BENIGN DISORDERS OF LARYNX

By Dr. Trilok Guleria

JR , ENT-HNS IGMC, Shimla

BENIGN DISORDERS OF LARYNX

Divided into - Non neoplastic - Neoplastic

CLASSIFICATION

SOLID CYSTICVOCAL NODULE DUCTAL CYSTSVOCAL POLYP SACCULAR CYSTSREINKE’S OEDEMA LARYNGOCELECONTACT ULCERINTUBATION GRANULOMA

LEUKOPLAKIA OR KERATOSIS

AMYLOID TUMOR

SQUAMOUS PAPILLOMAJUVENILE PAPILLOMAADULT ONSET PAPILLOMA

GRANULAR CELL TUMOR

CHONDROMA GLANDULAR TUMORHAEMANGIOMA RHABDOMYOMA

NON-NEOPLASTIC

NEOPLASTIC

Vocal nodule

Benign bilateral small swellings < 3mm that develop on free edge at the junction of anterior 1/3 and posterior 2/3 of vocal cord as this is the area of maximum vibration and thus subjected to maximum trauma

Mostly seen in teachers, actors, singers, vendors

( SINGER’S/SCREAMER’S /TEACHER’S /HAWKER’S /MUMMY’S NODULE )

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 Predisposing factors: allergies, infections,

extraoesophageal reflux

Vocal nodules- clinical features

Patient complains Hoarseness Vocal fatigue Pain in neck on prolonged phonation Soreness in throat on long phonation Voice breaks at higher range

On examination the nodule appears soft, reddish and oedematous swelling, later becomes grayish or whitish in colour

Vocal nodules- Treatment Medical

Speech therapy should be utilized as a first-line treatment. It is the mainstay of treatment in both children and adults.

May resolve spontaneously Speech therapy-lifestyle modification, voice

care, less strain on voice Treat the aggravating factors-inadequate vocal

cord lubrication, allergies, infections, reflux Photodocumentation of the nodules in voice

clinic indicates the treatment progress and aids patient compliance during speech therapy.

Surgery For larger nodules and long

standing nodules in adults Formal excision of the

nodules may be performed using appropriate microsurgical instruments, but other techniques, such as laser vaporization of the nodules using a pulsed CO2 laser also suitable.

Speech therapy and re-education in voice production is necessary to prevent recurrence

VOCAL POLYP

Vocal polyp is a benign swelling of greater than 3 mm that arises from the free edge of the vocal fold .

It is usually solitary, but can occasionally affect both vocal cords.

It is the most common structural abnormality that cause hoarseness

Affect men more than women. Most frequently seen in

smokers and between the age of 30-50 years.

Exact cause of polyp formation is not known Phonotrauma is an important etiological

factor. Sudden onset of hoarseness after shouting,

particularly if the vocal folds are inflamed from acute infective laryngitis or extraoesophageal reflux.

There appears to be disruption to the vascular basement membrane, capillary proliferation, thrombosis, minute haemorrhage and fibrin exudation.

Vocal Polyp : Pathology

TYPES OF VOCAL POLYP1. Gelatinous Gelatinous stroma with fibrosis

2. Haemorrhagic /Telengiectatic Dilated blood vessels haemorrhage within

polyp

3. Mixed / Transitional Dilated blood vessels with in gelatinous

substance

Hoarseness is a common symptom Break in speech Lowered pitch Loss of part of voice range Strain during phonation Very rarely, large polyps can cause difficulty

in breathing and episodes of choking. Some patients may complain of diplophonia

due to different vibratory frequencies of two vocal cords

Vocal Polyp : Clinical Features

Vocal Polyp : TreatmentMedical However medical management is unlikely to

cause resolution of polyps Intake of anticoagulant medications (e.g.,

aspirin, NSAIDs, warfarin) should be stopped. Because acid reflux can increase hyperemia

and dilate capillaries, this condition should be controlled.

A short course of voice therapy is appropriate. The occasional small, early hemorrhagic polyp

resorbs completely with conservative measures.

Surgical Voice therapy unlikely to

result in resolution of polyp. Most polyps need removal

under GA. Excision using microsurgical

instruments or laser. Microflap excision with

preservation of normal mucosa is performed for sessile polyps.

Truncation (excision) is performed for pedunculated polyps.

Voice rest after surgery

Capillary Ectasias / Varices Microvascular lesions

(varices or capillary ectasias) are collections of abnormally large and weakened vessels that are most commonly found on the superior or medial aspect of the mid membranous portion of the vocal folds .

Most often with vocal abuse. Female preponderance , estrogen effect. Repeated vibratory microtrauma can lead to capillary

angiogenesis. Predisposes to vocal fold haemorrhage, scarring & polyp

formation Without mucosal swelling, voice may be normal. With

swelling, vocal limitations may be similar to nodules. If mucosal hemorrhage is recent, speaking voice & singing voice may be very hoarse.

Laryngeal Examination Abnormal dilation of the long arcades of capillaries that proceeds

mostly from anterior to posterior. Aberrant clusters of dilated capillaries also may be seen. Occasionally, a vascular dot may appear when a loop comes from Reinke's space to the surface and doubles back down into the submucosa. Some dilated capillaries are confluent or become so large as to almost resemble a chronic hemorrhage; this variant can be termed a capillary lake.

Management   Intake of anticoagulant medications (e.g., aspirin, NSAIDs,

warfarin) should be stopped. Because acid reflux can increase hyperemia and dilate

capillaries, this condition should be controlled. Voice therapy If the patient cannot accept residual vocal symptoms and

limitations after medical and behavioral management, laryngeal microsurgery is option.

Dilated capillaries are spot-coagulated to interrupt blood flow every few millimeters. Capillaries proximal to each interrupted segment may subsequently dilate. Even so, not all visible dilations should be ablated; those that remain visible at the end of the procedure involute within a few weeks.

REINKE’S OEDEMA

Term used to describe the vocal folds when they become chronically and irreversibly swollen.

Occurring usually in the middle aged women

Usually bilateral.

SYN: POLYPOID DEGENERATION, POLYPOID HYPERTROPHY, CORDAL POLYPOSIS, CHRONIC OEDEMA OF VC,

PSEUDOMYXOMATOUS LARYNGITIS, SMOKER’S LARYNX

Reinke’s Space

REINKE’S OEDEMA It occurs almost exclusively in moderate to heavy

smokers, although the exact role of smoking in inducing these changes is not known.

Voice strain & extraesophageal reflux may also play a part in its development.

Hypothyroidism may be found as a concomitant feature in some cases.

The epithelium shows nonspecific changes and the basement membrane layer is usually thickened.

In Reinke's space, there are lakes of oedema, extravasated erythrocytes & thickening of the walls of the subepithelial vessels.

REINKE’S OEDEMAMost common symptoms are : Deepening of the pitch of the voice,

women often being mistaken for a man, particularly on the telephone

Gruffness of the voice Effortful speaking An inability to raise the pitch of the voice Choking episodes Other symptoms associated with

extraesophageal reflux.

Reinke’s Oedema Vocal cords may appear grey

or yellowish with prominent superficial vessels.

They appear oedematous In severe cases, they

resemble bags of fluid that flop up & down with respiration.

Gross oedema causing choking

Rarely may be associated with leukoplakia.

Grading of Reinke's oedema ( Savic )

Grade Appearance

1 Marginal edge oedema

2 Obvious sessile swelling, thrown over vocalis muscle during phonation

3 Large bag-like swelling, filled with fluid

4 Partially obstructing lesion, medial borders in contact along most of length

Reinke’s Oedema : Treatment

The decision to treat a patient with Reinke's oedema depends on their symptoms, the severity of the oedema and the presence of leukoplakia.

Medical Treatment In most cases conservative measures,

such as reassurance, vocal hygiene advise, smoking cessation

Treatment of URI, hypothyroidism, allergies and reflux disease

Surgical Treatment Indicated when:

Leukoplakia is present (biopsy required) Gross oedema causing choking Pitch elevation of voice is required

The principles of surgery for Reinke's oedema include: Reducing the bulk of the mucosa of the vocal fold Obtaining a straight mucosal edge, i.e. avoiding leaving

small deposits of the myxoematous material behind Avoiding damage to and exposure of the underlying

ligament, thereby reducing the chances of scarring and web formation.

'Reduction glottoplasties' can be performed with phonosurgical instruments or one of the new generation of microspot lasers. The myxoematous material from the superficial lamina propria layer is aspirated, removed with forceps or vaporized and the epithelial edges apposed following excision of redundant mucosa as necessary.

Postoperative voice therapy may be required

Contact Ulcer Contact granuloma or ulceration

is seen primarily in men Aetiology: Chronic coughing or

throat clearing and reflux of acid The thin mucosa and

perichondrium overlying the cartilaginous glottis become inflamed during chronic coughing or throat clearing. Acid reflux may also increase inflammation of the vocal process area. The traumatized area ulcerates or produces a heaped-up granuloma.

Diagnosis  

History : Caffeine and alcohol consumption , late-night eating, acid reflux symptoms.

Frequent symptoms include unilateral discomfort over midthyroid cartilage, occasionally referred pain to ear.

Voice of a patient with contact ulcer or granuloma may sound normal or only slightly husky.

Laryngeal Examination : A depressed, ulcerated area with a whitish exudate or a bilobed, heaped-up lesion on the vocal process.

Treatment

Medical treatment Voice modification to prevent continued trauma Antireflux treatment Steroid

Surgical : Surgery should be a last resort because

postoperative recurrence of the ulcer or granuloma is predictable.

Mircrolaryngeal excision of granuloma : Removal should be limited, leaving the base or pedicle undisturbed.

Intubation Granuloma

Intubation granuloma occurs in patients undergone endolaryngeal surgery affecting the arytenoid perichondrium, acute or chronic intubation, rigid bronchoscopy, or other direct laryngeal manipulations.

Granuloma after intubation can occur because of direct abrasion of the arytenoid perichondrium, a break in the mucosa as a result of coughing on an endotracheal tube, or long-term pressure necrosis of the vocal process area. The resulting reparative granuloma may initially progress from fairly sessile to large and pedunculated, but it may then regress entirely with maturation over several months.

Symptoms: Hoarseness (small), Dyspnoea (large). The granuloma can vary in size but is often large and

spherical with some pedunculation. The granulomas are attached directly to the vocal process and are frequently bilateral.

In even more severe cases, there may be partial or complete fixation of one or both arytenoid cartilages. An interarytenoid synechia may also be noted on occasion.

Management

If the injury is recent, antibiotic coverage for several weeks seems to be helpful.

Speech therapy If become mature & persistent, surgery or a trial of

indirect corticosteroid injection. During microlaryngoscopy, corticosteroid injection into

the base of the granuloma before its removal is suggested.

Any identifiable stalk should be left to minimize size of surgical wound.

Topical application of mitomycin C, to inhibit fibroblast proliferation that might lead to reformation of granulation.

Intracordal Cysts Intracordal cysts are classified as either mucus

retention or epidermoid .

Mucus retention (ductal) cyst is thought to arise from a blocked minor salivary gland, possibly secondary to phonotrauma or inflammation. It is usually unilateral and is found on the free edge of the vocal fold or can arise in the ventricular fold (false cord).

Epidermoid cysts filled with keratin and cholesterol debris. Two theories state that the epidermoid cyst results from a rest of epithelial cells buried congenitally in the subepithelial layer or from healing of mucosa injured by voice abuse over buried epithelial cells.

Mucus retention (ductal) cyst

Epidermoid cyst

Both cause the voice to be constantly hoarse which may worsen with use with varying degrees of roughness and breathiness depending on the interference with vocal fold vibration and closure.

Trial of voice therapy should be given when symptoms are mild.

Many will require surgery but this must be done precisely preserving the overlying mucosa as much as possible & avoid leaving part of the wall behind.

Postoperative voice therapy. Occasionally problems with glottal closure

following excision of large cysts and fat or collagen medialization may be of beneficial.

VOCAL SULCUS This is a groove along the mucosa.

Classified into three types First is a physiological or pseudosulcus often

associated with reflux Second is a sulcus vergeture, which goes down

to the superficial layer of the lamina propria Third is a sulcus vocalis going down to the

deeper layers of the ligament.

There is a theory that a sulcus is related to ruptured congenital cysts.

Present with variable degrees of dysphonia, roughness & breathiness, depending on lesion.

Sulcus vergeture often have high pitched monotone, weak, breathy & strained voice which is an effort to produce.

Treatment of both sulci is difficult & results variable. Sulcus vocalis, careful dissection of the pocket off

the ligament is required. The difficulty is in defining the plane between base of sulcus & ligament, avoiding excessive resection of mucosa & damage to ligament.

Sulcus vergeture may be best treated by bilateral medialization procedures rather then attempted resection of the vergeture, which is technically extremely difficult.

Amyloid Tumour Amyloidosis can affect the larynx as part of a primary or

secondary process of systemic amyloidosis. Amyloid deposits can occur as a diffuse submucosal process

or as small subepithelial masses. Dysphonia because of the presence of the deposits in the

various subsites of the larynx & their subsequent effect on the vocal cord mobility.

The mainstay of treatment is microlaryngeal surgery to remove the deposits while minimizing the laryngeal damage and this can be by either cold techniques or by CO2 laser.

The use of CO2 laser tends to be effective because of its ability to vaporize the high fluid content within the deposits.

Diagnosis is confirmed histologically because of the affinity of the amyloid for Congo Red.

Laryngeal Keratosis & Leukoplakia Laryngeal keratosis is a clinical

term which refers to a group of epithelial lesions in which abnormality of epithelium, changes of growth & maturation occurs, including keratosis, hyperkeratosis, cellular atypia, dyskeratosis and malignant dyskeratosis.

Leukoplakia is the clinical term for a white plaque like lesion over the superior surface of the cord. These lesions have the potential to evolve into carcinoma-in-situ.

Keratosis is more localised than leukoplakia. Exact aetiology remains obscure. The lesions are common in elderly males,

especially those with a habit of exposure to smoking.

Pathologically there is thickening of mucosa, submucosal edema, hyperplasia, hyperkeratosis, dysplasia and epithelial atypia.

Symptoms: Hoarseness, Constant feeling to clear the throat.

Signs: Mobile cords with a thickened white area, seen on laryngoscopy

Investigations: Microlaryngoscopy assisted biopsy.

Treatment: CO2 laser / Microlaryngoscopic excision of the lesion, with biopsy

Saccular Disorders At its anterior end, the normal laryngeal

ventricle has a small outpouching called the saccule or laryngeal appendix.

This structure is a blind sac that extends upward between the false vocal fold and thyroid cartilage.

Containing many mucous glands, the saccule empties through an orifice in the anterior part of the ventricle.

Classification Saccular disorders can be classified in various

ways

Based on contents: •    Air-filled = laryngocele with patent saccular

orifice•    Mucus-filled = saccular cyst with blocked

orifice•    Purulence-filled = laryngopyocele with

blocked orifice

Based on size and direction of cyst dissection: o Anterior saccular cyst : Tends to protrude from the

anterior ventricle toward the laryngeal vestibule. When large, it may “push down” on the vocal fold and cause dysphonia.

o Lateral saccular cyst or laryngocele internal : This lesion tends to dissect more superiorly and laterally up into the false and aryepiglottic folds, sometimes bulging not only those structures (medially), but also the medial wall of the pyriform sinus (laterally) or even to fill the vallecula.

o Lateral saccular cyst or laryngocele internal/external This variant tends to dissect as described for the lateral cyst, but also to penetrate through the thyrohyoid membrane and to appear as a swelling palpable in the neck.

Saccular cysts The saccule contains mucus

secreting glands Saccular cysts are retention

cysts due to obstruction to opening of the saccule

Anterior saccular cysts present in the anterior part of ventricle and obscure part of vocal cord.

Lateral saccular cysts, which are larger, extend into the false cord, aryepiglottic fold and may even appear in the neck through thyrohyoid membrane just as laryngoceles do.

Laryngocele A laryngocele is an air

filled cystic dilatation of the saccule or appendix of the ventricle.

It is predisposed by activities which increase the intralaryngeal pressure, like straining (weight lifters), glass blowers and trumpet players.

InternalExternal Combined

PATHOLOGICAL TYPES

LaryngoceleSymptoms: Internal & Mixed: Hoarseness

and cough. Stridor if large. External: Compressible mass in

the neck, that increases on coughing or Valsalva manoeuvre.

Bryce’s sign: Gurgling and hissing sound when the neck mass is compressed.

Investigations: X-Ray during Valsalva, Laryngoscopy to rule out

malignancy. CT scan / MRI

Treatment This depends on the symptoms, signs, size and extent of

the laryngocoele. An acutely inflamed combined cyst may first be aspirated

percutaneously with a needle and treated with appropriate antibiotics, needle aspiration may also be employed as an emergency measure to relieve acute airway obstruction.

Small, asymptomatic laryngocoeles do not require surgical intervention.

Symptomatic internal laryngocoeles and saccular cysts are widely deroofed/uncapped or excised endoscopically, ideally with CO2 laser.

Larger internal laryngocoeles (especially if recurrent), external & combined laryngocoele excised by an external approach.

SURGICAL TECHNIQUE An internal laryngocele or saccular cyst may be

treated by transoral endoscopic CO2 laser excision. The cyst may be removed in one of two ways. If a CO2 laser is available, the entire false vocal cord is

removed in an anterior-to-posterior direction. Dissection carried down to perichondrium of ventricle &

tissue removed. The cystic structure that will be revealed is the

epithelial lining of the laryngocele; this is dissected out with the lesion.

Endoscopic laser marsupialization or laser vestibulectomy have been used for the treatment of intact laryngocele and symptomatic saccular cysts.

Endoscopic Marsupialisation

If a CO2 laser is not available, the incision in the false vocal cord can be made as described earlier with upward biting microscissors. Via sharp dissection, the false vocal cord may also be removed piecemeal with large-cup biting forceps. Once the false vocal cord is removed, the cystic lesion is revealed and dissected free from the mucosa or perichondrium of the ventricle without injuring the vocal cord.

Transcervical Approach An incision is made in skin crease at the level of

thyrohyoid membrane. Dissection is carried down through platysma

muscle and fascia. The wall of the sac is grasped gently and dissected

medial to its point of origin in the larynx, which protrudes through the thyrohyoid membrane just superior to the thyroid ala.

An incision is made in the perichondrium of the superior aspect of the thyroid cartilage; a sharp periosteal elevator is used to elevate the perichondrium of the inner aspect of the thyroid cartilage while the soft tissue attachments of the laryngocele are dissected out.

If further exposure is necessary, an oscillating saw may be used to resect the superior one third of the thyroid ala.

Further medial dissection leads to the ventricle, where the remainder of the sac can be identified, dissected out and excised.

The interior of the larynx should be examined by direct laryngoscopy.

Benign Mesenchymal Neoplasms

Epithelial Tumors

Squamous papilloma

Caused by the Human Papilloma Virus (HPV) subtypes 6 and 11.

RRP may commence in childhood or adulthood

Juvenile Papilloma Juvenile respiratory papillomatosis was first

described by Morrell Mackenzie. Triad of susceptibility factors for JORRP - young

mother, vaginal delivery and low maternal socioeconomic status.

Commonly designated papillomatosis because of diffuse involvement of the larynx, usually manifests in infancy or childhood as hoarseness and stridor

This form of papillomatosis is often aggressive and rapidly recurrent, requiring frequent laryngoscopic removal for management.

Rarely, papillomas may regress spontaneously, especially at puberty.

Adult Papilloma Adult-onset papillomas are occasionally solitary

or more localized & are more likely of the carpet variant(does not show the typical exophytic growth pattern, causing a velvety appearance with little projection from surface).

Behavior of adult-onset papillomatosis may also be less aggressive, and, rarely, a single removal leads to “cure.”

However, adult-onset papillomatosis can also behave like the more aggressive juvenile-onset form.

DIAGNOSIS Macroscopically papillomas can

be pedunculated or sessile, exuberant tissue resembling miniature clusters of grapes may be seen, especially on the anterior part of the TVC, FVC & epiglottis.

Microscopically, the papillomas appear as exophytic projections of keratinized squamous epithelium overlying a fibrovascular core, with varying degrees of dyskeratosis, parakeratosis and dysplasia.

Coltera and Derkay have evolved a staging system to stage recurrent papillomatous lesions involving respiratory tract.

Coltera-Derkay Staging :

Clinical score:1. Voice Normal - 0, Abnormal - 1, Aphonia - 22. StridorAbsent - 0, Present on activity - 1, Present at rest - 23. Respiratory distressNone - 0, Mild - 1, Moderate - 2, Severe - 3, Extreme - 4.

Anatomical score:For each site0 = none, 1=surface lesion, 2= raised lesion, 3=bulky lesion.

Total score = Anatomical score + Total clinical score

Treatment

Medical: Inteferons; anti virals like acyclovir and ribavirin; and immunomodulator therapy.

Surgical: Endoscopic removal using KTP-532/CO2 LASER, forceps, cryotherapy or electrocautery

Excision is followed by interferon therapy to prevent recurrence

Adjuvant therapy

Adjuvant medical therapies can be broadly divided into antiviral therapies and drugs with anti proliferative or immunomodulatory properties. Vaccines & gene therapy in the early experimental stages.

INTERFERON-α Interferon - α have antiviral, antiproliferative

and immunomodulatory properties. Interferons exert an indirect antiviral action by interfering with normal host cell translation mechanisms and by inducing synthesis of intracellular enzymes that act to control viral growth.The main problem preventing more widespread use of interferon-α is that there are many serious, idiosyncratic and unpredictable side effects including pancytopenia, hepatorenal failure and cardiac dysfunction. There is also a rebound phenomenon associated with withdrawal of the drug therapy.

CIDOFOVIR Cidofovir is an acyclic nucleoside

phosphonate which is active against a broad spectrum of DNA viruses including CMV, EBV & HPV. Its mechanism of action is by inhibition of viral DNA polymerases essential for viral replication. High doses is associated with neutropenia and nephrotoxicity. Intralesional injection of cidofovir into JORRP is not associated with similar side effects. Intralesional injections of cidofovir at a concentration f 1 mg/mL. Concomitant laser surgery for bulky lesions.

RIBAVIRIN Ribavirin is a synthetic nucleoside which has activity

against a broad spectrum of viruses. However, Ribavirin is not widely used as an adjuvant treatment of JORRP.

ACYCLOVIR Acyclovir has a medium spectrum of antiviral activity,

it does not directly inhibit HPV. Adult patients, but not paediatric patients, with RRP have been shown to have molecular evidence of coinfection with other viruses, particularly HSV which may have a potentiating effect on HPV. It has been suggested that the mechanism of action of acyclovir is to eradicate HSV, thus removing this synergism. Side effects are rare and include nausea, vomiting, diarrhoea, fatigue and headache.

INDOLE-3-CARBINOL Indole-3-carbinol is a substance derived from

cruciferous vegetables (e.g. cabbage, broccoli) which has been shown to alter growth patterns of JORRP cell cultures in vitro. It affects oestrogen metabolism, shifting production to antiproliferative oestrogen.

CIMETIDINE Cimetidine – H2 antagonist has been reported

as a useful treatment for cutaneous warts. The mechanism is attributed to immunomodulatory side effects of cimetidine at high doses.

Surgical treatment

POWERED MICRODEBRIDER Gentle but comprehensive removal of papillomas

with minimal contamination of the lower respiratory tract with blood or papillomas. There is no thermal trauma and using direct endoscopic control it is extremely precise with minimal mucosal damage.

COLD STEEL SURGERY Use of a microflap technique minimizes trauma

to the vocal fold while satisfying disease clearance. Disadvantage of having no direct haemostasis when dealing with vascular lesion.

CO2, KTP, ND:YAG AND PULSED-DYE LASER C02 laser mainstay of surgical management of JORRP

because of its ability to ablate the papillomas with minimal bleeding and its ease of use with a microscope and micromanipulator.

The KTP laser and the Nd:YAG laser are as effective as the CO2 laser in papilloma ablation and haemostasis but, in addition, can be delivered through an optical fibre. Fibre-delivered laser systems playa role predominantly in the treatment of tracheal and bronchial papillomas.

PHOTODYNAMIC THERAPY Rapidly proliferating tissue selectively takes up a

number of photosensitizing agents when administered I.V., and that these agents release tumoricidal oxygen derivatives when activated by laser light of the appropriate wavelength.

Muscle Neoplasms

Rhabdomyoma Most extracardiac rhabdomyomas are

found in the head and neck region, especially in the pharynx and larynx.

Arise from striated muscle. Divided into foetal or adult type.

Rhabdomyoma can be confused with a granular cell tumor or a rhabdomyosarcoma.

Complete local excision is curative.

Neoplasms of Adipose Origin

Lipoma Because lipomas occurred more frequently in parts of the

larynx in which fat was a normal part of the subepithelium, most tumors arose on the aryepiglottic fold and epiglottis (the periphery of the laryngeal vestibule).

Of the intrinsic tumors, the most common site of origin was the false vocal fold.

In general, respiratory symptoms were most common, and hoarseness was relatively infrequent.

Procedures such as endoscopic removal, subhyoid pharyngotomy, lateral pharyngotomy, and laryngofissure were used according to tumor size and location.

Benign Neoplasms of Glandular Origin

Pleomorphic adenomas Pleomorphic adenomas(Benign mixed tumors

) are extremely uncommon in the larynx. Most of these tumors involve the subglottic &

supraglottis region The typical appearance as that of a smooth,

ovoid submucosal mass. Surgical excision of a benign mixed

neoplasm of the larynx depends on the tumor's size and location.

Oncocytic Neoplasms

Oncocytic tumors are actually oncocytic metaplasia and hyperplasia of the ductal cell portion of glandular tissue.

Simple excision, by whatever approach necessary according to lesion size and location, is the management of choice.

Cartilaginous Neoplasms

Chondroma Chondroma of Laryngeal cartilage is a

rare, benign neoplasm. Difficult to distinguish from a low

grade chondrosarcoma Symptoms:

Hoarseness or Dyspnea Dyphagia Neck mass

Posterior lamina of the cricoid cartilage > Thyroid > Arytenoid > Epiglottis

Laryngofissure with submucosal resection as the most common approach to these tumors.

Vascular Neoplasms

Polypoid Granulation Tissue Polypoid granulation tissue is the most common vascular tumor

in the larynx. Polypoid granulation tissue consists of radially arranged

capillaries. Polypoid granulation tissue in the larynx to one of several forms

of trauma (i.e., caused by laryngeal biopsy, intubation, direct external trauma to the larynx, and an external penetrating wound).

Granulation tissue in the larynx should be handled primarily by conservative measures, including removal of the source of any ongoing irritation (e.g., from inappropriate voice use or acid reflux laryngitis) and intralesional corticosteroids.

Nonresponse and continuing symptoms, careful endoscopic removal may be considered after the granulation tissue has been allowed to mature and to become less active and vascular.

Haemangioma larynx Infantile haemangioma

involves subglottic area and presents with stridor in first six months of life.

Tend to involute spontaneously but tracheostomy may be needed to relieve respiratory obstruction.

Most of them are of capillary type can be vaporized with CO2 laser

Adult haemangiomas involve vocal cord or Supraglottic larynx, they are cavernous type & can not be treated by laser, they are left alone if asymptomatic

Larger ones causing symptoms steroid or radiation therapy may be employed

Neoplasms of Neural Origin

Granular Cell Neoplasms Granular cell tumors originate in Schwann cells; these

tumors had previously been called granular cell myoblastomas because they resemble muscle tissue.

A notable characteristic of granular cell tumors is frequent association with overlying pseudoepitheliomatous hyperplasia of the mucosa.

Insufficiently deep biopsy of this lesion can lead to an incorrect diagnosis of epidermoid carcinoma.

Although granular cell neoplasm can involve any part of the larynx, the middle to posterior part of the true vocal fold is the most common site, and hoarseness is thus the most common complaint.

Conservative but complete local excision is considered definitive therapy.

Neurofibroma Solitary neurofibromas of the larynx not associated with

von Recklinghausen's disease were more common than those associated with the disease.

The most common symptoms in patients with laryngeal involvement were hoarseness, dyspnea and dysphagia.

On physical examination, lobulated nodules ranging from less than 2 to 8 cm in diameter were noted, and the most common site of origin was the arytenoid or aryepiglottic fold.

Because these lesions are benign, the surgical approach should balance conservatism with the need for complete excision. For larger tumors, an external approach (e.g., lateral pharyngotomy, laryngofissure, lateral thyrotomy) may be needed.

Neurilemmoma Neurilemmomas are less common than

neurofibromas and usually involve AEF & FVC. Symptoms correspond with the slow growth of these

lesions & include a sensation of fullness in the throat, voice change, and slow development of respiratory distress.

Management should consist of conservative but complete removal by an approach consistent with tumor size and location.

Neurilemmomas are more encapsulated than neurofibromas; simple enucleation (e.g., by a lateral thyrotomy) with removal of a portion of the thyroid cartilage is believed to be adequate management.

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