Benign Lesions of Larynx

Benign Lesions

of Larynx

Dr. Vishal Sharma

Common Non-neoplastic Lesions

Classification

Solid

1. Vocal nodules 6. Leukoplakia

2. Vocal polyp Cystic

3. Reinke’s edema 1. Laryngocoele

4. Contact ulcer 2. Saccular cyst

5. Intubation granuloma 3. Ductal cyst

Vocal nodules

Synonyms: singer’s / screamer’s / teacher’s nodes

B/L, symmetrical, localized, benign, superficial

growths on medial surface of true vocal folds

Appear at junction of anterior & middle 1/3 of vocal

cords (area of maximum vibration)

Etiology: overtaxing & incorrect use of voice over

long period in teachers, telephone operators,

entertainers, singers, vendors & stock traders

Stage of transudation:

Reversible edema in submucosal plane

Stage of in growth of vessels:

Reversible, submucosal neo-vascularisation

Stage of fibrous organization:

Submucosal transudate replaced by fibrous / hyaline

material, resistant to conservative treatment

Pathogenesis

Clinical Features

Small nodule: unable to sing high pitch notes, ed

effort required for singing, normal speaking voice

Large nodule: Low pitch, harsh, breathy speaking

voice fatigability of voice, decreased pitch range

Indirect laryngoscopy / flexible laryngoscopy:

Early nodules: soft, reddish & edematous

Late nodules: hard, grayish or white

Spindle shaped nodules Often asymmetrical nodules

Vocal nodules

Non-surgical treatment

Absolute voice rest: (or < 20 min / day) for 1-4 weeks

Vocal hygiene: Avoid (mouth breathing, smoke + other

allergens, repeated throat clearing, straining of voice)

Maintain adequate hydration, steam inhalation

Voice therapy for 3-6 months: emphasis on use of

optimum pitch (effortless voice)

Surgical Treatment

Indicated if adequate voice therapy shows no

result for 3-6 months

Micro-laryngoscopy dissection

Laser-assisted dissection

Post-operative voice therapy given for 3-4 weeks

for residual hoarseness

Excision of vocal nodule

Voice use after surgery

Talking: Absolute voice rest ** for 1 week → Limited

talking for 2nd week → average talking only.

Avoid excessive talking.

Singing: None for 1 week → 5-10 min BD for 2nd

week → 15-20 min BD for weeks 3 to 4.

** absolute rest from talking, humming, whispering,

throat clearing, forceful coughing

Vocal polyp

Introduction

Accumulation of fluid in subepithelial layer

followed by ingrowth of connective tissues

Mostly affects men b/w 30-50 years

90% solitary & thus unilateral

May be pedunculated or sessile vocal cord mass

Most common near anterior commissure

Etiology: severe vocal trauma causing vocal cord

hemorrhage, chronic inhalation of irritants

(cigarette smoke, industrial fumes) gastric

reflux, untreated hypothyroid states,

chronic laryngeal allergy

Pathogenesis: extreme vocal exertion → breakage

of capillary in Reinke’s space → extra-vasation

of blood & edema formation → fibrosis of

resulting hematoma → polyp formation

Symptoms

Hoarseness

Normal voice if polyp hangs in subglottis space.

Sudden episode of hoarseness may occur due to

superior displacement of polyp during phonation.

Dyspnoea due to large polyp

Diplophonia

Laryngoscopic examination

Types of vocal polyps

Gelatinous:

Edematous stroma with fibrosis

Telengiectatic / hemorrhagic:

Dilated blood vessels, hemorrhage within polyp

Transitional or mixed:

Dilated blood vessels within gelatinous substance

Vocal polyp

Treatment

1. Micro-laryngoscopy & excision of polyp

a. Micro-flap approach

b. Truncation approach

2. Voice therapy: for 1 week before surgery

& 3 weeks after surgery

Elevation of micro-flap

Excision of polyp

Trimming of excess mucosa

Redraping of mucosa

Truncation approach

Reinke’s edema

Introduction

Accumulation of fluid in Reinke’s space

Synonyms: Bilateral diffuse polyposis,

Smoker’s polyps, Polypoid corditis,

Polypoid degeneration of

vocal cords, Localized

hypertrophic laryngitis

10% of benign laryngeal lesions

Reinke’s space

Etiology

Irritants: tobacco smoke, dry air, dust, alcohol

Laryngeal allergy

Infection: chronic sinusitis

Idiopathic

Edema limited to superior surface of vocal cord

due to dense fibrous attachment to conus

elasticus on under surface of vocal cord

Clinical Features Common in men b/w 30 – 60 years

Hoarseness: monotonous low-pitch voice

Diplophonia: in asymmetric vocal cord involvement

Stridor: in B/L gross edema

Early cases: ed convexity of medial cord margin

Late cases: Pale, watery bags of fluid on superior

surface of vocal cords, move to & fro on phonation

Reinke’s edema

Treatment

Elimination of causative factors. Stop smoking.

Vocal cord stripping (decortication) under MLS:

postero-anterior incision made on superior vocal

cord surface → edematous fluid sucked out →

edematous tissue removed with cup forceps

Voice therapy: 1 wk before & 3 wks after surgery

Vocal cord stripping

Removal of edematous tissue

Trimming & re-draping

Pre-op vs. post-op

Contact ulcer

Synonym: pachydermia laryngis, contact granuloma

Ulcer misnomer as overlying epithelium is intact

Saucer like lesions (thickened epithelium with

central indentation) at site of muco-perichondrium

covering medial surface of vocal process

Etiology: vocal abuse (forceful voice), gastric

reflux, obsessive clearing of throat

Contact ulcer in voice abuse

Contact granuloma in GERD

Clinical presentation: low pitch hoarseness in

tense, middle aged person

Treatment:

Voice therapy: use of higher tone

Management of psychological stress

Medical treatment of gastric reflux

Micro-laryngeal excision of granuloma

Intubation granuloma Mushroom-shaped, pedicled granuloma situated

superiorly or medially on vocal process

Detected 2-4 weeks after prolonged (> 10 days) or

traumatic nasal endotracheal intubation

Pathogenesis: long term intubation → pressure

necrosis → reactive granuloma

Treatment: Endoscopic excision

Intubation granuloma

Intubation granuloma

Vocal cord leukoplakia White plaque on vocal cord that cannot be scraped

off & has no clinico-pathological correlate

Involves upper surface of vocal cord

Pt presents with hoarseness / incidental finding

Tx: excision / vocal cord stripping & histo-

pathological examination to r/o carcinoma

Elimination of smoking

Vocal cord leukoplakia

Incision & dissection

Excision of leukoplakia

Laryngocoele

Arises from expansion of saccule of laryngeal

ventricle due to ed intra-luminal pressure in

larynx or congenital large saccule

Causes of ed intra-luminal pressure in larynx:

Occupational (?): trumpet players, glass blowers

Coexistence of larynx cancer

Male : female 5:1, Peak age = 6th decade,

Unilateral in 85 % cases, 1% contain carcinoma

Swelling enlarges on Valsalva

Types of laryngocoele

Internal (20%): contained entirely within endolarynx

with bulge in false vocal fold & aryepiglottic

fold

External (30%): only neck swelling without visible

endolaryngeal swelling

Combined (50%): Also extends into anterior triangle

of neck through foramen for superior laryngeal nerve &

vessels in thyrohyoid membrane. Dumbbell shaped.

Types of laryngocoele

Internal External Combined

Clinical Features

Hoarseness

Stridor in large endolaryngeal laryngocoele

Neck swelling

Manual compression of neck swelling results in

escape of fluid / gas into airway (Boyce’s sign)

10% cases are pyocele: sore throat, cough

Flexible laryngoscopy

Swelling of false vocal

folds & ary-epiglottic

fold

Swelling easily emptied

Escape of purulent fluid

into airway = pyocoele

X-ray neck AP view

X-ray soft tissue neck AP

view during Valsalva

maneuver shows air-

filled radiolucent

swelling

CT scan: mixed laryngocoele

Treatment No symptom: no treatment

Infected laryngocoele: aspiration & antibiotics

Internal laryngocoele: endoscopic marsupialization

External laryngocoele: Excision by external

approach. Cyst exposed by removing upper half of

thyroid cartilage. Cyst incised at its neck & stitched.

Endoscopic marsupialization

External approach

Saccular cysts Due to obstruction of orifice of saccule in

laryngeal ventricle. May be congenital or acquired

40% congenital cysts found within hours of birth

95% of infants have symptoms within 6 months

C/F: Inspiratory stridor improves during head

extension; dyspnea, apnea, cyanosis;

feeding problems & failure to thrive

Anterior saccular cystSmaller in size, project into laryngeal lumen in

anterior ventricular region

Lateral saccular cystLarger, present as bulge in false vocal fold or

ary-epiglottic fold, extend into neck

C.T. scan

Treatment

1. Emergency tracheostomy for acute stridor

2. Endoscopic de-roofing or marsupialization:

cold knife Laser-assisted

3. Endoscopic incision & drainage

4. Total excision:

endoscopic laryngofissure approach

Cyst exposed after incision

Incision & exposure

Final cut of cyst with false vocal cord

Dissection of cyst

Ductal cysts

Retention cysts due to blockage of ducts of

seromucinous glands

Sites: Vocal cord, false cord, vallecula,

aryepiglottic fold, ventricles,

pyriform fossa

Clinical features: asymptomatic, hoarseness,

dyspnoea for large cyst

Rx: Microlaryngoscopy & excision

Ductal cysts

Excision of ductal cyst

Neoplastic lesions

Classification1. Squamous papilloma: commonest

2. Chondroma

3. Haemangioma

4. Rhabdomyoma

5. Schwannoma

6. Paraganglioma

7. Lipoma

8. Fibroma & neurofibroma

Squamous papilloma

Most common benign tumor of larynx (85%)

Etiology: Human papilloma virus strain 6,11,18.

Transmitted during delivery from genital

warts.

Juvenile onset: multiple, diffuse, aggressive, resistant

to Rx, recurrent (recurrent respiratory

papilloma)

Adult onset: single, non-aggressive, does not recur

Clinical FeaturesSymptoms:

Majority present before 4 yrs of life

Hoarseness / abnormal cry + increasing stridor

Signs:

Glistening, whitish-pink, irregular, pedunculated or

sessile growth, friable, bleeds easily

Involve anterior vocal cord, anterior commissure.

Later involve remaining larynx & trachea.

Adult onset papilloma

Tracheal involvement

Treatment1. Micro-laryngoscopy + excision with: cup forceps /

electrocautery / microdebrider / Laser / cryosurgery /

application of podophyllin. HPE to rule out cancer.

2. Interferron: viral replication, immune response

3. Antiviral agents: Acyclovir, Ribavirin

4. Immuno-modulators: Adenine arabinoside, lysozome

chlorhydrate

Tracheostomy to be avoided to prevent stomal seeding

Cause for recurrence Virus remains in basal layer of mucus membrane

replicating by episomal maintenance

Virus remains undetectable unless determined by

DNA hybridization

Virus only seen in stratum corneum & granulosum

High affinity for areas of airway constriction (due

to ed airflow, drying & crusting

Micro-flap removal

Cup forceps & microdebrider removal

Thank You