Carcinoma of Larynx

Causes of referred otalgia

Ear receives nerve supply from Vth (auriculotemporal), 1Xth (tympanic br.) and Xth (auricular br.) cranial nerves; and from C2 (lesser occipital) and C2 and C3 (greater auricular), pain may be referred from these remote areas

1. Via Vth cranial nerve

• Dental; Caries tooth, apical abscess, impacted molar, malocclusion.
• Oral cavity; Benign or malignant ulcerative lesions of oral cavity or tongue.
• Temporomandibular joint disorders; Bruxism, osteoarthritis, recurrent dislocation,  ill-fitting denture.
• Sphenopalatine neuralgia.

2. Via IXth cranial nerve

• Oropharynx; Acute tonsillitis, peritonsillar abscess, tonsillectomy. Benign or malignant ulcers of soft palate, tonsil and its pillars.
• Base of tongue; Tuberculosis or malignancy.
• Elongated styloid process.

3.   Via Xth cranial nerve. Malignancy or ulcerative lesion of: vallecula, epiglottis, larynx or laryngopharynx, esophagus.

4.   Via C2 and C3 spinal nerves. Cervical spondylitis, injuries of cervical spine, caries spine.

Role of smoking and development of nasopharyngeal carcinoma is still not clear.

Otalgia can occur as a symptom of carcinoma on the base of tongue, pharynx or larynx.

Laryngeal keratosis is a precancerous condition.

Treatment modalities includes avoidance of aetiological factors such as smoking, stripping of vocal cords and examination of tissues for malignancy and use of laser vaporization.

The treatment of Keratosis of the larynx is conservative involving microsurgical excision. Partial laryngectomy may be used in the presence of certain T1 stage malignancy of Larynx.

This patients staging is limited to the supraglottic region (T2 lesion – Tumor involving more than one adjacent subsite of supraglottis, glottis, or region outside the supraglottis (vallecula, tongue base, medial wall of pyriform sinus). A voice conserving surgery would be ideal for him. The supraglottis is excised by partial horizontal laryngectomy.

General indications for vertical partial laryngectomy is T2 glottic cancers with impaired vocal cord mobility.

Current recommendations by the American Society of Clinical Oncology are that all patients with T1 or T2 laryngeal cancer, with rare exceptions, should be treated initially with the intent to preserve the larynx.

The advantages of surgery compared with radiation are a shorter treatment period (compared with 6–7 weeks for radiation) and the option of saving radiation for recurrence.

This patient is suffering from stage IV disease. Advanced-stage larynx cancer (Stages III and IV) is treated by dual-modality therapy with surgery and radiation. For most T3 and T4 tumors, where total laryngectomy is required for the complete removal of the tumor with amply clear margins, organ preservation treatment with combined chemotherapy and radiation therapy is preferred. Adjuvant radiation should start within 6 weeks of surgery and, on once-daily protocols, lasts 6–7 weeks.

This patient is in stage III carcinoma of larynx. 

The spinal accessory nerve (cranial nerve XI) is a motor nerve (special visceral efferent) that innervates the sternocleidomastoid and trapezius muscles. The trapezius, a broad, flat, triangular muscle, has fibers in its superior part that originate from the external occipital protuberance and the superior nuchal line, the ligamentum nuchae, and the spinous processes of vertebrae C-7 through T-4.

These upper fibers pass laterally to insert onto the acromion and the spine of the scapula. Activation of this part of the muscle results in elevation of the point of the shoulder (acromion moves superiorly), as in shrugging.

The muscles that promote movement of the arm away from the midline of the body include the deltoid, subscapularis, supraspinatus, and infraspinatus muscles which are innervated by branches of the brachial plexus, not the spinal accessory nerve (CN XI).

When there is damage to the spinal accessory nerve, they may also have difficulty elevating (abducting) the arm above a horizontal plane because the superior fibers of the trapezius, along with the serratus anterior, externally rotate the scapula about an anteroposterior axis, which is required for elevation of the arm beyond a horizontal plane.

However, this is a question of “magnitude”: loss of trapezius function would have greater effect on scapular elevation than rotation (i.e. serratus anterior is better able to compensate for loss of external rotation than levator scapulae can for elevation).

The trapezius adducts the scapula, whereas the major arm adductors include the pectoralis major, teres major, latissimus dorsi, and coracobrachialis muscles. These muscles are innervated by branches of the brachial plexus.

The muscles that act to laterally rotate the arm include the teres minor, infraspinatus, supraspinatus, and the dorsal portion of the deltoid muscles. These muscles are innervated by branches of the brachial plexus, not the spinal accessory nerve (CN XI).

B i.e. Larynx; C i.e. Ant 2/3 of tongue

• Radiotherapy is reserved for early larynx CA which has not involved cartilage or cervical lymphnodes & don’t impair cord mobilityQ.
• Surgery is the treatment of choice for early lesions suitable for simple infra oral excision, for tumors on the tip of tongue but brachy therapy with iridium wires has the advantage of preserving the tongue.
• Stomach, colon, lung CA in early stage are treated by surgery.

Ans is None > Ca Nasopharynx

All the given options are mentioned by Harrison:

• Harrison 17/e p2737 writes- “Tobacco smoking causes cancer of the lung, oral cavity, naso-, oro-, and hypopharynx, nasal cavity and paranasal sinuses, larynx, esophagus, stomach, pancreas, liver, kidney (body and pelvis), ureter, urinary bladder, and uterine cervix and also causes myeloid leukemia. There is evidence suggesting that cigarette smoking may play a role in increasing the risk of colorectal and possibly premenopausal breast cancer, but there is no association with postmenopausal breast cancer. There does not appear to be a causal link between cigarette smoking and cancer of the endometrium, and there is a lower risk of uterine cancer among postmenopausal women who smoke.”
• Thus the answer should be none, however Nasopharyngeal carcinoma is found to be least associated with smoking. Head & Neck Cancers by Enslow Jacobs 2003e p492 writes-“Association between smoking and nasopharyngeal carcinoma has been shown only by a few studies. If the association of tobacco and NPC is real, the possible mechanism of tumor induction would be the nitrosamines and its precursors in tobacco.”

Most common cause for stridor in 60 years old male will be carcinoma larynx as carcinoma larynx occurs in males (predominantly) at the age of 40-70 years.

Most common and earliest symptom of subglottic cancer is stridor.

• Nasopharyngeal cancer does not lead to stridor
• Thyroid cancer causes stridor rarely.

• There are lots of controversies regarding the reflux laryngitis secondary to reflux gastrointestinal disease. But now some studies document that there is a clear relation between the two.
• Reflux laryngitis may have the following sequlae:

Bronchospasm

Chemical pneumonitis

Refractory subglottic stenosis

Refractory contact ulcer

Peptic laryngeal granuloma

Acid laryngitis (Heart burn, burning pharyngeal discomfort, nocturnal chocking due to interarytenoid pachydermia)

Laryngeal Carcinoma .

Laryngopharyngeal Reflux

Here classical GERD symptoms are absent. Patients have more of daytime/upright reflux without the nocturnal/supine reflux of GERD. In laryngopharyngeal reflux esophageal motility and lower esophageal sphincter is normal, while upper esophageal sphincter is abnormal. The traditional diagnostic tests for GERD are not useful in LPR.

Symptom Chronic or Intermittent dysphonia, vocal strain, foreign body sensation, excessive throat mucus, Postnasal discharge and cough. Laryngeal findings: Interarytenoid bunching, Posterior laryngitis and subglottic edema (Pseudosulcus)

Sequelae of Laryngopharyngeal Reflux

• Subglottic stenosis
• Carcinoma larynx
• Contact ulcer/granuloma
• Cricoarytenoid joint fixity
• Vocal nodule/polyp
• Sudden infant deaths
• Laryngomalacia (Association)

Treatment is in similar lines as GERD, but we need to give proton pump inhibitors at a higher dose and for a longer duration (at least 6-8 months).

Keratosis of larynx/leukoplakia:‑

It is epithelial hyperplasia of the upper surface of one or both vocal cords.

• Appears as a white plaque or warty growth on cord without affecting its mobility
• Regarded as a precarcerous condition as Ca in situ develops frequently
• T/t=stripping of cords

• Subglottic cancer is the rarest of laryngeal cancer.
• Earliest presentation is a globus or foreign body sensation in throat followed by stridor or laryngeal obstruction.
• Hoarseness is a late feature and occurs due to involvement of glottis or recurrent laryngeal nerve.
• Lymphatic spread occurs to prelaryngeal, pretracheal, paratracheal and lower jugular nodes (i.e. mediastinal nodes.)

According to Dhingra

• Radiotherapy is the treatment of choice for all stage I cancers of larynx, which neither impair mobility nor invade cartilage or cervical nodes.
• The greatest advantage of radiotherapy over surgery in Ca larynx glottic cancer is – preservation of voice.

Not effective :

• If cords are fixed
• In subglottic extension                  
• In cartilage invasion
• If nodal metastasis is present

Microlaryngeal Surgery

i.e. endoscopic removal of selected larynx by operating microscope and microlaryngeal dissection instruments is used for treating early stages of cancer larynx.

The advantages of surgery compared to radiation are :

• A shorter treatment period (compared to 6 – 7 weeks for radiation)
• Saving the option of radiotherapy for recurrence

Drawback of Surgery – Poor Voice Quality

• Hence from above discussion it can be concluded that microlaryngoscopic surgery / Radiotherapy is the TOC for stage I of laryngeal cancer.
• In the option – Surgery and not microlaryngoscopic surgery is given.
• Hence Radiotherapy is being taken as the correct option.

Carcinoma larynx presenting with stridor means it is subglottic laryngeal carcinoma .Ideally in such cases emergency laryngectomy should be performed.

But not done in cases if

• Intubation can not be done as growth is seen in subglottic area, therefore tube can not be put.
• Planned tracheostomy can not be done as patient is suffering from stridor, which is an emergency. Therefore we will have to do emergency tracheostomy. With the precaution that the area of cancer should be removed within 72 hours.

Fully mobile vocal cord means either stage I or II carcinoma.TOC in stage I and II is radiotherapy. Radiotherapy is not a given option, therefore voice conservation surgery is done. However the tumor involve left half of supraglottis. Therefore hemilaryngectomy is done.

Vertical hemilaryngectomy means excission of one half of the larynx on one side, i.e., vertical half is removed which include vertical half of supraglottis, glottis and subglottis.

• It is indicated for specific T, and T₂ glottic cancer

Horizontal hemilaryngectomy is the excision of supraglottis only sparing true vocal cords and arytenoids also known as supraglottic laryngectomy.

• It is indicated for specific T1 and T2 supraglottic cancers which donot involve true vocal cord.

Hence, in supraglottic cancer horizontal hemilaryngectomy should be done to remove supraglottis.

The most significant problem with partial laryngectomies (horizontal/vertical) is aspiration and subsequent pneumonia. Therefore patients with good pulmonary reserve should only be selected.

Perichondritis of thyroid cartilage in a patient of Ca larynx suggests invasion of thyroid cartilage i.e. stage T4.

Stage T4 lesions glottic cancer are managed by total laryngectomy with neck dissection for clinically positive nodes and post opera­tive radiotherapy if nodes are not palpable.

Indication of Total laryngectomy in Ca larynx       – Current Otolaryngology 2/e pg-449; Dhingra 5/e, pg-330, 6/e p 310

• T₃ lesions (i.e. with cord fixed) not amenable to chemoradiation or partial laryngectomy procedures
• All T₄ lesions
• Invasion of thyroid or cricoid cartilage
• Bilateral arytenoid cartilage involvement
• Lesions of posterior commissure
• Failure after radiotherapy or conservation surgery
• Transglottic cancers i.e. tumors involving supraglottis and glottis across the ventricle, causing fixation of the vocal cord.

Total laryngectomy is contraindicated in patients with distant metastasis.

Treatment for stage I of cancer larynx (glottic cancer) is either microlaryngoscopic surgery or Radiotherapy.

External Bean Radiation or Brachytherapy

External bean radiation is most often used to treat laryngeal and hypopharyngeal cancer.

Brachytherapy is rarely used to treat laryngeal or hypopharyngeal cancer.                                                    

Radiation given as the primary treatment for larynx cancer or as an adjuvant treatment after surgery is most often done using an external beam technique, a dose of 6000-7000 cGy is admistered to the primary site.

Verrucous Carcinoma

• Verrcous carcinoma makes up only 1-2% of laryngeal carcinomas.
• The larynx is the second most common site of occurence in the head and neck after the oral cavity.
• Most common site of involvement is vocal cord.
• Grossly, verrucous carcinoma appears as a fungating, papillomatous, grayish white neoplasm.
• Microscopically, it is well differentiated squamous cell carcinoma with minimal cytological atypis.
• It has low metastatic potential
• Hoarseness is the most common presented symptom. Pain and dysphagia may occur but are less common.
• Treatment of most verrucous tumors is primary surgery. Endoscopic laser surgery is appropriate as the tumor is less aggressive than usual squamous cell carcinoma.

Methods mmunication in laryng zed patient

• Oesophageal speech
• Electrolarynx
• Transoral pneumatic device
• Tracheo-oesophageal speech – Blom-Singer prosthesis – Panje prosthesis

Ans: D i.e. Lymphoma

• Patient with with glottis carcinoma extending to the supra glottis region along with vocal cord fixation (bad prognostic sign; involvement of thyroarytenoid muscle) belongs to T3 stage og glottis carcinoma
• Single ipsilateral lymph node of 2 cm size signifies N1 nodal status
• And there is no evidence of distal metastases so MO
• This patient belongs to T3N1 MO.
• Treatment of choice in such patient is total laryngectomy with radical neck dissection.

STAGING OF LARYNX CANCER

• Treatment of larynx cancer depends upon the stage of the tumor.
• Therefore, one should know the TNM staging (TNM classification) of large cancer.