Carcinoma of the Larynx - Comprehensive Exam Answer

Case Summary

(a) Probable Clinical Diagnosis

• Age >40 years (over 90% of laryngeal cancers occur in this group)
• Male sex (7:1 male-to-female ratio - highest gender disparity among head and neck cancers)
• Long-term tobacco use (bidis + chewing tobacco) - the single most important risk factor
• Hoarseness/voice change for 4 weeks - hallmark symptom of glottic carcinoma
• Difficulty breathing suggests advanced disease with airway compromise
• Tobacco and alcohol act synergistically; tobacco is strongly associated with glottic carcinoma

(b) How to Examine the Patient

1. History Taking

• Detailed history of voice change (onset, progression, character)
• Dysphagia, odynophagia, hemoptysis, referred otalgia (via Arnold's nerve - suggests hypopharyngeal extension)
• Dyspnea - rest vs. exertion (assess airway compromise)
• Duration and type of tobacco/alcohol use
• Weight loss, fatigue (constitutional symptoms)
• Occupational exposure history

2. General Examination

• General condition, nutritional status, body weight
• Respiratory rate, use of accessory muscles, stridor (inspiratory = supraglottic; biphasic = glottic/subglottic)
• Signs of anemia, cachexia

3. Local/Regional Examination

• Inspect for neck swelling, previous scars
• Palpate cervical lymph nodes - level by level (Levels I-V)
  • Supraglottic carcinoma drains to Levels II, III, IV bilaterally
  • Glottic carcinoma has low nodal involvement (5.9% overall)
• Palpate laryngeal framework - loss of crepitus (laryngeal crepitus) indicates posterior extension / fixation to prevertebral fascia
• Laryngeal mobility over the spine - loss suggests fixation

1. Indirect Mirror Laryngoscopy (IDL) - standard bedside technique
   • Position patient in sniffing position
   • Warm the laryngeal mirror to prevent fogging
   • Depress tongue with gauze-protected fingers
   • Place warm mirror against soft palate
   • Visualize: epiglottis, aryepiglottic folds, false cords, true cords, subglottis, piriform fossae
2. Flexible Fiberoptic Laryngoscopy - preferred modern technique
   • Better visualization of larynx and hypopharynx
   • Video documentation
   • Assesses vocal cord mobility in real time
   • Not dependent on patient cooperation / gag reflex
3. Rigid Telescopy (70° or 90° laryngoscope) - if available
4. Videostroboscopy - for small glottic lesions; assesses mucosal wave

4. Investigations

• CT scan neck with contrast - imaging of choice for laryngeal cancer; evaluates cartilage invasion, paraglottic space, nodal involvement
• MRI - useful in selected cases (soft tissue assessment)
• Chest X-ray / CT chest - exclude pulmonary metastases or synchronous primary
• PET-CT - for advanced tumors, nodal disease, distant metastases
• Microlaryngoscopy under GA + biopsy - definitive diagnosis and histopathological confirmation
• Esophagoscopy + bronchoscopy - to exclude synchronous second primary tumor (field cancerization effect)
• Routine bloods: CBC, LFT, RFT, coagulation, ECG, PFT

(c) Expected Findings on Examination

Symptoms/Signs Pattern by Site:

Typical Findings:

• Irregular, ulcerative, exophytic or warty mass on the true vocal cords (glottic cancer) or epiglottis/aryepiglottic folds (supraglottic cancer)
• Surface may be white (leukoplakia), red (erythroplakia), or mixed
• Impaired or absent vocal cord mobility (arytenoid fixation or vocalis invasion)
• Extension to anterior commissure (important for staging and surgery)
• Narrowed airway lumen

• Cervical lymphadenopathy (Levels II-IV for supraglottic; Levels II-IV and VI for glottic)
• Loss of laryngeal crepitus
• Thyroid cartilage destruction / tenderness (T4 disease)

• Cachexia, weight loss
• Secondary chest findings if aspiration pneumonia

• Moderately or poorly differentiated squamous cell carcinoma
• Keratin pearl formation in well-differentiated tumors

(d) Counseling the Patient Who Refuses Tracheostomy

Key Points of Counseling:

• Ask the patient what he understands about his condition
• Identify the specific reasons for refusal (fear of surgery, cosmesis, cultural beliefs, financial concerns, denial)

• Tell him plainly but compassionately: his airway is dangerously narrow and progressive obstruction can cause sudden respiratory arrest ("suffocation") if left untreated
• The tumor is growing and the situation will worsen without intervention
• Stridor indicates critical narrowing - this is a potential life-threatening emergency

• It is a breathing tube placed in the neck (not in the throat/tumor area)
• It is often temporary - can be removed once definitive cancer treatment is completed
• It prevents sudden airway obstruction while the patient receives definitive treatment (radiotherapy, surgery, or chemoradiation)

• Tracheostomy alone does not treat the cancer
• It is a life-saving bridge to definitive cancer treatment
• Without it, cancer treatment (radiotherapy, chemotherapy, laryngeal surgery) cannot be safely administered

• Without tracheostomy, progressive dyspnea, inability to sleep flat, inability to eat
• Risk of sudden total airway obstruction (acute asphyxia) - potentially fatal within minutes
• Inability to proceed with any anti-cancer therapy safely

• Endoscopic tumor debulking (CO2 laser/microdebrider) to relieve airway obstruction - a temporary measure that may defer tracheostomy
• Emergency tracheostomy under local anesthesia is always possible if condition deteriorates
• If the patient opts for non-surgical treatment, tracheostomy may still be required if airway deteriorates during radiotherapy (radiation edema)

• With patient's consent, involve close family members or caregivers in the discussion
• Cultural and religious sensitivities should be acknowledged

• If the patient still refuses after full counseling, document the informed refusal
• Ensure he understands the risks, signs of acute airway obstruction, and when to return/call for help
• Arrange close follow-up

TNM "T" Classification of Squamous Cell Carcinoma - Supraglottis (AJCC)

Subsites of the Supraglottis (for T1 reference):

• Suprahyoid epiglottis (lingual and laryngeal surface)
• Infrahyoid epiglottis
• Aryepiglottic folds (laryngeal surface)
• Arytenoids
• False cords (ventricular folds)

Stage Grouping (for completeness):

Causes of Hoarseness of Voice (for KMCRI question)

Laryngeal Causes:

• Inflammatory: Acute laryngitis, chronic laryngitis, TB larynx, syphilis
• Neoplastic: Carcinoma larynx (SCC), benign tumors (polyp, nodule, papilloma)
• Trauma: Foreign body, post-intubation granuloma, cricoarytenoid joint injury
• Functional: Functional dysphonia, puberphonia

Neurological (Recurrent Laryngeal Nerve Palsy):

• Left side: Lung carcinoma (commonest), aortic aneurysm, mediastinal tumors, thyroid carcinoma, post-cardiac surgery
• Right side: Apical lung tumors, thyroid carcinoma
• Bilateral: Central causes (bulbar palsy, MS), bilateral thyroid surgery

Systemic/Endocrine:

• Hypothyroidism (myxedema voice)
• Acromegaly
• Amyloidosis

Other:

• Severe GERD / LPR
• Reinke's edema
• Psychogenic causes

Summary of Management of Carcinoma Larynx

• Single modality: Surgery or Radiotherapy
• Glottic T1/T2: Trans-oral laser microsurgery (TLM), CO2 laser cordectomy, or primary RT (81-90% local control for T1)
• Aim: Laryngeal preservation

• Combined modality therapy
• Options:
  • Organ preservation protocol: Concurrent chemoradiotherapy (cisplatin-based) - VA larynx trial established this
  • Surgery: Total laryngectomy ± partial pharyngectomy + post-op RT
  • Neck dissection: Bilateral selective (Levels II-IV) for supraglottic; unilateral selective for glottic

• Creates a permanent tracheostome
• Voice rehabilitation options: tracheoesophageal puncture (TEP) with voice prosthesis, esophageal speech, or electrolarynx

• Indicated for impending/acute airway obstruction
• Preferred under local anesthesia for a compromised airway
• Endoscopic debulking preferred over tracheostomy if feasible (avoids stomal seeding)
• High tracheostomy preferred if future total laryngectomy is planned