Furunculosis of the nasal vestibule: causes, diagnosis, complications, treatment

Definition: Malignant tumor of the larynx (voice box).
Incidence:

• Age: most common age at presentation is 40 to 70 years.
• Gender: male to female 10 to 1, (now it is about 7 to 1)
• Larynx cancer is more prevalent among lower socioeconomic groups.
  

Risk factors for Laryngeal SCC

• Exposure to human papillomavirus (HPV)
• Tobacco use. Both active & passive smoking are harmful. There is 13-fold risk for laryngeal cancer for smokers
• Alcohol consumption. Alcohol is thought to promote carcinogenesis.
• The combination of smoking and alcohol (tabagism) use has a more than additive carcinogenic effect on the larynx (synergistic effect).
• Chronic Gastric Reflux 
• Prior history of head and neck irradiation.
• Occupational exposures: Several types of industrial agents and toxic inhalants are carcinogenic such as (tar, nickel, heat, and asbestos).
• Leukoplakia and adult papilloma.

Pathology:

• Site: Glottic Carcinoma: 59%, Supraglottic Cancer: 40%, and subglottic Cancer 1%.
• Histological Types: 85-95% of laryngeal tumors are squamous cell carcinoma. Other types include verrucous carcinoma, fibrosarcoma, chondrosarcoma, adenocarcinoma and others.

Clinical: Malignant ulcer, fungating mass, or infiltrating nodule.
Spread:
1. Direct, to adjacent areas, tongue base, or trachea.

2. Lymphatic spread.
A. Glottic: very rare, as there is no lymphatics in Reinke’s space.
B. Supraglottic: common & early due to rich lymphatics >> UDCLN.
C. Subglottic: common may be bilateral >> pre laryngeal, pre tracheal, paratracheal >> middle & LDCLN.

3- Blood spread rare & late: lungs, liver, bone, brain.

Staging of laryngeal carcinoma

T for primary tumor
Tis Carcinoma in situ.
T1 One region (in glottic T1a : one cord, T1b : two cords).
T2 Two regions.
T3 Fixed cord.
T4 Extra laryngeal spread.

N: Nodes
N0: No cervical lymph nodes positive.

N1: Single ipsilateral lymph node ≤ 3cm.
N2a: Single ipsilateral node > 3cm and ≤6cm.
N2b: Multiple ipsilateral lymph nodes, each ≤ 6cm.
N2c:Bilateral lymph nodes ≤ 6cm.
N3: Single or multiple lymph nodes > 6cm.

M: Distant metastasis
M0: No clinical or radiological evidence of metastasis.
M1: Present clinical or radiological evidence of metastasis.

Symptoms of cancer larynx

• Hoarseness or dysphonia: Persistent hoarseness in an old male for 2-3 weeks is suspicious for carcinoma.
• Stridor: It is the early symptom which may alter the attention to subglottic carcinoma.
• Pain: referred otalgia: may result from ulcer over the inlet of the larynx or perichondritis.
• Dysphagia: common in supraglottic lesions.
• Neck mass : mostly lymph nodes.

Signs:

I. General: 

Teeth for sepsis & oral hygiene. 

Chest : distant metastasis.

II. Local: (Larynx)

1-External (Neck): Lymph nodes, swelling, broadening, tenderness, and thyroid cartilage.

2-By Indirct Laryngoscopy, flexible or Direct Laryngoscopy examination:

Tumor: Hyperkeratotic warty or papillary growth, malignant ulcer, or raised nodule.

V.C mobility: 

• Freely mobile.
• Fixed: deep muscle invasion.
• Limited: weight of tumor or moderate invasion

Extension: to hypopharynx, trachea or tongue.

NB: some areas are difficult to be examined: ventricle, subglottis, posterior surface of epiglottis.

Investigations:

1- Radiology:

Chest X Ray

CT scan: to detect cartilage invasion, extra laryngeal spread and subglottic extension.

MRI: Superior than CT scan in demonstrating soft tissue involvement.

2-DL: Site, extent, and biopsy.

3-Metastatic work up. (Chest X ray, abdominal sonar & bone scan).

4-Routine preoperative investigations.

Treatment of cancer larynx:

Tis stage: 

Surgery: carcinomatous transformation, without basal membrane penetration. .

• Complete excision Conservative management: stripping of VC
• Frequent follow up and re biopsy 6 to 12 weeks later.
• There is no role for radiotherapy.

T1 Laryngeal Cancer:

• Radiation therapy.
• Endoscopic laser microsurgery.
• Partial laryngectomy (vertical in glottis, and horizontal in supraglottis).
• In subglottic, either radiotherapy, or total laryngectomy.

T2 Laryngeal Cancer:

• Radiation therapy.
• Endoscopic laser microsurgery.
• Partial laryngectomy (vertical in glottis, and horizontal in supraglottis).
• In some cases, supracricoid laryngectomy is done.
• In subglottic, either radiotherapy, or total laryngectomy.

T3 Laryngeal Cancer:

• Total laryngectomy with or without postoperative chemo radiotherapy.
• Supracricoid laryngectomy in selected cases.
• Chemo radiation therapy.

T4 Laryngeal Cancer:

• Total laryngectomy, usually combined with thyroidectomy and followed by postoperative radiotherapy.
• Chemoradiation therapy.

NB: Supracricoid laryngectomy

• Remove the mid third of the larynx. One arytenoid can be resected.
• Preserve functions of larynx (deglutition, respiration, phonation and airway protection) without compromising cure rate. Patient ends without a tracheotomy.
  

Indications of total laryngectomy:

1- T3, T4 glottic, supraglottic.

2- All subglottic & transglottic.

3- Recurrence or failure after conservative surgery.

4- Recurrence or failure after radiotherapy.

5- Contraindication for conservative or radiotherapy.

6- Certain histological types.

Contra indications of total laryngectomy:

1- Poor general condition.

2- Patient refusal.

3- Distant metastasis.

4- Involvement of unresectable structures.

Disadvantages of total laryngectomy

1- Loss of voice.

2- Inability to increase intra thoracic pressure.

3- Permanent tracheostomy.

4- Loss of nasal functions.

5- Limitation of activities.

Voice Rehabilitation after total laryngectomy

• Tracheostomal prosthesis

• Electrolarynx

• Pure esophageal speech.

Management of cervical metastasis:

-If palpable LN >> Neck dissection should be performed.

- If no palpable LN >> Glottic (nothing)

Supra glottic >> prophylactic(elective) neck dissection, or radiotherapy.

Sub glottic >> prophylactic(elective) neck dissection, or radiotherapy

Palliative treatment

Indicated in: Unresectable tumors, surgery refusal, distant metastasis & poor general condition

1- Tracheostomy. 

2- Ryle or gustrostomy for feeding.

3- Pain killers. 

4- Palliative laser, radiotherapy, chemotherapy.

Prognosis:

 Early cancer has good prognosis, glottic cancer has best cure rate up to 90% due to early presentation (hoarseness) &absent lymphatic spread.

References:

Head and neck cancers [Fact sheet]. (2017).
cancer.gov/types/head-and-neck/head-neck-fact-sheet
Laryngeal and hypopharyngeal cancer. (2017).
cancer.org/cancer/laryngeal-and-hypopharyngeal-cancer/about/what-is-laryngealand-hypopharyngeal.html
Laryngeal cancer treatment (adult). (2018).
cancer.gov/types/head-and-neck/patient/adult/laryngeal-treatment-pdq
Mayo Clinic Staff. (2018). Throat cancer.
mayoclinic.org/diseases-conditions/throat-cancer/symptoms-causes/syc-20366462