Barona, Titus Levi

Briosos, Harold B.
Ruiz, Elenita Rose B.
Sy, Stephanie
Sy, Ysabella

Case Presentation

History and P.E.

General Data

This is the case of A. B, 68 years old

male, married, Filipino, Roman
Catholic, born on November 22,
1947, currently residing at Dela
Fuente St, Sampaloc , Manila and
was admitted in our institution on
January 6, 2016

Chief Complaint
Vomitting of Blood

History of Present Illness

3 months prior to admission, patient
noticed a gradually enlarging marble
like mass on both lateral neck, nontender, movable associated with nonproductive cough (whitish phlegm),
odynophagia and hoarseness. Patient
sought consult at San Lazaro Hospital,
Chest x-ray was done which revealed
pulmonary tuberculosis thus referred

2 months PTA
still with above sign and symptoms,
now associated with difficulty of
breathing. Patient sought consult in
our institution where fine needle
aspiration biopsy was done on the
neck mass which revealed squamous
papilloma with chronic inflammation.
Trachestomy was also done.

1 month PTA

Persistence of the above sign and

symptoms prompted the patient to
once again seek consult in our
institution. Repeat fine needle
aspiration
biopsy
was
done
revealing squamous cell carcinoma
grade 1-2.

Past Medical History

(+) Hypertension- since 1995, Losartan 50
mg/tab OD
(+) Pulmonary Tuberculosis- unrecalled year,
incomplete medication ( 2 months)
(-) kidney Disease
(-) Asthma
(-) CVD
(+) previous surgery- Appendectomy,
unrecalled year

Family History
(+) Hypertension- maternal side
(+) Diabetes Mellitus- maternal side
(+) Pulmonary Tuberculosis- maternal
side
(-) Kidney disease
(-) Cancer

Personal and Social History

(+) smoker- 30 pack years
(-) alchoholic beverage drinker
(-) illicit drug use

Physical Examination
(+) patent external auditory canal,
both ears
(+) patent tymphanic membrane,
both ears
Midline nasal septum
No nasal discharge

No tonsillipharyngeal congestion

6X3X2 cm multilobulated
tender movable
Movable mass

tracheostomy

3X2X2 cm non

Salient Features
30 pack years smoking history
Odynophagia
Hoarseness
Gradually enlarging neck mass
Male

Differential Diagnosis

ESOPHAGEAL CARCINOMA
(lower portion)
RULE IN
+ More common in male
+ Dysphagia/
odynophagia
+ Hoarseness of voice
+ Smoker
+ Hematemesis
+ Easy fatigability
+ Weakness

RULE OUT
Weight loss
Chest pain
Worsening indigestion
or heartburn
No history of acid
reflux
No history of alcohol
intake
Obese

LARYNGOCELE
A rare, benign dilatation of the laryngeal
saccule that may extend internally into the
airway or externally through the thyrohyoid
membrane.
It may be congenital or acquired and may
occur at any age

LARYNGOCELE
RULE IN
+ Hoarseness
+ Dyspnea
+ Dysphagia
+ Mass
+ Cough

RULE OUT
Common to middle age
Hematemesis
Easy fatigability
Weakness

PARAGANGLIOMA
Rare neuroendocrine neoplasm that may
develop at various sites of the body, and
may present as a painless mass.
Appear grossly as sharply circumscribed
polypoid masses, with firm to rubbery
consistency.

PARAGANGLIOMA
RULE IN
+ 40-70 years old
+ Mass
+ Hoarseness
+ Dysphagia/
odynophagia
+ Hypertension

RULE OUT
More
common
in
women
Aural
signs
and
symptoms
Hematemesis
Easy fatigability

EXTRAPULMONARY TB
RULE IN
+ Filipino
+ Cough
+ Smoker
+ Hoarseness
+ Easy fatigability
+ Weakness
+ Dyspnea
+ Dysphagia
+ Hematemesis
+ Cervical
lymphadenopathy

RULE OUT
Night sweats
Weight loss
Chills
Loss of appetite

Final Diagnosis
Squamous Cell Carcinoma, Larynx,
Transglottic (T4a, N2b, M0)

ANATOMY
of
L A the
RYNX

 Protective
sphincter at
the inlet of
the air
passages
Voice
production

CARTILAGES OF THE
LARYNX

VOCAL
PROCES
S

MUSCULA
R
PROCESS

MEMBRANES &
LIGAMENTS OF THE
LARYNX

MUSCLES OF THE
LARYNX

ELEVATIO
EXTRINSIC MUSCLES

MUSCLES OF THE
LARYNX

DEPRESSI
EXTRINSIC MUSCLES

INTRINSIC MUSCLES

INTRINSIC MUSCLES

INTRINSIC MUSCLES

VASCULAR SUPPLY
SUPRAGLOTTIC
and GLOTTIC
Superior laryngeal
artery

SUBGLOTTIC
Inferior laryngeal
artery

 Superior laryngeal
veins drain into the
superior thyroid veins,
which empty into the
internal jugular veins.
The inferior laryngeal
veins drain into the
inferior thyroid veins,
which both empty into
the left brachiocephalic
vein

LYMPHATIC DRAINAGE

NERVE SUPPLY
SUPERIOR
LARYNGEAL
NERVE
Motor innervation of the
extrinsic muscles
(external branch)
Internal sensory branch
supplies the mucosa of
the upper larynx

 RECURRENT LARYNGEAL NERVE

Supplies all the intrinsic muscles
Sensory fibers to the laryngeal mucosa below
the glottis and tracheal mucosa

TUMOR SPREAD
The PRE-EPIGLOTTIC
SPACE (PES) and the
PARAGLOTTIC SPACE
(PGS) provide pathways
for spread of laryngeal
tumors.

Case Discussion

Squamous Cell Carcinoma

of the Larynx
Most common
>95% of Laryngeal carcinomas
Male:Female 4-5:1
Accounts for 25% of head and neck cancers
Approx. 1/3 eventually die
Most prevalent in the 6th and 7th decades

Risk Factors

Smoking
Excessive alcohol consumption
Exposure to Human Papilloma Virus 16 &18
Chronic Gastric Reflux
Occupational exposures
Prior history of head and neck irradiation

Carcinogenesis

Environmental exposure, viral infection, spontaneous

mutation.
Alteration in the P53
Loss of cellular signaling mechanisms
Malignant transformation

Squamous Cell Carcinoma

Glottic

Supraglottic

Subglottic

Transglottic

Involves true
vocal cords

Confined to
the
supraglottic
area (free
border of the
laryngeal
epiglottis,
false vocal
cords and
laryngeal
ventricles

Extend or
arise more
than 10mm
below the free
margin of the
true vocal fold
up to the
inferior border
of the cricoid
cartilage

Cross the
ventricle from
the
supraglottic
area to
involve the
true and false
vocal folds or
involve the
glottis and
extend
subglotically
more than
10mm or both

 Glottic: mojority of laryngeal cancers (50%60%)

Supragtlottic: 30%-40%
Subglottic: <5%

Supraglottic

Glottic

Subglottic

- More Aggressive
- Direct extension
into pre-epiglottic
space
Lymph node
metastasis
Direct extension
into lateral
hypopharnyx,
glossoepiglottic fold,
and tongue base

- grow slower and tend

to metastasize late
owing to a paucity of
lymphatic drainage
- metastasize after they
have invaded adjacent
structures with better
Drainage
- Extend superiorly into
ventricular walls or
inferiorly into subglottic
space
- Can cause vocal cord
fixation

- Uncommon
- Glottic spread to
the subglottic
space is a
sign of poor
prognosis
- Increases chance
of bilateral disease
and
mediastinal
extension
- Invasion of the
subglottic space
associated with
high incidence of
stomal
reoccurrence

Manifestations
Supraglottic
Chronic sore
throat
Dysphonia
Dysphagia
Neck mass
secondary to
regional
metastasis

Glottic
Hoarseness
Airway
obstruction
late symptom

Subglottic
Vocal cord
paralysis
Airway
compromise

Diagnosis and Staging

Assessment of vocal cord mobility as well as
local tumor extension
Laryngoscopy
used to assess the extent of local spread.
Radiographic imaging by CT and/or MRI
Cartilage erosion or invasion and extension
into the preepiglottic or paraglottic spaces.

TNM Staging
TX - Minimum requirements to assess
primary tumor cannot be met
T0 - No evidence of primary tumor
Tis - Carcinoma in situ

Staging-Supraglottis

T1

limited to one subsite of supraglottis with normal vocal cord

mobility

T2

involves mucosa of more than one adjacent subsite of

supraglottis or glottis, or region outside the supraglottis
without fixation

T3

limited to larynx with vocal cord fixation and or invades any of

the following: postcricoid area, preepiglottic tissue,
paraglottic space, and/or minor thyroid cartilage erosion

T4a

invades through the thyroid cartilage and/or invades tissue

beyond the larynx (e.g. trachea, soft tissues of neck including
deep extrinsic muscles of the tongue, strap muscles, thyroid,
or esophagus)

T4b

invades prevertebral space, encases carotid artery, or

invades mediastinal structures

Staging - Glottis
T1

Tumor limited to the vocal cord (s) (may involve anterior

or posterior commissure) with normal mobilty

T1
a

Tumor limited to one vocal cord

T1
b

Tumor involves both vocal cords

T2

Tumor extends to supraglottis and/or subglottis, and/or

with
impaired vocal cord mobility

T3

Tumor limited to the larynx with vocal cord fixation

and/or invades paraglottic space, and/or minor thyroid
cartilage erosion

T4

Tumor invades through the thyroid cartilage, and/or

Staging - Subglottis

T1

Tumor limited to the subglottis

T2

Tumor extends to vocal cord (s) with normal or

impaired
mobility

T3

Tumor limited the larynx with vocal cord fixation

T4
a

Tumor invades cricoid or thyroid cartilage and/or

invades
tissues beyond larynx

T4
b

Tumor invades prevertebral space, encases

carotid artery, or invades mediastinal structures

Staging - Nodes

N0

No cervical lymph nodes positive

N1

Single ipsilateral lymph node 3cm

N2a

Single ipsilateral node > 3cm and 6cm

N2b

N2b Multiple ipsilateral lymph nodes, each

6cm

N2c

N2c Bilateral or contralateral lymph nodes,

each 6cm

N3

N3 Single or multiple lymph nodes > 6cm

Staging - Metastasis

M0
M1

No distant metastases
Distant metastases
present

Stage Grouping

Treatment
CO2 Laser
Resection: severe
dysplasia and
carcinoma in situ
Radiotherapy
Chemotherapy
Partial/Total
Laryngectomy:
advanced tumors

T1-T2
Radiotherapy or surgery alone
85-95% cure rate

T3-T4 Lesions
Total Laryngectomy
Small T3 and lesser sized tumors can be
treated with partial laryngectomy

Post-op Radiation

Indications:
T4 primary
Bone/cartilage invasion
Vascular invasion
Multiple positive nodes
Nodal extracapsular extension
Subglottic extension of primary tumor

Chemotherapy
Advanced stage cancers
Cisplatinum and 5-flourouracil

Complications

Infection
Voice alterations
Loss of taste and smell
Tracheostomy dependence

Prognosis

5 year
survival
Stage 1
Stage 2
Stage 3
Stage 4

>95%
85-90%
70-80&
50-60%

 Patients considered cured after being

disease free for five years
Most laryngeal cancers reoccur in the first
two years
Treatment options the five year survival
has not improved much over the last thirty
years

Thank you!