GRAND ROUND

PRESENTED BY : DR ALI JABER ASIRY

PGY 4 ORL-HNS – ACH

SUPERVISER : DR.MUBARAK ALQAHTANI

MBBS,SBORL,ABORL,FEBORL, KSU-HNSF
CASE

60 Y\O MALE CAME TO ER COMPLAINING OF HOARSNESS AND

NOISY BREATHING
Sarting with ABC : Patient was stabilized

Patient still having mild inspiratory stridor

ICU TEAM AND ANASTHESIA INVOLVED
66-year-old man presented to the emergency room with noisy
breating since 2 hours progressive associated with
hoarsness , He had complained of progressive hoarseness for
almost 1 year , During the last 2 months, he experienced
difficulty swallowing solid food, which resulted in loss of
appetite and weight. One month prior to his presentation , he
experienced stridor. No hx of otalgia , no odynophagia ,
He had chronic atrial fibrillation , no recent hx of URTI
No surgical history , no history of recent intubation , or
recent chest or neurological surgery
40 pack-year smoking history.
On aspirin and Plavix
No hx of allergy to medication or food
No recent contact to sick patient
No family hx of similar illness
He was a industrial worker
Patient with inspiratory stridor in a semi-recumbent position;
no use accessory respiratory muscles . Maintained on O2 mask
, not pale or cynosed , On IV cannula

Vitals :
Sat : 98 % on O2 mask
BP : 140 / 95
RR : 32
TEMP : 37

Full ENT exam including all lymph node exam uremarkable

Laryngoscopy exam next slide

Laryngoscopy
Differential Diagnosis:
1. Carcinoma of the larynx
2. Minor Salivary gland ca
3. Benign lesion of the larynx
4. Infection
5. Granulomatous dx
6. Other causes
Investigation.

Routine investigation , including ABO groubing and cross matching

CRP , ESR
CXR
CT SCAN neck with contrast.
MRI not done
Operation
Patient was intubated in OR , and consented for MLS + BIOPSY +
Trachestomy

Biopsy result : The pathology of the specimen was

consistent with a trans glottic squamous carcinoma
with right thyroid lobe invasion.
CT CAP :
NO LN DETECTED .

Distant metastasis were negative.

Q: What's important information's you would like to obtain from Neck
CT in malignant laryngeal lesions ?
Pre-epiglottic space involvement
Para-glottic space involvement
Thyroid cartilage invasion internally and externally.
Subglottic involvement.
Extent of the disease supra-glottic.
Nodal Disease.
What's the TNM staging for this patient ?
T4aN0M0
What's the Laryngeal subsites ( supra glottic,
glottic, and sub glottic ) ?
Pre-epiglottic fat space??
Pre-epiglottic fat space
Anterior: thyrohyoid membrane

Superior: hyo-epiglottic ligament

Posterior: part of the epiglottis

Para-glottic Space??
Para-glottic Space
superomedial: quadrangular
membrane
inferomedial: conus elasticus
posterior: piriform sinus mucosa
lateral: thyroid cartilage and
cricothyroid membrane
What's the anatomical barrier of the laryngeal cancer ?
What's the anatomical barrier of the laryngeal
cancer ?
Answer :

Conus elasticus (esp. against inferior spread(

Quadrangular membrane
Vocal ligament
Broyle’s ligament
Laryngeal framework (e.g thryoid cartilage and its
perichondrium, arytenoid cartilage, etc.(
Hyoepiglottic ligament
Thyrohyoid membrane
What's the anatomical route of
spread in laryngeal cancer ?
 Answer: Routes of
Spread:
Lateral cricothyroid space within
the Paraglottic space
Pre-epiglottic space dehiscence's
Deficient perichondrium
subjacent to AC
Fenestrations within epiglottis
Subglottic extension through the
conus
What's the best Treatment modality in this
patient ?
TREATMENT

total laryngectomy + Thyroidevtomy + /-

unilateral or bilateral neck dissection and
pretracheal and ipsilateral paratracheal
lymph node dissection + adi radiotherapy +/-
chemo
 SUMMERY OF Laryngeal lesions Approach
History related laryngeal functions ( Voice, aspiration ,
breathing and Risk Factors.
Physical Examinations) general ex +complete ENT EX +Neck + cranial
nerves)
Fibrotic scope:
Complete visualization of intrinsic larynx, epiglottis, false and true
vocal cords, anterior commissure
Pyriform fossae must be free of saliva in order to evaluate mucosa
Mobility of the VOCAL CORDS
Video stroboscope.
Pulmonary functions tests.
CT +/- MRI
CXR.
 LARYNGEAL CANCER

INTRODUCTION
EPDIMIOLOGY
RISK FACTORS
CLINICAL
PRESENTATION
EXAMINATION
INVESTIGATION
STAGING
TREATMENT
 LARYNGEAL CANCER

EPIDEMIOLOGY:

Laryngeal cancer is the 2nd most common type of head

and neck cancer worldwide.
Male to female ratio 6:1
60 % of laryngeal CA cases are diagnosed as Early
Laryngeal cancer (T1,T2)
1.7% of all cancer in male in KSA
90- 95% OF MALIGNANT LARYNGEAL TUMERS
ARE SCC
 Risk factors

Smoking ( Strongly related to laryngeal cancer )

Alcohol
About 5% of laryngeal cancers occur in nonsmokers and nondrinkers, suggesting
other factors :
Diet
GERD
Previous radiation,
Viral infection
Human papilloma-virus (16 & 18) in 5% to 32% of analyzed samples in
laryngeal cancer ,
Occupational exposures to wood dust, polycyclic hydrocarbons, and asbestos

Genetics : alteration in P53 , Mutations in pl6, Over expression of cyclin D1

 Presentation
Mass effect:

hoarseness, dysphagia, hemoptysis, neck mass, SOB , Aspiration

Supraglottic sx : sore throat, hemoptysis , aspiration,

Dysphagia , hoarsness in late

Glottic sx: hoarseness(early ), aspiration, dysphagia , odynophagia ,

Stridor

Subglottic sx : biphasic stridor , hemoptysis

Weight loss (from Ca and from decreased swallowing)

HX OF Occupational hazard : metals; asbestos , Wood dust

Quantify smoking/alcohol
family Hx of Ca
 Physical Exam

- Airway distress mandate urgent airway protection

Complete ENT
head and neck exam
Palpation for nodes; restricted laryngeal crepitus.
Also asses Quality of voice
Breathy voice = cord paralysis
Muffled voice = supraglottic lesion
-Fibroptic examination
-Stroboscopy
 Imaging
CT or MRI
Cervical node mets
Evaluate pre-epiglottic or paraglottic space
Laryngeal cartilage erosion

PET:
For residual or recurrence mostly
also can be used for Distant or cervical
mets
 Biopsy
-Pathologic diagnosis would likely require Direct laryngoscopy
with biopsy , esophagoscopy; bronchscopy if needed

-Assess passive mobility of cords

-Fine- needle aspiration (FNA) biopsy of palpable neck node

can be used.
Subtypes:

Glottic Cancer
Most common subtype of laryngeal cancer 50-60%

Typically diagnosed at early stages due to early (hoarseness)

limited regional metastasis, primary drainage to nodal levels II–IV
 Supraglottic Cancer
30–40% of laryngeal cancer
overall 25–75% risk of regional metastasis,
primarily to nodal levels II–IV, especially bilateral neck disease
 Subglottic Cancer
1% to 5% of laryngeal cancers rare
poor prognosis
<20% regional metastasis

* Most subglottic masses are extension from glottic carcinomas

American Joint Committee on Cancer (AJCC) TNM
Staging System for the Larynx (8th edition )

TNM STAGING
Supra-glottic
GLOTTIC
Sub-glottic
Nodal Staging
Staging
 TUMOR BOARD

(otolaryngologists) - oncologists - Radiation

oncologists - dentist - plastic surgeon -
reconstructive surgeon - speech and language
pathologist -dietitian – Pathologist
- ICU - mental health counselor – social worker
The choice of treatment depends
mainly on :

The location and stage

patient’s general health

(Performance status)

Maintaining the patient’s ability to

talk, eat, and breathe as normally
as possible

Whether the cancer has returned

Propper Pt Counseling
 Treatment Goals

Complete removal of all malignant disease.

Preservation of function ) Larynx (

Predictable and reliable rehabilitation of the patient

Treatment perspectives

The Primary lesion

The Neck
Airway
+/- Adjuvant Treatment
Reconstruction
Rehabilitation
According to NCCN Guidelines Cancer of
the Larynx
Treatment of the 1ry lesion

Stage I-II:
Single Modality(Surgery or XRT)

Stage III:
Double Modality(CCRT)

Stage VI:
Sx+XRT+/-Chemo
 Tx Supraglottic Ca

T1/2 : Single modality treatment ( Suregery or Rx )

- CO2 LASER Resection Or
- Partial Supraglottic Laryngectomy Or
- Radiotherapy

T3 : Doube modality treatment

- Organ preservation Chemo/Radiotherapy Or
- Partial Supraglottic Laryngectomy (selected cases) + Adj.
Radiotherapy +/- Chemo.
- Total Laryngectomy + Adj. Radiotherapy +/- Chemo.

T4 : Doube modality treatment

- Total Laryngectomy + Adj. Radiotherapy +/- Chemo
Partial Supraglottic Laryngectomy
Involves resection of supraglottic area
including the pre- epiglottic space,
epiglottis, upper half of the thyroid
cartilage through the plane of
ventricles and the hyoid bone.
Partial Supraglottic Laryngectomy

1- Horizental supraglottic laryngectomy without

arytenoidectomy2- Horizental supraglottic
laryngectomy with arytenoidectomy3- Horizental
supraglottic laryngectomy with ipsilatral true cord
resection ( 3/4 Laryngectomy )
 Tx Glottic Ca

T1/2 : Single modality treatment ( Suregery or Rx )

- CO2 LASER Resection Or
- HemiLaryngectomy Or
- Radiotherapy

T3 : Doube modality treatment

- Organ preservation Chemo/Radiotherapy Or
- HemiLaryngectomy + Adj. Radiotherapy +/- Chemo.
- Total Laryngectomy + Adj. Radiotherapy +/- Chemo.

T4 : Doube modality treatment

- Total Laryngectomy + Adj. Radiotherapy +/- Chemo.
 Tx Glottic Ca

T1 : Single modality treatment ( Suregery or Rx )

Debate between surgery or radiation
Both has a good Cure rate
Radiotherapy : “better voice”
Endoscopic Sx: Lower cost, immediate defnitive mx, less
SE, saving Rx
Other surgical methods :
A- Hemi-Laryngectomy ( Ant. Commisure Involvment )
B- Extended Hemi-Laryngectomy ( Arytenoid Involvment,
Reconstructed with muscle flap to prevent aspiration and
breathy voice )
 Tx Subglottic Ca

Very Uncommon 1-5% of La. Ca.

Advanced at time of diagnosis with high mortality
rate
Usually Require Total Laryngectomy
High Risk of Stomal Recurrence : due to positive
tracheal margins and/or medistinal LN Involvment
Q: Mention the landmark studies names , arms and
outcomes promoted organ preservation in laryngeal
cancers?
 RTOG-911 ( Radiation therapy oncology Group ) ,
2003 :

Included patients : T3 ( T4 was excluded (

Study Arms / Survival Rate at 3 years :

1. Concurrent Chemo + XRT ( 88%)
2. Induction Chemotherapy followed by XRT (75%).
3. RT alone ( 70%)

Overall survival : No difference.

 Veterans Affairs 1991:
Included patient : Stage III – IV ( 2/3 of them were supraglottic with
advance nodal disease as well as T3 primary staging ).
Study Arms:
1- Total Laryngectomy + Adjuvant RT.
2- Induction Chemotherapy ( Cisplatin & Fluorouracil ) Followed by
XRT.
3- Trials of 2 cycles chemotherapy → No initial response patient cross
over to Surgery arm.

Laryngeal preservation was possible in 68% at 2 years.

 EORCT:
Eurpean / Comp Neoaduvent Vs Surgery
Involved all from stage 2 – 4
Similar VA study result
Treatment perspectives

The Primary lesion

The Neck
Airway
+/- Adjuvant Treatment
Reconstruction
Rehabilitation
 Treatment of the
Neck
- N0 Neck Reported rates of occult met. Range 20%-40% in
supraglottic and subglottic
- Most authors agree that these rates support the neck mangmnet
BL regardless to the site and stage.
-

- N+ Neck : Neck should be adressed in all types

 Treatment of the Neck

- Supraglottic : ≥ T1, BL , Level II-IV*

- Glottic : ≥ T3, Unilatrally Level II-IV
-

- Subglottic : ≥ T1, BL , Level II-IV + VI +/- Total

thyroidectomy )variation )
 Indications for hemi-thyroidectomy or subtotal
thyroidectomy in carcinoma of the larynx/hypopharynx:

1.

1. Palpable disease present

2. Glottic or subglottic carcinoma with greater than
1cm subglottic extension
3. T4 glottic carcinoma
4. T4 pyriform sinus carcinoma
Treatment perspectives

The Primary lesion

The Neck
Airway
+/- Adjuvant Treatment
Reconstruction
Rehabilitation
 Adjuvent treatments

General Indications for post op. General Indications for post op.
Rx Chemo./Rx
1. T3 /T4 1. Extracapsular Extension
2. Perineural or Vascular Invasion 2. +ve Margins
3. +ve Resection Margin
4. Multiple Histiological +ve Nodes
(N2b / N2c)
5. Extracapsular Spread
 NCCN GAUIDLINES:

IF AFTER SURGERY THERE IS :

1- ONE positive node (without other adverse features):
Radiotherapy
2- positive node with positive margin :
Re resection if feasible (in selected cases )
Or RT Or systemic therapy\RT
3- extra-nodal extension :
systemic therapy\RT or RT (in selected cases)
4- positive node with other adverse features:
RT or systemic therapy\RT
Treatment perspectives

The Primary lesion

The Neck
Airway
+/- Adjuvant Treatment
Reconstruction
Rehabilitation
 Reconstruction
Least Complex , Safest while maintaining form and
function
Treatment perspectives

The Primary lesion

The Neck
Airway
+/- Adjuvant Treatment
Reconstruction
Rehabilitation
Voice Rehabilitation Post Total Laryngectomy

Elements for Voice Production Normally

Air Generator ( Lung Expiration )

Vibration ( Vocal Fold )
Articulation ( Pharynx / Oral Cavity )
Voice Rehabilitation Post Total Laryngectomy

Modalities of Voice Restoration

1-Esophageal Speech
2-Electro-Larynx
3-Tracheoesophageal Puncture (TEP)
 Voice Rehabilitation Post Total Laryngectomy

Esophageal Speech

Air Generator
( Insufflation of air into
essophagus )
Vibration ( Esophagus/
Neopharynx )
Articulation ( Pharynx / Oral
Cavity )
 Voice Rehabilitation Post Total Laryngectomy

Electro-Larynx
Air Generator ( Lung )
Vibration ( Ext.
Vibrating
Apparatus )
Articulation ( Pharynx /
Oral Cavity )
 Voice Rehabilitation Post Total Laryngectomy

Tracheoesophageal Puncture (TEP)

Air Generator ( Lung )

Vibration (
Pharynx/Neopharynx )
Articulation ( Pharynx / Oral
Cavity )
 Complications
-Sign of fistula?
3rd – 8 th day fever, wound
erythema, wound swelling, or
persistent elevated neck drain
output with bubbles and organ
Pharyngo-cutaneous material , wound breakdown
Fistula:The risk factors:Poor
Nutritional Status
Smoker/alcoholDM Prolonged
trach pre opPrevious Radiation
TherapySurgical Technique
 INDICATION FOR SURGERY IN PCF?

FAILED CONSERVATIVE treatment (NPO , NGT, pack compressive ,AB

, rule out residual or recurrence disease )
Large defect
Carotid artery at risk
Early leak 48 hours
Stomal Recurrence:
The risk factors:Tumor Factors
Pre-operative Tracheostomy
What's the risk factors for stomal recurrence?
Subglottic laryngeal cancer
Preoperative tracheotomy

Advance Stage T and N

Salvage laryngectomy
 Sisson stages of stomal recurrence

Type 1—localized. Usually discreet nodule in superior aspect of

stoma

-Type 2— Oesophageal involvement. No inferior extension

-Type 3— Inferior to stoma. Usually mediastinal extension

-Type 4— Lateral extension. +/– Carotid sheath involvement.

 What are the management options in this
condition?
Radical surgery —only consider this if sufficient surgical margins can
be predicted.

Plliative care:
Trach
Steroid
Debulking
brachytherapy
Thank you ☺
NCCN Guidelines Cancer of the
Supraglottic Larynx
NCCN Guidelines Cancer of the
Glottic Larynx