Benign Laryngeal LesionsBenign Laryngeal Lesions

Factors contributing to vocal fold Factors contributing to vocal fold lesionslesions

• voice overuse or misusevoice overuse or misuse• smokingsmoking• etohetoh• Laryngopharyngeal refluxLaryngopharyngeal reflux

HistoryHistory

• medical conditions medical conditions – AR, GERD, asthma, bronchitis, sinusitisAR, GERD, asthma, bronchitis, sinusitis

• medicationsmedications• Environmental exposure: smoke, Environmental exposure: smoke,

allergens, particulates (dust)allergens, particulates (dust)

LPRLPR

• baseline inflammation predisposes VF to baseline inflammation predisposes VF to other stressesother stresses

• 78% w/ nodules had LPR 78% w/ nodules had LPR

Allergy Allergy

• pts treated for AR had better outcome for pts treated for AR had better outcome for treatment of laryngitistreatment of laryngitis

• hypersensitivity makes laryngeal mucosa hypersensitivity makes laryngeal mucosa more susceptible to stressmore susceptible to stress

PathophysiologyPathophysiology• mech stress least at midpoint of membranous VF during mech stress least at midpoint of membranous VF during

phonationphonation

• during hyperfunctioning dysphonia increased stress at during hyperfunctioning dysphonia increased stress at midpointmidpoint

• increased stiffness in body of VF at midpoint results in increased stiffness in body of VF at midpoint results in higher shearing stresses, worse if nodule or mass higher shearing stresses, worse if nodule or mass presentpresent

• mass adds wt to VF decreasing vibratory qualities and mass adds wt to VF decreasing vibratory qualities and frequency on stroboscopyfrequency on stroboscopy

PathophysiologyPathophysiology

• decrease in pitch range and impaired closure decrease in pitch range and impaired closure leads to breathy voice and fatigue. leads to breathy voice and fatigue.

• Asymmetry adds grainy quality to voiceAsymmetry adds grainy quality to voice

• once initiated, can cause compensatory muscle once initiated, can cause compensatory muscle tension to reduce air flow through glottistension to reduce air flow through glottis

Anatomy of vocal foldAnatomy of vocal fold

NodulesNodules

NodulesNodules

• bilateral symmetric epithelial swelling of bilateral symmetric epithelial swelling of ant/mid third of TVFant/mid third of TVF

• More prevalent in children, adolescents, More prevalent in children, adolescents, females females – softer intensity of voice causes hyperfunctionsofter intensity of voice causes hyperfunction

• Result of abuse or misuseResult of abuse or misuse

Nodule formationNodule formation

• junction of anterior to middle VF experience junction of anterior to middle VF experience maximal shearing and collision forces. maximal shearing and collision forces.

• vascular congestion and edemavascular congestion and edema• hyalinization of Reinke space and thickening of hyalinization of Reinke space and thickening of

epithelium with epithelial hyperplasiaepithelium with epithelial hyperplasia• nodules are acellular with thick epithelium over nodules are acellular with thick epithelium over

matrix of abundant fibrin and organized collagen matrix of abundant fibrin and organized collagen IV in BMIV in BM

SymptomsSymptoms

• decreased amplitude mucosal wavedecreased amplitude mucosal wave• SymmetricSymmetric mucosal wave mucosal wave• decreased closure: hourglass-shape decreased closure: hourglass-shape

glottal closure glottal closure • chronic hoarsenesschronic hoarseness• singers: frequent voice breaks, singers: frequent voice breaks,

breathiness, vocal fatiguebreathiness, vocal fatigue

Treatment of NodulesTreatment of Nodules

• conservative voice useconservative voice use• speech therapy to address technique speech therapy to address technique • Microsurgery when speech tx and other Microsurgery when speech tx and other

contributing factors optimized contributing factors optimized

Vocal fold polypsVocal fold polyps

PolypsPolyps

• UnilateralUnilateral • Broad-based vs. PedunculatedBroad-based vs. Pedunculated• Formed by capillary break in Reinke space Formed by capillary break in Reinke space

with leakage of blood resulting in local with leakage of blood resulting in local edema and organization with hyalinized edema and organization with hyalinized stromastroma

• Hemorrhagic (feeding vessel) vs. Hemorrhagic (feeding vessel) vs. nonhemorrhagic (pseudocyst)nonhemorrhagic (pseudocyst)

Vocal fold polypsVocal fold polyps

Effect of polyps on mucosal waveEffect of polyps on mucosal wave

Asymmetric mass produces more chaotic Asymmetric mass produces more chaotic vibrations and aperiodic mucosal wavesvibrations and aperiodic mucosal waves

Larger polyps cause decreased wave Larger polyps cause decreased wave amplitudeamplitude

Excessive air egress during phonationExcessive air egress during phonation FatigueFatigue Frequent voice breaksFrequent voice breaks decreased vocal powerdecreased vocal power

TreatmentTreatment

• Conservative for small polypsConservative for small polyps• Microsurgery mainstay of therapyMicrosurgery mainstay of therapy• Hemorrhagic polypsHemorrhagic polyps

– Pulsed-dye lasers absorbed by hemoglobin Pulsed-dye lasers absorbed by hemoglobin (585 nm)(585 nm)

– Lasers more effective for smaller polypsLasers more effective for smaller polyps

Vocal fold cystsVocal fold cysts

Vocal fold cystsVocal fold cysts

• Subepidermal epithelial-lineds sacs within Subepidermal epithelial-lineds sacs within lamina proprialamina propria

• Mucus retention cystsMucus retention cysts• Epidermoid cysts congenital cell rests in Epidermoid cysts congenital cell rests in

the subepithelium of 4th and 6th branchial the subepithelium of 4th and 6th branchial arch or healing injured mucosa burying arch or healing injured mucosa burying epithelium epithelium

Vocal fold cystsVocal fold cysts

• Ruptured cyst may result in LP scarring or Ruptured cyst may result in LP scarring or in a sulcusin a sulcus

• May cause May cause reactive lesionreactive lesion on contralateral on contralateral VFVF

• Size may vary with menstrual cycleSize may vary with menstrual cycle– Caution when operating on premenstrual Caution when operating on premenstrual

females females

Strobolaryngoscopy Strobolaryngoscopy

• Asymmetric vocal foldAsymmetric vocal fold• Decreased or absent mucosal wave on cyst sideDecreased or absent mucosal wave on cyst side• DiplophoniaDiplophonia• Glottic closure depends on cyst size and Glottic closure depends on cyst size and

reactive lesion on contralateral sidereactive lesion on contralateral side• Mucosal wave Mucosal wave

– present in 80% of polyps BUT present in 80% of polyps BUT – absent in almost 100% of cysts absent in almost 100% of cysts

Treatment of cystsTreatment of cysts

• Does not resolve with conservative Does not resolve with conservative managementmanagement

• SurgerySurgery– Dissection in submucosal plane with complete Dissection in submucosal plane with complete

cyst removalcyst removal– Prolonged mucosal wave recovery Prolonged mucosal wave recovery – Discuss risks with ptDiscuss risks with pt

Reactive LesionsReactive Lesions

Reactive lesionsReactive lesions

• Reaction to unilateral VF lesionReaction to unilateral VF lesion• Contralateral VF reactive callus with Contralateral VF reactive callus with

epithelial hyperplasiaepithelial hyperplasia• Bilateral like nodulesBilateral like nodules• Strobe: asymmetry not seen in nodulesStrobe: asymmetry not seen in nodules• Tx: treatment of primary lesion, may Tx: treatment of primary lesion, may

resolve with conservative managementresolve with conservative management

Before and AfterBefore and After

Intracordal ScarringIntracordal Scarring

• Scarring in Reinke space after repeated Scarring in Reinke space after repeated inflammation, trauma or vocal hemorrhageinflammation, trauma or vocal hemorrhage

• Subepithelial scar Subepithelial scar – Disorganized collagenDisorganized collagen– Loss of ECMLoss of ECM– Distinguish from epithelial scarring or vocal sulcusDistinguish from epithelial scarring or vocal sulcus

• VF appears stiff, white or opaqueVF appears stiff, white or opaque• Hoarseness, vocal fatigue, breathiness, loss of Hoarseness, vocal fatigue, breathiness, loss of

projectionprojection

Sulcus VocalisSulcus Vocalis

Causes of Intracordal scarringCauses of Intracordal scarring

• Cysts predispose to scar formation (ruptured, epidermoid Cysts predispose to scar formation (ruptured, epidermoid origin)origin)

• Trauma Trauma – Vocal fold surgery involving lamina propriaVocal fold surgery involving lamina propria– Repeated epithelial proceduresRepeated epithelial procedures– Biopsy, strippingBiopsy, stripping– InhalationalInhalational– IntubationIntubation

• CO2 laserCO2 laser• RadiationRadiation• Rheumatologic diseaseRheumatologic disease

• StroboscopyStroboscopy– Markedly reduced or Markedly reduced or

absent mucosal waveabsent mucosal wave– Asymmetry affects Asymmetry affects

phase closurephase closure

Treatment of vocal scarTreatment of vocal scar

• Microflap to remove cyst elements and Microflap to remove cyst elements and adynamic fibrous componentsadynamic fibrous components

• Medialization thyroplasty for glottic gapsMedialization thyroplasty for glottic gaps• Replacement soft tissue (Fillers)Replacement soft tissue (Fillers)

– CollagenCollagen– FatFat– Hyaluronic acidHyaluronic acid

Reinke EdemaReinke Edema

Reinke edemaReinke edema

• polypoid corditispolypoid corditis• proliferation of superficial lamina propriaproliferation of superficial lamina propria• chronic irritant exposurechronic irritant exposure

– Smoke, LPR, occupational exposuresSmoke, LPR, occupational exposures

• water-balloon outpouching from water-balloon outpouching from membranous VFmembranous VF

• ball-valving effect ball-valving effect

TreatmentTreatment

• SurgerySurgery– Airway compromiseAirway compromise– Preserve some superficial lamina propria and Preserve some superficial lamina propria and

overlying epithelium to preserve mucosal overlying epithelium to preserve mucosal wavewave

• Stage for bilateral disease to prevent Stage for bilateral disease to prevent anterior web anterior web

• Remove irritants and treat LPRRemove irritants and treat LPR

Feeding varices and hemorrhageFeeding varices and hemorrhage

• Aberrant microvessels in superficial Aberrant microvessels in superficial lamina proprialamina propria

• Result of shearing forces and traumaResult of shearing forces and trauma• Predispose to formation of polyps and Predispose to formation of polyps and

hemorrhagehemorrhage

• TreatmentTreatment– Microdissection and CO2 laserMicrodissection and CO2 laser

• Risks of scarring and sulcusRisks of scarring and sulcus– Pulsed lasers (KTP, 585nm PDL)Pulsed lasers (KTP, 585nm PDL)

• No adverse scarring or reduction in mucosal waveNo adverse scarring or reduction in mucosal wave

Vocal Process GranulomaVocal Process Granuloma

GranulomasGranulomas

• Response to trauma Response to trauma • LPR, throat clearing, chronic coughLPR, throat clearing, chronic cough• IntubationIntubation• Compensatory forceful glottic closureCompensatory forceful glottic closure

– VF paresisVF paresis– PresbylaryngesPresbylarynges

• Does not affect mucosal wave or phase Does not affect mucosal wave or phase closureclosure

TreatmentTreatment

• LPR treatmentLPR treatment• Speech therapy Speech therapy • Botox to thyroarytenoid muscleBotox to thyroarytenoid muscle• SurgerySurgery

– Compromise voice, breathing or swallowing Compromise voice, breathing or swallowing – Suspicion for malignancy Suspicion for malignancy – High recurrence rateHigh recurrence rate

PapillomasPapillomas

PapillomasPapillomas

• HPV (Strain 6 and 11 most common)HPV (Strain 6 and 11 most common)• 2% malignant transformation (HPV 16 and 18)2% malignant transformation (HPV 16 and 18)• 10% rate of spread to other sites (trachea, 10% rate of spread to other sites (trachea,

supraglottis, NP)supraglottis, NP)• Most commonly found at columnar and Most commonly found at columnar and

squamous junctionsquamous junction• Host immune recognitionHost immune recognition

– HPV 11 growth more aggressive during pregnancyHPV 11 growth more aggressive during pregnancy– 40% HPV+ larynx without RRP40% HPV+ larynx without RRP

Treatment Treatment

• CO2 laserCO2 laser– Controversy: depth risks scarring and Controversy: depth risks scarring and

implantation of HPVimplantation of HPV– Avoided in most centersAvoided in most centers

• MicroshaverMicroshaver• Cidofovir injection (adjuvant tx)Cidofovir injection (adjuvant tx)• VaccineVaccine

CidofovirCidofovir

• Acyclic nucleoside Acyclic nucleoside phosphonatephosphonate

• Once phosphorylated, Once phosphorylated, resembles nucleotideresembles nucleotide

• incorporated into DNA, incorporated into DNA, halting DNA synthesishalting DNA synthesis

• ANP’s have greater ANP’s have greater affinity for viral DNA affinity for viral DNA polmerase and reverse polmerase and reverse transcriptase than host transcriptase than host DNA polymeraseDNA polymerase

• Off-label useOff-label use

Cidofovir studies limitedCidofovir studies limited

LeukoplakiaLeukoplakia

LeukoplakiaLeukoplakia• Spectrum of change in epitheliumSpectrum of change in epithelium• HyperkeratosisHyperkeratosisDysplasia (mild, Dysplasia (mild,

moderate)moderate)CIS/ severe dysplasiaCIS/ severe dysplasia• Pattern of growthPattern of growth

– Superficial, broadSuperficial, broad– Verrucous, exophytic with surrounding erythemaVerrucous, exophytic with surrounding erythema

• Appearance does not correlate with degree of Appearance does not correlate with degree of dysplasiadysplasia

• 8% to 14% rate of malignant transformation8% to 14% rate of malignant transformation

TreatmentsTreatments

• CO2 laserCO2 laser• PDLPDL• microflap excisionmicroflap excision• Preservation of normal mucosal wave for Preservation of normal mucosal wave for

mild dysplasiamild dysplasia

• More aggressive excision with increasing More aggressive excision with increasing dysplasiadysplasia

Fungal LaryngitisFungal Laryngitis

• Disease of both immunocompromised and Disease of both immunocompromised and immunocompetent hostsimmunocompetent hosts

• May mimick leukoplakia or malignancyMay mimick leukoplakia or malignancy– White or gray pseudomembrane on mucosaWhite or gray pseudomembrane on mucosa– Mucosal erythema and edema (focal or Mucosal erythema and edema (focal or

diffuse) surrounding white plaquesdiffuse) surrounding white plaques– Mucosal ulcerationsMucosal ulcerations– Contact bleedingContact bleeding

Fungal laryngitisFungal laryngitis

Risk factors Risk factors

• Risk factors: LPR, smoking, inhaled Risk factors: LPR, smoking, inhaled steroids, prolonged antibiotic use, XRTsteroids, prolonged antibiotic use, XRT

• DM, immunosuppressants, CA, nutritional DM, immunosuppressants, CA, nutritional deficitsdeficits

• Compromise mucosal barrier Compromise mucosal barrier

DiagnosisDiagnosis

• Suspicion and response to empiric Suspicion and response to empiric therapytherapy

• Any question can culture by laryngeal Any question can culture by laryngeal brushing or biopsy brushing or biopsy

• Dysphagia may also have esophageal Dysphagia may also have esophageal involvementinvolvementTNETNE

• Candida species most commonly culturedCandida species most commonly cultured• Blastomyces (Eastern US and Midwest)Blastomyces (Eastern US and Midwest)• Histoplasma (Ohio and Mississippi River Histoplasma (Ohio and Mississippi River

Valleys)Valleys)• Coccidioides (Southwestern US)Coccidioides (Southwestern US)• Bacterial superinfection Bacterial superinfection

– Honey-colored crustsHoney-colored crusts

Treatment of fungal laryngitisTreatment of fungal laryngitis

• Fluconazole x 3wksFluconazole x 3wks• Nystatin swish and swallow (100,000 Nystatin swish and swallow (100,000

units/ml, 10ml tid)units/ml, 10ml tid)• Prevention Prevention

– spacers for inhaled steroidsspacers for inhaled steroids– oral rinse, gargle with water after useoral rinse, gargle with water after use