This document discusses several benign lesions of the larynx including vocal nodules, vocal polyps, Reinke's edema, contact ulcers, intubation granulomas, leukoplakia, ductal and saccular cysts, juvenile and adult papillomas, chondromas, and haemangiomas. It provides descriptions of their causes, symptoms, clinical signs, investigations, and treatment options which typically involve voice therapy, medical management, or surgical excision depending on the specific lesion.

1. Benign lesions of larynx
DR JOEL G MATHEW
SGMC/2014/01/27-01

2. Question 1
• 36 year old female mother of two with a 4-year history of intermittent
hoarseness. Nonsmoker, generally very healthy, regular exercise. Very
talkative person with outgoing personality and work which requires constant
talking both to groups and on a one-to-one basis. Reports that her family is
also very loud in general. Gradual deterioration of voice over the past few
years. Some environmental allergies.
• Videostroboscopic examination reveals bilateral vocal cord masses 2mm,
which impede normal voicing.

3. Question 2
• 54 year old male with 3-year history of vocal problems. Teacher and sports
coach, with recurrent hoarseness especially towards the end of semesters.
Non-drinker and non-smoker with admitted voice abuse patterns particularly
while coaching sport. Hoarseness resolved over the summer vacation. During
recent vaction, problems did not resolve, and patient returned to the Voice
Clinic. Previously told that it was unlikely that the problem would resolve in
the long-term. Speech therapy has helped with vocal abuse patterns but has
not succeeded in reslving the lesions.

4. • The patient presents with very
restricted vocal range, pitch breaks
throughout this range, and persistent
hoarseness. His voice exhibits a
significant strained quality and some
breathiness.
• Video examination of his vocal cords
revealed bilateral polypoid masses 5mm
at the midpoint of the membranous
vocal fold .

5. Question 3
• 68 year old cigar smoking male; reduced smoking
because of voice problems; originally 10-15 cigars a
day for 20 years, and cigarette smoking prior to
that. "Lots of pepsi" (caffeinated) and maybe 3
cups of coffee a day. Minimal water intake (2
glasses per day). Clip shows extensive oedema of
the vocal folds.
• Initial examination of the larynx using a rigid
endoscope (images below) reveals extensive
bilateral oedema of the vocal cords

6. Question 4
• The patient, a 75-year-old male had been suffering from hoarseness for
approximately 5 years. Over the last month, he had been suffering from
dyspnoea on exertion and, in the last few days even when at rest.
• The patient also suffered from hypertension, chronic atrial fibrillation,
emphysema and chronical bronchitis; despite these problems, he managed a
mixed farm with crops and livestock.

7. • On examination, he was found to
have a painless soft mass at the right
side of the neck, about 5 cm in size,
conducting vibration during speech,
manually reducible, covered with
normal skin

8. CLASSIFICATION
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

9. VOCAL NODULE
• SYNONYMS: SINGER’S
/SCREAMER’S /TEACHER’S
/HAWKER’S /MUMMY’S NODULE
• BENIGN BILATERAL SMALL
SWELLINGS < 3MM THAT
DEVELOP AT THE JUNCTION OF
ANTERIOR 1/3 AND POSTERIOR
2/3 OF VOCAL CORD
• AETIOLOGY: VOICE ABUSE

10. • PREDISPOSING FACTORS:
ALLERGIES, INFECTIONS, EX
TRAOESOPHAGEAL REFLUX
• REPEATED TRAUMA -
>THICKENING OF
BASEMENT
MEMBRANE, HAEMORRHAG
E, FIBRIN
DEPOSITS, HYALINIZATION
• SYMPTOMS: HUSKY &
BREATHY VOICE
(HOARSENESS), WORSENIN

11. VOCAL NODULE
• SIGNS:
• PINKISH TO WHITISH SWELLINGS
• AT THE JUNCTION OF ANTERIOR 1/3
AND POSTERIOR 2/3 OF VOCAL CORD
• SIZE < 3MM
• NORMAL VOCAL CORD MOBILITY

12. TREATMENT OF VOCAL NODULE
• MEDICAL
• MAY RESOLVE SPONTANEOUSLY AS DEMAND ON VOICE RETURNS TO
NORMAL -> VOICE REST
• TREAT THE AGGRAVATING FACTORS-INADEQUATE VOCAL CORD
LUBRICATION, ALLERGIES, INFECTIONS, REFLUX
• VOICE THERAPY-LIFESTYLE MODIFICATION, VOICE CARE, LESS STRAIN ON
VOICE

13. SURGICAL
• FAILURE OF VOICE THERAPY
• INCLUDES HOLDING THE CENTRE OF THE
NODULE, AND CUTTING THE MUCOSA WITH
MICROSCISSORS
• POSTOPERATIVE VOICE REST

14. VOCAL POLYP
• BENIGN UNILATERAL SWELLINGS >3MM, ON
THE FREE EDGE OF VOCAL CORD, AT THE
JUNCTION OF ANTERIOR 1/3 AND POSTERIOR
2/3 OF VOCAL CORD
• MOST COMMON STRUCTURAL ABNORMALITY
OF VOCAL CORD THAT CAUSES
HOARSENESS
• AETIOLOGY: PHONOTRAUMA (SHOUTING)

15. • PREDISPOSING FACTORS: MALE,
SMOKERS, 30-50 YRS
• PATHOLOGY: DISRUPTION OF
BASEMENT MEMBRANE, CAPILLARY
PROLIFERATION, THROMBOSIS,
HAEMORRHAGE AND FIBRIN
EXUDATION
• SYMPTOMS: SUDDEN ONSET OF
HOARSENESS OF VOICE/LOSS OF

16. VOCAL POLYP
• SIGNS: UNILATERAL
SWELLING AT THE JUNCTION
OF ANTERIOR 1/3 AND
POSTERIOR 2/3 OF VOCAL
CORD
• HAEMORRHAGIC IN
APPEARANCE OR
GELATINOUS GREY.

17. TREATMENT OF VOCAL POLYP
• POLYPS MAY SHRINK SPONTANEOUSLY
• MEDICAL
• VOICE THERAPY MAY PROVIDE COPING STRATEGIES, PREVENTIVE ADVICE, AND
REDUCE SYMPTOMS
• HOWEVER MEDICAL MANAGEMENT IS UNLIKELY TO CAUSE RESOLUTION OF POLYPS
• MOST POLYPS REQUIRE REMOVAL UNDER G.A.

18. SURGICAL TREATMENT OF VOCAL POLYP
• POLYP IS GRASPED TOWARDS THE OPPOSITE CORD,
AND BASE OF THE POLYP CUT WITH
MICROSCISSORS
• VOICE REST FOR 48 HRS AFTER SURGERY

19. REINKE’S OEDEMA
SYN: POLYPOID VC, POLYPOID DEGENERATION, POLYPOID
HYPERTROPHY, CORDAL POLYPOSIS, POLYPOID CORDOSIS,
CHRONIC OEDEMA OF VC, PSEUDOMYXOMA OF VC,
PSEUDOMYXOMATOUS LARYNGITIS, SMOKER’S LARYNX
CHRONIC AND IRREVERSIBLY SWOLLEN VOCAL CORDS
PREDISPOSING FACTORS: HEAVY SMOKING, VOICE STRAIN, REFLUX
DISEASE
PATHOLOGY: THICKENING OF BASEMENT MEMBRANE, REINKE’S
SPACE SHOWS OEDEMA, RBCs, and thickening of walls of subepithelial
vessels
Symptoms: deepening of pitch of voice, gruffiness of voice, effortful speaking,
inability to raise pitch of voice, choking episodes

20. Reinke’s space

21. Clinical signs of reinke’s oedema
Vocal cords may appear grey or
yellowish with prominent superficial
vessels. Alternately, they may appear
diffusely red when associated with reflux
disease
They appear oedematous
In severe cases, they resemble bags of
fluid that flop up and down through the
glottis with respiration.
Rarely may be associated with
leukoplakia, gross oedema causing
choking

22. Medical treatment
Reassurance, vocal hygiene advise, smoking cessation
Treatment of URI, hypothyroidism, allergies and reflux disease

23. Surgical therapy of Reinke’s
oedema
Indicated when:
Leukoplakia is present (biopsy required)
Gross oedema causing choking
Pitch elevation of voice is required
Treatment includes needle aspiration/removal with forceps/vaporization of
myxomatous material from superficial lamina propria, redundant mucosa
excised, and the epithelial edges apposed
Postoperative voice therapy may be required

24. CONTACT ULCER
• Syn: Pachyderma laryngitis, Contact granuloma
• Aetiology: Voice abuse, Gastric reflux, Obsessive
clearing of throat
• Symptoms: Hoarseness of voice, Throatache
worsened by talking,
• Signs: Unilateral or bilateral ulceration of vocal cords
with congestion of arytenoid cartilages
• Occasionally granuloma formation may occur
• Medical treatment-Voice modification to prevent
continued trauma, antireflux treatment, steroid
inhalation
• Surgical-Mircrolaryngeal excision of granuloma

25. INTUBATION GRANULOMA
• Aetiology: Rough endotracheal intubation, improper
selection of tube, prolonged intubation
• Pathology: Mucosal ulceration occurs due to pressure
necrosis, followed by granuloma formation.
• Symptoms: Hoarseness (small), Dyspnoea (large).
• Signs: Bilateral granulomas involving posterior 1/3 of
the cords
• Treatment: Voice rest and microlaryngeal excision of
granuloma.

26. LARYNGEAL KERATOSIS AND
LEUKOPLAKIA
• Laryngeal keratosis is a clinical term which
refers to a group of epithelial lesions in which
abnormality of epithelium and changes of growth
and 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.

27. • 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 stratum corneum and mucosa, submucosal edema,
hyperplasia, hyperkeratosis, dysplasia and epithelial atypia.
• Symptoms: Hoarseness, Constant feeling of needing to clear the throat.
• Signs: Mobile cords with a thickened white area, seen on laryngoscopy
• Investigations: Microlaryngoscopy assisted biopsy.
• Treatment: Microlaryngoscopic excision of the lesion, with biopsy

28. DUCTAL CYSTS
• Retention cysts due to block of laryngeal mucosal
glands
• Involve the vallecula, aryepiglottic folds, false cords,
ventricles and pyriform fossa
• Small cysts are usually asymptomatic
• Larger ones may cause obstructive symptoms

29. SACCULAR CYSTS
• The laryngeal saccule is a membranous sac in
the larynx located between the false vocal cords
and the inner surface of the thyroid cartilage
• The saccule contains mucus-secreting glands
• Saccular cysts are retention cysts due to
obstruction to opening of the saccule

30. SACCULAR CYST

31. Laryngocele
• A laryngocele is an air filled cystic dilatation of the
saccule or appendix of the ventricle.
• It occurs in people with congenitally large ventricular
appendix.
• It is predisposed by activities which increase the
intralaryngeal pressure, like straining (weight lifters),
glass blowers and trumpet players.
• Pathological types:
 External-swelling lateral to thyrohyoid membrane
 Internal-swelling of false cords and aryepiglottic
folds
 Combined/Mixed

32. InternalExternal Combined

33. Laryngocele
• 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, CT scan,
Laryngoscopy to rule out malignancy.

34. • Treatment:
 External/mixed: Transcervical neck
dissection with removal of part of
thyroid lamina.
 Excision of the cyst or
marsupialisation

35. Juvenile papilloma
 Squamous papillomas the most common (80%) benign tumors of larynx.
 Juvenile papillomas are seen in children
 Associated with Human Papilloma Virus types 6 and 11 infection
 They are usually multiple, and well known for recurrence after removal
 Symptoms: Hoarseness and stridor
SQUAMOUS PAPILLOMA
ADULT PAPILLOMA
• They are single, less aggressive, and less prone for recurrence

36. Papilloma
 Signs: Warty masses which may be
sessile/predunculated, and friable to touch.
 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

37. Chondroma
 Chondroma of Laryngeal cartilage is a rare, benign
neoplasm
 Symptoms:
 Neck mass
 Progressive obstruction, Hoarseness or Dyspnea
 Posterior lamina of the cricoid cartilage > Thyroid >
Arytenoid > Epiglottis
 Difficult to distinguish from a low grade chondrosarcoma

38. Haemangioma larynx
 Commonly seen in children
 Usually involve the subglottis in
children and presents with stridor
 May be associated with
haemangioma in other sites
 Treatment is excision with CO2
LASER.
 Adult type is rare, involves the glottis
or supraglottis