3 Malign Voice Speech Tracheostomy Foreign Bodies

DISEASES OF
THE LARYNX
CANCER OF THE LARYNX
males are predominantly affected 10:1
incidence in females has increased in
western countries due to smoking
Mostly seen in age group: 40-70 years
ETIOLOGY
 Tobacco, alcohol
 Previous radiation
 Genetic factors
 Occupational exposure
a) Epiglottis.
b) Hyoid bone.
c) Thyroid cartilage.
d) Cricoid cartilage.
e) Ventricular fold.
f) Vocal fold.
Supraglottic g) Ventricle.
h) Vocalis muscle.
i) Trachea.
Classification and Staging

Glottic •The larynx is subdivided into three regions:
•1. Supraglottic
•2. Glottic
Subglottic •3. Subglottic
•UICC and TNM systems:
•T – tumor and its extent
•N – nodal involvement and its degree
•M – distant metastasis
Cavity of the Larynx

CLASSIFICATION AND STAGING
TNM definitions
Primary tumor (T)
TX: Primary tumor cannot be assessed
T0: No evidence of primary tumor
Tis: Carcinoma in situ
Supraglottis:
T1: Tumor limited to one subsite* of supraglottis with normal vocal cord mobility
T2: Tumor invades mucosa of more than one adjacent subsite* 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
T3: Tumor limited to larynx with vocal cord fixation and/or invades any of the
following: postcricoid area, pre-epiglottic tissues
T4: Tumor invades through the thyroid cartilage, and/or extends into soft tissues of
the neck, thyroid, and/or esophagus
*Subsites include the following:

ventricular bands (false cords), arytenoids, suprahyoid epiglottis, infrahyoid
epiglottis, aryepiglottic folds (laryngeal aspect)
Glottis:
T1: Tumor limited to vocal cord(s) (may involve anterior or posterior
commissure) with normal mobility
T1a: Tumor limited to one vocal cord
T1b: 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
T4: Tumor invades through the thyroid cartilage and/or to other tissues
beyond the larynx (e.g., trachea, soft tissues of neck, including thyroid,
pharynx)
Subglottis:
T1: Tumor limited to the subglottic
T2: Tumor extends to vocal cord(s) with normal or impaired mobility
T3: Tumor limited to larynx with vocal cord fixation
T4: Tumor invades through cricoid or thyroid cartilage and/or extends to
other tissues beyond the larynx (e.g., trachea, soft tissues of neck,
including thyroid, esophagus)
Regional lymph nodes (N)

NX: Regional lymph nodes cannot be assessed
N0: No regional lymph node metastasis
N1: Metastasis in a single ipsilateral lymph node, 3 cm or less in greatest
dimension
N2: Metastasis in a single ipsilateral lymph node, more than 3 cm but
not more than 6 cm in greatest dimension, or in multiple ipsilateral lymph
nodes, none more than 6 cm in greatest dimension, or in 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
N3: Metastasis in a lymph node more than 6 cm in greatest dimension
Distant metastasis (M) AJCC stage groupings
MX: Distant metastasis
cannot be assessed Stage III
M0: No distant metastasis T3, N0, M0
M1: distant metastasis T1, N1, M0
T2, N1, M0
T3, N1, M0
AJCC stage groupings
Stage IVA
Stage 0 T4, N0, M0
Tis, N0, M0 T4, N1, M0
Stage I Any T, N2, M0
T1, N0, M0 Stage IVB
Stage II Any T, N3, M0
T2, N0, M0 Stage IVC
Any T, Any N, M1
Glottis
extends from
the horizontal
plane
passing
through apex
of ventricle to
1 cm. below it
Laryngeal
Carcinoma
A. Supraglottic
B. Glottic
C. Subglottic
Supraglottic Cancer
Less frequent than glottic cancer
 Spread: locally, adjoining areas (vallecula, base of tongue,
pyrifotm fossa), pre-epiglottic space. Nodal metastases occur
early.
 Symptoms: often silent, hoarseness is a late symptom,
throat pain, dysphagia, referred pain in the ear, mass of lymph
nodes, weight loss, respiratory obstruction, halitosis are late
features
Glottic Cancer
Free edge and upper surface of vocal cord in
its anterior and middle third
 Spread: locally to anterior commisure, and then to opposite
cord,posteriorly to vocal process and arytenoid region, upward to
ventricle and false vocal cord, and downwards to subglottic region.
 Vocal cord fixation – spread to thyroarytenoid muscle
– bad prognosis
 There are few lymphatic vessels – no nodal
metastases
 Symptoms: hoarseness is an early symptom, stridor and
laryngeal obstruction in late stages
Subglottic Cancer
 Spread: around the anterior wall to the opposite side or
downwards to the trachea.
 Lymphatic vessels – go to prelaryngeal, pretracheal,
paratrachealand lower deep cervical nodes
 Symptoms: stridor may be the earliest symptom,
hoarseness indicates extension to glottic level
Diagnosis of laryngeal cancer
 History: any patient in cancer age group having persistent or gradually
increasing hoarseness of voice for 3 weeks must have laryngeal
examination to exclude cancer
 Indirect laryngoscopy:
 Appearance of lesion
 Vocal cord mobility
 Extent of disease
 Examination of neck
 Radiography
 CT scan
 Direct laryngoscopy
 Microlaryngoscopy
 Supravital staining and biopsy
Treatment of laryngeal cancer
 Radiotherapy
 For early lesions which do not impair cord mobility nor invade
cartilage or cervical nodes
 Does not gives good results in lesions with fixed cords,
subglottic extension, cartilage invasion, and nodal metastases.
This lesions require surgery
 Surgery
Conservation laryngeal surgery
Total laryngectomy
 Combined therapy
 Surgical ablation ,ay be combined with pre- or post-operative
radiation to decrease the incidence of recurrence
Surgery
 Conservation laryngeal surgery
Excision of vocal cord after splitting the larynx (Cordectomy via
laryngofissure)
Excision of vocal cord and anterior commisure region (partial fronto-lateral
laryngectomy)
Excision of supraglottis (epiglottis, aryepiglottic folds, false vocal cords and
ventricle) a sort of transverse section of larynx above the vocal cords (partial
horizontal laryngectomy)
 Total laryngectomy: the entire larynx, including the hyoid bone, pre-
epiglottic space, strap muscles, and one or more rings of trachea are removed.
Indicated in cases of cord fixation, bilateral cordal lesions, subglottic
extension, supraglottic lesions, cartilage invasion with perichondritis, cervical
nodal metastases and failed cases after radiotherapy or conservative surgery
It is contraindicated in patients with distant metastsis
Anterior Glottic Stenoses Postbilateral
Cordectomy for T1b Glottic Carcinoma
M, 74 years
Preoperative
view
Anterior Glottic Stenoses Postbilateral
Cordectomy for T1b Glottic Carcinoma
M, 74 years
Final intraoperative view

Malignant Tumors of the Larynx
with Glottic Localization
Types of cordectomies (UICC 2002):
type I - a subepithelial cordectomy, which is resection of the
epithelium;
type II - a subligamental cordectomy, which is a resection of the
epithelium, Reinke's space and vocal ligament;
type III - transmuscular cordectomy, which proceeds through
the vocalis muscle;
type IV - total cordectomy;
type Va - extended cordectomy, which encompasses the
contralateral vocal fold and the anterior commissure;
type Vb - extended cordectomy, which includes the arytenoid;
type Vc - extended cordectomy, which encompasses the
subglottis;
type Vd - extended cordectomy, which includes the ventricle.
Malignant Tumors of the Larynx
with Glottic Localization
Types of cordectomies:
Type 1: subepithelial cordectomy, which is total resection of
the epithelium, conserving vocalis muscle;
Type 2: partial muco-ligamental resection, include resection
of epithelium, vocal ligament and a part of vocalis muscle;
Type 3: total muco-ligamental-muscular resection;
Type 4: extended cordectomy, include total resection of
unilateral vocal cord, anterior commissure and anterior 1/3 of
contralateral vocal cord;
Transglottic resection: total resection of endolaringeal
structures (vocal cords, ventricular folds), which may includes
unilateral arytenoidectomy.
T1a Glottic Carcinoma Type I Cordectomy
M, 43 years
Intraoperative
view
M, 43 years

T1a Glottic Carcinoma
Postradiotherapy recurrence after 12 years
A. E, 59 years
preoperative view
6 month
postoperative view
M, 43 years Fibrolaryngoscopy, 12 months
T1a Glottic Carcinoma Type II Cordectomy
M, 46 years
Intraoperative
view

T1a Glottic Carcinoma Type II Cordectomy

T2 Glottic Carcinoma Type III Cordectomy
M 49 years
Intraoperative
view
M 49 years

M 49 years Fibrolaryngoscopy, 3 months

M 49 years Fibrolaryngoscopy, 24 months

M, 51 years
Intraoperative
view
M, 51 years
Intraoperative
view

T1b Glottic Carcinoma Type III Cordectomy
M, 47 years
Intraoperative
view
T1b Glottic Carcinoma Type III
Cordectomy
M, 47 years
Intraoperative
view
T1b Glottic Carcinoma Type III
Cordectomy
M, 47 years, Fibrolaryngoscopy, 12 months
Supraglottic Carcinoma
Horizontal Supraglottic Laryngectomy
M, K.F., 54 years

M, K.F.,
54 years
Intraoperative
view
M, K.F., 54 years
Fibrolaryngoscopy, 12 months
Extended Epiglotectomy M, G.M., 43 years
Intraoperative
view
Intraoperative
view
Final intraoperative
view
Fibrolaryngoscopy, 24 months
HSL, M, C.G., 56 years
Intraoperative
view
Intraoperative
view
Final intraoperative
view
HSL, Flexible fibroscopy after 6 weeks
M, C.G., 56 years
Postoperative Endoscopy View after 6 months
with 70 Degree Rigid Endoscope
Epiglotectomy, M, D.N., 64 years
Preoperative Endoscopy View
Epiglotectomy M, D.N., 64 years
Intraoperative
view
Epiglotectomy M, D.N., 64 years
Intraoperative
view
Epiglotectomy, M, D.N., 64 years
Postoperative Endoscopy View after 4 weeks
ENDOSCOPIC LASER SGL
ADVANTAGES DISADVANTAGES
 No trach  Specialized equipment
 Shorter OR time  Surgeon inexperience
 Decreased P-C fistula  Prolonged healing time
 No neck incisions  Staged neck dissection
 Earlier swallow
Indications Contraindications
 T1/T2  T4
 Suprahyoid epiglottis,  Paraglottic space
aryepiglottic fold, involvement
vestibular fold Relative Contraindications
 Minimal preepiglottic  T3
space involvement  Infrahyoid epiglottis, upper
false vocal cord
 Extensive preepiglottic
space involvement
EXPOSURE, EXPOSURE, EXPOSURE
 Steiner, bivalved laryngopharyngoscope
 Zeitels, adjustable supraglottiscope
SURGERY VS. XRT
Surgery Radiation Therapy
 Advantages
 Advantages
Avoid operative
Less long term tissue morbidity/mortality
damage
Reserve surgery for salvage
Better f/u examination  Disadvantages
Reserve XRT for recurrence More long term tissue damage
Pathologic staging More difficult f/u exam
 Disadvantages Chondroradionecrosis
Postop rehabilitation Cannot be used again for
recurrence or second primary
Conversion to TL
Surgical salvage more difficult
MANAGEMENT OF THE NECK
Neck disease is associated with 50% decrease in

overall survival.
Supraglottic cancer is associated with early metastasis
to the neck.
More than 50% of patients will present with neck
disease.
More than 25% of patients will have occult neck
disease.
QUESTION 1
Should the neck be treated with surgery or

radiation therapy?
Answer: single modality therapy is best.

QUESTION 2
Which side of the neck should be dissected?
Answer: both.
 Hicks et al found that of the 30% of patients with
supraglottic SCCA and a clinically N0 neck, 44%

had bilateral neck disease.
 Lutz et al found that in patients with N0 or N+
necks, the most common site of locoregional failure

was the unoperated neck regardless of the location
of the primary tumor.
QUESTION 3
Which levels of the neck should be dissected?
Answer: Levels I-IV

 Pressman
 Hicks et al
PERISTOMAL RECCURENCE
PERISTOMAL RECCURENCE
POSSIBLE CONSEQUENCES OF
SALVAGE LARYNGECTOMIES
Vocal rehabilitation after total

laryngectomy
Esophageal speech
Artificial larynx
Electrolarynx
Transoral pneumatic device
Trache-Esophageal speech
VOICE AND SPEECH DISORDERS
HOARSENESS
Rough voice resulting from variations of periodicity and/or intensity of
consecutive sound waves
Loss of approximation
Size of the cord
Stifness
 Etiology – a symptom
 Investigations
History
Indirect laryngoscopy
Examination of neck, chest, cardiovascular and neurological
system
Laboratory investigations
Direct laryngoscopy
Bronchoscopy and esophagoscopy
HOARSENESS
 Etiology
Acute and chronic inflammations
Benign and malignant tumors
Trauma
Paralysis
Fixation of cords
Congenital
Miscellaneous
Functional
DYSPHONIA PLICA VENTRICULARIS
(Ventricular Dysphonia)
Produced by ventricular folds (false cords)
Voice is rough, low-pitched, unpleasant
Impaired function of vocal cords, psychogenic causes,
FUNCTIONAL APHONIA (Hysterical Aphonia)

Functional disorder in abducted position
Communication with whisper
PUBEROPHONIA (Mutational Falsetto Voice)

Exclusively to males
Emotionally immature, feel insecure, excessive fixation to their
mother
Treatment: pressing the thyroid prominence
PHONASTENIA
 Weakness of voice
due to fatigue
 Easy fatigability
voice
 Treatment: rest
and voice hygiene
Appearance of glottis in
phonasthenia
A.Weakness of thyroarytenoid
B. Weakness of interarytenoid
C. Both
HYPONASALITY (Rhinolalia Clausa)
Lack of resonance for words which resonated in the nasal
cavity: m, n, ng
Blockage of nose and nasopharynx
HYPERNASALITY (Rhinolalia Aperta)
Certain words with little nasal resonance
Failure of nasopharynx to cut off from oropharynx
STUTTERING
Fluency of speech disorder
Hesitation to start, repetitions, prolongations of blocks
Eye blink
Abnormal head movements
TRACHEOTOMY
Making an opening in the anterior wall of trachea and
converting it into a stoma on the skin surface
Functions of tracheotomy
 Alternative pathway for breathing
 Improves alveolar ventilation
 Protects the airways
 Cleaning of secretions by repeated suction
 Superior to intubations if IPPR is required beyond 72
hours
 In cases where endotracheal intubations is difficult or
impossible
TRACHEOTOMY
Indications of Tracheotomy
A. Respiratory obstruction
B. Retained secretions
C. Respiratory insufficiency
Infections
Trauma
Neoplasms
Foreign body larynx
Larynx edema
Bilateral abductor paralysis
Congenital anomalies
TRACHEOTOMY
Indications of Tracheotomy
C. Respiratory insufficiency
Inability to cough
Painful cough
Aspiration of pharyngeal secretions
C. Respiratory insuffiency
Chronic lung conditions
Condition listed in A and B
TRACHEOTOMY
Types of Tracheotomy
Emergency tracheotomy
Elective tracheotomy
Therapeutic
Prophylactic
Permanent tracheotomy
High tracheotomy: above the level of thyroid isthmus

Mid tracheotomy: through the II and III rings
Low tracheotomy: below the level of thyroid isthmus
TRACHEOTOMY
Technique:
Whenever is possible endotracheal intubation should be done before
Supine position
No anesthesia in unconscious or when it is an emergency procedure
1-2% lydocaine, sometimes general anesthesia
Steps of operation:
1.Vertical incision vs. transverse incision
2.Dissection of the tissues
3.Sepatation of strap muscles
4.Thyroid isthmus is displaced
5.Lydocaine 1-2% injected in the trachea
6. Opening of the trachea
7. Tracheotomy tube
8. Suture of skin incision
9. Gauze dressing
TRACHEOTOMY
Mid tracheotomy. Thyroid isthmus is divided and ligated

TRACHEOTOMY
Tracheotomy in children and infants:
1. Trachea of infants and children is soft and compressible and its
identification may become difficult
2. During positioning do not extend the neck too much as this pulls
structures from chest into the neck and thus injury may occur to
pleura, innominate vessels and thymus
3. Before incising trachea silk sutures are placed in the trachea
4. Tracheal lumen is small, do not insert knife to deep
5. Trachea is simply incised
6. Avoiding infolding the anterior wall
7. Selection of tube is important
8. Use of silastic or protex tube, metallic tube cause more trauma
9. Take a postoperative X-ray
TRACHEOTOMY
Postoperative Care
1. Constant supervision
2. Suction
3. Preventing of crusting and tracheitis
4. Care of tracheotomy tube
Complications:
Immediate
 Hemorrhage, apnoea, pneumothorax, injury to recurrent laryngeal
nerves, aspiration of blood, injury to esophagus
Late
 Bleeding, displacement of tube, blocking of tube, subcutaneous
emphisema, tracheitis, atelectasis, lung abscesslocal wound
infection, laryngeal stenosis, tracheal stenosis, problems of
decannulation, tracheoesophageal fistula
TRACHEOTOMY
Procedures for Immediate Airway Establishment:
1. Endotracheal intubation
2. Cricothyrotomy or laryngotomy
3. Emergency tracheotomy
FOREIGN BODIES OF AIR PASSAGE
A foreign body aspirated into air passage can

lodge in the larynx, trachea or bronchi
Etiology:
children are more often affected, suddenly inspire
during play or fight, while having something in the
mouth
in adults foreign bodies are aspirated during coma,
deep sleep or alcoholic intoxication
Nature of Foreign Bodies:

A. Non-irritating type
Plastic, glass, metallic
B. Irritating type
Vegetables, peanuts, beans, seeds
Clinical Features
Laryngeal foreign body
Tracheal foreign body
Bronchial foreign body
Initial period of choking, gagging and wheezing
Symptomless interval
Later symptoms
A traheo/bronhic foreign body should be

suspected in the case of bronhopulmonary
pathology with history of penetration and / or
in case of pulmonary radiography which
indicate a ventilatory disorders
Tracheo Bronchoscopy with rigid endoscope is
the safest method in diagnostic and treatment
of traheo/bronhic foreign body
A traheo/bronhic foreign body should be

suspected in the case of bronhopulmonary
pathology with history of penetration and / or
in case of pulmonary radiography which
indicate a ventilatory disorders
Tracheo Bronchoscopy with rigid endoscope is
the safest method in diagnostic and treatment
of traheo/bronhic foreign body
Clinical exam: brutal aces of suffocations with

spasmodic cough, supraclavicullar tenderness,
inspiratory bradipneea during alimentation or
playing
Thoracic radiography
Tracheo Bronchoscopy with rigid endoscope
CLINICAL EXAM AND THORACIC
RADIOGRAPHY
Auscultator asymmetry - bronchic foreign body

Atelectazy, emphysema, wheezing, bronchial rales
Possible: normal exam
Ventilation modifications – obstructive emphysema
(thoracic distends and hyper transparency)
Atelectazy (opacity with retraction)
TREATMENT
Tracheo Bronchoscopy with rigid endoscope and
extraction (accepted by majority of authors)
Flexible Bronchoscopy pre and post Bronchoscopy
with rigid endoscope permit to complete this
exploration
Bronchoscopy with C-arm fluoroscopy
Use of Dormia basket or Fogarthy’s balloon for
rounded objects
Tracheotomy and bronchotomy
Flexible fibre optic bronchoscopy in selected adults
patients.
GENERAL RULES OF EXTRACTION
Necessary equipment and a team with
experience
A good collaboration between the
anesthesiologist and surgeon
General anesthesia without curare and
spontaneous ventilation
The comfort and security of the patient (vital
risk, permanently)
NECESSARY EQUIPMENT
(Storz for children, which include: cold light,
different optical systems, tubes and aspirators
with variable diameters and lengths, different
forceps
Video systems which allow photography and
recording, connections to monitors. Material
for tracheotomy
NECESSARY EQUIPMENT
NECESSARY EQUIPMENT
NECESSARY EQUIPMENT
NECESSARY EQUIPMENT
CONCLUSIONS
Close cooperation between the ENT,
endoscopist, radiologist and anesthesiologist
are needed for a safe outcome and efficient
team-work is absolute necessary for these
major emergency represented by
tracheobronchial foreign bodies.
1ST CASE
L.S. 20 months. The pediatricians ignored the penetration
syndrome, the diagnose has been taken ambulatory:
persistent sub acute bronchiopneumopathy which not
respond at treatment.
Hospitalizations nearly 30 days after the penetration,
emergency thoracic radiography revealed left lung
emphysema, left pulmonary hyper transparency, right
displacement of the mediastine
3 fragment of peanuts in left inferior lobar bronchia
1ST CASE
2ND CASE
B.A. 2 years. Urgency, at about 4 hours after
the penetration. The diagnose was quickly
established. Clinical: moderate dispneea,
persistent cough
2 fragments of peanuts in right and left inferior
lobar bronchia
3RD CASE
D.A. 2,6 years. Emergency, at about 4 hours
after the penetration. Clinical: moderate
dispneea, spasmodic cough, right hemitoracic
base flatness at percussion
pumpkin seed in right inferior lobar bronchia

3 Malign Voice Speech Tracheostomy Foreign Bodies

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DISEASES OF

Classification and Staging

Cavity of the Larynx

*Subsites include the following:

Final intraoperative view

Final intraoperative view

Final intraoperative view

M, 46 years Fibrolaryngoscopy, 24 months

Final intraoperative view

M 49 years Fibrolaryngoscopy, 3 months

M 49 years Fibrolaryngoscopy, 24 months

M, 51 years Fibrolaryngoscopy, 12 months

Final intraoperative view

Neck disease is associated with 50% decrease in

Should the neck be treated with surgery or

Answer: single modality therapy is best.

Which side of the neck should be dissected?

supraglottic SCCA and a clinically N0 neck, 44%

necks, the most common site of locoregional failure

Answer: Levels I-IV

Vocal rehabilitation after total

FUNCTIONAL APHONIA (Hysterical Aphonia)

PUBEROPHONIA (Mutational Falsetto Voice)

High tracheotomy: above the level of thyroid isthmus

Mid tracheotomy. Thyroid isthmus is divided and ligated

A foreign body aspirated into air passage can

Nature of Foreign Bodies:

A traheo/bronhic foreign body should be

A traheo/bronhic foreign body should be

Clinical exam: brutal aces of suffocations with

Auscultator asymmetry - bronchic foreign body

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