Surgery of the larynx Supraglottic partial laryngectomy

1
(No Transcript)
2
Tumours of the larynx

• Pseudo tumours
• Benign neoplasms
• Malignant neoplasms

3
Tumours of the larynx

• PSEUDO TUMOURS
• Cyst
• Granulomata
• Amyloidosis

4
cysts

• Congenital cysts
• Retention cysts

5
Congenital Laryngeal Cysts

• Mucus filled dilatation of saccule.
• Asymptomatic- if infected can cause hoarseness,
  stridor and rapidly increasing airway
  obstruction.
• Endoscopy- Large bluish swelling in the region of
  aryepiglottic folds.
• Endolaryngeal excision or Marsupialisation.

6
Acquired Retention Cyst

• True cysts formed as a result of blockage of a
  duct resulting in mucus filled cysts.
• Asymptomatic- if infected can cause hoarseness,
  stridor and rapidly increasing airway
  obstruction.
• Endoscopy- Small smooth swelling.
• Endolaryngeal excision or Marsupialisation.

7
(No Transcript)
8
Granulomata

• Contact ulcer and granuloma
• Intubation Granuloma

9
Contact Ulcers

• Saucer like lesions on the medial edge of vocal
  cords exactly at the vocal process.
• Not true ulcer-no epithelial defect.
• Thickened epithelium with central indentation
  exactly at the site of vocal process.
• Pain, over use and abuse of voice, tense type A
  personality.

10
(No Transcript)
11
Contact Granuloma

• Granulomatous lesions on the medial edge of vocal
  cords exactly at the vocal process.
• Prolonged intubation is the cause Intubation
  granuloma.
• Hoarseness and Pain.
• Excision biopsy by endoscopy followed by
  histopathology treatment.

12
(No Transcript)
13
Amyloidosis

• Extracellular deposits of proteinaceous substance
  which gives red colour with congo red and apple
  green on polarizing light.
• Primary - Generalized
• Secondary - Localized.

14
Benign Neoplasms

• Papilloma
• Vascular Neoplasms
• Chondromata
• Myogenic tumours.
• Granular cell tumours
• Fibroma
• Lipoma
• Adenoma
• Neurogenic tumours.
• Para- gangliomata.

15
Benign Neoplasms

• Asymptomatic to start with
• Give symptoms when sufficient in size due to
  pressure on nerves muscles and other tissues
• Excision biopsy followed by histopathology is the
  treatment of choice in most of the cases

16
Benign Neoplasms of the Larynx General Features

• Early hoarseness later stridor, dyspnoea cough,
  pain
• Slow to grow.
• Endoscopic removal or laryngofissure followed by
  histopathology.

17
Recurrent Respiratory Paplliomatosus

• Human papilloma virus- causative agent
• Presents before 4 years of age.
• Hoarseness, abnormal cry, increasing stridor,
  respiratory distress.
• Disturbance of mucous blanket- causative factor.
• Multiple, recurrent, remission.
• Co2 laser, tracheostomy, Interferon.

18
(No Transcript)
19
(No Transcript)
20
Malignant Neoplasms

• Incidence
• Aetiology
• Pathology
• Clinical features
• Investigations
• Classification and staging
• Treatment

21
Incidence

• Brazil
• Hong Kong
• Black population of USA
• Skin 8.2, Larynx 1.3 oral cavity 0.6
• Oropharynx 0.4, Hypopharynx 0.3
• Nose and PNS 0.2 Nasopharynx0.1

22
Incidence

• Skin 8.2
• Larynx 1.3
• Oral cavity 0.6
• Oropharynx 0.4
• Hypopharynx 0.3
• Nose and PNS 0.2
• Nasopharynx0.1
• TOTAL 11

23
Aetiology

• Genetic predisposition
• Environmental pollution
• Cigarette smoking
• Alcohol intake
• Chronic irritation
• Pre-malignant conditions e.g. Leukoplakia,
  Keratosis

24
(No Transcript)
25
Pathology

• Macroscopy
• Microscopy
• Site
• Spread

26
Macroscopy

• Cauliflower like
• Infiltrative
• Ulcerative
• Sheets of keratotic epithelium

27
Microscopy

• A- Epithelial tumours
• B- Connective tissue tumours

28
Epithelial Tumours

• From surface epithelium
• From glandular epithelium
• From Pigment epithelium

29
From Surface Epithelium

• Squamous cell carcinoma
• Well differentiated
• Moderately differentiated
• Poorly differentiated
• Anaplastic carcinoma

30
From glandular Epithelium

• Adenocarcinoma
• Adenoid cystic carcinoma
• Mucoepidermoid carcinoma
• Acinic cell carcinoma

31
From Pigment Epithelium

• Malignant melanoma

32
FROM CONNECTIVE TISSUE

• Fibrosarcoma
• Liposarcoma
• Osteogenic sarcoma
• Chondrosarcoma
• Lieomysarcoma
• Rhabdomyosarcoma
• Angiosarcoma
• Lymphomas Hodgkin and non-Hodgkin
• Neurogenic tumours

33
SITE OF ORIGIN

• Most of the tumours (73) arise from the vocal
  cords

34
Site of Origin

• Supraglottis - 19
• Glottis - 76
• Subglottis - 05

35
Epilarynx 11

• Suprahyoid epiglottis- 02
• Aryepiglottic fold - 07
• Arytenoid - 02

36
Supraglottis 8

• Infra hyoid epiglottis- 02
• Ventricle - 01
• Ventricular hand - 05

37
Glottis 76

• Vocal cords - 73
• Anterior commissure- 02
• Posterior commissure- 01

38
spread

• Local
• Regional
• distant

39
local

• Anteriorly, posteriorly
• Involves other divisions of the larynx
• Spread beyond the larynx to involve tongue,
  trachea, pyriform sinus, oesophagus, thyroid etc.

40
Regional

• To the cervical lymph nodes 18
• Supraglottis 39
• Glottis - 05
• Subglottic - 13

41
Distant

• Lung
• Liver
• Brain
• Bone

42
Clinical features- Symptoms

• Progressive and unremitting dysphonia
• Dyspnoea
• Stridor
• Pain / Referred pain
• Dysphagia
• Cough and irritation
• Neck swelling
• Hemoptysis, Anorexia, Cachexia.

43
Clinical Features- Signs

• EXAMINATION OF LAYNX
• External examination Mobility
• I.D.L.
• Examination of the neck
• Examination of ear, nose and throat
• Systemic examination.

44
(No Transcript)
45
(No Transcript)
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
(No Transcript)
50
(No Transcript)
51
Investigations

• Routine investigations
• Blood C/E
• Urine C/E
• Blood sugar
• Blood urea
• X-ray chest PA view
• E.C.G.

52
Investigations

• Specific investigations
• X-ray neck A.P and lateral views
• CT Scan
• MRI
• Laryngography
• Direct Laryngoscopy
• Histopathology

53
Staging

• TNM classification
• T- Tumour
• N- Lymph node
• M- Metastasis.

54
T-Primary Tumour

• Tis - Preinvasive carcinoma
• To- No evidence of primary tumour.
• T1- Tumour confined to the region with normal
  
• mobility.
• T1a and T1b

55
T-Primary Tumour

• T2- Tumour confined to the larynx with
• extension to adjacent sites without
  vocal cord
• fixation / superficial involvement of
  adjacent
• oro/hypopharynx.
• T3- Tumour confined to the larynx with vocal cord
• fixation or deep spaces involvement.
• T4- Direct extralaryngeal spread.
• 4a and 4b (prevertebral space,
  mediastinal
• structures or encases carotid artery)

56
N- Lymph Nodes

• No- No evidence of lymph node metastasis
• NX- Regional lymph nodes cannot be assessed
• N1- Metastatic ipsilateral lymph nodes 3cm or
  less than 3cm
• in greatest dimension.
• N2a- Metastasis in Single ipsilateral lymph nodes
  between
• 3cm-6cm in greatest dimensions.
• N2b- Metastasis in Multiple ipsilateral L-nodes,
  none more
• than 6cm in greatest dimensions.
• N2C-Metastasis in Bilateral or contralateral
  L.N. none more
• than 6 cm in greatest dimension
• N3- Metastasis in a lymph node more than 6 cm in
  greatest
• dimensions

57
M-Metastasis

• Mo - No evidence of metastasis
• M1- Evidence of distant
• metastasis present.

58
Treatment

• Palliative
• Attempts to suppress the size and
  symptoms
• of the tumour without the intent to cure.
• Curative
• Treatment of the tumour with the intent
  to
• cure.

59
Treatment

• MAJOR MODALITIES
• Radiations
• Surgery
• Chemotherapy
• MINOR MODALITIES
• Laser
• Cryosurgery

60
Radiations - Advantages

• Functional preservation.
• Patient's preference
• No post. Operative complication
• Deals effectively with the microscopic invasion
  into the adjacent lymphatic and venous channels
• Can be employed for all sorts of curative and
  palliative purposes

61
Radiations - Disadvantages

• Ineffective at the necrotic centre of tumour so
  ineffective against large bulky tumours
• Relatively ineffective against Radio resistant
  tumours
• Post radiation reactions
• Morbidity

62
Radiations

• Curative small superficial lesions and highly
  radiosensitive tumours.
• Palliative
• Adjunctive
• for Massive tumours

63
Surgery

• Advantages
• Can be employed for all tumour sizes for
  palliative and curative purposes.
• Can be used for nodal disease.
• Tumour can be assessed per-operatively.

64
Surgery

• Disadvantages
• Functional loss.
• Complications of anaesthesia and surgery.
• Patients reluctance.
• Problems of reconstruction.

65
Suspicion of ResidualDisease

• Clinical
• Frozen section
• Paraffin section.

66
Surgery of the larynx

• Supraglottic partial laryngectomy
• Vertical partial laryngectomy.
• Total laryngectomy
• Extended total laryngectomy
• E. Total laryngectomy with radical neck
  dissection.

67
(No Transcript)
68
(No Transcript)
69
(No Transcript)
70
(No Transcript)
71
(No Transcript)
72
(No Transcript)
73
(No Transcript)
74
(No Transcript)
75
(No Transcript)
76
(No Transcript)
77
(No Transcript)
78
(No Transcript)
79
(No Transcript)
80
(No Transcript)
81
(No Transcript)
82
Chemotherapy

• Palliative
• Adjunctive
• Chemoradiation
• Surgery followed or preceded by
• Chemoradiation

83
Laser Cryosurgery

• Palliative role .
• CO2 Laser may be employed for very small lesions
  as curative e.g. T1a lesions.

84
SPEECH REHABILATATION

• Esophageal speech
• Artifical prosthesis
• Electrolaynx

85
(No Transcript)
86
(No Transcript)