Benign Lesion of The Larynx
Benign Lesion of The Larynx
Benign Lesion of The Larynx
EVALUATION OF PATIENT
skillful history
perceptual assessment of vocal capabilities and limitations, particularly through
elicitation of vocal tasks designed to detect mucosal disturbances
High-quality laryngeal examination (often including laryngeal videostroboscopy).
Risk factors for Benign Vocal fold mucosal disorders:
vibratory trauma (excessive voice use):
the primary cause
Talkative personality on the part of the patient correlates most consistently with
most of these disorders.
Occupational and lifestyle vocal demands are minor risks by comparison, unless
these demands are truly extreme.
Cigarette smoking and liberal voice use are cofactors in the formation of Reinke's
edema.
secondary influences increase the mucosa's vulnerability to vibratory trauma,
leading to injury
o infection
o Allergy
o acid reflux also may
o alcohol use
General treatment
hydration
antireflux
treatment of sinonasal disease
short course of steroid for singers
speech therapy
Reinke's edema V.C Nodule V.C polyp Epidermoid Cysts
middle aged below 30 yr 30-50 yr
women women; boys; cleft men
long term smoking palate
permanent generalized edema capillary vascular localized edema of cyst containing accumulated
(diffuse polypoid change) in the congestion** the reinke’s space keratin
superficial layer of the lamina
propria
reduction glottoplasty: trimmed away mucosal incision is made on
microlaryngoscopy incision then superficially / the superior
evacuation of gelatinous + exudate microflap excision VC, parallel
material in Reinke’s space with and the cyst is dissected with
mucosal preservation mucosal preservation
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reading only.
one VC at a time
Reinke's edema:
is a term used to describe the vocal folds when they become chronically and
irreversibly swollen
Other terms for the condition include:
o polypoid vocal cord
o polypoid degeneration or polypoid hypertrophy; Bilateral diffuse polyposis
o cordal polyposis or polypoid corditis;
o chronic oedema of vocal folds;
o pseudomyxoma or pseudomyxomatous laryngitis;
o smoker's polyps; smoker's larynx.
Usually: middle-aged women who
have been long-term smokers
(almost exclusively in moderate to
heavy smokers)
Almost always ass with smoking (the
most common benign lesion ass with
smoking)
smokers who use their voices a lot
GERD is also a risk factor
The most common symptoms are:
deepening of the pitch of the voice
with 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 extraoesophageal reflux.
Bilateral in 60-80%
Examination:
voice examination reveals lower pitch than would be expected, often well into the
masculine range for women
Typically the vocal folds are grey or yellowish in colour with prominent superficial
vessels.
Alternatively the oedematous folds may appear diffusely red when coexistent
extraoesophageal reflux
In severe cases the vocal folds look like bags of fluid that flop up and down through
the glottis with respiration.
Grading
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 a long most of length
Management:
TFT if hypothyroidism is suspected
Conservative:
Reassurance, vocal hygiene advice including smoking cessation, should be tried
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initially. Hypothyroidism, upper airway infections and allergies and
extraoesophageal reflux should be treated
behavioral: short-term voice therapy: may reduce the polyps’ turgidity, with a
corresponding modest improvement in vocal functioning
Surgical:
Surgical treatment should be considered when:
o leukoplakia is present and a histological diagnosis is required;
o gross Reinke's oedema is present causing choking episodes or airway
compromise;
o pitch elevation of the voice is the main requirement of treatment
Patients must be aware that after surgery:
friends and relatives may not recognize them by their voice;
the singing voice may be permanently altered;
speaking may be more effortful for up to one year (or occasionally permanently),
particularly if excessive mucosa is removed due to stiffness from scarring and
anterior web formation;
the voice seldom returns to 'normal', but is generally of better quality;
Reinke's oedema is likely to return within 2 years if the patient continues to smoke.
The principles of surgery for Reinke's oedema include:
reducing the bulk of the mucosa (mass per unit length) 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.
microlaryngoscopy incision ,then evacuation
of gelatinous material in Reinke’s space with
mucosal preservation
V.C Nodule:
Occurs due to capillary vascular congestion
Common among voice over doer:
o Female under 30 years
o Boys
o Children with cleft palate
Usually bilateral (rarely unilateral)
small swellings (less than 3 mm in diameter)
Nodules involve a minimal disruption of the mucosal wave on stroboscopy
the basement membrane zone is thickened, having increased fibronectin
Location: midportion of the membranous (vibratory) portion of the vocal folds
Pathophysiology:
Vibration that is too forceful or prolonged causes localized vascular congestion with
edema at the midportion of the membranous (vibratory) portion of the vocal folds
Fluid accumulation in the submucosa from acute abuse or overuse results in
submucosal swelling (sometimes unwisely called incipient or early nodules).
Long-term voice abuse leads to some hyalinization of Reinke's potential space and
possibly some thickening of the overlying epithelium.
This pathophysiologic sequence explains the easily reversible nature of most acute
nonhemorrhagic swellings vs slower or failed resolution of chronic vocal nodules.
The change in mucosal mass, lessened ability to thin the free margin, and
incomplete glottic closure caused by the nodules account for a constellation of vocal
symptoms and limitations that is characteristic of mucosal swelling
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
Treatment :
conservative
Nodules disappear spontaneously in boys with the relatively large
growth of the larynx in puberty. In girls, they may persist into early
adulthood.
The voice quality is often husky and breathy worsening with voice
use and often associated with perilaryngeal discomfort or throat
soreness on phonation.
If nodules are not causing significant voice problems they should be
left alone.
Aggravating factors, such as inadequate vocal fold lubrication,
allergies, infections and extraoesophageal reflux, should be treated
the mainstay of treatment for persistent vocal nodules is voice
therapy
surgery is reserved for resistant cases (generally after a minimum of 3 months
duration of conservative treatment)
postoperative:
The patient is asked not to speak for 4 days, although sighing sounds begin 1 day
after surgery.
Beginning on the fourth day, the patient gradually progresses over 6 weeks to full
voice use under a speech pathologist's supervision
VC Fibrous mass
may be unilateral or bilateral
Increased deposition of unorganized collagen in the superficial lamina propria or
near the vocal ligament.
mucosal wave is typically reduced on stroboscopy
VC Polyp:
A true vocal polyp is a benign swelling of greater than 3 mm that arises from the free
edge of the vocal fold
Polyps can shrink spontaneously or even be coughed up.
Localized edema of the Reinke’s space
More common in males
Between the age of 30-50 year
Most need surgical removal
The lesions are often exophytic in nature and may be associated with an enlarged
blood vessel or hemorrhage.
In contrast to vocal nodules, polyps are not typically associated with a thickening of
the basement membrane.
The stroboscopic features of a vocal fold polyp are variable, dependent on the size
and morphology of the lesion.
Typically, there is only minor if any
disruption of the mucosal wave
vibratory activity
Can show vertical mobility on
inspiration and expiration.
Capillary ectasia:
abnormal dilation of the long arcades
of capillaries that proceed mostly
anterior to posterior
Occur mainly in singer females
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reading only.
May be ass with:
o Decrease voice endurance
o Formation of hemorrhagic polyp
Treatment:
o Behavioral
o Stop anticoagulant medications
o Microlaryngoscopy
Intra-cordal cyst:
Mucus retention cyst:
arise when the duct of a minor salivary/ mucus
gland becomes plugged possibly secondary to
phonotrauma or inflammation and retains glandular
secretions
It is usually unilateral and is found on the free edge of the vocal fold or can arise in
the ventricular fold (false cord)
Can be difficult to distinguish from polyps on
laryngoscopy. Stroboscopy can help in the DDX , but
frequently a definitive diagnosis can only be made on
microlaryngoscpy and by performing a cordotomy
Epidermoid cyst:
Description:
unilateral (often occurs with ass
edema of the contralateral vocal fold)
submucosal swelling of the superior
mid-third surface
Lined with stratified keratinizing
squamous epithelium
contain accumulated keratin
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Two theories:
o rest of epithelial cells buried congenitally in the subepithelial layer
o healing of mucosa injured by voice abuse over buried epithelial cells
vocal symptoms:
diplophonia in the upper voice
abrupt and irreducible transition to severe impairment at a relatively specific
frequency rather than a more gradual transition to greater degrees of impairment,
as often noted in patients with nodules
voice breaks
vocal fatigue
stroboscopy findings:
o Reduced mucosal waves
o incomplete glottic closure
DDx are often mistaken for vocal nodules
Note: Mucus retention cysts often cause less vocal limitation than anticipated from the
laryngeal appearance; epidermoid inclusion cysts often cause more limitation than
expected.
Voice therapy:
More appropriate for persons with epidermoid cysts than for those with the mucus
retention variety.
This is because persons with epidermoid inclusion cysts are more likely to be vocal
over doers than persons with mucus retention cysts
surgery: (deroofing with mucosal preservation)
Patients with large mucus retention cysts and no history of voice abuse may be
scheduled for surgery promptly
Results are not uniformly as good as for nodules and polyps.
Patients should also know that postoperative recovery takes longer than for nodule
or polyp surgery (many months rather than a few weeks)
The diagnosis only be confirmed at micro laryngoscopy and cordotomy
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Cause: Voice over doer
Laryngeal manifestations: Same as epidermoidal cyst
Sulcus vergeture may be best treated by bilateral medialization
A mucosal bridge
may also be found in the presence of sulci and epidermoid cysts
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repeated high velocity impact of the vocal processes against each other from throat
clearing, coughing
seen primarily in males who abuse their voices (men more) talking habitually low
pitched, creaky, hyperfunctionally: commonly
in lawyers, ministers, teachers, and
executives, sales
intubation (women more)
reflux of acid from the stomach into the
posterior larynx during sleep also seem to
cause contact ulceration
Pathophysiology:
These consist of a proliferation of granulation tissue
with epithelial hyperplasia.
They result from injury to the thin
mucoperichondrium over the vocal processes
from mechanical trauma
thin mucosa and perichondrium overlying the cartilaginous glottis (arytenoid)
become inflamed
Acid reflux may also increase inflammation of the vocal process area.
traumatized area ulcerates or
produces a heaped-up granuloma
Most common location:
near or at the vocal process of the
arytenoid cartilage
bilateral involving posterior thirds
of true cords
Symptoms:
discomfort or pain localized to the
posterosuperior aspect of the
larynx which is worse on
phonation
Unilateral discomfort over the mid
thyroid cartilage
occasionally with referred pain to the ipsilateral ear.
coughing and throat clearing and it can radiate to the ear.
When contact granulation tissue becomes large, hoarseness can occur.
Patients present with a change in the voice and/or vocal fatigue, a constant tickling
sensation
laryngeal examination:
depressed, ulcerated area with a whitish exudate clinging to it or a bilobed, heaped-
up lesion on the vocal process may be noted
May be unilateral or bilateral and range from a nodular, diffuse thickening over the
vocal process to large pedunculated, exophytic masses obscuring the posterior
glottis.
Types:
intubation related : treated conservatively; spontaneously resolving
characterized by rapid resolution of the lesion once all the offending agents are
removed e.g:
o endotracheal intubation
o laryngopharyngeal reflux
o vocal abuse
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
o chronic cough
Non-intubation related: More difficult to treat.
Management:
biopsy should be taken to exclude malignancy
stopping smoking, improving vocal hygiene, treating any respiratory tract infections
Voice therapy, in terms of raising awareness of and reducing hyperfunctional and
vocally abusive behaviour
empiric anti-reflux regimen
maturation and resolution may occur spontaneously over 3 to 6 months
surgery as last resort because postoperative recurrence of ulcer or granuloma
With time and use of these measures, intubation granulomas usually mature and
"fall off."
If they become mature and persistent, however, surgery or a trial of indirect
corticosteroid injection in the office may be an option.
During microlaryngoscopy, corticosteroid injection into the base of the granuloma
before removal is suggested.
More recently, topical application of mitomycin C has come into use to inhibit
fibroblast proliferation that might lead to the reformation of granulation tissue
Surgery does not usually cure arytenoid granulomas when used in isolation, as there
is a high rate of recurrence. It is useful in confirming the diagnosis histologically,
excluding a carcinoma and in debulking large lesions. Laser vapourization after
biopsy reduces the amount of bleeding but it is important to avoid thermal damage
to the underlying cartilage.
There is no good evidence in support of the use of antibiotics or steroids in general.
Botulinum toxin injections into the thyroarytenoid muscle can be useful as an
adjunct treatment In resistant cases as it helps reduce the impact of vocal processes
against each other allowing the epithelium to heal. This approach has not been
thoroughly studied. Causes A different type of vocal fold granuloma is a
membranous vocal fold granuloma
o occur after microlaryngeal surgery and typically arise at the surgical site
o in the early postoperative course
o treated with a PPI and the condition usually resolves spontaneously under
this management.
o Surgical excision is of little benefit and in most cases can accelerate the
formation of additional granulation tissue
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reading only.
Laryngocele
Saccular disorders Classification:
• Air-filled = with patent saccular orifice
• Mucus-filled = saccular cyst with blocked orifice
• Purulence-filled = laryngopyocele with blocked orifice
Laryngocele:
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2.
External/ lateral:
Extend superiolaterally
through thyrohyoid membrane at the site of entry of the
superior laryngeal artery and nerve and artery and present
as lateral neck mass
3. Mixed: the most common type 50%
Symptoms:
HOV
Stridor
Intermittent compressible mass :
o External type: lateral neck mass
o cystic swellings of the aryepiglottic fold
Cough
Dysphagia
Sore throat
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
X-ray with valsava man/CT scan:
Air filled sac
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Surgical Anatomy
The saccule or appendix of the ventricle is normally present in most larynges. It arises
anteriorly in the ventricle and extends superiorly through the paraglottic space with the
ventricular fold (false cord) situated medially and the thyroid lamina laterally
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reading only.
The thyrohyoid membrane extends be-tween the body and greater cornua of the hyoid
bone, and the superior rim of the thyroid cartilage. It is pierced by the internal branch of
the superior laryngeal nerve and the superior laryngeal branch of the thyroid artery
The superior laryngeal nerve is at risk of injury when resecting a laryngocoele due to its
intimate relationship to the external component of the cyst. It arises from the ganglion
nodosum of the vagus nerve, descends alongside the pharynx, passes behind the
internal carotid artery, and divides into
external and internal branches. The internal
branch crosses the thyrohyoid membrane
and pierces it, accompanied by the superior
laryngeal artery, and provides sensory
innervation to the larynx
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reading only.
The superior laryngeal artery is
encountered during surgery and
can either be preserved or
sacrificed. It is a branch of the
superior thyroid artery
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reading only.
DDX:
differential diagnosis of a combined laryngocoele includes:
branchial cyst, neck abscess, cold abscess (tuberculosis), lymphoadenopathy, and a
laterally-located thyroglossal duct cyst
internal laryngo-coele can be confused with a carcinoma centered deep in the ventricle
which bulges the ventricular fold upwards and medially
Needle aspiration
An acutely inflamed combined cyst may first be aspirated percutaneously with a needle
and treated with appropriate anti-biotics to avoid doing a suboptimal resection in a septic
field; needle aspiration may also be employed as an emergency mea-sure to relieve acute
airway obstruction.
Treatment:
Should do direct laryngoscopy to exclude malignancy involving the ventricle,
the region of the saccular orifice, or the saccule
Early excision is not indicated
Surgery is indicated if symptoms (HOV/Dysphagia) are causing problems to
the patient
Internal type:
Endoscopic deroofing/decapping ideally with CO2 laser.
External type:
Lateral external neck approach to Excise of the Laryngocele (excision of the
posterior superior part of the thyroid cartilage so we can ligate the neck of
the sac and deliver the internal part through the external incision)
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.