This document provides information on benign mucosal lesions of the larynx, including their etiology, clinical presentation, diagnosis, and management. The main lesions discussed are vocal fold nodules, polyps, cysts, fibrous masses, and scar tissue. Vocal fold nodules are typically caused by vocal hyperfunction and present with hoarseness and vocal fatigue. Polyps often arise from vocal hemorrhage during exertion. Intracordal cysts can be mucus retention or epidermoid in origin. These lesions are usually diagnosed via laryngoscopy and treated behaviorally or surgically via microlaryngeal techniques to remove the lesion while preserving healthy vocal fold tissue.

1. BENIGN MUCOSAL
LESIONS OF LARYNX
DR. YASHA C.

2. Benign epithelial lesions- caused by
•Infectious processes (fungal)
•Keratosis of the epithelium
•Papillomatous growth of the epithelium
•Malignant degeneration

3. Benign lesions of lamina propria
•Vocal fold nodules
•Laryngeal polyps
•Intrachordal cyst
•Fibrous mass
•Reactive vocal fold lesion
•Nonspecific vocal fold lesion
•Sulcus vocalis

4. Miscelleneous lesions
•Rheumatologic lesions
•Vocal fold granuloma
•Vascular lesions
•Reinke oedema

5. ANATOMY OF LARYNX
•The cartilages of the larynx- thyroid cartilage, the
epiglottis, the cricoid cartilage, and the arytenoid,
corniculate & cuneiform cartilages.
•Functionally, there are three groups of intrinsic laryngeal
muscles – the abductors, adductors, and tensors.
•Anatomy of the vagus nerve is important because
branches of the vagus nerve are responsible for
innervation of the larynx.

7. The vocal cords are
apart for breathing
in. The rings of the
trachea (wind pipe)
can be seen. They
are at their widest
apart during a sniff.
The vocal cords blur
once they are vibrating,
but at the instant before
they vibrate, the vocal
cords can be seen in
this shortened position,
slightly bowed.
The arytenoids have
come together
At a high pitch, at
the onset of
phonation, the vocal
cords are stretched.

8. HISTOLOGY OF VOCAL FOLDS
•Vocal folds epithelial lining- pseudostratified squamous
on the superior and inferior aspects of the fold and
nonkeratinizing squamous epithelium on the medial
contact surface.
•The subepithelial tissues are composed of a three-layered
lamina propria
•Deep to the lamina propria is the vocalis muscle.

10. MECHANISM OF INJURY
•Vocal fold lesions disrupt closure and vibration.
•Regardless of type, benign vocal fold lesions –
nodules, polyps, or cysts – cause hoarseness by
disrupting the vocal fold closure and vibration pattern.

11. ETIOLOGY
•Vibratory injury -excessive amount or manner of voice
use
•Single episode of voice strain
•Cigarette smoking
•Allergy
•LPR
•Medical conditions- AR, GERD, asthma, bronchitis,
sinusitis
•Medications

12. LPR
•Prevalence of LPR in patients of laryngeal & voice
disorders is about 50%
•78% with nodules had LPR
•When gastric refluxate reaches larynx or pharynx- is
called LPR
•Synonyms- extraesophageal reflux, atypical reflux,
gastropharyngeal reflux, pharyngoesophageal reflux,
supraesophageal reflux

13. •1 or 2 episodes of acid exposure (pH<4) at the proximal
probe located above the upper esophageal sphincter-
diagnostic of LPR
•Mucosa of larynx & pharynx is more susceptible to acid
attack than esophagus

14. PATHOPHYSIOLOGY
•Upper esophageal sphincter dysfunction
•Dysmotility
•Lower oesophageal sphincter dysfunction
•Action of acid & activated pepsin mucosal damage
•Laryngeal mucosa shows irreversible damage on
repeated refluxate exposure

15. SYMPTOMS
•Hoarseness
•Chronic cough
•Clearing of throat
•Globus pharyngeus
•Dysphagia
•Laryngospasm
•Postnasal drip
•Heartburn
REFLUX SYMPTOM INDEX
• Score >5 favors LPR
• Validated tool for LPR

16. PHYSICAL FINDINGS
•Most commonly related to laryngeal mucosal oedema &
injury
•Laryngoscopy
o Subglottic oedema posterior to vocal process of arytenoid
oVentricular obliteration
oInterarytenoid erythema
oVocal cord oedema

17. REFLUX FINDINGS SCORE
•Subglottic oedema
•Ventricular obliteration
•Laryngeal erythema/ hyperemia
•Vocal cord edema
•Diffuse laryngeal oedema
•Posterior commissure hypertrophy
•Granuloma / granulations
•Thick endolaryngeal mucus
Score >11 is in
favour of LPR

18. INVESTIGATIONS
•Dual pH probe monitoring- most sensitive
•Patient monitered for 18-24 hours
•Lower probe- 5cm above LES
•Upper probe- just above UES
•pH< 4 - >1 episode in 24hr- suggestive of LPR

19. COMPLICATIONS
•Granulomas/ granulations
•Ulcerations
•Subglottic stenosis
•Larygeal Ca.
•Laryngospasm

20. MANAGEMENT
•MINOR- PPI once daily for 6 months
•MAJOR- PPI bd for 6 months
•LIFE THREATENING- Fundoplication

21. ALLERGY
•Pts treated for allergic rhinitis had better outcome for
treatment of laryngitis
•Hypersensitivity makes laryngeal mucosa more
susceptible to stress

22. PATHOPHYSIOLOGY
•Mechanical stress least at midpoint of membranous VF
during phonation
•During hyperfunctioning dysphonia increased stress at
midpoint
•Increased stiffness in body of VF at midpoint results in
higher shearing stresses, worse if nodule or mass
present

23. •Mass adds wt to VF decreasing vibratory qualities and
frequency on stroboscopy
•Decrease in pitch range and impaired closure leads to
breathy voice and fatigue
•Asymmetry adds grainy quality to voice
•Once initiated, can cause compensatory muscle tension
to reduce air flow through glottis

24. SYMPTOMS OF BENIGN LESIONS
•Hoarse and rough voice
quality
•Vocal fatigue
•Unreliable voice
•Delayed voice initiation
•Low, gravelly voice
•Low pitch
•Voice breaks in first
passages of sentences
•Airy or breathy voice
•Inability to sing in high,
soft voice
•Increased effort to speak or
sing
•Frequent throat clearing
•Extra force needed
for voice

25. PHYSICAL EXAMINATION
•The indirect mirror exam is the initial procedure used to
view the larynx
•Gross abnormalities may be detected quickly, but subtle
abnormalities may be missed.
•Disadvantages- larynx not being in physiologic
phonation position (the tongue is extended and the larynx
is elevated), some anatomic features limit the exam, and
a hyper-reflexive gag

26. RIGID LARYNGOSCOPE
• Rigid laryngeal endoscopy is performed in the office using 70
or 90 degree telescopes passed through the mouth to obtain
images of the larynx and pharynx
• High quality images with excellent magnification.
• The patients are viewed in a nonphysiologic phonation
position. Anatomic factors and hyper-reflexive gags can limit
the results

27. FLEXIBLE LARYNGOSCOPE
•Most relied upon tool for evaluation of dysphonia
•It is the sole method that allows examination of the
nasopharynx, palate, larynx, and pharynx in a near
physiologic position.
•It can be performed relatively easily even in patients with
hyper-responsive gags and pediatric patients.

28. VIDEO STROBOSCOPY
•A specialized diagnostic procedure in which a
stroboscopic light is used in conjunction with a
laryngoscope to electronically slow down the motion of
the vocal folds
• To identify subtle changes in vibratory patterns that are
diagnostically significant
•Video stroboscopy is used to differentiate vocal fold
nodules from vocal fold polyps and cysts

29. • Videostroboscopy provides a
highly detailed view of the vocal
folds
• Can be performed via a nasal or
oral pathway
• Stroboscopic examination of the
vocal fold lesion is essential for
accurate diagnosis and successful
treatment.

30. Stroboscopy of left VF cyst

31. MICROLARYNGOSCOPY
A procedure conducted under general
anesthesia which allows the physician
to examine the vocal folds of the
larynx with magnification tools.
Microsurgical and laser removal of
lesions is done at this time

32. BEHAVIOURAL TREATMENT
•Behavioral modification is the primary treatment of
mucosal lesions
•Likely a lifelong treatment of the problem
•This may reduce a vocal fold swelling to an acceptable
size such that the voice becomes dependable and
acceptable to the patient.
•Hemorrhage can generally be managed behaviorally,
particularly if it was from a one time indiscretion

33. •Traditional voice therapy consists of two primary
avenues-
•Vocal hygiene is a daily regimen to achieve and maintain
a healthy voice. It includes maintaining adequate
hydration, minimizing exposure to noxious chemicals, no
smoking, and the avoidance of loud voice use.
•Voice therapy is a behavioral intervention technique that
makes use of vocal exercises, speaker awareness and
proper postures and alignment when using the voice.

34. MEDICAL TREATMENT
•Reflux may be a contributing factor- two week trial of
medication, dietary and life-style adjustments and bed
positioning
•Granulomas should be managed medically as they nearly
always spontaneously decapitate in 4 to 6 months. They
tend to recur because they are located in an area of
constant movement. The first line of treatment should be
an antireflux regimen

35. •Steroid treatment reduces the overlying and sometimes
camouflaging inflammation and swelling while
leaving the cyst unchanged, thus making its diagnosis
easier.
•Patients may be placed on a 2-week period of vocal
rest, perhaps accompanied by a high-dose
corticosteroid taper

36. SURGICAL MANAGEMENT
•Surgery is directed at removing only the mucosal lesion
and preserving as much of the intermediate and deep
layers of the vocal fold as possible.
•Surgery is performed when the nodules or polyps are
very large or have existed for a long time and if the
lesion extends deeper into the layers of the vocal fold.

37. •MICROFLAP TECHNIQUES
• The use of microflap techniques avoids a raw mucosal
surface that heals by secondary intention
• Avoidance of the deeper layers of the lamina propria and
vocal ligament minimizes the fibroblastic response

38. SURGICAL COMPLICATIONS
• Complications are related either to laryngoscopy or to vocal fold
mucosal injury.
• Pressure effects from suspension laryngoscopy- tongue
numbness, altered taste, and oropharyngeal, mucosal, and dental
injuries.

39. •Deep-plane dissection or exposure of the vocal
ligament can result in scarring and fibrosis of the
mucosa with loss of mucosal wave and glottal
insufficiency.
•Injudicious use of the laser can result in a wide zone of
thermal damage with mucosal scarring and fibrosis,
unintended burn injuries, and endotracheal tube fires.

40. VOCAL NODULES
•Bilateral small swellings (<3mm) that develop on the
free edge of vocal fold at membranous portion
ETIOLOGY
•Hyperkinetic phonation
•Chronic cough
•GERD
•Infections- nasal, throat, chest
•Allergy
•Cleft palate

41. •PATHOPHYSIOLOGY

42. SYMPTOMS
•Hoarseness
•Loss of the ability to sing high notes softly
•Delayed phonatory onset
•Increased breathiness (air escape), roughness, and
harshness
•Reduced vocal endurance

43. CLINICAL FEATURES
•Bilateral
•At the junction of anterior one thirds and posterior two
thirds of free edge of vocal cords
•Varies in size, symmetry, color
•Stroboscopic pattern shows normal or minimal reduction
of the mucosal wave activity

45. MANAGEMENT
•MEDICAL- good hydration, management of allergy &
reflux
•BEHAVIOURAL- Speech therapy
•SURGICAL- Laryngeal microsurgery with precise
excision

46. VOCAL FOLD POLYPS
•Benign swelling > 3 mm that arise from free edge of
vocal fold
•Unilateral or bilateral lesions
•Typically exophytic lesions
•Associated with vocal fold haemorrhage

47. ETIOPATHOGENESIS
•ETIOLOGY- Intermittent voice abuse, sudden shouting,
aspirin
•PATHOGENESIS- Vocal exertion Shearing forces
act on capillaries of mucosa capillary rupture
•Extravasation of blood focal accumulation of blood
hemorrhagic polyp

48. SYMPTOMS
•Abrupt onset of hoarseness during extreme vocal effort
•Intermittent subtle aberrant sounds
•Impaired falsetto register
•Chronic vocal huskiness

49. CLINICAL FEATURES
•Unilateral
•At the junction of anterior one thirds and posterior two
thirds of free edge of vocal cords
•May appear dark & blood filled in early stages
•May become pedunculated- moving in and out of the
glottis with inspiration and expiration

52. MANAGEMENT
•Microlaryngeal precise excision
•Speech therapy

53. INTRACORDAL CYSTS
• Classified as either mucus retention cysts or epidermoid
inclusion cysts
•PATHOPHYSIOLOGY-
• MUCUS RETENTION CYST- arise when the duct of a
mucus gland becomes plugged and glandular secretions
•EPIERMOID INCLUSION CYST-
contain accumulated keratin
Healing of injured mucosa
Epithelial cell rests in
subepithelial layer

54. CLINICAL FEATURES
•Voice abuse- in epidermoid cyst
•Husky, breathy or harsh voice
•Mucus retention cyst- less vocal limitations
•Originate just below the free margin of the vocal fold
with medial projection
•Stroboscopy- mucosa overlying cysts stops vibrating
before mucosa surrounding the cyst

56. EPIDERMOID INCLUSION
CYST
MUCUS RETENTION
CYST

57. MANAGEMENT
•SURGICAL-
•Small shallow incision is made on the fold’s superior
surface.
•Careful dissection reveals the cyst
•Excision of the cyst free of the mucosa and vocal ligament
•SPEECH THERAPY

58. EXCISION OF MUCUS RETENTION CYST

59. FIBROUS MASS OF VOCAL CORD
•unilateral or bilateral
•located in the subepithelial or ligamentous area
•do not respond to voice therapy
•impairment in the mucosal wave activity during
stroboscopy
•Intraoperatively- fibrous gray, well organized,
encapsulated lesion in the midmembranous vocal fold
•Rx- microflap excision

60. B/L subepithelial fibrous mass Microflap excision

61. REACTIVE VOCAL FOLD LESION
•Occurs in response to a contralateral lesion
•Has an indentation where the contralateral lesion has
created a concavity due to repeated trauma during vocal
fold vibration
•The two lesions interdigitating with each other during
vocal fold closure and vibration is called Cup and Saucer
deformity
•Reduces in size with behavioral therapy.

62. Reactive vocal fold lesion of left true vocal fold

63. NON SPECIFIC VOCAL FOLD LESIONS
•Unilateral or bilateral
•Subepithelial or ligamentous pathology
•Not responsive to non surgical interventions- voice
rest, medical therapy of comorbidities,voice therapy
•But does not impair function sufficiently to necessitate
phonomicrosurgical removal

64. INTRACORDAL SCARRING
•Scarring in Reinke space after repeated inflammation,
trauma or vocal hemorrhage
•Subepithelial scar
oDisorganized collagen
oLoss of ECM
oDistinguish from epithelial scarring or vocal sulcus
•VF appears stiff, white or opaque
•Hoarseness, vocal fatigue, breathiness

65. SULCUS VOCALIS

66. CAUSES OF INTRACORDAL SCARRING
• Cysts predispose to scar formation (ruptured, epidermoid
origin)
• Trauma
oVocal fold surgery involving lamina propria
oRepeated epithelial procedures
oBiopsy, stripping
oInhalational
oIntubation
• CO2 laser
• Radiation
• Rheumatologic disease

67. Stroboscopy
• Markedly reduced or absent
mucosal wave
• Asymmetry affects phase
closure

68. TREATMENT
•Microflap to remove cyst elements and adynamic
fibrous components
•Medialization thyroplasty for glottic gaps
•Replacement soft tissue (Fillers)
oCollagen
oFat
oHyaluronic acid

69. REINKE OEDEMA
•Polypoid corditis
•Proliferation of superficial lamina propria
•Chronic irritant exposure
•Smoke, LPR, occupational exposures
•Water-balloon outpouching from membranous VF
•Ball-valving effect

71. TREATMENT
•Surgery
•Airway compromise
•Preserve some superficial lamina propria and overlying
epithelium to preserve mucosal wave
•Stage for bilateral disease to prevent anterior web
•Remove irritants and treat LPR

72. VOCAL PROCESS GRANULOMA

73. GRANULOMAS
•Response to trauma
•LPR, throat clearing, chronic cough
•Intubation
•Compensatory forceful glottic closure
oVF paresis
oPresbylarynges
•Does not affect mucosal wave or phase closure

74. TREATMENT
•LPR treatment
•Speech therapy
•Botox to thyroarytenoid muscle
•Surgery
oCompromise voice, breathing or swallowing
oSuspicion for malignancy
oHigh recurrence rate

75. PAPILLOMAS

76. PAPILLOMAS
• HPV (Strain 6 and 11 most common)
• 2% malignant transformation (HPV 16 and 18)
• 10% rate of spread to other sites (trachea, supraglottis,
NP)
• Most commonly found at columnar and squamous
junction
• Host immune recognition
oHPV 11 growth more aggressive during pregnancy
o40% HPV+ larynx without RRP

77. 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

78. ADULT PAPILLOMA
•They are single
•Less aggressive
•Less prone for recurrence
SIGNS
•Signs: Warty masses which may be
sessile/pedunculated, and friable to touch.

79. TREATMENT
• Medical: Inteferons; anti virals like cedofovir, acyclovir
and ribavirin; and immunomodulator therapy.
• Surgical: Endoscopic removal using KTP-532/CO2
LASER, forceps, cryotherapy electrocautery, or
microshaver
• Excision is followed by interferon therapy to prevent
recurrence
• Vaccine

80. LEUKOPLAKIA

81. LEUKOPLAKIA
• Spectrum of change in epithelium
• Hyperkeratosis Dysplasia (mild, moderate)
CIS/ severe dysplasia
•Pattern of growth
oSuperficial, broad
oVerrucous, exophytic with surrounding erythema
•Appearance does not correlate with degree of dysplasia
• 8% to 14% rate of malignant transformation

82. TREATMENT
• CO2 laser
• PDL
• Microflap excision
• Preservation of normal mucosal wave for mild dysplasia
•More aggressive excision with increasing dysplasia

83. FUNGAL LARYNGITIS
•Disease of both immunocompromised and
immunocompetent hosts
•May mimic leukoplakia or malignancy
oWhite or gray pseudomembrane on mucosa
oMucosal erythema and edema (focal or diffuse) surrounding
white plaques
oMucosal ulcerations
oContact bleeding

84. FUNGAL LARYNGITIS

85. RISK FACTORS
•LPR, smoking, inhaled steroids, prolonged antibiotic
use
•DM, immunosuppressants, CA, nutritional deficits
•Compromise mucosal barrier

86. DIAGNOSIS
•Suspicion and response to empiric therapy
•Any question can culture by laryngeal brushing or biopsy
•Dysphagia may also have esophageal involvement

87. •Candida species most commonly cultured
•Blastomyces (Eastern US and Midwest)
•Histoplasma (Ohio and Mississippi River Valleys)
•Coccidioides (Southwestern US)
•Bacterial superinfection
oHoney-colored crusts

88. TREATMENT
•Fluconazole x 3wks
•Nystatin swish and swallow (100,000 units/ml, 10ml
tid)
•Prevention
ospacers for inhaled steroids
ooral rinse, gargle with water after use

89. SACCULAR CYST
•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

90. SACCULAR CYST

91. 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

92. Pathological types:
•External-swelling lateral to thyrohyoid membrane
•Internal-swelling of false cords and aryepiglottic folds
•Combined/Mixed

95. •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

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

98. THANK YOU