laryngeal cancer

Question 1

What are the 3 subsites of larynx?

Answer 1

Supraglottis

• True cord + 5 mm up
• epiglottis, false cords, ventricles, arytenoids, aryepiglottic folds
• Will mets to nodes early, bc rich in lymphatics 🡪 poor prognosis

Glottis

• 10 mm gap
• vocal folds* (most common)
• Devoid of lymphatics
• Isolated glottic CA generally present w/ hoarseness early, w/o LN (even with T4)

Subglottis

• True cord + 5 mm down
• inferior surface of vocal folds, trachea
• Will mets to nodes early, bc rich in lymphatics 🡪 poor prognosis

Question 2

How will you confirm the diagnosis?

Answer 2

• Arrange for pan-endoscopy and biopsy under GA w/ possible need for tracheostomy
• Arrange for MRI neck
• Arrange for FNAC
• Arrange for biopsy in clinic

Question 3

What is the mx for glottis CA/CA larynx?

Answer 3

Early (single modality): Stage 1 or 2

• Primary radiotherapy or local endoscopic excision
• Advantages of radiotherapy 🡪 voice is preserved
• Advantages of endoscopic excision 🡪 no S/E of RT, e.g. mucositis, skin reactions, troublesome dry throat

Late (multiple modality): Stage 3 or 4

• Radical surgery, combined radiotherapy (pre-op/post-op)
• Total laryngectomy for advanced laryngeal cancer 🡪 demands permanent stoma, ↓ communicating ability to oesophageal speech
• Newer methods 🡪 hemilaryngectomy (vertical/horizontal), near-total laryngectomy

Question 4

What are the 3 voice restoration options after total laryngectomy?

Answer 4

Oesophageal speech

• Extremely difficult to master
• Pharyngo-oesophageal segment is used to modulate air expulsion from stomach
• Gruff voice 🡪 not suited for female patients
• Only a small amount of air can be swallowed at each time 🡪 staccato speech

Electrolarynx (vibrating box):

• If the neck is woody hard from RT 🡪 cannot vibrate, cannot use this device at all
• However, speech is robotic-sounding

Tracheo-oesophageal puncture (TEP)

• One way valve between posterior wall of trachea and anterior wall of pharynx
• Occlude trachea 🡪 air flows into pharyngeal cavity
• Currently the gold standard for voice restoration

Question 5

what are the symptoms of laryngeal cancer?

Answer 5

Hoarseness

• For cancer of vocal cords
• Cancer here has a good prognosis (95% at 5yrs) 🡪 causes symptoms early, poor lymph drainage
• Any patient w/ persistent hoarse voice > 3 wks should be referred ENT to exclude this

Throat irritation, cough, referred otalgia, node in neck
- For cancer at sub- and supra-glottic regions
Late 🡪 airway compromise, hoarseness
- Any patient w/ unexplained lymph node in the neck should be referred to ENT for endoscopic examination of aerodigestive tract

Question 6

What are the complications of tracheo-oesophageal fistula (using trachea-oesophageal prothesis [TEP])?

Answer 6

• Needs changing every 6 months
• Often gets Candida infection (need to clean with brush + nyastatin gargles)
• Dislodgement
• Aspiration pneumonia
• Leaking around prosthesis (e.g. post-RT poor wound healing)