Non neoplstic and benign lesions of larynx is an important topic for both MBBS and MS ENT students in their final exam. Vocal nodule, polyps, Reinke's edema are the common problems in voice abusers and smokers. Dr. Krishna Koirala has discussed this topic thoroughly in this lecture.

1. Dr. Krishna Koirala

3. Solid
1. Vocal nodules
2. Vocal polyp
3. Reinke’s edema
4. Contact ulcer
5. Intubation granuloma
6. Leukoplakia
Cystic
1. Laryngocoele
2. Saccular cyst
3. Ductal cyst

4. Vocal Nodules
• Synonyms : Singer’s / teacher’s / screamer’s nodules
• Bilaterally 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, singers

5. Pathogenesis
• Stage of transudation
• Reversible edema in submucosal plane
• Stage of in growth of vessels
• Reversible, submucosal neo - vascularization
• Stage of fibrous organization
• Submucosal transudate replaced by fibrous / hyaline
material, resistant to conservative treatment

6. 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 , fatigability of voice, decreased
pitch range
• Indirect laryngoscopy / flexible laryngoscopy
• Early nodules: soft, reddish & edematous
• Late nodules: hard, grayish or white

7. Vocal nodules

8. Treatment
• Non-surgical
• Absolute voice rest for 2 weeks
• Vocal hygiene : Avoid mouth breathing, smoke and
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)

9. • Surgical
• Indicated if adequate voice therapy shows no
improvement in 3 - 6 months
• Micro - laryngoscopic surgery (MLS)
• Laser - assisted surgery
• Post-operative voice therapy continued for 3-4
weeks for residual hoarseness

12. • Talking
• Absolute voice rest (absolute rest from talking,
humming, whispering, throat clearing, forceful
coughing) for 1 week → Limited talking for 2nd
week
• Singing
• None for 1 week → 5 - 10 min BD for 2nd week →
15 -20 min BD for 3 to 4 week s

13. Vocal polyp
• Accumulation of fluid in subepithelial layer followed
by ingrowth of connective tissues
• Mostly affects men b/w 30-50 years
• 90% solitary & unilateral
• May be pedunculated or sessile vocal cord mass
• Most common near the anterior commissure

14. • Etiology
• Severe vocal trauma causing vocal cord hemorrhage
• Chronic inhalation of irritants (cigarette smoke, industrial
fumes)
• Gastric reflux
• Untreated hypothyroid states,
• Chronic laryngeal allergy

15. •Pathogenesis
Extreme vocal exertion → breakage of
capillaries in Reinke’s space → extra -
vasation of blood & edema formation →
fibrosis of hematoma → polyp formation

16. 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

17. 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

19. Treatment
1. Micro-laryngoscopy & excision of polyp
a. Micro-flap Technique
b. Truncation Technique
2. Voice therapy
• For 1 week before surgery and 3 weeks after
surgery

25. • 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 of larynx

26. • Etiology
• Irritants : tobacco smoke, dry air, dust, alcohol
• Laryngeal allergy
• Infection: chronic sinusitis
• Idiopathic
• Edema limited to superior surface of vocal cord
( dense fibrous attachment to conus elasticus on
undersurface of vocal cord)

27. Clinical Features
• Common in men b/w 30 – 60 years
• Hoarseness : monotonous low-pitch
• Diplophonia : asymmetric vocal cord involvement
• Stridor : 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
• Fusiform swelling of the vocal cords

29. • 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

34. Contact ulcer
• Synonym: pachydermia, contact granuloma
• Ulcer : misnomer as overlying epithelium is intact
• Saucer like lesions (thickened epithelium with central
indentation) at site of mucoperichondrium covering medial
surface of vocal process
• Etiology: vocal abuse (forceful voice), gastric reflux, obsessive
clearing of throat

36. • Clinical presentation
• Low pitch hoarseness in tense, middle aged
person
• Treatment:
• Voice therapy : use of higher tone
• Management of psychological stress
• Treatment of gastric reflux
• Micro-laryngeal excision of granuloma

37. • 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 : MLS excision

39. • White plaque on vocal cord that cannot be scraped off & has
no clinicopathological correlate
• Involves upper surface of vocal cord
• Presentation as hoarseness / incidental finding
• Treatment
• Stop smoking
• Excision / vocal cord stripping & HPE to r/o carcinoma

43. Laryngocele
• 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 with laryngeal cancer
• Male : female 5:1, Peak age = 6th decade, Unilateral in 85 %
cases, 1% contain carcinoma

44. • Internal (20%)
• Contained entirely within endolarynx with bulge in false
vocal fold & aryepiglottic fold
• External (30%)
• Only neck swelling without endolaryngeal swelling
• Combined (50%)
• Also extends into anterior triangle of neck through foramen
for superior laryngeal nerve & vessels in thyrohyoid
membrane
• Dumbbell shaped

45. Internal External Combined

46. • Hoarseness
• Stridor in large endolaryngeal laryngocoele
• Neck swelling, increases with valsalva
• Manual compression of neck swelling results in
escape of fluid / gas into airway (Broyce’s sign)
• 10% present with pyocele: sore throat, cough

47. Swelling of false vocal
cords & aryepiglottic fold

48. X-ray soft tissue neck AP
view during Valsalva
maneuver shows air-filled
radiolucent swelling

50. Treatment
• No symptoms: 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, incised at its neck & stitched

53. • Due to obstruction of orifice of saccule in laryngeal
ventricle
• 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, cyanosis; feeding problems &
failure to thrive

54. Smaller in size, project into laryngeal lumen in
anterior ventricular region

55. Larger, present as bulge in false vocal fold or
ary-epiglottic fold, extend into neck

57. 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

58. Cyst exposed after incision

59. Final cut of cyst with false vocal
cord

61. 1. Squamous papilloma: commonest
2. Chondroma
3. Hemangioma
4. Rhabdomyoma
5. Schwannoma
6. Paraganglioma
7. Lipoma
8. Fibroma & neurofibroma

62. • 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, mostly does not recur

63. 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

66. 1. Micro-laryngoscopy + excision with cup forceps /
electrocautery / microdebrider / Laser / cryosurgery
(HPE to rule out cancer)
2. Application of podophyllin
3. Interferron:  viral replication,  immune response
4. Antiviral agents: Acyclovir, Ribavirin
5. Immunomodulators: Adenine arabinoside
 Tracheostomy to be avoided to prevent stomal seeding

67. • Cause for recurrence
• Virus remains in basal layer of mucus membrane
replicating by episomal maintenance, only visible
in stratum corneum & granulosum
• Virus remains undetectable unless determined by
DNA hybridization
• High affinity for areas of airway constriction (due to
ed airflow, drying & crusting