1.  About 90-95% of laryngeal malignancies are squamous
cell carcinoma with various grades of differentiation
Squamous cell subtypes include keratinizing and
nonkeratinizing and well-differentiated to poorly
differentiated grade
 The rest 5-10% of lesions include verrucous
carcinoma, spindle cell carcinoma, malignant salivary
gland tumor and sarcomas.
 Glottic (59%)> Supraglottic (40%)> Subglottic
(1%)..
 Widely prevalent in the Indian Sub-continent in
comparison to the west

2.  The larynx is divided into the following three
anatomical regions:
 The Supraglottic larynx includes the epiglottis, false
vocal cords, ventricles, aryepiglottic folds, and
arytenoids.
 The Glottis includes the true vocal cords and the
anterior and posterior commissures.
 The Subglottic region begins about 1 cm below the
true vocal cords and extends to the lower border of the
cricoid cartilage or the first tracheal ring.
Ref. American Cancer Society.: Cancer Facts and Figures
2012. Atlanta, Ga: American Cancer Society, 2012. Last
accessed January 5, 2012

3.  Most common- 59%
 Spread: Anteriorly- anterior commisure
Posteriorly- vocal process and arytenoid process
Upward- ventricle and false cord
Downward- Subglottic region
Symptoms:
Hoarseness of voice is an early sign bcoz lesions of cord
affect its vibratory capacity, stridor when growth
becomes larger in size.

4.  There are few lymphatics in vocal cords and
nodal metastasis are never seen unless the
disease spreads beyond the region of
membranous cords.
 Good Prognosis : Bcoz of early presentation
and late spread, it has good prognosis.

5. Picture of glottic squamous cell carcinoma of
the larynx. The tumor involves the anterior
half of the left vocal cord.

7.  Less frequent than glottic cancer
 Majority of lesion are seen on epiglottis,false cord
followed by aryepiglottic fold, in that order
 May spread locally and invade the adjoining areas
(vallecula, base of tounge and pyriform fossa)
 Nodal metastases occur early(T1- 20%,T2-35%,T3-
50%,T4-65%)
 Upper and middle jugular nodes are often involved
 Bilateral metastases may be seen in cases of
epiglottic cancer.

8.  Symptoms: Often silent, Hoarseness is a late
symptom. May present with throat pain, dysphagia
and referred pain in ear, mass of lymph node in the
neck.
 Bad Prognosis : Due to early spread and late
presentation.

9.  Preepiglottic space
involvement through
foramen in infrahyoid
epiglottis.
 Paraglottic space
involvement through
mucosa of the
ventricle.

10.  Lesions rare( 1 - 2%)
 Spread: Anterior wall, to the opposite side or
downwards to the trachea
 May invade cricothyroid membrane, thyroid
gland and muscles of neck
 Paratracheal LN involved
 Symptoms: Stridor is the
Earliest presentation.

11. Hoarseness is a late symptom as upward spread
to the vocal cords is late.
Hoarseness of voice indicates :
 Spread of disease to undersurface of vocal cords.
 Infiltration of thyroarytenoid muscle.
 Involvement of recurrent laryngeal nerve.

12. 1. History :
Symptomatology of glottic, subglottic, supraglottic is
different as explained earlier.
2. Indirect Laryngoscopy :
It is done to see the-
A) Appearance of lesion- which vary according to the
site of origin.
B) Vocal Cord Mobility – Fixation of vocal cords
indicate deeper infiltration.

13. C) Extent of the disease.
3. Direct Laryngoscopy :
It is done to see the-
a) Hidden areas of larynx
b) Extent of disease.
4. Examination Of Neck :
It is done to find the-
a) Extralaryngeal spread of the disease.
b) Nodal metastasis.

14. 5. Radiography :
Chest X Ray – Essential for co-existent lung
diseases,pulmonary metastasis and mediastinal
nodes.
CT Scan – Useful investigation to find the
extent of the tumour,invasion of pre and para
epiglottic space,destruction of cartilage and
lymph node involvement.
Laryngograms using dionosil are obsolete.

15. 6. Microlaryngoscopy:
For smaller lesions, laryngoscopy is done
under microscope for better visualisation.
7. Supravital staining and biopsy:
Toluidine blue is applied to the laryngeal
lesion and then washed and examined. CIS and
superficial carcinomas take up dye while
leukoplakia does not and thus helping in
selecting the area for biopsy.

16.  The staging system for laryngeal cancer is
clinical and based on the best possible estimate
of the extent of disease before treatment.
 Staging of disease is very important
 it influences the choice of therapy and
 helps in predicting the overall prognosis,
 it provides confirmity amongst clinicians thereby
helping in comparing the efficacy of various forms of
therapy.

17. Tx - Primary tumor cannot be assessed.
T0 - No evidence of primary tumor.
Tis - Carcinoma in situ.
Supraglottis
T1 Tumor limited to one subsite of supraglottis with normal vocal
cord mobility.
T2 Tumor invades mucosa of more than one adjacent subsite of
supraglottis or glottis or region outside the supraglottis
(e.g., mucosa of base of tongue, vallecula, medial wall of pyriform
sinus) without fixation of the larynx.
T3 Tumor limited to larynx with vocal cord fixation and/or invades
any of the following: postcricoid area, pre-epiglottic
space, paraglottic space, and/or inner cortex of thyroid cartilage.

18. T4a Moderately advanced local disease.Tumor invades through the
thyroid cartilage and/or invades tissues beyond the larynx (e.g.,
trachea, soft tissues of neck including deep extrinsic muscle of the
tongue, strap muscles, thyroid, or esophagus).
T4b Very advanced local disease.Tumor invades prevertebral space,
encases carotid artery, or invades mediastinal structures
GLOTTIS
T1 Tumor limited to the vocal cord(s) (may involve anterior
or posterior commissure) with normal mobility.
T1a Tumor limited to one vocal cord.
T1b Tumor involves both vocal cords.

19. T2 Tumor extends to supraglottis and/or subglottis and/or with
impaired vocal cord mobility.
T3 Tumor limited to the larynx with vocal cord fixation and/or
invasion of paraglottic space and/or inner cortex of the thyroid
cartilage.
T4a Moderately advanced local disease.Tumor invades through the
outer cortex of the thyroid cartilage and/or invades tissues beyond
the larynx (e.g., trachea, soft tissues of neck including deep
extrinsic muscle of the tongue, strap muscles, thyroid, or
esophagus).
T4b Very advanced local disease.Tumor invades prevertebral
space, encases carotid artery, or invades mediastinal structures.

20. • Subglottis
– 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
• Nodes
– Nx: regional LN can’t be
assessed
– 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

21. Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II T2 N0 M0
Stage III
T3 N0 M0
T1-3 N1 M0
Stage IVA
T4a N0-1 M0
T1-4a N2 M0
Stage IVB
T4b any N M0
any T N3 M0
Stage IVC any T any N M1
Early
stage
Advanced
stage

22.  Carcinoma in situ(Tis):if b/l staged procedure
/web formation
•Complete mucosal cord
stripping with co2 laser
•Quit smoking/no RT
•Vigilant follow up
Diffuse lesion
• Excision of leukoplakia with
microscissors/forceps
• Quit smoking/ no RT
• Vigilant f/u
Localised lesion

23. T1 Carcinoma
• RT or CO2 laser
• Laryngofissure
and cordectomy
T1 Carcinoma with
ext. to anterior
commissure
• RT
• Partial
frontolateral
laryngectomy
T1 with ext. to
arytenoid
• Endoscopic laser
resection
• Laryngofissure &
cordectomy
(surgery
preferred)
• RT

24. CO2 laser

25. Transoral endoscopic CO2 laser cordectomy
 Cure rates are uniformly above 90%
 Quality of voice depents on extend of resection
Laryngofissure and cordectomy..
rarely used now
 When endoscopic exposure is very poor

26.  Tumor limited to the
glottis (T1/T2/early
T3)normal vocal cord
mobility
 localised residual /recurrent
disease following failure of
RT for early cancer
 debulking of tumour for
stridor

27. - Radiotherapy to the primary including radiation
to upper neck nodes.
If failure occurs, Conservative laryngectomy or
Total laryngectomy +/- neck dissection is done.

28. RT is avoided bcoz of the possibility of
developing perichondritis. Also impaired
mobility indicates deeper invasion and thus
poorer response to radiation.
- Conservative laryngectomy is done, if failure
occurs Total laryngectomy is done.

29.  Best treated by total laryngectomy combined
with neck dissection if lymph nodes are
palpable.
 Can also be combined with post operative RT.

30. Subglottic carcinoma
T1 & T2 are treated by RT.
T3 & T4 require total laryngectomy and post-op. RT
(radiation should also include superior mediastinum)

31. T1 lesions are treated by Rt or CO2 Laser.
T2 lesions require consideration of pulmonary function.
If pulmonary function is good, supraglottic laryngectomy is done.
If pulmonary function is poor, RT can be given with follow up.
T3 & T4 lesions require total laryngectomy with neck
dissection and post-op RT.

32. 1. Oesophageal Speech :
The patient is taught to swallow air in the oesophagus and to
release it slowlyfrom oesophagus to pharynx. Patient can speak
upto 6-10 understandable words.
2. Artificial Larynx :
a) Electrolarynx – It has a vibrating disc
which is held against the soft tissues of
the neck.
b) Transoral Pneumatic Device – Here
vibrations produced in a rubber diaphragm is carried by a
plastic tube into the back of oral cavity where sound is converted
to speech by modulators.

33. Tracheo-oesophageal Speech
Here attempt is made to carry air from trachea to oesophagus or
hypopharynx by the creation of skin lined fistula or nowdays,
prosthesis (Blom-Singer or Panje) are used which prevent the risk
of aspiration.
Thank You!!!