Tumours of the Larynx

BENIGN TUMOURS Benign tumours of the larynx are rare and cause persistent hoarseness.The commonest tumours encountered are: 1 papilloma—solitary or multiple; 2 haemangioma—almost exclusively in infants; 3 fibroma. Papillomata and haemangiomata are considered in more detail in Chapter 37. MALIGNANT TUMOURS PATHOLOGY Malignant tumours of the larynx are virtually always squamous cell carcinoma. Adenoid cystic carcinoma and sarcoma may occur on rare occasions. AETIOLOGY Malignant tumours are commoner in males by a ratio of 10:1, occurring almost exclusively in smokers. The peak age incidence is 55–65 years, but it can occur in young adults. Glottic carcinoma (60% of cases) The prime symptom of glottic carcinoma (Fig. 35.1) is hoarseness, which may persist as the only symptom for many months. Only when spread from the cord has occurred will earache, dysphagia and dyspnoea supervene. Supraglottic carcinoma (30% of cases) Supraglottic carcinoma, as well as producing a change in the voice, may metastasize early to the cervical nodes. Subglottic carcinoma Subglottic carcinoma produces less hoarseness but increasing airway obstruction. It must not be mistaken for asthma or chronic bronchitis. SPREAD OF LARYNGEAL CARCINOMA Spread is local initially and proceeds: 1 along the cord to the anterior commissure and onto the opposite cord; 2 upwards onto the ventricular band and epiglottis; 3 downwards to the subglottis; 4 deeply into the laryngeal muscles, causing cord fixation. Lymphatic spread from glottic lesions is late, but occurs readily from supraglottic and subglottic sites to the deep cervical nodes. Pulmonary metastases occur occasionally but other distant metastases are rare. DIAGNOSIS Every case of hoarseness should be examined by indirect laryngoscopy; malignant growths are usually seen easily. Diagnosis is confirmed by microlaryngoscopy and biopsy. The chest must be X-rayed as bronchial carcinoma also may be present. CT scanning of the larynx is often helpful in defining the extent of spread, and is usually performed prior to deciding on treatment. TREATMENT 1 Radiotherapy by external radiation is usually employed. In a small tumour limited to one cord (the stage at which it should be diagnosed), the 5- year survival rate is 80–90% and the patient retains a normal larynx. 2 In very extensive disease or if there is recurrence following radiotherapy, total laryngectomy is necessary (Fig. 35.2).The patient obviously then has a permanent tracheostomy and will need to develop oesophageal speech. Good oesophageal speech is attained by about 30% of patients; a further 30% develop reasonable voice but the remainder never manage more than a mouthed whisper. Many patients are now provided with a tracheopharyngeal valve. A fistula is formed between the trachea and pharynx and a prosthetic valve fitted to the fistula. Occlusion by the finger of the tracheostomy allows air to flow into the hypopharynx, while vibration of the soft tissue produces phonation. This then allows fluent lung-powered voice for the laryngectomee. Rehabilitation following laryngectomy concentrates on the development of speech with help from the speech therapist, but also requires training in looking after the tracheostomy, changing the tube as necessary and developing confidence socially after mutilating surgery. PROGNOSIS Glottic carcinoma diagnosed early and treated effectively is virtually a curable disease.The later the diagnosis is made, the worse the prognosis. Never neglect hoarseness. Supraglottic and subglottic tumours have a poorer prognosis owing to the likelihood of rather later development of symptoms and early nodal spread. About 10% of all patients successfully treated for laryngeal cancer will subsequently develop carcinoma of the bronchus.

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