Benign disorders of larynx

1. By
Dr. Trilok Guleria
JR , ENT-HNS
IGMC, Shimla

2.  Divided into
- Non neoplastic
- Neoplastic

3. SOLID CYSTIC
VOCAL NODULE DUCTAL CYSTS
VOCAL POLYP SACCULAR CYSTS
REINKE’S OEDEMA LARYNGOCELE
CONTACT ULCER
INTUBATION GRANULOMA
LEUKOPLAKIA OR KERATOSIS
AMYLOID TUMOR
SQUAMOUS PAPILLOMA
JUVENILE PAPILLOMA
ADULT ONSET PAPILLOMA
GRANULAR CELL TUMOR
CHONDROMA GLANDULAR TUMOR
HAEMANGIOMA RHABDOMYOMA

4.  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 )

5.  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

6.  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

7.  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.

8.  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

9.  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.

10.  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.

11. 1. Gelatinous
 Gelatinous stroma with fibrosis
2. Haemorrhagic /Telengiectatic
 Dilated blood vessels haemorrhage within polyp
3. Mixed / Transitional
 Dilated blood vessels with in gelatinous substance

12.  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

13. Medical
 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.

14. 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

15.  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 .

16.  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.

17. 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.

18.  Term used to describe the
vocal folds when they
become chronically and
irreversibly swollen.
 Occurring usually in the
middle aged women
 Usually bilateral.

20.  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.

21. Most 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.

22.  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.

23. 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

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

25.  In most cases conservative measures, such as
reassurance, vocal hygiene advise, smoking cessation
 Treatment of URI, hypothyroidism, allergies and
reflux disease

26.  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.

28.  '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

29.  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.

30. 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.

31. 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.

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

33.  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.

34. 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.

35.  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.

36. Mucus retention
(ductal) cyst
Epidermoid cyst

37.  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.

38.  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.

40.  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.

41.  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.

42.  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.

43.  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.

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

45.  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.

46.  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

47. 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.

48.  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.

49.  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.

50. InternalExternal Combined
PATHOLOGICAL TYPES

51. Symptoms:
 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

52.  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.

53.  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.

55.  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.

56.  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.

58.  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.

61.  Caused by the Human Papilloma Virus (HPV)
subtypes 6 and 11.
 RRP may commence in childhood or adulthood

62.  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.

63.  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.

64.  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.

65.  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 - 2
2. Stridor
Absent - 0, Present on activity - 1, Present at rest - 2
3. Respiratory distress
None - 0, Mild - 1, Moderate - 2, Severe - 3, Extreme - 4.
 Anatomical score:
For each site
0 = none, 1=surface lesion, 2= raised lesion, 3=bulky lesion.
 Total score = Anatomical score + Total clinical score

66.  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

67. 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.

68. 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.

69. 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.

70. 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.

71. 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.

72. 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.

73. 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.

75.  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.

77.  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.

79.  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.

80.  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.

82.  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.

84.  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.

85.  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

87.  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.

88.  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.

89.  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.