ENT

Otorhinolaryngology

Lec: 13

Laryngeal masses

Benign lesions

Benign tumors

Malignant tumors

Benign laryngeal lesions

Vocal cord nodules

Polyp

Renkie’s edema

Granuloma

Anatomy of the true vocal cord

1

ENT

Vocal cord nodules (singer’s nodules)

Bilateral, symmetrical situated at the junction of anterior third with the posterior 2 thirds of the true vocal cords.

Etiology: voice abuse or misuse

More prevalent in children, teachers, lawyers, singers, house wife and other habitual voice users.

Treatment: voice rest

speech therapy

Microsurgery in longstanding cases after failure of conservative treatment.

Vocal cord polyp

Unilateral

Broad-based or pedunculated

Hemorrhagic or non-hemorrhagic

Caused by localized collection of fluid in Renkei’s

space.

Etiology:

Voice abuse

2

ENT

Smoking

Gastroesophageal reflux

Treatment:

Microsurgery

Laser ( Co2 or pulsed dye )

Renkie’s edema

Bilateral diffuse involvement of true vocal cords.

Subepithelial collection of fluid in Renkie’s space.

In addition to hoarseness might cause dyspnea and stridor if large and obstructing the airway.

Treatment:

Microsurgery

Laser

Granuloma

3

ENT

Specific: TB granuloma

Non-specific: intubation granuloma (due to rough traumatic endotracheal intubation)

Affects the posterior part (arytenoid) of the vocal cord.

Unilateral.

Treatment:

Microsurgery

Laser

Intralesional steroid injection (for small granulomas)

Benign Tumors of the Larynx

Papilloma: 85%

Chondroma

Hemangioma

Schwannoma

Neurofibroma

Adenoma

Fibroma, lipoma and leiomyoma

Papilloma: 2 types

a- Juvenile: usually multiple, recurrent after treatment but might regress after puberty

b- Adult: single lesion and no spontaneous regression

4

ENT

HPV type 6 and 11 play role in juvenile type , less consistently in adult type, presentation usually hoarseness, dyspnea and stridor

Treatment:

Microsurgical excision

Co2 laser .

Antiviral agents: cidofovir or Interferones

Every effort should be made to avoid tracheotomy.

Malignant laryngeal tumors

Squamous cell ca is the commonest (more than 90%), adenocarcinoma, sarcoma, lymphoma...etc

SCC of the larynx is the most common head and neck cancer with high cure rate reaching 90%.

Incidence:

Male more than female 5:1

Elderly , 7th decade

Etiology:

1- Tobacco

2- Alcohol

3- Asbestoses

4- Radiation

5- Premalignant conditions

5

ENT

Pathology:

Site:

Glottic 75%

Supraglottic 20%

Subglottic 5%

Histopathology:

The vast majority SCC with different grades of differetiation( poor, moderate or well differentiated)

Risk Factors

6

ENT

Although alcohol is a less potent carcinogen than tobacco, alcohol consumption is a risk factor for laryngeal tumors.

In individuals who use both tobacco and alcohol, these risk factors appear to be synergistic, and they result in a multiplicative increase in the risk of developing laryngeal cancer.

Etiology

The incidence of laryngeal tumors is closely correlated with smoking, as head and neck tumors occur 6 times more often among cigarette smokers than among nonsmokers.

The age-standardized risk of mortality from laryngeal cancer appears to have a linear relationship with increasing cigarette consumption.

7

ENT

The supraglottic larynx

� It consists of epiglottis, false vocal cords, ventricles, aryepiglottic folds, and arytenoids

8

ENT

The glottic larynx

� It consists of the true vocal cords and anterior commissure and posterior commissure

The

subglottic larynx

9

ENT

� It consists of the region between the vocal cords and the trachea.

Spread

Direct spread: vertical and circumferential, inside the larynx and to the nearby organs

Lymph node spread: to the pre-tracheal, paratracheal and deep cervical LNs. more common in the supraglottic and subglottic tumors. Pure glottic tumors rarely metastasize because practically there is no lymphatic drainage in the glottic region.

Distant: only 5 % at the time of presentation have distant metastasis.

Clinical features:

1- Progressive unremitting dysphonia or hoarseness, early symptom in glottic t.

2- Pain : more prominent in supraglottic t.

10

ENT

3- Dyspnea and stridor: in advanced tumors and could be the first presentation of subglottic t.

4- Dysphagia: due to invasion of pharynx or esophagus

5- Cervical lymphadenopathy: neck mass

6- Cough and hemoptysis

7- Anorexia and cachexia: late features

On examination: by a mirror or flexible endoscopy might shows the presence of a mass or ulcerative lesion . The vocal cords mobility should be assessed.

True vocal cord immobility in Ca larynx: causes

1- Nerve palsy (recurrent laryngeal nerve)

2- Vocal cord muscle involvement

3- Laryngeal joints involvement

4- Mass effect of the tumor

Investigations

. Assessment of general condition and fitness

. Diagnosis of the disease

. Determination of the extent and stage

1- Hematological : CBP, ESR

2- Biochemical profile: renal and liver function tests, serum electrolytes and blood sugar

3- Radiological : CXR, CTS and MRI

4- ECG

11

ENT

5- Endoscopic exam. Of the larynx, pharynx, bronchial tree and esophagus and biopsy from any suspicious lesion.

TNM classification of glottic tumors

T1: Tumor limited to the vocal cord with normal mobility

T2: Tumor extension to the supraglottis and/or subglottis and/or impaired vocal cord mobility

T3: Tumor limited to the larynx with vocal cord fixation

T4: Tumor invasion through the thyroid cartilage and/or other tissues beyond the larynx .

Staging- Nodes

N0 No cervical lymph nodes positive

N1 Single ipsilateral lymph node ≤ 3cm

N2a Single ipsilateral node > 3cm and ≤6cm

N2b Multiple ipsilateral lymph nodes, each ≤ 6cm

N2c Bilateral or contralateral lymph nodes, each ≤6cm

N3 Single or multiple lymph nodes > 6cm

M = metastasis

M0 : no distant metastasis

M1 : distant metastasis is present

Staging

Stage 1: T1N0M0

12

ENT

Stage 2: T2N0M0

Stage 3: T3N0M0

Or T1N1M0

Or T2N1M0

Or T3N1M0

Stage 4: anything else

Treatment:

1- Early tumors :( stage 1 and 2)

Best treated by radiotherapy (with or without chemotherapy) , external beam or interstitial radiation with preservation of the larynx.

Cure rate : 85-90%

The alternatives to radiotherapy are:

1- Partial laryngectomy as cordectomy or epiglottectomy

2- Laser therapy: applicable for small marginal tumours and Carcinoma in situ.

Complications of radiotherapy:

1- Oral mucositis

2- Skin complications: necrosis, depigmentation, hair loss

3- Perichondritis

4- Laryngeal oedema

5- General side effects: malaise, anorexia

6- Late: induction of other malignancies as osteosarcoma

2- Advanced tumors( stage 3 and 4):

13

ENT

The best is radical surgery in the form of total laryngectomy with or without partial pharyngectomy if the pharynx is involved, or neck dissection for lymph node metastasis. Post-operative radiotherapy might be given for extensive tumors to eradicate microscopic metastasis.

3- Palliative treatment : indicated when there is

. Distant metastasis

. Inoperable primary tumor

. Poor general health (unfit for surgery )

Includes:

1- Pain relief

2- Tracheostomy for airway obstruction

3- Radiotherapy and chemotherapy.

14