BENIGN TUMOURS OF BENIGN TUMOURS OF LARYNXLARYNX

Department of Otorhinolaryngology

J.J.M. Medical College

BENIGN TUMOURS OF BENIGN TUMOURS OF LARYNXLARYNX

• These are uncommon

• Divided into

I. Non neoplastic

II. neoplastic

NON-NEOPLASTIC

• These are not true neoplasms

• These are formed as a result of infection, trauma or degeneration

NON-NEOPLASTIC- SOLID LESIONS

• Vocal nodules (singer’s nodules/screamers nodules)

Appear symmetrically In the free edge of the vocal cord at the junction of anterior 1/3rd and posterior 2/3rd, as this is the area of maximum vibration and thus subjected to maximum trauma

Usually they measure less than 3mmThey are results of vocal traumaMostly seen in teachers, actors, singers, vendors

Vocal nodules- pathology

• Trauma to the vocal cords in the form of vocal abuse or misuse causes oedema and hemorrhage in the Submucosal space

• This undergoes hyalinization and fibrosis

• Underlying epithelium also undergoes hyperplasia forming a nodule

Vocal nodules- clinical features

• Patient complains of hoarseness, vocal fatigue and pain in neck on prolonged phonation

• On examination the nodule appears soft, reddish and oedematous swelling, later becomes grayish or whitish in colour

Vocal nodules- Treatment

• Voice rest• Surgery for larger nodules and long

standing nodules in adults• Excised by Microlaryngeal surgery• Speech therapy and re-education in

voice production is necessary to prevent recurrence

Vocal polypVocal polyp

• Result of vocal abuse or misuse• Allergy and smoking are other contributing factors• Mostly affects men in age group of 30-50• Typically its unilateral and arising from same

position as vocal nodule• Its soft smooth and often pedunculated• It may flop up and down during phonation or

respiration• Its caused by sudden shouting resulting in

haemorrhage in the vocal cord and subsequent submucosal oedema

Vocal polyp- clinical featuresVocal polyp- clinical features

• Hoarseness is a common symptom• Large polyp may cause dyspnoea,

stridor or intermittent choking • Some patients may complain of

diplophonia due to different vibratory frequencies of two vocal cords

• Treatment: surgical excision under operating microscope and speech therapy

Reinke’s oedemaReinke’s oedema

• This is due to collection of the oedema fluid in the subepithelial space of reinke

• Usual cause is vocal abuse and smoking• Both vocal cords show diffuse symmetrical

swellings• Treatment is vocal cord stripping preserving

enough mucosa for epithelisation• Only one cord is operated at a time• Cessation of smoking is important to

prevent recurrence

Contact ulcerContact ulcer

• This is again due to faulty voice production• Vocal process of arytenoid hammer against each

other resulting in ulceration and granuloma formation

• Some cases are due to laryngopharyngeal reflux• Complaints are hoarseness, constant desire to clear

the throat and pain in the throat which worsens on phonation

• Examination reveals unilateral or bilateral ulcers with congestion of arytenoid cartilages

• There may be granuloma formation

Intubation GranulomaIntubation Granuloma

• It results from injury to vocal processes of arytenoids due to rough intubation

• Use of large tube or prolonged intubation are the common causes

• Mucosal ulceration followed by granuloma formation over the exposed cartilage

• Usually these are bilateral involving posterior third of true cords

• They present with hoarseness, if large dyspnoea• Treatment is voice rest and endoscopic removal

of granuloma

Leukoplakia (keratosis) larynxLeukoplakia (keratosis) larynx

• This is localized form of epithelial hyperplasia involving upper surface of one or both vocal cords

• It appears as white plaque or warty growth on cord without affecting its mobility

• Its regarded as pre cancerous condition because carcinoma in situ frequently supervenes

• Hoarseness is common presenting symptom• Treatment is stripping of the vocal cords and

histopathological examination to rule out malignancy

Amyloidosis of larynxAmyloidosis of larynx

• Mostly affects men aged between 50-70 years

• Tumour presents as smooth plaque or a pedunculated mass

• Diagnosis is only on histology

• Treatment is endoscopic surgical excision

Cystic lesions of larynxCystic lesions of larynx

• There are 3 types of cysts in larynxDuctal cystDuctal cyst: they are retention cysts due 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

Epidermoid inclusion cyst

Cystic lesions of larynxCystic lesions of larynx

Saccular cystSaccular 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. Anterior saccular cysts present in the anterior part of the ventricle and obscure part of the vocal cord. Lateral saccular cysts which are larger extend into the false cord, AE folds and may even appear in the neck

Cystic lesions of larynxCystic lesions of larynx

• LaryngocoeleLaryngocoele: 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

LaryngocoeleLaryngocoele• 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

Neoplastic laryngeal lesionsNeoplastic laryngeal lesions

• Squamous Papillomas: can be juvenile or adult onset type• Juvenile laryngeal Papilloma: They are viral in origin and

multiple, often involving infants and young children who present with hoarseness and stridor

• They are mostly seen on the true, false vocal cords and epiglottis, but they may involve other sites in larynx and trachea

• Clinically appear as glistening white irregular growths, pedunculated or sessile, friable and bleeding easily

Juvenile laryngeal PapillomaJuvenile laryngeal Papilloma

• They are known for recurrence after removal, therefore multiple laryngoscopies may be required

• Tend to disappear spontaneously after puberty• Treatment: endoscopic removal with cup

forceps, Cryotherapy, microelectrocautery• CO2 laser is preferred these days• Interferon therapy to prevent recurrence

Juvenile laryngeal PapillomaJuvenile laryngeal Papilloma

Adult onset PapillomaAdult onset Papilloma

• Usually single, smaller in size, less aggressive and does not recur after surgical removal

• It is common in males in age group of 30-50 years

• Usually arises from anterior half of the vocal cord or anterior commissure

• Treatment is same as for juvenile type

ChondromaChondroma

• Arise from cricoid cartilage and present in subglottic area causing dyspnoea

• May grow outward posterior plate of cricoid and cause sense of lump in the throat and dysphagia

• Mostly affect men in age group 40-60 years

HaemangiomaHaemangioma• Infantile haemangioma involves subglottic area and presents

with stridor in first six months of life, about 50% of such children have haemangioma elsewhere in the body, particularly in the head and neck

• Tend to involute spontaneously but tracheostomy may be needed to relieve respiratory obstruction if airway is compromised

• Most of them are of capillary type and can be vaporized with CO2 laser

• Adult haemangiomas involve vocal cord or Supraglottic larynx, they are cavernous type and can not be treated by laser, they are left alone if asymptomatic

• Larger ones causing symptoms steroid or radiation therapy may be employed

Granular cell tumourGranular cell tumour

• It arises from the Schwann cells and is often submucosal

• Overlying epithelium shows pseudoepitheliomatous hyperplasia, which may on histopathology resemble well differentiated carcinoma

Glandular TumourGlandular Tumour

• Pleomorphic adenoma or oncocytoma are rare tumours

• Other rare tumours include rhabdomyoma, neurofibroma, neurilemmomas, Lipoma or fibroma