Management of ca larynx & post laryngectomy voice rehabilitation

1. Management of ca larynx & post laryngectomy voice rehabilitation Dr. Sheetal Rai Asst. Professor Dept of ENT, YMC

2. Specific learning objectives • Outline the steps in the diagnosis of laryngeal cancer • Outline the treatment options for laryngeal cancer • Discuss the treatment of glottic, subglottic and supraglottic cancer • Describe the three methods of voice rehabilitation after total laryngectomy

3. Diagnosis of ca larynx A) Clinical diagnosis: • History • Indirect laryngoscopy • Neck examination

4. History : • Supraglottis – Foreign body sensation • Glottis – hoarseness of voice • Subglottis– stridor on exertion ILS : • Appearance of the lesion • Vocal cord mobility • Extent of the disease Videolaryngoscopy – flexible orrigid

5. Neck examination : • ? Extralaryngeal spread • ? Nodal metastasis Look for – • Midline swelling • Splaying of thyroid cartilage • Tenderness over thyroid cartilage • Hard, fixed lymph nodes

6. Diagnosis of ca larynx B) Investigations : 1) Radiological: i) X ray neck – soft tissue lateral view ii) X ray chest – PA view iii) CT scan/MRI 2) Direct laryngoscopy/ Microlaryngoscopy and biopsy 3) Supravital staining and biopsy

7. TREATMENT OPTIONS 1) Radiotherapy 2) Surgery a)Conservation laryngeal surgery b)Total laryngectomy 3) Combined therapy 4) Endoscopic CO2 laser excision 5)Organ preservation

8. TREATMENT OPTIONS Radiotherapy: • Early lesions – no cord fixity - no cartilage invasion - no nodal metastasis • Advantage – VOICE PRESERVATION

9. Radiotherapy complications include: • Mucositis • Radiation dermatitis • Laryngeal edema • Xerostomia • Osteoradionecrosis • Hypothyroidism

10. TREATMENT OPTIONS • Surgery a)Conservation laryngeal surgery b)Total laryngectomy

11. Total laryngectomy

12. TREATMENT OPTIONS • Combined therapy Surgery with pre or post op RT

13. Endoscopic CO2 Laser excision • For T1 lesion on Vocal cord, supra and infrahyoid epiglottis Advantages • Good results • Shorter hospital stay • Less morbidity

14. Organ preservation • For advanced T3 and T4 lesions • Induction Chemotherapy (CT) followed by Radiotherapy (RT) or • Concurrent Chemoradiation • Better quality of life

15. Glottic ca • Cacinoma in situ – transoral endoscopic CO2 laser excision or stripping of vocal cord ↓ ↓ biopsy – invasive CA CA in situ ↓ ↓ Radiotherapy Follow up

16. Glottic ca • Invasive Carcinoma – • T1 – RT/ CO2 laser excision • T2 – depends on CORD MOBILITY T2 with mobile VC – RT T2 with fixed mobile VC – Total laryngectomy N0 – RT, N1-3 – neck dissection • T3 /T4 – Total laryngectomy with neck dissection followed by post op RT • Advanced T4 – palliative therapy

17. Subglottic ca • T1 and T2 – RT • T3 and T4 – TL with neck dissection with post op RT

18. Supraglottic ca • T1 – RT / CO2 laser excision • T2 – TL with RT (if N0) TL with Neck dissection with RT (if N+) • T3 , T4 – TL with neck dissection with post op RT

19. Voice rehabilitation after total laryngectomy

20. Three methods : 1)Oesophageal speech 2)Artificial larynx i) Electrolarynx ii) Transoral pneumatic device 3)Tracheo - oesophageal Prosthesis

21. Oesophageal speech • Air is swallowed into cervical esophagus • Swallowed air is expelled out vibrations of pharyngeal mucosa • These vibrations along with articulations of tongue cause speech to occur • The exact vibrating portion of pharynx is the pharyngo-oesophageal segment

22. Pumping air into cervical oesophagus • Injection method • Inhalational method

23. OESOPHAGEAL SPEECH ADVANTAGES DISADVANTAGES • Hands free • No additional surgery / prosthesis needed. Hence no extra cost. • Easily adapted to oesophageal voice • Quality of voice poor • Can’t speak continuously without interruption. • Training is necessary • Loudness / pitch control is difficult

24. Artificial larynx • Electrolarynx Electronic vibrating device placed against the neck creates vibration in the mouth that the speaker then articulates into speech. 

25. Transoral pneumatic device Here vibration sound is transmitted directly into the mouth via a small tube

26. electrolarynx ADVANTAGES DISADVANTAGES • short learning time • ability to use immediately postop • availability and low cost • speech sounds non-human (mechanical, robotic, monotone) • reduced intelligibility and loudness • draws undesirable attention to the user

27. Tracheo - oesophageal Prosthesis • Primary – inserted on table • Secondary – inserted later

28. tep Advantages : • Patient can get his new voice fairly soon after surgery • Ability to control the volume, intonation and length of sentences • Lung powered speech

29. SUMMARY • Treatment of CA larynx is based on TNM classification. • Organ preservation protocol is a newer and upcoming concept in treatment of advanced cancer. • Voice rehabilitation post laryngectomy is a challenging task.

30. Thank you All images used in this presentation are obtained from a Google image search