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SECTION V — Diseases of Larynx and Trachea
B. CHONDROMA
Most of them arise from cricoid cartilage though they also
occur on thyroid or arytenoid cartilages. They may present in the subglottic area causing dyspnoea or may
grow outward from the posterior plate of cricoid and
cause sense of lump in throat and dysphagia. They affect
men four times more than women in the age group of
40–60 years.
CT scan is helpful and delineates its extent. Biopsy is
required for diagnosis. Use of CO2 laser is more helpful
in taking biopsy of this hard tumour. Treatment consists
of excision by laryngofissure or lateral pharyngotomy approach depending on the location of the tumour. Large
and recurrent tumours require laryngectomy.
Figure 61.8. Supraglottic papillomatosis.
Patient, often a child, between the age of 3 and 5 years
presents with hoarseness or aphonia with respiratory difficulty or even stridor. Diagnosis is made by flexible fibreoptic laryngoscopy and later confirmed by direct laryngoscopy and biopsy. Papillomas are known for recurrence
but rarely undergo malignant change.
Treatment consists of microlaryngoscopy and CO2
laser excision avoiding injury to vocal ligament. Recurrence is common and procedure needs to be repeated several times. In the absence of facilities of CO2 laser, tumour
can be removed under microscope with cup forceps or
a debrider similar to the one used in endoscopic nasal
surgery. Aim of therapy is to maintain a good airway, preserve voice and avoid recurrence.
Besides surgery, various medical therapies are being used an adjuvants. Interferon alpha-2a has shown
promising results but has several side effects including fever, chills, myalgia, arthralgia, headache, loss
of weight and suppression of bone marrow. Similarly
13-cis-retinoic acid has been used. This too has several
side effects.
2. Adult-onset papilloma
Usually, it is single, smaller in size, less aggressive and
does not recur after surgical removal. It is common in
males (2:1) in the age group of 30–50 years and usually arises from the anterior half of vocal cord or anterior
commissure. Treatment is the same as for juvenile type.
C. HAEMANGIOMA
Infantile haemangioma involves the subglottic area and
presents with stridor in the first 6 months of life. About
50% of such children have haemangiomas elsewhere in
the body particularly in the head and neck area. They
tend to involute spontaneously but a tracheostomy may
be needed to relieve respiratory obstruction if airway is
compromised. Most of them are of capillary type and can
be vaporized with CO2 laser.
Adult haemangiomas involve vocal cord or supraglottic larynx. They are cavernous type and cannot be treated
with laser. They are left alone if asymptomatic. For larger
ones causing symptoms, steroid or radiation therapy may
be employed.
D. GRANULAR CELL TUMOUR
It arises from Schwann cells and is often submucosal.
Overlying epithelium shows pseudoepitheliomatous
hyperplasia, which may on histology, resemble welldifferentiated carcinoma. Treatment is removal under microscope. Recurrence can occur if not excised completely.
E. GLANDULAR TUMOURS
Pleomorphic adenoma or oncocytoma are rare glandular
tumours.
F. RARE BENIGN LARYNGEAL TUMOURS
Other rare benign laryngeal tumours include rhabdomyoma, neurofibroma, neurilemmoma, lipoma or fibroma.
Chapter 62
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Cancer Larynx
EPIDEMIOLOGY
Cancer larynx constitutes 2.63% of all body cancers in
India. It is ten times more common in males than in females (4.79% versus 0.47%). Its incidence is 3.29 new
cases in males and 0.42 new cases in females per 100,000
population (National Cancer Registry, ICMR, April
2005 report). Recently, its incidence in females has increased in western countries due to more women taking
to smoking. Disease is mostly seen in the age group of
40-70 years but younger people in thirties may occasionally be affected.
AETIOLOGY
Both tobacco and alcohol are well-established risk factors
in laryngeal cancer. Cigarette smoke contains benzopyrene and other hydrocarbons which are carcinogenic in
man. Combination of alcohol and smoking increases the
risk 15-folds compared to each factor alone (2-3 folds).
Previous radiation to neck for benign lesions or laryngeal
papilloma may induce laryngeal carcinoma. Japanese and
Russian workers have reported cases of familial laryngeal
malignancy incriminating genetic factors. Occupational ex-
posure to asbestos, mustard gas and other chemical or petroleum products has also been related to the genesis of
laryngeal cancer but without conclusive evidence.
HISTOPATHOLOGY
About 90-95% of laryngeal malignancies are squamous
cell carcinoma with various grades of differentiation.
Cordal lesions are often well-differentiated while supraglottic ones are anaplastic.
The rest 5-10% of lesions include verrucous carcinoma,
spindle cell carcinoma, malignant salivary gland tumours
and sarcomas.
TABLE 62.1 CLASSIFICATION OF SITES AND
VARIOUS SUBSITES UNDER EACH SITE IN LARYNX
(AJCC CLASSIFICATION, 2002)
Site Subsite
Supraglottis • Suprahyoidepiglottis(bothlingualand
laryngeal surfaces)
• Infrahyoidepiglottis
• Aryepiglotticfolds(laryngealaspectonly)
• Arytenoids
• Ventricularbands(orfalsecords)
Glottis True vocal cords including anterior and posterior
commissure
Subglottis Subglottis up to lower border of cricoid cartilage
TNM CLASSIFICATION AND STAGING
According to AJCC (2002), larynx has been divided into
three sites (or regions) with several subsites under each
site (see Table 62.1 and Figure 62.1).
Tumours arising from these sites are further classified
by TNM system where:
T-indicates tumour and its extent, e.g. T1, T2, T3, etc.
N-indicates regional lymph node enlargement and its
size, e.g. N0, N1, N2, etc.
M-indicates distant metastasis. Absence of metastasis is
M0 while presence of metastasis is M1. Depending on
TNM, tumour is further grouped into various stages.
Thus, each laryngeal cancer can be staged, depending
upon the extent of disease, nodal or distant metastasis
(Table 62.2). This international staging of disease helps to
compare the results of different modalities of treatment
by different workers and assists in the choice of treatment
and prognosis of disease.
Figure 62.1. According to AJCC, the glottis extends from the horizontal plane passing through the lateral margin of ventricle at its junction with the superior surface of the vocal cord to 1 cm below it.
The subglottis extends from the lower limit of the glottis to the lower
border of the cricoid cartilage.
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TABLE 62.2 TNM CLASSIFICATION OF CANCER LARYNX (AMERICAN JOINT COMMITTEE ON CANCER, 2002)
Supraglottis
T
1
T
2
T
3
T4a Tumour invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of
T4b Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures.
Glottis
T
1
T1a Tumour limited to one vocal cord.
T1b Tumour involves both vocal cords.
T
2
T
3
T4a Tumour invades through thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck
T4b Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures.
Subglottis
T
1
T
2
T
3
T4a Tumour invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of
T4b Tumour invades prevertebral space, encases carotid artery or invades mediastinal structures.
Tumour limited to one subsite of supraglottis with normal vocal cord mobility.
Tumour invades mucosa of more than one adjacent subsites of supraglottis or glottis or region outside the
supraglottis (e.g., mucosa of base of tongue, vallecula, medial wall of pyriform sinus) without fixation of the larynx.
Tumour limited to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic
tissues, paraglottic space and/or minor thyroid cartilage invasion.
neck including deep extrinsic muscle of tongue, strap muscles, thyroid or oesophagus).
Tumour limited to vocal cord(s) (may involve anterior or posterior commissures) with normal mobility.
Tumour extends to supraglottis and/or subglottis, and/or with impaired vocal cord mobility.
Tumour limited to the larynx with vocal cord fixation and/or invades paraglottic space and/or minor thyroid cartilage
erosion.
including deep extrinsic muscles of the tongue, strap muscles, thyroid, or oesophagus).
Tumour limited to the subglottis.
Tumour extends to vocal cord(s) with normal or impaired mobility.
Tumour limited to larynx with vocal cord fixation.
neck including deep extrinsic muscle of tongue, strap muscles, thyroid or oesophagus).
Regional lymph nodes (N)
N
X
N
0
N
1
N
2
Regional lymph nodes cannot be assessed.
No regional lymph node metastasis.
Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest dimension.
Metastasis in a single ipsilateral lymph node, more than 3 cm but not more than 6 cm in greatest dimension, or
multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension, or bilateral or contralateral lymph
nodes, none more than 6 cm in greatest dimension.
N2a Metastasis in a single ipsilateral lymph node more than 3 cm but not more than 6 cm in greatest dimension.
N2b Metastasis in multiple ipsilateral lymph nodes, none more than 6 cm in greatest dimension.
N2c Metastasis in bilateral or contralateral lymph nodes, none more than 6 cm in greatest dimension.
N
3
Metastasis in a lymph node more than 6 cm in greatest dimension.
Distant metastasis (M)
M
X
M
0
M
1
Distant metastasis cannot be assessed.
No distant metastasis.
Distant metastasis.
Stage grouping
0 T
I T
II T
III T
is
1
2
3
T
1
T
2
T
3
IVA T4a N
T4a N
T
1
T
2
T
3
T4a N
IVB T4b Any N M
Any T N
IVC Any T Any N M
N
0
N
0
N
0
N
0
N
1
N
1
N
1
0
1
N
2
N
2
N
2
2
3
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
M
0
0
M
0
1
Histopathologic grade (G)
Grade 1: Well-differentiated
Grade 2: Moderately differentiated
Grade 3: Poorly differentiated
Source: Greene FL, Page DL, Fleming ID, et al. (editors). American Joint Committee on Cancer Staging Manual, 6th edition, New York: Springer-Verlag, 2002.
Figure 62.2. Supraglottic cancer involving epiglottis and right
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aryepiglottic fold.
1. Supraglottic Cancer
Supraglottic cancer is less frequent than glottic
cancer. Majority of lesions are seen on epiglottis, false
cords followed by aryepiglottic folds, in that order
(Figures 62.2, 62.3 and 62.4A).
spread. Cancer of supraglottic region may spread locally and invade the adjoining areas, i.e. vallecula, base
of tongue and pyriform fossa. Cancer of infrahyoid
epiglottis and anterior ventricular band may extend
into pre-epiglottic space and penetrate the thyroid
cartilage.
Nodal metastases occur early. Upper and middle jugular nodes are often involved. Bilateral metastases may be
seen in cases of epiglottic cancer.
Chapter 62 — Cancer Larynx
Figure 62.4. Cancer of the larynx. (A) Supraglottic, (B) glottic and
(C) subglottic.
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symptoms. Supraglottic growths are often silent. Hoarseness is a late symptom. Throat pain, dysphagia and referred pain in the ear or mass of lymph nodes in the neck
may be the presenting features. Weight loss, respiratory
obstruction and halitosis are late features.
2. Glottic Cancer
In vast majority of cases, laryngeal cancer originates in
the glottic region. Free edge and upper surface of vocal
cord in its anterior and middle third is the most frequent
site (Figures 62.4B and 62.5).
spread. Locally, the lesion may spread anteriorly to anterior commissure and then to the opposite cord; posteriorly to vocal process and arytenoid region; upward to
ventricle and false cord; and downwards to subglottic
region. Vocal cord mobility is unaffected in early stages.
Fixation of vocal cord indicates spread of disease to
thyroarytenoid muscle and is a bad prognostic sign.
There are few lymphatics in vocal cords and nodal metastases are practically never seen in cordal lesions unless
the disease spreads beyond the region of membranous cord.
symptoms. Hoarseness of voice is an early sign because lesions of cord affect its vibratory capacity. It
is because of this that glottic cancer is detected early.
Figure 62.3. Supraglottic cancer also invading the right piriform
fossa (arrow).
Figure 62.5. Cancer involving supraglottic, glottic and subglottic areas on the left of the larynx, as seen in rigid endoscopy.
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SECTION V — Diseases of Larynx and Trachea
DIAGNOSIS OF LARYNGEAL CANCER
1. history. Symptomatology of glottic, subglottic and
supraglottic lesions would vary and is described under
appropriate heads. It is a dictum that any patient in cancer
age group having persistent or gradually increasing hoarseness for 3 weeks must have laryngeal examination to exclude
cancer.
2. indirect laryngoscopy
(a) Appearance of lesion. Appearance of lesion will vary
with the site of origin.
(i) Lesions of suprahyoid epiglottis are usually exo-
phytic while those of infrahyoid epiglottis are
ulcerative.
(ii) Lesions of vocal cord may appear as raised nod-
ule, ulcer or thickening.
(iii) Lesions of anterior commissure may appear as
granulation tissue.
(iv) Lesions of subglottic region appear as a raised
submucosal nodule, mostly involving the anterior half.
(b) Vocal cord mobility. Impairment or fixation of vocal
cord indicates deeper infiltration into thyroarytenoid
muscle, cricoarytenoid joint or invasion of recurrent
laryngeal nerve and is an important sign.
(c) Extent of disease. Spread of disease to vallecula, base of
tongue and pyriform fossa should be noticed.
Figure 62.6. Flexible fibreoptic laryngoscopy.
Increase in size of growths with accompanying oedema or
cord fixation may cause stridor and laryngeal obstruction.
3. Subglottic Cancer (1-2%)
Subglottic region extends from glottic area to lower border of cricoid cartilage. Lesions of this region are rare
(Figure 62.4C).
spread. Growth starts on one side of subglottis and
may spread around the anterior wall to the opposite
side or downwards to the trachea. Upward spread to
the vocal cords is late and that is why hoarseness is not
an early symptom. Subglottic growths can invade cricothyroid membrane, thyroid gland and ribbon muscles
of neck.
Lymphatic metastases go to prelaryngeal, pretracheal,
paratracheal and lower jugular nodes.
symptoms. The earliest presentation of subglottic cancer
may be stridor or laryngeal obstruction but this is often
late and by this time disease has already spread sufficiently to encroach the airway.
Hoarseness in subglottic cancer indicates spread of
disease to the undersurface of vocal cords, infiltration of
thyroarytenoid muscle or the involvement of recurrent
laryngeal nerve at the cricoarytenoid joint. Hoarseness is
a late feature of subglottic growth.
3. Flexible Fibreoptic or rigid laryngoscopy or
Video laryngoscopy. It is an outdoor procedure and
allows detailed documentation of laryngeal pathology
(Figure 62.6).
4. examination oF neck. It is done to find (i) extralaryngeal spread of disease and (ii) nodal metastasis.
Growths of anterior commissure and subglottic region
spread through cricothyroid membrane and may produce
a midline swelling. They may also invade the thyroid cartilage and cause perichondritis when cartilage will be tender on palpation. Thyroid gland and strap muscles may
also be invaded.
Search should be made for metastatic lymph nodes,
their size and number; and also if they are mobile or
fixed, unilateral, bilateral or contralateral.
5. radiography
(a) X-ray chest. It is essential for coexistent lung disease
(e.g. tuberculosis), pulmonary metastasis or mediastinal nodes.
(b) Soft tissue lateral view neck. Extent of lesions of epiglot-
tis, aryepiglottic folds, arytenoids and involvement of
pre-epiglottic space may be seen. Destruction of thyroid cartilage may be seen. This is now superceded by
computed tomography (CT) scan and magnetic resonance imaging (MRI).
(c) CT scan. It is a very useful investigation to find the
extent of tumour, invasion of pre-epiglottic or paraglottic space, destruction of cartilage and cervical
lymph node involvement.
(d) MRI. More useful in recurrent cancers after radio-
therapy.
Chapter 62 — Cancer Larynx
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6. direct laryngoscopy. It is done to see (i) the hidden areas of larynx and (ii) extent of disease.
Hidden areas of the larynx include infrahyoid epiglottis, anterior commissure, subglottis and ventricle, which
may not be clearly seen by mirror examination making
direct laryngoscopy essential.
7. microlaryngoscopy. For small lesions of vocal
cords, laryngoscopy is done under microscope to better
visualize the lesion and take more accurate biopsy specimens without damaging the cord.
8. supraVital staining and biopsy. It is useful in
selection of the site of biopsy in leukoplakic lesion. Toluidine blue is applied to the laryngeal lesion and then
washed with saline and examined under the operating
microscope. Carcinoma in situ and superficial carcinomas
take up the dye while leukoplakia does not. Thus, it helps
to select the area for biopsy in a leukoplakic patch.
TREATMENT OF LARYNGEAL CANCER
It depends upon the site of lesion, extent of lesion, presence or absence of nodal and distant metastases. Treatment consists of:
1. Radiotherapy
2. Surgery
(a) Conservation laryngeal surgery
(b) Total laryngectomy
3. Combined therapy. Surgery with pre- or postoperative
radiotherapy
4. Endoscopic resection with CO2 laser
5. Organ preservation
1. radiotherapy. Curative radiotherapy is reserved for
early lesions which neither impair cord mobility nor invade cartilage or cervical nodes. Cancer of the vocal cord
without impairment of its mobility gives a 90% cure rate
after irradiation and has the advantage of preservation
of voice. Superficial exophytic lesions, especially of the
tip of epiglottis, and aryepiglottic folds give 70-90% cure
rate. Radiotherapy does not give good results in lesions
with fixed cords, subglottic extension, cartilage invasion
and nodal metastases. These lesions require surgery.
2. surgery
(a) Conservation laryngeal surgery. Earlier total laryngectomy
was done for most of the laryngeal cancers and the patient was left with no voice and a permanent tracheostome. Lately, there has been a trend for conservation laryngeal surgery which can preserve voice and also avoids
a permanent tracheal opening. However, few cases would
be suitable for this type of surgery and they should be
carefully selected. Conservation surgery includes:
(i) Excision of vocal cord after splitting the larynx
(cordectomy via laryngofissure).
(ii) Excision of vocal cord and anterior commissure
region (partial frontolateral laryngectomy).
(iii) Excision of supraglottis, i.e. epiglottis, aryepi-
glottic folds, false cords and ventricle-a sort of
transverse section of larynx above the vocal cords
(partial horizontal laryngectomy).
(b) Total laryngectomy. The entire larynx including the hy-
oid bone, pre-epiglottic space, strap muscles and one
or more rings of trachea are removed. Pharyngeal wall
is repaired and lower tracheal stump sutured to the
skin for breathing.
Laryngectomy may be combined with block dissection
for nodal metastasis.
Total laryngectomy is indicated in the following con-
ditions:
(i) T3 lesions (i.e. with cord fixed)
(ii) All T4 lesions
(iii) Invasion of thyroid or cricoid cartilage
(iv) Bilateral arytenoid cartilage involvement
(v) Lesions of posterior commissure
(vi) Failure after radiotherapy or conservation surgery
(vii) Transglottic cancers, i.e. tumours involving supra-
glottis and glottis across the ventricle, causing fixation of the vocal cord.
It is contraindicated in patients with distant metastasis.
3. combined therapy. Surgical ablation may be combined with pre- or postoperative radiation to decrease the
incidence of recurrence. Preoperative radiation may also
render fixed nodes resectable.
4. endoscopic resection with co2 laser. Carcinoma of the mobile membranous vocal cord is traditionally treated with radiotherapy. Now such lesions can
be precisely excised with CO2 laser under microscope
with the same good results. Laser excision has the advantages of lower cost, lower duration of treatment and
morbidity.
Similar T1 lesions of the supra- or infrahyoid epiglottis
with or without neck nodes have been treated with CO2
laser. Cervical nodes in such cases are managed surgically
with appropriate neck dissection.
Endoscopic CO2 laser is getting popular at some
centres where facilities of CO2 laser and expertise are
available.
5. organ preserVation. To avoid total laryngectomy
in stage III and IV, trials were conducted for laryngeal
preservation. They showed that induction chemotherapy followed by radiotherapy or concurrent chemoradiation showed better locoregional control of disease than
laryngectomy with postoperative radiotherapy. It also
had the advantage of preservation of laryngeal function.
However concurrent chemoradiation causes more toxicity and proper selection of cases should be made. Such
studies of organ preservation may also improve quality
of life.
GLOTTIC CARCINOMA
carcinoma in situ. It is best treated by transoral endoscopic CO2 laser. If laser is not available, stripping of vocal
cord is done under microscope and tissue subjected to
biopsy. If biopsy shows invasive carcinoma, radiotherapy
is given. If biopsy confirms only carcinoma in situ, treatment is regular follow-up.
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SECTION V — Diseases of Larynx and Trachea
inVasiVe carcinoma
T1-carcinoma. Radiotherapy is the treatment of choice.
If radiotherapy is refused or not available, excision of cord
by endoscopic CO2 laser or laryngofissure is performed.
T1-carcinoma with extension to anterior commissure. Radiotherapy is the best choice. In the absence of this, frontolateral partial laryngectomy is done with regular followup. If it fails, total laryngectomy is performed.
T1-carcinoma with extension to arytenoid. Treatment is
same as above but surgery is preferred.
T2N0-It implies tumour of the glottic region, i.e. vocal cord(s), anterior commissure and/or vocal process of
the arytenoid with extension to supraglottic or subglottic
regions but with no lymph node involvement. Treatment
depends on two factors (see Figure 62.7).
1. Is mobility of vocal cord normal or impaired?
2. Is there involvement of anterior commissure and/or
arytenoid?
If cord is mobile and anterior commissure and arytenoid are not involved, radiotherapy gives good results.
Such patients are kept under regular follow-up. If disease
recurs, total laryngectomy is performed. Some surgeons
will still consider partial vertical laryngectomy to preserve voice in such radiation-failed cases.
If anterior commissure and/or arytenoid are involved
or cord mobility is impaired, radiotherapy is not preferred because of the possibility of developing perichondritis which would entail total laryngectomy. In such
cases, some form of conservation surgery such as vertical
hemilaryngectomy or frontolateral laryngectomy is done
to preserve the voice. Such patients are also kept under
regular follow-up and converted to total laryngectomy if
disease recurs.
In N0 neck, in T2 carcinoma, chances of occult nodal
metastasis are less than 25%, therefore prophylactic neck
dissection is not done. However, if radiation is considered
the mode of treatment, for the primary, upper neck nodes
are included in the radiation field.
Cord mobility is important in determining the outcome of T2 lesions. Normal cord mobility suggests growth
is only limited to the surface. Impaired mobility indi-
cates deeper invasion into intrinsic laryngeal muscles or
paraglottic space and thus poor response to radiation.
Invasion of paraglottic or subglottic space is also associated with undetected invasion of laryngeal cartilages and
hence poor survival results. With radiation, cure rate of T2
lesions, with normal cord mobility, is 86% and it drops to
63% if cord mobility is impaired.
T3 and T4 glottic carcinomas are best treated by total laryngectomy. It is combined with neck dissection if
nodes are palpable. More advanced T4 lesions are treated
by combined therapy, i.e. surgery with postoperative radiotherapy or only palliative treatment.
subglottic cancer. Early lesions T1 and T2 are treated
by radiotherapy. T3 and T4 lesions require total laryngectomy and postoperative radiation. Radiation portal
should also include superior mediastinum.
supraglottic cancer. Following factors are considered
in the treatment option:
1. Status of cervical lymph nodes
2. Mobility of cord
3. Age of the patient
4. Status of lung functions
5. Cartilage invasion
6. Subsite of supraglottis involved
7. Status of pre-epiglottic space involvement
T1 lesions respond well to radiation. They can also be
excised with CO2 laser.
T2 lesions are treated by supraglottic laryngectomy
with or without neck dissection if lung function is good.
If lung function is poor, radiotherapy can be given to the
primary and the nodes.
T3 and T4 lesions often require total laryngectomy with
neck dissection and postoperative radiotherapy to neck.
VOCAL REHABILITATION AFTER TOTAL
LARYNGECTOMY
After laryngectomy, patient loses his speech completely.
Various methods by which communication can be established are listed in Table 62.3.
Figure 62.7. Algorithm for treatment of T2N0 glottic cancer.
1. oesophageal speech. In this, patient is taught to
swallow air and hold it in the upper oesophagus and then
slowly eject it from the oesophagus into the pharynx. Patient can speak six to ten words before reswallowing air.
Voice is rough but loud and understandable.
TABLE 62.3 METHODS OF COMMUNICATION IN
LARYNGECTOMIZED PATIENTS
• Writtenlanguage(penandpaper)
• Aphoniclipspeech(bytrappingairinbuccalcavity;often
combined with sign language)
• Oesophagealspeech
• Electrolarynx
• Transoralpneumaticdevice
• Tracheo-oesophagealspeech
• Blom-Singer prosthesis
• Panje prosthesis
Chapter 62 — Cancer Larynx
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Figure 62.8. (A) An electrolarynx. (B) A laryngectomised patient using the electrolarynx to produce sound.
353
2. artiFicial larynx. It is used in those who fail to
learn oesophageal speech.
(a) Electrolarynx. It is a transistorized, battery operated
portable device. Its vibrating disc is held against the
soft tissues of the neck and a low-pitched sound is
produced in the hypopharynx which is further modulated into speech by the tongue, lips, teeth and palate
(Figure 62.8A–B).
(b) Transoral pneumatic device. Another type of artificial
larynx is a transoral device. Here vibrations produced
in a rubber diaphragm are carried by a plastic tube
into the back of the oral cavity where sound is converted into speech by modulators. This is a pneumatic
type of device and uses expired air from the tracheostome to vibrate the diaphragm.
3. tracheo-oesophageal speech. Here attempt is made
to carry air from trachea to oesophagus or hypopharynx
by the creation of skin-lined fistula or by placement of an
artificial prosthesis (Figure 62.9). The vibrating column of
air entering the pharynx is then modulated into speech.
This technique has the disadvantage of food entering the
trachea. These days prosthesis (Blom-Singer or Panje) are
being used to shunt air from trachea to the oesophagus.
They have inbuilt valves which work only in one direction thus preventing problems of aspiration.
Figure 62.9. Tracheo-oesophageal speech. Finger closes the tracheal
opening and air from trachea is directed via opening in prosthesis to
oesophagus.
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Chapter 63
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Voice and Speech Disorders
HOARSENESS
Hoarseness is defined as roughness of voice resulting from
variations of periodicity and/or intensity of consecutive
sound waves.
For production of normal voice, vocal cords should:
1. Be able to approximate properly with each other.
2. Have a proper size and stiffness.
3. Have an ability to vibrate regularly in response to air
column.
Any condition that interferes with the above functions
causes hoarseness.
(a) Loss of approximation may be seen in vocal cord pa-
ralysis or fixation or a tumour coming in between the
vocal cords.
(b) Size of the cord may increase in oedema of the cord or a
tumour; there is a decrease in partial surgical excision
or fibrosis.
(c) Stiffness may decrease in paralysis, increase in spastic
dysphonia or fibrosis.
Cords may not be able to vibrate properly in the pres-
ence of congestion, submucosal haemorrhages, nodule or
a polyp.
AETIOLOGY
Hoarseness is a symptom and not a disease per se. The
causes of hoarseness are summarized in Table 63.1.
EVALUATION OF HOARSENESS
1. History. Mode of onset and duration of illness, patient’s occupation, habits and associated complaints
are important and would often help to elucidate the
cause. Any hoarseness persisting for more than 2 weeks
deserves examination of larynx. Malignancy should be excluded in patients above 40 years.
2. Indirect laryngoscopy. Many of the local laryngeal
causes can be diagnosed.
3. Examination of neck, chest, cardiovascular and neurological system would help to find cause for laryngeal
paralysis.
4. Laboratory investigations and radiological examination should be done as per dictates of the cause suspected on clinical examination.
5. Direct laryngoscopy and microlaryngoscopy help in
detailed examination, biopsy of the lesions and assessment of the mobility of cricoarytenoid joints.
6. Bronchoscopy and oesophagoscopy may be required
in cases of paralytic lesions of the cord to exclude malignancy.
DYSPHONIA PLICA VENTRICULARIS
(VENTRICULAR DYSPHONIA)
Here voice is produced by ventricular folds (false cords)
which have taken over the function of true cords. Voice
is rough, low-pitched and unpleasant. Ventricular voice
may be secondary to impaired function of the true cord
such as paralysis, fixation, surgical excision or tumours.
Ventricular bands in these situations try to compensate
or assume phonatory function of true cords.
Functional type of ventricular dysphonia occurs in
normal larynx. Here cause is psychogenic. In this type,
voice begins normally but soon becomes rough when
false cords usurp the function of true cords. Diagnosis is
made on indirect laryngoscopy; the false cords are seen
to approximate partially or completely and obscure the
TABLE 63.1 CAUSES OF HOARSENESS
1. Inflammation
Acute Acute viral laryngitis, diphtheria,
whooping cough, noxious gases
Chronic Chronic laryngitis (smoking, occupational
gastro-oesophageal reflux, steroid
inhalations for asthma), tuberculosis,
syphilis, leprosy, fungal infections
2. Neoplasms
Benign Papillomas (solitary or multiple),
haemangioma, chondroma,
schwannoma, granular cell myoblastoma
Premalignant Leukoplakia
Malignant Cancer, sarcoma
3. Non-neoplastic
lesions
4. Trauma Forceful shouting (submucosal vocal
5. Paralysis Paralysis of recurrent, superior laryngeal
6. Fixation of cords Arthritis or traumatic fixation of
7. Congenital Laryngeal web, cyst, laryngocoele,
8. Systemic disorders Hypothyroidism, sarcoidosis, Wegener’s
Vocal nodules, vocal polyp, contact ulcer,
cyst, laryngocoele, amyloid deposit
cord haemorrhage), blunt and sharp
laryngeal trauma, foreign body,
intubation
or both the nerves
cricoarytenoid joints
paralysis, vocal sulcus
granulomatosis, amyloidosis,
myasthenia gravis
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