1. LARYNX

7. Anatomy Skeleton Thyroid cartilage Cricoid cartilage
Arytenoid cartilage
Epiglottis
Corniculate cartilage
Cuneiform acrtilage
In males, thyroid cartilage presents a externally visble prominence known as adam’s apple.
Largeneal cartilages ossify by the age of 20.

9. Each of the inferior of the thyroid cartilage articulates withe cricoid forming cricothyroid joint: tilting in the saggital plane
The superior border of the cricoid cartilage forms cricoarytenoid joint resposible for rotating and glining movement.

12. Larynx is the narrowest portion of the upper repiratory tract more susceptible to obstructions
Cricioid cartilage encloses subglottis like a ring imparting mechanical ability that helps to prevent collapse of the larynx skeleton. It also ensues that any mucosal swelling... Particularly important to newborms and infants because a circumferential swelling of the glottic mucosa by 1 mm can cause 60% reduction in total luminal section.

13. Nerve supply -from the VAGUS NERVE Superior laryngeal nerve
motor: extrinsic laryngeal muscle (anterior cricothyroid) and its external branches
sensory: mucosa of the upper larynx including glottic plane
Recurrent laryngeal nerve
motor: supplies all the intrinsic muscles of the larynx
sensory: fibers to the layngeal mucosa below the glottis and to the tracheal mucosa
Recurrent open and close the glottic
Left recurrent: aortic arch
Right: subclavian

16. Blood supply: Arterial
Supraglottic and glottic levels: superior laryngeal artery from ECA
Subglottic: inferior layngeal coming from the subclavian and thyrocervical trunk

17. Blood supply: venous Superior thyroid vein drains into IJV
Inferior thyroid vein drain into Branchiocephalic vein

18. Croup symtoms
Croup syndrome: inspriratory stridor caused ny inflammation of the latyngeal or subglottic stenosis. Respiratory distress, cough, and hoarseness True droup: diptheria Pseudocroup: viral, bacterial, spastic forms of the subglottic laryngitis

20. Vocal Cord Nodules Usually bilateral
Anterior or middle third of true vocal cord
Any age group
Prevent the vocal folds from meeting in the midline and thus produce hourglass deformity on closure resulting in a raspy breathing voice
Hoarseness or voice changes
Related to chronic voice abuse
Microlaryngeal surgery

22. Vocal Cord Polyps Usually single
Middle third of true vocal cord, but may originate from the ventricular area
Locating in the phonating margin of the vocal folds and prevent the vocal folds from meeting in the midline
Male
Sessile, raspberry-like, pedunculated
Related to chronic voice abuse, infection, ETOH, smoking, hypothyroidism
Hoarseness or voice changes

23. Vocal Cord Polyp

24. Laryngocele
Abnormal dilatation of the saccule (appendix of the ventricle) containing air and maintaining an open communication with laryngeal lumen
Men >women
Bilateral - 25%
Hoarseness, lateral neck mass, dyspnea, dysphagia, laryngopyocele (pain)

25. Laryngocele: Types
Internal: laryngocele confined to the intrinsic larynx
External: dilated sac projects upward and laterally
Combined

26. Laryngocele: Etiology
Acquired: increased intralaryngeal pressure (glassblowers, musicians, weight lifters)
Congenital
SCC in 15% of cases

27. Laryngocele
Smooth -surfaced, sac-like structure usually filled with air

28. Laryngocele
Respiratory epithelial-lined (ciliated, columnar) cyst with a fibrous wall
Squamous metaplasia
Oncocytic metaplasia

29. Contact Ulcers of the Larynx (Pyogenic Granuloma of the Larynx)
Benign, tumor-like condition, occurring most commonly along the posterior aspect of one or both vocal cords
Men>Women, usually adults
Hoarseness, dysphagia, sore throat, dysphonia, difficulty breathing, choking, pain
Etiology: vocal abuse, acid regurgitation, postintubation trauma

30. Contact Ulcers of the Larynx (Pyogenic Granuloma of the Larynx)
Ulcerated, polypoid, nodular, or fungating mass with a beefy red to tan-white appearance, up to 3 cm in diameter

31. Laryngeal Amyloidosis
Extracellular, eosinophilic, amorphous material deposited randomly throughout submucosa; depositions around or within the walls
Disappearance of the seromucous glands,
Mixed chronic inflammatory infiltrate

32. Laryngeal Amyloidosis
Congo red: apple-green birefringence under polarized light

33. Subglottic Stenosis Congenital or acquired
Rare; acquired > congenital
Progressive respiratory difficulty, stridor, dyspnea, air hunger, hoarseness, abnormal cry, aphonia, dysphagia
Etiology: trauma, neoplasms, infectious or autoimmune diseases, idiopathic

34. Subglottic Stenosis
Narrowing of the endolaryngeal diameter with mucosal or submucosal mass or bulging
Histologic picture depends on the cause
Idiopathic stenosis: submucosal fibrous proliferation with associated non-specific chronic inflammation
Differential diagnosis: infectious diseases, Wegener’s granulomatosis, collagen vascular diseases, neoplasms

35. Benign Neoplasms of the Larynx

36. Laryngeal Papilloma
Benign, exophytic neoplastic growth composed of branching fronds of squamous epithelium with fibrovascular cores
The most common benign laryngeal neoplasm
No sex predilection
Changes in phonation, dyspnea, cough, dysphagia, stridor
HPV types 6 and 11

37. Laryngeal Papilloma
Juvenile type: multiple lesions with extensive growth and rapid recurrence, may remit spontaneously or persist into old age
Adult type: more often single, recurs less often, less likely to spread

38. Exophytic, warty, friable, tan-white to red growths

39. Papillary fronds of multilayered benign squamous epithelium containing fibrovascular cores
Little or no keratin production

40. Laryngeal Papilloma Absence of stromal invasion
Certain degree of cellular atypia
Koilocytic changes

42. Laryngeal Granular Cell Tumor
Men > women
Hoarseness
Along the posterior aspect of true vocal cord ( but also in supraglotic and infraglotic areas)

43. Granular Cell Tumor
Solitary, polypoid, sessile, papillary, or cystic lesion, measuring up to 3.0 cm in diameter

44. Granular Cell Tumor
Poorly circumscribed subepithelial lesion with syncytial, trabecular, or nested growth pattern
Round to polygonal cells with round to vesicular nuclei and coarsely granular cytoplasm. Poorly defined cell borders.
Variable degree of cellular pleomorphism
Absence of mitoses or necroses

45. Granular Cell Tumor
Cytoplasmic granules: PAS/d +, Alcian blue pH 2.5 +, trichrome + (red)
Angulate bodies: needle shaped, PAS + bodies in the interstitial cells
Tumor cells: S-100+, NSE +
Interstitial cells with angulate bodies: S and myelin protein +
EM: membrane bound autophagic vacuoles containing mitochondria, RER, myelin, axon-like structures

46. Malignant Granular Cell Tumor
Rare ( 1% of all GCT)
Do not occur in newborns
Size > 4 cm
Increased cellularity, pleomorphism, necrosis, prominent nucleoli, spindle shaped cells and > 2 mitoses/10 HPF
Metastasize via lymphatics and blood vessels

47. Chordoma Uncommon Males > females Dyspnea, strydor, and hoarseness
May originates from epiglottis, cricoid, arytenoid, or thyroid cartilages
May arise in Reinke’s space
Lobulated, firm to hard, blue-gray, submucosal mass, usually < 1 cm

48. Chordoma Lobulated, normally looking chondrocytes
Absence of pleomorphism, binucleated chondrocytes, or mitotic activity

49. Malignant Laryngeal Neoplasms

50. In Situ Squamous Cell Carcinoma
Males > females
6th – 7th decades
Most often involves anterior portion of true vocal cord
Hoarseness
May coexist with invasive SCC
May be isolated or multifocal
Circumscribed or diffuse lesion with a white, red, or gray color and smooth or granular appearance

51. In Situ Squamous Cell Carcinoma
Dysplastic process involves the entire thickness of the epithelium
Loss of cellular maturation and polarity
Increase of nuclear/cytoplaslic ratio
Normal and abnormal mitoses
Keratosis and dyskeratosis
Extension into adjacent seromucinous glands

52. Microinvasive or Superficially Invasive Squamous Cell Carcinoma
Nests of malignant cells that have penetrated the basement membrane and invaded superficially into the submucosa
Capable of metastasizing
Development from carcinoma in situ or from epithelium with no evidence of CIS

53. Invasive Squamous Cell Carcinoma
2.5% of all cancers in men
0.5% of all cancers in women
95% of all laryngeal carcinomas
Etiology: ETOH (supraglottic), tobacco (glottic), asbestos, nickel, wood, isopropyl alcohol, radiation
DD: reactive epithelial changes, pseudoepitheliomatous hyperplasia

54. Supraglottic Squamous Cell Carcinoma
25–40% of laryngeal SCC
Epiglottis (base), false vocal cords
Changes in the quality of voice, dysphagia, odonophagia, hoarseness, hemoptisis, dyspnea
Marginal carcinomas (suprahyoid epiglottis, aryepiglottic folds); remain quiescent for longer period and present at more advanced stage

55. Supraglottic Squamous Cell Carcinoma
Ulcerated, flat, exophytic, or papillary
Tend to be nonkeratinizing
In situ component
Mitoses and necrosis

56. Supraglottic Squamous Cell Carcinoma
Large, tan-white neoplasm in the right supraglottis, extending upward toward epiglottis

57. Supraglottic Squamous Cell Carcinoma

58. Glottic SCC Early: irregular area of mucosal thickening
Advanced: exophytic, fungatic, endophytic, ulcerated mass
More commonly keratinizing, well to moderately differentiated
In situ component
Invasive component predominantly infiltrative

59. Glottic SCC

60. Subglottic Squamous Cell Carcinoma
5% of all laryngeal tumors
Tend to remain clinically quiescent, presenting with advanced stage
Airway obstruction (dyspnea, stridor) and vocal cord fixation (voice changes)
Large exophytic, fungating, ulcerating, or endophytic
Tend to be keratinizing moderately to poorly differentiated
In situ component is less common
Invasive pattern is predominantly infiltrative

61. Subglottic SCC

62. Subglottic Squamous Cell Carcinoma
Overall 5-year survival rate < 40%
Spread:
Into thyroarytenoid muscle (vocal cord fixation)
Anteriorly: through cricothyroid membrane into thyroid gland superiorly: glottis and supraglottis
inferiorly: trachea posteriorly: below the cricoid cartilage and into the esophagus
Lymphatic drainage: upper and lower jugular chains, perlaryngeal and paratracheal nodes
Stomal recurrent tumor

63. Transglottic SCC Involves both glottic and supraglottic structures
Represents advanced tumor
Nodal metastases and extranodal spread
Overall 5-year survival rate < 40%

64. Transglottic SCC

65. Spindle Cell (Squamous) Carcinoma (SCSC)
Foci of conventional SCC associated with malignant spindle cell stromal component
Synonyms: carcinosarcoma, pleomorphic carcinoma, metaplastic carcinoma, collision tumor, pseudosarcoma, Lane tumor
Men (85%), 6th –8th decades
True vocal cords > false vocal cords and supraglottis > oral cavity > skin > tonsil and pharynx
Symptoms vary according to site
No specific etiology

66. Spindle Cell (Squamous) Carcinoma (SCSC)

67. Spindle Cell (Squamous) Carcinoma (SCSC)
Spindle cell component with variable degree of pleomorphism, mitoses
Fascicular, storiform, or palisading patterns; may be associated with myxomatous stroma

68. Spindle Cell (Squamous) Carcinoma (SCSC)
Differential diagnosis:
Reactive (fibroblastic) proliferation
Malignant fibrous histiocytoma
Fibrosarcoma
Malignant melanoma

69. Spindle Cell (Squamous) Carcinoma (SCSC)
Controversial histogenesis. Epithelial derivation is support by:
Association with conventional SCC
ICH: cytokeratin +
Cartilage or bone component have not been reported in metastases
Metastases may include conventional or/and spindle cell component
Poor prognosis (metastases in lymph nodes and lungs)

70. Verrucous Carcinoma
Tan or white, warty, fungating, or exophytic, firm to hard mass, attached by a broad base
Squamous cell proliferation:
uniform cells without dysplastic features and mitoses
marked surface keratinization
broad or bulbous rete pegs with pushing, NOT infiltrative margin
Dysplastic features limited and confined to basal sone
Mixed chronic immflammarory cell infiltrate

71. Verrucous Carcinoma
Tan or white, warty, fungating, or exophytic, firm to hard mass, attached by a broad base

72. Verrucous Carcinoma

73. Verrucous Carcinoma Squamous cell proliferation:
uniform cells without dysplastic features and mitoses
marked surface keratinization
broad or bulbous rete pegs with pushing, NOT infiltrative margin
Dysplastic features limited and confined to basal zone
Mixed chronic inflammatory cell infiltrate

74. Verrucous Carcinoma Differential diagnosis:
Keratotic squamous papilloma
Reactive keratosis and epithelial hyperplasia
Pseudoepitheliomatous hyperplasia
Verruca vulgaris
Keratoacantoma
“Conventional” SCC

75. Verrucous Carcinoma
Metastasis in regional lymph nodes are rare, and distant metastases do not occur
Excellent prognosis after complete surgical removal
Anaplastic transformation may result in distant metastases
Adequate biopsy material with a good epithelial-stromal interface is critical for the interpretation
Cervical adenopathy- reactive changes

76. Recurrent Laryngeal nerve paralysis
UNILATERAL
BILATERAL
ETIOPATHOGENESIS:
Thyroid surgery
Idiopathic
SYMPTOMS
Hoarseness
DYSPNEA
DIAGNOSIS
Telescopic laryngoscopy:
Respiration- unilateral vocal cord immobility
Cord fixed in a paramedian position
EMG: differentiate it from arytenoid dislocation / fixation
Respiration-fixed in a paramedian position and displaying only passive motion in response to transglottic airflow
TREATMENT
decompression
Surgery (considered no earlier than 6 months after the onset of paralysis)
COMPLICATIONS
Muscular atropy with excavation of the vaocal cord and persistent vocal dysfunction
Voice therapy -> reduce hoarseness
Idiopathic men left viral preceded by upper respiratory infection
Vocal cord position alone is not a reliable indicator of lesion location
Arytenoid dislocation -> intubation trauma
Fixation s-> scar tissue detectable muscle activity
RECURRRENT LARYNGEAL NERVE RESPONSIBLE supplies nerve fibers to both agonistic (abductors) and antaganistic ( adductors)
Unsevered nerve can regenerate and recovery occur within 6-12 months
DYSPNEA- because paralyzed vocal assume an almost closed position due to the relative predominance of the adductor muscles over the abductors
Severity depends on the glottic gap
Mucosal swelling due to intubation or infection can exacerbate the respiratory distress