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Tumors of Larynx

Tumors of Larynx. Prepared by Dr.Hiwa Asad. Benign Tumors. Ectodermal Mesodermal pseudotumours. Ectodermal Tumours. Papilloma: single or multiple Adenoma Paraganglioma Neurilemmoma. Single papilloma. Common in adults, rare in children Sessile or pedunculated

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Tumors of Larynx

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  1. Tumors of Larynx Prepared by Dr.Hiwa Asad

  2. Benign Tumors • Ectodermal • Mesodermal • pseudotumours

  3. Ectodermal Tumours • Papilloma: single or multiple • Adenoma • Paraganglioma • Neurilemmoma

  4. Single papilloma • Common in adults, rare in children • Sessile or pedunculated • Usual sites anterior commissure, anterior half of the vocal cords • Men : women ratio 2:1 • Present with hoarseness • If small removed endoscopically • If large by laryngofissure • Biopsy to exclude malignancy specially if recurrent

  5. Squamous papilloma of the aryepiglottic fold Laryngeal papilloma

  6. Multiple papillomas • Infants and young children, rare in adults • A virus may be responsible (HPV) • Vocal cords are the usual site • Hoarsness if vocal cords affected • Dyspnoea may occur ---- tracheostomy • Removed endoscopically by CO2 laser • Spontaneous recovery in puberty may occur

  7. Juvenile laryngeal papillomas

  8. Juvenile papillomas Before and after removal

  9. Mesodermal tumours • Vascular neoplasms • Chondroma • Myogenic tumours • Fibroma • Lipoma

  10. Vascular neoplasms • Arise from blood or lymphatic vessels Haemangioma • Rare in adults • Telangiectatic vocal cord polyp

  11. Chondroma • Arise from cartilages (Mostly cricoid) • More in men (40-70 years) Clinical features • Hoarsness and dyspnoea • Stridor (extention into subglottic space) • Dysphagia (extension into hypopharynx) • External swelling (cricoid ring or thyroid cartilage)

  12. Chondroma • Indirect laryngoscopy reveals a smooth mass covered by intact mucosa • Radiology shows calcific stippling or coarse irregular calcificatuon • Biopsy specimens is unrepresentative, the tumour is hard and difficult to penetrate • Surgery is the treatment of choice • Radiptherapy is of little value

  13. Malignant Tumors • 1% of all malignancies In UK • More in men • Predominantly of squamous pathology • Interfere with function and emotion • High cure rate 85%

  14. Incidence • Higher in urban than rural population • Social and racial differences reflect different habits (tobacco and alcohol)

  15. Classification The International Union against Cancer (UICC) classified Ca larynx on anatomical bases 20% 10% 70%

  16. Epilarynx Suprahyoid epiglottis Aryepiglottic folds Supraglottis infrahyoid epiglottis false cords ventricles Supraglottis Glottis True cord,ant&postcomissure 1 cm Subglottis UICC classification of Ca larynx

  17. Glottis true cords anterior commissure posterior commissure

  18. Aetiology • Unknown • Possibly related factors genetic and social factors male predominance racial predilection urban pollution tobacco and alcohol radiation asbestos occupational factors

  19. Examination and diagnosis • Diagnosis will be made after consideration of: • History • Examination of the larynx • Examination of the neck • General examination of the patient • Radiology • Clinical investigations • Histological examination

  20. 1-Symptoms • Dysphonia progressive and unremitting • Cough and irritation in the throat (early) • Dyspnoea & stridor in advanced tumour, specially in subglottic Ca • Pain more typical of supraglottic Ca, late and uncommon • Referred otalgia may occur • Swelling of the neck or larynx (tumour or LN) • Haemoptysis (rare ,in lesions of the margin of epiglottis) • Anorexia, cachexia or fetor are late symptoms • Progress of the disease

  21. examine for Focal abnormality Vocal cord lesion Mass Mobility examine by Indirect laryngoscopy (LA) Flexible laryngoscopy (LA) Direct laryngoscopy (GA) Microlaryngoscopy (GA) 2-Examination of the larynx

  22. 3-Examination of the neck A palpable neck mass could be due to: 1.Direct spread of the tumour. 2.Regional lymph nodes metastasis. 3.Enlarged thyroid lobe which suggest invasion

  23. 4-General examination • To identify metastasis e.g. to the liver • To assess the overall physical status of the individual who is likely to need GA and biopsy, surgery, radiotherapy or chemotherapy

  24. 5-Radiological examination • Chest X-ray • Larynx Tomography • CT and MRI of neck and larynx

  25. Supraglottic tumour Tomography AP Lateral

  26. CT scan Axial CT shows loss of pre-epiglottic fat by carcinomatous infiltrarion

  27. MRI Epiglotic tumor（laryngeal Ca. supraglotic type）

  28. MRI • Sagittal T2 image of supraglottic Ca • Extension involves the epiglottis :E • Loss of normal pr-epiglottic fat plane: solid arrows • Tongue base involvement : open arrow

  29. Axial MRI showing tumour of the Rt. VC

  30. MRI Coronal view of MRI showing subglottic extension

  31. MRI Sagittal view showing transglottic tumour

  32. 6-Clinical investigations • Full hematological screen • Biochemical profile including liver function tests and serum protein • A urine screen for diabetes • ECG

  33. 7-Histological examination • Proof diagnosis of malignancy • Type of the tumor • Degree of differentiation

  34. Diagnostic difficulties • Negative biopsy • Keratosis • Previous radiation • Miscellaneous conditions: chronic laryngitis, TB, Syphilis…

  35. Pathology • Squmous cell carcinoma: The vast majority of laryngeal malignant tumours. • Verrucous carcinoma (Ackerman’s tumour): A distinct variant of well differentiated squamous cell Ca is the

  36. Glottic Ca Origin : the free margin of the vocal cords Invasion & extension anterior commissure cartilage (Ossified more prone) arytenoid & posterior cricoarytenoid muscle vertical extension to the subglottis &/orsupraglottis is more frequent than to the opposite side

  37. Cancer of the Lt true vocal cord

  38. glottic CA

  39. cancer involving the true vocal cords and arytenoid.  The cancer also extends onto the supraglottis

  40. Impaired mobility: superficial invasion of the thyroarytenoidmuscle Fixationof the vocal cords: by invasion of: - thyroarytenoid muscle - arytenoid cartilage - cricoid cartilage -cricoarytenoid joint Glottic Ca

  41. Supraglottic Ca • Often involving both sides • Seldom extend to the glottic region due to different embryological derivations and various lymphatic supplies

  42. Supraglottic Ca • thyroid cartilage • pre-epiglottic space occur in 40% of supraglottic Ca and 70% of epiglottic Ca • vallecula & base of the tongue • Arytenoid • Pyriform sinus Invasion

  43. Epiglottic tumpur Supraglottic Ca Tumour of Lt aryepiglottic fold Tumour ofRt false cord

  44. Subglottic Ca • Primary are rare • Grow circumferentially and extensively • Invasion of the vocal cords may lead to impairment of mobility and hoarsness • Can spread through the cricothyroid membrane anteriorly or cricotracheal membrane posteriorly or invade the trachea caudally

  45. Subglottic Ca

  46. Lymph node involvement • 18% had LN metastasis at the time of referral Supraglottic ( 40% ) Glottic Ca ( 5% ) Subglottic Ca ( 13% )

  47. Distant metastasis • Few present with distant metastasis at the time of diagnosis • 11% have distant metastasis, mostly in the lung ( 6.8% )

  48. TNM classification T:Primary tumour N: Nodal deposits M: Metastasis

  49. T : Primary tumour TX Primary tumour can not be assesed T0 No evidence of primary tumour Tis Carcinoma insitu

  50. Glottic T1 limited / mobile a: one cord b: both cords T2 extends to supra or subglottic /mobile T3 cord fixation T4 extends beyond the larynx Supra & subglottic T1limited / mobile cords T2 extends to glottis/mobile T3 cord fixation T4 extends beyond the larynx T : Primary tumour

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