Carcinoma Larynx – case study

Dr Sunila BHMS,MD(Hom)
Email : babuabau@gmail.com

Case

Admission No: 1317     Date of Admission: 26/ 03/ 05

Presenting Complaints

1.      Hoarseness of voice (5 months)

• Hoarseness with obstructed feeling in throat
• No pain in throat
• No dysphagia
• Hoarseness < evening

2.      Redness of left eye (1 month)

• No itching
• No pain
• No lachrymation
• There is sand sensation in left eye.
• Dimness of vision for distant objects

History of presenting complaint
Complaint started 5 months back. He took allopathic treatment with radiotherapy.

Past History
No relevant complaints in the past

Family history
No similar complaint among the family members

Personal History
Born and brought up at Mankavu. He has the habit of smoking started at the age of 20. One packet of cigarettes a day and he is still continuing the habit.

Regionals

• Appetite                      :           Good; Desires pungent food
• Thirst                           :           Good
• Bowels                        :           Regular
• Urine                           :           No complaints
• Sweat                          :           N
• Sleep                           :           Good
• Thermal reaction         :           Not specific

Physical Examination:

Pulse Rate: 68/ minute    Respiratory Rate: 20/ minute

BP: 110/ 70mm of Hg    Temperature : 98.6ºF

General Survey

• Moderately built and nourished
• Pallor present
• No cyanosis, No icterus.
• No clubbing, No lymphadenopathy and No pedal oedema.

 O/E: Oral cavity and Oropharynx

• Lips                 (N)                   Tongue      (N)
• Gums               (N)                   Pillars        (N)     Tonsils    (N)

Internal Larynx Examination

Epiglottis         (N)

There is an ulceroproliferative growth involving the anterior commissures and anterior ⅔ of medial borders and superior surface of (L) vocal cord.

Vocal cords mobile B/L

Neck

No neck node

Carotid palpable (B/L)

Impression     : Carcinoma Larynx T2 N0 M0

Biopsy :

Squamous cell Carcinoma- moderately differentiated

Systemic Examination

Examination of Respiratory system

Examination of Upper Respiratory tract

• No congestion of nasal mucosa, no deviation of nasal septum& no nasal polyp
• Uvula centrally placed & no tonsillar enlargement.

Examination of lower Respiratory tract

Inspection

• Trachea appears to be centrally placed
• Chest wall bilaterally symmetrical
• No kyphosis, scoliosis or lordosis; no prominent vessels and visible pulsations.

Palpation

No palpable swelling; Trachea centrally placed; Apex beat palpable.

Percussion

Normal lung resonance

Auscultation

No wheeze heard

Examination of Central Nervous system

Examination of higher mental functions

Patient is conscious, intelligent, normal behaviour, past and present memory present, orientation of time, place and person present, no hallucination, delusion, illusion and speech normal.

Examination of Cranial nerves

Olfactory Nerve

No anosmia, parosmia and hallucination of smell.

Optic Nerve

There is no obstruction on the field of vision

Oculomotor Nerve, Trochlear Nerve, Abducens

Ocular movements are within normal limits, no nystagmus. Pupil reacts to light.

Trigeminal Nerve

Sensation over face is intact; corneal and conjunctival reflexes intact.

Jaw jerk present

Facial Nerve

Eye closure, frowning, raising the eye brow present

Can blow, whistle and show the teeth 

Vestibulocochlear Nerve

No impairment of hearing

Glosopharyngeal Nerves and Vagus

Gag reflex present

Uvula centrally placed

Hypoglossal Nerve  Can move tongue in all directions

Sensory System: With in normal limit

Examination of motor System: Within normal limits

Signs of meningeal irritation: No signs of meningeal irritation

Analysis of symptoms

 Evaluation of symptoms

Totality of Symptoms

• 1.      Patient desires pungent things
• 2.      Hoarseness of voice
• 3.      Hoarseness of voice < Evening
• 4.      Redness of left eye
• 5.      Ca larynx

Miasmatic cleavage  

 Predominant Miasm: Syphilis

 Rubrics Selected

1. STOMACH, DESIRE pungent things.
2. LARYNX AND TRACHEA VOICE hoarseness.
3. LARYNX AND TRACHEA VOICE hoarseness evening.
4. LARYNX AND TRACHEA CANCER larynx.
5. EYE REDNESS canthi.

Medicines

• Phosphorous- 9/3               Hepar sulph- 6/3
• Carbo veg- 8/3                   Causticum- 6/2
• Graphitis- 6/3                     Calcarea carb-

Prescription                       

• 26-3-05   Calcarea Carb 200/2 dose
• 27-3-05    Sac lac 2 dose         (Hoarseness slightly relieved)
• 28-4-05     Calc carb 200/2 dose
• 15-5-05     Sac lac 2 dose  (Patient has symptomatic relief and discharged)

Tumors of the larynx
Benign tumours of the larynx are extremely rare and squamous carcinoma of the larynx predominates over all others, being responsible for more than 90% of tumours within the larynx. It is the commonest head and neck cancer and almost always occurs in the elderly male smokers. The squamous epithelium of the vocal folds and the respiratory epithelium of the supraglottis undergo dysplastic change stimulated by cigarette smoking and other factors. The incidence of laryngeal cancer in three compartments- supraglottis, glottis and subglottis, varies around the world; the glottis is generally the commonest site followed by the supraglottis. True carcinomas of the subglottis are very rare and most are a consequence of inferior spread from the glottis.

Clinical Features
The frequent glottic origin means that patients almost always present with hoarseness. This is of great importance because if a diagnosis can be made while the tumour is in the first stage. I.e. confined to only one vocal fold, these cancers have more than a 5 year disease-free cure rate when treated with radiotherapy alone. The cure rate drops dramatically once the lymphatically rich supraglottis or subglottis is involved, owing to spread to neck nodes. The appearance of more than one neck gland halves the overall prognosis of the patient.

TNM Classification of Laryngeal Cancer 

• T          –           Primary Tumour
• T x       –           Primary tumour cannot be assessed.
• To        –           No evidence of primary tumour
• T is      –           Carcinoma in site

Supraglottis 

• T1 – Tumour limited to one sub site of supraglottis, with normal vocal cord mobility.
• T2 – Tumour invades more than one sub site of supraglottis, with normal vocal cord mobility
• T3 – Tumour limited to larynx with vocal cord fixation and/ or invades post cricoid area, medial wall of piriform sincit or pre-epiglottic tissues.
• T4 – Tumour invades through thyroid cartilage and/ or extends to other tissues beyond the larynx, e.g. to oropharynx, soft tissues of neck.

Glottis 

• T1 – Tumour limited to vocal cords, (may involve anterior or posterior commissures) with normal mobility
• T1a- Tumour limited to one vocal cord
• T1b- Tumour involves both vocal cords
• T2 – Tumour extends to supraglottis and/ or with impaired vocal cord mobility
• T3 – Tumour limited to larynx with vocal cord fixation.
• T4 – Tumour invades through thyroid cartilage and/ or extends to other tissues beyond the larynx; e.g. to oropharynx, soft tissues of the neck.

Subglottis

• T1 – Tumour limited to subglottis
• T2 – Tumour extends to vocal cord(s) with normal or impaired mobility.
• T3 – Tumour limited to the larynx with vocal cord fixation
• T4 – Tumour invades through cricoid or thyroid cartilage and/ or extends to other tissues beyond the larynx; e.g. to oropharynx, soft tissues of the neck.
• N   – Regional lymph nodes
• M   – Distant metastasis

Stage Grouping  

• Stage 0                        T is                  No                   Mo
• Stage I             T1                    No                   Mo
• Stage II           T2                    No                   Mo-
• Stage III          T1                    N1                   Mo
•                         T2                    N1                   Mo
•                         T3                    No, N1                        Mo
• Stage IV          T4                    No, N1                        Mo
•                         Any T              No, N1                        Mo
•                         Any T              Any N             M1 

Investigations
Direct laryngoscopy, together with Hopkins rod examination allows precise determination of the extent tumours and biopsy confirms an exact histology. CT and MRI scanning give further details of the extent of larger tumours and suspicious nodal involvement within the neck which may not be determined on clinical examination.

Treatment
Early supraglottis and glottis tumours are optimally treated with mega voltage radiotherapy. Five-year cure for Stages I & II are approximately 90 and 70% respectively, and the patient has an excellent voice following this type of treatment. If modern mega voltage radiotherapy is not available then early tumours may be excised by endoscopic laser surgery or open partial laryngeal surgery. With early bilateral supraglottic tumours a horizontal laryngectomy may be undertaken excising the supraglottic growth and the remainder of the glottis. The subglottic part of the larynx is then stitched tongue base to provide continuity. In most patients undergoing partial laryngeal surgery of this type the voice result is not satisfactory as that with radiotherapy.

Advanced Laryngeal Disease
Once the squamous carcinoma has caused fixation of the vocal fold or has infiltrated outside the larynx into adjacent such as thyroid gland and strap muscles, some form of subtotal or total laryngectomy is required to attempt to cure the disease. Total laryngectomy is frequently required when radiotherapy fails.  Part or all of thyroid gland and associated parathyroid glands may also need to be removed depending on the extent of the disease, so patients after this type of radical surgery may require oral thyroxin and calcium supplement for the remainder of their lives. Laryngectomy patients must obviously avoid immersion in water as this would flow directly into their tracheal stoma.

Homoeopathic Management 

1.Homoeopathic Medical Repertory by Robin Murphy

• Diseases, CANCER general
• Larynx, CANCER
• Larynx, Cancer: ars, con, phytolacca, ars-I, bell, carb-an, clem, hydr, iod, kreos, lach, morph, nit-ac, phos, sang, thuja

2. Repertory of Homeopathic Materia Medica- J.T. Kent : LARYNX AND TRACHAEA; CANCER, larynx: ars, nit-ac, phos, sang, thuja

3. Synthesis – Dr. Frederick Schroyens  LARYNX AND TRACHEA, CANCER, larynx: arg-cy, ars, nit-ac, phos, sang, thuja

4. Synthetic Repertory :  Cancerous affections   +3 – Ars, Brom, carb-an, conium, Lycopodium, Nit-ac, phos, phytolacca, silicia

Indications of some important medicines in the treatment of     carcinoma larynx

1) Ars alb: Unable to lie down. Fear of suffocation. Air passages constricted. Cough< after midnight, lying on back. Extreme prostration & anxiety.

2)  Conium mac: Oppressed breathing, constriction & pain in chest. Expectoration only after long coughing. Dry cough; <evening & night; caused by dry spot in larynx with itching in chest & throat, when lying down. 

3) Phytolacca: Aphonia. Difficult breathing. Tickling cough < at night. Decrease of weight. 

4) Phosphorous: Hoarseness< evening. Larynx very painful. Tickling in larynx while speaking. Aphonia< evening with rawness. Cannot talk on account of pain in larynx 

5) Argentum met: Chronic hoarseness & aphonia< from use of voice. Larynx is a special centre for this drug. 

6) Causticum: Hoarseness with pain in chest; aphonia. Larynx sore. Difficulty of voice of singers & public speakers.

7) Carbo veg:  Cough with itching in the larynx. Deep, rough voice failing on slight exertion. Hoarseness< evening, talking.

8)  Calcarea carb: Painless hoarseness& bloody expectoration.

9)  Bromium: Dry cough with hoarseness & burning pain behind sternum. Difficult & painful breathing. 

References:

1. Synthesis Repertory by Fredericke Schroyens
2. Homoeopathic medical repertory by Robin Murphy
3. Repertory of Homoeopathic Materia Medica by J T Kent.
4. Allen’s Key notes.
5. Boericke’s Materia Medica
6. Bailey & love’s short practice of surgery.