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Diseases of Pharynx and Larynx. Anatomy of Pharynx Fibromuscular Tube Fibromuscular Tube Base of Skull to C6 (12cm) Base of Skull to C6 (12cm) Divided.

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Presentation on theme: "Diseases of Pharynx and Larynx. Anatomy of Pharynx Fibromuscular Tube Fibromuscular Tube Base of Skull to C6 (12cm) Base of Skull to C6 (12cm) Divided."— Presentation transcript:

1 Diseases of Pharynx and Larynx

2 Anatomy of Pharynx Fibromuscular Tube Fibromuscular Tube Base of Skull to C6 (12cm) Base of Skull to C6 (12cm) Divided into three parts Divided into three parts Nasopharynx Nasopharynx Oropharynx Oropharynx Laryngopharynx Laryngopharynx 4 Layers 4 Layers Mucosal, submucosal (Fibrous), Muscular, Fascial layer (buccal pharyngeal) Mucosal, submucosal (Fibrous), Muscular, Fascial layer (buccal pharyngeal)

3 Nasopharynx Base of skull to the soft palate Base of skull to the soft palate Key components Key components Pharyngeal Tonsil (Adenoids) Pharyngeal Tonsil (Adenoids) Pharyngeal Recess (ICA) Pharyngeal Recess (ICA) Opening of Auditory tube Opening of Auditory tube

4 Oropharynx Soft Palate to the epiglottis Soft Palate to the epiglottis Key Components Key Components Palatopharyngeal and Palatoglossal arches Palatopharyngeal and Palatoglossal arches Palantine Tonsil – project from tonsillar fossa Palantine Tonsil – project from tonsillar fossa Lingual Tonsil Lingual Tonsil Valleculae – lie between epiglottis and posterior border of the tongue Valleculae – lie between epiglottis and posterior border of the tongue

5 Laryngopharynx Epiglottis to the level of cricoid cartilage Epiglottis to the level of cricoid cartilage Key features Key features Opening to the larynx Opening to the larynx Piriform recess (endoscope) Piriform recess (endoscope)

6 Anatomy of Pharynx Blood supply Blood supply Branches of many arteries (ascending pharyngeal, greater palantine, lingual, tonsilar) Branches of many arteries (ascending pharyngeal, greater palantine, lingual, tonsilar) Nerve Supply Nerve Supply Afferent; maxillary nerve, glossopharyngeal, internal and recurrent laryngeal nerves Afferent; maxillary nerve, glossopharyngeal, internal and recurrent laryngeal nerves Motor; Pharyngeal Plexus (Vagus, glossopharyngeal, Cervical Sympathetic) Motor; Pharyngeal Plexus (Vagus, glossopharyngeal, Cervical Sympathetic)

7 Larynx Respiratory Organ Respiratory Organ Lying between pharynx and trachea Lying between pharynx and trachea Becomes continuous with the trachea at the level of the cricoid cartilage (C6) Becomes continuous with the trachea at the level of the cricoid cartilage (C6) Function Function Primary – protective sphincter at the inlet of the air passages Primary – protective sphincter at the inlet of the air passages Phonation Phonation

8 Larynx Components Components Cartilages Cartilages Singular; thyroid, cricoid, epigolittic Singular; thyroid, cricoid, epigolittic Paired; Arytenoid, corniculate, cuneiform Paired; Arytenoid, corniculate, cuneiform Joints Joints Cricothyroid, cricoarytenoid Cricothyroid, cricoarytenoid Ligaments and Membranes Ligaments and Membranes Intrinsic; Quandrangular membrane, Cricothyroid ligament (Vocal folds) Intrinsic; Quandrangular membrane, Cricothyroid ligament (Vocal folds) Extrinsic; Thyrohyoid membrane, cricotracheal, hypoepiglottic, thyroepiglottic ligaments, cricothyroid Extrinsic; Thyrohyoid membrane, cricotracheal, hypoepiglottic, thyroepiglottic ligaments, cricothyroid

9 Cavities Inlet + Vestibule Inlet + Vestibule Rima of glottis Rima of glottis Subglottic space Subglottic space

10 Layrnx - Intrinsic Membranes Quadrangular membrane Quadrangular membrane Arytenoid Cartilage and epiglottis Arytenoid Cartilage and epiglottis Lower border; vestibular folds (false cord) Lower border; vestibular folds (false cord) Upper border; aryepiglottic folds Upper border; aryepiglottic folds Cricovocal Membrane Cricovocal Membrane Formed from lateral part of cricothyroid ligament Formed from lateral part of cricothyroid ligament Upper thickened border forms cricovocal ligaement Upper thickened border forms cricovocal ligaement Vocal folds which bounds the glottis anteriorly Vocal folds which bounds the glottis anteriorly

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12 Laryngeal Muscles - Intrinsic 1. Those that alter size and shape of the inlet Aryepiglottic Muscles Aryepiglottic Muscles Oblique arytenoids Oblique arytenoids Thyroepiglottic muscles Thyroepiglottic muscles Act as Sphincter for the inlet Act as Sphincter for the inlet Provide valvular protection from above Provide valvular protection from above

13 Laryngeal Muscles - Intrinsic 2. Responsible for Phonation by moving vocal folds Abduction; Posterior Cricoarytenoids Abduction; Posterior Cricoarytenoids Adduction; Lateral cricoarytenoid and transverse arytenoid Adduction; Lateral cricoarytenoid and transverse arytenoid Lengthen; Cricothryroid Lengthen; Cricothryroid Shorten; Thyroarytenoid, vocalis Shorten; Thyroarytenoid, vocalis

14 Phonation Pitch; Vibration of the folds through shortening and lengthing of the volds Pitch; Vibration of the folds through shortening and lengthing of the volds Intensity; Pressure through the glottis Intensity; Pressure through the glottis Quality; Resonating chambers above the glottis Quality; Resonating chambers above the glottis Articulation; tongue, teeth and lips Articulation; tongue, teeth and lips

15 Larynx Blood supply Blood supply Superior and Inferior Laryngeal Branches from Superior and Inferior Thyroid Artery Superior and Inferior Laryngeal Branches from Superior and Inferior Thyroid Artery Nerve Supply Nerve Supply Recurrent Laryngeal Nerve Recurrent Laryngeal Nerve All intrinsic Muscles except cricothyroid All intrinsic Muscles except cricothyroid Mucous Membranes below the folds Mucous Membranes below the folds External Layngeal Nerve External Layngeal Nerve Cricothyroid muscle Cricothyroid muscle Internal Laryngeal Nerve Internal Laryngeal Nerve Mucous Membranes below the folds Mucous Membranes below the folds

16 Nerve Palsies Recurrent Laryngeal Nerve Recurrent Laryngeal Nerve Number of causes Number of causes Left; Left; Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg Carcinoma of bronchus, oesophagus, Aortic anuersym, cardiac surg Left or Right; Left or Right; Iatrogenic, Trauma, Thyroid disease Iatrogenic, Trauma, Thyroid disease Complete (Cadaveric Position) Complete (Cadaveric Position) Half abducted position with arytenoid cartilage slightly in front Half abducted position with arytenoid cartilage slightly in front Hoarse Voice Hoarse Voice Bovine cough Bovine cough Incomplete Incomplete Adducted position as posterior cricoarytenoid more susceptible Adducted position as posterior cricoarytenoid more susceptible External Laryngeal Nerve External Laryngeal Nerve Hoarse voice that recovers Hoarse voice that recovers Inability to hit high frequencies Inability to hit high frequencies

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19 Extrinsic Muscles Elevators Elevators Indirectly; Indirectly; Mylohyoid, digastric, stylohyoid, geniohyoid Mylohyoid, digastric, stylohyoid, geniohyoid Directly; Directly; Stlyopharyngeus, salingopharyngeus, palatopharyngeus Stlyopharyngeus, salingopharyngeus, palatopharyngeus Depressors Depressors Sternohyoid, omohyoid stenothyroid Sternohyoid, omohyoid stenothyroid

20 4 year old boy 4 year old boy Pain in right ear and fevers Pain in right ear and fevers Recurrent ear infections Recurrent ear infections Noisy breather Noisy breather Overweight Overweight Examination – Sore right ear, hyperaemic tympanic membrane, breathing with mouth open Examination – Sore right ear, hyperaemic tympanic membrane, breathing with mouth open

21 Adenoid Hypertrophy Occupies large area of nasopharynx age <6 Occupies large area of nasopharynx age <6 Atrophies and by age 15 little remains Atrophies and by age 15 little remains Recurrent URTI or allergies can lead to hypertrophy Recurrent URTI or allergies can lead to hypertrophy Clinical Clinical Nasal Obstruction; Mouth breathing / Adenoid Facies, chest infections, pharyngeal infections, sinusitis, snoring Nasal Obstruction; Mouth breathing / Adenoid Facies, chest infections, pharyngeal infections, sinusitis, snoring Eustachian Tube; Recurrent Otitis Media, CSOM Eustachian Tube; Recurrent Otitis Media, CSOM Choanal Obstruction; OSA, chronic sinusitis Choanal Obstruction; OSA, chronic sinusitis

22 Ix Ix Nasopharyngeal Exam Nasopharyngeal Exam Nasopharyngoscopic Exam Nasopharyngoscopic Exam Lateral Xray Lateral Xray Tx Tx Supportive Supportive Adenoidectomy Adenoidectomy

23 Adenoidectomy Criteria for surgery Criteria for surgery Chronic upper airway obstruction with OSA +/- cor pulmonale Chronic upper airway obstruction with OSA +/- cor pulmonale Chronic serous/suppurative otitis media Chronic serous/suppurative otitis media Recurrent acute otitis media Recurrent acute otitis media Suspicion of nasopharyngeal malignancy Suspicion of nasopharyngeal malignancy Chronic sinusitis Chronic sinusitis Complications Complications Early Haemorrhage Early Haemorrhage Otitis media Otitis media Regrowth of residual adenoid tissue Regrowth of residual adenoid tissue

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25 Tonsillitis Commonest area of infection of head and neck Commonest area of infection of head and neck Clinical; Sore throat and Odynophagia, Otalgia, headache, malaise, Fever, hyperaemic tonsils, cervical lymphadenopathy DDx; Clinical; Sore throat and Odynophagia, Otalgia, headache, malaise, Fever, hyperaemic tonsils, cervical lymphadenopathy DDx; Viral Viral Group A Streptococcus (20-30%) Group A Streptococcus (20-30%) EBV; Palatal petechia EBV; Palatal petechia Diptheria; Unimmunised, grey membrane Diptheria; Unimmunised, grey membrane Tx; Rest, paracetamol +/- ABx Tx; Rest, paracetamol +/- ABx

26 Tonsillitis Complications; Complications; Acute Otitis Media (most common) Acute Otitis Media (most common) Peritonsillar abscess (Quinsy) Peritonsillar abscess (Quinsy) GAS GAS Post Strep GN Post Strep GN Rhuematic Fever Rhuematic Fever Scarlet Fever; Strawberry tongue and scarlitiform rash Scarlet Fever; Strawberry tongue and scarlitiform rash Recurrent Tonsillitis Recurrent Tonsillitis Tonsillar Hypertrophy Tonsillar Hypertrophy

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28 Tonsillectomy Indications for surgery Indications for surgery Absolute Absolute Airway obstruction Airway obstruction Suspicion of malignancy Suspicion of malignancy Relative Relative Sleep apnoea, mouth breathing, difficulty swallowing Sleep apnoea, mouth breathing, difficulty swallowing Recurrent tonsillitis >5 episodes Recurrent tonsillitis >5 episodes Any complications Any complications Complications Complications Reactionary haemorrhage Reactionary haemorrhage Secondary haemorrhage Secondary haemorrhage 5-10 days post op 5-10 days post op Due to fibrinolysis aggravated by infection Due to fibrinolysis aggravated by infection

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30 Pharyngitis Acute Acute >70% Viral Cause, GAS >70% Viral Cause, GAS Supportive Treatment Supportive Treatment Chronic Chronic Persistent mild soreness and dryness Persistent mild soreness and dryness Predisoposing factors include; smoking, ETOH, mouth breathing, chronic sinusitis, Industrial fumes, antiseptic throat lozengers Predisoposing factors include; smoking, ETOH, mouth breathing, chronic sinusitis, Industrial fumes, antiseptic throat lozengers Enlarged lymphoid tissue can be removed Enlarged lymphoid tissue can be removed

31 64 Male recently Immigrated from Hong Kong 64 Male recently Immigrated from Hong Kong Lump in right side of neck Lump in right side of neck Progressive enlarged, non-painful Progressive enlarged, non-painful Exam; firm, fixed, solid mass lateral to midline in posterior triangle Exam; firm, fixed, solid mass lateral to midline in posterior triangle

32 Nasopharyngeal Carcinoma Rare in Europe Rare in Europe Common in Asian countries Common in Asian countries 20% of all malignancies in Hong Kong 20% of all malignancies in Hong Kong Pathology Pathology Squamous cell/undifferentiated Squamous cell/undifferentiated Aietology Aietology Unknown, however EBV plays a role Unknown, however EBV plays a role Others; ingestion of preserved foods Others; ingestion of preserved foods

33 Nasopharyngeal Carcinoma Clinical; Clinical; Most commonly as lump in the neck Most commonly as lump in the neck Local; Nasal obstruction, blood stained discharge Local; Nasal obstruction, blood stained discharge Neurological; Invasion of skull base causing cranial nerve palsies (V, VI, IX, X, XII) Neurological; Invasion of skull base causing cranial nerve palsies (V, VI, IX, X, XII) Otological; Serous otitis media Otological; Serous otitis media Metastasis to bone, lung, liver Metastasis to bone, lung, liver

34 Nasopharyngeal Carcinoma Ix; Ix; Tissue sampling, CT/MRI, Staging Tissue sampling, CT/MRI, Staging Management Management Radiotherapy with concominant chemotherapy Radiotherapy with concominant chemotherapy Poorly amendable to surgery due to anatomical location Poorly amendable to surgery due to anatomical location DDx DDx Lymphoma, cystic adenocarcinoma, Infection Lymphoma, cystic adenocarcinoma, Infection

35 Pathology of the Larynx Infectious Infectious Inflammatory Inflammatory Congenital Congenital Mucosal Mucosal Malignancy Malignancy

36 5 Year old boy 5 Year old boy Hx of Hx of 3/7 Low grade fever and URTI Sx 3/7 Low grade fever and URTI Sx 1/7 history Biphasic Stridor, barking cough 1/7 history Biphasic Stridor, barking cough No obvious respiratory distress No obvious respiratory distress

37 Laryngotracheitis (Croup) Inflammation of tissues of subglottic space +/- tracheobronchial tree Inflammation of tissues of subglottic space +/- tracheobronchial tree Mucopurulent exudate -> airway obstruction Mucopurulent exudate -> airway obstruction Aetiology; Parainfluenza I (most common), II,III, influenza A,B, RSV Aetiology; Parainfluenza I (most common), II,III, influenza A,B, RSV Presentation; night, inspiratory/biphasic stridor, barking cough Presentation; night, inspiratory/biphasic stridor, barking cough Beware loss of stridor, Decr SaO2 Beware loss of stridor, Decr SaO2 DDx; FB, subglottic stenosis, Epiglottitis DDx; FB, subglottic stenosis, Epiglottitis

38 Laryngotracheitis + Epiglottitis FeatureLaryngotracheitisEpiglottitis Inflammation Subglottic space Supraglottic space Age 4month-5 years1-4 years OnsetGradual (days)Acute (hours) Fever Low grade/afebrile High fevers Stridor Biphasic/inspiratory Inspiratory CoughBarkyNormal PostureSupineSitting DroolingNoYes Radiograph Steeple sign Thumb sign, enlarged epiglottis Appearance Non-toxic Toxic/cyanotic Cause ViralBacterial Treatment Supportive Keep child calm O2, Adrenalin nebsAirway management -ETT O2, Adrenalin nebsAirway management -ETT Steroids ABx, IV hydration, Moist air Steroids ABx, IV hydration, Moist air

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40 18 month girl 18 month girl Asthma Attack Asthma Attack Wheezy Wheezy ?trigger ?trigger Family Hx of Asthma, Eczema Family Hx of Asthma, Eczema No stridor, but tachypnea, intercostal recession No stridor, but tachypnea, intercostal recession Unilateral wheeze on Right with Decreased air entry in lower zones Unilateral wheeze on Right with Decreased air entry in lower zones

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42 Foreign Body Usually stuck at right main bronchus Usually stuck at right main bronchus Anything thats small enough Anything thats small enough Presentation; Presentation; Stridor if at level of trachea Stridor if at level of trachea Unilateral asthma if bronchial Unilateral asthma if bronchial Complications Complications Atelectasis, lobar pneumonia, pneumothorax, mediastinal shift Atelectasis, lobar pneumonia, pneumothorax, mediastinal shift Dx; Dx; Inspiratory/Expiratory X-rays Inspiratory/Expiratory X-rays Bronchoscopy Bronchoscopy

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44 Signs of Airway Obstruction Stretor; obstruction in the throat, low pitched choking noises Stretor; obstruction in the throat, low pitched choking noises Stridor; High pitched, inspiratory, biphasic or expiratory depending on location Stridor; High pitched, inspiratory, biphasic or expiratory depending on location Accessory Muscle use Accessory Muscle use Pallor, diaphoresis, restlessness Pallor, diaphoresis, restlessness Tachycardia Tachycardia Cyanosis and altered concious state Cyanosis and altered concious state Intercostal recession Intercostal recession Nasal Flaring Nasal Flaring Exhaustion Exhaustion Bradycardia – most dangerous sign Bradycardia – most dangerous sign

45 Upper Airway Obstruction - Neonates Subglottic Stenosis Subglottic Stenosis Congenital or Acquired (trauma, intubation) Congenital or Acquired (trauma, intubation) Biphasic stridor, resp distress, recurrent croup Biphasic stridor, resp distress, recurrent croup Diagnosis; CT, laryngoscopy Diagnosis; CT, laryngoscopy Tx; Soft tissue – laser and steroids Tx; Soft tissue – laser and steroids Cartilage – Laryngotracheoplasty or tracheostomy (intubation) Laryngomalacia Laryngomalacia Soft immature cartilage Children or older patients with NM disorders Soft immature cartilage Children or older patients with NM disorders Inspiratory stridor at 1-2 weeks, worse supine + feeding difficulties Inspiratory stridor at 1-2 weeks, worse supine + feeding difficulties Dx; Bronchoscopy Dx; Bronchoscopy Tx; Usually self resolves after 18-24months Tx; Usually self resolves after 18-24months

46 44 Female 44 Female 6 week history of hoarse voice 6 week history of hoarse voice Irritation and dryness in throat Irritation and dryness in throat History of heartburn History of heartburn Smoker Smoker No history of weight loss, fatigue No history of weight loss, fatigue Examination; Unremarkable Examination; Unremarkable

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48 Chronic Laryngitis Most common cause is GORD Most common cause is GORD Recurrent Acute laryngitis Recurrent Acute laryngitis Heavy smoking Heavy smoking Chronic infection of nasal sinuses Chronic infection of nasal sinuses Mouth breathing from nasal obstruction Mouth breathing from nasal obstruction Clinically Clinically Hoarseness or loss of voice Hoarseness or loss of voice Spasmodic cough Spasmodic cough DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis, TB DDx; Malignancy, inhaled corticosteroids, laryngeal paralysis, TB General; Voice resting, avoid smoking General; Voice resting, avoid smoking Specific; eg. Lifestyle modifications, Medications Specific; eg. Lifestyle modifications, Medications

49 35 year old 35 year old Blunt trauma to neck 5 hours ago Blunt trauma to neck 5 hours ago Difficulty swallowing + Voice changes Difficulty swallowing + Voice changes No history of LOC, resp distress, confusion No history of LOC, resp distress, confusion Examination showed midline tenderness of neck, subcutaneous emphysema Examination showed midline tenderness of neck, subcutaneous emphysema

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51 Laryngeal Trauma Rare Rare Causes Causes Penetrating Penetrating Blunt trauma; majority are MVAs, clothesline injuries, sporting injuries Blunt trauma; majority are MVAs, clothesline injuries, sporting injuries Manual strangulation Manual strangulation Inhaled flames Inhaled flames Swallowed poisons, foreign body Swallowed poisons, foreign body ETT ETT Injuries; Injuries; Cricotracheal separation -> Asphyxia Cricotracheal separation -> Asphyxia Fractures of larynx, hyoid bone, joint disruption Fractures of larynx, hyoid bone, joint disruption Open wounds Open wounds Mucosal Tears Mucosal Tears

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56 Laryngeal Injuries Presentation Presentation Significant cervical trauma Significant cervical trauma Hoarse voice, neck pain, dyspnea, hypoxia, aphonia dysphasia Hoarse voice, neck pain, dyspnea, hypoxia, aphonia dysphasia Goals of treatment Goals of treatment Protect the airway; Intubation, tracheostomy Protect the airway; Intubation, tracheostomy Restoration of function; Surgical repair Restoration of function; Surgical repair Complications Complications Laryngeal stenosis; permanent tracheostomy Laryngeal stenosis; permanent tracheostomy

57 33 year old male singing teacher 33 year old male singing teacher Progressively hoarse voice Progressively hoarse voice Normal Cough Normal Cough Non-smoker Non-smoker No weight loss/fatigue No weight loss/fatigue

58 Benign Vocal Fold Lesions Reactive nodules (singers nodules) Reactive nodules (singers nodules) Bilateral Bilateral Smooth, rounded/pedunculated Smooth, rounded/pedunculated Small Small Located on true vocal folds Located on true vocal folds Treatment; Treatment; Voice training, re-education Voice training, re-education Rarely surgical if fibrosed, chronic Rarely surgical if fibrosed, chronic Virtually never give rise to malignancy Virtually never give rise to malignancy

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60 Laryngocele Abnormal dilatation of the laryngeal ventricle Abnormal dilatation of the laryngeal ventricle Contains air Contains air Men>Women Men>Women Bilateral 25% Bilateral 25% Aeitology; Aeitology; Acquired; Incr. Intraluminal pressure (musicians) Acquired; Incr. Intraluminal pressure (musicians) Congenital Congenital SCC <15% SCC <15% Hoarse voice, pain, dysphagia, lateral neck mass Hoarse voice, pain, dysphagia, lateral neck mass

61 Squamous Papilloma Most common benign neoplasm of larynx (84%) Most common benign neoplasm of larynx (84%) Found on true vocal cords Found on true vocal cords Caused by HPV 6 and 11 Caused by HPV 6 and 11 Soft Raspberry like appearance Soft Raspberry like appearance May ulcerate resulting in haemoptysis May ulcerate resulting in haemoptysis Usually Single in Adults Usually Single in Adults Multiple in Children (Laryngeal Papillomatosis) with extended growth and recurrence Multiple in Children (Laryngeal Papillomatosis) with extended growth and recurrence Malignant transformation extremely rare Malignant transformation extremely rare

62 Investigation and Treatment Ix; Ix; Laryngoscopy Laryngoscopy Tx; Tx; CO2 Laser CO2 Laser Surgical removal Surgical removal ?Antivirals ?Antivirals

63 55 year old male 55 year old male History of GORD, cardiac disease History of GORD, cardiac disease Recurrent hoarse voice Recurrent hoarse voice Right otalgia Right otalgia Smoker + ETOH abuse Smoker + ETOH abuse

64 Squamous Cell Carcinoma Most common malignancy of larynx Most common malignancy of larynx Male>Female 6;1x Male>Female 6;1x 2.5% all cancers in men 2.5% all cancers in men Aeitology Aeitology Tobacco: Tobacco: Alcohol: (x 2.2) Alcohol: (x 2.2) Radiation, asbestos Radiation, asbestos GORD GORD HPV HPV

65 Squamous Cell Carcinoma Glottic SCC most common (60%) > supraglottic SCC (30%) > subglottic SCC ( supraglottic SCC (30%) > subglottic SCC (<10%). Sx: hoarseness, throat pain, cough, hemoptysis, referred otalgia, dysphagia Sx: hoarseness, throat pain, cough, hemoptysis, referred otalgia, dysphagia Diagnosis; Diagnosis; Laryngoscopy with FNA Laryngoscopy with FNA CT/MRI CT/MRI

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67 Squamous Cell Carcinoma Management Management Eradication of disease Eradication of disease Restoration of function; swallowing and speech Restoration of function; swallowing and speech Radiation treatment Radiation treatment Especially early stage disease Especially early stage disease Cure rates equivalent to surgery Cure rates equivalent to surgery Surgical Management Surgical Management Emphasis on organ preservation Emphasis on organ preservation Partial Larygectomy Partial Larygectomy

68 Learning Radiology Learning Radiology Clinical Cases and Osces in Surgery. Ramachandran, Poole Clinical Cases and Osces in Surgery. Ramachandran, Poole Apleys Orthopaedics Apleys Orthopaedics


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