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Benign Laryngeal LesionsBenign Laryngeal Lesions
Factors contributing to vocal foldFactors contributing to vocal fold
lesionslesions
• voice overuse or misusevoice overuse...
HistoryHistory
• medical conditionsmedical conditions
– AR, GERD, asthma, bronchitis, sinusitisAR, GERD, asthma, bronchiti...
LPRLPR
• baseline inflammation predisposes VF tobaseline inflammation predisposes VF to
other stressesother stresses
• 78%...
AllergyAllergy
• pts treated for AR had better outcome forpts treated for AR had better outcome for
treatment of laryngiti...
PathophysiologyPathophysiology
• mech stress least at midpoint of membranous VF duringmech stress least at midpoint of mem...
PathophysiologyPathophysiology
• decrease in pitch range and impaired closuredecrease in pitch range and impaired closure
...
Anatomy of vocal foldAnatomy of vocal fold
NodulesNodules
NodulesNodules
• bilateral symmetric epithelial swelling ofbilateral symmetric epithelial swelling of
ant/mid third of TVF...
Nodule formationNodule formation
• junction of anterior to middle VF experiencejunction of anterior to middle VF experienc...
SymptomsSymptoms
• decreased amplitude mucosal wavedecreased amplitude mucosal wave
• SymmetricSymmetric mucosal wavemucos...
Treatment of NodulesTreatment of Nodules
• conservative voice useconservative voice use
• speech therapy to address techni...
Vocal fold polypsVocal fold polyps
PolypsPolyps
• UnilateralUnilateral
• Broad-based vs. PedunculatedBroad-based vs. Pedunculated
• Formed by capillary break...
Vocal fold polypsVocal fold polyps
Effect of polyps on mucosal waveEffect of polyps on mucosal wave
 Asymmetric mass produces more chaoticAsymmetric mass pr...
TreatmentTreatment
• Conservative for small polypsConservative for small polyps
• Microsurgery mainstay of therapyMicrosur...
Vocal fold cystsVocal fold cysts
Vocal fold cystsVocal fold cysts
• Subepidermal epithelial-lineds sacs withinSubepidermal epithelial-lineds sacs within
la...
Vocal fold cystsVocal fold cysts
• Ruptured cyst may result in LP scarring orRuptured cyst may result in LP scarring or
in...
StrobolaryngoscopyStrobolaryngoscopy
• Asymmetric vocal foldAsymmetric vocal fold
• Decreased or absent mucosal wave on cy...
Treatment of cystsTreatment of cysts
• Does not resolve with conservativeDoes not resolve with conservative
managementmana...
Reactive LesionsReactive Lesions
Reactive lesionsReactive lesions
• Reaction to unilateral VF lesionReaction to unilateral VF lesion
• Contralateral VF rea...
Before and AfterBefore and After
Intracordal ScarringIntracordal Scarring
• Scarring in Reinke space after repeatedScarring in Reinke space after repeated
...
Sulcus VocalisSulcus Vocalis
Causes of Intracordal scarringCauses of Intracordal scarring
• Cysts predispose to scar formation (ruptured, epidermoidCys...
• StroboscopyStroboscopy
– Markedly reduced orMarkedly reduced or
absent mucosal waveabsent mucosal wave
– Asymmetry affec...
Treatment of vocal scarTreatment of vocal scar
• Microflap to remove cyst elements andMicroflap to remove cyst elements an...
Reinke EdemaReinke Edema
Reinke edemaReinke edema
• polypoid corditispolypoid corditis
• proliferation of superficial lamina propriaproliferation o...
TreatmentTreatment
• SurgerySurgery
– Airway compromiseAirway compromise
– Preserve some superficial lamina propria andPre...
Feeding varices and hemorrhageFeeding varices and hemorrhage
• Aberrant microvessels in superficialAberrant microvessels i...
• TreatmentTreatment
– Microdissection and CO2 laserMicrodissection and CO2 laser
• Risks of scarring and sulcusRisks of s...
Vocal Process GranulomaVocal Process Granuloma
GranulomasGranulomas
• Response to traumaResponse to trauma
• LPR, throat clearing, chronic coughLPR, throat clearing, chr...
TreatmentTreatment
• LPR treatmentLPR treatment
• Speech therapySpeech therapy
• Botox to thyroarytenoid muscleBotox to th...
PapillomasPapillomas
PapillomasPapillomas
• HPV (Strain 6 and 11 most common)HPV (Strain 6 and 11 most common)
• 2% malignant transformation (H...
TreatmentTreatment
• CO2 laserCO2 laser
– Controversy: depth risks scarring andControversy: depth risks scarring and
impla...
CidofovirCidofovir
• Acyclic nucleosideAcyclic nucleoside
phosphonatephosphonate
• Once phosphorylated,Once phosphorylated...
Cidofovir studies limitedCidofovir studies limited
LeukoplakiaLeukoplakia
LeukoplakiaLeukoplakia
• Spectrum of change in epitheliumSpectrum of change in epithelium
• HyperkeratosisHyperkeratosis...
TreatmentsTreatments
• CO2 laserCO2 laser
• PDLPDL
• microflap excisionmicroflap excision
• Preservation of normal mucosal...
Fungal LaryngitisFungal Laryngitis
• Disease of both immunocompromised andDisease of both immunocompromised and
immunocomp...
Fungal laryngitisFungal laryngitis
Risk factorsRisk factors
• Risk factors: LPR, smoking, inhaledRisk factors: LPR, smoking, inhaled
steroids, prolonged anti...
DiagnosisDiagnosis
• Suspicion and response to empiricSuspicion and response to empiric
therapytherapy
• Any question can ...
• Candida species most commonly culturedCandida species most commonly cultured
• Blastomyces (Eastern US and Midwest)Blast...
Treatment of fungal laryngitisTreatment of fungal laryngitis
• Fluconazole x 3wksFluconazole x 3wks
• Nystatin swish and s...
Benign laryngeal lesions presentation
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Benign laryngeal lesions presentation

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Benign laryngeal lesions presentation

  1. 1. Benign Laryngeal LesionsBenign Laryngeal Lesions
  2. 2. Factors contributing to vocal foldFactors contributing to vocal fold lesionslesions • voice overuse or misusevoice overuse or misuse • smokingsmoking • etohetoh • Laryngopharyngeal refluxLaryngopharyngeal reflux
  3. 3. HistoryHistory • medical conditionsmedical conditions – AR, GERD, asthma, bronchitis, sinusitisAR, GERD, asthma, bronchitis, sinusitis • medicationsmedications • Environmental exposure: smoke,Environmental exposure: smoke, allergens, particulates (dust)allergens, particulates (dust)
  4. 4. LPRLPR • baseline inflammation predisposes VF tobaseline inflammation predisposes VF to other stressesother stresses • 78% w/ nodules had LPR78% w/ nodules had LPR
  5. 5. AllergyAllergy • pts treated for AR had better outcome forpts treated for AR had better outcome for treatment of laryngitistreatment of laryngitis • hypersensitivity makes laryngeal mucosahypersensitivity makes laryngeal mucosa more susceptible to stressmore susceptible to stress
  6. 6. PathophysiologyPathophysiology • mech stress least at midpoint of membranous VF duringmech stress least at midpoint of membranous VF during phonationphonation • during hyperfunctioning dysphonia increased stress atduring hyperfunctioning dysphonia increased stress at midpointmidpoint • increased stiffness in body of VF at midpoint results inincreased stiffness in body of VF at midpoint results in higher shearing stresses, worse if nodule or masshigher shearing stresses, worse if nodule or mass presentpresent • mass adds wt to VF decreasing vibratory qualities andmass adds wt to VF decreasing vibratory qualities and frequency on stroboscopyfrequency on stroboscopy
  7. 7. PathophysiologyPathophysiology • decrease in pitch range and impaired closuredecrease in pitch range and impaired closure leads to breathy voice and fatigue.leads to breathy voice and fatigue. • Asymmetry adds grainy quality to voiceAsymmetry adds grainy quality to voice • once initiated, can cause compensatory muscleonce initiated, can cause compensatory muscle tension to reduce air flow through glottistension to reduce air flow through glottis
  8. 8. Anatomy of vocal foldAnatomy of vocal fold
  9. 9. NodulesNodules
  10. 10. NodulesNodules • bilateral symmetric epithelial swelling ofbilateral symmetric epithelial swelling of ant/mid third of TVFant/mid third of TVF • More prevalent in children, adolescents,More prevalent in children, adolescents, femalesfemales – softer intensity of voice causes hyperfunctionsofter intensity of voice causes hyperfunction • Result of abuse or misuseResult of abuse or misuse
  11. 11. Nodule formationNodule formation • junction of anterior to middle VF experiencejunction of anterior to middle VF experience maximal shearing and collision forces.maximal shearing and collision forces. • vascular congestion and edemavascular congestion and edema • hyalinization of Reinke space and thickening ofhyalinization of Reinke space and thickening of epithelium with epithelial hyperplasiaepithelium with epithelial hyperplasia • nodules are acellular with thick epithelium overnodules are acellular with thick epithelium over matrix of abundant fibrin and organized collagenmatrix of abundant fibrin and organized collagen IV in BMIV in BM
  12. 12. SymptomsSymptoms • decreased amplitude mucosal wavedecreased amplitude mucosal wave • SymmetricSymmetric mucosal wavemucosal wave • decreased closure: hourglass-shapedecreased closure: hourglass-shape glottal closureglottal closure • chronic hoarsenesschronic hoarseness • singers: frequent voice breaks,singers: frequent voice breaks, breathiness, vocal fatiguebreathiness, vocal fatigue
  13. 13. Treatment of NodulesTreatment of Nodules • conservative voice useconservative voice use • speech therapy to address techniquespeech therapy to address technique • Microsurgery when speech tx and otherMicrosurgery when speech tx and other contributing factors optimizedcontributing factors optimized
  14. 14. Vocal fold polypsVocal fold polyps
  15. 15. PolypsPolyps • UnilateralUnilateral • Broad-based vs. PedunculatedBroad-based vs. Pedunculated • Formed by capillary break in Reinke spaceFormed by capillary break in Reinke space with leakage of blood resulting in localwith leakage of blood resulting in local edema and organization with hyalinizededema and organization with hyalinized stromastroma • Hemorrhagic (feeding vessel) vs.Hemorrhagic (feeding vessel) vs. nonhemorrhagic (pseudocyst)nonhemorrhagic (pseudocyst)
  16. 16. Vocal fold polypsVocal fold polyps
  17. 17. Effect of polyps on mucosal waveEffect of polyps on mucosal wave  Asymmetric mass produces more chaoticAsymmetric mass produces more chaotic vibrations and aperiodic mucosal wavesvibrations and aperiodic mucosal waves  Larger polyps cause decreased waveLarger polyps cause decreased wave amplitudeamplitude  Excessive air egress during phonationExcessive air egress during phonation  FatigueFatigue  Frequent voice breaksFrequent voice breaks  decreased vocal powerdecreased vocal power
  18. 18. TreatmentTreatment • Conservative for small polypsConservative for small polyps • Microsurgery mainstay of therapyMicrosurgery mainstay of therapy • Hemorrhagic polypsHemorrhagic polyps – Pulsed-dye lasers absorbed by hemoglobinPulsed-dye lasers absorbed by hemoglobin (585 nm)(585 nm) – Lasers more effective for smaller polypsLasers more effective for smaller polyps
  19. 19. Vocal fold cystsVocal fold cysts
  20. 20. Vocal fold cystsVocal fold cysts • Subepidermal epithelial-lineds sacs withinSubepidermal epithelial-lineds sacs within lamina proprialamina propria • Mucus retention cystsMucus retention cysts • Epidermoid cysts congenital cell rests inEpidermoid cysts congenital cell rests in the subepithelium of 4th and 6th branchialthe subepithelium of 4th and 6th branchial arch or healing injured mucosa buryingarch or healing injured mucosa burying epitheliumepithelium
  21. 21. Vocal fold cystsVocal fold cysts • Ruptured cyst may result in LP scarring orRuptured cyst may result in LP scarring or in a sulcusin a sulcus • May causeMay cause reactive lesionreactive lesion on contralateralon contralateral VFVF • Size may vary with menstrual cycleSize may vary with menstrual cycle – Caution when operating on premenstrualCaution when operating on premenstrual femalesfemales
  22. 22. StrobolaryngoscopyStrobolaryngoscopy • Asymmetric vocal foldAsymmetric vocal fold • Decreased or absent mucosal wave on cyst sideDecreased or absent mucosal wave on cyst side • DiplophoniaDiplophonia • Glottic closure depends on cyst size andGlottic closure depends on cyst size and reactive lesion on contralateral sidereactive lesion on contralateral side • Mucosal waveMucosal wave – present in 80% of polyps BUTpresent in 80% of polyps BUT – absent in almost 100% of cystsabsent in almost 100% of cysts
  23. 23. Treatment of cystsTreatment of cysts • Does not resolve with conservativeDoes not resolve with conservative managementmanagement • SurgerySurgery – Dissection in submucosal plane with completeDissection in submucosal plane with complete cyst removalcyst removal – Prolonged mucosal wave recoveryProlonged mucosal wave recovery – Discuss risks with ptDiscuss risks with pt
  24. 24. Reactive LesionsReactive Lesions
  25. 25. Reactive lesionsReactive lesions • Reaction to unilateral VF lesionReaction to unilateral VF lesion • Contralateral VF reactive callus withContralateral VF reactive callus with epithelial hyperplasiaepithelial hyperplasia • Bilateral like nodulesBilateral like nodules • Strobe: asymmetry not seen in nodulesStrobe: asymmetry not seen in nodules • Tx: treatment of primary lesion, mayTx: treatment of primary lesion, may resolve with conservative managementresolve with conservative management
  26. 26. Before and AfterBefore and After
  27. 27. Intracordal ScarringIntracordal Scarring • Scarring in Reinke space after repeatedScarring in Reinke space after repeated inflammation, trauma or vocal hemorrhageinflammation, trauma or vocal hemorrhage • Subepithelial scarSubepithelial scar – Disorganized collagenDisorganized collagen – Loss of ECMLoss of ECM – Distinguish from epithelial scarring or vocal sulcusDistinguish from epithelial scarring or vocal sulcus • VF appears stiff, white or opaqueVF appears stiff, white or opaque • Hoarseness, vocal fatigue, breathiness, loss ofHoarseness, vocal fatigue, breathiness, loss of projectionprojection
  28. 28. Sulcus VocalisSulcus Vocalis
  29. 29. Causes of Intracordal scarringCauses of Intracordal scarring • Cysts predispose to scar formation (ruptured, epidermoidCysts predispose to scar formation (ruptured, epidermoid origin)origin) • TraumaTrauma – Vocal fold surgery involving lamina propriaVocal fold surgery involving lamina propria – Repeated epithelial proceduresRepeated epithelial procedures – Biopsy, strippingBiopsy, stripping – InhalationalInhalational – IntubationIntubation • CO2 laserCO2 laser • RadiationRadiation • Rheumatologic diseaseRheumatologic disease
  30. 30. • StroboscopyStroboscopy – Markedly reduced orMarkedly reduced or absent mucosal waveabsent mucosal wave – Asymmetry affectsAsymmetry affects phase closurephase closure
  31. 31. Treatment of vocal scarTreatment of vocal scar • Microflap to remove cyst elements andMicroflap to remove cyst elements and adynamic fibrous componentsadynamic fibrous components • Medialization thyroplasty for glottic gapsMedialization thyroplasty for glottic gaps • Replacement soft tissue (Fillers)Replacement soft tissue (Fillers) – CollagenCollagen – FatFat – Hyaluronic acidHyaluronic acid
  32. 32. Reinke EdemaReinke Edema
  33. 33. Reinke edemaReinke edema • polypoid corditispolypoid corditis • proliferation of superficial lamina propriaproliferation of superficial lamina propria • chronic irritant exposurechronic irritant exposure – Smoke, LPR, occupational exposuresSmoke, LPR, occupational exposures • water-balloon outpouching fromwater-balloon outpouching from membranous VFmembranous VF • ball-valving effectball-valving effect
  34. 34. TreatmentTreatment • SurgerySurgery – Airway compromiseAirway compromise – Preserve some superficial lamina propria andPreserve some superficial lamina propria and overlying epithelium to preserve mucosaloverlying epithelium to preserve mucosal wavewave • Stage for bilateral disease to preventStage for bilateral disease to prevent anterior webanterior web • Remove irritants and treat LPRRemove irritants and treat LPR
  35. 35. Feeding varices and hemorrhageFeeding varices and hemorrhage • Aberrant microvessels in superficialAberrant microvessels in superficial lamina proprialamina propria • Result of shearing forces and traumaResult of shearing forces and trauma • Predispose to formation of polyps andPredispose to formation of polyps and hemorrhagehemorrhage
  36. 36. • TreatmentTreatment – Microdissection and CO2 laserMicrodissection and CO2 laser • Risks of scarring and sulcusRisks of scarring and sulcus – Pulsed lasers (KTP, 585nm PDL)Pulsed lasers (KTP, 585nm PDL) • No adverse scarring or reduction in mucosal waveNo adverse scarring or reduction in mucosal wave
  37. 37. Vocal Process GranulomaVocal Process Granuloma
  38. 38. GranulomasGranulomas • Response to traumaResponse to trauma • LPR, throat clearing, chronic coughLPR, throat clearing, chronic cough • IntubationIntubation • Compensatory forceful glottic closureCompensatory forceful glottic closure – VF paresisVF paresis – PresbylaryngesPresbylarynges • Does not affect mucosal wave or phaseDoes not affect mucosal wave or phase closureclosure
  39. 39. TreatmentTreatment • LPR treatmentLPR treatment • Speech therapySpeech therapy • Botox to thyroarytenoid muscleBotox to thyroarytenoid muscle • SurgerySurgery – Compromise voice, breathing or swallowingCompromise voice, breathing or swallowing – Suspicion for malignancySuspicion for malignancy – High recurrence rateHigh recurrence rate
  40. 40. PapillomasPapillomas
  41. 41. PapillomasPapillomas • HPV (Strain 6 and 11 most common)HPV (Strain 6 and 11 most common) • 2% malignant transformation (HPV 16 and 18)2% malignant transformation (HPV 16 and 18) • 10% rate of spread to other sites (trachea,10% rate of spread to other sites (trachea, supraglottis, NP)supraglottis, NP) • Most commonly found at columnar andMost commonly found at columnar and squamous junctionsquamous junction • Host immune recognitionHost immune recognition – HPV 11 growth more aggressive during pregnancyHPV 11 growth more aggressive during pregnancy – 40% HPV+ larynx without RRP40% HPV+ larynx without RRP
  42. 42. TreatmentTreatment • CO2 laserCO2 laser – Controversy: depth risks scarring andControversy: depth risks scarring and implantation of HPVimplantation of HPV – Avoided in most centersAvoided in most centers • MicroshaverMicroshaver • Cidofovir injection (adjuvant tx)Cidofovir injection (adjuvant tx) • VaccineVaccine
  43. 43. CidofovirCidofovir • Acyclic nucleosideAcyclic nucleoside phosphonatephosphonate • Once phosphorylated,Once phosphorylated, resembles nucleotideresembles nucleotide • incorporated into DNA,incorporated into DNA, halting DNA synthesishalting DNA synthesis • ANP’s have greaterANP’s have greater affinity for viral DNAaffinity for viral DNA polmerase and reversepolmerase and reverse transcriptase than hosttranscriptase than host DNA polymeraseDNA polymerase • Off-label useOff-label use
  44. 44. Cidofovir studies limitedCidofovir studies limited
  45. 45. LeukoplakiaLeukoplakia
  46. 46. LeukoplakiaLeukoplakia • Spectrum of change in epitheliumSpectrum of change in epithelium • HyperkeratosisHyperkeratosisDysplasia (mild,Dysplasia (mild, moderate)moderate)CIS/ severe dysplasiaCIS/ severe dysplasia • Pattern of growthPattern of growth – Superficial, broadSuperficial, broad – Verrucous, exophytic with surrounding erythemaVerrucous, exophytic with surrounding erythema • Appearance does not correlate with degree ofAppearance does not correlate with degree of dysplasiadysplasia • 8% to 14% rate of malignant transformation8% to 14% rate of malignant transformation
  47. 47. TreatmentsTreatments • CO2 laserCO2 laser • PDLPDL • microflap excisionmicroflap excision • Preservation of normal mucosal wave forPreservation of normal mucosal wave for mild dysplasiamild dysplasia • More aggressive excision with increasingMore aggressive excision with increasing dysplasiadysplasia
  48. 48. Fungal LaryngitisFungal Laryngitis • Disease of both immunocompromised andDisease of both immunocompromised and immunocompetent hostsimmunocompetent hosts • May mimick leukoplakia or malignancyMay mimick leukoplakia or malignancy – White or gray pseudomembrane on mucosaWhite or gray pseudomembrane on mucosa – Mucosal erythema and edema (focal orMucosal erythema and edema (focal or diffuse) surrounding white plaquesdiffuse) surrounding white plaques – Mucosal ulcerationsMucosal ulcerations – Contact bleedingContact bleeding
  49. 49. Fungal laryngitisFungal laryngitis
  50. 50. Risk factorsRisk factors • Risk factors: LPR, smoking, inhaledRisk factors: LPR, smoking, inhaled steroids, prolonged antibiotic use, XRTsteroids, prolonged antibiotic use, XRT • DM, immunosuppressants, CA, nutritionalDM, immunosuppressants, CA, nutritional deficitsdeficits • Compromise mucosal barrierCompromise mucosal barrier
  51. 51. DiagnosisDiagnosis • Suspicion and response to empiricSuspicion and response to empiric therapytherapy • Any question can culture by laryngealAny question can culture by laryngeal brushing or biopsybrushing or biopsy • Dysphagia may also have esophagealDysphagia may also have esophageal involvementinvolvementTNETNE
  52. 52. • Candida species most commonly culturedCandida species most commonly cultured • Blastomyces (Eastern US and Midwest)Blastomyces (Eastern US and Midwest) • Histoplasma (Ohio and Mississippi RiverHistoplasma (Ohio and Mississippi River Valleys)Valleys) • Coccidioides (Southwestern US)Coccidioides (Southwestern US) • Bacterial superinfectionBacterial superinfection – Honey-colored crustsHoney-colored crusts
  53. 53. Treatment of fungal laryngitisTreatment of fungal laryngitis • Fluconazole x 3wksFluconazole x 3wks • Nystatin swish and swallow (100,000Nystatin swish and swallow (100,000 units/ml, 10ml tid)units/ml, 10ml tid) • PreventionPrevention – spacers for inhaled steroidsspacers for inhaled steroids – oral rinse, gargle with water after useoral rinse, gargle with water after use

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