1. The document discusses the anatomy, staging, and gross examination procedure for laryngectomy specimens. 2. It describes the three regions of the larynx - supraglottis, glottis, and subglottis - and notes that tumor location impacts lymphatic spread and symptoms. 3. The gross examination procedure involves examining resection margins, identifying tumor location and extent, and slicing the specimen to assess depth of invasion.

1. Total laryngectomy
Dr.Kiran M. Gore

2. • Laryngectomy is usually done for malignant
tumours, especially for carcinoma. It is
essential to understand the anatomy of larynx
and behaviour of tumour involving different
parts of larynx in order to understand the
grossing of larynx.

3. In one year from 16.12.13 to 16.12.14 we got 25
laryngectomy specimens for 9 were glottic, 6
were supraglottic, 2 were subglottic and 8 were
hypopharynx(pyriform sinus) tumours.
We are getting both total laryngectomies and
excision laser biopsies.

4. • Surgical anatomy
• Staging
• Grossing

5. • Larynx is a tubular structure extending from
epiglottis superiorly to cricoid cartilage
inferiorly.
• Divisions of larynx- Clinically divded into 3
parts based on
• Embryological development
• Lymphatic drainage
• Pattern of tumour growth

6. Anatomy
• Refresh your memory of laryngeal anatomy.
• Three anatomic regions:
• The supraglottis is the portion of the larynx superior to
the ventricles. It is composed of the epiglottis,
arytenoids, aryepiglottic folds and the false cords.
• The glottis is composed of the true vocal cords and
their anterior and posterior attachments, the anterior
and posterior commissures.
• The subglottis begins 1 cm below the free edge of the
vocal cords and extends inferiorly to the trachea.

16. Pyriform fossa

17. Pyriform fossa
• It is a potential space that lie on either side of the larynx. It
is shaped like a pyramid with the base above and the apex
below. They belong to the hypopharyngeal area of the
pharynx. It has two parts; the shallow upper part and a
deeper lower part.
• Boundaries: The pyriform fossa is bounded laterally by the
mucosa covering the lamina of the thyroid cartilage.
Medially it is bounded by the aryepiglottic fold and
arytenoid cartilages above and the cricoid cartilage below.
Superiorly it is bounded by the lateral glosso epilglottic fold
(Pharyngoepiglottic fold), inferiorly it continues with the
oesophagus.

18. • 1. Anatomically it is a hidden area. Any
malignancy in this area will initially cause fewer
symptoms and has a tendency to present very
late.
• 2. This area is richly endowed with lymphatics.
They drain into the upper deep cervical group of
lymph nodes. Any malignancy in this area has a
tendency for nodal metastasis.
• 3. Foreign bodies in the throat commonly gets
lodged here.

19. • Preepiglottic space: Is a wedge shaped space
lying in front of the epiglottis. It is bounded
anteriorly by the thyrohyoid ligament and the
hyoid bone. This space is continuous laterally
with that of paraglottic space.
• Paraglottic space: is a potential space present on
either side of glottis. It is bounded by the mucosa
covering the lamina of thyroid cartilage laterally,
the conus elasticus and quadrangular membranes
medially and the anterior reflection of the
pyriform fossa mucosa posteriorly.

21. Clinical significance
• The supraglottic region is rich in lymphatic
network, crosses the midline. Hence,
supraglottic cancers are more commomnly
accompanied by lymph node involvement,
requiring bilateral neck dissection.
• Glottis- virtually devoid of lymphatics, spread
to adjacent structures.
• Subglottic tumours spread to the adjacent
structures first and then to lymph nodes.

22. Barriers and compartments of larynx
1.Barriers.
• Conus elasticus
• Quadrangular membrane .
2. Compartments
• Pre-epiglottic space.
• Paraglottic space

23. Rationale
• Majority of the laryngeal cancers we receive are
glottic region, followed by supraglottic and very
few in subglottic region.
• Clinically divided into 2 broad categories
depending upon the stage, treatment modality
and type of laryngectomy.
• Features that decide stage of tumour are size and
extent of tumour, extension to pre-epiglottic,
paraglottic spaces as well as extension to the
other organs.

24. 1. Early stage cancers
a) T1 or T2 and N0, M0 tumours
b) No invasion of pre-epiglottic or paraglottic
space
c) Vocal cord mobility may be impaired but they
are not fixed.
2. Advanced stage cancers.
a) Any T3, T4 tumour or nodal
metastasis(N1,N2)
b) Vocal cords are usually fixed
c) Needs multimodality treatmemt

25. Types of specimens
• Endoscopic excision (laser)- T1, T2 glottic or
supraglottic cancers. (Widelocal excision)
• Partial laryngectomy- Early laryngeal cancers and
selected T3 cancers.
a) Vertical partial laryngectomy including
hemilaryngectomy: For true vocal cord cancers,
limited to anterior commisure and includes
vertical division of thyroid cartilage and
resection of variable portion of ipsilateral larynx.

26. b) Supraglottic laryngectomy: Resection of
uppoer half of larynx above ventricle, done for
supraglottic tumours( epiglottis, false cords) as
well as for hypopharynx or pyriform fossa
cancers.
c) Supracricoid subtotal laryngectomy: Resection
of larynx above cricoid cartilage (include
removal of entire thyroid cartilage).
3. Near total laryngectomy: Sparing the
posterolateral strip of contralateral larynx,
including arytenoids. This procedure helps in
voice preservation.

27. Types of specimens, contd..
4. Total laryngectomy: Resection of enrire
larynx, usually done for advanced laryngeal or
pyriform fossa cancers as well as cancers
spreading across the midline.

28. STAGING

29. Glottis
T1 Tumor limited to the vocal cord(s) (may involve
anterior or posterior commissure) with normal
mobility
T1a Tumor limited to one vocal cord
T1b Tumor involves both vocal cords
T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord
mobility
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic
space, and/or inner cortex of the thyroid cartilage
T4a Moderately advanced local disease. Tumor invades through the outer cortex of
the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft
tissues of neck including deep extrinsic muscle of the tongue,
strap muscles, thyroid, or esophagus)
T4b Very advanced local disease
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal
structures

30. Subglottis
T1 Tumor limited to the subglottis
T2 Tumor extends to vocal cord(s) with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fi xation
T4a Moderately advanced local disease
Tumor invades cricoid or thyroid cartilage and/ or invades tissues beyond the larynx
(e.g., trachea, soft tissues of neck including deep extrinsic
muscles of the tongue, strap muscles, thyroid, or
esophagus)
T4b Very advanced local disease. Tumor invades prevertebral space, encases carotid
artery, or invades mediastinal structures

31. Steps in grossing
• Identify the type of specimen received and
orient it.
• Note the dimensions
• Carefully examine the external surface to
identify hyoid bone, thyroid cartilage, thyroid
lobe and anterior strap muscles. Look for any
extralaryngeal spread of tumour and check
ifany of the above structures involved or not.

32. 4. Note if any tracheostoma present anteriorly
and describe its dimensions, and whether
involved by tumour or not.
5. Dissect out the thyroid lobe and anterior
both the pyriform sinuses for presence of any
tumour.
6. Examine both the pyriform sinuses for
presence of any tumour.
7. Ink the external surface.
8. Open the specimen posteriorly to open
laryngeal lumen.

33. 9. Examine the supraglottis, glottis and
subglottis, carefully and identify the tumour.
Document
a. Location and extent
b. Laterality, tumour crossing midline?
c. Gross appearance of tumour (flat, ulcerated,
verrucous, exophytic, endophytic etc.)
d. Size of tumour. (3rd dimension / depth of
tumour can be better assessed after slicing
the tumour)

34. 10. Identify all mucosal and soft tissue resection
margins and note the distance of the tumour from
the margis. Marginsd include.
a. Superior epiglottic mucosal
b. Right and left lateral mucosal
c. Posterior/ posterio-inferior mucosal
d. Inferior tracheal
e. Anterior strap muscles
All the mucosal margins are submitted
radially/perpendicularly, while remaining margins
are shaved.

35. 11. Identify pre-epiglottic space anterior the
epiglottis and note if it is involved by tumour or
not. Submit the pre-epiglottic fat.
12. Now serially cut the through the tumour.
The approach and plane of cutting can be
different for tumours located at different sites.
Note if underlying cartilage involved by tumour
or not.
a. Slice the tumour along the entire length of
larynx.

37. Submit sections of pyriform sinuses on both the
sides.