Supraglottis - need preserve 2/3 - cricoartenoid joints, epiglottis for swallow rehabilitation
European Laryngological Society Classification Supraglottic Carcinoma
Type 1 - superficial tumour
Medial supraglottic laryngectomy with partial resection of pre-epiglottic space
Type IIa Tumours of laryngeal surface of epiglottis located above the hyoid bone: resection includes the suprahyoid epiglottis
Type IIb Tumours extending below the hyoid: resection includes a total epiglottectomy
Medial supraglottic laryngectomy with resection of the pre-epiglottic space
IIIa Tumours extending to petiole of epiglottis: resection must include the pre-epiglottic space
IIIb Tumours of the infrahyoid epiglottis extending to the ventricular fold: resection includes ventricular folds dissected from the thyroid cartilage
Lateral supraglottic laryngectomy
IVa Tumors of the threefolds’ region: resection of free edge of the epiglottis, the aryepiglottic fold, the pharyngo-aryepiglottic fold and the ventricular fold
IVbTumour extending to arytenoids: resection includes the arytenoids and inner/medial or anterior wall of the pyriform fossa
Human Papilloma Virus
non-enveloped and contain a circular double stranded DNA
Exerts effects via p53 & pRb
p53=tumour suppressor gene, if dna damage - repair or apoptosis
retinoblastoma protein = tumour suppressor, regulates progression G1 to S
HPV tumours nonkeratinising, basaloid morphology
Early T stage, advanced N stage presentation
Tests - need demonstarted HPV biological activity
HPV DNA tests
PCR E6 protein
Chromogenic in situ hybridisation
Tests HPV activity
PCR cDNA E6 & E7
Surrogate markers - overexpression p16
Neurofibromatosis type 2
< 18 years, isolated meningioma or vestibular schwannoma has a 20% and 10% risk of having NF2 respectively.
Management aim = maintain function quality of life whilst managing the tumour load.
majority tumours demonstrate significant growth,
growing by at least 5mm/year in over 80% of patients
surgery more difficult, facial preservation rate lower
Stereotactic radiosurgery controls tumour growth in 60-92% of cases over a five-year period, 33-57% chance of preserving serviceable hearing over a five-year period, up to 10% facial weekness but ?malignant transformation poorer outcomes after salvage surgery
Bevacizumab, an anti-vascular endothelial growth factor monoclonal antibody
auditory brainstem implantation
electrode in brainstem cochlear nucleus, provide aid to lip reading, implant even if unilateral disease to maintain neural plasticity
MRI 1.5 tesla & head bandage
Spinal schwannomas and meningiomas may require excision if they are causing compressive symptoms
children start at 10 mri/audiology up age 40
Once diagnosed annual MRI head, 3yrly spine if spinal tumour, otherwise 5 yearly
Changes caused by
Mass changes - alter pitch(fundamental frquency)
Poor closure - breathy/weak voice
Changes vibration/tension vocal cord - harshness
rate of each cycle of vibration of the folds determines the fundamental frequency (pitch) and the amplitude ofthe wave (its loudness).
Periodicity (the regularity of apparent successive cycles of vocal fold vibration)
Amplitude (the extent of horizontal excursion of the vocal folds)
Presence of stiffness or adynamic (non-vibratory segments) on the vocal fold
Pattern of closure.
Laryngeal biomechanics (pattern of closure)patterns
Glottic - posterior chink due to posterior cricoartenoid, seen with nodules
Supraglottic - lateral squeeze, often compensating for underlying glottic insuifficiency
Supraglottic - ant - post squeeze
Supratentorial - vocal cords abducted for phonation but normal for laughing, coughing,whistling
High seed video - aphonic voice,children
Kymography - digital technique for high-speed visualization of vibration at one point along vocal cords, 8000f/sec
Voice quality measurement
Subjectively -Voice handicap index(VHI-10)
Objectively - GRBAS Grade(overall),Roughness, Breathiness, Asthenia and Strain. 0 = normal, 1 = mild, 2= moderate, and 3 = severe
rectus muscles of orbit (esp medial rectus), mylohyoid muscle, palatine and lingual tonsils and major salivary glands can all display increased SUV(standardised uptake values) compared to surrounding tissues.
Also brain and renal tract- FDG-glucose not reabsorbed
Fast 4hrs pre scan so normal tissues metabolising free fatty acids
Lie still 45 mins after injection so muscles do not use glucose
CT/MR identify 80% primaries
PET 1/3 of remainder
Advanced disease changes management plan 10-20%
Better at estimating gross tumour volume than CT
Disease response surveillance
overall sensitivity of 94% and specificity of 82% following chemo-radiotherapy or radiotherapy, and 89% and 74% respectively for laryngeal tumours.
Neck disease - normally upstages
Other uses - melanoma, lymphoma
Comprehensive - levels 1-5
- Modified radical
- Extended more levels or non lymphatic structures
- Elective - occult nodes, if >20% chance occult mets
Poor prognostic indicators
Carotid invasion 10% 5yr survival
Skin invasion 15% 5 yr survival
Salvage surgery following recurrence post neck dissection <5%
5% solitary nodules malignant on US, 10% palpable
Malignancy in MNG 5-20%
US feaures suggestive of malignancy
hypoechogenicity, irregular margins, absence of through transmission, micro-calcification and nodule size greater than 3cm
Salivary gland malignancy
Molinary et al 1993 Meta-analysis 23% local control benefit with post op radiotherapy
Veterans Administration Cooperative Study randomised 332 patients with Stage III or IV glottic or supraglottic carcinoma to receive laryngectomy and postoperative radiotherapy or 3 cycles of neaodjuvant cisplatin and 5FU chemotherapy followed by definitive radiotherapy in responders. Larynx preservationwas possible in 64% of patients randomized to the neoadjuvant chemotherapy arm without detriment to overall survival.
3 arm study comparing neoadjuvant chemotherapy followed by radiotherapy versus concurrent chemoradiotherapy versus radiotherapy alone. There was no difference in the survival rates, but the rates of laryngeal preservation were higher in the groups assigned to either concurrent chemotherapy or neoadjuvant chemotherapy.
Neoadjuvant chemo - cisplatin/5-fu 5–6 days via an intravenous infusion every 3 weeks. Usually 2–6 cycles
EORTC 22931 trial randomised 334 patients to receive either post-operative concurrent chemoradiotherapy or radiotherapy alone. Concurrent treatment has improved the 3 year disease free survival from 41% to 59% and the 3 year overall survival from 49% to 65%. There is no difference in the rate of metastatic relapses.This benefit is at the cost of increasing acute radiotherapy toxicity (grade 3 and above) from 21% to 41%. Concurrent CRT should be considered for high risk postoperative cases (for instance, those with positive margins or extracapsular extension in nodal disease).
Saliary fistula/sialocoele aspirat, botox if persistent, fistula manage conservatively
malignant transformation up to 5% over 20 years
If >4cm dont treat conservatively, increased risk malignancy
RCT pharyngeal SCC IMRT v CRT
significantly less xerostomia, no significant difference survival
EORTC 22791 trial were randomised to receive conventional treatment or 80.5Gy given in twice daily fractions of 1.15Gy per fraction over 7 weeks. Hyperfractionation resulted in an increase in tumour control from 40% to 59% with no increase in late normal tissue toxicity.
specifically uptaken by thyroid, some salivary gland uptake & lactating breast
Half life 8 days
beta(tissue damage) and gamma radiation(detectable)
Papillary <1cm, Follicular no vascular invasion <2cm
Post surgery radiotherapy 60G no worrying features, 66Gy worrying features
Palliative radiotherapy 27 Gy in 6 does, X3/week
Bilateral parotid swelling investigations
Muscle tension dysphonia
Type I: Glottic/laryngeal isometry features a posterior chink due to simultaneous (and inappropriate) contraction of the posterior cricothyroid muscle and lateral cricoarytenoid muscle during phonation.
Type II: Supraglottic/plica ventricularis is A false vocal fold approximation that may be functional or compensatory.
Type III: Supraglottic/partial anterior-posterior contraction.
Type IV: Supraglottic/complete anterior-posterior contraction in which the petiole of the epiglottis approximates the arytenoids.