Tumours of the hypopharynx larynx and trachea Introduction

The Natural Thyroid Diet

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M. Brandwein-Gensler M. Urken

P. Slootweg N. Gale A. Cardesa N. Zidar P. Boffetta

With emphasis now on accurate staging and conservative surgery to retain as many functions as possible, especially in the larynx, the pathologist has emerged as an invaluable member of the health care team. Precise and detailed examination of resected head and neck specimens regarding the site of origin of the tumour, structures involved, tumour grade, adequacy of resection margins, and the presence of lymph node metastasis, extranodal spread of tumour, perineural involvement, and vascular invasion are just a few of many features that are important to the clinician who must decide on the total therapeutic regimen for the patient.

Definitions / anatomy

Larynx

The larynx extends from the tip of the epiglottis to the inferior border of the cricoid cartilage. Anteriorly, its boundaries are the lingual epiglottis, the thyro-hyoid membrane, the anterior commissure, thyroid cartilage, cricothyroid membrane and the anterior arch of the cricoid cartilage. The posterior boundaries include the posterior commissure mucosa (which covers the cricoid cartilage) the arytenoid region, and the inter-arytenoid space.

The larynx is divided into three compartments - supraglottis, glottis, and subglottis. The supraglottis is composed of the epiglottis, aryepiglottic folds, false vocal cords (vestibular folds), ventricles and saccules. The tip of the epiglottis and the aryepiglottic folds form the superior and lateral supraglottic margins. The inferior limit is a horizontal plane passing through the lateral margin of the ventricle at its junction with the superior surface of the true vocal cord (vocal fold) {947}. The ventricle is the "pocket" between the true and false vocal cords. The lateral superior ventricular extension, or "cul-de-sac", is variably sized, and referred to as the saccule. The epiglottis is further divided into suprahyoid and infrahyoid components by a plane at the level of the hyoid bone.

The glottis extends, superiorly, from a horizontal plane passing through the lateral margin of the ventricle, at its junction with the superior true vocal cord, to an imaginary horizontal plane 10 mm inferi-orly from the lateral margin of the ventricle {947}. The glottis consists of the true vocal cords, plus their undersurfaces, and the anterior and posterior commissures. The subglottis extends from 10 mm below the true vocal cords to the inferior margin of the cricoid cartilage. Most tumours that clinically appear as

"subglottic", actually arise from the undersurface of the true vocal cord and are still considered glottic. The term "transglottic" does not refer to a specific anatomic site. It designates those tumours that cross the ventricle vertically, to involve both the supraglottis and glottis, and occasionally subglottis {1679}. The growth and spread of laryngeal tumours is determined by the site of origin and the anatomic barriers of the different laryngeal compartments {1941}. Three of these are especially important: anterior commissure tendon (Broyles' ligament), paraglottic space and the pre-epiglottic space.

The anterior commissure tendon is a band of fibrous tissue 1 mm in width and 10 mm in length that extends from the vocal ligaments to the midline of the inner surface of the upper thyroid cartilage {286}. It is significant not only because it contains lymphatic and blood vessels, but also because it is devoid of peri-chondrium at the attachment to the thyroid cartilage, thereby acting as a conduit for tumour spread into the adjacent soft tissue or the prelaryngeal (Delphian) lymph node.

The paraglottic space is a potential space deep to the ventricles and sac-cules filled with adipose and loose connective tissue. It is bounded by the

Paraglottic Space

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