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Carcinoma of the Larynx - Complete Exam Answer

Probable Clinical Diagnosis

• 65-year-old male farmer
• Hoarseness (change of voice) for 4 weeks - the cardinal symptom of glottic carcinoma
• Difficulty breathing (dyspnea) - suggests significant tumor bulk or subglottic extension causing airway compromise
• Long-standing tobacco chewing + bidi smoking = two major independent risk factors, acting synergistically

• 90% of laryngeal cancers occur after age 40 in tobacco users; M:F ratio 7:1

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b) How Will You Examine the Patient?

General Examination

• General condition, built, nutrition, pallor, cachexia
• Respiratory rate, SpO2, stridor (inspiratory = supraglottic, biphasic = glottic/subglottic)
• Cervical lymphadenopathy - level II, III, IV nodes (palpate both sides)

Local Examination

• Inspect neck for swelling, fullness, prominent laryngeal cartilages
• Palpate larynx - loss of crepitus on rocking larynx over spine (Muller's sign / "cricoid click" - Murat's sign) suggests post-cricoid/subglottic spread
• Palpate thyroid cartilage for tenderness or destruction
• Palpate hyoid bone
• Palpate bilateral cervical lymph nodes systematically (Levels I-VI)

• Use a size 5 or 6 laryngeal mirror
• Visualize: epiglottis, aryepiglottic folds, arytenoids, false cords, true vocal cords (TVCs), anterior commissure, posterior commissure, piriform fossae, subglottis
• Assess vocal cord mobility - pooling of saliva in pyriform fossa (suggests impaired swallowing/hypopharyngeal involvement)
• Note: color, surface (ulceration, exophytic growth, leukoplakia), extent

• Superior to mirror examination
• Dynamic assessment of vocal cord movements, subglottic extension, arytenoid involvement

Investigations to Order

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c) Expected Examination Findings

On Indirect Laryngoscopy:

• Glottic tumor (most common): Pearly-gray/white, irregular, ulcerated lesion on one or both vocal cords; restricted or absent vocal cord mobility; cord may be fixed (indicates T3)
• Supraglottic tumor: Mass on epiglottis, aryepiglottic folds, or false cords; pooling of saliva in pyriform fossa
• Anterior commissure involvement: lesion bridging both cords
• Mucosal irregularity, ulceration, or exophytic mass
• Adjacent mucosa may show leukoplakia / erythroplakia

On Neck Examination:

• Glottic Ca: Often NO lymph nodes (glottis has sparse lymphatics; N0 is common at presentation)
• Supraglottic Ca: Palpable cervical lymphadenopathy in 25-50% of cases at presentation, typically ipsilateral Levels II, III, IV; bilateral nodes if midline tumor
• Thyroid cartilage tenderness or palpable destruction - T4a disease

General:

• Stridor (biphasic = critical airway)
• Reduced vocal cord mobility or fixation
• Weight loss, dysphagia if advanced disease

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d) Counseling the Patient Refusing Tracheostomy

Why Tracheostomy is Recommended:

1. Secure the airway before definitive treatment (radiation or surgery)
2. Prevent acute airway obstruction - which can be fatal (sudden death from asphyxia)
3. Allow safer administration of anesthesia for microlaryngoscopy and biopsy
4. Enable definitive treatment - radiation therapy can cause initial tumor swelling, worsening obstruction

Counseling Points (Patient-Centered Approach):

"You have a growth in your voice box that is narrowing your airway. Your breathing difficulty will worsen - without securing the airway, you risk suffocating suddenly, even at rest or during sleep."

• Many patients fear tracheostomy = permanent disability or loss of voice
• Clarify: Tracheostomy can be temporary - it is a bridge to definitive treatment; in many cases it can be closed after laryngeal rehabilitation
• Explain the procedure is performed under anesthesia and is relatively safe

• Progressive dyspnea leading to acute respiratory failure
• Risk of aspiration pneumonia
• Emergency tracheostomy in crisis is far more dangerous than planned one

• After airway is secured → biopsy → staging → curative treatment (radiation ± surgery)
• Without airway security → definitive treatment cannot be safely initiated
• If cancer is early stage, voice preservation may still be possible with radiation or conservation surgery

• In selected cases, radiation can be started without tracheostomy if the tumor is not critically obstructing; however, this requires close monitoring in a hospital setting
• If patient refuses despite full counseling, document the refusal, ensure patient has 24-hour emergency access, and involve hospital ethics committee if needed

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TNM Staging - Carcinoma of Supraglottis (AJCC 8th Edition)

T Classification - Supraglottis:

Subsites of Supraglottis:

• Suprahyoid epiglottis
• Infrahyoid epiglottis
• Aryepiglottic folds (laryngeal aspect)
• Arytenoids
• False (ventricular) cords

N Classification (same for all larynx Ca):

M Classification:

• M0: No distant metastasis
• M1: Distant metastasis present (most common site: lungs)

Overall Stage Grouping:

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Causes of Hoarseness of Voice (for KMCRI 10-mark question)

Laryngeal Causes:

• Malignant: Carcinoma larynx (most important to exclude)
• Benign tumors: Polyp, nodule, papilloma, cyst, fibroma
• Inflammatory: Acute/chronic laryngitis, laryngeal TB, laryngeal syphilis
• Traumatic: Intubation injury, neck injury
• Systemic: Amyloidosis, pemphigus, sarcoidosis

Non-Laryngeal Causes (Recurrent Laryngeal Nerve Palsy):

• Mediastinal: Carcinoma esophagus/bronchus, mediastinal lymphadenopathy, aortic aneurysm, mitral stenosis (Ortner's syndrome)
• Neck: Thyroid carcinoma, thyroidectomy injury
• Central: Bulbar palsy, syringomyelia, MS, stroke
• Idiopathic

Functional/Other:

• Functional dysphonia
• Conversion aphonia
• Hypothyroidism (myxedema voice)
• Androphonia (puberphonia)

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• Probable diagnosis = Carcinoma Larynx (SCC, likely glottic given hoarseness as predominant symptom)
• 95% of laryngeal Ca = SCC; tobacco is the #1 risk factor
• Indirect laryngoscopy is the key bedside examination - assess cord mobility and tumor extent
• Tracheostomy refusal = explain life-threatening airway risk, temporary nature, treatment dependency
• Supraglottic T-staging: T1 (one subsite) → T2 (multi-subsite, no fixation) → T3 (fixation) → T4a (thyroid cartilage) → T4b (carotid/prevertebral/mediastinum)