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Questions and Answers
What imaging study is best for detecting cartilage invasion in suspected laryngeal cancer?
CT scan
What is the main purpose of conducting a neck examination in a patient suspected of having laryngeal cancer?
To check for potential metastasis or lymph node involvement.
How does MRI assist in the evaluation of laryngeal tumors compared to CT scans?
MRI can differentiate between edema and tumor and detect small foci of tumor.
What is the significance of tumor staging in laryngeal cancer assessment?
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Describe the criteria for classifying a T3 tumor in the context of supraglottic laryngeal cancer.
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What percentage of patients typically present with regional nodal metastasis?
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Identify the three most common sites for distant metastatic disease.
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What is the primary symptom leading to the assessment of glottic cancer?
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How does dysphagia typically relate to supraglottic tumors?
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What does a cough in patients with glottic tumors usually signify?
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What clinical sign may indicate advanced disease and possibly cartilage involvement?
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Why should patients with hoarseness lasting two weeks or longer undergo evaluation?
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What method should be used for examining the larynx when cancer is suspected?
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What are the clinical appearances of premalignant lesions associated with laryngeal tumors?
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What is the significance of persistent hoarseness in laryngeal neoplasms?
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Identify the primary type of cancer associated with laryngeal carcinoma.
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What demographic factors influence the prevalence of laryngeal cancer?
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List at least two risk factors associated with developing laryngeal cancer.
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What types of benign laryngeal tumors are mentioned in the text?
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What is the annual incidence of larynx cancer diagnoses in the United States?
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Explain the potential effect of lifestyle choices on the risk of laryngeal carcinoma.
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What are the vital functions of the larynx?
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How do supraglottic tumors typically spread?
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What symptoms often lead to delayed presentation in patients with supraglottic tumors?
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What is the correlation between lymphatic drainage and glottic carcinoma prognosis?
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What characterizes the typical presentation of subglottic cancers?
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What is the incidence of glottic tumors relative to supraglottic and subglottic tumors?
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What factors delay the diagnosis of patients with supraglottic tumors?
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When do distant metastases usually occur in laryngeal cancers?
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What is the classification for a T1a tumour in the glottis?
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Describe the extent of invasion for a T4b tumour in the larynx classification.
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What treatment options are available for early-stage larynx cancer?
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What distinguishes a T2 tumour from a T3 tumour in the glottis classification?
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What surgical procedures are involved in treating early glottic carcinoma?
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In the context of laryngeal cancer, what does T4a classify as?
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For a T1 tumour involving the subglottis, what does this indicate?
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What is the role of the carbon dioxide laser in early-stage larynx cancer treatment?
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Study Notes
Laryngeal Diseases
- Laryngeal diseases include premalignant, benign, and malignant tumors.
- Premalignant lesions may develop into carcinoma.
- These lesions often have variable gross clinical appearance.
- Histological diagnosis is required for premalignant lesions.
- Leukoplakia is white patches of mucosa that cannot be rubbed away.
- Erythroplakia is a reddish non-keratinized lesion with a high risk for malignant transformation.
- Pachydermia is epithelial thickening covered by keratin scales.
- Benign laryngeal tumors are uncommon compared to their malignant counterparts.
- Papillomas, neuroendocrine tumors, schwannomas, neurofibromas, vascular tumors, leiomyomas, and chondromas fall under the category of benign laryngeal tumors.
- Hemangiomas are simple (capillary) or cavernous vascular tumors.
- Lymphangiomas are also vascular tumors.
Laryngeal Carcinoma
- The larynx is essential for breathing, vocalization, protecting the lungs, and increasing upper-body strength.
- Laryngeal carcinoma is the most common head and neck cancer worldwide.
- The cardinal symptom of all laryngeal neoplasms, regardless of benign or malignant nature, is persistent hoarseness.
- 11,000 new cases of larynx cancer are diagnosed annually in the US.
- 1% of new cancer diagnoses are larynx cancer.
- Roughly 1/3 of patients with laryngeal cancer die from their disease.
- Male-to-female ratio for larynx cancer is 4:1.
- Larynx cancer is most common in the sixth and seventh decades of life.
- Lower socioeconomic groups have higher prevalence of larynx cancer.
- More than 90% of larynx cancer is squamous cell carcinoma (SCC) and is linked to tobacco and alcohol use.
Risk Factors for Laryngeal Carcinoma
- Tobacco use
- Excessive alcohol use
- Male sex
- Infection with human papillomavirus
- Increasing age
- Diets low in green leafy vegetables
- Diets rich in salt-preserved meats and dietary fats
- Metal or plastic workers
- Exposure to paint
- Exposure to diesel and gasoline fumes
- Exposure to asbestos
- Exposure to radiation
- Laryngopharyngeal reflux
Pathophysiology of Laryngeal Carcinoma
- Malignant tumors of the larynx affect laryngeal physiology depending on their size and location.
- Supraglottic tumors often cause upper airway obstruction.
- Glottic tumors primarily affect voice quality.
Anatomical Subsites and Spread Patterns of Laryngeal Tumors
- Cancer spread in the larynx follows predictable patterns.
- The supraglottis has different lymphatic drainage patterns compared to the glottis and subglottis due to different embryologic origins, often referred to as compartmentalization.
Supraglottic tumors
- Involve the area between the free border of the epiglottis (superiorly) and the false vocal folds and laryngeal ventricles (inferiorly).
- Usually spread by local extension.
- Tend to spread via lymphatics.
- Long delays in diagnosis are common due to vague symptoms like globus sensation and otalgia.
- Often diagnosed with nodal metastases, leading to higher clinical stages.
- Patients often present at advanced stages with stridor.
Glottic Cancer
- Usually presents early with voice changes.
- The true vocal folds have sparse lymphatic drainage.
- Glottic carcinoma has a better prognosis due to earlier presentation and limited lymphatic drainage.
Subglottic Cancers
- Located from 10mm below the vocal folds to the inferior border of the cricoid cartilage.
- Primary tumors in the subglottis are rare.
- Likely have intermediate lymphatic spread risk compared to supraglottic and glottic tumors.
- Airway obstruction (biphasic stridor) is a common symptom.
Distant Metastasis
- Occurs late in the disease process.
- 25% of patients have regional nodal metastasis at presentation.
- 8 to 10% have distant metastasis at presentation.
- Lung, liver, and bone are the most common sites for metastatic disease.
Clinical Evaluation of Laryngeal Carcinoma
- Persistent hoarseness for three weeks or longer warrants urgent referral to an otolaryngologist.
- Hoarseness is the main symptom in patients with glottic cancer.
- Hoarseness develops later in supraglottic tumors when they become bulky or spread to the paraglottic space.
- Dysphagia and odynophagia are late symptoms (laryngeal dysfunction) and are more common with supraglottic tumors.
- Cough and hemoptysis indicate low-grade aspiration and are often seen in glottic tumors.
- Foul odor is seen in larger tumors with significant necrosis, particularly in the supraglottis.
- Pain is a late sign, sometimes referred to as otalgia, and indicates cartilage involvement or extralaryngeal spread.
- Weight loss is a sign of poor prognosis and suggests potential distant metastasis.
- Stridor indicates advanced disease.
Physical Examination for Laryngeal Carcinoma
- All patients with hoarseness of 2 weeks or longer should be evaluated by a head and neck specialist.
- Comprehensive evaluation of the larynx should be performed.
- Indirect mirror laryngoscopy is sufficient for cooperative patients.
- Flexible or rigid fiber-optic laryngoscopy is recommended in suspected cases of cancer.
- Malignant laryngeal lesions may have various appearances, including fungating, friable, nodular, or ulcerative, or simply color changes.
- Video documentation is valuable for patient education, examiner review, consultations, and comparison to treated larynx post-treatment.
- Videostroboscopy is a useful tool for examining the larynx.
- Neck examination is mandatory in suspected cases of laryngeal cancer.
Imaging Studies for Laryngeal Carcinoma
- CT scan: superior for showing cartilage invasion but less detailed in tumor characterization.
- MRI: helpful for detecting small tumor foci, differentiating between edema and tumor, but less effective in detecting cartilage invasion.
- Positron emission tomography (PET): useful for detecting recurrence in irradiated patients.
Endoscopy and Biopsy for Laryngeal Carcinoma
- Direct laryngoscopy is mandatory when laryngeal cancer is suspected to allow for examination and biopsy under general anesthesia.
Tumor Staging (TNM) for Laryngeal Cancer
- TNM staging aims to assist in treatment planning, prognosis indication, evaluating treatment results, and information exchange.
Classification for the Supraglottis
- T1: Tumor limited to one supraglottic subsite with normal vocal cord mobility.
- T2: Tumor invades mucosa of multiple adjacent supraglottic subsites or glottis, or regions outside the supraglottis (e.g., base of tongue, vallecula, pyriform sinus) without larynx fixation.
- T3: Tumor confined to the larynx with vocal cord fixation or invades areas like the postcricoid area, pre-epiglottic tissues, paraglottic space, or with minor thyroid cartilage erosion (inner cortex).
- T4a: Tumor invades through the thyroid cartilage or beyond the larynx, including structures like trachea, neck soft tissues, deep/extrinsic tongue muscles, strap muscles, thyroid, and esophagus.
- T4b: Tumor invades the prevertebral space, mediastinal structures, or encases the carotid artery.
Classification for the Glottis
- T1a: Tumor confined to one vocal cord (may involve anterior or posterior commissure) with normal mobility.
- T1b: Tumor involves both vocal cords (may involve anterior or posterior commissure) with normal mobility.
- T2: Tumor extends to the supraglottis or subglottis, or with impaired vocal cord mobility.
- T3: Tumor limited to the larynx with vocal cord fixation or invades the paraglottic space, or with minor thyroid cartilage erosion (inner cortex).
- T4a: Tumor invades through the thyroid cartilage or tissues beyond the larynx (e.g., trachea, neck soft tissues, deep/extrinsic tongue muscles, strap muscles, thyroid, and esophagus).
- T4b: Tumor invades the prevertebral space, mediastinal structures, or encases the carotid artery.
Classification for the Subglottis
- T1: Tumor confined to the subglottis.
- T2: Tumor extends to the vocal cord(s) with normal or impaired mobility.
- T3: Tumor limited to the larynx with vocal cord fixation.
- T4a: Tumor invades through the cricoid or thyroid cartilage or tissues beyond the larynx (e.g., trachea, neck soft tissues, deep/extrinsic tongue muscles, strap muscles, thyroid, and esophagus).
- T4b: Tumor invades the prevertebral space, mediastinal structures, or encases the carotid artery.
Treatment of Laryngeal Cancer
- Early-stage larynx cancer (stages I and II) can be treated with surgery, radiation, or a combination of the two.
- Aim: Cure the tumor while preserving the larynx as much as possible.
Surgical Procedures for Early-Stage Glottic Carcinoma
- Microlaryngeal surgery: Uses an operating microscope and microlaryngeal instruments. Carbon dioxide lasers are also used.
- Hemilaryngectomy: Removal of one vertical half of the larynx.
- Supraglottic laryngectomy: Removal of the supraglottis or upper part of the larynx.
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Description
This quiz covers the essential aspects of laryngeal diseases, including premalignant, benign, and malignant tumors. It highlights the characteristics and risks associated with various lesions such as leukoplakia and erythroplakia. Understanding these conditions is crucial for identifying potential laryngeal carcinoma and its implications on vocal health.
