Laryngeal Tumours (喉腫瘤)

Papilloma (乳頭狀瘤)

Aetiology:

Localized infection with human papillomavirus (HPV).

Clinical features:

• In the child (juvenile form): multiple lesions that may spread to the trachea and bronchi. Cases may regress at puberty.
• In the adult: less common and usually a single lesion.

Both forms present with hoarseness or airway obstruction.

Management:

Endoscopic removal using either suction diathermy or a CO2 laser. Surgical seeding of lesions within the larynx or trachea is common, and removal may be necessary for frequent recurrence.

Carcinoma (癌)

Aetiology:

Associated with cigarette smoking and high alcohol intake, although the latter is more important in causing piriform fossa carcinoma.

Clinical features:

Usually presents as persistent hoarseness. Dysphagia, chronic cough, stridor and referred otalgia may also occur. Occasionally a supraglottic tumour may present with metastatic neck nodes. The tumour may be evident on indirect laryngoscopy but endoscopic assessment and biopsy are mandatory before deciding on the appropriate treatment. A second primary (1%) in the upper aerodigestive tract should be searched for at this time.

Fine-needle aspiration cytology of any suspicious neck mass should also be undertaken. A CT scan will show any spread outside the larynx, or involvement of laryngeal cartilages.

Management:

Small (T1 and T2) carcinomas are best treated with primary radiotherapy, laryngectomy being reserved for post-radiation recurrences, larger (T3 and T4) lesions and primary tumours associated with neck nodes greater than 2cm in diameter. Primary endoscopic excision of laryngeal carcinomas with a carbon dioxide laser is now being undertaken by some surgeons.

Voice rehabilitation:

Following total laryngectomy the patient may be able to speak again by:

• Learning oesophageal speech (swallowed air is voluntarily regurgitated through the pharynx)
• Using an artificial larynx, which transmits vibrations into the pharynx and oral cavity while the patient articulates
• Surgical provision of a tracheo-oesophageal fistula, which is fitted with a button or valve. The button has a one-way flutter valve, which allows airflow from the trachea into the pharynx when the tracheostome is occluded. In selected patients this enables the development of good voice.

Results:

Patients require close follow-up. Recurrences can develop in the larynx, pharynx, stoma or neck. Further surgery or radiotherapy may be indicated. The expected 5-year survival for a T1 laryngeal cancer is about 95%. This falls to about 50% for T4 disease.

Tumours of the tonsil (扁桃體腫瘤)

Benign cysts (良性囊腫)

Clinical features:

Mucous retention cysts, tonsilloliths or cysts of inspissated epithelial debris may occur. They are smooth and localized to one portion of the tonsil.

Management:

Symptomatic cysts may be helped by tonsillectomy.

Lymphoma (淋巴瘤)

Clinical features:

Unilateral tonsillar swelling with an intact overlying mucosa may cause dysphagia and is suspicious of a lymphoma. The tonsil feels rubbery. Excision biopsy confirms the diagnosis.

Management:

After staging the disease, treatment involves radiotherapy for localized disease, with chemotherapy being added in more advanced cases.

Carcinoma (癌)

Clinical features:

Squamous carcinoma of the tonsil presents as otalgia, sore throat or dysphagia in heavy drinkers and smokers. More than 50%of cases have involved neck nodes ipsilaterally: this may be the mode of presentation. The tonsil is hard and ulcerated.

Management:

After full endoscopy and biopsy small primaries without nodes are best treated by radiotherapy. Surgery (which involves a block dissection of neck, partial mandibulectomy and excision of the primary) is reserved for radiation failures and large primaries.