6. HISTORY OF PRESENT ILLNESS
Hoarseness of voice
Insidious onset and progressive
Breathing Difficulty
Inspiratory stridor
7. Past history
Personal history
25 cigarettes a day
Family history
Drug history
Socioeconomic history
Not Contributory
8. GENERAL PHYSICAL EXAMINATION
PULSE 98 bpm
BLOOD PRESSURE 130/80 mm of Hg
TEMPERATURE 98.2 ˚
F
RESPIRATORY RATE 28 breaths/min
9. EXAMINATION (contd)
PALLOR
CYANOSIS
CLUBBING
JAUNDICE
OEDEMA
KOILONYCHIA
THYROID Not enlarged
JVP Not raised
LYMPH NODES Not palpable
ABSENT
10. ENT EXAMINATION
THROAT
No abnormality found in oral cavity
INDIRECT LARYNGOSCOPY
Exophytic growth arising from left vocal cord
involving supraglottis and anterior commissure with
narrow glottic chink
Fixed Lt vocal cord
14. Normal study
INVESTGATIONS
Blood complete picture
Haemoglobin: 13g/dl
Platelets: 291x109
/L
X Ray Neck Lat view
X Ray Chest PA
USG Neck
USG Abdomen
Narrowed airway in
supraglottis & glottis
18. DIRECT LARYNGOSCOPY
Exophytic growth on left vocal cord involving
left supraglottis and anterior commissure
Pyriform fossae, Posterior pharyngeal wall
and Post-cricoid region - Normal
Biopsy
22. MANAGEMENT
PRE-OP WORK UP
Counseling
Details of the nature and severity of the disease
Treatment options available
Specific risk of surgery and GA
Understanding the total laryngectomy state & life
style after surgery
Informed written consent
Pre-anesthesia assessment: ASA-II
2 Unit RCC arranged
40. RECOVERY
1st
Post operative day
Folley catheter removed
Patient mobilized
3rd
Post op day
Neck drains removed
N/G feed started with clear water
7th
Post op day
Neck stitches removed
10th
Post op day
Oral sips started with clear water
41. POST OP HISTOPATHOLOGY
WELL DIFFERENTIATED
SQUAMOUS CELL
CARCINOMA
Clear resection margins
Thyroid gland not involved
44. THE ANATOMY
Extends from pharynx to trachea in front of 3 to 6
cervical vertebrae
Acts as a compound sphincter
Prevents aspiration
Glottic closure for pressure build-up
Phonation
Provides attachment to ligaments & muscles
Cartilages
Unpaired Paired
Thyroid Arytenoids
Cricoids Corniculate
Epiglottis Cuneform
46. LYMPHATIC DRAINAGE
Supraglottic Larynx
Upper deep cervical nodes (level ll & lll)
Infraglottic larynx
Lower deep cervical and mediastinal nodes
(level IV &VI)
Glottis
Lymphatic watershed
47. EPIDEMIOLOGY
6th
commonest cancer world wide.
Incidence in UK is 1% of all malignancies
Male & female ratio 4:1
Peak incidence 55 to 65 years
Laryngeal cancer is approximately 4/100,000
Incidence in females has increased in the western world
48. Wide prevalence
Mean age at presentation 40-70 years
Male Female ratio 10:1
Incidence in India 10/10,000
Incidence in Pakistan 8.6/10,000
REGIONAL STATISTICS
49. AETIOLOGY
Tobacco and alcohol
Benzopyrine and other hydrocarbons
Alcohol and smoking increases the risk 15 folds
Previous radiation to neck for benign
lesions
Genetic factor
Occupational exposure
Asbestos,mustard gas and petroleum products
50. HISTOPATHOLOGY
90-95% are squamous cell
carcinoma with various grades
of differentiation
5-10% lesion includes
Verrucous carcinomas
Spindle cell carcinomas
Malignant salivary gland tumors
Sarcomas
51. SUPRAGLOTTIC CARCINOMA
Less frequent than the glottic cancer
Spreads locally and invades
adjoining areas
Nodal metastasis occurs early
Symptoms
Hoarseness, throat pain, dysphagia, neck nodes,
referred pain in ear, wt loss, and respiratory obstruction
52. GLOTTIC CARCINOMA
More frequent
Spreads locally
Few lymphatics with no nodal
metastasis
Symptoms
Hoarseness of voice (early sign)
Cord fixation leads to stridor and laryngeal
obstruction
54. DIAGNOSIS
History
Indirect laryngoscopy
Examination of neck
Soft tissue x-ray of neck
CT & tomography
Direct laryngoscopy & biopsy - confirms
55. TNM Classification of cancer larynx
(American joint committee on cancer)
SUPRAGLOTTIS
T1 Tumor confined to one subsite of larynx; normal mobility
(i.e., ventricular bands; arytenoids; epiglottis)
T2 Involving more than one subsite (supraglottis or glottis;
normal mobility)
T3 Tumour limited to larynx with vocal cord fixation and/or
invades
any of the following: postcricoid area, pre-epiglottic tissues
T4 Tumor invasion of cartilage or tissue beyond larynx
56. TNM Classification of cancer larynx
(American joint committee on cancer)
GLOTTIS
T1 Tumor limited to vocal cords, normal mobility
T1a Tumour limited to one vocal cord
T1b Tumour involves both vocal cords
T2 Extension to supraglottis and/or subglottis; may be
impaired cord mobility
T3 Limited to larynx with cord fixation
T4 Extension beyond larynx or into cartilage
57. TNM Classification of cancer larynx
(American joint committee on cancer)
SUBGLOTTIS
T1 Tumour limited to the subglottis
T2 Tumour extends to vocal cord(s) with normal or impaired
mobility
T3 Tumour limited to larynx with vocal cord fixation
T4 Extension beyond larynx or into cartilage
58. Regional Lymph Nodes (N)
Nx Cannot be assessed
N0 No regional metastasis
N1 Single positive ipsilateral node, less than 3 cm
N2 Nodes less than 6 cm
N2a Single ipsilateral node 3-6 cm
N2b Many ipsilateral nodes less than 6 cm
N2c Bilateral and contralateral node less than 6 cm
N3 Node(s) greater than 6 cm
59. Distant Metastasis (M)
Mx Distant metastasis cannot be assessed
M0 No distant metastasis
M1 Distant metastasis
Stage Grouping
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 M0
T1 N1 M0
T2 N1 M0
T3 N1 M0
IVA T4 N0 M0
Any T N2 M0
IVB Any T N3 M0
IVC Any T Any N M1
Histopathologic Grades
Grade 1 : Well-differentiated
Grade 2 : Moderately differentiated
Grade 3 : Poorly differentiated
61. TREATMENT PLAN
For the first and second stages
Radiation therapy and/or conservative surgery
For the third and fourth stages
Radical surgery
Total laryngectomy
Laryngopharyngectomy
Combined with unilateral radical neck dissection with
or without contralatral modified neck dissection
Post operative radiotherapy
63. COMPLICATIONS OF SURGERY
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
66. VOICE REHABILITATION
The process of rehabilitation begins with
counselling before the patient undergoes
treatment
Meeting with a fellow patient who has already
undergone the procedure
Pre-operative visits to the speech therapist
Booklets and websites hosted by the
laryngectomee clubs
72. 0
2
4
6
8
10
12
14
16
18
20
Mandibulectomy & Neck
Dissection
Maxillectomy Laryngectomy Parotidectomy Neck Dissection Glossectomy & Neck
Dissection
Laryngo-Pharyngo-
Esophagectomy
Extended Radical
Mastoidectomy
Misc Excisions
19
11
9
6
12
1 3 1
9
Summary of head and neck cases done at ENT Dept
July 2012 JUNE 2015
73. Current thought for laryngeal cancer is
organ sparing therapy for voice
preservation.Radiation therapy is ideal for
this and works well for early stages of the
disease.Surgical therapy has also evolved
organ sparing techniques.However,the older
proven technique of total
laryngectomy is still a primary
modality for advanced laryngeal cancers.
CONCLUSION
74. Nutting CM, Robinson M, Birchall M. Survival from '
laryngeal cancer in England and Wales up to 2001. British
Journal of Cancer 2008; 99(5uppl 1): S38-9.
Lauder E. The laryngectomee and the artificial larynx—a second look.
J Speech Hear Disord 1970;35:62–5.
list MA, Ritter-Sterr CA , Baker TM et ai. Longitudinal assemsment of quility of life
in laryngeal cancer patients 1996; 18: 1-10
Cancer research UK website, accessed Oct 5, 2009
Silver SE . Surgery for of the larnyx and related structures, 2nd
edn. Philadelphia: WB
Saunders 1996
REFERENCES
Worthy commandant, respected seniors and my fellow colleagues, I Dr Tariq Ahmed, from the dept of ENT and head and neck surgery,
, will be presenting a case of Carcinoma larynx, managed at ENT dept,
My patient 65 yrs old pensioner Havildar , resident of kotla arab ali khan tahsil kharian, presented in ENT OPD
with comlpaints of hoarseness of voice for the last 6 months and respiratory difficulty for the last 2 weeks
Initially the hoarseness was insidious and was associated with an irritation in throat latter it became progressive. For the last two weeks he was also having a respiratory difficulty which was associated with a noisy breathing on exertion.
There was no history of pain, dysphagia, hemoptysis or weight-loss.
He was a chronic smoker for the last 40 years,
His past, family and drug histories were not contributory
On examination, my patient was an elderly male with stable vitals, sitting anxiously on bed as he could not lie down due to difficulty in breathing
while rest of his GPE was unremarkable
On Indirect & Fibreoptic laryngoscopy, an exophytic growth was seen on left vocal cord involving anterior commissure and supraglottis with narrow glottic chink . left vocal cord was fixed
Neck nodes were not palpable and Rest of the ENT examination did not reveal any abnormality
His Systemic examination was also unremarkable
Due to stridor , emergency tracheostomy was done under local anaesthesia
In the meantime, patient was thoroughly investigated. His x-ray neck lat view showed narrowing of airway at supraglottic
Rest of investigations were within normal limits
Ct scan of neck showed left voal cord & supra glottic growth
On the basis of history and clinical examination a provisional diagnosis of growth larynx, probably malignant, was made. Direct laryngoscopy and biopsy under general anaesthesia was planned to obtain a tissue diagnosis.
On direct laryngoscopy an exophytic growth of the left vocal cord was seen involving entire its length and anterior commisure extending up to supraglottis . left vocal cord was fixed and right vocal cord was mobile and intact .biopsy was taken for tissue diagnosis
His histopath report revealed well differentiated squamous cell carcinoma
A final diagnosis of well differentiated squamous cell carcinoma larynx was made and tumour was classified as T3 N0 MO
The case was discussed in ENT Dept and Total Laryngectomy followed by adjuvant Radiotherapy was planned.
A counselling session was arranged in which the patient and the attendants were told about the nature of the disease, the treatment options available with their merits and demerits and the possible risks involved in the surgery
Special emphasis was given on understanding the total laryngetomy state and life style after the surgery
patient was prepared for surgery
Gluck sorenson incision was marked
Patient was draped under asceptic measures
an incision was made, and
sub platysmal flaps were elevated
Dissection continued
Larynx was separated from sternomastoid muscle and carotid sheath
Contra lateral thyroid freed and secured
Infra hyoid muscle were ressected and larynx moblised
Ressection continued upward
Larynx was removed
Nasogastric feeding tube passed
And neopharynx reconstruted in three layers
Radivac suction drains were placed on both sides
Wound closed in layers and tracheostome fashioned
This was the ressected specimen of larynx and sent for histopath studies
Post operatively patient was nursed in the ITC
He had a smooth post operative recovery, and was discharged on 7th post op day
His post op histopath report confirmed the diagnosis with clear resection margins
The patient is on regular monthly follow up and he has received adjuvant radiotherapy. His speaking skills are progressively improving
Now the case discussion
The larynx is a hollow muscular organ that provides a passage for respiration, prevents aspiration, produces sound and allows stabilization of thorax.
Larynx has three subsites
Lymphatic drainage of larynx is to deep cervical lymph nodes level ii, iii & iv
carcinoma larynx make up 6% of all body cancers. in western world It usually presents between the ages of 50 to 70 years and is four times more common in male
our regional data shows its wide prevalence & is ten times more common in male
Etiology of carcinoma larynx is multifactorial. Smoking, taking alcohol & exposure to radiation in the past is a recognized risk factor, while a positive family history of ca larynx points towards genetic factors.
On the basis of histology ,more then 90% are sq cell ca with various grades
Supra glottic carcinoma is less frequent then glottic cancer that spreads locally with early nodal mets
glottic carcinoma is more common and spreads locally with few lymphatic mets
Sub glottic carcinoma is a rare upto 2 %
Although there are many staging systems in practice, but mostly tumour staging is carried out with AJCC(american joint committee on cancer) and UICC (uninion of international cancer control) is based on TNM classification system
The management of laryngeal cancer depends on the stage of tumour at presentation. However a variety of other factors are also involved in decision making including the the pateints age, comorbidities, treating multidisciplinary team and importantly the wishes of the pt
Treatment of choice For 1st & 2nd stages is radiotherapy and conservatie surgery ,for 3rd & 4th stages total laryngectomy is the mainstay of treatment , usually combined with post- operative radio therapy of residual disease.
These are types of laryngectomy
These are complications of surgery
These are complications of radiotherapy.
Prognosis depends on the tumour stage
The process of rehabilitation begins with counselling before the patient undergoes treatment. A meeting with a fellow patient who has already undergone the procedure helps the patient to understand post laryngectomy life style and problems.
There are three methods of speech restoration after laryngectomy. Oesohageal speech, tracheo-oesophageal puncture and artificial electro larynx devices.
artificial electro larynx devices.
If the patient can not be helped by any of these methods then other methods of communication can be acquired like Lip reading classes for attendants or Sign language classes for both patient and attendants.
In our set up Total 49 cases of head & neck cancer were reported in last two and half years
Total 12 cases of ca larynx were diagnosed ,out of them ten were operated here rest two were declared unfit for ga and reffered for radiotherapy
I would conclude by saying that Current thought for laryngeal cancer is organ sparing therapy for voice preservation. Radiation therapy is ideal for this and works well for early stages of the disease. Surgical therapy has also evolved organ sparing techniques. However, the older proven technique of total laryngectomy is still a primary modality for advanced laryngeal cancers