Case Discussion: Laryngeal Tumor + Cervical Spine Tumor with Paraplegia

Part 1 — Laryngeal Tumor

Classification & Anatomy

Presentation

• Hoarseness — earliest sign of glottic tumors (vocal cord involvement)
• Dysphagia, odynophagia — supraglottic tumors
• Stridor, airway compromise — advanced disease
• Neck mass — cervical lymph node metastasis (more common with supraglottic tumors)

TNM Staging (AJCC) — Key Points

• T1: Tumor limited to vocal cord(s), normal mobility
• T2: Tumor extends to supra/subglottis, or impaired cord mobility
• T3: Vocal cord fixation; paraglottic space invasion
• T4a: Thyroid cartilage invasion; extends beyond larynx
• T4b: Prevertebral space invasion, carotid encasement, mediastinal involvement

• cN1: Single ipsilateral node ≤3 cm
• cN2: Multiple/bilateral nodes; none >6 cm, ENE(−)
• cN3: Node >6 cm or any node with clinically overt extranodal extension (ENE+)

Management Principles

Part 2 — Cervical Spine Tumor Causing Paraplegia (Malignant Spinal Cord Compression)

Pathophysiology

• Quadriplegia/paraplegia depending on level
• Respiratory compromise (high cervical — C3–C5 diaphragm control)
• Bladder/bowel dysfunction

Clinical Features

• Radicular pain at the level of compression
• Sensory loss distal to the level (hyperesthesia at level → anesthesia below)
• Urinary retention, fecal incontinence, impotence — late/severe signs
• Paraplegia — established motor deficits >12 h have poor recovery prognosis; >48 h, recovery is very unlikely

Diagnosis

• Images entire spinal column (up to 40% of patients have silent metastases at other levels)
• T1: vertebral metastases hypointense vs. normal marrow
• Gadolinium enhancement may normalize appearance (can be deceptive)
• Distinguishes tumor from epidural abscess, hematoma, tuberculoma

Treatment — Urgency is Critical

Emergency — treatment must begin immediately. Once paraplegia is established >48 h, functional recovery is very poor.

• Ambulatory at diagnosis → ~90% remain ambulatory after radiotherapy
• Non-ambulatory but has motor function → ~50% recover ambulation with RT
• Complete paraplegia at diagnosis → very few recover lower extremity motor function

Part 3 — Clinical Considerations in This Combined Case

Most Likely Scenario: Laryngeal SCC with Cervical Spine Metastasis → Cord Compression

• Laryngeal SCC with T4b disease can invade the prevertebral space directly
• Advanced laryngeal/hypopharyngeal cancer can also spread to cervical lymph nodes and adjacent cervical vertebrae
• Resulting epidural compression → paraplegia

Workup Priority

1. Urgent MRI full spine with gadolinium — characterize cord compression level and extent
2. CT neck/chest/abdomen/pelvis — staging of laryngeal primary and systemic disease
3. PET-CT — define full extent of metastatic burden
4. Laryngoscopy + biopsy — histologic confirmation of laryngeal tumor
5. Multidisciplinary team (MDT) review — oncology, neurosurgery, ENT/head & neck surgery, radiation oncology, palliative care

Management Priorities (Simultaneous)

Physiotherapy Management — Laryngeal Tumor + Cervical Spine Tumor with Paraplegia

⚠️ Pre-Physiotherapy Safety Checklist

• Spinal stability status — confirmed by spinal surgeon/oncologist; unstable spine = strict restrictions
• Current dexamethasone dose and response
• Platelet count — if <50 × 10⁹/L, manual techniques are contraindicated
• Pain control — optimize analgesia before therapy
• Airway status — laryngeal tumor may cause partial obstruction; coordinate with ENT team

Phase 1 — Acute / Unstable Spine (Pre-RT or Pre-Surgery)

Goal: Prevent complications of bed rest; educate patient; prepare for mobilization

Positioning & Bed Rest

• Patient nursed supine, one pillow (spinal precautions)
• Log rolling technique for all turns (with team assistance; maintain spinal alignment)
• 2-hourly repositioning to prevent pressure ulcers
• Heel protectors; pressure-relieving mattress
• No sitting, standing, or transfers until spine declared stable by MDT

Upper Limb & Passive Exercises (in bed)

• Passive range-of-motion (PROM) to all paralyzed limbs 1–2×/day
• Active-assisted exercises for any preserved motor function
• Upper limb active exercises to maintain strength (important for future wheelchair independence)
• Ankle/foot exercises — dorsiflexion pumps ± anti-embolic stockings → prevent DVT and drop foot contracture

Respiratory Physiotherapy (especially critical here — laryngeal tumor complicates airway)

• Respiratory assessment on admission
• Active Cycle of Breathing Technique (ACBT) — huffing, breathing control, thoracic expansion
• Postural drainage (within spinal precautions)
• Assisted cough technique if cough is weak:
  • Hands placed bilaterally over lower thorax; push inwards and upwards during cough attempt
  • (Contraindicated over rib metastases)
• Monitor SpO₂; suction if secretions cannot be cleared
• Incentive spirometry if available

Patient Education

• Explain purpose of physiotherapy and expected recovery trajectory
• Teach log roll technique to patient and family
• Educate on pressure ulcer prevention (skin inspection)
• Neurogenic bladder management advice (in coordination with nursing)
• Set realistic, goal-directed expectations

Phase 2 — Post-Radiotherapy / Post-Surgical Stabilization

Goal: Progressive mobilization; regain maximum functional independence

⚠️ Completion of radiotherapy does NOT automatically mean the spine is stable — re-assess with MDT before mobilizing.

Progressive Mobilization

Strengthening Programme

• Graded resistance exercises — target preserved muscle groups
• Focus on upper limbs (shoulder depressors, triceps, wrist extensors) for wheelchair propulsion
• Core stabilization (within pain and spinal stability limits)
• Electrical stimulation (NMES/FES) — to weak/partially paralyzed muscles to reduce atrophy and facilitate motor recovery

Spasticity Management

• Stretching programme — daily passive stretching of spastic limbs (hip flexors, hamstrings, calf)
• Splinting/casting — if spasticity causes contracture risk (foot drop splint at night)
• Positioning in anti-spasticity patterns

Pain Management (Physiotherapy Contribution)

• TENS (Transcutaneous Electrical Nerve Stimulation) — for neuropathic pain and bone pain
• Heat/cold therapy (if sensation intact — assess carefully)
• Manual therapy — only in stable spine with oncologist clearance; gentle soft tissue techniques for paraspinal muscle spasm
• Positioning aids and supportive seating

Neurogenic Bladder & Bowel

• Education on bladder drainage and catheter care (in liaison with nursing)
• Pelvic floor awareness exercises (if partial innervation retained)
• Bowel management positioning advice (upright sitting optimizes bowel transit)

Phase 3 — Rehabilitation / Community Phase

Goal: Maximize independence, quality of life, community reintegration

Functional Rehabilitation

• ADL training — dressing, grooming, feeding from wheelchair level
• Home visit — assess and adapt home environment; liaise with OT for ramps, grab rails, hospital bed
• Wheelchair skills training — propulsion, pressure relief lifts (every 15–20 min to prevent pressure sores), curb negotiation
• Driving assessment — if appropriate and patient wishes

Exercise Programme (Evidence-Based)

• Aerobic training via upper limb ergometry (arm cycling) — improves cardiovascular fitness, fatigue, and QOL
• Evidence: Exercise in advanced cancer meta-analysis (PMID 35411694) — physical exercise significantly reduces fatigue and improves physical function even in advanced-stage cancer
• Target: 20–30 min, 3–5×/week, moderate intensity (RPE 12–14), adapted to tolerance

Fatigue Management

• Energy conservation techniques — pacing, activity scheduling, rest-activity balance
• Cognitive-behavioral strategies for cancer-related fatigue (in liaison with psychologist)

Laryngeal Tumor — Specific Physiotherapy/Rehabilitation Inputs

Precautions & Contraindications

Summary Framework

ACUTE PHASE          → Prevent complications (DVT, pressure sores, respiratory failure)
                        Respiratory PT (critical — laryngeal + cord compression)
                        Passive ROM, positioning, patient education

SUBACUTE PHASE       → Progressive mobilization post-RT/surgery
                        Strengthening, wheelchair training, spasticity management
                        Pain management (TENS, positioning)

CHRONIC/COMMUNITY    → Maximize independence, ADL training
                        Upper limb aerobic training
                        Fatigue management, home adaptation
                        Laryngeal rehabilitation (SLP-led with PT support)