1. DIAGNOSTIC EVALUATION
2. EXAMINATION UNDER ANESTHESIA AND BIOPSY
3. TREATMENT
4. POSTOPERATIVE IRRADIATION
5. FOLLOW UP
6. BIBLIOGRAPHY

I.DIAGNOSTIC EVALUATION:

Clinical Evaluation:

• Complete history and physical examination
  
  Recording the presence and duration of symptoms such as pain, soreness of throat, otalgia, odynophagia, dysphagia, trismus and hoarseness. It should include history of risk factors such as the use of tobacco and alcohol, the occurrence and extent of weight loss and of all other medical conditions.

• Complete examination of the head and neck.
  
  Includes examination of all the areas of the oral cavity, pharynx, and indirect laryngoscopy. If indirect laryngoscopy is not adequate, fiberoptic examination of the larynx and pharynx is necessary. Palpation of the floor of the mouth, tongue, base of the tongue and/or tonsil. The examination includes an assessment of the status of the dentition, as well as an evaluation of the status of the airway. Palpation of the neck bilaterally, recording the location (Group or Level I - VI), size, mobility, and relationship of the node(s) to adjacent structures. The staging of the primary and of the cervical lymph nodes must be documented.

• Biopsy of primary usually requires direct laryngoscopy under general anesthesia. In selected cases, it may be done in the outpatient setting employing indirect mirror exposure of the larynx or through a flexible fiberoptic laryngoscope.

Imaging Studies:

• Chest radiographs, PA and lateral.

  To rule out (1) a synchronous, asymptomatic lung tumor, (2) acute or chronic pulmonary disease. Abnormal findings on chest x-ray with suspicious lesions may need further imaging including a chest CT.

• A high-resolution CAT scan or an MRI of the larynx

  This should be employed when there is clinical evidence of anterior commissure involvement (to assess invasion of the thyroid cartilage), or decreased true vocal cord mobility. In the rare patient with nodal metastases, imaging is used to assess paratracheal node involvement.

• Pre-anesthesia laboratory tests (according to patient factors as well as institutional guidelines)

• Baseline liver function tests (optional)

• Radiation therapy
  
  In anticipation of possible treatment of T1-T2 tumors and in patients with nodal metastases.
  
• Dental (optional)
  
  To assess the status of the dentition as well as supporting periodontal structures and make recommendations considering that radiation therapy may be indicated (in instances where glottic carcinomas have significant supraglottic extent and require probable radiation therapy to the Level II lymphatics).
  
• Speech Pathology
  
  For pre-treatment counseling regarding alterations in postoperative speech and swallowing as well as rehabilitation.
  
• Internal Medicine/ Cardiology/ Pulmonology/ Anesthesiology
  
  When a disease is present or is suspected, which may affect the use of general anesthesia or influence treatment decisions

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To rule out the existence of other primary tumors in the upper aerodigestive tract and to confirm the extent of the primary tumor as well as extension to adjacent structures, including the supraglottic and subglottic larynx. This examination should include:

• Examination and palpation of the tongue and oro/nasopharynx 
• Direct laryngoscopy and pharyngoscopy 
• Esophagoscopy, optimal rules symptoms present. 
• Bronchoscopy if indicated by clinical or radiographic findings

  Based upon the presenting neoplasm as well as preoperative consideration of all patient factors, in selected patients definitive surgical excision can be performed at the time of biopsy.

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Irradiation for T1 and T2 Glottic Cancers:

Indications:

T1 and T2N0 and N1 squamous carcinomas.

Primary tumor:

In some institutions, definitive external beam radiation therapy is the preferred initial treatment modality in the management of T1 and T2 glottic cancer. The minimum portals for patients with T1 disease extend from the thyroid notch superiorly to the inferior border of cricoid; the posterior border encompasses the greater cornus of the thyroid cartilage and generally abuts the anterior border of the vertebral body. Anteriorly the portal flashes beyond the skin surface. T2 lesions, the portals are adjusted to cover subglottic or supraglottic extension. 

N0: In general, T1 and T2 glottic carcinomas are rarely associated with neck metastasis. The primary echelon of nodal drainage for the glottic larynx should include the delphian pre-tracheal node, intrathyroidal nodes, and paratracheal lymph nodes. These potential lymphatics are treated in the narrow field laryngeal portals. Portals are not otherwise adjusted to encompass nodes. There is no indication for surgical management of the neck.

N1: Early glottic cancers may metastasize to Levels II, III or IV jugular lymphatics. In these rare instances, definitive radiation therapy to the primary neoplasm as well as bilateral Level II, III and IV lymphatics is indicated. A lateral or a modified radical neck dissection with preservation of the spinal accessory nerve, sternocleidomastoid muscle, or internal jugular vein is performed in cases of N1 disease where the primary site is treated surgically.

N2-3: In these rare instance where the larynx is best treated by radiation alone, an ipsilateral radical neck dissection or modified radical neck dissection with preservation of the spinal accessory nerve, sternocleidomastoid muscle, or internal jugular vein, if possible, can be performed prior to radiation. Otherwise, the neck dissection is performed 4 - 6 weeks after completion of radiation therapy.    

T1 and T2 lesions are treated to 56-70 Gy in 6 to 8 weeks at 1.8 to 2.2 Gy per fraction. The dose may vary depending upon the extent of the tumor, whether or not the mobility of the vocal cord is impaired, or whether there is little or no tumor visible after biopsy. The patient may be treated with multiple daily fractions on investigational protocols approved by the institutional review board. 

Surgery for T1 and T2 Glottic Cancers:

Indications:

• For most T1 cancers not involving the anterior commissure or posterior larynx (arytenoid area or posterior commissure). 
  
• Prior history of radiation therapy to the area in a patient who otherwise would have been an initial surgical candidate
  
• T2 cancer patient with adequate pulmonary function
  
• Extent of disease process limited to mobile cord areas or extending across anterior commissure, not further than 1/3 down the contralateral cord. Additionally, absence of arytenoid involvement is preferential in all early glottic cancer surgery
  
• Patient desires brief treatment course. This may include patients living in rural areas away from radiation therapy centers.
  
• When the potential for compromised vocal quality is not a major factor in the patient's decision process.

• Endoscopic laser resection
  
• Indicated in mobile true cord lesions and in limited T2 lesions involving the false vocal cord. 
  
• Frozen section evaluation of margins as needed.
  
• Surgical treatment for T1 and T2 glottic carcinomas includes vertical hemi-laryngectomy, extended vertical hemi-laryngectomy, and frontal lateral partial laryngectomies.
  
• The surgical treatment should include:
  
• Frozen section evaluation of margins as needed to ensure an adequate resection
  
• Insertion of a feeding tube, and tracheostomy in open procedures
  
• Proper orientation of the surgical specimen for pathologic examination.

• Laser cordectomy may be done as ambulatory surgical procedure. (If excision of T2 lesions is done, this is not an ambulatory surgery).
  
• Hospitalization for 3 - 10 days.
  
• Tube feedings for 5-14 days. (rarely needed for selected lesions treated endoscopically)
  
• Low pressure suction drains
  
• Removal of drains when drain output is < 30 - 50 cc's over two consecutive 24-hour periods
  
• Tracheostomy care
  
• Change tracheostomy as needed
  
• Suture removal from neck wound in 7 - 10 days
  
•  If the patient is discharged with a tracheostomy in place, the patient and at least one family member must be instructed on tracheostomy care. In addition, the discharged patient must have available a portable suction machine as well as the potential for home-visiting nurse services. 

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Not indicated in partial laryngeal surgery unless positive margins or previously unrecognized thyroid cartilage invasion is found on permanent specimen analysis.

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• Periodic examinations by the head and neck surgeon may be necessary during radiation therapy in patients experiencing difficulty with nutritional intake, airway or pain control..
  
• Periodic examinations by the radiation oncologist and, if appropriate, a dentist in patients that received radiation therapy
  
• After all treatment is completed, a general formula which is modified according to the individual patient's characteristics is:
  
  1st year post treatment: 1-3 months
  2nd year post treatment: 2-4 months
  3rd year post treatment: 3- 6 months
  4th and 5th years: 4- 6 months
  After 5 years: Every 12 months
  
• Chest radiographs, yearly.
  
• Liver enzymes, yearly.
  
• Thyroid function tests should be monitored if the patient received radiation to the lower neck. These studies should be repeated according to clinical findings on follow-up examinations.

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Duncavage JA. Outpatient evaluation and Diagnosis, Head and Neck Surgery-Otolaryngology ed. Byron J. Bailey, JB Lippincott Co, Philadelphia 1993, 199-203.

Curtin HD. Larynx in Head and Neck Imaging, Third edition, ed. PH Som, HD Curtin, Mosby, St. Louis MO, 1996, 612-707.

Mendenhall WM, Parson JT, Million RR, Fletcher GH. T1-T2 Squamous Cell Carcinoma of the Glottic Larynx Treated with Radiation Therapy: Relationship of Dose-Fractionation to Local Control and Complications, Int J Radiation Oncology Biol Phys Volume 15, 1267-1273, 1988.

Le Q-TX, Fu KK, Kroll S, Ryu JK, Quivey JM, Meyler TS, Krieg RM, PhillipsTL: Influence of Fraction Size, Total Dose, and Overall Time on Local Control of T1 - T2 Glottic Carcinoma. Int.J. Radiation Oncology, Biol Phys Vol 39 (1):pp 115-126, 1997.

Mukherji SK, Mancuso AA, Mendenhall W, Kotzur IM, Kubilus P: Can Pretreatment CT Predict Local Control of T2 Glottic Carcinomas Treated with Radiation Therapy Alone? AJNR 1995. 16:655-662.

Rothfield RE, Johnson JT, Myers EN, Wagner RL: The Role of Hemilaryngectomy in the Mangagement of T1 Vocal Cord Cancer, Arch Otolaryngol Head and Neck Surg 1989, 115:677-680.

Ton Van J, Lefebvre JL, Stern JC, Buisset E, Coche-Dequent B, VanKammel B, Comparison of Surgery and Radiotherapy in T1 and T2 Glottic Carcinoma. Am J Surg , 1991. 162(10):447-534.

Davis RK, Kelly SM, Parkin JL, Stevens JH, Johnson LP: Selective Management of Early Glottic Cancer, Laryngoscope, 1990. 100(12): 1306-1309.

Laccourreye H, Laccourreye O, Weinstein G, Laccourreye H, Brasnu D. Supracricoid laryngectomy with cricohyoidepiglottopexy: a partial laryngeal procedure for glottic carcinoma. Ann Otol Rhinol Laryngol, 1990;99:421-426.

Laccourreye H, Brasnu D, Lacau-St. Guily J, Fabre A. New concepts in conservation surgery of the larynx. In: Fried MP, ed. The Larynx: A Multidisciplinary Approach. Boston, Mass.: Little Brown & Co Inc.; 1998:297-308.