benign lesions of larynx
DESCRIPTION
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 - PowerPoint PPT PresentationTRANSCRIPT
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Benign Lesions
of Larynx
Dr. Vishal Sharma
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Common Non-neoplastic Lesions
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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
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Vocal nodules
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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
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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
Pathogenesis
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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
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Spindle shaped nodules Often asymmetrical nodules
Vocal nodules
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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)
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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
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Excision of vocal nodule
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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
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Vocal polyp
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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
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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
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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
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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
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Vocal polyp
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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
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Elevation of micro-flap
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Excision of polyp
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Trimming of excess mucosa
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Redraping of mucosa
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Truncation approach
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Reinke’s edema
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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
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Reinke’s space
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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
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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
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Reinke’s edema
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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
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Vocal cord stripping
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Removal of edematous tissue
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Trimming & re-draping
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Pre-op vs. post-op
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Contact ulcer
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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
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Contact ulcer in voice abuse
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Contact granuloma in GERD
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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
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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
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Intubation granuloma
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Intubation granuloma
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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
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Vocal cord leukoplakia
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Incision & dissection
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Excision of leukoplakia
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Laryngocoele
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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
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Swelling enlarges on Valsalva
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Types of laryngocoele
Internal (20%): contained entirely within endolarynx
with bulge in false vocal fold & aryepiglottic
fold
External (30%): only neck swelling without visible
endolaryngeal swelling
Combined (50%): Also extends into anterior triangle
of neck through foramen for superior laryngeal nerve &
vessels in thyrohyoid membrane. Dumbbell shaped.
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Types of laryngocoele
Internal External Combined
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Clinical Features
Hoarseness
Stridor in large endolaryngeal laryngocoele
Neck swelling
Manual compression of neck swelling results in
escape of fluid / gas into airway (Boyce’s sign)
10% cases are pyocele: sore throat, cough
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Flexible laryngoscopy
Swelling of false vocal
folds & ary-epiglottic
fold
Swelling easily emptied
Escape of purulent fluid
into airway = pyocoele
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X-ray neck AP view
X-ray soft tissue neck AP
view during Valsalva
maneuver shows air-
filled radiolucent
swelling
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CT scan: mixed laryngocoele
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Treatment No symptom: no treatment
Infected laryngocoele: aspiration & antibiotics
Internal laryngocoele: endoscopic marsupialization
External laryngocoele: Excision by external
approach. Cyst exposed by removing upper half of
thyroid cartilage. Cyst incised at its neck & stitched.
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Endoscopic marsupialization
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External approach
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Saccular cysts Due to obstruction of orifice of saccule in
laryngeal ventricle. May be congenital or acquired
40% congenital cysts found within hours of birth
95% of infants have symptoms within 6 months
C/F: Inspiratory stridor improves during head
extension; dyspnea, apnea, cyanosis;
feeding problems & failure to thrive
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Anterior saccular cystSmaller in size, project into laryngeal lumen in
anterior ventricular region
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Lateral saccular cystLarger, present as bulge in false vocal fold or
ary-epiglottic fold, extend into neck
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C.T. scan
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Treatment
1. Emergency tracheostomy for acute stridor
2. Endoscopic de-roofing or marsupialization:
cold knife Laser-assisted
3. Endoscopic incision & drainage
4. Total excision:
endoscopic laryngofissure approach
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Cyst exposed after incision
Incision & exposure
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Final cut of cyst with false vocal cord
Dissection of cyst
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Ductal cysts
Retention cysts due to blockage of ducts of
seromucinous glands
Sites: Vocal cord, false cord, vallecula,
aryepiglottic fold, ventricles,
pyriform fossa
Clinical features: asymptomatic, hoarseness,
dyspnoea for large cyst
Rx: Microlaryngoscopy & excision
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Ductal cysts
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Excision of ductal cyst
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Neoplastic lesions
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Classification1. Squamous papilloma: commonest
2. Chondroma
3. Haemangioma
4. Rhabdomyoma
5. Schwannoma
6. Paraganglioma
7. Lipoma
8. Fibroma & neurofibroma
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Squamous papilloma
Most common benign tumor of larynx (85%)
Etiology: Human papilloma virus strain 6,11,18.
Transmitted during delivery from genital
warts.
Juvenile onset: multiple, diffuse, aggressive, resistant
to Rx, recurrent (recurrent respiratory
papilloma)
Adult onset: single, non-aggressive, does not recur
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Clinical FeaturesSymptoms:
Majority present before 4 yrs of life
Hoarseness / abnormal cry + increasing stridor
Signs:
Glistening, whitish-pink, irregular, pedunculated or
sessile growth, friable, bleeds easily
Involve anterior vocal cord, anterior commissure.
Later involve remaining larynx & trachea.
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Adult onset papilloma
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Tracheal involvement
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Treatment1. Micro-laryngoscopy + excision with: cup forceps /
electrocautery / microdebrider / Laser / cryosurgery /
application of podophyllin. HPE to rule out cancer.
2. Interferron: viral replication, immune response
3. Antiviral agents: Acyclovir, Ribavirin
4. Immuno-modulators: Adenine arabinoside, lysozome
chlorhydrate
Tracheostomy to be avoided to prevent stomal seeding
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Cause for recurrence Virus remains in basal layer of mucus membrane
replicating by episomal maintenance
Virus remains undetectable unless determined by
DNA hybridization
Virus only seen in stratum corneum & granulosum
High affinity for areas of airway constriction (due
to ed airflow, drying & crusting
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Micro-flap removal
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Cup forceps & microdebrider removal
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Thank You