Documente Academic
Documente Profesional
Documente Cultură
• think of it as
“ultralight”…
OCT tomorrow???
Laryngeal Cancer
• Hypopharynx cancers: Glottic (62%)
supraglottic (37%) and subglottic (2%).
• Main risk factors: tobacco and alcohol
– Others include HPV, GERD, passive smoke,
(for the test… Plummer-Vinsen Syndrome >>
post-cricoid SCCA)
Clinical Pearls
• 78% of patients with hypopharyngeal
carcinoma have palpable cervical
metastases when initially seen.
• The average duration of symptoms before
presentation is 2 to 4 months.
• 20% have an asymptomatic mass in the
neck, usually ipsilateral, a jugulodigastric
or midjugular lymph node
Anatomy: Think Spaces
• Quadrangular
membrane: Fibrous
drape from
epiglottis over
arytenoids.
• Conus elasticus:
See diagram.
• Anterior
commissure tendon
(Broyles ligament):
- No perichondrium.
• Hyoepiglottic
ligament:
– Roof of the
paraglottic and
preepiglottic
spaces.
Anatomy
• Paraglottic space:
• Superior border :
quadrangular membrane
• Inferior border: conus
elasticus
• Lateral border: inner
surface of the thyroid
cartilage
• Medial border: ventricle
T3 supraglottic cancer
spreading into glottis
through the paraglottic
space.
Anatomy
• Preepiglottic space
• Superior border : hyoepiglottic
ligament
• Anterior border: thyrohyoid
membrane and ligament
• Posterior border: anterior surface
of the epiglottis and thyroepiglottic
ligament
Path of
subglottic
tumor spread
Radiology
• Only 46% positive predictive value of CT
for detecting cartilage invasion
• 50% of tumors radiologically staged as T3
had microinvasion of cartilage, usually at
thyroid notch.
• CT most useful, but MRI useful for
detecting submucosal lesions.
• Don’t forget CXR: lung CA most common
second primary.
Staging: Glottic
• T1-tumor limited to the vocal cords
– T1a-tumor limited to one vocal cord
– T1b-tumor involves both vocal cords
• T2-tumor extends to the supraglottis and/or
subglottis and/or impaired vocal cord mobility
• T3-tumor with vocal cord fixation (a cord cannot
move at all)
• T4-tumor invades outside of the larynx (trachea,
soft tissues of the neck, etc.)
Staging: Supraglottic
• T1-tumor limited to one subsite of the supraglottis with
normal vocal cord mobility
– B: If Chylous fistulae becomes apparent only after enteral feedings are resumed,
and particularly those that drain less than 600 mL of chyle per day
• >>> conservative: closed wound drainage, pressure dressings, and low-fat nutritional
support.
– C: General:
• the area should be observed for 20 or 30 seconds while the anesthesiologist increases
the intrathoracic pressure.
• Even the smallest leak of chylous material should be pursued seriously until it is
arrested. Direct clamping and ligating may be difficult and sometimes
counterproductive because of the fragility of the lymphatic vessels and the surrounding
fatty tissue.
• Hemoclips are ideal to control a source of leakage that is clearly visualized.
Stomal Recurrence
• Prevention of stomal recurrence in
tumor with one cm transglottic
spread.
– postoperative stomal XRT.
– paratracheal lymph node dissection.
• Stomal recurrence classified by
Sisson:
– Type I – tumor involves the superior
one half of the stoma without
esophageal involvement.
– Type II – tumor involves superior one
half of the stoma with esophageal
involvement, or the inferior half of the
stoma
– Type III – Tumor involves the inferior
one half of the stoma and extends into
the mediastinum.
– Type IV-Extends beneath the clavicle