5. malignant tumours of the larynx (prof. hesham fattah
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4/14/2009
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MALIGNANT TUMORSMALIGNANT TUMORSOF THE LARYNXOF THE LARYNX
Prof Prof HeshamHesham AbdAbd Al Al ––FattahFattah
OF THE LARYNXOF THE LARYNX
Department of Otolaryngology H & N SurgeryDepartment of Otolaryngology H & N SurgeryUniversity of AlexandriaUniversity of Alexandria
LARYNGEAL MASSES
TUMOUR-LIKE TUMOURS
CONGENITAL ACQUIRED BENIGN MALIGNANT
•SACCULAR CYST•LARYNGOCELE
•TRAUMATIC•NODULES•POLYPS•INTUBATION GRANULOMA
•INFLAMMATORY
•PAPILLOMA•MJP & ADULT
•HAEMANGIOMA•CHONDROMA
•PRIMARY•INFLAMMATORY•ADV REFLUX LARYNGITIS•RIENKE’S OEDEMA >> D POLYP•VENTRICULAR PROLAPSE
•REACTIVE•HYPERKERATOSIS•LEUKOPLAKIA•ERYTHROPLAKIA
•SCC•VERRUCOUS•ADENOID CYS•LYMPHOEPI
•SECONDARY•HYPOPHARYN•THYROID
•METASTATIC5.5.20085.5.2008 22Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Normal St Sq Epi Hyerplasia Hyperkeratosis
EPITHELIAL CHANGES IN THE LARYNGEAL M MEPITHELIAL CHANGES IN THE LARYNGEAL M M
Benign Changes
Dysplasia Ca in situ
Premalignant changesMicro invasive Camod Sever
5.5.20085.5.2008 33Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
HYPERPLASIAHYPERPLASIA DYSPLASIADYSPLASIA
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HYPERKERATOSISHYPERKERATOSIS
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Erythroplakia
LeukoplakiaLeukoplakia
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SEVER SEVER DYSPLASIADYSPLASIA CA IN SITUCA IN SITU
CA IN SITUCA IN SITU
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TT1 1 glotticglottic CaCa
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PapillomaPapilloma--Adult typeAdult type
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Precancerous lesionsPrecancerous lesions
Sever Dysplasia Leukoplakia
Erythroplakia Adult Papilloma
Of the larynxOf the larynx5.5.20085.5.2008 1010Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Malignant Laryngeal Tumors
Primary Secondary Metastatic
1. SCC2. Verrucous Ca3 Spindle Ca 1 Hypopharyngeal Ca3. Spindle Ca4. Lymphoepithelioma5. Glandular Ca6. Sarcoma
1.Hypopharyngeal Ca2.Thyroid Tumours
Adenoid CysticAdenosquamousAdenocarcinoma
10 sites5.5.20085.5.2008 1111Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
SCC of LarynxType of Patient
• Male > 50 ys•Rural >> Urban ( Now-a-days)
• Smoker & Ex-Smoker (up to 20ys)
• Refluxer TakesTakes 1010 2020ys for a Cell toys for a Cell to
male to female =male to female =2222--2525::1 1 in Egyptin Egypt
• Refluxer•Spices Eater•Alcohol Drinker
Takes Takes 1010--2020ys for a Cell to ys for a Cell to turn into Carcinoma in situturn into Carcinoma in situ
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Reflux laryngitis Reflux laryngitis (Laryngopharyngitis) (Laryngopharyngitis) SignsSigns
••CongestionCongestion
••EdemaEdema
••Post Com Post Com
SymptomsSymptoms--2222
HypertrophyHypertrophy
••Interarytnoid foldingInterarytnoid folding
••WebbingWebbing
1212y M spasmodic coughy M spasmodic cough 4545y M on steroids for SLEy M on steroids for SLE5.5.20085.5.2008 1313Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Predisposing FactorsPredisposing Factors
1.Hydrocarbons2.Tar & Benzopyrenes3.Pesticides4.Radiation5 Genetic ( ariable non consistent genes)5.Genetic (variable non consistent genes)
6.Chronic Inflammation7.Enzymes (acid-pepsin)
8.Viruses (papillomatosis)
•Non-Specific(common)•Specific
•T.B. (rare)•Syphilis ( does not exist)
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LateralMedialArcuate Line
Glottic
I. According to its Location
1 cm
SupraglotticGlotticSubglotticTransglottic sc
ulat
ure
•parallel to vascular arcades
Lateral Arcuate line
Changes:
Tumour Location Cor
d Va
sarcades
•Sٍquamous to pseudo stratified epithelium
•Scarce dispersed to frequent lymphatics
• vocal ligament to vocalis muscle5.5.20085.5.2008 1515Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
II. According to its Pathology 1. N.E.A
Supraglottic are derived from the Supraglottic are derived from the 44thth
BranchialBranchial arch and Glottic & arch and Glottic & subglotticsubglotticfrom the from the 66thth explaining the different explaining the different bldbld
d l h ti l Td l h ti l T
i. Ulcerating(everted edges)
ii. Fungating ( exophytic)
, nerve and lymphatic supply. Tumors , nerve and lymphatic supply. Tumors respect this embryological and respect this embryological and anatomical barrieranatomical barrier
iii. Infiltrating ( submucosal5.5.20085.5.2008 1616Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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II. According to its Pathology2.Microscopic Appearance
ModifiedModified Broder’sBroder’s ClassificationClassification(WHO(WHO 19871987))•Well Differentiated•Moderately Differentiated•Poorly Differentiated
Original Broder’s•Grade I-IV,•0-100%•UndifferentiatedX5.5.20085.5.2008 1717Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
III. According To T.N.M ClassificationT-primary tumour:T1: tumour confined to one anatomical site in the regionT2: tumour involves more than one anatomical sitein the same region or adjacent region without cord fixationg j gT3: Cord fixation or pre-epiglottic/ Postcricoid/ Internal
Perichondrium invasionT4: Cartilage invasion or direct extralaryngeal spread
N-regional Lymph nodeN1: < 3 cm diameter lymph node enlargementN2: 3-6 cm diameter lymph node enlargementN3: >6 cm diameter lymph node enlargement
M-distant metastasesM0: No evidence of distant metastasesM1: Evidence of distant metastases
(AJC 1998/2005)5.5.20085.5.2008 1818Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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StagesStage1: T1N0M0
III. According To T.N.M Classification
Stage2: T2N0M0Stage3: T3N0M0, T1,2,3 N1M0,Stage4: a. T4N0M0
b. Any T , N2 or more , M0b. Any T , N2 or more , M0c. Any T , Any N + M1
5.5.20085.5.2008 1919Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Tumour Behaviour ((Spread &Spread & Destruction)Destruction)
Guarded by:1. Host Defenses
a. Ageb. Systemic disease1. Host Defenses
2.Tumour a. Differentiationb. Size > 4 cmc. Thickness >1.5 cmd Location
a. Embryologicalb. Anatomicali. Lymphatics
b Syste c d seasec. Inflammatory Reaction
••LigamentsLigamentsd. Locatione. Margins (Pushing/Infiltrating)
f. Cell Size
ii. Barriersiii. Preformed
Pathwaysiv. Silent or Not
••LigamentsLigaments••CartilagesCartilages
•Broyles Ligament•Pre-epiglottic Sp•Paraglottic Sp
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Tumour Spread1.1.Local ( Direct )Local ( Direct )2.2.Regional (Lymphatic)Regional (Lymphatic) ••PermeationPermeation
••EmbolismEmbolism3.3.Distant(Blood ) Distant(Blood ) 77..5 5 %%4.4.Perineural Perineural
••PerilymphaticPerilymphatic
••Lungs (Lungs (5050--80 80 %)%)••LiverLiver••BonesBones 75 75 % %
DetectedDetectedS d P i Detected Detected after deathafter deathSecond Primary
10-25 % Upper AerodigestiveUpper AerodigestiveOther Organs(Other Organs(1010sites)sites)
5.5.20085.5.2008 2121Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
ManifestationsManifestationsA. SymptomsA. Symptoms
Early:Early:
Late:Late:1.1.Hot Potato Voice Hot Potato Voice 2.2.StridorStridor3.3. DysphagiaDysphagiaEarly:Early:
1.1.Change of Voice Change of Voice 2.2.HoarsenessHoarseness3.3. F.B. SensationF.B. Sensation4.4. OtalgiaOtalgia
4.4. Lump in the NeckLump in the Neck5.5. PainPain6.6. Bld Tinge SputumBld Tinge Sputum
Very Late:Very Late:gg5.5. Irritative CoughIrritative Cough6.6. Sense of Air WaySense of Air Way
ObstructionObstruction
Very Late:Very Late:1.1.Weight LossWeight Loss2.2.Fetor OrisFetor Oris
5.5.20085.5.2008 2222Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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ManifestationsManifestationsB. Signs B. Signs (Inspect, Palpate)Early:Early:11 Neck Free except Marginal TsNeck Free except Marginal Ts1.1.Neck Free, except Marginal TsNeck Free, except Marginal Ts2.2.Laryngeal ExaminationLaryngeal Examination
•• Disturbed Vascular PatternDisturbed Vascular Pattern•• Thickening/Mass/UlcerThickening/Mass/Ulcer
••LumpLumpF ll Th h idF ll Th h id
••Upper Deep C LNUpper Deep C LN••Prelaryngeal LNPrelaryngeal LN
Late:Late:1.1.NeckNeck2.2.Cord FixationCord Fixation
••Fullness Thyrohyoid mFullness Thyrohyoid m••Broadening laryngeal BoxBroadening laryngeal Box••Tender laryngeal BoxTender laryngeal Box
••MechanicalMechanical••InfiltrativeInfiltrative••ParalyticParalytic
MusclesJointJoint5.5.20085.5.2008 2323Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Diagnosis1.1.HistoryHistory2.2.Clinical ManifestationsClinical Manifestations3.3.Office LaryngoscopyOffice Laryngoscopy4.4.Operating Laryngoscopy & BiopsyOperating Laryngoscopy & Biopsy5.5.Radiological Investigations:Radiological Investigations:
a.a. Plain Neck & ChestPlain Neck & Chestb.b. Barium Swallow & MealBarium Swallow & Mealc.c. Ultrasound AbdomenUltrasound Abdomend.d.MultiMulti--slice CT scan Neck &Upper Chestslice CT scan Neck &Upper Cheste.e. Bone Scan (Whole Body Isotope study)Bone Scan (Whole Body Isotope study)5.5.20085.5.2008 2424Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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ManagementManagementDiagnosis &Diagnosis & TreatmentTreatmentAim of Treatment1.Local Control2.Regional Control3.Distal Control4.Rehabilitatione ab tat o5.Palliation
5.5.20085.5.2008 2525Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Local ControlLocal Control1.1.Early ( TEarly ( T1 1 & T& T22))
a.a.Conservative SurgeryConservative Surgeryi.i. EndoscopicEndoscopic ••M L SM L Sppii.ii.Open SurgeryOpen Surgery
b.b.RadiotherapyRadiotherapy2.2.Late ( TLate ( T3 3 & T& T44))
a.a.Total LaryngectomyTotal Laryngectomybb Laryngeal Preservation ProtocolLaryngeal Preservation Protocol
••LaserLaser
b.b.Laryngeal Preservation ProtocolLaryngeal Preservation Protocol( Combined Chemo radiotherapy)( Combined Chemo radiotherapy)
5.5.20085.5.2008 2626Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Local ControlLocal Control1.Early ( T1 & T2)
a.Conservative Surgeryi E d i ••M L SM L S
Local ControlLocal Control
i. Endoscopicii.Open Surgery
M L SM L S••LaserLaser
•Frontal•Frontolateral•Hemilaryngectomy
•Supraglottic Laryngectomy•Extended S L
•BOT Hemilaryngectomy• Supracricoid•¾ Laryngectomy
Glottic SCCGlottic SCC
•BOT•Arytenoid
Supraglottic SCCSupraglottic SCC5.5.20085.5.2008 2727Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Local ControlLocal Control1.Early ( T1 & T2)
a.Conservative Surgeryi E d i
Local ControlLocal Control
LLi. Endoscopicii.Open Surgery
LaserLaser
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5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 2929
Rt Aryepiglottic SCCRt Aryepiglottic SCC LT Supraglottic SCCLT Supraglottic SCC
One Year AfterOne Year After One Year AfterOne Year After5.5.20085.5.2008 3030Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Local ControlLocal Control1.Early ( T1 & T2)
a.Conservative Surgeryi E d i ••M L SM L S
Local ControlLocal Control
i. Endoscopicii.Open Surgery
M L SM L S••LaserLaser
•Frontal•Frontolateral•Hemilaryngectomy
S i id• Supracricoid•¾ Laryngectomy
Glottic SCCGlottic SCC5.5.20085.5.2008 3131Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Cordectomy throughLaryngofissure
Frontal Laryngectomy
Leroux –Robert 1957
5.5.20085.5.2008 3232Prof Hesham Abd AlProf Hesham Abd Al--FattahFattahFrontolateralLaryngectomy
Hemilaryngectomy Extended hemi
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5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 3333
Local ControlLocal Control1.Early ( T1 & T2)
a.Conservative Surgeryi E d i
Local ControlLocal Control
i. Endoscopicii.Open Surgery
•Supraglottic Laryngectomy•Extended S L
•BOT•Arytenoid•Arytenoid
Supraglottic SCCSupraglottic SCC5.5.20085.5.2008 3434Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Preop
operative
5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 3535
Local ControlLocal Control1.1.Early ( TEarly ( T1 1 & T& T22))
a.a.Conservative SurgeryConservative Surgeryi.i. EndoscopicEndoscopic ••M L SM L Sppii.ii.Open SurgeryOpen Surgery
b.b.RadiotherapyRadiotherapy2.2.Late ( TLate ( T3 3 & T& T44))
a.a.Total LaryngectomyTotal Laryngectomybb Laryngeal Preservation ProtocolLaryngeal Preservation Protocol
••LaserLaser
b.b.Laryngeal Preservation ProtocolLaryngeal Preservation Protocol( Combined Chemo radiotherapy : ( Combined Chemo radiotherapy : 22cyclescyclesOf Cis/carbo platinOf Cis/carbo platin100100g/mg/m2 2 on day on day 11+ + 5 5 FUFU11--5 5 days….. Response…..days….. Response…..4545Gy+Gy+2525GyGy
…...If no Response…….TL)…...If no Response…….TL)5.5.20085.5.2008 3636Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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After 2 cycles of chemo
After radiotherapy
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Regional ControlRegional Control1.1.Prophylactic > NProphylactic > N002.2.Therapeutic > N+Therapeutic > N+2.2.Therapeutic NTherapeutic N1.1.Radical NeckRadical Neck2.2.Modified RNDModified RND
a.a.Accessory NAccessory Nb.b.Jugular VJugular Vc.c. a +b + SCMa +b + SCM
3.3.SelectiveSelective4.4.ExtendedExtended
5.5.20085.5.2008 3838Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
AccordingAccording to the level clearedto the level cleared
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Memorial SloanMemorial Sloan--Kettering Hospital Kettering Hospital LevelLevel II -- SubmentalSubmental andand submandibularsubmandibular
IaIa -- NodesNodes inin thethe submentalsubmental triangletriangle boundbound byby thetheanterioranterior bellybelly ofof thethe digastricdigastric andand thethe hyoidhyoid boneboneIbIb -- NodesNodes inin thethe triangletriangle boundbound byby thethe anterioranterior andandposteriorposterior belliesbellies ofof thethe digastricdigastric andand bodybody ofof thethemandiblemandible
LevelLevel IIII -- UpperUpper jugularjugular lymphlymph nodes,nodes, includingincludingthethe jugulodigastricjugulodigastric nodesnodes
IIaIIa -- NodesNodes inin thethe regionregion anterioranterior toto thethe spinalspinalaccessoryaccessoryIIbIIb -- NodesNodes inin thethe regionregion posteriorposterior toto thethe spinalspinalaccessoryaccessory
LevelLevel IIIIII -- NodesNodes fromfrom thethe carotidcarotid bifurcationbifurcation toto thetheomohyoidomohyoid musclemuscleLevelLevel IVIV -- NodesNodes ofof thethe lowerlower jugularjugular areaarea thatthatj gj gextendextend fromfrom thethe omohyoidomohyoid toto thethe clavicleclavicleLevelLevel VV -- AllAll lymphlymph nodesnodes withinwithin thethe posteriorposteriortriangletriangle ofof thethe neckneckLevelLevel VIVI -- NodesNodes inin thethe anterioranterior compartmentcompartmentgroup,group, includingincluding thethe lymphlymph nodesnodes thatthat surroundsurroundthethe midlinemidline structuresstructures ofof thethe neckneck (These(These nodesnodesextendextend fromfrom thethe hyoidhyoid bonebone superiorlysuperiorly toto thethesuprasternalsuprasternal notchnotch inferiorlyinferiorly..))
6
7
RND exRND
Types of neck dissectionTypes of neck dissection
MRND I MRND IIIMRND II
5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 4040
Supraomohyoid Ballantyne Central Extended
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5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 4141
RND
MRND III
MRND II
5.5.20085.5.2008 Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah 4242
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•Distal Control•Rehabilitation•Palliation
Tracheostomy
1.Voice• Esophageal• Prosthesis
TracheostomyChemotherapyRadiotherapy
2.Swallowing3.Psychological
More than More than 6666GyGy
5.5.20085.5.2008 4343Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
CisCis//CarboplatinCarboplatin 100100mg/ mmg/ m2 2 Day Day 11& & 55--FU Days FU Days 11--55
Thank You Thank You
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Calcified Calcified Saccular CystSaccular Cyst
•Vestigial Structure•Congenital in origin•Important to Aquatic Apes•Usually Asymptomatic
5.5.20085.5.2008 4545Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
CYSTSCYSTS
SACCULAR
CORDAL CYST
PATTERN VOCAL CORD VASCULATURE5.5.20085.5.2008 4646Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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5.5.20085.5.2008 4747Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
NoduleNodule PolypPolypScreamer’sSinger’s
Gelatinous & thrombotic
After laser excisionAfter MLS
Immature >>>> Mature5.5.20085.5.2008 4848Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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PolypsPolyps
1.Gelatinous 2.Hyaline3.Vascular4.Myxomatous5.Mixed
Thrombotic
5.5.20085.5.2008 4949Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
Rienke’S OedemaRienke’S Oedema Diffuse Cordal PolyposisDiffuse Cordal Polyposis
Ventricular Ventricular prolapseprolapse5.5.20085.5.2008 5050Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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Contact granuloma
Signs:Signs:
Signs of RLPSigns of RLP
••CongestionCongestion••EdemaEdema••InterInter--arytenoid folding>> Webbingarytenoid folding>> Webbing••Contact ulcer>> Contact GranulomaContact ulcer>> Contact Granuloma
5.5.20085.5.2008 5151Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
TT2 2 SCC Glottic TSCC Glottic T
Two Years AfterTwo Years After5.5.20085.5.2008 5252Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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INTUBATIONINTUBATIONGRANULOMAGRANULOMA
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ChondromaChondroma
•Arises from the cricoid or thyroid•TL is the treatment•TL is the treatment•Malignancy depends on behavior
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HaemangiomaHaemangioma
•Subglotticg•Posterior•50 % other haemangiomata•Laser Debulking +
Prophylactic Tracheostomy
5.5.20085.5.2008 5555Prof Hesham Abd AlProf Hesham Abd Al--FattahFattah
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