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Benign Tumors of Larynx presentation
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BENIGN TUMOURS OF LARYNXBENIGN TUMOURS OF LARYNX
Benign tumours of the larynx are not as common as the malignant ones.
Divided into
I. Neoplastic
II. Non-neoplastic
NEOPLASTIC
Laryngeal fibroma and papilloma are the most frequent.
FIBROMA
Occurs with equal frequency in men and women aged 20-50 years , children are extremely rare.
Usually grow on the free edge on the upper surface of the vocal fold , have a dark cherry (sometimes lighter ) color, usually solitary, mobile.
Its size ranges from a grain of lentil to a pea.
Complaints of the patient – hoarse and whispered voice.
Treatment - surgery. Removed under local or general anesthesia , with special forceps (Moritz -Schmidt or Cordes).
SQUAMOUS PAPILLOMAS
They are viral in origin (HPV types 6 and 11)
1. Juvenile
2. Adult onset type
JUVENILE LARYNGEAL PAPILLOMA
Often involving infants and young children who present with hoarseness and stridor
They are mostly seen on the true, false vocal cords and epiglottis, but they may involve other sites in larynx and trachea
Clinically appear as glistening white irregular growths, pedunculated or sessile, friable and bleeding easily
JUVENILE LARYNGEAL PAPILLOMA
They are known for recurrence after removal, therefore multiple laryngoscopies may be required
The other way to diagnose laryngeal papilloma is for a biopsy to be conducted and for the lesion to be tested for HPV.
Tend to disappear spontaneously after puberty
Treatment: endoscopic removal with cup forceps, cryotherapy, microelectrocautery
CO2 laser is preferred these days
Interferon therapy to prevent recurrence
ADULT ONSET PAPILLOMAADULT ONSET PAPILLOMA
Usually single, smaller in size, less aggressive and does not recur after surgical removal
It is common in males in age group of 30-50 years
Usually arises from anterior half of the vocal cord or anterior commissure
Treatment is same as for juvenile type
CHONDROMACHONDROMA
Arise from cricoid cartilage and present in subglottic area causing dyspnoea
May grow outward posterior plate of cricoid and cause sense of lump in the throat and dysphagia
Mostly affect men in age group 40-60 years
HAEMANGIOMA
Infantile haemangioma involves subglottic area and presents with stridor in first six months of life, about 50% of such children have haemangioma elsewhere in the body, particularly in the head and neck
Direct laryngoscopy , X-ray Tend to involute spontaneously but tracheostomy may be
needed to relieve respiratory obstruction if airway is compromised
Most of them are of capillary type and can be vaporized with CO2 laser
Adult haemangiomas involve vocal cord or supraglottic larynx, they are cavernous type and can not be treated by laser, they are left alone if asymptomatic
Larger ones causing symptoms steroid or radiation therapy may be employed
GRANULAR CELL TUMOUR It arises from the
Schwann cells and is often submucosal
Overlying epithelium shows pseudoepitheliomatous hyperplasia, which may on histopathology resemble well differentiated carcinoma
Treated by surgical resection under a fine dissection laryngomicroscope
OTHER RARE TUMORS
Pleomorphic adenoma or oncocytoma are rare tumours
Other rare tumours include rhabdomyoma, neurofibroma, neurilemmomas,
NON-NEOPLASTIC
These are not true neoplasms
These are formed as a result of infection, trauma or degeneration
Divide into:
Solid
Cystic
NON-NEOPLASTICSOLID LESIONS
VOCAL NODULES (SINGER’S NODULES/SCREAMERS NODULES)
Appear symmetrically in the free edge of the vocal cord at the junction of anterior 1/3rd and posterior 2/3rd, as this is the area of maximum vibration and thus subjected to maximum trauma
Usually they measure less than 3mm
They are results of vocal trauma
Mostly seen in teachers, actors, singers, vendors
VOCAL NODULES- PATHOLOGY
Trauma to the vocal cords in the form of vocal abuse or misuse causes oedema and hemorrhage in the submucosal space
This undergoes hyalinization and fibrosis
Underlying epithelium also undergoes hyperplasia forming a nodule
VOCAL NODULES- CLINICAL FEATURES
Patient complains of hoarseness, vocal fatigue and pain in neck on prolonged phonation
On examination the nodule appears soft, reddish and edematous swelling, later becomes grayish or whitish in colour.
VOCAL NODULES- TREATMENT
Early cases of vocal nodules can be treated conservatively by educating the patient in proper use of voice. With this treatment, many nodules in children disappear completely.
Surgery for larger nodules and long standing nodules in adults - excised by microlaryngeal surgery
Speech therapy and re-education in voice production is necessary to prevent recurrence
VOCAL POLYPVOCAL POLYP Result of vocal abuse or
misuse
Allergy and smoking are other contributing factors
Mostly affects men in age group of 30-50
Typically its unilateral and arising from same position as vocal nodule
Its soft smooth and often pedunculated
It may flop up and down during phonation or respiration
Its caused by sudden shouting resulting in haemorrhage in the vocal cord and subsequent submucosal oedema
VOCAL POLYP- CLINICAL FEATURESVOCAL POLYP- CLINICAL FEATURES
Hoarseness is a common symptom
Large polyp may cause dyspnoea, stridor or intermittent choking
Some patients may complain of diplophonia due to different vibratory frequencies of two vocal cords
TREATMENT: surgical excision under operating microscope and speech therapy
REINKE’S EDEMA (BILATERAL DIFFUSE REINKE’S EDEMA (BILATERAL DIFFUSE POLYPOSIS)POLYPOSIS)
This is due to collection of the eedema fluid in the subepithelial space of reinke
Usual cause is vocal abuse and smoking
Both vocal cords show diffuse symmetrical swellings
Individuals with Reinke's edema typically have low-pitched, husky voices, as they use false vocal folds for voice production.
Treatment is vocal cord stripping preserving enough mucosa for epithelization
Only one cord is operated at a time Cessation of smoking is important to
prevent recurrence
CONTACT ULCERCONTACT ULCER
This is again due to faulty voice production Vocal process of arytenoid hammer against each other resulting in
ulceration and granuloma formation. The most common cause of the condition is sustained periods of
increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively such as singers.
Some cases are due gastroesophageal reflux Complaints are hoarseness, constant desire to clear the
throat and pain in the throat which worsens on phonation Examination reveals unilateral or bilateral ulcers with congestion of
arytenoid cartilages (endoscopy). There may be granuloma formation TREATMENT: Resting the vocal cords for as long as six weeks,
normally followed by vocal therapy.
INTUBATION GRANULOMAINTUBATION GRANULOMA
It results from injury to vocal processes of arytenoids due to rough intubation
Use of large tube or prolonged intubation are the common causes Mucosal ulceration followed by granuloma formation over the exposed
cartilage Usually these are bilateral involving posterior third of true cords They present with hoarseness, if large dyspnoea Treatment is voice rest and endoscopic removal of granuloma
LEUKOPLAKIA (KERATOSIS) LARYNXLEUKOPLAKIA (KERATOSIS) LARYNX
This is localized form of epithelial hyperplasia involving upper surface of one or both vocal cords
It appears as white plaque or warty growth on cord without affecting its mobility
Its regarded as pre cancerous condition because carcinoma in situ frequently supervenes
Hoarseness is common presenting symptom
Treatment is stripping of the vocal cords and histopathological examination to rule out malignancy
AMYLOIDOSIS OF LARYNXAMYLOIDOSIS OF LARYNX Mostly affects men
aged between 50-70 years
Patient usually complains of hoarseness of voice.
Presents as smooth plaque or a pedunculated mass
Diagnosis is only on histology
Treatment is endoscopic surgical excision
NON-NEOPLASTICCYSTIC LESIONS
CYSTIC LESIONS OF LARYNXCYSTIC LESIONS OF LARYNX
There are 3 types of cysts in larynx Ductal cyst Saccular cyst Laryngocele
DUCTAL CYST
They are retention cysts due to blockage of ducts of the seromucinous glands of laryngeal mucosa.
They are seen in vallecula, aryepiglottic folds, false cords, ventricles and pyriform fossa.
They remain asymptomatic if small, or cause hoarseness, cough, throat pain and dyspnoea if large.
Sometimes a intracordal cyst may occur on true cords. It is similar to epidermoid inclusion cyst
EPIDERMOID INCLUSION CYST
SACCULAR CYSTSACCULAR CYST
Obstruction to the orifice of the saccule causes retention of secretions and distention of the saccule which presents as cyst in the laryngeal ventricle.
Anterior saccular cysts present in the anterior part of the ventricle and obscure part of the vocal cord.
Lateral saccular cysts which are larger extend into the false cord, aryepiglottic folds and may even appear in the neck.
Removed endoscopically
LARYNGOCELELARYNGOCELE
It is an air filled cystic swelling due to the dilatation of the saccule
It may be internal, external or combined (mixed)
Internal laryngocoele: it is confined within the larynx and present as distension of the false cord and AE fold
External laryngocoele: here distended saccule herniates through the thyrohyoid membrane and present in the neck
Mixed laryngocoele: here both internal and external laryngocoeles are seen
LARYNGOCOELELARYNGOCOELE Laryngocoele is supposed to arise from raised transglottic air
pressure as in trumpet players, glass blowers and weight lifters
Clinical features: presents with hoarseness, cough and if large may cause obstruction to the airway
External laryngocoele presents as reducible swelling in neck, which increases in size on coughing and on performing valsalva
Diagnosis can be made by indirect laryngoscopy and x-ray of soft tissue AP and lateral views of the neck with valsalva
CT scan helps to find the extent of the lesion Surgical excision through external neck incision (laryngotomy) Marsupialisation of internal laryngocoele can be done by
laryngoscopy, but chances of recurrence are high Laryngocoele in an adult may be associated with carcinoma
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