Zhang, Lei MSOtolaryngology and Head & Neck Department

Sir Run Run Shaw HospitalEmail:dr_zhanglei@hotmail.com

Acute epiglottis Acute laryngotracheobranchitis in

children Chronic laryngitis Vocal fold polyps Vocal fold nodules Leukoplakia of larynx Laryngeal papillomas Laryngeal cancer Squamous cell carcinoma of

pharynx(cancer of hypopharynx)

Verrucous Carcinoma

11,000 new cases of laryngeal cancer per year in the U.S.

Accounts for 25% of head and neck cancer and 1% of all cancers

One-third of these patients eventually die of their disease

Most prevalent in the 6th and 7th decades of life

4:1 male predilection Downward shift from 15:1 post WWII Due to increasing public acceptance of

female smoking More prevalent among lower

socioeconomic class, in which it is diagnosed at more advanced stages

Glottic Cancer: 59%

Supraglottic Cancer: 40%

Subglottic Cancer: 1%

Most subglottic masses are extension from glottic carcinomas

The first laryngectomy for cancer of the larynx was performed in 1883 by Billroth

Patient was successfully fed by mouth and fitted with an artificial larynx

In 1886 the Crown Prince Frederick of Germany developed hoarseness as he was due to ascend the throne.

Crown Prince Frederick of Germany

Was evaluated by Sir Makenzie of London, the inventor of the direct laryngoscope

Frederick’s lesion was biopsied and thought to be cancer

He refused laryngectomy and later died in 1888

Frederick was succeeded by Kaiser Wilhelm II, who along with Otto von Bismark militarized the German Empire and led them into WW I

Could an Otolaryngologist have prevented WW I?

Prolonged use of tobacco and excessive alcohol use primary risk factors

The two substances together have a synergistic effect on laryngeal tissues

90% of patients with laryngeal cancer have a history of both

Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposures

Asbestos mustard gaspetroleum products other risk factors.

Prior history of head and neck irradiation

85-95% of laryngeal tumors are squamous cell carcinoma

Histologic type linked to tobacco and alcohol abuse

Characterized by epithelial nests surrounded by inflammatory stroma

Keratin Pearls are pathognomonic

Verrucous Carcinoma Fibrosarcoma Chondrosarcoma Minor salivary carcinoma Adenocarcinoma Oat cell carcinoma Giant cell and Spindle cell carcinoma

Thyroid cartilage

cricoid

hyoid

epiglottic

cricothyroid ligament

epiglottic

Thyroid

Arytenoidscorniculate, cuneiform

cricoid

sagittal viewcoronal view

Supraglottic tumors more aggressive:Direct extension into pre-epiglottic spaceLymph node metastasisDirect extension into lateral hypopharnyx,

glossoepiglottic fold, and tongue base

Glottic tumors grow slower and tend to metastasize late owing to a paucity of lymphatic drainageThey tend to metastasize after they have

invaded adjacent structures with better drainage

Extend superiorly into ventricular walls or inferiorly into subglottic space

Can cause vocal cord fixation

True subglottic tumors are uncommonGlottic spread to the subglottic space is a

sign of poor prognosis Increases chance of bilateral disease and

mediastinal extension Invasion of the subglottic space associated

with high incidence of stomal reoccurrence following total laryngectomy (TL)

HoarsenessMost common symptomSmall irregularities in the vocal fold result in

voice changesChanges of voice in patients with chronic

hoarseness from tobacco and alcohol can be difficult to appreciate

Patients presenting with hoarseness should undergo an indirect mirror exam and/or flexible laryngoscope evaluation

Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color

Videostrobe laryngoscopy may be needed to follow up these subtler lesions

Good neck exam looking for cervical lymphadenopathy and broadening of the laryngeal prominence is required

The base of the tongue should be palpated for masses as well

Restricted laryngeal crepitus may be a sign of post cricoid or retropharyngeal invasion

Other symptoms include:DysphagiaHemoptysisThroat painEar painAirway compromiseAspirationNeck mass

Biopsy is required for diagnosis Performed in OR with patient under

anesthesia Other benign possibilities for laryngeal

lesions include: Vocal cord nodules or polyps, papillomatosis, granulomas, granular cell neoplasms, sarcoidosis, Wegner’s granulomatosis

Other potential modalities:Direct laryngoscopyBronchoscopyEsophagoscopyChest X-rayCT or MRILiver function tests with or without USPET ?( Positron emission tomography)

Malignant lesions can appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color

TXTX Minimum requirements to assess Minimum requirements to assess primary tumor cannot be metprimary tumor cannot be met

T0T0 No evidence of primary tumorNo evidence of primary tumor

TisTis Carcinoma in situCarcinoma in situ

T1T1 Tumor limited to one subsite of supraglottis with normal Tumor limited to one subsite of supraglottis with normal vocal cord mobility vocal cord mobility

T2T2 Tumor involves mucosa of more than one adjacent Tumor involves mucosa of more than one adjacent subsite of supraglottis or glottis, or region outside the subsite of supraglottis or glottis, or region outside the supraglottis (e.g. mucosa of base of the tongue, supraglottis (e.g. mucosa of base of the tongue, vallecula, medial wall of piriform sinus) without fixation vallecula, medial wall of piriform sinus) without fixation

T3T3 Tumor limited to larynx with vocal cord fixation and or Tumor limited to larynx with vocal cord fixation and or invades any of the following: postcricoid area, invades any of the following: postcricoid area, preepiglottic tissue, paraglottic space, and/or minor preepiglottic tissue, paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) thyroid cartilage erosion (e.g. inner cortex)

T4T4aa

Tumor invades through the thyroid cartilage and/or Tumor invades through the thyroid cartilage and/or invades tissue beyond the larynx (e.g. trachea, soft invades tissue beyond the larynx (e.g. trachea, soft tissues of neck including deep extrinsic muscles of the tissues of neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus) tongue, strap muscles, thyroid, or esophagus)

T4T4bb

Tumor invades prevertebral space, encases carotid Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures artery, or invades mediastinal structures

T1T1 Tumor limited to the vocal cord (s) (may involve Tumor limited to the vocal cord (s) (may involve anterior or posterior commissure) with normal mobilty anterior or posterior commissure) with normal mobilty

T1aT1a Tumor limited to one vocal cord Tumor limited to one vocal cord

T1bT1b Tumor involves both vocal cords Tumor involves both vocal cords

T2T2 Tumor extends to supraglottis and/or subglottis, Tumor extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility and/or with impaired vocal cord mobility

T3T3 Tumor limited to the larynx with vocal cord fixation Tumor limited to the larynx with vocal cord fixation and/or invades paraglottic space, and/or minor thyroid and/or invades paraglottic space, and/or minor thyroid cartilage erosion (e.g. inner cortex) cartilage erosion (e.g. inner cortex)

T4aT4a Tumor invades through the thyroid cartilage, and/or Tumor invades through the thyroid cartilage, and/or invades tissues beyond the larynx (e.g. trachea, soft invades tissues beyond the larynx (e.g. trachea, soft tissues of the neck including deep extrinsic muscles of tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus the tongue, strap muscles, thyroid, or esophagus

T4bT4b Tumor invades prevertebral space, encases carotid Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures artery, or invades mediastinal structures

T1T1 Tumor limited to the subglottis Tumor limited to the subglottis

T2T2 Tumor extends to vocal cord (s) with normal or Tumor extends to vocal cord (s) with normal or impaired mobility impaired mobility

T3T3 Tumor limited the larynx with vocal cord fixation Tumor limited the larynx with vocal cord fixation

T4aT4a Tumor invades cricoid or thyroid cartilage and/or Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond larynx (e.g. trachea, soft invades tissues beyond larynx (e.g. trachea, soft tissues of the neck including deep extrinsic tissues of the neck including deep extrinsic muscles of the tongue, strap muscles, thyroid, or muscles of the tongue, strap muscles, thyroid, or esophagus) esophagus)

T4bT4b Tumor invades prevertebral space, encases Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures carotid artery, or invades mediastinal structures

N0N0 No cervical lymph nodes positive No cervical lymph nodes positive

N1N1 Single ipsilateral lymph node ≤ Single ipsilateral lymph node ≤ 3cm 3cm

N2aN2a Single ipsilateral node > 3cm and Single ipsilateral node > 3cm and ≤6cm ≤6cm

N2bN2b Multiple ipsilateral lymph nodes, Multiple ipsilateral lymph nodes, each ≤ 6cmeach ≤ 6cm

N2cN2c Bilateral or contralateral lymph Bilateral or contralateral lymph nodes, each ≤6cm nodes, each ≤6cm

N3N3 Single or multiple lymph nodes > Single or multiple lymph nodes > 6cm 6cm

M0M0 No distant metastasesNo distant metastases

M1M1 Distant metastases presentDistant metastases present

00 TisTis N0N0 M0M0

II T1T1 N0N0 M0M0

IIII T2T2 N0N0 M0M0

IIIIII T3T3 N0N0 M0M0

T1-3T1-3 N1N1 M0M0

IVAIVA T4aT4a N0-2N0-2 M0M0

T1-4aT1-4a N2N2 M0M0

IVBIVB T4bT4b Any NAny N M0M0

Any TAny T N3N3 M0M0

IVCIVC Any TAny T Any NAny N M1M1

Premalignant lesions or Carcinoma in situ can be treated by surgical stripping of the entire lesion

CO2 laser can be used to accomplish this but makes accurate review of margins difficult

Early stage (T1 and T2) can be treated with radiotherapy or surgery alone, both offer the 85-95% cure rate.

Surgery has a shorter treatment period, saves radiation for recurrence, but may have worse voice outcomes

Radiotherapy is given for 6-7 weeks, avoids surgical risks but has own complications

XRT complications include:MucositisOdynophagiaLaryngeal edemaXerostomiaStricture and fibrosisRadionecrosisHypothyroidism

Advanced stage lesions often receive surgery with adjuvant radiation

Most T3 and T4 lesions require a total laryngectomy

Some small T3 and lesser sized tumors can be treated with partial larygectomy

Adjuvant radiation is started within 6 weeks of surgery and with once daily protocols lasts 6-7 weeks

Indications for post-op radiation include: T4 primary, bone/cartilage invasion, extension into neck soft tissue, perineural invasion, vascular invasion, multiple positive nodes, nodal extracapsular extension, margins<5mm, positive margins, CIS margins, subglottic extension of primary tumor.

Chemotherapy can be used in addition to irradiation in advanced stage cancers

Two agents used are Cisplatinum and 5-flourouracil

Cisplatin thought to sensitize cancer cells to XRT enhancing its effectiveness when used concurrently.

Induction chemotherapy with definitive radiation therapy for advanced stage cancer is another option

Studies have shown similar survival rates as compared to total laryngectomy with adjuvant radiation but with voice preservation.

Role in treatment still under investigation

Modified or radical neck dissections are indicated in the presence of nodal disease

Neck dissections may be performed in patients with supra or subglottic T2 tumors even in the absence of nodal disease

N0 necks can have a selective dissection sparing the SCM, IJ, and XI

N1 necks usually have a modified dissection of levels II-IV

No more than 1cm subglottic extension anteriorly or 5mm posteriorly

Mobile affected cord Minimal anterior

contralateral cord involvement

No cartilage invasion No neck soft tissue

invasion

T1,2, or 3 if only by preepiglottic space invasion

Mobile cords No anterior commissure

involvement FEV1 >50% No tongue base disease

past circumvallate papillae

Apex of pyriform sinus not invloved

Resection of true vocal cords, supraglottis, thyroid cartilage

Leave arytenoids and cricoid ring intact

Half of patients remain dependent on tracheostomy

Indications:T3 or T4 unfit for partialExtensive involvement of thyroid and

cricoid cartilages Invasion of neck soft tissuesTongue base involvement beyond

circumvallate papillae

Tracheostomal prosthesis

Electrolarynx

Pure esophageal speech

Inaccurate staging 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 Radiation induced fibrosis

5 year survival5 year survival

Stage IStage I >95%>95%

Stage IIStage II 85-90%85-90%

Stage IIIStage III 70-80%70-80%

Stage IVStage IV 50-60%50-60%

After initial treatment patients are followed at 4-6 week intervals. After first year decreases to every 2 months. Third and fourth year every three months, with annual visits after that

Patients considered cured after being disease free for five years

Most laryngeal cancers reoccur in the first two years

Despite advances in detection and treatment options the five year survival has not improved much over the last thirty years

The pyriform sinus is the most common site for hypopharyngeal cancer (65-75%). Cancer may extend from here into the subglottis, thyroid

cartilage, postcricoid region, or cricoarytenoid joint. Three of every four patients presenting with hypopharyngeal

cancer at this subsite may have regional metastasis with apical primaries, resulting in a poorer prognosis.

A life-threatening infectionAcute epiglottitis in the

Children Acute epiglottitis in the Adult

Acute epiglottitis in the Children Organisms

non–type B H. influenzae( in vaccinated children)

Streptococcus pyogenes, S. pneumoniae S. aureus.

Diagnosis history and clinical findingsLateral soft tissue radiographs

“thumb sign” a dilated hypopharynx. Occasionally, supraglottic region appears hazy In severe cases, treatment should not be

delayed to obtain radiographs

Differentiating Diagnosis laryngotracheitis is not always easy, but it

is of paramount importance

The signs and symptoms Signs

A toxic appearance is involved, with the child assuming an upright sitting position with the chin up and mouth open, bracing themself on the hands (the "tripod" position).

Patients often have difficulty in handling their secretions.

Speech is limited due to pain. Stridor is a late finding and signals nearly complete

airway obstruction. Symptoms

Severe throat pain Fever Irritability and respiratory distress that are rapidly

progressive Muffled voice

How is acute epiglottitis managed? arrangements for airway endoscopy in the

operating room All anxiety-provoking maneuvers should be

avoided. endotracheal intubation, and appropriate staff

should be prepared to perform a tracheotomy. spontaneous ventilation should be maintained The intubated child should be transferred to the

ICU. laryngoscopy to obtain swab cultures from the

epiglottis appropriate intravenous antibiotic therapy

a second- or third-generation cephalosporin cefuroxime, cefotaxime, or ceftriaxone

Ampicillin/ sulbactam trimethoprim/sulfamethoxazole Chloramphenicol

Symptom fever, sore throat, a muffled voice, dysphagia, and

odynophagia. longer than that seen in children (usually more than

24 hours) Sign

swollen, bright-red epiglottis swollen epiglottis and dilated hypopharynx on a

lateral neck radiograph infectious etiology

Haemophilus group A streptococcus.

The clinical course appears less severe Conservative measures include oxygenation,

humidification, hydration, corticosteroids, and intravenous antibiotics

Acute laryngotracheobronchitis (LTB), or croup

Viral laryngotracheitis is the most common laryngeal inflammatory disorder of childhood.

Organisms parainfluenza virus respiratory syncytial virus influenza rubeola Adenoviruses Mycoplasma pneumoniae

history viral upper respiratory infection with

rhinitis, cough, and low-grade feversymptoms

hoarseness, dyspnea, stridor, and a barking cough

characteristic cough gives its common name, croup

airway obstruction is caused by laryngotracheitis, the stridor is characteristically inspiratory, or biphasic.

diagnosis based on the history,examination of the larynx

erythematous and edematous mucosa with normal vocal fold mobility(although not necessary)

Radiographs, reveal a narrowing of the subglottic lumen, the “steeple sign,”

How is LTB managed?Most cases are alleviated by simple home

methods, such as humidification most severe cases cause acute airway

obstruction Hydration, Humidification supplemental oxygen, fluids, nebulized racemic epinephrine The use of oral and/or intramuscular

glucocorticoids ( dexamethasone) Antipyretics, decongestants, Artificial airway support (eg, intubation) is

necessary in a relatively small proportion of patients

Secondary bacterial infection high temperature spikes and exudative,

purulent drainageRadiographically

the lumen of the upper airway will appear narrowed, shaggy, and irregular

Organisms Haemophilus influenzae, Staphylococcus aureus, Streptococcus pneumoniae, Moraxella catarrhalis, hemolytic streptococci

Antibiotic therapy is indicated

. How is chronic laryngitis treated? general inflammation of the larynx smoking, voice abuse, or laryngopharyngeal

reflux symptoms chronic hoarseness, chronic cough,

throat irritation, frequent throat clearing, and globus sensation.

The voice usually improves if the irritating factors are discontinued. This may involve smoking cessation or voice rest.

H2 blockers and proton pump inhibitors are highly effective in treatment. In addition

resting their voice, sleeping with the head of the bed elevated, and waiting 3-4 hours after eating before going to bed.

Polyps asymmetric and appear soft and smooth on one or both vocal folds

vocal nodules usually paired small and discrete located in the 1/3 the distance from the anterior

commissure. Contact granulomas

found on the vocal processes of the arytenoid cartilage.

Vocal fold cysts mucous retention or epidermoid cysts located in the superficial layer of lamina propria at the middle third of the vocal fold in the medial

and superior aspect

What are the treatment options for vocal fold nodules?Vocal fold nodules often arise as a result of

excessive laryngeal use. Voice therapy is a highly effective method of treatment. In rare cases in which voice therapy does not give satisfactory results, surgical removal of nodules may improve the voice. Generally, surgery will not resolve the hoarseness completely, and it is rarely indicated because vocal coaching is usually curative.

How is a laryngeal polyp treated?A laryngeal polyp is a single benign lesion

of the larynx. Voice therapy is recommended before and after surgery and could be the only required treatment. Laryngeal polyps can be removed with a standard cold knife, which is preferable, or with a carbon dioxide laser. Microflap technique is used to preserve the mucosal cover and the underlying vocal ligament, when possible. Normal voice usually returns after treatment.

Leukoplakia (precancerous lesions) a characteristic white lesion on the vocal

foldexhibit thickening of the epithelial layerabnormal keratinization of the superficial

layerssolitary or multifocal. benign and malignant

Histologically, most of these lesions are benign, but there is thought to be an approximately 3% risk of malignancy for leukoplakia of the vocal fold

Laryngeal papillomatosis affects mucous membranse of the larynx characterized by multiple and recurrent

squamous papillomatamay more prevalent in children and less

common in individuals over 30 years of age.causing hoarseness some degree of respiratory

obstruction,particularly in chidren .which is associated with human papilloma

virus (HPV) types 6 and 11.

Papillomatosis in children

Papillomatosis in Adult

How is laryngeal papillomatosis transmitted?Transmission is multifactorial. Fifty percent

of mothers have a history of active or prior HPV infection. The risk of transmission is 1 in 400. Cesarean section is not recommended for mothers with either active or latent infection because transmission has occurred despite cesarean section.

gross inspectionappear in a multinodular pattern sessile or exophytic.

Histologicallypapillary projections and hypervascular

fibroconnective tissus covered by hyperplastic squamous epithelium that shows maturation.

Cellular atypia is the rule rather than the exception

Histologic differentiation from early carcinoma may sometimes be difficult.

What triad is associated with laryngeal papillomatosis?Firstborn child: primigravid mothers are

more likely to have a prolonged second stage of labor, which increases the risk for infection

Teenage mother Vaginal delivery

How are laryngeal papillomas treated?spontaneous remissions can occurMultiple surgical resections, often with a

laser, are required. cidofovir (intraoperative injections), indole

3-carbinol/diindolylmethane, acyclovir, and interferon-α are under investigation.

Malignant Tumors of the Larynx and Hypopharynx. Cummings- Otolaryngology- Head and Neck Surgery. 4th ed., Mosby, 2005.

Malignant Laryngeal Lesions. Lawani- Current Diagnosis and Treatment in Otolaryngology- Head and Neck Surgery. McGraw-Hill and Lange, 2004.

Neck. Moore- Essential Clinical Anatomy. 2nd ed., Lippincott, 2002. Head and Neck. Rohen- Color Atlas of Anatomy. 5th ed., Lippincott, 2002. Surgery for Supraglottic Cancer. Myers- Operative Otolaryngology Head and Neck

Surgery Vol. 1. 1st ed., Saunders, 1997. Surgery for Glottic Carcinoma. Myers- Operative Otolaryngology Head and Neck Surgery

Vol. 1. 1st ed., Saunders, 1997. The Larynx. Lore and Medina- An Atlas of Head and Neck Surgery. 4th ed., Elsevier,

2005. Hinerman, R, Morris, C, et al. Surgery and Postoperative Radiotherapy for Squamous

Cell Carcinoma of the Larynx and Pharynx. Am J Clin Oncol. 2006; 29(6): 613-621. Huang, D, Johnson, C, et al. Postoperative Radiotherapy in Head and Neck Carcinoma

with Extracapsular Lymph Node extension and/or Positive Resection Margins: a Comparative Study. Int J Radiat Oncol Biol Phy. 1992; 23:737-742.

Bernier, J, Domenge, C, et al. Postoperative Irradiation with or without Concomitant Chemotherapy for Locally Advanced Head and Neck Cancer. N Engl J Med. 2004; 350: 1945-1952.

Sessions, D, Lenox, J, et al. Supraglottic Laryngeal Cancer: Analysis of Treatment Results. Laryngoscope. 2005; 115: 1402-1410.

Wolf, GT. The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction Chemotherapy Plus Radiation Compared with Surgery Plus Radiation in Patients with Advanced Laryngeal Cancer. New England Journal of Medicine. 1991; 324: 1685-90.

Lefebre J, Chevalier D, Luboinski B, Kirkpatrick A, Collette L, Sahmoud T. Larynx Preservation in Pyriform Sinus Cancer: Preliminary Results of a European Organization for Research and Treatment of Cancer Phase III Trial. Journal of the National Cancer Institute. Jul 1996. 88(13): 890-899.

Grant’s Atlas 10th ed. CD-ROM

Laryngeal carcinoma Etiology:

tobacco and excessive alcohol use primary Human Papilloma Virus 16 &18 Chronic Gastric Reflux Occupational exposures

Presentation Hoarseness, Dysphagia,Hemoptysis,Throat pain,

Ear pain, Airway compromise, Aspiration,Neck mass

appear as friable, fungating, ulcerative masses or be as subtle as changes in mucosal color

Laryngeal carcinoma Diagnosis

History Endoscopy Biopsy

Treatment Operation Radiotherapy Chemotherapy

Distinguish characteristic between laryngotracheitis and supraglottitis

Distinguish characteristic between nodular and polyps

Leukoplakia are the precancerous lesions

What triad is associated with laryngeal papillomatosis?