This document provides information about cancer of the larynx, including its epidemiology, risk factors, clinical presentation, diagnosis, staging, and treatment options. Some key points: - Laryngeal cancer most commonly affects men aged 60-70 and is strongly associated with smoking and heavy alcohol use. - Common symptoms include hoarseness, neck mass, cough, and difficulty swallowing. Examination includes laryngoscopy and imaging like CT scans to assess tumor size and spread. - Tumors are staged based on location (supraglottic, glottic, subglottic), size, involvement of surrounding structures, and presence of lymph node metastases. - Treatment depends on stage but

2. {‫لعاملني‬‫ا‬ ‫رب‬ ‫األرض‬ ‫ورب‬ ‫لسموات‬‫ا‬ ‫رب‬ ‫احلمد‬ ‫فلله‬}‫اجلاثية‬:36

3. {‫وسلم‬ ‫وصحبه‬ ‫اله‬ ‫وعلى‬ ‫محمد‬ ‫على‬ ‫صلى‬ ‫اللهم‬}

4. {‫يعلمون‬ ‫ال‬ ‫الناس‬ ‫أكثر‬ ‫ولكن‬ ‫الناس‬ ‫خلق‬ ‫من‬ ‫اكبر‬ ‫واألرض‬ ‫السموات‬ ‫لخلق‬}‫غافر‬:57

5. (‫أحُاها‬ ٌ‫الر‬ ‫إن‬ ‫وزبث‬ ‫اهحزت‬ ‫الماء‬ ‫علُها‬ ‫أوزلىا‬ ‫فإذا‬ ‫خاشعة‬ ‫األزض‬ ‫جسي‬ ‫اوك‬ ‫آَاجه‬ ‫ومه‬
‫قدَس‬ ‫شٍء‬ ‫كل‬ ً‫عل‬ ‫اوه‬ ً‫المىج‬ ًُ‫لمح‬)–‫فصلت‬:39.

6. Cancer of the larynx
By
Dr, IBRAHIM H. AHMED
M.D.
otorhinolaryngology

7. introduction
Incidence : 10,000 cases per year in U S A .
Most frequent upper aerodigestive tract cancer
The integration of chemotherapy and radiation
therapy has expanded organ preservation
options .
The patient’s perspective , with emphasis on
retention of speech , swallowing , & quality of
life has affected the decision making process.

10. Anatomy of larynx
area extending from :
tip of epiglottis to
lower border of cricoid cartilage .
divided into 3 anatomical subsites :
Supraglottis
glottis,
subglottis.

12. supraglottis
Lingual & laryngeal surfaces of the
epiglottis .
Arytenoid fold .
Arytenoid cartilages .
False vocal folds .
Ventricle .

14. glottis
- true vocal cord .
- Anterior commisure .
- post . Commisure .
Upper border : floor of ventricle .
Lower border : 1 cm below apex of
ventricle

19. subglottis
• Upper border :
• lower limit of glottis .
• Lower limit :
• inferior rim of cricoid cartilage.

21. embryology
Supraglottic
Buccopharyngeal
anlagen of branchial
arches 3&4 .
Glottis &subglottis
Tracheobroncial anlagen
of branchial arches
5&6 branchial arches

23. Histology of supraglottis
• Ciliated columnar epithelium except
free edges of epiglottis &
aryepiglottic fold
( stratified squamous mucosa ) .
• Mucous gland are abundant esp.
( saccule & periarytenoid areas ) .
• Rich vascularity & lymphatic .

24. Histology of glottis
Vocal cord : stratified squamous epithelium
(edges) .
peudostratified ciliated
epithelium ( sup. & inf. Aspect )
Lamina propria : superficial ( Reink’s space )
intermediate & deep ( vocal lig.
* blood vessels & lymphatics are
almost absent in Reinke’s space.
* no mucous glands on free edge
of vocal cord .

25. Blood supply of the larynx
Arterial supply of larynx
•1- sup. Laryngeal a.
( branch of sup. Thyroid a. )
2- inf. Laryngeal a.
( branch of inf. Thyroid a. )
Venous drainage
1- Sup. Thyroid v .
, ends in I . J . V .
2- inf. Thyroid v .
, ends in innominate v .

26. Nerve supply of the larynx
Motor supply :
supplies all laryngeal musclesrecurrent laryngeal nerve
externalexcept cricothyroid muscle which supplied by
laryngeal n. ( branch of sup. Laryngeal nerve ) .
Sensory supply :
.internal laryngeal n. ( branch of sup. Laryngeal n )
supply mucous membrane above the vocal cords .
suppliesRecurrent laryngeal n.
mucous membrane below the vocal cords.

30. Lymphatics of larynx
1- The vocal cords & upper part of the larynx
drain into the upper deep cervical lymph
nodes .
2- The lower part of the larynx drain into
the lower deep cervical lymph nodes &
prelaryngeal lymph nodes .
.

32. Cancer of the larynx
epidemiology
•10,000 new cases per year
in U S A
etiology
Excessive tobacco use &
alcohol consumption .

34. Epidemiology of cancer larynx
- 1% of all cancer related deaths in U S A .
- 10,000 new cases / year in U S A .
- 5 year survival is 65 % .
- Male to female ratio :
9,2 : 1 for glottic ca.
3-5 : 1 for supraglottic.
- Age : affect elderly . The peak incidence is 6th
& 7th decades .
< 1% in < 30 years of age .
- No rational predominance in U S A .

35. Risk factors
- tobacco .
- Synergistic effect with heavy alcohol intake in
Smokers .
- occupational exposure
Painter – metal working – plastic working –
diesel & gasoline fumes .wood dust & asbestos .
- G O R .
- Infectious agents especially papilloma virus .

38. Clinical presentation
symptoms :
1 – hoarseness .
2 – dysnea & stridor .
3 – pain .
4 – dysphagia .
5 – swelling in the neck .
6 – cough & irritation in the throat .
7- hemoptysis .
8 – fetor & anorexia .

39. Clinical presentation
Hoarseness
Hot potato voice
Hemoptysis
Weight loss & dysphagia
Referred otalgia
Palpable neck lump
Dysnea & stridure
Vocal cord involvement . Progressive &
unremitting .
supraglottic ca.
Large fungating or ulcerated lesion (epiglottic
lesion )
Malnutrition . (advanced lesion _pharyngeal
involvement )
Cartilage invasion .
Direct extension in soft tissue neck
1st presentation -subglottic or supraglottic ca
2nd presentation in glottic ca .

41. Clinical evaluation
- complete history of the disease
- weight and weight loss
- performance status
- fiberoptic examination of H&N
mucosa
- neck examination
- drawing of any lesions

42. Complete examination of
the head and neck
Includes examination
• oral cavity,
• pharynx,
• indirect laryngoscopy.
• fiberoptic examination of the larynx and pharynx
- videostroboscopy
.

43. videostroposcopy
- proper assessment of glottic lesion :
1- Detailed vibrator behavior of vocal cord .
- amplitude of vibration
- mucosal wave
- non vibrating portion
2- Outpatient procedure .
3- Documentation .
4- Selection of patient for biopsy .

44. The examination
status of the dentition,
the status of the airway,
vocal cord mobility ,
laryngeal crepitus,
tumor extension

45. Palpation of the neck bilaterally,
Recording
1- the location (Group or Level II - IV),
- size,
- mobility,
- relationship of the node(s) to adjacent
structures.
2- widening of thyroid angle .
3- direct extention of the lesion .
4- Fixation of the larynx.
5- carotid pulsation .

46. Pattern of lymphatic spread
Supraglottic ca:
Primary glottic ca :
Subglottic ca :
Lymph node
Metastases 44%
L. N. metastases 5%
L. N. metastases 6%

47. Mobility of larynx
Vocal cord mobility .
Arytenoid mobility .
Hemilarynx mobility .
Laryngeal mobility over prevertebral
fascia (More’s sign )

48. The staging of the primary
and of the cervical lymph
nodes must be documented

49. Radiological examination of
cancer larynx
To reveal tumour invasion of laryngeal
cartilages & extra laryngeal tissues .
With clinical / endoscopic examination
result in proper staging accuracy .

50. Imaging Studies:
•Chest radiographs, PA and lateral
To rule out
(1) A synchronous pulmonary tumor,
(2) Acute or chronic pulmonary
disease
(3) Metastatic tumor.

51. imaging
.
Thickness , invasion ,
Lymph node metastasis .
Under estimate cartilage invasion .
More accurate than C T scan .
Soft tissue details & fat planes ,
Tissue edema & tumor extention .
Over estimate cartilage invasion .
Viability of a tumor .
Residual , recurrent tumor after
Radiotherapy & or chemotherapy .
Sensitive for detection of lymph node
metastasis.
C T scan
Spiral C T scan
M R I
P E T

52. a mass is seen eroding the thyroid
cartilage and spreading into the
soft tissue of the neck.

53. the thyroid cartilage is seen to be
eroded. The airway also appears
to be compromised.

54. The tumor appears to be eroding the
anterior commissure area of the thyroid
cartilage. The tumor appears large and
predominately on the right side of the
larynx. The airway also appears to be
compromised.

55. Laboratory Tests:
•C .B .C , B . T . , C . T . , serum calcium.
• Pulmonary function and arterial blood
gases in the patients with COPD or who
are candidates for surgery .
•Liver & kidney function tests (optional).

57. ENDOSCOPIC EXAMINATION & BIOPSY UNDER
ANESTHESIA
Direct laryngoscope :
1 - confirmation .
2 - site , size , extent of the tumour .
3 - vocal cord mobility .
4 - arytenoid mobility .
5 - type of lesion .
6 - neck is felt .
7 - biopsy .
8 - drawing in axial & sagittal plane .
Pan endoscopy to exclude 2nd primary .

60. Pathology of cancer larynx
1- keratosis :
2- dysplasia :
Keratin layer in a normally non
keratinized epithelium .
Involves true vocal cords &
interarytenoid area .
Cellular atypia , loss of maturity ,
and loss of stratification in some
cases of keratosis .
1- mild .
2- moderate .
3- severe .

61. Leukoplakia of right vocal cord

62. Pathology of cancer larynx
3- carcinoma in situ Atypical changes throughout the
epithelium without evidence
of surface maturation or
invasion trough the basement
membrane .

63. Invasive squamous cell carcinoma
Incidence
Grades :
Variants :
> 90% of laryngeal carcinoma .
- Well differentiated .
- moderately differentiated
- poorly differentiated .
1- papillary SCC .
2- Sarcomatoid carcinoma .
3- Basaloid SCC .

64. Verrucous carcinoma
A slow – growing , locally aggressive
tumor with an exophytic , fungating ,
warty , gray – white appearance and
well defined margins .

65. Non squamous tumors
Mucous gland tumors.
Cartilaginous tumors .
Neuroendocrine tumors
Adenocarcinoma .
Adenoid cystic carcinoma .
Mucoepidermoid carcinoma.
Chondrosarcoma .
Paraganglioma .
Large cell tumor .
Atypical carcinoid .
Small cell tumor .

67. Consultations
•Radiation therapy
In anticipation of possible need for post-operative
radiation therapy or to use radiation therapy as a
definitive primary modality of treatment in early
stage tumors.

68. Consultations:
•Dental
To assess the status of the teeth and make
recommendations considering that radiation
therapy may be indicated. The evaluating dentist
should be versed in the effects of radiotherapy on
dentition. This evaluation should be done with
knowledge of the treatment portals planned for
the radiotherapy.

69. Consultations
•Speech pathology
For pre-operative counseling regarding possible
post-operative speech and swallowing
rehabilitation.

71. TMN / PRIMARY TUMOR ( T )
TX : Primary tumor cannot be assessed .
To : No evidence of primary tumor .
Tis : Carcinoma in situ .
Supraglottis .
Glottis .
Subglottis .

72. SUPRGLOTTIS ( T )
T1 : Tumor limited to one subsite of supraglottis with
normal vocal cord mobility .
T2 : Tumor invades mucosa of more than one subsite of
supraglottis or region outside the supraglottis ( e.g.,
mucosa of base of tongue , vallecula , medial wall of
pyriform sinus ) without fixation of the larynx .
T3 : Tumor limited to the larynx with vocal cord fixation
and/or invade any of the following : postcricoid area ,
pre-epiglottic tissues .
T4 : tumor invade through the thyroid cartilage and/or
extends into soft tissue of the neck , thyroid and/or
esophagus .

73. supraglottic squamous cell
carcinoma of the larynx

74. GLOTTIS
T1 : Tumor limited to the vocal cord(s) ( may involve
anterior or posterior commisure ) with normal mobility
.
T1a : Tumor limited to one vocal cord .
T1b : Tumor involves both vocal cords .
T2 : Tumor extends to supraglottis and/or subglottis
and/or occurs with impaired vocal cord mobility .
T3 : Tumor limited to the larynx with vocal cord fixation .
T4 : Tumor invades through the thyroid cartilage and/or
to other tissues beyond the larynx ( e.g., trachea , soft
tissue of neck , including thyroid and pharynx .

75. Cancer of the left vocal cord

76. Picture of
glottic squamous cell carcinoma of the
larynx. The tumor involves the anterior half of the left
vocal cord.

77. SUBGLOTTIS
T1 : Tumor limited to the subglottis .
T2 : Tumor extended to vocal cord(s) with
normal or impaired mobility .
T3 : Tumor limited to the larynx with vocal cord
fixation .
T4 : Tumor invade through the cricoid or thyroid
cartilage and/or to other tissues beyond the
larynx ( e.g., trachea , soft tissues of neck ,
including the thyroid and pharynx )

78. Picture of an extensive squamous cell carcinoma of
the larynx. The tumor involves the subglottic region,
the glottis and the supraglottic area.

79. TNM STAGING
No : no regional node metastasis .
Nx : regional nodes cannot be assessed .
N1 : single ipsilateral node,≤3cm
N2a : single ipsilateral nodes, > 3cm and ≤ 6cm
N2b : multiple ipsilateral nodes , ≤ 6cm
N2c : controlateral or bilateral nodes , ≤ 6cm
N3 : node > 6cm

80. ≤
TNM staging
Mx: Distant metastasis can’t be assessed
M0: No distant metastasis
M1: Distant metastasis

82. Treatment of glottic ca.
1- carcinoma in situ .
2 - Stage 1 .
3 – stage II ..
Micro laryngeal surgery –
Radiotherapy .
Radiotherapy .
Partial surgery .
Trans oral co2 laser .
Radiotherapy .
Chemotherapy & radiotherapy .
Partial surgery .
Trans oral laser excision ..

83. T1 squamous cell carcinoma of vocal cord

85. Immediate post operative , after biopsy & surgical
removal of leukoplakia .This patient will be treated
with full course of radiotherapy .

86. Pre and post biopsy views of a patient
with two T1 SCC of true vocal cords .
The patient was treated with vocal
cord stripping and radiation therapy

87. Treatment of glottic ca
4 – stage III .
5 – stage IV .
1 – radiotherapy . or
chemo&radiotherapy .
2 - trans oral co2 laser excision
3 - surgery .
1- total laryngectomy +
Post operative radiotherapy .

88. Management of neck in glottic ca.
1- No .
2 – NI , NII .
3 – N III.
1 – radiotherapy .
2 – elective neck dissection .
1 – selective neck
dissection .
1 – modified or radicalneck
dissection + radiotherapy .

92. Treatment of supraglottic ca.
1- TI .
2- TII .
1- radiotherapy .
2- open epiglottictomy .
3- co2 laser epiglottictomy
1- radiotherapy .
2- supraglottic laryngectomy .
3- trans oral co2 laser resection .

95. Treatment of supraglottic ca.
3- TIII .
4- TIV .
1- accelerated
radiotherapy .
2- co2 laser resection .
3- near total laryngectomy
4- cicohyoidopexy .
1- 1ry radiotherapy .
2- total laryngectomy &
post . op . radiotherapy

96. Management of neck in supraglottic ca.
1- No
2- N1 , N2 , N3 ,
Ipsilateral selective neck
dissection . IF +ve ----- contra
lateral selective neck dissection
level II , III , IV .
Radical neck dissection + post
operative radiotherapy .

97. Treatment of subglottic ca .
T1 .
T2 .
T3 .
Radiotherapy .
Radiotherapy or total laryngectomy.
Radiotherapy or total laryngectomy .

98. Management of neck in
subglottic ca.
Ipsilateral level VI dissection . If
lymph node +ve , post
operative radiotherapy .

102. {....‫عظُما‬ ‫علُك‬ ‫هللا‬ ‫فضل‬ ‫وكان‬ ‫جعلم‬ ‫جكه‬ ‫لم‬ ‫ما‬ ‫وعلمك‬}‫النساء‬:113

103. HABIBIBRAHIM,DRThank you