TITLE: Laryngeal Carcinoma 2007: An Overview SOURCE: Grand Round !

re en"a"ion# UT$%# &e'"( o) O"olaryngology &ATE: *uly 20# 2007 UT$% $edical S"uden" +: Ryan E( ,eilan -ACULT. !/.SICIA,: -ranci %( 0uinn# *r(# $& SERIES E&ITORS: -ranci %( 0uinn# *r(# $&
"This material was prepared by resident physicians in partial fulfillment of educational requirements established for the Postgraduate Training Program of the UTMB Department of Otolaryngology/ ead and !ec" #urgery and was not intended for clinical use in its present form$ %t was prepared for the purpose of stimulating group discussion in a conference setting$ !o warranties& either e'press or implied& are made with respect to its accuracy& completeness& or timeliness$ The material does not necessarily reflect the current or past opinions of members of the UTMB faculty and should not be used for purposes of diagnosis or treatment without consulting appropriate literature sources and informed professional opinion$"

There are around 11,000 new cases of laryngeal cancer per year in the United States accounting for 25% of all head and neck cancers and 1% of all cancers. One third of these patients will e!entually go on to die of their disease. "aryngeal cancer is #ost pre!alent in the si$th and se!enth decades of life and has a %&1 #ale predilection which is still in the process of shifting downward ha!ing 'een 15&1 post (orld (ar )). This is thought to 'e due to the changing pu'lic acceptance of fe#ale s#oking. This cancer is also #ore pre!alent a#ong lower socioecono#ic classes which in who# it is usually, particularly in supraglottic carcino#a, diagnosed at #ore ad!anced stages. *lottic cancer #akes up 5+% of laryngeal cancers, supraglottic %0%, and the rare su'glottic carcino#a the rest. Su'glottic #asses when seen are #ost likely direct e$tensions of glottic carcino#a.

History
The first laryngecto#y for cancer of the laryn$ was perfor#ed in 1,,- 'y .illroth. The patient was a'le to 'e fed 'y #outh and was e!en fitted with an artificial laryn$. )n fact, laryngeal carcino#a #ay ha!e led to (orld (ar ). )n 1,,/ the 0rown 1rince 2rederick of *er#any de!eloped hoarseness as he was due to ascend the throne. 3e was e!aluated 'y a "ondon physician Sir 4aken5ie, who was also the in!entor of the direct laryngoscope. 2rederick6s lesion was 'iopsied and thought to 'e cancer. Su'se7uently he refused a laryngecto#y and later died in 1,,,. 3is successor 8aiser (ilhel# )), along with .is#ark, #ilitari5ed the *er#an 9#pire and led the# into (orld (ar ).

Etiology
The pri#ary factors in the de!elop#ent of carcino#a of the laryn$ are the prolonged use of to'acco, principally cigarettes, and:or alcohol use. The co#'ination of the two ha!ing synergistic carcinogenic effects on laryngeal tissues, with o!er +0% of patients ha!ing a history of 'oth. This along with poor access to healthcare #ay e$plain its higher incidence in lower socioecono#ic classes. "aryngeal cancer is also seen in nons#okers 'ut this is usually due to their e$posure to secondary s#oke. "aryngeal papillo#atosis due to infection with hu#an papillo#a !irus su'types 1/ and 1, ha!e

'een known to transfor# into carcino#as. 0hronic gastroesophageal reflu$ and occupational e$posures to as'estos, #ustard gas, and petroleu# products are other risk factors. ; prior history of head and neck radiation is also an i#portant risk factor for the de!elop#ent of laryngeal cancers. ,5 to +5 percent of laryngeal tu#ors are s7ua#ous cell carcino#a, and is the histologic type linked to to'acco and e$cessi!e alcohol use. S7ua#ous cell cancer is on the far end of continuu# of change fro# a nor#al phenotype and is characteri5ed 'y epithelial nests surrounded 'y infla##atory stro#a with keratin pearls 'eing pathogno#onic. <errucous carcino#a is a distinct type of s7ua#ous cancer with an incidence if 1 2% of laryngeal cancer. )t has a warty, e$ophytic look and is significant in that it is thought to 'e radiation resistant. Other types of #alignant tu#ors include fi'rosarco#a, chondrosarco#a, #alignant #inor sali!ary carcino#a, adenocarcino#a, oat cell carcino#a, and giant cell and spindle cell carcino#a.

Anatomy
The laryn$ lies in the anterior part of the neck at the !ery top of the trachea. )t is the phonating #echanis# designed for !oice production= it also di!ides the respiratory and digesti!e tracts and protects the airway particularly during swallowing. The laryngeal skeleton consists of a fra#ework of nine cartilages connected 'y liga#ents, #e#'ranes and #uscles and is lined 'y stratified s7ua#ous and respiratory epitheliu#. Three of the cartilages are singular thyroid, cricoid, and epiglottic and three are paired arytenoids, corniculate, and cuneifor#. The thyroid cartilage is the largest of the si$ different structures= its two la#inae are fused along their inferior 'order in the #edian plane to for# the laryngeal pro#inence noticea'le on the surface of the anterior neck and otherwise known as an ;da#6s apple. The superior 'order of the thyroid cartilage is attaches to the hyoid 'one 'y the thyrohyoid #e#'rane. 1osteriorly the inferior portion of the thyroid cartilage is attached at the cricothyroid >oints to the cricoid cartilage= anteriorly, the thyroid cartilage is attached 'y the cricothyroid liga#ent to the cricoid cartilage. This liga#ent is easily palpated o!er the surface of the neck and can 'e used for access when an e#ergency airway is needed. The cricoid cartilage is the only laryngeal cartilage to for# a co#plete ring. The arytenoid cartilages are pyra#ids that sit on the superior 'order of the posterior cricoid cartilage& the true !ocal cords e$tend out anteriorly fro# these cartilages and #eet #edially on the thyroid cartilage to for# the anterior co##issure. The corniculate and cuneifor# cartilages are located in the posterior aryepiglottic fold. The corniculate cartilages sit atop the arytenoids, and the cuneifor#s sit with in the ;9 folds and are not attached to other cartilages. Sensation to the laryn$ is pro!ided 'y the internal laryngeal ner!e a 'ranch of the superior laryngeal ner!e which also inner!ates the cricothyroid #uscle 'y the e$ternal laryngeal ner!e. The intrinsic #uscles of the laryn$ are inner!ated 'y the recurrent laryngeal ner!e. The laryn$ is supplied 'y the superior laryngeal artery, a 'ranch of the superior thyroid artery, which pierces the thyrohyoid #e#'rane along with the internal laryngeal ner!e. The superior laryngeal supplies the internal surface of the laryn$. The inferior laryngeal artery, a 'ranch of the inferior thyroid artery, acco#panies the inferior laryngeal ner!e, and supplies the #ucous #e#'ranes and #uscles in the inferior portion of the laryn$. The superior laryngeal !ein >oins with the superior thyroid !ein and into the internal >ugular !ein. The inferior laryngeal !ein drains into the #iddle thyroid and

the thyroid ple$us of !eins. The superior portion of the laryn$ drains into the superior deep cer!ical ly#ph nodes, while the inferior portion of the laryn$ drains into the inferior deep cer!ical ly#ph nodes. These nodal 'asins e!entually drain into le!els )), ))), and )< of the neck. The laryn$ is su'di!ided into three regions& the supraglottis, the glottis, and the su'glottis. The supraglottis is defined 'y the tip of the epiglottis and !allecula superiorly and the undersurface of the false !ocal cords inferiorly. )t contains the arytenoids, the aryepiglottic fold, the false !ocal cords, and the epiglottis. The glottic laryn$ houses the true !ocal cords and e$tends fro# the 'eginning of the !entricle to 0.5 c# 'elow the inferior edge of the !ocal cords. The su'glottic laryn$ e$tends fro# the inferior #ost e$tent of the glottis to the inferior edge of the cricoid cartilage. )nternal liga#ents of the laryn$ also create two spaces surrounding the laryn$& the preepiglottic space, and the paraglottic space. The preepiglottic space is 'ound 'y the hyoid 'one and hyoepiglottic liga#ent superiorly, the thyrohyoid #e#'rane anteriorly, and the epiglottis posteriorly. This area is filled with fat and connecti!e tissue and #ay help to pre!ent e$ternal tu#or progression, though in!ol!e#ent of this space is often seen in supraglottic carcino#a and #ay 'e an indication of 'ilateral in!ol!e#ent in con>uction with neck #etastases. The paraglottic spaces are the lateral pyrifor# sinuses 'ordered 'y the conus elasticus anteriorly and #edially and the thyroid cartilage laterally. )n!asion of tu#or into this space #ay fi$ the ipsilateral cord.

Natural History
The natural history of laryngeal cancer !aries with the anato#ic site of origin. Supraglottic tu#ors are usually #ore aggressi!e in direct e$tension into the preepiglottic space and ly#ph node #etastasis. The higher incidence of ly#phatic spread has to do with the e#'ryologic origin of the region. The supraglottis is deri!ed fro# #idline 'uccapharyngeal pri#ordiu# and 'rachial arches - and % which ha!e rich 'ilateral ly#phatics. This is in contrast to the glottis which for#s fro# #idline fusion of lateral tracheo'ronchial pri#ordiu# and arches %, 5, and /= here there is a paucity of ly#phatics hence glottic cancers ha!e less regional ly#phatic spread. )n supraglottic carcino#as one third to one half will ha!e ly#ph node in!ol!e#ent. These ly#ph channels drain into the internal >ugular chain. ?irect e$tension can also occur into the lateral hypopharyn$, glossoepiglottic fold and the tongue 'ase. *lottic carcino#as are usually well differentiated, grow slow, and tend to #etastasi5e late in their course. ?ue to e#'ryonic reasons #entioned earlier glottic tu#ors typically #etastasi5e after they ha!e directly in!aded ad>acent structures with 'etter drainage. These tu#ors do ha!e early e$tension toward the anterior third of the !ocal cord and the anterior co##issure with su'se7uent spread to the opposite cord or anteriorly in!ade the thyroid cartilage. This thyroid cartilage in!asion #ay 'e noted clinically as 'roadening of the thyroid cartilage. *lottic cancer can also e$tend superiorly into the !entricular walls or inferiorly into the su'glottic space. These tu#ors can also cause cord fi$ation, as #entioned pre!iously, owing #ore often to direct e$tension than ner!e in!ol!e#ent 'ut #ay 'e due only to shear 'ulk of the tu#or.

True su'glottic carcino#as are unco##on, 'ut can #ore often 'e seen in e$tension fro# glottic carcino#a which is a sign of poor prognosis. The ly#phatic drainage patterns fro# this area increases the incidence of ha!ing 'ilateral disease and can lead to e$tension into the #ediastinu#. ;ccordingly glottic tu#ors with su'glottic e$tension re7uire, in addition to a total laryngecto#y with ipsilateral thyroidecto#y, an e$tensi!e ly#ph node dissection including the superior #ediastinal nodes. This rich nodal spread is also thought to play a role in the high sto#al reoccurrence after a total laryngecto#y.

Presentation
One of the #ost co##on presentations of laryngeal cancer is hoarseness. S#all irregularities of the !ocal fold will change the !i'ratory pattern of the cord resulting in !oice changes. ?istinguishing a change in !oice #ay 'e difficult in patients with chronic hoarseness due to to'acco or alcohol use which unfortunately is a #a>ority of those at risk for laryngeal cancer. ?ysphagia is #ore co##on in supraglottic carcino#a in which hoarseness would 'e a late finding due to e$tension= he#optysis can also 'e a co##on presentation. Other sy#pto#s of laryngeal cancer in general include throat pain, ear pain, airway co#pro#ise, aspiration, and a #ass in the neck. 9!eryone who presents with hoarseness should ha!e an indirect #irror e$a# and:or e!aluation with a fle$i'le laryngoscope. 4alignant lesions can appear as fria'le fungating ulcerati!e #asses or can 'e as su'tle as changes in the #ucosal color. )f necessary a !ideostro'e laryngoscopy can 'e e#ployed to e!aluate these su'tler lesions. "aryngoscopic e$a#ination should include the intrinsic laryn$, epiglottis, true and false cords, anterior co##issure, and #ucosa of 'oth pyrifor# sinuses. ; good neck e$a#ination looking for cer!ical ly#phadenopathy and 'roadening of the thyroid cartilage is essential. One should always palpate the 'ase of the tongue for #asses as well. @odes should 'e felt for si5e, fir#ness, #o'ility, and location. ;ny restricted laryngeal crepitus can 'e a sign of postcricoid or retropharyngeal in!asion. ; 'iopsy of any laryngeal lesion is necessary to #ake the diagnosis. Other 'enign possi'ilities for a laryngeal lesion include !ocal cord nodules or polyps, papillo#atosis, granulo#as, granular cell neoplas#s, sarcoidosis, or (egner6s granulo#atosis. This is usually acco#plished in the operating roo# with the patient under general anesthesia. ?irect laryngoscopy utili5ing the ?edo or 3olinger hourglass speculu# is ade7uate for e!aluation. 2urther !isuali5ation with esophagoscopy or 'ronchoscopy #ay 'e re7uired for staging. .iopsy of suspected #alignant sites can 'e done with cup forceps. ;lso with the patient anestheti5ed and paraly5ed a 'etter neck e$a#ination can 'e perfor#ed. ;fter spread to the regional ly#ph nodes the ne$t co##on site is the lungs so a chest $ ray is warranted as part of a #etastatic work up, if any a'nor#alities are present it should 'e followed up 'y a 0T scan of the chest to further delineate the a'nor#ality. "ung lesions #ay represent #etastasis fro# the laryn$ itself or an additional pul#onary pri#ary carcino#a especially since to'acco is a risk factor for 'oth cancers. The li!er is another co##on site for #etastases and screening li!er function test should 'e perfor#ed with or without additional ultrasound or 0T scan of the li!er.

2or the laryn$ itself, i#aging is not necessary for early glottic cancer without clinically palpa'le nodes. .ut it #ay 'e needed in early stage supraglottic cancer 'ecause of its high incidence of nodal spread. )f there is any i#paired #o'ility of the !ocal cord i#aging should 'e o'tained. ;d!anced stage laryngeal cancers re7uire i#aging, particularly for preoperati!e planning. .oth 0T and 4A) are useful in e!aluation with 4A) 'eing #ore sensiti!e to soft tissue changes and 0T for 'ony or cartilaginous a'nor#alities. 19T scans can 'e useful in identifying unknown pri#aries and occult nodal disease 'ut is not yet the standard of care.

TNM Staging
Staging for laryngeal cancer is 'ased on the T@4 classification of the ;#erican Boint 0o##ittee on 0ancer&

!rimary Tumor 1T2

TC T0 Tis T1 T2 TT%a T%' 4ini#u# re7uire#ents to assess pri#ary tu#or cannot 'e #et @o e!idence of pri#ary tu#or 0arcino#a in situ

Su'raglo""i
Tu#or li#ited to one su'site of supraglottis with nor#al !ocal cord #o'ility Tu#or in!ol!es #ucosa of #ore than one ad>acent su'site of supraglottis or glottis, or region outside the supraglottis De.g. #ucosa of 'ase of the tongue, !allecula, #edial wall of pyrifor# sinusE without fi$ation Tu#or li#ited to laryn$ with !ocal cord fi$ation and:or in!ades any of the following& postcricoid area, preepiglottic tissue, paraglottic space, and:or #inor thyroid cartilage erosion De.g. inner corte$E Tu#or in!ades through the thyroid cartilage and:or in!ades tissue 'eyond the laryn$ De.g. trachea, soft tissues of neck including deep e$trinsic #uscles of the tongue, strap #uscles, thyroid, or esophagusE Tu#or in!ades pre!erte'ral space, encases carotid artery, or in!ades #ediastinal structures

Glo""i
T1 T1a T1' T2 TT%a T%' Tu#or li#ited to the !ocal cord DsE D#ay in!ol!e anterior or posterior co##issureE with nor#al #o'ility Tu#or li#ited to one !ocal cord Tu#or in!ol!es 'oth !ocal cords Tu#or e$tends to supraglottis and:or su'glottis, and:or with i#paired !ocal cord #o'ility Tu#or li#ited to the laryn$ with !ocal cord fi$ation and:or in!ades paraglottic space, and:or #inor thyroid cartilage erosion De.g. inner corte$E Tu#or in!ades through the thyroid cartilage, and:or in!ades tissues 'eyond the laryn$ De.g. trachea, soft tissues of the neck including deep e$trinsic #uscles of the tongue, strap #uscles, thyroid, or esophagusE Tu#or in!ades pre!erte'ral space, encases carotid artery, or in!ades #ediastinal structures

Su3glo""i
T1 T2 TT%a T%' Tu#or li#ited to the su'glottis Tu#or e$tends to !ocal cord DsE with nor#al or i#paired #o'ility Tu#or li#ited the laryn$ with !ocal cord fi$ation Tu#or in!ades cricoid or thyroid cartilage and:or in!ades tissues 'eyond laryn$ De.g. trachea, soft tissues of the neck including deep e$trinsic #uscles of the tongue, strap #uscles, thyroid, or esophagusE Tu#or in!ades pre!erte'ral space, encases carotid artery, or in!ades #ediastinal structures

,ode
@0 @1 @2a @2' @2c @40 41 Stage 0 ) )) ))) )<; )<. )<0 @o cer!ical ly#ph nodes positi!e Single ipsilateral ly#ph node F -c# Single ipsilateral node G -c# and F/c# 4ultiple ipsilateral ly#ph nodes, each F /c# .ilateral or contralateral ly#ph nodes, each F/c# Single or #ultiple ly#ph nodes G /c#

$e"a "a i
@o distant #etastases ?istant #etastases present

S"age Grou'ing
Tis T1 T2 TT1 T%a T1 %a T%' ;ny T ;ny T @0 @0 @0 @0 @1 @0 2 @2 ;ny @ @;ny @ 40 40 40 40 40 40 40 40 40 41

Treatment
1re#alignant lesions or carcino#a in situ can 'e treated surgically 'y stripping the entire lesion. So#e ad!ocate the use of a 0O2 laser to acco#plish this 'ut there are concerns a'out accuracy of re!iew of the pathology. 9arly stage laryngeal cancer DT1 and T2E can 'e treated with either radiation therapy or surgery alone. )n this setting they offer a'out the sa#e ,5 +5% cure rate. Surgery has a shorter treat#ent period, sa!es the option of radiation for reoccurrence, 'ut #ay ha!e worse !oice outco#es. The procedure of choice is usually a partial laryngecto#y. Aadiotherapy is gi!en for / H weeks, a!oids surgical risks, 'ut does ha!e co#plications including& #ucositis, odynophagia, laryngeal ede#a, $erosto#ia, esophageal stricture, laryngeal fi'rosis, radionecrosis, and hypothyroidis#. )n ad!anced staged lesions patients usually recei!e surgery and radiation, #ost often with surgery 'efore ad>u!ant radiation. 2or #ost T- and T% lesions

a total laryngecto#y is re7uired, so#e s#all T- lesions can 'e treated with a partial laryngecto#y. The ad>u!ant radiation is started within / weeks of the surgery, and with once daily protocols lasts / H weeks. )ndications for post operati!e radiation include& T% pri#ary, 'one:cartilage in!asion, e$tension into soft tissue of the neck, perineural in!asion, !ascular in!asion, #ultiple positi!e nodes, nodal e$tracapsular e$tension, #argins less than 5##, positi!e #argins, carcino#a in situ at #argins, and su'glottic e$tension of pri#ary tu#or. ; study 'y 3iner#an et al deter#ine the factors that significantly affect disease specific sur!i!al in laryngeal cancer are 'one:cartilage in!asion, four or #ore indications for radiotherapy, and #ultiple positi!e ly#ph nodes. The pri#ary site is treated with /000 H000 c*y, while draining nodal areas recei!e 5000 H000 c*y. )n one study of laryngeal cancer with e$tracapsular e$tension or positi!e #argins 3uang, ?T et al de#onstrated a two fold increase in o!erall sur!i!al in the irradiated group !s. surgery alone. 0he#otherapy can 'e used in addition to radiotherapy in ad!anced stage laryngeal cancers. The two agents typically used are cisplatinu# and 5 flourouracil. 0isplatinu#, in particular is thought to sensiti5e cancer cells to e$ternal 'ea# radiation, enhancing its effecti!eness. ; study 'y .ernier et al de#onstrated increased rates of local control, disease specific sur!i!al, and o!erall sur!i!al using high dose cisplatin and radiotherapy concurrently. They did not find an increase in the incidence of late ad!erse effects o!er radiotherapy alone. ; study 'y (olf *T et al looked at using induction che#otherapy and definiti!e radiotherapy with laryngecto#y 'eing sa!ed for sal!age surgery. They found that two thirds of patients responded well to the induction che#otherapy and had si#ilar sur!i!al as co#pared to the control ar# which recei!ed a total laryngecto#y with ad>u!ant radiation. ;nother si#ilar study 'y "efe're B et al showed no significant difference in fi!e year sur!i!al 'etween the induction che#otherapy and traditional surgical group. .oth of these induction che#otherapy studies did show a lower rate of response with #ore ad!anced stage tu#ors. The role of induction che#otherapy is still under in!estigation. Aadical or #odified radical neck dissections are indicated in the presence of positi!e nodal disease. 1atients with Supraglottic or su'glottic T2 tu#ors #ay need neck dissection e!en in the a'sence of nodal disease. 2or clinically @0 necks a selecti!e dissection can 'e perfor#ed sparing the S04, internal >ugular !ein, and the spinal accessory ner!e. ; #odified dissection can 'e perfor#ed for @1 necks usually in le!els )) )<. Surgical options for treat#ent of the laryn$ include a partial laryngecto#y with a !ariety of !ariations, and a total laryngecto#y. "esions confined to the #e#'ranous cord can 'e re#o!ed endoscopically using an operating #icroscope and #icrolaryngeal instru#ents or a car'on dio$ide laser Dthough this #odality #ay pre!ent deter#ination of ade7uate #arginsE. This is generally only reco##ended if the lesions do not in!ol!e the arytenoids, e$tend into the !entricle, or in!ol!es the anterior co##issure. (ith this #ethod the use of intraoperati!e fro5en sections is necessary to ensure ade7uate resection. )f !oice or swallowing changes are anticipated a preoperati!e consultation with a speech pathologist would 'e appropriate. ; he#ilaryngecto#y is typically re#o!al of one !ertical half of the laryn$ though in so#e cases a portion of the opposite cord is also re#o!ed. )f #ore than half of the opposite cord is re#o!ed, an epiglottople$y will 'e necessary in order to preser!e a sufficient airway. Tu#ors suited for this procedure include those that ha!e no #ore than

1c# of su'glottic e$tension at the anterior co#issure and 5## posteriorly, a #o'ile affected cord, unilateral or #ini#al anterior contralateral cord in!ol!e#ent, no cartilage in!asion, and no e$tralaryngeal soft tissue disease. 0ancer in!ol!ing an arytenoid is resecta'le as long as the opposite arytenoids can 'e left intact. Though if the cancer e$tends o!er the posterior co##issure it is considered unresecta'le 'y this procedure for part of the contralateral arytenoid #ust 'e resected to pro!ide for ade7uate #argins. )n this procedure !oice reconstruction can 'e done 'y transposing a strap #uscle, gi!ing 'ulk for which the re#aining cord can !i'rate against. This can i#pro!e the 'reathy !oice resulting fro# dead space in the su'glottic region. 2or supraglottic tu#ors, a supraglottic laryngecto#y can 'e considered if& tu#ors are T stage 1, 2 or - if 'y preepiglottic space in!asion only, T<0s are #o'ile, there is no cartilage in!ol!e#ent, no anterior co##issure in!ol!e#ent, the patient has good pul#onary in!ol!e#ent with 29<1 greater than 50%, the 'ase of the tongue is not in!ol!ed past the circu#!allate papillae, and the ape$ of the pyrifor# sinus is not in!ol!ed. This procedure can 'e perfor#ed in patients that failed radiation therapy 'ut is generally not offered 'ecause of the difficulty in e!aluating the e$tent of the disease, stiffened laryngeal tissues and healing difficulties which #ay worsen the degree of aspiration and lea!e the patient with a non functional laryn$. (ith a supraglottic laryngecto#y an ipsilateral radical neck dissection should 'e e#ployed in patients with a pri#ary lesion of greater than 2c#, lesions e$tending to the 'ase of the tongue, aryepiglottic fold, false cords, or 'ase of the epiglottis. )n the presence of diseased ly#ph nodes a 'ilateral neck dissection should 'e undertaken= 'ecause of the unoperated side of the neck is the #ost co##on site of surgical failure. )n one study of supraglottic cancers 'y Sessions et al they concluded that patients with clinically negati!e neck could 'e treated 'y o'ser!ation alone. The study also showed no 'enefit to the use of post operati!e radiation therapy in supraglottic cancers. ; newer #odification of the supraglottic laryngecto#y is the supracricoid laryngecto#y. This procedure is for cancers in!ol!ing the anterior true !ocal cords including the anterior co##isure and the supraglottis. )n this procedure the T<0s, the supraglottis and the thyroid cartilage are resected lea!ing the arytenoids and cricoid cartilages. One draw 'ack is reportedly half of patients re#ain dependent on their tracheosto#y. ;nother procedure a near total laryngecto#y is so#ewhat like an e$tended !ertical he#ilaryngecto#y. ; s#all strip of #ucosa and a single arytenoid re#ain 'ehind as a speaking shunt. The patients re7uire a tracheosto#y per#anently. The total laryngecto#y is the standard therapy and is e$tre#ely effecti!e in controlling carcino#as originating in the glottis due to the fact that the area is relati!ely de!oid of ly#phatics unlike the supraglottis. This procedure can cure a #a>ority of T- or less patients. )ndications for this procedure include& T- or T% cancer unfit for a partial laryngecto#y, e$tensi!e in!ol!e#ent of thyroid and cricoid cartilages, in!asion of the soft tissues in the neck, and tongue 'ase in!ol!e#ent 'eyond the circu#!allate papillae. )n this procedure the entire laryn$ is re#o!ed including the hyoid 'one, thyroid and cricoid cartilages and a few of the upper tracheal rings. The tracheal stu#p re#aining is

anasto#osed to an opening created at the root of the neck, creating a co#plete separation of the respiratory and digesti!e tracts. The re#aining pharyngeal #ucosa if reappro$i#ated with the goal of allowing the patient to continue to ingest nutrients 'y #outh and swallow nor#ally. )f not enough of the pharyngeal #ucosa re#ains= tissue fro# >e>eunu#, radial forear#, or anterolateral thigh can 'e used in the reconstruction. )f the tu#or has e$tended su'glottically or in!aded through the anterior cartilaginous fra#ework, an ipsilateral thyroid lo'ecto#y with re#o!al of ?elphian nodes is indicated. (ith su'glottic e$tension these nodes are often in!ol!ed and can lead to sto#al recurrence if not addressed initially. <oice reha'ilitation is 'est acco#plished 'y a tracheosto#al de!ice which acts as a one way !al!e directing air fro# the trachea into the pharyn$ when the de!ice is digitally occluded in the sto#a. The puncture itself is typically placed intraoperati!ely and kept open with a ru''er catheter. So#e do prefer to perfor# this as a secondary procedure, the thought 'eing that it has a lower co#plication rate. "ater in the post operati!e course the de!ice is actually fitted and placed. ;nother option is an electrolaryn$ which generates sounds 'ased on e$ternally created !i'rations. )t can difficult to learn to operate and those listening #ust 'eco#e fa#iliar with the sounds in order for the speech to 'e understood. So#e patients can also learn to utili5e pure esophageal speech which in!ol!es forcing air fro# the sto#ach into the esophagus and out the #outh all the while using the tongue, teeth, cheeks, and lips to produce the speech.

Complications
The list of possi'le co#plications in treating laryngeal cancer is long and related to the co#ple$ function and anato#y of the laryn$ and its surrounding structures. The co#plications the#sel!es depend on the #odalities of treat#ent used. One of the #ost co##on pro'le#s with laryngeal cancer is staging. ;ppropriate patient selection is key for good outco#es. )nappropriate staging can lead to unnecessary loss of !oice or i##inent disease recurrence. Staging re7uires not only e$a# under anesthesia, 'ut the co#'ining of infor#ation fro# #ultiple #odalities. 0are #ust 'e taken to ensure accurate staging and it #ight 'e prudent to o'tain a consent for total laryngecto#y 'efore operating. )nfection can 'e a pro'le# in operations in!ol!ing the upper aerodigesti!e tract= typically this is less of a pro'le# if anti'iotics are properly ad#inistered. )nfections can result fro# a #isplaced tracheoesophageal puncture or inade7uate closure of the re#aining pharyngeal #ucosa leading to chronic drainage. Though a presenting sy#pto# of laryngeal cancer, hoarseness #ay worsen after treat#ent, patients can lose a range of !oice or ha!e a !oice that is easily fatigued. This is a greater pro'le# in a total laryngecto#y where the patient has the potential to fail at learning tracheoesophageal speech. Swallowing difficulties are another co#plication= these can 'e due to e$ternal 'ea# radiation such as #ucositis of $erosto#ia or to an anato#ical stricture or stenosis of the neopharny$. 1atients #ay also lose their sense of taste due either to direct da#age fro# radiation therapy or fro# anato#ic changes surgically in which air no longer flows into the #outh. This lack of airflow #ay also alter the patient6s sense of s#ell.

2istulas can de!elop with failure of the surgical closure of the neopharny$, particularly if the edges of the #ucosa are not in!erted properly. This leads to drainage of oral secretions onto the skin with further 'reakdown. These fistulas often close on their own with close #anage#ent 'ut so#e will re7uire reinforce#ent with a #yocutaneous pectoralis or radial forear# flap. 1atients #ay also re#ain dependent on their tracheosto#y tu'es= either 'ecause of significant aspiration or laryngeal ede#a fro# radiation therapy. The tracheosto#y itself can 'eco#e o'structed due to e$cessi!e secretions and crusting of #ucus. The surgical dissection can result in in>ury to !arious cranial ner!es including& <)), )C, C, C), C)). Such in>uries can 'e te#porary or per#anent depending on the whether the ner!e was stretched or transected all together. )t is also possi'le that so#e of the deficits e$ist due to perineural in!ol!e#ent 'y the cancer. These in>uries can clinically present as asy##etric s#ile and #outh droop, difficulty swallowing, hoarseness and aspiration, shoulder drop, and loss of tongue #o'ility. 1atients need careful assess#ent 'oth pre and post operati!ely and need to 'e counseled a'out the possi'ility of such in>uries occurring. ?uring laryngecto#y there is a risk of stroke 'ut it is a rare occurrence= though this risk is increased in those with atherosclerosis or pre!ious radiation. )n patients with ad!anced tu#ors and necrosis can ha!e I'lowoutsJ of the carotid or internal >ugular, when this occurs sal!age surgery is atte#pted 'y ligating the !essel pro$i#al to the 'leed. This procedure results in stroke in greater than 50% of cases 'ut otherwise a I'lowoutJ is a fatal e!ent. 3ypothyroidis# is yet another potential co#plication either due to thyroidecto#y or to radiation to the anterior neck. )t can take up to one year following treat#ent for this disorder to 'eco#e apparent so TS3 and free T% should 'e checked often. 3ypothyroidis# is easily treated with daily Synthroid. Aadiation to the neck can also cause fi'rosis to the tissues resulting in neck stiffness, loss of range of #otion, and pain.

Prognosis
2i!e year sur!i!al for laryngeal cancer is 'etter than that of other neck cancers owing partly to hoarseness as a clinically detecta'le sy#pto# leading to early care, and to the fact that #ost are glottic carcino#as with a low rate of spread. 2i!e year sur!i!al for Stage ) is G+5%, Stage )) ,5 +0%, Stage ))) H0 ,0%, and Stage )< 50 /0%. ;fter initial treat#ent these patients are followed at % / week inter!als with the goal of searching for re#aining disease and second pri#ary lesions. ;fter the first year !isit fre7uency decreases to e!ery 2 #onths, and during the third and fourth year to e!ery three #onths with annual follow up after that. 1atients are considered cured after fi!e years disease free and #ost cancer reoccurs in the first two years. ?espite ad!ances in detection and treat#ent options the fi!e year sur!i!al has not i#pro!ed #uch o!er the last thirty years.

References
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