Carcinoma of larynx

Nomenclature

1. Neoplasm – (Neo + New , Plasia + growth)

“A mass of tissue formed as a result of abnormal, excessive, uncordinated, autonomous and purposeless proliferation of cells”.

2. Oncology – (Oncos = Tumor, Logus = Study)

“The branch of science dealing with the study of Neoplasms or tumors is called as oncology.”

The word CANCER means CRAB. Thus, reflecting the true character of cancer, since it sticks to the part stubbornly like a crab.

Types of neoplasm –

1. Benign –

When tumors are slow growing and localized without causing much difficult to host is called as Benign.

2. Malignant –

When they proliferate rapidly, spread throughout the body and may eventually cause death of the host. The common term used for all malignant tumors in cancer.

3. Sarcomas –

Malignant mysenchymal tumors are called as sarcomas.

4. Carcinoma –

Malignant tumors of epithelium are called as carcinoma.

Aetiology –

- Both tobacco and alcohol are well established use factors in laryngeal cancer.

- Previous repetition of radiation to neck.

- Genetic factor

- Occupational exposure to asbestos, mustered gas, other chemical and petroleum products.

Pathology –

About 95% of laryngeal carcinoma are typical squamous cell lesions, rarely, adenocarcinomas are seen, presumably arising from mucus glands. The tumour usually develops directly on vocal cords, but it may arise above or below the cords, on the epiglottis or aryepglottic folds, or in the pyriform sinuses. Those confined within the larynx proper are termed intrinsic, whereas those arise or extend outside the larynx are called extrinsic. Squamous cell carcinomas of larynx follow the growth pattern of all squamous cell carcinomas. They begin as in situ lesions that later appear as pearly grey, wrinkled plaques on the mucosal surface, ultimately ulcerating and fungating. The degree of anaplasia of these laryngeal tumours is highly variable. Sometimes massive tumors, giant cells and multiple bizarre mitotic figures are seen. As expected with lesions arising from recurrent exposure to environmental carcinogens, adjacent mucosa may demonstrate squamous cell hyperplasia with foci of dysplasia or even carcinoma in situ.

Classification -

1/ Supra Glottic

2/ Glottic

3/ Sub-glottic

TNM Classification –

T - Primary tumour

Tx - Primary tumour can not be assessed.

To - No evidence of primary tumour

T - is carcinoma in situ.

1) Supra Glottic –

T_{1 -} Tumour limited to in subside and normalvocal cord mobility.

T₂ - Tumour invade more than one subside of supraglotties or glottis and normal vocal cords mobility.

T₃ - Tumour limited to larynx with vocal cord fixation.

T₄ - Tumour invades through thyroid cartilage or extend to other tissue beyond larynx.

2) Glottic –

T₁ - Limited to vocal cord and normal

mobility.

T₂ - Extend to supra glottis with impaired vocal cord mobility.

T₃ - Tumour limited to larynx and vocal

cord fixation.

T₄ - Tumour extend to thyroid cartilage or

extend beyond larynx.

Supraglottic –

T₁ - Tumour limited to supraglottis

T₂ - Tumour limited to supraglottis impaired

with vocal mobility.

T₃ - Tumour invade cricoid and thyroid

cartilages or extend to tissue beyond

larynx.

N - Regional lymph node involvement

M - Distance metastasis.

Stages –

O                    Tis           No              Mo

I                      T₁               No               Mo

II                     T₂               No               Mo

III                    T₁               No               Mo

                       _T2                N1               M

                       T₃               No                Mo

                                       N₁                     Mo

IV                     T₁               N₁                    Mo

                                        N₂                    M1

                                        N₃

                        T2            N₁                   Mo

                                         N₂                  M1

                                         N₃

                        T3             N₁                  Mo

                                         N₂                   M1

                                         N₃

                        T4             N₁                  Mo

                                         N₂                   M1

                                          N₃

Supraglottic Cancer –

Lesion seen on epiglottis, false cord, spread to tongue pyriform fossa, deep cervical node.

Symptom:Throat pain, dysphagia, referred pain

presenting features, hoarseness and weight loss, respiratory obstruction, halistosis are late features, total loss of appetite.

Glottis Cancer -

Majority of cancer originate from glottis cancer.

Spread: Arytenoids region, subglottic region and lymphatic cord.

Symptom: Hoarseness of voice is early sign. Further, oedema and cord fixation may cause stridors and laryngeal obstruction.

Subglottic - Lesion is rare.

Cancer -

Spread: Side walls or trachoea. Lymphnode involved are prelaryngeal, pretrachoeal, para trachoeal and deep cervical nodes.

Symptom: Stridors and laryngeal obstruction.

Hoarseness of voice is late feature.

Clinical Features

1/ Carcinoma of larynx manifest itself clinically by persistent hoarseness.

2/ Laryngeal tumours may produce pain, dysphagia and haemoptysis.

3/ Patients with this conditions are extremely vulnerable to secondary infection of the ulcerating lesions.

4/ About 1/3^rd die of the disease.

5/ Severe sore throat infection not responding to general line of treatment.

6/ Difficulty in deglutition of hard food, has to

swallow semisolid food with small quantity of

water.

7/ At times there is vomiting.

8 / Loss of voice with chronic coug

Investigations -

1. Biopsy: Perform by direct laryngoscopy or micro laryngopscopy is diagnostic. Endoscopy helps to estimate the extent of growth.

2. Routine Investigation : Like examination of blood, urine, blood sugar and Electro cardiogram are required for determining the general fitness for surgery.

3. VDRL Test: should be performed.

4. Radiograph of Chest : is advised to rule out tuberculosis and secondary infection.

5. Soft Tissue Radiography : of the neck (lateral view), laryngograms with radio-opaque contrast study and tomograms may help to decide the extent of growth.

6. C.T. Scan : Reveals the extent of the growth.

7. Direct laryngoscopy.

Treatment –

1. Radiotherapy

2. Surgery –

a) conservational laryngeal surgery

b) total laryngectomy

3. Combined therapy-

Treatment depends upon many factor.

1. Stage of the growth.

2. Histopathology

3. General fitness

4. Facilities available

5. Occupation : If the patient needs speech for

his profession, an attempt should be made

to preserve the speech.

Stage of the growth

Stage I and Stage II – (Without cord fixation)

Irradiation or surgery by laryngo - fissure technique

gives equally good result. However, radiotherapy is preferred

as the function of larynx is unaffected. Partial laryngectomy can be performed in certain selected cases to preserve laryngeal function.

Stage III & Stage IV tumors : (with fixation or cords or cartilage involvement)

Are best treated by total laryngectomy. If the lymph nods are involved, block dissection of the neck is required simultaneously. For residual or recurrent growth after radiotherapy, surgery is the treatment of choice.

Palliative treatment for advanced cases –

1. Analgesics for relieving pain.

2. Antibiotics for controlling infecti 3. Tracheostomy for stridor.

4. Ryle tube feeding or gastrostomy for

dysphagia.

5. Chemotherapy.

6. Irradiation.

Chemotherapy -

Chemotherapy in malignancy may help as a palliative measure to a certain extent. Chemotherapy is also given to reduce the extent of the growth.

Radiotherapy -

It is useful under following circumstances.

1. For early growth with the advantage of preserving

voice.

2. In combination with surgery.

3. Palliative measure for advance cases.

4. Anaplastic growth, as they trend to recur rapidly after surgery. But the results and eradication are equally poor.

Prevention and early detection of cancer :

1. Education and healthful habits.

a) Smoking Cessation –

Cigarette smoking is the most avoidable risk factor for Ca larynx. Those who stop smoking have a lower larynx cancer mortality.

b) Diet modification –

Dietary modification may have significant potential for lowering cancer risk. The anti carcinogens found in vegetables, fruits, legumes, nuts and grains are beneficial for protection against carcinoma. Fiber rich diet also helps to protect against the cancer by absorbing and inactivating dietary compounds that serve as cancer promotors.

HOMEOPATHIC REMEDIES

1. Argentum Nitricum –

It is an wonderful polychrest drug suited to the persons of lean, thin, taller having light hairs.

Physicals -

- Symptmos of inco-ordination, loss of

control.

- Splincter like pains.

- Much thick mucus secretion in throat.

- Sensation of splinter in throat.

- Strangulated feeling in throat.

- Smokers catarrhal with sensation of

hair in throat.

- Chronic harshness, redness of throat.

- Loss of voice.

- High notes causes cough.

- chronic Laryngitis.

Mentals

- It has having many fears like fear or

accident, closed places, irritability,

indolent.

- Anticipation, apprehension and fear of

height.

- Impulsive.

- Time passes too slowly.

Modalities -

< Hot things

< Hot weather

> By cold

2. Arsenicum Album -

It is an pre-eminently a cancer drug covering a sycotic miasm. Persons of lean, thin having offensive discharges. Great exhaustion after slightest exertion, restlessness with nightly aggravation are most important.

Physicals –

- Grimmer stated that arsenic has helped in

cancer, epithelioma, lupus.

- Cancer pains.

- Throat swollen, oedematous.

- Constricted, unable to swallow.

- Aphonia.

- Haemoptysis with pain between shoulder.

- Sensation of vapours of sulphur in a larynx.

Mentals -

- Irritable, extremly restless, fear of death.

fear of health, anxiety.

- Fastidious, restless.

- Fear of disease and death.

- Hallucinations of smell and sight.

Modalities -

< Cold application

> Hot application

3) Lachesis -

It is the drug from snake group having special affinity for throat. It causes constriction in throat and makes pathology.

Physicals -

- Used in malignant and septic state.

- Sensation of constriction in throat.

- Ascending sensation in throat from hot

flushes.

- Sensation of lump in the throat.

Purple livid colour of throat .

Pain worst by swallowing.

Loss of voice.

Mentals -

- Religious insanity, fear going to sleep.

- Loquacity, insane, jealousy, suspicious.

Modalities -

< Hot application

< In sleep

> Discharges

> Cold application.

4. Phosphorus -

It is an important drug which is used in day to day practice for many complaints. It is the deep constitutional polychrest remedy. It produces the picture of destructive metabolism. It causes inflammation and irritates serious membranes. Blood extravasations, fatty degeneration and caries.

Physicals -

- Dryness in fauces.

- Larynx raw, sore, painful.

- Voice low, Hoarse, worse in morning and

evening.

- Violent tickling in larynx while speaking.

- Cough from tickling in throat, worse cold

air, laughing, talking.

- Blood in sputum with fatty degeneration of

tissue.

Mentals -

- Mentally patient is low spirited,

easily vexed.

- Fearfulness as if something were cripping out of every corner, clairvoyant state, oversensitive to external impression, loss of memory. Paralysis of insane. Brain feels tired, restless and indifferent.

Modalities -

< By touch, physical or mental exertion.

< Warm food and drink, change of

weather

> In dark, lying on right side, cold food

> Open air, sleep

5) Thuja -

It is king of antisycotic drug. It acts mainly on the skin produces a condition that correspondence to sycotic dyscrasia, which mainly manifest on the skin producing hypertrophy and condylomata. It is a polychrest drug which produces deep constitutional changes in pathology.

Physicals -

- Polyps in vocal cord.

- Papilloma in larynx.

- Chronic laryngitis.

- Mucous in throat hawked up with

difficulty.

Mentals -

Fixed ideas, as if strange persons were at his side, as if soul and body were separated, as if something alive in throat. Emotionally sensitiveness, music causes weeping and trembling sensation as if body were made of glass and would break easily.

Modalities -

< night, heat of bed, -

< at 3 a.m. and 3 p.m. – cold damp air

> by left side, while drawing up a limb.

6) Nitric Acid –

It is a drug from acid group and having special affinity for mucous membrane. It is an antisycotic and antisyphilitic drug. It causes blisters and ulcer in mouth,

Physicals -

- Hoarseness and dry hawking cough.

- White patches and sharp points as from

splinters.

- Difficulty in swallowing.

- Splinter like pain in throat.

- Pain referred to ear.

- Vomits or nausea after taking milk or meat.

Mentals –

Anxiety about disease, pessimism, unmoved by apologies, irritable hateful, headstrong, hopeless, despair, sensitive to noise.

Modalities –

< Evening, night

< Cold climate, hot weather.

> riding in carriage.

Role of Nosodes in cancer of Larynx

Introduction –

Nosodes are remedies derived from diseased tissues and secretion containing the specific organism of the disease.

The only way the use a nosode is to prove it on the healthy, like any other drug and note its symptoms in the recognized way of provings. By potentising a nosode develops their latent dynamic forces. Hence, they should be prescribed as conscientiously as any other remedy. Use the nosode when there is obstacle to recovery. Used as prophylactic medicine in children with strong family history. Used as intercurrent remedy to receive the complete cure.

Important nosodes for carcinoma of larynx

1) Psorinum -

It is one of the greatest antipsoric constitutional polychrest remedy. It produces offensiveness of all the discharges. All secretions and exertions are extremely total carrion like odoured. Acting on larynx. It produces hawking up of cheesy pea like balls of disgusting smell and taste. Profuse offensive saliva and tough mucus in pit of throat.

Causation – Supression of skin eruptions.

Physicals –

Extremely chilly patient hungry in the middle of night, profuse perspiration after acute disease with relief of all sufferings. Great offensiveness.

Feels unusually well day before the attack begins.

Mentals –

- Patient is very anxious, fall of tear, melancholic, very depressed with suicidal thoughts. Fear that he will die and will fail in business. Religious melancholy. Despair of recovery from its sickness extremely irritable and want to be alone.

Modalities –

< Change of weather, excessive heat of sun, drought of cold air.

> From warm clothing, sweating, eating.

2) Syphillinum –

It is the king of antisyphilitics. Useful in chronic cases when the reaction is poor and indicated remedy gives partial relief. Especially when there is hereditary tendency to alcoholism or syphilitic miasm. Aphonia. Buring in throat like fire. Throat studded with ulcers. Mouth and tongue ulcerated. Breath foetid. Tongue soft and spongy red, excoriated, cracked and sore. Pathces on tongue. Copious viscid saliva in mouth, bleeding from ulcers.

Physicals –

Pains from darkness to daylight. Begins with night light and ends with day light. Whenever there is history of syphilis in patient or family, we can think of syphilinum. Pain increases and decreases gradually which is shifting in nature. Pain while swallowing. Requires frequent changes in position. Obstinate constipation for years with foetid breath.

Mentals –

Loss of memory, looses remembrance of present occurances. Arithmatic calculations are very difficult. Sensation as if going to be insane as it about to be paralyzed. Fears of terrific suffering from exhausting on awaking.

Modalities –

< night, seashore,

3) Medorrhinum -

It is a king of antisycotic. It predominately affects mucous membrane of larynx and trachea. It is to be thought of in all cases of constitutional effects of maltreated or suppressed gonorrhoea, where the best selected remedy fails to relieve or permanently improve. Voice is hoarse while reading. Larynx feels sore, dyspnoea cannot exhale, cough better by lying on stomach. Sensation as if cold settled down in throat with distressing pain and soreness. Throat is filled with thick, grey, blood stained mucus. The patient cannot swallow either liquid or solid.

Physicals –

Wants to be fanned all the time, a stage of collapse persists in medorhinum. Trembling all over the body with intense nervousness and profound exertion. Coldness all over still does not like covering. Intense restlessness and fidgety feeling in legs. Inordinate craving for salt, liquor, acids. Ravenous hunger immediately after eating.

Mentals –

Great weakness of memory always has weeping tendency. Cannot speak without weeping. Medorrhinum patients predict the future events very correctly. Time passes very slowly.

Modalities –

< Sunrise to sunset, when thinking of

complaints.

> at seashore

4) Carcinosin -

It is claimed that the carninosin acts favourably and modifies all cases in which either history of carcinoma can be elicited or symptom of the disease itself exist.

Carcinoma of larynx with great pain and induration, offensive discharge, haemorhage and pain are greatly relieved. Cancerous cachexia.

Role of some rare remedies in cancer of larynx

1/ Hydrastis -

It specially acts on mucous membrane relaxing them and producing a thick, yellowish, ropy secretion, Cancer and cancerous state before ulceration, when pain is principal symptom this remedy is indicated. Smarting excoriating sensation in throat. Hawking of yellow tenacious mucous.

Physicals -

Hydrastis is especially active in old easily tired people, cachetic individuals with great debility, weak muscular power, poor digestion, obstinate constipation, emaciation and prostration.

Mentals –

Depressed, sure of death and desires it.

2/ Cistus Canadensis –

A deep acting anti-psoric remedy with marked action on glandular affections when patient is extremely sensible to cold. Malignant disease of the glands of the neck.

Spongy feeling, very dark and cold air passing over parts causes pain. Throat feel cold, a small dry spot in throat, must sip water frequently. Hawking of mucous. Head drawn to one side by swelling of neck. Sore throat from inhaling the least cold air. Heat and itching in throat.

Modalities –

< Slightest exposure to cold air,

mental exertion, excitement.

> Eating

3/ Lapis Albus –

It is an important remedy for pre-ulcerative stage of carcinoma. Burning and stinging pain in throat suited to fat anaemic babies with iodine appetite, ravenous appetite. Remarkably successful in scrofulous affections, intense burning pains in larynx with profuse haemorrhage.

4/ Mercurius Iodatus Flavus –

Throat affections with greatly swollen glands and characteristic coating of tongue. Tendency to much warm perspiration and gastric disturbances.

Cheesy exudates with offensive breath. swelling begins on right side. Small ulcers on posterior pharynx much tenacious mucous sensation of lump, constant inclination to swallow.

5/ Morphinum -

It is not a polychrest drug. But this drug is very useful in releiving the symptom of patient. It represents nervous side. It is less stimulating less convulant and more decidedly hypnotic.

Physicals -

- Throat dry and constricted.

- Hoarseness.

- Swallowing is almost impossible.

- Burning back of fauces.

- Jugular vein swollen.

- Carotid artery pulsating.

Mentals -

- Delirium, melancholic in character, shock induced by terror, hysterical, dream like state, fault finding.

Modalities –

< Worse by solids

> Hot drinks

6/ Oscimum Sanctum –

It has wonderful oxidative power. It is to be remembered in diseases of throat, respiratory tract, skin. It is an important remedy for purulent discharges.

Physicals –

- Neck glands very much swollen.

- Intense pain of all kind.

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