PHAYNX AND LARYNX benign conditions.pptx

The anatomy and the benign conditions of the pharynx and larynx

1. BENIGN AND MALIGNANT CONDITIONS OF PHARYNX AND LARYNX

2. ANATOMY OF PHARYNX ► The pharynx is a musculomembranous tube that extends from the base of the skull to the level of the sixth cervical vertebra.. Pharynx composed of 3 distinct areas: ► Nasopharynx : The upper portion of the pharynx, the nasopharynx , extends from the base of the skull to the upper surface of the soft palate ▸ Oropharynx : located between the soft palate and the superior border of the epiglottis. ► Laryngopharynx : located between the superior border of the epiglottis and inferior border of the cricoid cartilage (C6), Pharyngeal walls composed of superior, middle & inferior pharyngeal constrictor muscles.

3. NASOPHARYNGEAL TUMORS ► Benign (non-cancerous) & malignant (cancerous). ► Benign tumors Rare Occur in children and young adults Include tumors or malformations of the vascular system, such as angiofibromas and hemangiomas , and benign tumors of the minor salivary glands that are found within the nasopharynx

4. MALINANT CONDITIONS Presentation Neck mass (most common initial symptom, 70%). Serous otitis media from eustachian tube obstruction (second most common presentation, 50%). Nasal obstruction. Cranial nerve palsies ( abducent nerve most common cranial nerve palsy) Villaret's syndrome* Recurrent epistaxis . Trismus , headache.

5. RISK FACTORS Regional distribution (Southern China, Northern Africa, Southeast Asia, Alaska, Greenland). Epstein-Barr Virus (EBV) most immunological finding in nasopharyngeal cancer Genetic predisposition (genotypes HLA-A2 and HLA-Bsin2). Nitosamines (smoked meat and salted fish).

6. DIAGNOSTIC TESTS Diagnosis is made by biopsy of the nasopharyngeal mass. Workup includes the following: Careful visual examination (by fiberoptic endoscopic examination or examination under anesthesia [EUA]). Documentation of the size and location of the tumor and neck nodes. Evaluation of cranial nerve function including neuro -ophthalmological evaluation and audiological evaluation. Computed tomographic (CT) scan or positron emission tomography (PET)-CT scan. Magnetic resonance imaging (MRI) to evaluate skull base invasion. Epstein-Barr virus titers.

7. OROPHAYNGEAL TUMORS Benign oropharyngeal tumor Papilloma : usually asymptomatic, surgical excision is the treatment of choice. (HPV) Haemangioma : may be capillary or cavernous. Treatment is diathermy coagulation or injection of sclerosing agents. Cryotherapy and laser coagulation is also effective Pleomorphic adenoma: mostly seen submucosally on the hard or soft palate. It is potentially malignant and should be excised totally. Mucous cyst: usually seen in vallecula . Surgical excision is the treatment of choice in case of symptomatic cysts Lipoma

8. Malignant oropharyngeal tumor Squamous cell carcinoma being by far the most common histologic type. The most important causative factors are prolonged tobacco and alcohol exposure Potential fascial spaces: The retropharyngeal space the parapharyngeal space When invasion does occur, tumors may spread into these potential spaces

9. Common sites of malignancy in oropharynx are: Tonsil and tonsillar fossa (most common) Base of tongue Posterior pharyngeal wall

10. PRESENTATION Older than 45 years of age Throat discomfort. Odynophagia Otalgia Trismus , dysphagia , and dysarthria may develop with deeper invasion. Bleeding, aspiration, airway obstruction, and weight loss (Late). Neck mass (most of the patients with oropharyngeal primaries present with cervical adenopathy at the time of diagnosis)

11. Treatment Surgery Preferred treatment for most oropharyngeal and hypopharyngeal cancers. The cancer is considered localized Tumor is considered surgically resectable . Likely to obtain clean surgical margins Radiotherapy Postoperative to improve clinical outcomes Higher-stage or larger tumors Local invasion or metastasis May be used by itself or in combination with chemotherapy in cases where the tumor may be too large to be surgically removed Most cases of nasopharyngeal cancer ((no role for surgery in treatment)) ‣ Useful as palliative treatment

12. Chemotherapy Sometimes used with radiation in metastatic, unresectable and/or recurrent tumors. Postsurgically with radiation in late-stage or aggressive cancers. Rarely effective by itself in pharyngeal cancer, but is instead a valuable part of a multimodality treatment approach. Immunotherapy In Advanced Nasopharyngeal Cancers, because associated with Epstein-Barr virus (EBV) infection, an immunotherapeutic treatment was designed to target this virus. Investigators isolated T cells from the blood of EBV-positive nasopharyngeal cancer patients, and then modified the T cells to attack the EBV virus.

13. Prognosis Pharynx cancer tends to grow silently with symptoms of cancer often not evident until the cancerous disease is quite advanced. The early the diagnosis the better the prognosis Involvement of lymph nodes in the region is associated with a poorer prognosis of the cancer. 5 year survival rate is between 15-70% However, in some cancer patients the course of pharynx cancer is more indolent with a long survival rate even if the cancerous disease itself has been controlled but not cured. Smoking and alcohol worsen the survival rate.

14. Laryngeal tumours can be classified into benign and malignant. .Benign tumours are rare and include the following types. 1.Papilloma it may be single in adult or multiple in infants and children ,this type was discussed under the subject of stridor. 2.Chondroma it is more frequent in men ,present at the 6_7 th decade. It affect mostly the cricoid cartilage ,present with hoarseness and it is difficult to be differentiated from chondrosarcoma on histopathology. Treatment is by surgical excision.

15. 3.Paraganglioma more frequent in women ,present at 4_6 th decade. It arises from laryngeal paraganglia ,highly vascular lesion, it presents with hoarseness and treated by conservative surgical excision. Other types like schwanoma,neurofibroma and lipoma are extremely rare. Malignant tumours like squamous cell carcinoma ,lymphoma and lymphoepithelial tumour. Squamous cell carcinoma . It is the most common malignant tumours in the head and neck region.

16. It is more common in men due to high consumption of tobacco and alcohol although the incidence started to rise in women . Pathology . Macroscopically ,the tumour may be exophytic or endophytic ,microscopically ,it is characterized by the presence of prickle cells and keratin whorls. The tumour may be well, moderately or poorly differentiated, the first type is radio resistant in contrast to the last one which is radiosensitive.

17. Spread , the tumour may spread by the following routes; 1.Direct spread from the parts of the larynx to nearby structures like preepiglottic space ,thyroid cartilage ,tongue, pharynx and even skin. 2.Lymphatic , spread of glottic cancer is less common than other sub sites due to lack of lymphatics in this area while supraglottic tumours spread rapidly to the lymph nodes because this sub site is rich in lymphatics and the patient may present with cervical lymphadenopathy before laryngeal symptoms ,the lymph nodes mostly involved are submandibular,jugulodigastric,juguloomyohyoid and occipital groups.

18. Haematogenous spread to the lung, liver and bones. Risk factors; 1.Tobacco smoking. 2.Alcohol drinking . 3.Asbestos exposure. Clinical presentations. 1.General ; Laryngeal cancer may present with general symptoms like weight loss, anemia and paraneoplastic symptoms like neuropathy and rash.

19. Glottic cancer; Change of voice or hoarseness is the early symptom and any patient has hoarseness that continues for more than 3 weeks should be subjected for laryngeal examination by laryngoscope. Advanced lesions may lead to airway obstruction causing progressive dyspnea and stridor . Hemoptysis is usually associated with larger tumours. Referred otalgia is a sinister sign suggesting deep invasion. Dysphagia and odynophagia are rare and indicate advanced disease. Cervical lymphadenopathy is rare presenting symptom .

20. Right vocal cord carcinoma

21. Rt vocal cord carcinoma

22. Supraglottic cancer; Change of voice ,voice alteration is different from that seen with glottic and subglottic cancer. Small supraglottic lesions may present with globus or foreign body sensation . Hemoptysis in exophytic lesions. Hot potato voice in large lesions. Hoarseness if there is extension to the vocal cords. Referred otalgia ,odynophagia and true dysphagia indicate lateral extension of the tumour. Cervical lymph adenopathy may the first presenting symptom without any laryngeal symptoms . Stridor is late presentation and indicates advanced cancer.

23. Subglottic cancer; Globus felling or foreign body sensation in the throat. Hoarseness due to glottic or recurrent laryngeal nerves involvement. Progressive dyspnea and stridor in circumferential lesions. The tumour may involve the thyroid and may mimic a thyroid isthmus lesion. Examination; It includes general and ENT examination.

24. ENT examination; It includes complete examination by endoscope to check the site of the lesion,extension to the adjacent subsites,pyriform fossa,base of the tongue and check the mobility of the vocal cords . Neck examination to detect the cervical lymphadenopathy and thyroid gland to exclude its involvement. Drawing of the findings and video_recordings for documentation and follow_up .

25. Radiology ; 1.CT scan. Laryngeal tumours on CT scan are typically of soft_ tissue attenuation and enhance with intravenous contrast media. 2.MRI . The tumour has high water content and so has high intrinsic contrast on T2-weighted MRI . Both CT and MRI are complementary in detection of the tumour,its size ,extension and cartilage invasion. It is better to do radiological examination before taking biopsy because taking biopsy will affect the size and extension of the tumour.

26. Endoscopy and biopsy. Any patient with suspected laryngeal mass should be subjected for direct laryngoscopy (DL) and taking biopsy under general anesthesia. Complete investigations should be done for the patient before surgery in addition to ECG and chestX -ray . The patient should be informed that tracheostomy may be needed during or after surgery. The biopsy taken should be representative and not taken from necrotic areas. While the patient under GA ,we can asses the neck well for the presence or absence of cervical lymphadenopathy. At recovery from anesthesia,vocal cord mobility can be checked.

27. Staging of the tumour ; Any tumour should be staged clinically to know the size of the tumour , extension,lymph node involvement and distant metastases. Staging will detect the type of treatment required and predict the prognosis . The single most prognostic factor in head and neck tumours is the presence or absence of lymph adenopathy. The laryngeal cancer is curable disease and this will put a burden on the otolaryngologist to discover it early and treat it well.

28. Staging of glottis cancer

29. Staging of supraglottic cancer

30. Staging of the laryngeal carcinoma (T staging) depends on the sub site but the (N and M) staging is the same for all. Treatment; As mentioned previously, the type of treatment depends on the site of tumour ,size and the presence or absence of lymph nodes. Treatment requires a multidisciplinary team including surgeons,radiotherapists,physicians and speech therapists. Early_stage disease may be treated endoscopically or with radiotherapy. Advanced disease may be treated with laryngectomy or chemo radiotherapy.

31. 1.Radiotherapy; This type of treatment is indicated for early(T1) tumours but scrupulous follow-up is needed to detect the recurrence early. It may be complicated by laryngeal perichondritis which may require heavy antibiotics and even admission to hospital. It may be given before or after surgery. 2.Chemotherapy. It can be given alone for the patient or in combination with radiotherapy

32. 3.Endoscopic resection. It is indicated for early lesions ,and can be done with the aid of CO2 laser and should be done by expert surgeon. 4.Laryngectomy . It is partial or total removal of the larynx and may be classified into the following; A.Partial laryngectomy which includes partial vertical( cordectomy ) and partial horizontal laryngectomy. B.Total laryngectomy which includes removal of the whole larynx with its cartilages in addition to partial thyroidectomy, strap muscles and hyoid bone and the patient will be left with permanent tracheostomy.

33. 5.Treatment of the lymph nodes . Treated by radiotherapy or surgery(neck dissection)

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