benign malignant - gmch lectures/ent/tumours of larynx (2).pdfcarcinoma larynx • occurs in every...
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![Page 1: Benign Malignant - GMCH lectures/ENT/Tumours of Larynx (2).pdfCarcinoma Larynx • Occurs in every country in the world • 2.3% of all malignant male tumors & 0.4% of female • 1.3%](https://reader035.vdocuments.co/reader035/viewer/2022062914/5e8626a3f9f74833e832914b/html5/thumbnails/1.jpg)
Tumours of Larynx
Benign
Malignant
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Benign Tumours
Non-neoplastic
Neoplastic
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Non - NeoplasticSolid
• Vocal Nodule• Vocal Polyp• Rinke’s Oedema• Contact Ulcer• Intubation Granuloma• Leukoplakia• Amyloid Tumour
Cystic• Ductal Cyst• Saccular Cyst• Laryngocele
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Neoplastic
Squamous papilloma• Juvenile• Adult
ChondromaHaemangiomaGlandular Tumors
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Malignant Lesions of Larynx• Squamous cell carcinoma• Verrucous carcinoma• Spindle cell carcinoma• Malignant Glandular tumors
• Adenocarcinoma• Adenoid cystic carcinoma
• Lymphoid tumors• Non Hodgkin's tumor• Hodgkin’s tumor
• Muscular Tumors• Rhabdomyosarcoma
• Malignant Neurogenic tumors• Paraganglioma
• Vascular tumors• Haemangiopericytoma
• Cartilaginous tumors• Chondrosarcoma
• Bony tumors• Osteosarcoma
• Metastatic tumors• Renal• Breast• Ovary• Lungs
• Thyroid carcinoma
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Vocal Nodule
• B/L Symmetrically on free edge of cord • Jn of Ant 1/3rd and post 2/3rd
• Pin head to pea size• Vocal trauma due to unnatural low tones /
high intensities.• School going children, hawkers, singers,
teachers
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Pathogenesis
Vocal Nodule
Epithelial hyperplasia
Hyalinization & Fibrosis
Hemorrhage
Oedema
Vocal abuse
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Symptoms & Signs– Hoarseness– Vocal Fatigue– Pain in neck on prolonged phonation
Treatment:– Early cases – Conservative– Microlaryngeal surgery– Speech Therapy
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Vocal Polyp
•Vocal Abuse / misuse•Allergy & smoking•Age group 30 – 50 yrs•Hoarseness, Dyspnoea, stridor, choking•Soft smooth often pedunculated•May flop up & down with respiration•Treatment by MLS followed by speech therapy
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Reinke’s Oedema
• Collection of fluid in subepithelial space• Vocal abuse is the cause.• Both cords are affected.• Vocal cord stripping, one cord at atime.• Speech therapy
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Leukoplakia
• Whitish patch or warty growth• Premalihnant condition• Hoarseness • Stripping of cords and biopsy.• Repeat till biopsy is negative.
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LaryngoceleAir filled cystic swelling due to dilatation of
saccule.Types: Internal, External, Mixed• Cause: Raised transglottic pressure• Hoarseness, cough, airway obstruction• Reducible swelling in neck, cough & valsalva• Diagnosis : Laryngoscopy, X-ray STN_ Ap & Lat.
With valsalva, CT scan• Treatment: External- Excision, Internal –
marsupialisation• In adults exclude carcinoma
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Squamous PapillomaJuvenile & Adult• Juvenile:
– Viral in origin, Multiple– Infants & young children presenting with hoarseness & stridor– TC,FC & epiglottis common sites– Appear as glistening white irregular growths, pedunculated or
sessile, friable and bleed easily– Endoscopic removal, cupped forceps, Cautry, Co2 Laser– Known to recur after multiple surgeries– Tend to disappear after puberty– Interferon
• Adult-onset papilloma– Single, smaller, less aggressive, arises from Ant. ½ of cord– Common in males 30 -50 yrs– Treatment is surgical removal. Generally no recurrences
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Carcinoma Larynx
• Occurs in every country in the world• 2.3% of all malignant male tumors &
0.4% of female• 1.3% of all cancer diagnosis & 0.83 cancer
deaths (National Institute of Cancer)• Disease of elderly 6th-7th decade, reports
of cases <20 yrs are also available
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RISK FACTORS
• Tobacco• Alcohol• Radiation exposure• Laryngeal keratosis• Laryngeal papilloma• Industrial Exposure
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Tobacco• Rare in non smokers• Cigarette smoking is principle risk factor• Strong correlation between tobacco and
laryngeal cancer• Causative factor for all cancers in all parts• Combination of alcohol & smoking increases
the risk of supra glottic tumors.• Effect synergistic rather than additive• Risk is 50 times higher as compared to smoking
alone
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Radiations
• Low dose radiation has been identified
• Affects usually soft tissues or superficial glandular structures
• laryngeal tumors are also reported
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Laryngeal Papilloma
• Very rare in de novo• RT given as Rx of papilloma
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Laryngeal Keratosis
Keratosis is followed by malignancy in 3.3%
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INDUSTRIAL EXPOSURE
• SMOKE• TOXIC FUMES• CHEMICAL
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CLINICOPATHOLOGICAL FACTORS
• Lies in front of the Hypo pharynx
• 3rd to 6th cervical vertebra• Higher, smaller and pliable in
children• After puberty male larynx
grows rapidly• Lined by respiratory
epithelium• Has 3 paired & 3 unpaired
cartilages• Extrinsic & intrinsic muscles
help in movements of the joints
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CLINICOPATHOLOGICAL FACTORS
LARYNX• Sup.- Tip & lateral border of epiglottis
• Inf. – Inf. Margin of cricoid cartilage
• Ant. – Lingual surface of epiglottis, TH memb, Thyroid cart., CT memb., cricoid cartilage
• Post – AE folds, Arytenoid cart., Inter arytenoid mucosa & mucosa over cricoid cartilage
• Three regions: Supra glottis, Glottis & sub glottis
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Supraglottis• Extends from free border
of epiglottis superiorly to laryngeal ventricle inferiorly
• Includes:– Laryngeal surface of
epiglottis– AE folds– Arytenoids– False cords– Ventricle
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GLOTTIS• Extends from lat. Angle of ventricle to 1cm
below the cord
• Includes:
•Ant. Commissure•Post. Commissure•Both True cords
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SUBGLOTTIS• Extends from 1cm below the cord to
lower margin of cricoid
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TNM Staging• T – Tumor
– T0 – No evidence of tumor– Tis – Carcinoma in situ– T1 – Tumor confined to the region with
normal mobility– T2 – Tumor extension to adjacent site/sites
without fixation– T3 – Tumor confined to larynx with fixation of
cords or evidence of deeper infiltration– T4 – Tumor with direct extension beyond
larynx
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TNM Staging contd.
• N – Node– N0 – No evidence of regional lymph node involvement– N1 –Involvement of movable homolateral regional lymph
nodes– N2 – Involvement of movable contralateral or bilateral
regional lymph nodes– N3 – Fixed regional nodes– NX – The minimum requirements to assess the regional
lymph nodes • M – Metastases
– M0 – No evidence of distant metastases– M1 – Evidence of distant metastases
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SYMPTOMS
• Progressive & unremitting dysphonia• Dyspnoea & stridor• Pain• Dysphagia• Swelling• Cough & irritation• Anorexia, cachexia or fetor
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General Examination
•To exclude metastases•Liver •Lungs•Physical status•Fitness for surgery
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Indirect laryngoscopyFocal abnormality
& cord mobility
•Warty enlargement
•Nodule or thickening
•Hyperkeratosis•Ulceration
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Radiological examination
•X-ray chest•X-ray Soft tissue Neck•Laryngography•CT Scan•USG abdomen
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DocumentationBiopsyMLS
Direct Laryngoscopy
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Direct Laryngoscopy
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MICRO LARYNGOSCOPY
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Histological examination
•Definite diagnosis•Identification of tumor•Differentiation
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Examination of NECK
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Supraglottic Tumors• Less frequent than glottic tumor• Lesions seen on epiglottis, false
cord followed by aryepiglottic folds• Tend to remain confined above the
ventricle• Spread facilitated by mucus glands
& pits within the cartilage• Infiltrate the pre epiglottis space,
vallecula, base of tongue and glottis
• Involves upper deep cervical nodes
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Glottic Tumors
• Most common laryngeal tumor (50-75%)
• Early symptoms• Slow growing & well differentiated• Well localized & no metastasis• Highly curable• Can extend to ant. Commissure &
post. Commissure, supraglottis & subglottis
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Subglottic tumors
• Primary or Secondary tumors• Primary tumors very rare
(1-5%)• Clinically silent untill voice
change due mass or immobility• High incidence of cord fixation
due to thyro arytenoid invasion• Nodal invasion very high
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Treatment
• Depends upon the site & stage of the disease
• Broadly T1 & T2 – Radiotherapy or surgeryT3 & T4 – Combined therapy i.e.Surgery & radiotherapy
• Neck dissection for neck nodes
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Surgery• Conservative Surgery
• Stripping of cords• Cordectomy• Horizontal partial laryngectomy• Supraglottic laryngectomy• Hemilaryngectomy• Near total laryngectomy
• Radical Surgery• Total Laryngectomy
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Radiotherapy
• Good results in early lesions
• Preserves voice• T1 & T2 has >90% cure
rate• T3 & T4 not good results• Side effects : Dryness ,
skin excoriation, dysphagia, hair loss etc.
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• Esophageal speech• Electronic larynx• Tracheo-
oesophageal speech
Blom singer’s prosthesis
Provox prosthesis
Post laryngectomy speech