This includes benign lesions including vocal nodules and laryngocele. It includes benign and malignant tumours.

1. TUMOURS
OF
LARYNX
Brig Anwar ul Haq
ENT Specialist

2. BENIGN TUMOURS OF
LARYNX
Divided into
Non neoplastic
Not tumours
Neoplastic
Benign
Malignant
•
•

4. NON-NEOPLASTIC
• These are not true neoplasms
• These are formed as a result of
infection, trauma or degeneration
SOLID
CYSTIC

5. NON-NEOPLASTIC
SOLID LESIONS
• Vocal nodules
• (singer’s nodules/screamers
nodules)
• Symmetrical
• Free edge of the vocal cord
• Junction of anterior 1/3rd and posterior
2/3rd

6. NON-NEOPLASTIC
SOLID LESIONS
area of maximum vibration
subject to maximum trauma
U s u a l l y they measure less than 3mm
T h e y are results of vocal trauma
M o s t l y seen in teachers, actors,
singers, vendors

8. Vocal nodules- pathology
• Trauma
• Vocal abuse
• Misuse
Pathology
Oedema and hemorrhage in
the submucosal space
• Hyalinization
• Fibrosis
• Eithelial hyperplasia
• Nodule formation

9. Vocal nodules- clinical features
• Hoarseness
• Vocal fatigue
• Pain in neck on prolonged phonation
• On examination
• Nodule
• Soft
• Reddish
• Oedematous swelling
• Grayish or whitish in colour

10. Vocal nodules- Treatment
• Voice rest
• Surgery
• Microlaryngeal surgery
• Speech therapy
• Necessary to prevent recurrence

11. Vocal polyp
• Result of vocal abuse or misuse
• Allergy and smoking are other contributing
factors
• Mostly affects men (30-50 years)
• Typically
• Unilateral
• From same position as vocal nodule
(junction ant1/3 and post 2/3)

12. Vocal polyp
• Appreance
• Soft
• Smooth
• Pedunculated
• May flop up and down
• Phonation or respiration
• Etiology
• Sudden shouting
Haemorrhage
Submucosal oedema

13. Vocal cord polyp

14. Vocal polyp- clinical features
•Hoarseness
•Large polyp
•Dyspnoea
•Stridor
•Intermittent choking
•Diplophonia
•Different vibratory frequencies of
two vocal cords

15. Vocal polyp- clinical features
•Treatment:
•Direct laryngoscopy
•Microsurgical excision
•Speech therapy

16. Reinke’s oedema
• Collection of the oedema
fluid in the sub-epithelial
space of Reinke
• Usual cause
• Vocal abuse
• Smoking
• Appearance
• Diffuse symmetrical
swellings of both VC.

17. Reinke’s oedema
• Treatment
• Direct Laryngoscopy
• Micro-laryngoscopy
• Stripping of both vocal cords
• preserving enough mucosa
for epithelisation
• Only one cord is operated at a
time
• Cessation of smoking
• important to prevent
recurrence

18. Reinke’s oedema

19. Contact ulcer
• Faulty voice production
• Vocal process of arytenoid hammer against each
other resulting in ulceration and granuloma
formation
• Contributing factor
• Laryngopharyngeal reflux
• Complaints
• Hoarseness
• Constant desire to clear the throat
• Pain in the throat which worsens on phonation

20. Contact ulcer
• Examination
• unilateral or bilateral ulcers
• congestion of arytenoid cartilages
• There may be granuloma formation

21. Intubation Granuloma
• vocal processes of arytenoids due to
• rough intubation
• large tube
• prolonged intubation
• Symptoms
• hoarseness,
• if large dyspnea

22. Intubation Granuloma
• Signs
• Mucosal ulceration
• granuloma formation over the exposed
cartilage
• Usually these are bilateral involving
posterior third of true cords
• Treatment
• voice rest and
• Direct Laryngoscopy
• endoscopic removal of granuloma

23. Intubation Granuloma

24. Leukoplakia Larynx
Keratosis
• Epithelial hyperplasia
• upper surface of one or both vocal cords
• Appearance
• white plaque or warty growth
• No effect on cord mobility
• pre cancerous condition
• carcinoma in situ frequently supervenes
• Hoarseness is common presenting symptom
• Treatment
• Direct Laryngoscopy
• stripping of the vocal cords

25. Amyloidosis of larynx
• Mostly affects men
• Age
• Between 50- 70 years
• Tumour presents
• Smooth plaque
• Pedunculated mass
• Diagnosis is only on histology
• Treatment
• Endoscopic surgical excision

26. Cystic lesions of larynx
• There are 3 types of cysts in larynx
D u c t a l cyst: they are retention cystsdue
to blockage of ducts of the seromucinous
glands of laryngeal mucosa. They are seen
in vallecula, aryepiglottic folds, false cords,
ventricles and pyriform fossa. They remain
asymptomatic if small, or cause hoarseness,
cough, throat pain and dyspnoea if large.
Sometimes a intracordal cyst may occur on
true cords. It is similar to epidermoid
inclusion cyst

27. Epidermoid inclusion cyst

28. Cystic lesions of larynx
1. Saccular cyst: Obstruction to the
orifice of the saccule causes retention of
secretions and distention of the saccule
which presents as cyst in the laryngeal
ventricle.

29. Cystic lesions of larynx
2. Laryngocoele: it is an air filled cystic
swelling due to the dilatation of the saccule
• It may be internal, external or combined (mixed)
• Internal laryngocoele: it is confined within the
larynx and present as distension of the false cord
and AE fold
• External laryngocoele: here distended saccule
herniates through the thyrohyoid membrane and
present in the neck
• Mixed laryngocoele: here both internal and
external laryngocoeles are seen

30. Laryngocoele
•
•
•
•
•
•
•
•
Laryngocoele is supposed to arise from raised transglottic air pressure
as in trumpet players, glass blowers and weight lifters
Clinical features: presents with hoarseness, cough and if large
obstruction to the airway
External laryngocoele presents as reducible swelling in neck, which
increases in size on coughing and on performing valsalva
Diagnosis can be made by indirect laryngoscopy and x-ray soft tissue
AP and lateral views of the neck with valsalva
CT scan helps to find the extent of the lesion
Surgical excision through external neck incision
Marsupialisation of internal laryngocoele can be done by
laryngoscopy, but chances of recurrence are high
Laryngocoele in an adult may be associated with carcinoma

33. Neoplastic laryngeal lesions
• Squamous papillomas:
• Juvenile
• Adult onset type

34. Juvenile laryngeal Papilloma
• viral in origin
• Multiple
• often involving infants and young children
• Presentation
• hoarseness
• stridor
• Location
• True cords
• false vocal cords
• epiglottis
• may involve other sites in larynx and trachea
• Clinically appear as glistening white irregular growths,
pedunculated or sessile, friable and bleeding easily

35. Juvenile laryngeal Papilloma
• Known for recurrence after removal
• Multiple laryngoscopies may be required
• Tend to disappear spontaneously after puberty
• Treatment:
• Direct laryngoscopy
• Endoscopic removal with cup forceps,
cryotherapy
• Microelectrocautery
• CO2 laser
• Interferon therapy to prevent recurrence

36. Juvenile laryngeal Papilloma

37. Adult onset Papilloma
• Usually single
• smaller in size
• less aggressive
• Usually does not recur after surgical removal
• common in males in age group of 30-50 yrs
• Usually arises from anterior half of the vocal
cord or anterior commissure
• Treatment is same as for juvenile type

38. Other benign tumours
• Chondroma
• Haemangioma
• Granular cell tumour
• Glandular tumours
• Pleomorphic adenoma
• Oncocytoma are rare tumours
• Other tumours
• Rhabdomyoma,
• Neurofibroma,
• Neurilemmomas
• Lipoma
• Fibroma

39. Malignant Tumours
of
Larynx

40. squamous cell carcinoma 90-95%
keratinizing
non-keratinizing
well-differentiated
moderately differentiated
Poorly Differentiated

41. Supraglottic larynx includes
Epiglottis
False vocal cords
Ventricles
Aryepiglottic folds
Arytenoids.
Glottis
True vocal cords
Anterior and posterior commissures.
Subglottic region begins about 1 cm below the true
vocal cords and extends to the lower border of the
cricoid cartilage or the first tracheal ring.
Parts of Larynx

42. Classification
• Glottic tumour:
• Tumour in the glottis.
• Sub-glottic tumour:
• Tumour in the sub-glottic area.
• Supra-glottic tumour:
• Tumour in the supra- glottic area.

43. Etiology
• Cigarette smoking
• Alcoholism
• Occupational risk factors :
• asbestos
• wood dust
• mustard gas
• petroleum products.
• Inhalation of noxious fumes
• Chronic laryngitis and voice abuse

44. Pathophysiology
Etiological factors
Carcinoma of the squamous cell lining of the
larynx
Rapid metastasis of the carcinoma, due to
abundant lymphatic vessels, into lymph nodes
and lungs

45. Most common- 59%
Spread: Anteriorly- anterior commisure
Posteriorly- vocal process and arytenoid
process Upward- ventricle and false cord
Downward- Subglottic region
Symptoms:
Hoarseness of voice - an
stridor when growth becomes larger in size.
Glottic carcinoma

46. There are few lymphatics in vocal
cords and nodal metastasis are never
seen unless the disease spreads
beyond the region of membranous
cords.
Good Prognosis : Bcoz of early presentation and
late spread, it has good prognosis.
Glottic carcinoma

47. Picture of glottic squamous cell carcinoma of
the larynx. The tumor involves the anterior
half of the left vocal cord.

49. Less frequent than glottic cancer
Majority of lesion
epiglottis
false cord
aryepiglottic fold

50. May spread locally and invade the adjoining areas
(vallecula, base of tounge and pyriform fossa)
Nodal metastases occur early
T1- 20%
T2-35%
T3- 50%
T4-65%)
Upper and middle jugular nodes are often involved
Bilateral metastases may be seen in cases
of epiglottic cancer.

51. Symptoms: Often silent, Hoarseness is a late
symptom. May present with throat pain, dysphagia and
referred pain in ear, mass of lymph node in the neck.
Bad Prognosis : Due to early spread and
late presentation.

52. Lesions rare( 1 - 2%)
Spread: Anterior wall, to the opposite
side or downwards to the trachea
May invade cricothyroid membrane,
thyroid gland and muscles of neck
Paratracheal LN involved
Symptoms:
Stridor is the
Earliest
presentation.
Subglottic Cancer

53. Hoarseness is a late symptom as upward spread to
the vocal cords is late.
Hoarseness of voice indicates :
Spread of disease to undersurface of vocal
cords.
Infiltration of thyroarytenoid muscle.
Involvement of recurrent laryngeal nerve.

54. 1. History :
Symptomatology of glottic, subglottic, supraglottic is
different as explained earlier.
2. Indirect Laryngoscopy : It is done to see the-
A) Appearance of lesion- which vary according to the
site of origin.
B)Vocal Cord Mobility – Fixation of vocalcords
indicate deeper infiltration.
C)Extent of the disease.
Diagnosis of Cancer larynx

55. 3. Direct Laryngoscopy : It is done to see the-
a) Hidden areas of larynx
b) Extent of disease.
c) Biopsy
4. Examination Of Neck : It is done to find the-
a)Extralaryngeal spread of the disease.
b) Nodal metastasis.

56. 5. Radiography :
Chest X Ray –
Essential for co-existent lung diseases
pulmonary metastasis
mediastinal nodes.
CT Scan –
extent of the tumour
invasion of pre and para epiglottic space
destruction of cartilage
lymph node involvement.

57. 6. Microlaryngoscopy:
For smaller lesions, laryngoscopy is done
under microscope for better visualisation.
Biopsy and histopathology

58. CO2 laser

59. Transoral endoscopic CO2 laser cordectomy
Cure rates are uniformly above 90%
Quality of voice depents on extend of resection
Laryngofissure and cordectomy..
Rarely used now
When endoscopic exposure is very poor

60. Other surgical options
Partial laryngectomy
Hemilaryngectomy
Anterior laryngectomy
Superior larungectomy
Total Laryngectomy

61. • Total laryngectomy:
• Cervical lymph node dissection /
Neck dissection:
– Radical neck dissection / En Bloc
– Modified radical neck dissection

62. 1. Oesophageal Speech :
The patient is taught to swallow air in the oesophagus and to
release it slowlyfrom oesophagus to pharynx. Patient can
speak upto 6-10 understandable words.
2. Artificial Larynx :
a)Electrolarynx – It has a vibrating disc
which is held against the soft tissues of
the neck.
b) Transoral Pneumatic Device – Here
vibrations produced in a rubber diaphragm is carried by a
plastic tube into the back of oral cavity where sound is converted
to speech by modulators.

63. Tracheo-oesophageal Speech
Here attempt is made to carry air from trachea to oesophagus or
hypopharynx by the creation of skin lined fistula or nowdays,
prosthesis (Blom-Singer or Panje) are used which prevent the risk
of aspiration.

64. Clinical Manifestations
• Glottic tumour
• Voice changes
• Hoarsness
• Hemoptysis
• Dyspnoea
• Respiratory
obstruction
• Dysphagia
• Weight loss
• Pain
• Supraglottic tumor
• Aspiration on swallowing
• Persistent unilateral sore
throat
• Foreign body
• Dysphagia
• Weight loss
• Mass in neck
• Hemoptysis

65. Medical Management
• Radiation therapy
• 5 days a week for 5- 8 weeks.

66. Complications of surgery
• Haemorrhage
• Airway
obstruction
• Carotid artery
rupture
• Fistula
formation

67. Nursing Management
Partial laryngectomy
– Assess ABG values, pulse oximetry & FiO2
levels
– Semi fowlers to High fowlers position
– Monitor oxygen therapy
– Tracheostomy care and suctioning
– Chest physiotherapy
– Nebulization

68. Total laryngectomy
• Nutrition
– Tube feeding
– Start oral feeding with fluids & semi-soft
foods
• Communication
– Give pen and paper
– Communication board
– Keep speaking with the client; do not avoid
conversation because it will build up
frustration
• Artificial larynx