Carcinoma Larynx

Preliminary
Larynx Ca frequent malignancies in ENT: The second most common malignancy of the head and nec !merica: the order of 1 "#$ Ci%to &angun usumo 'os%ital ("#C&) and the "#$ *r$ #utomo: sequence + after the N,C and %aranasal sinus tumors -n the "#$ 'asan #adi in (2..+): 12$/0

!N!T1&2 !N* ,'2#-1L132 larynx

CARTILAGE LARYNX

EXTRINSIC MUSCLE

INTRINSIC MUSCLE

6asculari7ation

-nner8ation

Lym%hatic #ystem

LARYNX

EPIDEMIOLOGY
&en: ;omen "atio < +$4: 1 "#C& (19/.=19/4) < 144 cases> 7: 1 Canada < 5: 1 -taly < +2: 1 /40 ? smo ing @ alcohol ,! 6ieAs: 940 squamous cell carcinoma

Predilection
Common: the glottis Northern Euro%ean countries: ? 540 (glottis)B +40 (su%ra / suCglotis)$ #outhern Euro%ean countries: ? 5/0 (glottis)B +20 (su%ra / suCglotis)$ !merica: ? 5.0 (glottis)B 4.0 (su%ra / suCglotis)$

ETIOLOGY
= N1T 2ET DN1;N = "is factors: #mo ing Consum%tion of alcohol "adioacti8e rays *eficiency of 8itamins 6irus infection (',6)

Clinical Sym tom!

'oarseness EloAn Taste %ro% -m%aired sAalloAing Lum%s Nec

P"YSICAL EXAMINATION
3eneral ENT examination Nec %al%ation F%%er airAay oCstruction Local examination: laryngosco%yB tra eos o%iB Cronchosco%y

Indirec Laryn#o!$o y

direc Laryn#o!$o y

RADIOLOGIS
#oft Tissue Nec !ssess airAay CT=#can !ccurately assess the extension of tumor (thyroid cartilageB %re e%iglottisB lim%he) *etecting secondary %rimary tumors &"!ssessing s%ecial extension suCgloti from %rimary to on 6ocal Cords

"ISTOPATOLOGY

STAGING TNM %A&CC'

T( Limited 1 side su%raglotisB 8ocalist normal cord mo8ement T) Exit from 1 side su%raglotisB 8ocalist normal cord mo8ement T* limited in the larynxB chordae fixation 8ocalist / %ost ri oid extensionB the medial Aall of the sinus %iriformis or %re= e%iglottisB and erosion innercortex thyroid cartilage
T+a T+,

T
SUPRAGLOTIS

The in8asion came out through the thyroid cartilage and larynx or out

,re8erteCra s%ace in8asionB carotid arteryB or mediastinal structures

STAGING TNM %A&CC'

T( Limited to 8ocalist cordB can in8ol8e the commissures T) E stensi e su%raglotis/suCglotis/aCnormal cord mo8ement

T
GLOTIS

T*

Limited in the larynx Aith cord fixation 8ocalist The in8asion came out of the glottis through the thyroid cartilage and / or exit larynx

T+a

T+, ,re8erteCra s%ace in8asionB the carotid arteryB or mediastinal structures

STAGING TNM %A&CC'

T( Limited to suCglotisB 8ocalist cord mo8ement Aas normal Extensions to the cord singerB 8ocalist cord mo8ement is T) normal or slightly disturCed T* Limited in the larynxB 8ocalist cord fixation The in8asion came out suCglotis through thyroid cartilage and larynx or out

T
SU-GLOTIS

T+a

T+, ,re8erteCra s%ace in8asionB the carotid arteryB or mediastinal structures

STAGING TNM %A&CC'

Nx N. N( N) N*

can not %al%aCle lym%h nodes

no lym%h node metastases in the nec region

#ingle i%silateral lym%h nodesB si7e G+cm

- N2a: metastasis in 1 side of the lym%h nodesB si7e G5 cm - N2C: &ulti%le i%silateral metastasesB si7e G5 cm - N2c: Cilateral or contra lateral metastasisB si7e G5 cm

lym%h nodes Aith si7es larger than 5 cm

STAGING TNM %A&CC'

Mo

No distant metastases

M(

-t Aas found distant metastases

STAGE
Sta#e ----6! -6E -6C T T1 T2 T+ T1=+ T1=+ T4a T4C !ny T !ny T N No N. N. N1 N2 N. !ny N N+ !ny N M &o &. &. &. &. &1 &. &. &1

MANAGEMENT

Fnli e e8ery flashlight *e%ending on the location of %rimary tumorB stage -n general: surgeryB radiationB chemothera%yB and chemoradiation (comCination)$ stage -: radiationB if it fails L, / LT #tage --: L, / LT #tage ---: Aith / Aithout N1: LT Aith or Aithout the HN* / "N* folloAed Cy radiation #tage -6: Aithout N / &: LT I HN* folloAed Cy radiation 1ther: radiothera%y and chemothera%y

O erati/e T0era y

,artial Laryngectomy 1$ Laryngectomy %artial 8ertical / 'emilaryngectomy (L,6) 2$ Laryngectomy %artial hori7ontal (Js *3") Laryngectomy Total

Partial Laryn#ectomy

Larin#e$tomy artial /erti$al 1 0emilarin#e$tomi %LP2'

!n act of %artial resection of one or Coth 8ocal cords Aith or Aithout anterior commissures and thyroid cartilage This o%erating technique Cegan less used after an increase in radiothera%y technique and comCination Aith chemothera%y and the introduction of techniques laryngectomy su%racricoid

Larin#e$tomi ar!ial /erti$al 1 0emilarin#e$tomi %LP2'

1$ 2$ +$ 4$ 4$ Cordectomy Laryngectomy %arsial frontal Laryngectomy %arsial lateral Laryngectomy %arsial frontolateral Laryngectomy %arsial frontolateral ex%anded

Laryn#ectomi ar!ial /erti$al 1 0emilaryn#ectomy %LP2'

1$ !ction cordectomyB laringectomy %artial frontalB %artial lateral laringectomy = Tumors larynx on one side of the 8ocal cords = The tumor has not reached the anterior commissures = #u%raglotis tumor stage 2$ !ction laryngectomy %artial frontolateral: = Ex%ansion into the anterior commissures = Ex%ansion into the contralateral 8ocal cordB Aithout fixation

Laryn#ectomi ar!ial /erti$al 1 0emilaryn#ectomy %LP2'

+$ !ction laryngectomy frontolateral %artial ex%anded: = Ex%ansion suCglotis (G2=+ mm) = The ex%ansion to one of the %rocessus 8ocalis cart$ aritenoid

Com lication
- Ereathy 8oice - Laryngeal stenosis - Histula - !s%iration - *islocation - Edema treated Aith C12 laser - #uCcutaneous em%hysema installation of drains

Laryn#ectomy artial 0ori3ontal %LP"'

E%iglotectomy ,artial Laringectomy su%raglotis ,artial Laringectomy su%racricoid Aith Cricohyoidoe%igloto%lexy$

Laryn#ectomy artial 0ori3ontal %LP"'

E%yglotectomy !ctions: Tumor limited to the e%iglottis$ !ction L, su%raglotis: Tumor su%raglotis @ glottis (not yet on the anterior commissures) !ction L, su%racricoid Aith Cricohyoide%igloto%lexy: = 3lottis Cilateral tumorsB T1B ant$ commissures (I/=) = 3lottis unilateral tumorB T1B ant$ commissures (I) = Tumor glottis uni / CilateralB T2B im%aired 8ocal cord mo8ement (I/=)

Contraindication!
- !ritenoid i%silateral cartilage fixation - Ex%ansion of the tumor to suCglotis - ,atients Aith %ost=radiation - ,resurgery res%iratory disturCance

Laryn#ectomy S4 ra#loti$

Laryn#ectomy S4 racricoid 5it0 crico0yoide i#loto le$!i

Ad/anta#e! Laryn#ectomy S4 racricoid

1$ ;ider o%erating field 2$ Eetter outcome in Cilateral glottis tumors +$ The %atient can Creathe Aithout a tracheostomy

Com lication
- !s%iration - Histula - The difficulty of e8aluation of recurrence - Condritis Cricoid cartilage - *ys%hagia

Total Laryn#ectomy

DE6INITION
lift the entire structure of the larynx from the u%%er limit (e%iglottis @ os hioid) until the loAer limit (tracheal rings)

Indication
- Laryngeal tumor stage --- @ -6 - #tage - @ -- are recurrentB the failure of radiation thera%y - Can Ce conducted Aith radical nec dissection or functional - Limit cutting ring ex%ansion of tumor into the trachea suCglotis area

O eration! roced4re total Laryn#ectomy

Inci!ion

Di!ection 6la S4, lati!ma

Incition 7a!cia o/er M8 SCM

Incition Stra m4!cle

C4ttin# I!t0m4! and !e aration T0yroid

Se aration o! 0yoid

C4ttin# trac0ea

P0aryn#eal m4co!a i! !e arated 7rom t0e t4mor97ree !ide

De7ect a7ter remo/al o7 larynx

Se5in# Oe!o 0a#4!

Se5in# !toma

:o4nd Clo!4re

Po!to erati/e care

1$ 2$ +$ 4$ 4$ ,atients do not sAalloA 3i8ing antiCiotics Eating @ drin ing through N3T The test drin %rior to the release of N3T !8oid the occurrence of infection (ase%sis and antise%sis)

Com lication
- Histula and surgical Aound infections - Tracheostomal recurrence - 'y%othyroidism @ hi%o%aratiroidism - ,e%tic ulcer - ,haringoeso%hagus stenosis - Tracheitis

2oice Re0a,ilitation
There are + ty%es of s%eech rehaCilitation is %ossiCle to do: 1. Esophageal speech 2. Electrolaryngeal speech 3. Tracheoesophageal speech (tracheoesophageal puncture technique)

Esophageal speech
,atient deli8ers air into the eso%hagus due to the %ressure of intra thora al &edical "ehaCilitation Fnit needed long time to train 740 ex%erienced failure

Tracheoesophageal speech (tracheoesophageal puncture technique)

,rothesis that connects the trachea and eso%hagus The sound %roduced Cy means of 8iCrating segments faringoesofageal Then the 8oice on the articulated Aith the tongue in the oral ca8ity TE, insertion techniques are %rimarily tAo Aays: (simultaneously or in a secondary laryngectomy 5 Aee s after laryngectomy

Tracheoesophageal speech (tracheoesophageal puncture technique)

1 The ad8antage of su%%ly air from the lungsB fonasi natural sounding and rehaCilitation carried out 2 Aee s %ost surgery 2$ The disad8antage = !dditional o%erations = ,rosthesis must Ce maintained = !s%irations Ahen lea ing = Ex%ensi8e (K 1+.=19.)

Electrolaryn#eal ! eec0
Transcer8i al and intraoral Electromechanical 8iCration to generate sound -ntra oral iL a small tuCe %laced in the %osterior ca8ity oris and sound deli8ered later articulated

Electrolaryngeal speech

Nec Ty%e Equi%ment %laced on the nec s in under the chin or the chee s channeled into oro%aring 8oice and articulated in a normal

Electrolaryngeal speech
!d8antages: = "a%id rehaCilitation = Easy maintenance = *uraCle (2=1. years) = Commercially a8ailaCle *isad8antages : = Less natural sound quality = *e%ending on Cattery %oAer = Ex%ensi8e 424 dollars = -ntra oral ty%e must maintain hygiene

TE"-&! D!#-'

#emoga Eermanfaat

C!"! ,E&!#!N3!N

LARYNX
(8 EM-RIOLOGI ; Te i cranial < Laryn#otraceal #roo/e < ,ronc04! dan $iri %* (1) min##4 ' !edan#$an te i di!tal

Laryn#otrac0eal o,litera!i dan re$an4li!a! oe!o 0a#4! dan adit4! larynx rimiti7 ,ranc0ial I2 dan 28

len#$4n#

Adit4! larynx cela0 ,er,ent4$ < T < ; 9 < "y o,rac0ial eminence < e i#loti! 9 Arytenoid yan# mem,ent4$ =4#a ton=olan C4nei7orme dan Cornic4lata Otot larynx ertama ; interarytenoid erye i#lottica> ericoarytenoid o!terior dan ericot0yroid

P0y!iolo#y Larynx
Hunction Honasi ,rotection Hunction "es%iratory Hunction Circulation Hunction Hunction Hixation #AalloAing Hunction Hunction Cough Hunction E s%e torasi Hunction Emotion

at0o 0y!iolo#y

imCalance CetAeen stimulating and inhiCit cell groAth %4+ tumor su%%ressor gene mutation ToCacco smo e contains aromatic hydrocarCons formed nitro%olycyclic 7 methyl guanine and 4 aminoCi%henyl on guanine nucleotide gi8es carcinoma ty%e and descri%tion