Professional Documents
Culture Documents
CH 40
CH 40
NEOPLASMS OF THE
LARYNX AND
LARYNGOPHARYNX
Robert A. Weisman, MD
Kris S. Moe, MD
Lisa A. Orloff, MD
Granular cell tumors also arise from the Schwann cell and
are often multifocal in the head and neck, with the larynx
being the second most common site.
Hemangiomas may occur in the larynx or pharynx and
often present with significant bleeding. Diagnosis is typically
made by appearance, and biopsy may be hazardous. Surgical
excision often requires an external approach, and proximal
and distal control of vessels may be necessary. Preoperative
embolization should be considered.
The subglottic hemangioma presents in infancy, may be
associated with multiple cutaneous or mucosal heman-
giomas, and is often found in association with other con-
genital anomalies.
Lymphangiomas or cystic hygromas present in the supra-
glottis and hypopharynx. They may infiltrate extensively and
often cause airway obstruction. Myogenic tumors presenting
in this region include leiomyoma, myoma, and myoblastoma.
Local excision is usually adequate therapy.
MALIGNANT NEOPLASMS
Laryngeal and laryngopharyngeal cancers are the most com-
mon malignancy of the head and neck. Laryngeal cancer has
historically been a disease with a significant male predomi-
nance, although the gender distribution has been changing as
more women have begun to smoke. There are approximately
10,000 new cases of laryngeal cancer and 2,500 new cases of
hypopharyngeal cancer per year in the United States. The over-
all mortality rate for laryngeal cancer is 32%, with 25% of
patients presenting with regional and 10% with distant metas-
tasis. The majority of patients present between ages 55 and 65.
The most significant risk factors are the consumption of
tobacco and alcohol. Cigarettes carry the greatest risk of laryn-
geal cancer, but cigar and pipe smoking are also risk factors.
The primary carcinogens in tobacco are tars and polycyclic
472 Otorhinolaryngology
Pathology
The epithelium of the larynx is chiefly pseudostratified cili-
ated columnar with the exception of the true vocal folds where
it is stratified squamous. The epithelium appears to undergo
Neoplasms of the Larynx and Laryngopharynx 473
Clinical Evaluation
The primary presenting symptom in carcinoma of the glottis
is hoarseness. This occurs early in the disease process but has
often been present for 3 or more months by the time of diag-
nosis. Patients with supraglottic carcinoma tend to remain
asymptomatic until the tumor is locally advanced and often
present owing to nodal metastasis. The rare patient with car-
cinoma of the subglottis typically presents with stridor or
hemoptysis. Other symptoms of concern for laryngeal cancer
are dyspnea, dysphagia, and pain (particularly when referred
to the ear). Pain occurs with advanced tumors, owing to inva-
sion through cartilage and extralaryngeal structures. Pain
radiating to the ear may be caused by involvement of the glos-
sopharyngeal or vagus nerves. Other symptoms are cough,
hemoptysis, halitosis, and weight loss. Coughing is often
attributable to the aspiration seen with glottic tumors, and
weight loss is an ominous sign that often suggests distant
metastases. Tenderness on palpation of the larynx may indi-
cate extension through cartilage.
As the treatment of laryngopharyngeal tumors can be
physically demanding, the overall health and ability of the
patient to undergo treatment are very important. The patient’s
alcohol intake can have a direct bearing on the postoperative
course, and the smoking history may have an impact on
wound healing. Prior therapies such as local radiation are crit-
ical to ascertain.
A complete physical examination is required, with special
attention to the entire upper aerodigestive tract and cervical
region. Complete laryngoscopy is required, either with a mir-
Neoplasms of the Larynx and Laryngopharynx 477
Imaging Studies
The current modalities most commonly used for imaging of
the upper aerodigestive tract in the United States are CT and
MRI. These have been refined to the point that they can provide
important information on invasion of cartilage, local spaces,
and regional structures, as well as demonstrate lymph nodal
metastases. Both technologies have sensitivities ranging from
60 to 80%, with specificities between 70 and 90%. Additional
information on lymph node size, shape, and appearance may
suggest involvement by metastatic disease. Positron emission
tomography is based on differential uptake of radioactive [18F]
fluorodeoxyglucose. Tissues invaded by tumor typically take
up greater concentrations of the tracer owing to their increased
metabolic demands. Positron emission tomography has been
demonstrated to be more sensitive, specific, and accurate than
CT or MRI in detecting occult nodal disease. It alone does not
provide detailed anatomic information, but it is currently being
coupled with CT, which is expected to enhance the accuracy of
tumor imaging in the future.
Panendoscopy
Panendoscopy is a systematic survey of the upper aerodiges-
tive tract through laryngoscopy, esophagoscopy, and bron-
choscopy. Detailed information on the exact extent of the
primary tumor is obtained while concurrently searching for
additional primary malignancies. During laryngoscopy,
which is performed at the end of the procedure so that bleed-
478 Otorhinolaryngology
Tumor Staging
When all clinical investigations have been performed, staging
of the tumor is possible. The system used in the United States
is the tumor, node, metastasis (TNM) classification created by
the American Joint Committee on Cancer, which separates
patients into stages I to IV, with higher stages carrying a
poorer prognosis.