Benign lesions of larynx

BENIGN LESIONS OF

LARYNXDr Manpreet Singh Nanda

Associate Professor ENTMMMC&H Solan

CLASSIFICATION Non Neoplastic – vocal nodules, vocal

polyps, reinke’s oedema, contact ulcer, intubation granuloma, leukoplakia

Neoplastic - papillomas, chondroma, haemangioma

Saccular – laryngocele, cysts

VOCAL NODULES/SINGER NODULES Etiology Voice abuse (misuse/overuse) –

teachers, bad singers, politicians, school children

GERD Common in boys (children), females

aged 20-30 yrs Pathology Friction - Localised submucosal oedema,

heamorrhage, fibrosis, calcification – hyperplasia at midpoint of ant 2/3rd of vc

C/F Chronic hoarseness/repeated acute hoarseness,

worsens by evening Voice fatigue Pain neck on prolonged phonation (efforts to

improve voice strains muscles) FB sensation O/E B/L soft red nodule later grey/pale mostly

symmetrical at junction of ant 1/3rd and post 2/3rd of vocal cords

Size pin head to pea (1-5mm) Diagnosis – laryngoscopy/videostroboscopy

Treatment Voice rest/speech therapy Avoid smoking Treat allergy/reflux Treat local causes – tonsillitis/sinusitis Proper hydration Steroid inhalers Surgery – if no relief/longer duration –MLS

–precise excision followed by complete voice rest for four days and relative voice rest for six weeks. C/I - children

VOCAL POLYP MC benign lesion of larynx Etiology Extreme voice abuse (sudden shouting) Allergy/GERD Smoking URTI Males age gp 30-50 yrs Pathology Localised oedema in reinke’s space

leading to haematoma and fibrosis

C/F Sudden onset hoarseness Diplophonia (double voice) FB sensation Cough (polyp movement) Stridor/choking/dyspnoea (large polyp) O/E Reddish purple/pale U/L polypoidal mass

> 3 mm at junction of ant 1/3rd and post 2/3rd of free margin of vocal cord. Pedunculated at later stages

Treatment Treat acid reflux Voice therapy Surgery – MLS Superficial surgical excision followed by

speech therapy

REINKE’S OEDEMA/SMOKER’S POLYP Diffuse vocal polyposis Etiology Voice abuse Long term smoking URTI Hypothyroidism Common in middle aged females aged

40-60 yrs Pathology Collection of fluid in reinke’s space

C/F Severe hoarseness Females with male voice (low pitched

monotonous) Intermittent aphonia O/E B/L pale/bright red diffuse symmetrical

swelling over the length of both vocal cords (pale watery bag appearance) obliterating the ant glottis

Treatment Stop smoking Voice therapy MLS – incision of epithelium and suction

of fluid Once cord 1st later after one month (to

prevent glottic web) Followed by speech therapy

CONTACT ULCER Etiology Faulty voice production Chronic cough/throat clearing GERD/late night eating Alcohol/coffee abuse Smoking Pathology Ulceration and granuloma formation in

thin mucosal layer of vocal process of arytenoids (post larynx) due to hammering against each other

C/F U/L pain over thyroid cartilage worst on

phonation referred to ear Low pitch morning voice Hoarseness Heart burn/FB sensation O/E U/L ulcer with whitish exudates or granuloma

on vocal process pf arytenoids. One vc – projected epithelium, other – epithelial depression

Congestion of arytenoid mucosa

Treatment Voice therapy Anti reflux Inj depot corticosteroids into lesion Steroid inhalers Surgical limited removal

INTUBATION GRANULOMA Etiology Rough endotracheal intubation Large tube Prolonged tube Rigid bronchoscopy Pathology Local abrasion of epithelium of vocal process

of arytenoid – mucosal ulcer – granuloma formation

C/F Hoarseness Dyspnoea (large granulomas)

O/E Usually B/L sessile or large

pedunculated granulomas attached to vocal process of arytenoids

Treatment Antibiotics for several weeks Speech therapy Endoscopic corticosteroid injection into

lesion Surgery – leave behind stalk Post op – topical mitomycin application

to prevent recurrence

LEUKOPLAKIA/KERATOSIS Etiology Chronic laryngeal irritants – tobacco, alcohol Syphilis Elderly males Pathology Epithelial hyperplasia -> white plaque/warty

growth C/F Progressively increasing hoarseness FB sensation O/E White plaques or warty growth on one or both vc

Diagnosis Laryngoscopy and biopsy Prognosis – can lead to ca in situ Treatment Voice rest Steam inhalation Anti oxidants/vitamin A Avoid alcohol/smoking MLS – stripping of vc

PAPILLOMAS MC laryngeal tumour in children 80% of benign tumours are papilloma Types – juvenile and adult onset JUVENILE PAPILLOMA/RECURRENT

RESPIRATORY PAPILLOMATOSIS Etiology Viral – HPV 6, 11 (larynx, oropharynx, ano

genital region) – abnormal tissue response Mothers with genital warts (transplacental) Hormonal Age gp 3-4 yrs, boys and girls equal

C/F Manifests clinically few yrs after implantation Hoarseness Stridor O/E Inspiratory/biphasic stridor Glistening white/pinkish white irregular

growths (warts), pedunculated or sessile, seen on true cords, false cords and epiglottis which bleed on removal

Also seen on trachea, bronchi

Prognosis Aggressive Rapid recurrence Can get seeded to other structures Regress after puberty If child survives till puberty – good prognosis Diagnosis X Ray Neck Chest X Ray Excision biopsy Direct laryngoscopy/bronchoscopy

Treatment Repeated endoscopic surgical excision

of papillomas using cup forceps, laser, microdebrider

Interferon therapy/methotrexate/intralesional cidofir/radiation/vaccines/anti viral drugs

If stridor prefer endotracheal intubation Low tracheostomy

ADULT SOLITARY PAPILLOMAS Single Age gp 30-50 yrs M>F C/F Hoarseness Single white to pinkish red polyp limited to

one site of ant ½ of vc, bleeds on removal.. Prognosis – good, less aggressive, no

recurrence Premalignant Treatment – surgical removal

CHONDROMA Arise from cricoid cartilage Seen in subglottic region Men age gp 40-60 yrs C/F Dyspnoea Dysphagia FB sensation throat

HAEMANGIOMA Infantile/capillary Site – subglottic area C/F – stridor during 1st six months of life Also seen in other regions of head and neck Prognosis – involutes spontaneously Treatment – laser/tracheostomy/steroid Adult/cavernous Supraglottic region Asymptomatic Treatment – if symptomatic need steroids

or radiotherapy

LARYNGOCELE Etiology Raised transglottic/intrathoracic

pressure more on coughing and straining seen in trumpet players/wind instrument, glass blowers, weight lifters

M:F 5:1 Pathology Air filled cystic swelling due to dilatation

of saccule due to raised pressure

Types Internal (20%) – within larynx. Cystic swelling

involving false cords and aryepiglottic folds External (30%) – distended saccule herniates

through thyrohyoid membrane into neck Combined/mixed (50%) C/F Hoarseness Sore throat Dysphagia Cough Snoring

O/E Neck swelling in region of thyroid

cartilage, reduces on pressure and reappears on valsalva manoeuvre and coughing

Stridor Bryce’s sign – on compressing the

neck mass, gurgling and hissing sound in throat

Prognosis – in elderly leads to saccule carcinoma

Diagnosis X Ray Neck/CT scan with valsalva DL Scopy Treatment Surgical excision via external neck

approach Internal – endoscopic marsipulization Antibiotics – if pus

RETENTION CYSTS Ductal cysts Etiology – blockage of ducts of

seromucinous glands of laryngeal mucosa

Site – vallecula, aryepiglottic folds, false cords, ventricle and pyriform fossa

C/F Asymptomatic if small Large – hoarseness, cough, throat pain,

dysphagia Treatment – marsipulization/removal

SACCULAR CYSTS Etiology – obstruction of orifice of

saccule leading to retention of secretion causing distension of saccule

Types Anterior – small, seen in ant part of

ventricle Lateral – large, extends into neck through

thyrohyoid membrane. Internally to false cords, aryepiglottic folds, pyriform fossa

C/F – weak cry, stridor, cyanosis, hoarseness (adult)

Diagnosis – X Ray Neck/CT Scan Treatment Endoscopic aspiration/marsipulization External approach through thyrohyoid

membrane