Practice Essentials
Cancer of the supraglottis (supraglottic cancer) is almost exclusively squamous cell carcinoma (SCC), although SCC of the supraglottis is seen less frequently than cancer of the glottis and is treated differently from tumors of the glottis or subglottis. Because of its location, supraglottic cancer and its treatment can affect the function of the larynx, including speech, swallowing, and breathing. In workup, an accurate assessment of the anatomic extent of the tumor is needed, not only to select treatment modalities but also to compare therapeutic results of different modalities. Treatment options include surgery, radiation therapy, chemotherapy, or a combination thereof.
This article discusses the anatomy of the supraglottis, explains the staging of supraglottic lesions, and provides an overview of treatment options.
Signs and symptoms of supraglottic cancer
Patients with supraglottic cancer may present with the following signs and symptoms:
-
Persistent dysphagia
-
Odynophagia
-
Otalgia
-
Hoarseness
-
Hemoptysis
-
Stridor
-
Neck mass
Workup in supraglottic cancer
Clinical examination is notoriously inadequate for mapping tumor extent. Forty percent of diagnoses made based on clinical examination are inaccurate. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) are useful studies in evaluating the spread of supraglottic lesions (see CT Scan of the Larynx). These modalities are also effective in measuring lymph node size; both can show areas of central lucency, which is consistent with tumor involvement.
Panendoscopy (ie, laryngoscopy, bronchoscopy, esophagoscopy, nasopharyngoscopy) has traditionally been the criterion standard for the diagnosis of second primary lesions. The examination is controversial, however; some argue that bronchoscopy and esophagoscopy have only a slightly increased yield over chest radiography and barium swallow and are thus not worth the risks associated with endoscopy.
Management of supraglottic cancer
Early and moderately advanced lesions are usually managed with supraglottic laryngectomy or radiotherapy. Advanced lesions are usually treated with total laryngectomy, preoperative or postoperative radiotherapy, and, possibly, chemotherapy, since combined-modality therapy produces better results than a single modality alone.
The classic supraglottic laryngectomy extends through the vallecula superiorly, the aryepiglottic folds posteriorly, the apex of the ventricle inferiorly, and the thyroid cartilage anteriorly.
The transoral use of the carbon dioxide laser has made it possible to avoid some of the complications that have traditionally excluded patients with pulmonary comorbidities from undergoing supraglottic laryngectomy. Studies have shown a rapid return of swallowing function and the virtual elimination of the need for tracheostomy when a supraglottic laryngectomy is performed transorally with a carbon dioxide laser.
Bilateral neck dissections are performed when treating patients with advanced disease, with occult metastases present as much as 62% of the time in patients with T3/T4 tumors.
History of the Procedure
During the past 150 years, the treatment of supraglottic tumors has progressed significantly. In 1852, Horace Green reported the first surgical resection of a laryngeal lesion, a polyp in the ventricle, removed under direct vision. By 1859, the first transcervical resection of an epiglottic neoplasm was reported. Chevalier Jackson revolutionized supraglottic surgery in 1915, when he used a laryngoscope and a punch biopsy to remove an epiglottic tumor. [1] Alonso first described conservation surgery for cancer of the supraglottic larynx in 1947, and, in 1958, Ogura formalized the procedure as the supraglottic laryngectomy. [2, 3] During the 1950s, the surgical microscope and endotracheal anesthesia were brought to bear on this disease. In the 1970s, the carbon dioxide laser began to be used for supraglottic tumors.
Epidemiology
Frequency
Laryngeal cancer is the second most common type of head and neck cancer worldwide. [4] In the United States, about 12,500 new cases are diagnosed each year. It was estimated that worldwide, approximately 185,000 cases of laryngeal cancer and about 100,000 deaths from the disease occurred in 2020. [5, 6]
Laryngeal cancer is the 11th most common cancer in men worldwide but is much less common in women. Men have been reported to have as much as 30 times the risk that women have for this disease. Older individuals are also at a higher risk for laryngeal cancer; the highest number of diagnoses is made in patients age 60-74 years.
The percentage of laryngeal cancers that originate in the supraglottis varies from country to country. In the United States, for example, approximately 30-40% of laryngeal cancers originate in the supraglottis, while most occur in the glottis. In Spain and Finland, however, the supraglottis is the most frequent subsite. [7]
Etiology
Generally, the international occurrence of SCC is proportional to tobacco and alcohol use. In societies in which tobacco is chewed rather than smoked, tumor location favors the oral cavity rather than the larynx.
Numerous studies have correlated smoking of tobacco products with SCC of the larynx. In fact, some studies have shown that 97% of patients with laryngeal cancer have smoked. When compared with men who did not smoke, men who smoked at least 1.5 packs of cigarettes per day for more than 10 years were found to have a 30-fold increased risk of developing laryngeal cancer.
The risk for supraglottic cancer has been found to be higher with the use of black (air-cured) tobaccos than with the use of blonde (flue-cured) tobaccos. This difference is not found with glottic cancers, suggesting that the etiology for supraglottic cancers and glottic cancers may differ. [8]
Studies with controls for age, race, and smoking habits also suggest that consumption of alcohol increases the risk of laryngeal cancer. Alcohol consumption has been shown to have a synergistic effect with smoking; thus, the risk of developing carcinoma of the larynx is increased 100-fold in individuals who both smoke and drink. This may be partly due to the fact that alcohol serves as a solvent for the carcinogens of tobacco.
In 1946, Slaughter developed the theory of field cancerization in tumors of the head and neck. [9] In essence, this theory posits that the entire mucosa of the aerodigestive tract, when exposed to the same toxins, risks development of carcinoma. The vulnerable epithelium undergoes progressive changes that lead to malignancy as exposure to toxins continues. Hence, multiple areas of precancerous change can give rise to synchronous lesions. Supporting this theory is the high rate (4%) of synchronous lesions found upon workup of patients with lesions of the upper aerodigestive tract.
Dietary deficiencies, radiation exposure, human papillomavirus (HPV), and gastroesophageal reflux are other factors associated with laryngeal SCC.
Pathophysiology
The supraglottis is embryologically derived from the buccopharyngeal anlage in the region of the third and fourth branchial arches. The glottis and subglottis originate from the tracheobronchial anlage in the region of arches 5 and 6. Hence, the larynx virtually consists of 2 hemilarynges, each with different embryonal derivation and largely independent lymphatic circulation. Despite the theoretical separation of the supraglottis from the rest of the larynx, no anatomical or histological barrier has been identified. Furthermore, supraglottic tumors invading the paraglottic space have access to the glottis via the medial surface of the thyroid cartilage.
Lymphatic vascularity in the supraglottis is much denser than in the glottis and subglottis. This is important in the development of supraglottic cancer and leads to a significantly higher incidence of cervical lymph node metastases in tumors of this subsite. [10, 11]
Presentation
Symptoms
Minimal changes in the vibration of the vocal cord due to tumor growth often cause dysphonia or hoarseness at an early stage in glottic cancer. Subglottic carcinomas can cause airway compromise at an early stage. Supraglottic cancers are less likely than glottic and subglottic cancers to produce noticeable symptoms such as these early in the disease course and are more likely to present with the less specific symptoms of persistent dysphagia, odynophagia, or otalgia. [4] Patients with SCC of the supraglottis are not limited to these symptoms, however, and may also present with hoarseness, hemoptysis, stridor, or chronic cough. Patients with SCC of the supraglottis are more likely to present with a neck mass, partly because patients with supraglottic cancer generally present later than patients with glottic cancer, and partly because of the differences in anatomy and lymphatic drainage,
Examination
Due to the fact that supraglottic patients with SCC often present with nodal disease, palpation of the neck is important. Physical examination may reveal laryngeal or cervical findings.
Examination with a laryngeal mirror or a flexible nasopharyngoscope is necessary for the visualization of supraglottic lesions.
Relevant Anatomy
The supraglottic larynx is partitioned into 4 subdivisions, as follows: (1) aryepiglottic folds, (2) arytenoids, (3) false cords, and (4) epiglottis. For tumor-staging purposes, the epiglottis is further subdivided into suprahyoid and infrahyoid regions. These areas of the supraglottis are structured within the framework of the supraglottic larynx, which includes the upper half of the thyroid cartilage, the arytenoid cartilages, and the epiglottis. In the image below the vocal fold, epiglottis, aryepiglottic fold, and arytenoids are seen.
A surgical specimen after laryngectomy. The arrow points to the vocal fold. Note the epiglottis, aryepiglottic fold, arytenoids, and false folds superior to the arrow.
Supraglottis subsites
See the list below:
-
Suprahyoid epiglottis (lingual and laryngeal surfaces)
-
Infrahyoid epiglottis
-
False cords
-
Arytenoid
-
Aryepiglottic folds
Supraglottic squamous cell carcinoma (SCC) follows a predictable pattern of spread. Although tumors may extend inferiorly to involve the vocal folds and subglottis, invasion more often occurs in adjacent sites outside the larynx such as the base of tongue, vallecula, pyriform sinus, and postcricoid region. As the disease progresses, tumors of the supraglottis tend to metastasize to regional lymph nodes.
-
A surgical specimen after laryngectomy. The arrow points to the vocal fold. Note the epiglottis, aryepiglottic fold, arytenoids, and false folds superior to the arrow.
-
Laryngoscopic view of the larynx. Note the following supraglottic structures: epiglottis, aryepiglottic folds, arytenoids, and false folds.
-
Histological specimen of squamous cell carcinoma (SCC).
Tables
Stage |
Tumor Spread |
Node Involvement |
Distant Metastases |
Stage 0 |
Tis |
N0 |
M0 |
Stage I |
T1 |
N0 |
M0 |
Stage II |
T2 |
N0 |
M0 |
Stage III |
T3 |
N0 |
M0 |
T1 |
N1 |
M0 |
|
T2 |
N1 |
M0 |
|
T3 |
N1 |
M0 |
|
Stage IVA |
T4a |
N0 |
M0 |
T4a |
N1 |
M0 |
|
T1 |
N2 |
M0 |
|
T2 |
N2 |
M0 |
|
T3 |
N2 |
M0 |
|
|
T4a |
N2 |
M0 |
Stage IVB |
T4b |
Any N |
M0 |
|
Any T |
N3 |
M0 |
Stage IVC |
Any T |
Any N |
M1 |
