Zhang, Lei MSOtolaryngology and Head & Neck Department
Sir Run Run Shaw HospitalEmail:[email protected]
Acute epiglottis Acute laryngotracheobranchitis in
children Chronic laryngitis Vocal fold polyps Vocal fold nodules Leukoplakia of larynx Laryngeal papillomas Laryngeal cancer Squamous cell carcinoma of
pharynx(cancer of hypopharynx)
Verrucous Carcinoma
11,000 new cases of laryngeal cancer per year in the U.S.
Accounts for 25% of head and neck cancer and 1% of all cancers
One-third of these patients eventually die of their disease
Most prevalent in the 6th and 7th decades of life
4:1 male predilection Downward shift from 15:1 post WWII Due to increasing public acceptance of
female smoking More prevalent among lower
socioeconomic class, in which it is diagnosed at more advanced stages
Glottic Cancer: 59%
Supraglottic Cancer: 40%
Subglottic Cancer: 1%
Most subglottic masses are extension from glottic carcinomas
The first laryngectomy for cancer of the larynx was performed in 1883 by Billroth
Patient was successfully fed by mouth and fitted with an artificial larynx
In 1886 the Crown Prince Frederick of Germany developed hoarseness as he was due to ascend the throne.
Crown Prince Frederick of Germany
Was evaluated by Sir Makenzie of London, the inventor of the direct laryngoscope
Frederick’s lesion was biopsied and thought to be cancer
He refused laryngectomy and later died in 1888
Frederick was succeeded by Kaiser Wilhelm II, who along with Otto von Bismark militarized the German Empire and led them into WW I
Could an Otolaryngologist have prevented WW I?
Prolonged use of tobacco and excessive alcohol use primary risk factors
The two substances together have a synergistic effect on laryngeal tissues
90% of patients with laryngeal cancer have a history of both
Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposures
Asbestos mustard gaspetroleum products other risk factors.
Prior history of head and neck irradiation
85-95% of laryngeal tumors are squamous cell carcinoma
Histologic type linked to tobacco and alcohol abuse
Characterized by epithelial nests surrounded by inflammatory stroma
Keratin Pearls are pathognomonic
Verrucous Carcinoma Fibrosarcoma Chondrosarcoma Minor salivary carcinoma Adenocarcinoma Oat cell carcinoma Giant cell and Spindle cell carcinoma
Thyroid cartilage
cricoid
hyoid
epiglottic
cricothyroid ligament
epiglottic
Thyroid
Arytenoidscorniculate, cuneiform
cricoid
sagittal viewcoronal view
Supraglottic tumors more aggressive:Direct extension into pre-epiglottic spaceLymph node metastasisDirect extension into lateral hypopharnyx,
glossoepiglottic fold, and tongue base
Glottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainageThey tend to metastasize after they have
invaded adjacent structures with better drainage
Extend superiorly into ventricular walls or inferiorly into subglottic space
Can cause vocal cord fixation
True subglottic tumors are uncommonGlottic spread to the subglottic space is a
sign of poor prognosis Increases chance of bilateral disease and
mediastinal extension Invasion of the subglottic space associated
with high incidence of stomal reoccurrence following total laryngectomy (TL)
HoarsenessMost common symptomSmall irregularities in the vocal fold result in
voice changesChanges of voice in patients with chronic
hoarseness from tobacco and alcohol can be difficult to appreciate
Patients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluation
Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color
Videostrobe laryngoscopy may be needed to follow up these subtler lesions
Good neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is required
The base of the tongue should be palpated for masses as well
Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion
Other symptoms include:DysphagiaHemoptysisThroat painEar painAirway compromiseAspirationNeck mass
Biopsy is required for diagnosis Performed in OR with patient under
anesthesia Other benign possibilities for laryngeal
lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis
Other potential modalities:Direct laryngoscopyBronchoscopyEsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?( Positron emission tomography)
Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color
TXTX Minimum requirements to assess Minimum requirements to assess primary tumor cannot be metprimary tumor cannot be met
T0T0 No evidence of primary tumorNo evidence of primary tumor
TisTis Carcinoma in situCarcinoma in situ
T1T1 Tumor limited to one subsite of supraglottis with normal Tumor limited to one subsite of supraglottis with normal vocal cord mobility vocal cord mobility
T2T2 Tumor involves mucosa of more than one adjacent Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation vallecula, medial wall of piriform sinus) without fixation
T3T3 Tumor limited to larynx with vocal cord fixation and or Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) thyroid cartilage erosion (e.g. inner cortex)
T4T4aa
Tumor invades through the thyroid cartilage and/or Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) tongue, strap muscles, thyroid, or esophagus)
T4T4bb
Tumor invades prevertebral space, encases carotid Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures artery, or invades mediastinal structures
T1T1 Tumor limited to the vocal cord (s) (may involve Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty anterior or posterior commissure) with normal mobilty
T1aT1a Tumor limited to one vocal cord Tumor limited to one vocal cord
T1bT1b Tumor involves both vocal cords Tumor involves both vocal cords
T2T2 Tumor extends to supraglottis and/or subglottis, Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility and/or with impaired vocal cord mobility
T3T3 Tumor limited to the larynx with vocal cord fixation Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) cartilage erosion (e.g. inner cortex)
T4aT4a Tumor invades through the thyroid cartilage, and/or Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus the tongue, strap muscles, thyroid, or esophagus
T4bT4b Tumor invades prevertebral space, encases carotid Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures artery, or invades mediastinal structures
T1T1 Tumor limited to the subglottis Tumor limited to the subglottis
T2T2 Tumor extends to vocal cord (s) with normal or Tumor extends to vocal cord (s) with normal or impaired mobility impaired mobility
T3T3 Tumor limited the larynx with vocal cord fixation Tumor limited the larynx with vocal cord fixation
T4aT4a Tumor invades cricoid or thyroid cartilage and/or Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea, soft invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or muscles of the tongue, strap muscles, thyroid, or esophagus) esophagus)
T4bT4b Tumor invades prevertebral space, encases Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures carotid artery, or invades mediastinal structures
N0N0 No cervical lymph nodes positive No cervical lymph nodes positive
N1N1 Single ipsilateral lymph node ≤ Single ipsilateral lymph node ≤ 3cm 3cm
N2aN2a Single ipsilateral node > 3cm and Single ipsilateral node > 3cm and ≤6cm ≤6cm
N2bN2b Multiple ipsilateral lymph nodes, Multiple ipsilateral lymph nodes, each ≤ 6cmeach ≤ 6cm
N2cN2c Bilateral or contralateral lymph Bilateral or contralateral lymph nodes, each ≤6cm nodes, each ≤6cm
N3N3 Single or multiple lymph nodes > Single or multiple lymph nodes > 6cm 6cm
M0M0 No distant metastasesNo distant metastases
M1M1 Distant metastases presentDistant metastases present
00 TisTis N0N0 M0M0
II T1T1 N0N0 M0M0
IIII T2T2 N0N0 M0M0
IIIIII T3T3 N0N0 M0M0
T1-3T1-3 N1N1 M0M0
IVAIVA T4aT4a N0-2N0-2 M0M0
T1-4aT1-4a N2N2 M0M0
IVBIVB T4bT4b Any NAny N M0M0
Any TAny T N3N3 M0M0
IVCIVC Any TAny T Any NAny N M1M1
Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesion
CO2 laser can be used to accomplish this but makes accurate review of margins difficult
Early stage (T1 and T2) can be treated with radiotherapy or surgery alone, both offer the 85-95% cure rate.
Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomes
Radiotherapy is given for 6-7 weeks, avoids surgical risks but has own complications
XRT complications include:MucositisOdynophagiaLaryngeal edemaXerostomiaStricture and fibrosisRadionecrosisHypothyroidism
Advanced stage lesions often receive surgery with adjuvant radiation
Most T3 and T4 lesions require a total laryngectomy
Some small T3 and lesser sized tumors can be treated with partial larygectomy
Adjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 6-7 weeks
Indications for post-op radiation include: T4 primary, bone/cartilage invasion, extension into neck soft tissue, perineural invasion, vascular invasion, multiple positive nodes, nodal extracapsular extension, margins<5mm, positive margins, CIS margins, subglottic extension of primary tumor.
Chemotherapy can be used in addition to irradiation in advanced stage cancers
Two agents used are Cisplatinum and 5-flourouracil
Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.
Induction chemotherapy with definitive radiation therapy for advanced stage cancer is another option
Studies have shown similar survival rates as compared to total laryngectomy with adjuvant radiation but with voice preservation.
Role in treatment still under investigation
Modified or radical neck dissections are indicated in the presence of nodal disease
Neck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal disease
N0 necks can have a selective dissection sparing the SCM, IJ, and XI
N1 necks usually have a modified dissection of levels II-IV
No more than 1cm subglottic extension anteriorly or 5mm posteriorly
Mobile affected cord Minimal anterior
contralateral cord involvement
No cartilage invasion No neck soft tissue
invasion
T1,2, or 3 if only by preepiglottic space invasion
Mobile cords No anterior commissure
involvement FEV1 >50% No tongue base disease
past circumvallate papillae
Apex of pyriform sinus not invloved
Resection of true vocal cords, supraglottis, thyroid cartilage
Leave arytenoids and cricoid ring intact
Half of patients remain dependent on tracheostomy
Indications:T3 or T4 unfit for partialExtensive involvement of thyroid and
cricoid cartilages Invasion of neck soft tissuesTongue base involvement beyond
circumvallate papillae
Tracheostomal prosthesis
Electrolarynx
Pure esophageal speech
Inaccurate staging Infection Voice alterations Swallowing difficulties Loss of taste and smell Fistula Tracheostomy dependence Injury to cranial nerves: VII, IX, X, XI, XII Stroke or carotid “blowout” Hypothyroidism Radiation induced fibrosis
5 year survival5 year survival
Stage IStage I >95%>95%
Stage IIStage II 85-90%85-90%
Stage IIIStage III 70-80%70-80%
Stage IVStage IV 50-60%50-60%
After initial treatment patients are followed at 4-6 week intervals. After first year decreases to every 2 months. Third and fourth year every three months, with annual visits after that
Patients considered cured after being disease free for five years
Most laryngeal cancers reoccur in the first two years
Despite advances in detection and treatment options the five year survival has not improved much over the last thirty years
The pyriform sinus is the most common site for hypopharyngeal cancer (65-75%). Cancer may extend from here into the subglottis, thyroid
cartilage, postcricoid region, or cricoarytenoid joint. Three of every four patients presenting with hypopharyngeal
cancer at this subsite may have regional metastasis with apical primaries, resulting in a poorer prognosis.
A life-threatening infectionAcute epiglottitis in the
Children Acute epiglottitis in the Adult
Acute epiglottitis in the Children Organisms
non–type B H. influenzae( in vaccinated children)
Streptococcus pyogenes, S. pneumoniae S. aureus.
Diagnosis history and clinical findingsLateral soft tissue radiographs
“thumb sign” a dilated hypopharynx. Occasionally, supraglottic region appears hazy In severe cases, treatment should not be
delayed to obtain radiographs
Differentiating Diagnosis laryngotracheitis is not always easy, but it
is of paramount importance
The signs and symptoms Signs
A toxic appearance is involved, with the child assuming an upright sitting position with the chin up and mouth open, bracing themself on the hands (the "tripod" position).
Patients often have difficulty in handling their secretions.
Speech is limited due to pain. Stridor is a late finding and signals nearly complete
airway obstruction. Symptoms
Severe throat pain Fever Irritability and respiratory distress that are rapidly
progressive Muffled voice
How is acute epiglottitis managed? arrangements for airway endoscopy in the
operating room All anxiety-provoking maneuvers should be
avoided. endotracheal intubation, and appropriate staff
should be prepared to perform a tracheotomy. spontaneous ventilation should be maintained The intubated child should be transferred to the
ICU. laryngoscopy to obtain swab cultures from the
epiglottis appropriate intravenous antibiotic therapy
a second- or third-generation cephalosporin cefuroxime, cefotaxime, or ceftriaxone
Ampicillin/ sulbactam trimethoprim/sulfamethoxazole Chloramphenicol
Symptom fever, sore throat, a muffled voice, dysphagia, and
odynophagia. longer than that seen in children (usually more than
24 hours) Sign
swollen, bright-red epiglottis swollen epiglottis and dilated hypopharynx on a
lateral neck radiograph infectious etiology
Haemophilus group A streptococcus.
The clinical course appears less severe Conservative measures include oxygenation,
humidification, hydration, corticosteroids, and intravenous antibiotics
Acute laryngotracheobronchitis (LTB), or croup
Viral laryngotracheitis is the most common laryngeal inflammatory disorder of childhood.
Organisms parainfluenza virus respiratory syncytial virus influenza rubeola Adenoviruses Mycoplasma pneumoniae
history viral upper respiratory infection with
rhinitis, cough, and low-grade feversymptoms
hoarseness, dyspnea, stridor, and a barking cough
characteristic cough gives its common name, croup
airway obstruction is caused by laryngotracheitis, the stridor is characteristically inspiratory, or biphasic.
diagnosis based on the history,examination of the larynx
erythematous and edematous mucosa with normal vocal fold mobility(although not necessary)
Radiographs, reveal a narrowing of the subglottic lumen, the “steeple sign,”
How is LTB managed?Most cases are alleviated by simple home
methods, such as humidification most severe cases cause acute airway
obstruction Hydration, Humidification supplemental oxygen, fluids, nebulized racemic epinephrine The use of oral and/or intramuscular
glucocorticoids ( dexamethasone) Antipyretics, decongestants, Artificial airway support (eg, intubation) is
necessary in a relatively small proportion of patients
Secondary bacterial infection high temperature spikes and exudative,
purulent drainageRadiographically
the lumen of the upper airway will appear narrowed, shaggy, and irregular
Organisms Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis, hemolytic streptococci
Antibiotic therapy is indicated
. How is chronic laryngitis treated? general inflammation of the larynx smoking, voice abuse, or laryngopharyngeal
reflux symptoms chronic hoarseness, chronic cough,
throat irritation, frequent throat clearing, and globus sensation.
The voice usually improves if the irritating factors are discontinued. This may involve smoking cessation or voice rest.
H2 blockers and proton pump inhibitors are highly effective in treatment. In addition
resting their voice, sleeping with the head of the bed elevated, and waiting 3-4 hours after eating before going to bed.
Polyps asymmetric and appear soft and smooth on one or both vocal folds
vocal nodules usually paired small and discrete located in the 1/3 the distance from the anterior
commissure. Contact granulomas
found on the vocal processes of the arytenoid cartilage.
Vocal fold cysts mucous retention or epidermoid cysts located in the superficial layer of lamina propria at the middle third of the vocal fold in the medial
and superior aspect
What are the treatment options for vocal fold nodules?Vocal fold nodules often arise as a result of
excessive laryngeal use. Voice therapy is a highly effective method of treatment. In rare cases in which voice therapy does not give satisfactory results, surgical removal of nodules may improve the voice. Generally, surgery will not resolve the hoarseness completely, and it is rarely indicated because vocal coaching is usually curative.
How is a laryngeal polyp treated?A laryngeal polyp is a single benign lesion
of the larynx. Voice therapy is recommended before and after surgery and could be the only required treatment. Laryngeal polyps can be removed with a standard cold knife, which is preferable, or with a carbon dioxide laser. Microflap technique is used to preserve the mucosal cover and the underlying vocal ligament, when possible. Normal voice usually returns after treatment.
Leukoplakia (precancerous lesions) a characteristic white lesion on the vocal
foldexhibit thickening of the epithelial layerabnormal keratinization of the superficial
layerssolitary or multifocal. benign and malignant
Histologically, most of these lesions are benign, but there is thought to be an approximately 3% risk of malignancy for leukoplakia of the vocal fold
Laryngeal papillomatosis affects mucous membranse of the larynx characterized by multiple and recurrent
squamous papillomatamay more prevalent in children and less
common in individuals over 30 years of age.causing hoarseness some degree of respiratory
obstruction,particularly in chidren .which is associated with human papilloma
virus (HPV) types 6 and 11.
Papillomatosis in children
Papillomatosis in Adult
How is laryngeal papillomatosis transmitted?Transmission is multifactorial. Fifty percent
of mothers have a history of active or prior HPV infection. The risk of transmission is 1 in 400. Cesarean section is not recommended for mothers with either active or latent infection because transmission has occurred despite cesarean section.
gross inspectionappear in a multinodular pattern sessile or exophytic.
Histologicallypapillary projections and hypervascular
fibroconnective tissus covered by hyperplastic squamous epithelium that shows maturation.
Cellular atypia is the rule rather than the exception
Histologic differentiation from early carcinoma may sometimes be difficult.
What triad is associated with laryngeal papillomatosis?Firstborn child: primigravid mothers are
more likely to have a prolonged second stage of labor, which increases the risk for infection
Teenage mother Vaginal delivery
How are laryngeal papillomas treated?spontaneous remissions can occurMultiple surgical resections, often with a
laser, are required. cidofovir (intraoperative injections), indole
3-carbinol/diindolylmethane, acyclovir, and interferon-α are under investigation.
Malignant Tumors of the Larynx and Hypopharynx. Cummings- Otolaryngology- Head and Neck Surgery. 4th ed., Mosby, 2005.
Malignant Laryngeal Lesions. Lawani- Current Diagnosis and Treatment in Otolaryngology- Head and Neck Surgery. McGraw-Hill and Lange, 2004.
Neck. Moore- Essential Clinical Anatomy. 2nd ed., Lippincott, 2002. Head and Neck. Rohen- Color Atlas of Anatomy. 5th ed., Lippincott, 2002. Surgery for Supraglottic Cancer. Myers- Operative Otolaryngology Head and Neck
Surgery Vol. 1. 1st ed., Saunders, 1997. Surgery for Glottic Carcinoma. Myers- Operative Otolaryngology Head and Neck Surgery
Vol. 1. 1st ed., Saunders, 1997. The Larynx. Lore and Medina- An Atlas of Head and Neck Surgery. 4th ed., Elsevier,
2005. Hinerman, R, Morris, C, et al. Surgery and Postoperative Radiotherapy for Squamous
Cell Carcinoma of the Larynx and Pharynx. Am J Clin Oncol. 2006; 29(6): 613-621. Huang, D, Johnson, C, et al. Postoperative Radiotherapy in Head and Neck Carcinoma
with Extracapsular Lymph Node extension and/or Positive Resection Margins: a Comparative Study. Int J Radiat Oncol Biol Phy. 1992; 23:737-742.
Bernier, J, Domenge, C, et al. Postoperative Irradiation with or without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer. N Engl J Med. 2004; 350: 1945-1952.
Sessions, D, Lenox, J, et al. Supraglottic Laryngeal Cancer: Analysis of Treatment Results. Laryngoscope. 2005; 115: 1402-1410.
Wolf, GT. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. New England Journal of Medicine. 1991; 324: 1685-90.
Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890-899.
Grant’s Atlas 10th ed. CD-ROM
Laryngeal carcinoma Etiology:
tobacco and excessive alcohol use primary Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposures
Presentation Hoarseness, Dysphagia,Hemoptysis,Throat pain,
Ear pain, Airway compromise, Aspiration,Neck mass
appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color
Laryngeal carcinoma Diagnosis
History Endoscopy Biopsy
Treatment Operation Radiotherapy Chemotherapy
Distinguish characteristic between laryngotracheitis and supraglottitis
Distinguish characteristic between nodular and polyps
Leukoplakia are the precancerous lesions
What triad is associated with laryngeal papillomatosis?
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