TUMOURS of ENT-ORGANS

Like any other organ, the larynx may serve as a place of formation of tumours (benign
and malignant).
Benign laryngeal tumours may originate in the epithelium or connective tissue and be
differentiated as papillomata and fibromata.
In the group of papillomata, close attention should be paid to a white papilloma
(observed in the adults as a precancerous state) and laryngeal papilloinatosis (typical
for children).
Patients with a white papilloma complain mostly of a disruption of the vocal function;
the diagnosis is made with help of indirect laryngoscopy which reveals some white
"hairy" tumour localized on the vocal fold whose mobility during phonation is
preserved.
The etiology of laryngeal papilloinatosis is unknown, but it is supposed to be caused
by a virus (like Shop's papilloma). It develops at a very young age; the growth of the
tumour progresses up to an absolute closure of the true glottis. The course is
characterized by some malignancy, as there is recurrence of the tumour after its
removal with a disturbance of the breathing, thereby causing a chronic hypoxia in the
child with all its unpleasant features. Sometimes the patients have to undergo
tracheotomy and cany tubes till the puberty, when papillomata may regress or stop
recurring after their removal.
The diagnosis is made with help of indirect laryngoscopy (or direct one in young
children), when the tumour is revealed as a "cauliflower" closing the tine glottis.
The treatment is surgical: removal of the tumour together with the fold (in order to
prevent recurrences) by way of thyreotomy in patients with a white papilloma; while
the treatment in children consists in removal of the laryngeal papillomata with forceps
and
prevention of recurrences by oiling the places, where papillomata were removed, with
podophyllin. Cryoinfluence and chemotherapy are used too.
 It is not in rare cases that the larynx is a place for developing such benign connective-
tissue tumours as fibromata, which are usually located on the vocal folds and affect
phonation. A fibroma may contain a redundant amount of water (an oedematous form)
or vessels (an angiofibroma), be soaked with some amyloid (an amyloid tumour); in
case of its large size it is called a laryngeal polyp.
The main complaints are as follows: various degrees of dysphonia, a possible
hoarseness of the voice; laryngeal polyps are characterized by signs of stenosis. The
diagnosis is made on the basis of visual examination of the larynx.
The treatment consists in endolaryngeal removal with help of indirect laryngoscopy.
The larynx may also contain cysts localized on the epiglottis (they are called retention,
distention, or secretory cysts) and in the region of the laryngeal ventricle. In cysts,
unlike cases of tumours, laryngoscopy usually reveals some smooth protrusion above
the vocal fold, and this protrusion is covered with the normal mucous membrane.
The treatment is surgical.
Particularly interesting are aerial laryngeal cysts forming a peculiar sac which is
located in the depth of the laryngeal ventricle and has its exit on the lateral surface of the
neck. They are clinically determined as a tumour-like formation appearing on
exertion (cough) in the soft cervical tissues at the level of the larynx; it has a resilient
consistency with tympanitis on percussion and periodically disappears (a
laryngopneumatocele).

The cancer of larynx (T3).

 The cyst of the left vocal cord
The treatment is surgical.
Malignant larvngeal tumours. They are mostly represented by cancer, as sarcoma and
carcinosarcoma are very rare. The problem of laryngeal cancer is socially significant
because of its comparatively high prevalence. It makes up 1.5-7.0 % of all cancers and
is on the first place among malignant neoplasms of the ENT organs. The disease
affects mostly males. According to Zimont, the proportion between the male and female
patients ranges from 100:10 to 100:15. In our clinic, we have 3-4 female patients per
100 male ones (according to catamneses for 20 years of observation). It is supposed
that this proportion may be explained by peculiarities in the hormonal sphere, as ENT
oncologist Karpov believes that estrogens prevent development of laryngeal cancer;
the latter fact enabled the use of sinestrol for treating this disease.
The experience gained by us and other authors shows that the incidence of the disease
in males depends upon other things, life hazards (alcohol, smoking, working
conditions, etc.) in particular. Age is also important, as this cancer develops in
persons over 50, though the literature has data about cases of laryngeal cancer at the
age of 3 and 14 years. In our clinic, we observed this disease in an 18-years-old male
patient. In recent years, cancer of the larynx "has become younger" and is revealed in
persons at the age of 30-45 years. The geographical factor is important too, as
laryngeal cancer is more common in the countries of Europe and North America
than in those of Asia and Africa where cancers of the oral cavity and pharynx
prevail; it may be caused by peculiarities in diet, climate and bad habits. The urban
population suffers more frequently than the rural one, but introduction of different
mechanisms and chemical substances steadily reduces this difference.
 The causes of laryngeal cancer, like any cancer at all, are not still clear. There are
many theories known for the students from previous courses (anatomical pathology,
physiological pathology: Virchow's, Congame's, viral theories). Predisposing factors
are important too, e.g. chemical irritants (particularly tar, coal dust, etc.), occupational
and especially life hazards (smoking and taking of alcoholic drinks), as 98 % patients
with
laryngeal cancer are smokers and alcoholics. An important part is played by
ecological aspects, such as pollution of the environment and increased radiation,
including radioactive nucltdes (the Chernobyl catastrophe).
The development of the tumor in the larynx is, as a rule, primary and,
significantly more seldom, secondary (transfer from the adjacent regions of the
pharynx, trachea, thyroid gland, as well as metastatically). The peculiar character
of the course of laryngeal cancer depends upon the following tilings:
a) peculiarities in the distribution of the friable fatty tissue in the submucosal
layer at different levels of the larynx;
b) peculiarities in the lymph circulation and blood supply;
c) regional metastasis.
The above features also produce their effect on the localization rate of the
primary tumour: cancer lesions are more frequently found in the laryngeal
vestibule (the upper level of the larynx: the region of the vestibular folds,
ventricles, epiglottis, aryepiglottic folds) - 43-56.6 %, then follows the region of
the vocal folds (the middle level) - 15-17 %, and more seldom it is localized in the
subglottal space — 6.3-8.0 %.
The tumours of the upper level grow more rapidly, tend to metastasizing and are
radiosensitive. The tumours of the middle level grow slower and demonstrate a
good response to radiotherapy (at an early stage), their metastasizing occurs at later
stages.
Subglottal cancers (the lower level of the larynx) are resistant to radiotherapy and
require surgical treatment According to the direction of the growth, its two kinds are
distinguished: exophytic (towards the laryngeal lumen) and endophytic (inside the
laryngeal walls). The latter case is more difficult for diagnosis, and its course is more
malignant.
Histologically, laryngeal cancers may be squamous cell (in 98 % of cases),
keratinizing and nonkeratinizing. There are rare cases of columnar cell and
scirrhus, and the most seldom type is carcinoscleroma where both the epithelium
and the connective tissue of the organ become malignant. During last 100 years,
there were only 20 cases of laryngeal carcinoscleroma described in the world
literature.
The classification of laryngeal cancer lakes into consideration two criteria: its
localization and stage (the upper, middle and lower levels of the larynx; stages I, II III
and IV).
The international classification by TNM system considers localization and stage
(T) too, but also the state of regional (N) and distant metastases (M). Such criteria
broaden possibilities of using this classification for diagnosis, treatment and
prognostication of the outcome of laryngeal cancer.
The first stage is understood as localization of the process on its level at a
restricted area; the second one means that the tumour involves the whole level but
does not spread to another; the tumour involves an adjacent level with possible
mobile regional metastases — stage III; and, at last, the tumour either involves an
adjacent organ (the pharynx, the oesophagus, the trachea) or there are immobile
included regional (cervical lymph nodes) or any distant metastases.
Examples of variants: TiMpNo, T2M1Np, T^No, ToN3No, TjNoM], ToN0Mo (a
patient with laryngectomy, i.e. cured with catamnesis of 5 years).
The clinical manifestations of the disease depend upon its localization and stage. If
the tumour is localized on the vocal folds, it may manifest itself early by a change of
the voice. In other parts of the larynx, patients may feel sensitive symptoms later,
during stages III and IV characterized by appearance of some pain making the
patient visit a doctor. It happens with persons lacking culture and especially in cases
when they are examined by specialists with a low level of qualification who start
treating without making a diagnosis. Moreover, the truetumour process is often veiled
with other signs (oedema, inflammation, endophvtic growth, anatomical structure of the
larynx hampering visual examination, an increased vomiting reflex). For all the above
reasons, such patients are admitted for rational treatment rather late (40-60 % of cases at
stages III-IV). If we take into consideration that stages I and II of the laryngeal cancer may
be completely cured in 95 % of the cases, then it is a pity dial diagnosis is so bad and
inopportune. Therefore any ENT patient, even presenting no complaints, must undergo visual
examination of all his ENT organs, the larynx in particular.
If a cancer process is suspected, it is necessary to give local anaesthesia (2 % solution of
tetracaine hydrochloride) for elimination of the vomiting reflex and subsequent
execution of indirect laryngoscopy or to perform direct laryngoscopy.
Besides dysphoma, other symptoms include cough (particularly in cases of
localization in the subglottal space), tickling (the epiglottis), dysphagia (the arytenoid
cartilages); the late stages are characterized by stenosis with different degrees of
inspiratory dyspnoea. Laryngoscopically, it is necessary to pay attention to such
symptoms as colour, absence of any inflammation, tuberosity, disturbed mobility of the
vocal folds, liberation. Palpation of the neck is obligatory, as it may reveal lymph nodes
(enlarged to some extent) and their adhesion to underlying tissues (regional metastases).
Very important for diagnosis are cytological examinations of the sputum, smear,
punctate from a suspicious area, and especially biopsy with a histological examination
entitling the use of radical treatment.
Additional methods include roentgenography of the larynx, thermovision, seaming,
supersonic observation, radioisotope analysis and computed tomography.
If the malignant tumour is clinically revealed, but rejected by all the methods, it is
necessary to perform thyreotomy, open the larynx and make direct visual examination of
the tumour; if possible, it should be removed for histological examination.
Treating the laryngeal cancer, one should remember that its efficacy significantly
depends upon early diagnosis, age, sex, histological structure, localization, reactivity of the
organism, rational use of available therapeutic mediods.
The causes of late diagnosis are as follows:
a) insufficient oncological watchfulness of the doctor;
 b) an inopportune seeking medical advice (hence significance of sanitary-educational
work!);
c) the course of the disease has few symptoms.
There are the following kinds in the treatment of laryngeal cancer:
a) surgical - at early stages of the disease they make it possible to preserve all the
functions of the larynx (functional resections of the larynx at cancer stages I-II and
sometimes III, with subsequent laryngectomy and its broadened variants including an
operation on the lymph routes of the neck: its sheath-fascia resections, Crile operations);
b) radiation (irradiation with help of a cobalt unit, apparatuses of Agate-R, Rocus and
Betatron types) and combined treatment (irradiation + operation; operation + irradiation
and irradiation + operation + uradiation);
c) chemotherapy (cytostatic and antineoplastic drugs);
d) symptomatic treatment (dissection of the conoid ligament and tracheotomy in
stenosis, narcotic drugs for pains, etc.).
The prognosis is favourable at early stages and bad at late ones.