The document discusses the diagnosis and clinical features of laryngeal cancer. It outlines the various steps involved in diagnosis which include collecting a history, physical examination, laryngoscopy, endoscopy, biopsy, radiological imaging and staging. Specific symptoms associated with glottic, supraglottic and subglottic cancers are provided. Treatment options discussed include radiotherapy, conservative and total laryngectomy surgery, and combined therapy. Complications, disabilities after total laryngectomy and vocal rehabilitation methods are also summarized.

1. By: Nitesh Kr. 102
Mamc

2. DIAGNOSIS/CLINICAL FEATURE
I. History collection
II. Physical examination
III. Laryngoscopy
IV. Endoscopy
V. Biopsy
VI. Contrast laryngograms
VII.Radiography (CT scan, x-ray, and MRI )

3. 1. History collection
• History of supraglottic , glottic and subglottic
lesion vary.
• it is a dictum that
Any patient in cancer age group having
persistent or gradually increasing hoarseness x 3
weeks must have laryngeal examination to
exclude cancer….!

4. History in glottic cancer
Voice change
Hemoptysis
Dyspnea
Respiratory obstuction
Dysphasia
Weight loss
Pain

5. H/O Supraglottic
Aspiration on swallowing.
Sore throat
Foreign body sensation
Dysphasia
Neck mass
Haemoptysis
Dyspnoea
Pain in the throat referred to the ear

6. H/O Subglottic
 Airway obstruction
 Dysphasia
 Weight loss
 hemoptysis

7. 2. Physical examination
Done for :
1. Extralaryngeal spread of disease
a) Anterior commissure of vocal chord
b) Subglottic region through cricothyroid
membrane
c) Thyroid cartilage invasion (perichondritis).
2. Nodal metastasis
a) Metastatic L.N examined for :
size,number, mobile or fixed,
unilateral/bilateral/contraletral.

8. 3. Laryngoscopy
 Indirect laryngoscopy
 Direct laryngoscopy
 Microlaryngoscopy

9. A.Indirect laryngoscopy
this will show
1.Lesion appearance : vary
according to the site
Supra hyoid
epiglottis
Exophytic lesion
Infrahyoid
Epiglottis
Ulcerative lesion
Vocal cord Raised nodule,
ulcer or thickening
Anterior
commisure lesion
Granulation tissue
Subglottic region Raaised
submucosal nodule

10. Contd..
2. Vocal cord mobility :
Fixation of vocal cord
indicate deeper infiltration in
to
a. Thyroarytenoid muscles
b. Cricoarytenoid joint
c. Recurrent laryngeal
nerve invasion
3.Extent of disease :
a. Vallecula
b. Base of tongue
c. Pyriform fossa can be
noticed

11. B.Direct laryngocopy
• It is done to see :
a) The hidden areas of
larynx
 Infrahyoid epiglottis
 Anterior commisure
 Subglottis
 Ventricle
b) Extent of disease

12. C.Microlaryngoscopy
• This is done for small lesion
of vocal cord
• Laryngoscopy is done under
microscope to better
visualize the lesion
• Accurate biopsy specimen
can be taken

13. 4.Endoscopy
• Panendoscopy :combines
laryngoscopy,
esophagoscopy, and (at
times) bronchoscopy.
• This lets the doctor
thoroughly examine the
entire area around the
larynx and hypopharynx,
including the esophagus
and trachea (windpipe).
Endoscopic view :

14. 5.Biopsy
1.Endoscopic biopsy : larynx and hypopharynx are
deep inside the neck. Biopsies of these areas are
done in the operating room rigid laryngoscope
2.Fine needle aspiration (FNA) biopsy : This type
of biopsy is not used to remove samples in the larynx or
hypopharynx, but it may be done to find the cause of an
enlarged lymph node in the neck. A thin, hollow needle is
placed through the skin into a mass (or tumor) to get
cells for a biopsy. The cells are then looked at under a
microscope.

15. 6.Radiography
• X-ray chest : this is essential for co-existent lung
disease
• Soft tissue lateral view neck: extent of lesion
of epiglottis, aryepiglottic fold, arytenoids
and pre-epiglottic space involvement can
be seen
• CT-scan : useful for finding the extent of
tumor, invasion of pre-epiglottic space,
distruction of cartilage and lymph node
involvement .

16. Soft tissue lateral
view neck

17. CT-scan

18. Staging
Source: AJCC Cancer Staging Manual, 6th Ed (2002)
• Supraglottis
– Tis: CA in-situ
– T1: limited to subsite of supraglots
w/normal cord mobility
– T2: invade mucosa of > 1 subsite of
supraglottis, glottis, or outside of
supraglottis w/out fixation of the
larynx
– T3: limited to larynx w/vocal cord
fixation and/or invades postcricoid
area, pre-epiglottic
tissues, paraglottic space, and/or
minor thyroid cartilage erosion
– T4a: invades thyroid cartilage
and/or tissues beyond larynx
– T4b: invades prevertebral
space, encases carotid artery, or
invades mediastinal structures

19. • Subglottis
– Tis: CA in-situ
– T1: limited to subglottis
– T2: extends to vocal cord with
normal or impaired mobility
– T3: limited to larynx w/vocal cord
fixation
– T4a: invades cricoid or thyroid
cartilage, and/or invades tissues
beyond the larynx
– T4b: invades prevertebral space,
encases carotid artery, or invades
mediastinal structures
Staging
Source: 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/or
subglottis, and/or w/impaired cord
mobility
– T3: limited to larynx w/vocal cord
fixation and/or invades paraglottic
space, and/or minor thyroid
cartilage erosion
– T4a: invades thyroid cartilage
and/or tissues beyond larynx
– T4b: invades prevertebral
space, encases carotid artery, or
invades mediastinal structures

20. • 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 mets
Staging

21. Treatment of Ca larynx
On basis of nodal metastases , lesion and its
extent consist of :
1. Radiotherapy
2. Surgery (a) Conservation laryngeal surgery
(b) Total laryngectomy
3. Combined therapy

22. 1.Radiotherapy
 radiotherapy : is reserved for early lesions
which neither impair cord mobility nor
invade cartilage or cervical nodes. Cancer of
the vocal cord without impairment of its
mobility gives a 90% cure rate
Radiotherapy : does not give good results in
lesions with fixed cords, subglottic extension,
cartilage invasion, and nodal metastases

23. Preserves voice
No need for permanent
tracheal opening
Surgery
Conservative
Surgery
Total
Resection

24. A .Conservation
Surgery
Vertical Partial
Laryngectomy
Cordectomy
Partial Frontolateral
Laryngectomy
Horizontal Partial
Laryngectomy

25. B.Total laryngectomy
In this entire larynx including the
1. hyoid bone
2. pre-epiglottic space
3. strap muscles
4. one or more rings of trachea are
removed.
Indications:
a)T3 or T4 unfit for partial
b)Extensive involvement of thyroid and cricoid cartilages
c)Invasion of neck soft tissues
d)Tongue base involvement beyond circumvallate papillae

26. Complications
Pharyngocutaneous fistula
Haemorrage
Pulmonary and cerebral embolism
Tracheal crusting,granulations
Thyroid insufficiency in some cases where
total thyroidectomy is necessary
Parathyroid insufficiency usualy follows total
thyroidectomy

27. Disability After Total Laryngectomy
• Loss of voice
• Sense of smell impaired
• Loss of taste
• Patient must take care
that water does not enter
tracheostome
• Heavy lifting or strenuous
digging not possible
• Patient often socially
limited

28. 3. Combined therapy
• Surgical ablation may be combined with pre-
or post-operative radiation to decrease the
incidence of recurrence. Pre-operative
radiation may also render fixed nodes
resectable.

29. VOCAL REHABILITATION AFTER TOTAL
LARYNGECTOMY
• Written language (Pen & paper)
• Aphonic lip speech (By trapping air in buccal cavity
often combined with sign language)
• Oesophageal speech
• Electrolarynx
• Transoral pneumatic device
• Tracheo-oesophageal speech
-Blom-Singer prosthesis
-Panje prosthesis

30. Oesophageal speech
• Air swallowed and slowly ejected from
oesophagus into the pharynx
• Patient can speak 6-10 words before re-
swallowing air
• Voice rough but loud and understandable

31. Electrolarynx
• Vibrating disc produce a low pitched sound in
the hypopharynx
• Modulated into speech by tongue, lips, teeth
and palate

33. Tracheo-oesophageal speech
Air carried from trachea to oesophagus
Creation of skin lined fistula
Disadvantage: food can enter trachea
Artificial prosthesis: Blom-Singer or Panje
Inbuilt valves working in single direction
Preventing problems of aspiration
Disadvantage: need to replace regularly and
associated cost

34. Thankyou