Benign Lesion of the larynx

EVALUATION OF PATIENT
 skillful history
 perceptual assessment of vocal capabilities and limitations, particularly through
elicitation of vocal tasks designed to detect mucosal disturbances
 High-quality laryngeal examination (often including laryngeal videostroboscopy).
Risk factors for Benign Vocal fold mucosal disorders:
 vibratory trauma (excessive voice use):
 the primary cause
 Talkative personality on the part of the patient correlates most consistently with
most of these disorders.
 Occupational and lifestyle vocal demands are minor risks by comparison, unless
these demands are truly extreme.
 Cigarette smoking and liberal voice use are cofactors in the formation of Reinke's
edema.
 secondary influences increase the mucosa's vulnerability to vibratory trauma,
leading to injury
o infection
o Allergy
o acid reflux also may
o alcohol use
General treatment
 hydration
 antireflux
 treatment of sinonasal disease
 short course of steroid for singers
 speech therapy
Reinke's edema V.C Nodule V.C polyp Epidermoid Cysts
middle aged below 30 yr 30-50 yr
women women; boys; cleft men
long term smoking palate
permanent generalized edema capillary vascular localized edema of cyst containing accumulated
(diffuse polypoid change) in the congestion** the reinke’s space keratin
superficial layer of the lamina
propria
reduction glottoplasty: trimmed away mucosal incision is made on
microlaryngoscopy incision then superficially / the superior
evacuation of gelatinous + exudate microflap excision VC, parallel
material in Reinke’s space with and the cyst is dissected with
mucosal preservation mucosal preservation

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
 one VC at a time

Reinke's edema:
 is a term used to describe the vocal folds when they become chronically and
irreversibly swollen
 Other terms for the condition include:
o polypoid vocal cord
o polypoid degeneration or polypoid hypertrophy; Bilateral diffuse polyposis
o cordal polyposis or polypoid corditis;
o chronic oedema of vocal folds;
o pseudomyxoma or pseudomyxomatous laryngitis;
o smoker's polyps; smoker's larynx.
 Usually: middle-aged women who
have been long-term smokers
(almost exclusively in moderate to
heavy smokers)
 Almost always ass with smoking (the
most common benign lesion ass with
smoking)
 smokers who use their voices a lot
 GERD is also a risk factor
 The most common symptoms are:
 deepening of the pitch of the voice
with 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 extraoesophageal reflux.
 Bilateral in 60-80%
Examination:
 voice examination reveals lower pitch than would be expected, often well into the
masculine range for women
 Typically the vocal folds are grey or yellowish in colour with prominent superficial
vessels.
 Alternatively the oedematous folds may appear diffusely red when coexistent
extraoesophageal reflux
 In severe cases the vocal folds look like bags of fluid that flop up and down through
the glottis with respiration.
Grading
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 a long most of length
 Management:
 TFT if hypothyroidism is suspected
Conservative:
 Reassurance, vocal hygiene advice including smoking cessation, should be tried

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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 initially. Hypothyroidism, upper airway infections and allergies and
extraoesophageal reflux should be treated
 behavioral: short-term voice therapy: may reduce the polyps’ turgidity, with a
corresponding modest improvement in vocal functioning
Surgical:
 Surgical treatment should be considered when:
o leukoplakia is present and a histological diagnosis is required;
o gross Reinke's oedema is present causing choking episodes or airway
compromise;
o pitch elevation of the voice is the main requirement of treatment
 Patients must be aware that after surgery:
 friends and relatives may not recognize them by their voice;
 the singing voice may be permanently altered;
 speaking may be more effortful for up to one year (or occasionally permanently),
particularly if excessive mucosa is removed due to stiffness from scarring and
anterior web formation;
 the voice seldom returns to 'normal', but is generally of better quality;
 Reinke's oedema is likely to return within 2 years if the patient continues to smoke.
 The principles of surgery for Reinke's oedema include:
 reducing the bulk of the mucosa (mass per unit length) 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.
 microlaryngoscopy incision ,then evacuation
of gelatinous material in Reinke’s space with
mucosal preservation
V.C Nodule:
 Occurs due to capillary vascular congestion
 Common among voice over doer:
o Female under 30 years
o Boys
o Children with cleft palate
 Usually bilateral (rarely unilateral)
 small swellings (less than 3 mm in diameter)
 Nodules involve a minimal disruption of the mucosal wave on stroboscopy
 the basement membrane zone is thickened, having increased fibronectin
 Location: midportion of the membranous (vibratory) portion of the vocal folds
 Pathophysiology:
 Vibration that is too forceful or prolonged causes localized vascular congestion with
edema at the midportion of the membranous (vibratory) portion of the vocal folds
 Fluid accumulation in the submucosa from acute abuse or overuse results in
submucosal swelling (sometimes unwisely called incipient or early nodules).
 Long-term voice abuse leads to some hyalinization of Reinke's potential space and
possibly some thickening of the overlying epithelium.
 This pathophysiologic sequence explains the easily reversible nature of most acute
nonhemorrhagic swellings vs slower or failed resolution of chronic vocal nodules.
 The change in mucosal mass, lessened ability to thin the free margin, and
incomplete glottic closure caused by the nodules account for a constellation of vocal
symptoms and limitations that is characteristic of mucosal swelling

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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  Treatment :
 conservative
 Nodules disappear spontaneously in boys with the relatively large
growth of the larynx in puberty. In girls, they may persist into early
adulthood.
 The voice quality is often husky and breathy worsening with voice
use and often associated with perilaryngeal discomfort or throat
soreness on phonation.
 If nodules are not causing significant voice problems they should be
left alone.
 Aggravating factors, such as inadequate vocal fold lubrication,
allergies, infections and extraoesophageal reflux, should be treated
 the mainstay of treatment for persistent vocal nodules is voice
therapy
 surgery is reserved for resistant cases (generally after a minimum of 3 months
duration of conservative treatment)
 postoperative:
 The patient is asked not to speak for 4 days, although sighing sounds begin 1 day
after surgery.
 Beginning on the fourth day, the patient gradually progresses over 6 weeks to full
voice use under a speech pathologist's supervision
VC Fibrous mass
 may be unilateral or bilateral
 Increased deposition of unorganized collagen in the superficial lamina propria or
near the vocal ligament.
 mucosal wave is typically reduced on stroboscopy

VC Polyp:
 A true vocal polyp is a benign swelling of greater than 3 mm that arises from the free
edge of the vocal fold
 Polyps can shrink spontaneously or even be coughed up.
 Localized edema of the Reinke’s space
 More common in males
 Between the age of 30-50 year
 Most need surgical removal
 The lesions are often exophytic in nature and may be associated with an enlarged
blood vessel or hemorrhage.
 In contrast to vocal nodules, polyps are not typically associated with a thickening of
the basement membrane.
 The stroboscopic features of a vocal fold polyp are variable, dependent on the size
and morphology of the lesion.
Typically, there is only minor if any
disruption of the mucosal wave
vibratory activity
 Can show vertical mobility on
inspiration and expiration.
Capillary ectasia:
 abnormal dilation of the long arcades
of capillaries that proceed mostly
anterior to posterior
 Occur mainly in singer females

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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  May be ass with:
o Decrease voice endurance
o Formation of hemorrhagic polyp
 Treatment:
o Behavioral
o Stop anticoagulant medications
o Microlaryngoscopy

Intra-cordal cyst:
Mucus retention cyst:
 arise when the duct of a minor salivary/ mucus
gland becomes plugged possibly secondary to
phonotrauma or inflammation and retains glandular
secretions
 It is usually unilateral and is found on the free edge of the vocal fold or can arise in
the ventricular fold (false cord)
 Can be difficult to distinguish from polyps on
laryngoscopy. Stroboscopy can help in the DDX , but
frequently a definitive diagnosis can only be made on
microlaryngoscpy and by performing a cordotomy

Epidermoid cyst:
Description:
 unilateral (often occurs with ass
edema of the contralateral vocal fold)
 submucosal swelling of the superior
mid-third surface
 Lined with stratified keratinizing
squamous epithelium
 contain accumulated keratin

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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 Two theories:
o rest of epithelial cells buried congenitally in the subepithelial layer
o healing of mucosa injured by voice abuse over buried epithelial cells
vocal symptoms:
 diplophonia in the upper voice
 abrupt and irreducible transition to severe impairment at a relatively specific
frequency rather than a more gradual transition to greater degrees of impairment,
as often noted in patients with nodules
 voice breaks
 vocal fatigue
stroboscopy findings:
o Reduced mucosal waves
o incomplete glottic closure
DDx are often mistaken for vocal nodules
Note: Mucus retention cysts often cause less vocal limitation than anticipated from the
laryngeal appearance; epidermoid inclusion cysts often cause more limitation than
expected.
 Voice therapy:
 More appropriate for persons with epidermoid cysts than for those with the mucus
retention variety.
 This is because persons with epidermoid inclusion cysts are more likely to be vocal
over doers than persons with mucus retention cysts
surgery: (deroofing with mucosal preservation)
 Patients with large mucus retention cysts and no history of voice abuse may be
scheduled for surgery promptly
 Results are not uniformly as good as for nodules and polyps.
 Patients should also know that postoperative recovery takes longer than for nodule
or polyp surgery (many months rather than a few weeks)
 The diagnosis only be confirmed at micro laryngoscopy and cordotomy

Vocal cord Sulcus:

Pathophysiology:
Physiologic sulcus: type I
 Stroboscopy shows mild abnormality in mucosal waves (depression within the
lamina propria without vocal ligament involvement)
sulcus vergeture: type II
 Unilateral or more commonly bilateral,
 Surface epithelium invaginates into
Reinke's space and adheres to the vocal
ligament or muscle, resulting in a
longitudinal furrow along the
membranous portion of the vocal fold.
 They are thought to result from a
congenital failure of development of
Reinke's space as they are commonly
apparent at puberty and can be familial
 Stroboscopy: incomplete closure of the free
edges of the vocal folds. (moderate changes in
mucosal wave parrerns “loss of superficial lamina
propria and extend into vocal ligament but not
further”)

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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Cause: Voice over doer
Laryngeal manifestations: Same as epidermoidal cyst
Sulcus vergeture may be best treated by bilateral medialization

sulcus vocalis: type III

 best used to describe a localized invagination of the mucosa of varying depth
 may represent an epidermoid cyst that has
spontaneously emptied, leaving the collapsed
pocket behind to form a Sulcus described as
“open cysts',
 It is unclear whether epidermoid cysts and
Sulcus of the vocal folds are congenital or
acquired lesions
 On stroboscopy: usually gross changes on
mucousal waves due to extension beyond the
vocal ligament into thyroarytenoid muscle.

A mucosal bridge
may also be found in the presence of sulci and epidermoid cysts

Patients with sulcus vocalis and mucosal bridges present with:

 Variable degrees of dysphonia and roughness and breathiness, depending on the
number of lesions, position and depth of the sulcus, the effect on glottal closure and
degree of associated inflammation and muscle tension dysphonia.

Vocal fold contact ulcer/ arytenoid granuloma/

vocal process granuloma/intubation granuloma/
contact pachydermia/ peptic granuloma:
are benign inflammatory lesions that arise from the
medial surface of the arytenoid cartilages and in
particular the vocal processes
Causes:

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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  repeated high velocity impact of the vocal processes against each other from throat
clearing, coughing
 seen primarily in males who abuse their voices (men more) talking habitually low
pitched, creaky, hyperfunctionally: commonly
in lawyers, ministers, teachers, and
executives, sales
 intubation (women more)
 reflux of acid from the stomach into the
posterior larynx during sleep also seem to
cause contact ulceration
Pathophysiology:
These consist of a proliferation of granulation tissue
with epithelial hyperplasia.
 They result from injury to the thin
mucoperichondrium over the vocal processes
from mechanical trauma
 thin mucosa and perichondrium overlying the cartilaginous glottis (arytenoid)
become inflamed
 Acid reflux may also increase inflammation of the vocal process area.
 traumatized area ulcerates or
produces a heaped-up granuloma
Most common location:
 near or at the vocal process of the
arytenoid cartilage
 bilateral involving posterior thirds
of true cords
Symptoms:
 discomfort or pain localized to the
posterosuperior aspect of the
larynx which is worse on
phonation
 Unilateral discomfort over the mid
thyroid cartilage
 occasionally with referred pain to the ipsilateral ear.
 coughing and throat clearing and it can radiate to the ear.
 When contact granulation tissue becomes large, hoarseness can occur.
 Patients present with a change in the voice and/or vocal fatigue, a constant tickling
sensation
laryngeal examination:
 depressed, ulcerated area with a whitish exudate clinging to it or a bilobed, heaped-
up lesion on the vocal process may be noted
 May be unilateral or bilateral and range from a nodular, diffuse thickening over the
vocal process to large pedunculated, exophytic masses obscuring the posterior
glottis.
Types:
 intubation related : treated conservatively; spontaneously resolving
characterized by rapid resolution of the lesion once all the offending agents are
removed e.g:
o endotracheal intubation
o laryngopharyngeal reflux
o vocal abuse

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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 o chronic cough
 Non-intubation related: More difficult to treat.

Management:
 biopsy should be taken to exclude malignancy
 stopping smoking, improving vocal hygiene, treating any respiratory tract infections
 Voice therapy, in terms of raising awareness of and reducing hyperfunctional and
vocally abusive behaviour
 empiric anti-reflux regimen
 maturation and resolution may occur spontaneously over 3 to 6 months
 surgery as last resort because postoperative recurrence of ulcer or granuloma
 With time and use of these measures, intubation granulomas usually mature and
"fall off."
 If they become mature and persistent, however, surgery or a trial of indirect
corticosteroid injection in the office may be an option.
 During microlaryngoscopy, corticosteroid injection into the base of the granuloma
before removal is suggested.
 More recently, topical application of mitomycin C has come into use to inhibit
fibroblast proliferation that might lead to the reformation of granulation tissue
 Surgery does not usually cure arytenoid granulomas when used in isolation, as there
is a high rate of recurrence. It is useful in confirming the diagnosis histologically,
excluding a carcinoma and in debulking large lesions. Laser vapourization after
biopsy reduces the amount of bleeding but it is important to avoid thermal damage
to the underlying cartilage.
 There is no good evidence in support of the use of antibiotics or steroids in general.
 Botulinum toxin injections into the thyroarytenoid muscle can be useful as an
adjunct treatment In resistant cases as it helps reduce the impact of vocal processes
against each other allowing the epithelium to heal. This approach has not been
thoroughly studied. Causes A different type of vocal fold granuloma is a
membranous vocal fold granuloma
o occur after microlaryngeal surgery and typically arise at the surgical site
o in the early postoperative course
o treated with a PPI and the condition usually resolves spontaneously under
this management.
o Surgical excision is of little benefit and in most cases can accelerate the
formation of additional granulation tissue

Leukoplakia or Keratosis: c p99 new baily

 localised 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.
 It is regarded as a 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

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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 Laryngocele
Saccular disorders Classification:
   •    Air-filled = with patent saccular orifice
   •    Mucus-filled = saccular cyst with blocked orifice
   •    Purulence-filled = laryngopyocele with blocked orifice

Laryngocele:

 Dilatation of the saccule of the laryngeal ventricle.

They are therefore supraglottic cysts (epithelial lined
diverticulum)
 Congenital/ Developmental mass
 Air and mucus containing
 laryngocoeles are generally asymptomatic.
 Patients may pre-sent with voice change or a lateral
swelling in the neck overlying the thyrohyoid
membrane which may visibly distend when increasing
intraluminal pressure
 Seen among glass blower, air blowing musical instruments player (trumpet),
weight lifter
 White Men 55 year
 If infected becomes laryngopyocele
 Occasionally a laryngocoele may be the presenting symp-tom of
laryngeal malignancy obstructing the saccule.
Types: (expansion is upward because it has the least resistance which
inferior expansion is prevented by conus elasticus)
1. Internal/ anterior:
 Limited to the larynx and confined medially by the false vocal cord,
and laterally by the lamina of the thyroid cartilage.
 Anteriomedially
 Beneath the mucosa of the false VC and aryepiglottic folds.
 extends into the paraglottic area
 presents as cystic swellings of the aryepiglottic fold

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2.

External/ lateral:
 Extend superiolaterally
 through thyrohyoid membrane at the site of entry of the
superior laryngeal artery and nerve and artery and present
as lateral neck mass
3. Mixed: the most common type 50%
Symptoms:
 HOV
 Stridor
 Intermittent compressible mass :
o External type: lateral neck mass
o cystic swellings of the aryepiglottic fold
 Cough
 Dysphagia
 Sore throat

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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X-ray with valsava man/CT scan:
 Air filled sac

Laryngocoeles are filled with air when they retain a

communication with the laryngeal lumen; when they
become isolated from the laryngeal lumen they
become fluid-filled or infected (laryngopyocoele)

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Surgical Anatomy
The saccule or appendix of the ventricle is normally present in most larynges. It arises
anteriorly in the ventricle and extends superiorly through the paraglottic space with the
ventricular fold (false cord) situated medially and the thyroid lamina laterally

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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The thyrohyoid membrane extends be-tween the body and greater cornua of the hyoid
bone, and the superior rim of the thyroid cartilage. It is pierced by the internal branch of
the superior laryngeal nerve and the superior laryngeal branch of the thyroid artery

The superior laryngeal nerve is at risk of injury when resecting a laryngocoele due to its
intimate relationship to the external component of the cyst. It arises from the ganglion
nodosum of the vagus nerve, descends alongside the pharynx, passes behind the
internal carotid artery, and divides into
external and internal branches. The internal
branch crosses the thyrohyoid membrane
and pierces it, accompanied by the superior
laryngeal artery, and provides sensory
innervation to the larynx

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The superior laryngeal artery is
encountered during surgery and
can either be preserved or
sacrificed. It is a branch of the
superior thyroid artery

The muscles encountered during

resection of the external component
of a laryngocoele are

The thyrohyoid muscle is draped

over the cyst and may have to be
divided; the omohyoid can be
retracted anteriorly or divided; and
the sternomastoid retracted
posteriorly.

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
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 DDX:
differential diagnosis of a combined laryngocoele includes:
branchial cyst, neck abscess, cold abscess (tuberculosis), lymphoadenopathy, and a
laterally-located thyroglossal duct cyst
internal laryngo-coele can be confused with a carcinoma centered deep in the ventricle
which bulges the ventricular fold upwards and medially

Needle aspiration
An acutely inflamed combined cyst may first be aspirated percutaneously with a needle
and treated with appropriate anti-biotics to avoid doing a suboptimal resection in a septic
field; needle aspiration may also be employed as an emergency mea-sure to relieve acute
airway obstruction.

Treatment:
 Should do direct laryngoscopy to exclude malignancy involving the ventricle,
the region of the saccular orifice, or the saccule
 Early excision is not indicated
 Surgery is indicated if symptoms (HOV/Dysphagia) are causing problems to
the patient
 Internal type:
Endoscopic deroofing/decapping ideally with CO2 laser.
 External type:
Lateral external neck approach to Excise of the Laryngocele (excision of the
posterior superior part of the thyroid cartilage so we can ligate the neck of
the sac and deliver the internal part through the external incision)

Laryngeal/ saccular cyst

Anterior saccular cysts Lateral saccular cysts

size smaller larger
Direction medial and inferior lateral and superior
appearance smaller round swelling protruding from the smooth, mucosa-covered swelling of the
anterior ventricle and overhanging the anterior false vocal fold and Aryepiglottic fold
part of the ipsilateral vocal fold
symptoms Inspiratory stridor (infants) SAME + SOB, dysphagia, pain, neck pain
HOV(adult)
Laryngeal Malignancy in the ventricle, the region of the saccular orifice, or the
saccule should be excluded adults with laryngocele / lateral saccular cyst

© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.
© Summarized and modified by Dr. Diala Mardini, Dr. Mohammad Alsalem. For personal
reading only.