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Benign lesions of larynx
- 1. Benign Tumours of Larynx Presenter: Dr Avinav Senior Resident: Dr Abhinav Agarwal Consultant: Dr Vikas Malhotra
- 2. Dhingra Diseases of Ear, Nose and Throat PDF 7th Edition
- 3. VOCAL NODULES (SINGER’S OR SCREAMER’S NODES) A 1/3 & P 2/3 Voice abuse/misuse Pathology Dhingra Diseases of Ear, Nose and Throat PDF 7th Edition
- 4. C/f - Hoarsness Vocal fatigue Pain Rx - Early cases Large long standing Speech therapy https://specialist-ent.com/larynx-hoarseness-of-voice/
- 5. VOCAL POLYP Allergy and smoking U/L Hoarseness, dyspnoea, stridor or intermittent choking Pathology Rx https://voicesurgeon.net/voice-disorders/vocal-cord-polyp/
- 6. REINKE’S OEDEMA (BILATERAL DIFFUSE POLYPOSIS) Oedema fluid in the subepithelial space of Reinke Vocal abuse and smoking Rx- longitudinal incision https://www.wohlt.com/reinkes-edema-polypoid-corditis/
- 7. CONTACT ULCER OR GRANULOMA Faulty voice production/gastric reflux C/f- Hoarseness, a constant desire to clear the throat, pain (worse on phonation) https://www.northshore.org/otolaryngology-head-neck-surgery/adult-programs/voice-center/treatment/before-and-after-gallery/
- 8. Management consists of (a) Antireflux therapy. (b) Speech therapy (c) Steroids Micro-laryngeal surgery may be needed to remove granuloma https://www.istockphoto.com/vector/cartoon-stomach-suffering-from-acid-reflux-a-stomach-that-burning-like-a-fire-from-gm1194287854-340012529 https://imgbin.com/png/Ktiyx1Uy/speech-language-pathology-pathology-speech-and-language-therapist-therapy-speech-png https://www.clipartlogo.com/istock/cartoon-drugs-needle-413802.html
- 9. INTUBATION GRANULOMA Rough intubation B/L P1/3 Rx Liang, TJ., Wang, NY., Liu, SI. et al. Vocal cord granuloma after transoral thyroidectomy using oral endotracheal intubation: two case reports. BMC Anesthesiol 21, 170 (2021). https://doi.org/10.1186/s12871-021-01393-8
- 10. LEUKOPLAKIA OR KERATOSIS Epithelial hyperplasia White plaque or warty growth Precancerous Rx https://entokey.com/laryngeal-leukoplakia-and-neoplasm/
- 11. AMYLOID TUMOUR Diagnosis is made on biopsy and special staining Prognosis is good
- 12. B. CYSTIC LESIONS Ductal cysts Retention cysts Saccular cysts Laryngocele
- 13. Anterior saccular cysts - obscure part of vocal cord. Lateral saccular cysts - extend into the false cord, aryepiglottic fold
- 14. Laryngocele Air-filled cystic swelling due to dilatation of the saccule (a) Internal (b) External (c) Combined or mixed Dhingra Diseases of Ear, Nose and Throat PDF 7th Edition
- 15. Reducible swelling Increases in size on coughing or performing Valsalva https://www.nejm.org/doi/full/10.1056/NEJMicm1807310
- 16. C/f - hoarseness, cough, obstruction to the airway Dx - laryngoscopy CT scan Rx - Surgical excision Marsupialization Adult –a/w carcinoma https://laryngopedia.com/laryngocele/
- 19. A. SQUAMOUS PAPILLOMAS 1. JUVENILE PAPILLOMATOSIS (SYN. RESPIRATORY PAPILLOMATOSIS) m/c benign neoplasm of larynx in children HPV type 6 and 11 3 - 5 yrs c/f hoarseness or aphonia with respiratory difficulty or even stridor Dhingra Diseases of Ear, Nose and Throat PDF 7th Edition
- 20. Dx - laryngoscopy and biopsy Recurrence but rarely malignant change Interferon alpha-2a 13-cis-retinoic acid https://pedimedicine.com/laryngeal-papilloma-children/
- 21. ADULT-ONSET PAPILLOMA Single, smaller, less aggressive and does not recur after surgical removal. 30–50 yrs male Rx https://www.massgeneral.org/surgery/voice-center/treatments-and- services/recurrent-respiratory-papillomatosis-rrp
- 22. Other lesions: CHONDROMA HAEMANGIOMA GRANULAR CELL TUMOUR GLANDULAR TUMOURS RARE BENIGN LARYNGEAL TUMOURS: Other rare benign laryngeal tumours include rhabdomyoma, neurofibroma, neurilemmoma, lipoma or fibroma https://specialist-ent.com/larynx-hoarseness-of-voice/ https://www.sciencedirect.com/science/article/abs/pii/S0892199707001543
- 23. References:
- 24. THANK YOU
Editor's Notes
- Benign tumours of the larynx are not as common as the malignant ones.
- Symmetrically on the free edge of vocal cord A 1/3 & P 2/3 (area of maximum vibration of the cord - maximum trauma) Size - pin-head to half a pea. Teachers, actors, vendors or pop singers Vocal abuse or misuse causes oedema and haemorrhage in the submucosal space. This undergoes hyalinization and fibrosis. The overlying epithelium also undergoes hyperplasia forming a nodule. In the early stages, the nodules appear soft, reddish and oedematous swellings but later they become greyish or white in colour.
- c/f – Hoarseness, Vocal fatigue and pain in the neck on prolonged phonation Early cases treated conservatively by educating the patient in proper use of voice. With this treatment, many nodules in children disappear completely. Surgery is required for large nodules or nodules of long standing in adults. They are excised with precision under operating microscope either with cold instruments or laser avoiding any trauma to the underlying vocal ligament. Speech therapy and re-education in voice production are essential to prevent their recurrence
- It is also the result of vocal abuse or misuse. Other contributing factors are allergy and smoking. Mostly, it affects men in the age group of 30–50 years. Typically, a vocal polyp is unilateral arising from the same position as vocal nodule. It is soft, smooth and often pedunculated. It may flop up and down the glottis during respiration or phonation. Hoarseness is a common symptom. Large polyp may cause dyspnoea, stridor or intermittent choking. Some patients complain of diplophonia (double voice) due to different vibratory frequencies of the two vocal cords. Vocal polyp is caused by sudden shouting resulting in haemorrhage in the vocal cord and subsequent submucosal oedema. Treatment is surgical excision under operating microscope followed by speech therapy.
- This is due to collection of oedema fluid in the subepithelial space of Reinke. Usual cause is vocal abuse and smoking. Both vocal cords show diffuse symmetrical swellings. Treatment is longitudinal incision in the cord and removal of gelatinous fluid. Re-education in voice production and cessation of smoking are essential to prevent recurrence.
- Faulty voice production in which vocal processes of arytenoids hammer against each other resulting in ulceration and granuloma formation. Some cases are due to gastric reflux. Chief complaints are hoarse voice, a constant desire to clear the throat and pain in the throat which is worse on phonation. Examination reveals unilateral or bilateral ulcers on the vocal processes of arytenoids with mucosal congestion over the arytenoid cartilages. There may be granuloma formation.
- Management consists of (a) Antireflux therapy. (b) Speech therapy to stop throat clearing and correct the pitch of voice. (c) Inhaled steroids or intralesional injection of steroid to correct inflammation and size of granuloma. Micro-laryngeal surgery may be needed to remove granuloma
- It results from injury to vocal processes of arytenoids due to rough intubation, use of large tube or prolonged presence of tube between the cords. Mucosal ulceration is followed by granuloma formation over the exposed cartilage. Usually, they are bilateral involving posterior thirds of true cords. They present with hoarseness and if large, dyspnoea as well. Treatment is voice rest and endoscopic removal of the granuloma
- This is also a localized form of epithelial hyperplasia involving upper surface of one or both vocal cords. It appears as a white plaque or warty growth on the cord without affecting its mobility. Precancerous condition because “carcinoma in situ” frequently supervenes. Hoarseness is the common presenting symptom. Treatment is stripping of vocal cords and subjecting the tissues to histology for any malignant change. Chronic laryngeal irritants as the aetiological factors should be sought and eliminated.
- It mostly affects men in the age group of 50–70 years. Amyloid deposits involve vocal cord, ventricular band, sub-glottic area or trachea. It presents as a submucosal mass. Presenting symptoms are hoarseness or breathing difficulty. Systemic disease like multiple myeloma should be excluded. Diagnosis is made on biopsy and special staining. Treatment of localized deposits is by surgical removal. Prognosis is good
- Ductal cysts. Most often they are retention cysts due to blockage of ducts of seromucinous glands of laryngeal mucosa. They are seen in the vallecula, aryepiglottic fold, false cords, ventricles and pyriform fossa. They may remain asymptomatic if small, or cause hoarseness, cough, throat pain and dyspnoea, if large Sometimes, an intracordal cyst may occur on the true cord. It is similar to an epidermoid inclusion cyst.
- Saccular cysts. Obstruction to the orifice of saccule causes retention of secretion and distension of saccule which presents as a cyst in laryngeal ventricle. 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.
- It is an air-filled cystic swelling due to dilatation of the saccule A laryngocele may be: (a) Internal which is confined within the larynx and presents as distension of false cord and aryepiglottic fold. (b) External in which distended saccule herniates through the thyroid membrane and presents in neck. (c) Combined or mixed in which both internal and external components are seen. A laryngocele is supposed to arise from raised transglottic air pressure as in trumpet players, glass-blowers or weight lifters.
- A laryngocele presents with hoarseness, cough and if large, obstruction to the airway. An external laryngocele presents as a reducible swelling in the neck which increases in size on coughing or performing Valsalva Diagnosis can be made by indirect laryngoscopy, and soft tissue AP and lateral views of neck with Valsalva. CT scan helps to find the extent of lesion. Treatment is surgical excision through an external neck incision. Marsupialization of an internal laryngocele can be done by laryngoscopy but there are chances of recurrence. A laryngocele in an adult may be associated with carcinoma which causes obstruction of saccule.
- 1. JUVENILE PAPILLOMATOSIS (SYN. RESPIRATORY PAPILLOMATOSIS) Juvenile papillomatosis is the most common benign neoplasm of the larynx in children. It is viral in origin and is caused by human papilloma DNA virus type 6 and 11. It is presumed that affected children got the disease at birth from their mothers who had vaginal human papilloma virus disease. Papillomas mostly affect supraglottic and glottic regions of larynx but can also involve subglottis, trachea and bronchi. Children who had tracheostomy for respiratory distress due to laryngeal papillomas have higher incidence of tracheal and stomal involvement due to seeding. DNA virus particles have been found in the cells of basement membrane of respiratory mucosa and may account for widespread involvement and recurrence.
- Maintain a good airway, preserve voice and avoid recurrence. Besides surgery, various medical therapies are being used an adjuvants. Interferon alpha-2a has shown promising results but has several side effects including fever, chills, myalgia, arthralgia, headache, loss of weight and suppression of bone marrow. Similarly 13-cis-retinoic acid has been used.
- Usually, it is single, smaller in size, less aggressive and does not recur after surgical removal. It is common in males (2:1) in the age group of 30–50 years and usually arises from the anterior half of vocal cord or anterior commissure. Treatment is the same as for juvenile type.
- Most of them arise from cricoid cartilage though they also occur on thyroid or arytenoid cartilages. They may present in the subglottic area causing dyspnoea or may grow outward from the posterior plate of cricoid and cause sense of lump in throat and dysphagia. They affect men four times more than women in the age group of 40–60 years. CT scan is helpful and delineates its extent. Biopsy is required for diagnosis. Use of CO 2 laser is more helpful in taking biopsy of this hard tumour. Treatment consists of excision by laryngofissure or lateral pharyngotomy approach depending on the location of the tumour. Large and recurrent tumours require laryngectomy. Infantile haemangioma involves the subglottic area and presents with stridor in the first 6 months of life. About 50% of such children have haemangiomas elsewhere in the body particularly in the head and neck area. They tend to involute spontaneously but a tracheostomy may be needed to relieve respiratory obstruction if airway is compromised. Most of them are of capillary type and can be vaporized with CO 2 laser. Adult haemangiomas involve vocal cord or supraglottic larynx. They are cavernous type and cannot be treated with laser. They are left alone if asymptomatic. For larger ones causing symptoms, steroid or radiation therapy may be employed GRANULAR CELL TUMOUR It arises from Schwann cells and is often submucosal. Overlying epithelium shows pseudoepitheliomatous hyperplasia, which may on histology, resemble well-differentiated carcinoma. Treatment is removal under microscope. Recurrence can occur if not excised completely.