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Benign Lesions of Larynx

Benign Lesions of Larynx. Dr. Vishal Sharma. Common Non-neoplastic Lesions. Classification. Solid 1. Vocal nodules 6. Leukoplakia 2. Vocal polyp Cystic 3. Reinke’s edema 1. Laryngocoele 4. Contact ulcer 2. Saccular cyst

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Benign Lesions of Larynx

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  1. Benign Lesions of Larynx Dr. Vishal Sharma

  2. Common Non-neoplastic Lesions

  3. Classification Solid 1. Vocal nodules 6. Leukoplakia 2. Vocal polyp Cystic 3. Reinke’s edema 1. Laryngocoele 4. Contact ulcer 2. Saccular cyst 5. Intubation granuloma 3. Ductal cyst

  4. Vocal nodules

  5. Synonyms:singer’s / screamer’s / teacher’s nodes B/L, symmetrical, localized, benign, superficial growths on medial surface of true vocal folds Appear at junction of anterior & middle 1/3 of vocal cords (area of maximum vibration) Etiology:overtaxing & incorrect use of voice over long period in teachers, telephone operators, entertainers, singers, vendors & stock traders

  6. Pathogenesis Stage of transudation: Reversible edema in submucosal plane Stage of in growth of vessels: Reversible, submucosal neo-vascularisation Stage of fibrous organization: Submucosal transudate replaced by fibrous / hyaline material, resistant to conservative treatment

  7. Clinical Features Small nodule:unable to sing high pitch notes, ed effort required for singing, normal speaking voice Large nodule:Low pitch, harsh, breathy speaking voice fatigability of voice, decreased pitch range Indirect laryngoscopy / flexible laryngoscopy: Early nodules:soft, reddish & edematous Late nodules:hard, grayish or white

  8. Vocal nodules Spindle shaped nodules Often asymmetrical nodules

  9. Non-surgical treatment Absolute voice rest:(or < 20 min / day) for 1-4 weeks Vocal hygiene:Avoid (mouth breathing, smoke + other allergens, repeated throat clearing, straining of voice) Maintain adequate hydration, steam inhalation Voice therapy for 3-6 months:emphasis on use of optimum pitch (effortless voice)

  10. Surgical Treatment • Indicated if adequate voice therapy shows no result for 3-6 months • Micro-laryngoscopy dissection • Laser-assisted dissection • Post-operative voice therapy given for 3-4 weeks for residual hoarseness

  11. Excision of vocal nodule

  12. Voice use after surgery Talking:Absolute voice rest ** for 1 week → Limited talking for 2nd week → average talking only. Avoid excessive talking. Singing:None for 1 week → 5-10 min BD for 2nd week → 15-20 min BD for weeks 3 to 4. ** absolute rest from talking, humming, whispering, throat clearing, forceful coughing

  13. Vocal polyp

  14. Introduction • Accumulation of fluid in subepithelial layer followed by ingrowth of connective tissues • Mostly affects men b/w 30-50 years • 90% solitary & thus unilateral • May be pedunculated or sessile vocal cord mass • Most common near anterior commissure

  15. Etiology:severe vocal trauma causing vocal cord hemorrhage, chronic inhalation of irritants (cigarette smoke, industrial fumes) gastric reflux, untreated hypothyroid states, chronic laryngeal allergy Pathogenesis:extreme vocal exertion → breakage of capillary in Reinke’s space → extra-vasation of blood & edema formation → fibrosis of resulting hematoma → polyp formation

  16. Symptoms • Hoarseness • Normal voice if polyp hangs in subglottis space. Sudden episode of hoarseness may occur due to superior displacement of polyp during phonation. • Dyspnoea due to large polyp • Diplophonia

  17. Laryngoscopic examination Types of vocal polyps • Gelatinous: Edematous stroma with fibrosis • Telengiectatic / hemorrhagic: Dilated blood vessels, hemorrhage within polyp • Transitional or mixed: Dilated blood vessels within gelatinous substance

  18. Vocal polyp

  19. Treatment 1. Micro-laryngoscopy & excision of polyp a. Micro-flap approach b. Truncation approach 2. Voice therapy:for 1 week before surgery & 3 weeks after surgery

  20. Elevation of micro-flap

  21. Excision of polyp

  22. Trimming of excess mucosa

  23. Redraping of mucosa

  24. Truncation approach

  25. Reinke’s edema

  26. Introduction • Accumulation of fluid in Reinke’s space • Synonyms:Bilateral diffuse polyposis, Smoker’s polyps, Polypoid corditis, Polypoid degeneration of vocal cords, Localized hypertrophic laryngitis • 10% of benign laryngeal lesions

  27. Reinke’s space

  28. Etiology • Irritants:tobacco smoke, dry air, dust, alcohol • Laryngeal allergy • Infection:chronic sinusitis • Idiopathic Edema limited to superior surface of vocal cord due to dense fibrous attachment to conus elasticus on under surface of vocal cord

  29. Clinical Features • Common in men b/w 30 – 60 years • Hoarseness:monotonous low-pitch voice • Diplophonia:in asymmetric vocal cord involvement • Stridor: in B/L gross edema • Early cases:ed convexity of medial cord margin • Late cases:Pale, watery bags of fluid on superior surface of vocal cords, move to & fro on phonation

  30. Reinke’s edema

  31. Treatment • Elimination of causative factors. Stop smoking. • Vocal cord stripping (decortication) under MLS:postero-anterior incision made on superior vocal cord surface → edematous fluid sucked out → edematous tissue removed with cup forceps • Voice therapy:1 wk before & 3 wks after surgery

  32. Vocal cord stripping

  33. Removal of edematous tissue

  34. Trimming & re-draping

  35. Pre-op vs. post-op

  36. Contact ulcer

  37. Synonym:pachydermia laryngis, contact granuloma • Ulcer misnomer as overlying epithelium is intact • Saucer like lesions (thickened epithelium with central indentation) at site of muco-perichondrium covering medial surface of vocal process • Etiology:vocal abuse (forceful voice), gastric reflux, obsessive clearing of throat

  38. Contact ulcer in voice abuse

  39. Contact granuloma in GERD

  40. Clinical presentation:low pitch hoarseness in tense, middle aged person Treatment: Voice therapy: use of higher tone Management of psychological stress Medical treatment of gastric reflux Micro-laryngeal excision of granuloma

  41. Intubation granuloma • Mushroom-shaped, pedicled granuloma situated superiorly or medially on vocal process • Detected 2-4 weeks after prolonged (> 10 days) or traumatic nasal endotracheal intubation • Pathogenesis:long term intubation → pressure necrosis → reactive granuloma • Treatment:Endoscopic excision

  42. Intubation granuloma

  43. Intubation granuloma

  44. Vocal cord leukoplakia • White plaque on vocal cord that cannot be scraped off & has no clinico-pathological correlate • Involves upper surface of vocal cord • Pt presents with hoarseness / incidental finding • Tx:excision / vocal cord stripping & histo- pathological examination to r/o carcinoma • Elimination of smoking

  45. Vocal cord leukoplakia

  46. Incision & dissection

  47. Excision of leukoplakia

  48. Laryngocoele

  49. Arises from expansion of saccule of laryngeal ventricle due to ed intra-luminal pressure in larynx or congenital large saccule Causes of ed intra-luminal pressure in larynx: • Occupational (?): trumpet players, glass blowers • Coexistence of larynx cancer • Male : female 5:1, Peak age = 6th decade, Unilateral in 85 % cases, 1% contain carcinoma

  50. Swelling enlarges on Valsalva

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