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Carcinoma larynx ppt

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Carcinoma larynx ppt

  1. 1. CARCINOMA LARYNX BY DR TARIQUE AHMED MAKA REGISTRAR IN ENT
  2. 2. CARCINOMA LARYNX
  3. 3. PATIENT’S PROFILE  NAME XYZ  AGE 65 yrs  SEX Male  RESIDENCE Kotla Arab Ali Khan  DATE OF ADMISSION Jan 2014
  4. 4. PRESENTING COMPLAINTS  HOARSENESS - 6 Months  DIFFICULT - 2 weeks BREATHING
  5. 5. HISTORY OF PRESENT ILLNESS  Hoarseness of voice  Insidious onset and progressive  Breathing Difficulty  Inspiratory stridor
  6. 6.  Past history  Personal history 25 cigarettes a day  Family history  Drug history  Socioeconomic history Not Contributory
  7. 7. GENERAL PHYSICAL EXAMINATION  PULSE 98 bpm  BLOOD PRESSURE 130/80 mm of Hg  TEMPERATURE 98.2 ˚ F  RESPIRATORY RATE 28 breaths/min
  8. 8. EXAMINATION (contd)  PALLOR  CYANOSIS  CLUBBING  JAUNDICE  OEDEMA  KOILONYCHIA  THYROID Not enlarged  JVP Not raised  LYMPH NODES Not palpable ABSENT
  9. 9. 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
  10. 10. ENT EXAMINATION  THROAT No abnormality found in oral cavity  EARS  NOSE Normal  NECK
  11. 11. UNREMARKABLE SYSTEMIC EXAMINATION  Cardiovascular system  Respiratory system  Gastrointestinal system  Central nervous system
  12. 12. EMERGENCY TRACHEOSTOMY  Emergency tracheostomy was performed under local anesthesia to relieve stridor
  13. 13. 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
  14. 14. NORMAL INVESTIGATIONS (contd)  ECG ,2-D echo  Serum urea & electrolytes  PT, PTTK  LFTs  Blood Glucose levels  Hepatitis Profile
  15. 15. INVESTIGATIONS (contd)  CT Scan Neck
  16. 16. PROVISIONAL DIAGNOSIS  Growth larynx  Direct laryngoscopy and biopsy under GA planned
  17. 17. 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
  18. 18. HISTOPATHOLOGY  WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA
  19. 19. DIAGNOSIS WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA LARYNX STAGE (iii) T3 N0 M0
  20. 20. DECISION TOTAL LARYNGECTOMY FOLLOWED BY RADIOTHERAPY
  21. 21. 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
  22. 22. OPERATIVE STEPS
  23. 23. GLUCK SORENSON INCISION
  24. 24. DRAPING
  25. 25. SKIN FLAPS RAISED
  26. 26. DISSECTION CONTINUES
  27. 27. LARYNX DISSECTED FROM STERNOMASTOID AND CAROTID SHEATH
  28. 28. CONTRALATERAL THYRIOD FREED & SECURED
  29. 29. STRAP MUSCLES SECTIONED & LARYNX MOBILIZED
  30. 30. REMOVAL OF SPECIMEN Larynx mobilized
  31. 31. LARYNX REMOVED
  32. 32. NASOGASTRIC TUBE PASSED
  33. 33. Neopharyn The Resected Specimen NEOPHARYNX CONSTRUCTED Base of tongue Oesophagus Tracheostome Neopharynx
  34. 34. SUCTION DRAINS PLACED WITHOUT CROSSING THE NEOPHARYNX SUCTION DRAIN SUCTION DRAIN NEOPHARYNX
  35. 35. TRACHEOSTOME FASHIONED & WOUND CLOSSED TRACHEOSTOME
  36. 36. THE TRANSGLOTTIC GROWTH The Resected Specimen
  37. 37. POST OP MANAGEMENT  Tracheostomy care  Antibiotics :  Inj ceftriaxone 1g I/V 12 hourly (ATD)  Inj metronidazole 500mg I/V 8 hourly  Inj coamoxiclav 1.2g I/V 8 hourly (ATD)  Inj Diclofenac Sodium 75mg I/M 12 hourly  Omeprazole infusion 40mg I/V HS  Intra venous fluids
  38. 38. 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
  39. 39. POST OP HISTOPATHOLOGY  WELL DIFFERENTIATED SQUAMOUS CELL CARCINOMA  Clear resection margins  Thyroid gland not involved
  40. 40.  Regular follow-up  Adjuvant Radiotherapy  Voice Rehabilitation Healthy stoma FOLLOW UP Healthy stoma
  41. 41. CARCINOMA LARYNX CASE DISCUSSION
  42. 42. 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
  43. 43.  Supraglottis  Epiglottis  Aryepiglotic Fold  Arytenoids  False cords and Ventricle  Glottis  True vocal cords  Anterior & Posterior commissures  Subglottis  Upto lower border of cricoid catilage SUBSITES
  44. 44. 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
  45. 45. 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
  46. 46.  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
  47. 47. 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
  48. 48. 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
  49. 49. 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
  50. 50. 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
  51. 51. SUBGLOTTIC CARCINOMA  Rare (1-2%)  Invades cricothyriod membrane, thyroid gland and strap muscles of neck  Lymphatic metastasis  Prelaryngeal  Paratracheal  Lower jugular nodes  Symptoms  Stridor or laryngeal obstruction  Hoarseness (late feature)
  52. 52. DIAGNOSIS  History  Indirect laryngoscopy  Examination of neck  Soft tissue x-ray of neck  CT & tomography  Direct laryngoscopy & biopsy - confirms
  53. 53. 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
  54. 54. 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
  55. 55. 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
  56. 56. 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
  57. 57. 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
  58. 58. TREATMENT OPTIONS
  59. 59. 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
  60. 60. TYPES OF LARYNGECTOMY  Vertical partial laryngectomy (hemilaryngectomy)  Horizontal partial laryngectomy  Supracricoid laryngectomy (subtotal laryngectomy)  Near-total laryngectomy  Total laryngectomy
  61. 61. 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
  62. 62. XRT COMPLICATIONS  Mucositis  Odynophagia  Laryngeal edema  Xerostomia  Stricture and fibrosis  Radionecrosis  Hypothyroidism
  63. 63. PROGNOSIS 5 YEAR SURVIVAL STAGE I >95% STAGE II 85-90% STAGE III 70-80% STAGE IV 50-60%
  64. 64. 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
  65. 65. METHODS OF SPEECH RESTORATION  Electro larynx  Oesophageal speech  Transoral pneumatic device  Tracheo-oesophageal speech  Blom-singer prosthesis  Panje valve
  66. 66. ELECTRO LARYNX
  67. 67. OTHER METHODS OF COMMUNICATION  Lip reading classes for attendants  Sign language classes for patient and attendants
  68. 68. OTHERS Ca LARYNX n= 49 37 12 LARYNGEAL CANCERS ENT DEPT January 2012–June 2015
  69. 69. male female n= 49 36 13 ENT DEPT January 2012–June 2015
  70. 70. 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
  71. 71. 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
  72. 72. 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
  73. 73. DEPARTMENT OF ENT, HEAD AND NECK SURGERY

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