Transcript Benign lesions of larynx

Benign Lesions
of Larynx
Dr. Vishal Sharma
Common Nonneoplastic Lesions
Classification
Solid
1. Vocal nodules
2. Vocal polyp
6. Leukoplakia
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
Pathogenesis
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
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
Vocal nodules
Spindle shaped nodules
Often asymmetrical 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 & histopathological 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 airfilled 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 cyst
Smaller in size, project into laryngeal lumen in
anterior ventricular region
Lateral saccular cyst
Larger, 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
Incision & exposure
Cyst exposed after incision
Dissection of cyst
Final cut of cyst with false vocal cord
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
Ductal cysts
Excision of ductal cyst
Neoplastic lesions
Classification
1. 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 Features
Symptoms:

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
Treatment
1. 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