Benign Laryngeal LesionsBenign Laryngeal Lesions

Factors contributing to vocal Factors contributing to vocal fold lesionsfold lesions

• 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 baseline inflammation predisposes VF to other stressesVF to other stresses

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

Allergy Allergy

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

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

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

during phonationduring phonation

• during hyperfunctioning dysphonia increased during hyperfunctioning dysphonia increased stress at midpointstress at midpoint

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

• mass adds wt to VF decreasing vibratory qualities mass adds wt to VF decreasing vibratory qualities and frequency on stroboscopyand frequency 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 once initiated, can cause compensatory muscle tension to reduce air flow through muscle tension to reduce air flow through glottisglottis

Anatomy of vocal foldAnatomy of vocal fold

NodulesNodules

NodulesNodules

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

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

hyperfunctionhyperfunction

• 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 hyalinization of Reinke space and thickening of epithelium with epithelial hyperplasiaof epithelium with epithelial hyperplasia

• nodules are acellular with thick epithelium nodules are acellular with thick epithelium over matrix of abundant fibrin and organized over matrix of abundant fibrin and organized collagen IV in BMcollagen IV 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 speech therapy to address technique technique

• Microsurgery when speech tx and Microsurgery when speech tx and other contributing factors optimized other contributing factors optimized

Vocal fold polypsVocal fold polyps

PolypsPolyps

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

space with leakage of blood resulting space with leakage of blood resulting in local edema and organization with in local edema and organization with hyalinized stromahyalinized stroma

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

Vocal fold polypsVocal fold polyps

Effect of polyps on mucosal Effect of polyps on mucosal wavewave

Asymmetric mass produces more Asymmetric mass produces more chaotic vibrations and aperiodic chaotic vibrations and aperiodic mucosal wavesmucosal 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 Pulsed-dye lasers absorbed by

hemoglobin (585 nm)hemoglobin (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 Subepidermal epithelial-lineds sacs within lamina propriawithin lamina propria

• Mucus retention cystsMucus retention cysts

• Epidermoid cysts congenital cell Epidermoid cysts congenital cell rests in the subepithelium of 4th and rests in the subepithelium of 4th and 6th branchial arch or healing injured 6th branchial arch or healing injured mucosa burying epithelium mucosa burying epithelium

Vocal fold cystsVocal fold cysts

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

• May cause May cause reactive lesionreactive lesion on on contralateral VFcontralateral VF

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

premenstrual females premenstrual females

Strobolaryngoscopy Strobolaryngoscopy

• Asymmetric vocal foldAsymmetric vocal fold

• Decreased or absent mucosal wave on cyst Decreased or absent mucosal wave on cyst sideside

• 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 Dissection in submucosal plane with

complete cyst removalcomplete cyst 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 Distinguish from epithelial scarring or vocal

sulcussulcus

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

loss of projectionloss of projection

Sulcus VocalisSulcus Vocalis

Causes of Intracordal Causes of Intracordal scarringscarring• Cysts predispose to scar formation (ruptured, Cysts predispose to scar formation (ruptured,

epidermoid origin)epidermoid 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 Markedly reduced

or absent mucosal or absent mucosal wavewave

– Asymmetry affects Asymmetry affects phase closurephase closure

Treatment of vocal scarTreatment of vocal scar

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

• Medialization thyroplasty for glottic Medialization thyroplasty for glottic gapsgaps

• 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 proliferation of superficial lamina propriapropria

• 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 Preserve some superficial lamina propria

and overlying epithelium to preserve and overlying epithelium to preserve mucosal wavemucosal wave

• 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 Feeding varices and hemorrhagehemorrhage

• 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 Predispose to formation of polyps and hemorrhageand hemorrhage

• 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 No adverse scarring or reduction in mucosal

wavewave

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 Does not affect mucosal wave or phase closurephase closure

TreatmentTreatment

• LPR treatmentLPR treatment

• Speech therapy Speech therapy

• Botox to thyroarytenoid muscleBotox to thyroarytenoid muscle

• SurgerySurgery– Compromise voice, breathing or Compromise voice, breathing or

swallowing 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 2% malignant transformation (HPV 16 and

18)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 polmerase and reverse transcriptase reverse transcriptase than host DNA than host DNA polymerasepolymerase

• 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 Preservation of normal mucosal wave

for mild dysplasiafor mild dysplasia

• More aggressive excision with More aggressive excision with increasing dysplasiaincreasing dysplasia

Fungal LaryngitisFungal Laryngitis

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

• May mimick leukoplakia or malignancyMay mimick leukoplakia or malignancy– White or gray pseudomembrane on White or gray pseudomembrane on

mucosamucosa– 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, steroids, prolonged antibiotic use, XRTXRT

• DM, immunosuppressants, CA, DM, immunosuppressants, CA, nutritional deficitsnutritional deficits

• Compromise mucosal barrier Compromise mucosal barrier

DiagnosisDiagnosis

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

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

• Dysphagia may also have Dysphagia may also have esophageal involvementesophageal involvementTNETNE

• Candida species most commonly Candida species most commonly culturedcultured

• 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 Treatment of fungal laryngitislaryngitis

• 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