma, from the back wall of the
trachea i nto the esophageal wall, a small one-inched valved tube
(voice prosthesis) can be placed i nto thi s passage to enable
tracheoesophageal speech.
• Voi ce is produced by blocking the stoma, either with a finger or
an adjustable tracheostoma valve, so that exhaled air from the
lungs can be directed from the trachea through the prosthesis
i nto the esophagus (where vibrations are produced) and vibrations
whi ch are modified by the tongue, palate, and lips to produce
speech. Fluent, conversational speech is usually acquired within a
few days.
• Use of one way valve,
• like ,Blom-Singer voice prostheses,
• and Panje Voi ce Button
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Adjustable tracheostoma
Stoma occlusion with thumb.
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