ENT Benign Laryngeal Disorders

ENT BENIGN LARYNGEAL DISORDERS Page 1 of 6

BENIGN LARYNGEAL DISORDERSDr. Lazaro091109

Mucosal flap – creates the sound produced- Vibration of mucosal folds and through air

Laryngeal Anatomy- Differences in adults vs infants

o 1/3 size at birtho Narrow dimensions of subglottis and

glottis Subglottis us the narrowest (4-

5mm in diameter)o Higher in the neck

C4 at birth vs C6-c7 at 15 y/oo Epiglottis is narrower

Laryngeal function- Breathing passage- Airway protection- Aid in the clearance of secretions- Vocalization

Symptoms of laryngeal anomalies- Airway obstruction- Feeding difficulties- Abnormalities of phonation

Airway Obstruction- Symptoms

Stridor Increase work of breathing with

retraction, nasal flaring anf tachypnea Apnea episodes, cyanosis and sudden

death- Stridor

o Inspratory stridor (supraglottic and glottis)

Collapse during negative inspiratory pressure

Airway protection- 1st level: epig, aryepig folds and arytenoids- 2nd level: false- 3rd: TVC- Anomalies

o Lead to aspiration and swallowing dysfunction

Phonatory abnormality- Dependent on the level of abnormality

o Mufflec cry suggest supraglottic obstruction

o High pith or absent cry suggest glottis abnormality

Laryngomalacia- Most frequent cause of stridor in children- MC congenital laryngeal anomaly- Male predominance- Flaccidity o supraglottic laryngeal tissues

- Characterizsed by inward collapse of supraglottic structures during inspiration

Anatomic Abnormalities- Epiglottis

o Long tubularo Displaced posteriorly on inspirationo Inferior collapse to the vocal folds

- Short aryepiglottic folds- Inward collapse of aryepiglottic folds (primarily

cuneiform cartilages)- Anteromedial collapse of the arytenoids

cartilages

Symptoms- Airway obstruction

o Mild to mod obstn Stridor exacerbated by exertion

Crying, agitation, feeding or supine

o Severe Substetrnal retraction Pectus excavatum with chronic

severe obstructiono Other complications

Feeding difficulties GERD Failure to thrive Cyanosis, cardiac failure and

death

Stridor in Laryngomalacia- Inspiratory stride

o Intermittent low-pitched- Starts 1st 2 weeks of birth- Worsens in th 1st few most followed by gradual

improvement- Peak at 6months and most are symptom free

by 18-24 mos (75%)

Pathophysiology- Cause of collapse is unknown

o Theories Derangement of supraglottic

anatomy Laryngeal cartilage immaturity Histopathology – normal

microanatomy Subepithelial edema

- Neurologic involvemento Assoc with central apnea, hypotonia,

MR, and early speecho Abnormal neuromuscular control

Gastroesophageal Reflux- >50% of patients with laryngomalacia- Airway edema contributes to airway

compromise

Dx- Awake flexible fiberoptic laryngoscopy- Fluoroscopy


- Direct laryngoscopy and bronchoscopy – evaluate synchronous lesions (27%)

Treatment of Laryngomalacia- Observation – most cases resolev

spontaneously- Medical mngt for GERd- Surgical mangt – severe symptoms

o Supraglottoplastyo Tracheotomyo Iglauer amputation of epiglottic

redundant tissue with a wire snare

Supraglottoplasty complications- Aggressive approach

o Supraglottic stenosiso Exacerbation of dysphagia with

aspirationo Rare – massive collapse of supraglottic

frameworkConservative excision minimizes complications

LARYNGOCELEs and SACCULAR CYSTAnatomy

- Saccule – cecal pouch of mucous membrane in anterior roof of the laryngeal ventricle

- Connection with tracheal area- Cyst: no connection with tracheal area

Laryngoceles- Dilation or herniation of the saccule- Communicates with the lumen of the larynx- Filled by air or mucous- Internal-extend posterosuperior into the

arypeiglottic fold

Saccular cyst- Congenital cyst of the larynx or laryngeal

mucoceleo No communication with the laryngeal

lumeno Developmental failure to maintain

patency of the saccular orifice

Laryngoceles and Saccular Cyst- Acquired La

o Inc pressure on the laryngeal lumen (player of wind instruments)

- Acquired saccular cysto Occlusion of the ssaccular orifice

Inflame, trau, tumors- Laryngopyocele

Sx- Laryngocele

o Intermittent hoarseness and dyspneao Weak cry

- Saccular cysto Respiratory distress wit inspuiratory

stridor

Dx- Flexible and rigid laryngoscopy

- Soft tissue neck x-ray (distended with air)- Combined laryngocele – mass protrudes with

valsalva maneuver- Saccular cyst – needle aspiration confirms the

dx

Treatment- Sac – aspiration or unroofing with cup forceps- Endoscopic excision

o Removing remnants CO2 laser- Open procedure for recurrence

o Lateral cervical approachVOCAL CORD PARALYSIS

- 3rd MC laryngeal anomaly producing stridor- Unilateral and bilateral- Can have neurologic problem

Sym- Bilateral

o High-pitched inspiratory stridoro Inspiratory cryo Paradoxical function

- Unilateral (less symptoms)o Weak cry and occassionaly breathyo Feeding difficulties

Dx- Awake flexible fiberoptic laryngoscopy- Direct laryngoscopy

Unilateral VC paralysis treatment- Watchful waiting

o 70% resolve spontaneouslyo Most withing 6moo Feeding difficulties

- Inc ICP

Bilateral VC - Tracheotomy may be necessary (50%)- Lateralizing one or both paralyzed VC- Excisional procedure

o Tissue removed from posterior glottis

CONGENITAL LARYNGEAL WEB-ATRESIA- Uncommon- Failure of recanalization- Most are glottis (75%)- Sx

o Vocal dysfunction Hoarseness Aphonia if severe

o Airway obstruction- Complete laryngeal atresia is incompatible with

life and need emergent tracheostomy- Dx

o Flexible laryngoscopyo Direct laryngoscopy

Treatment- Thin anterior glttic web

o Incision or dilatin- Most significant glotic lesion


Glotic Anomalies- Congenital high Upper airway obstruction

(CHAOS)o UTZ with large lungs, flat diaphragms,

dilated airways, fetal ascites

Subglottic stenosis- 2nd MC cause of stridor- Incomplete recanalizxation of laryngeal lumen- NB larynx <4mm- Congenital less sever than acquired

Membranous strenosis- Circumferential and soft- Less severe than cartilaginous

*7mm AP; lateral 4mm

Cartilaginous subglottic stenosis- Cricoid thickening

Sx- Upper airway obstruction- Inspiratory stridor- Mild to mod stenosis

o Asymptomatic- Severe obstruction

o Respiratory distresso Intubation amy be needed

Diagnosis- DL and bronch

o Visualize the entire larynxo Distinction of membranous vs

cartilaginouso Synchronous lesions

- Measurement of stenosiso ET tube placement at sequential size

Classification- Gr 1 <50% obstruction- 2 51-70- 71-99- No detectable lumen

Tx gade 1- Watchful waiting for growth

>50% obstruction may require some interventionSoft tissue acquired lesions

- Dilation and laser

Tx grade 2-3- Multiple failed extubation- Tracheostomy may be neede

Anterior cricoids split- Horizontal skin incision over cricoids- Vertical miline incision

o Entire cricoidso 1st 2 tracheal rings

Grade 3- Laryngotracheal decompression

- Reconstruction

Laryngeal and laryngotracheoesophageal clefts- Rare- Incomplete devt of Tracheoespohageal septum- Communicatioi iof posterior larynx and

esophagus- Strong association with other anomalies

o Aspiration- Laryngeal clefting

o Inerarytenoids only- Laryngotracheoesophageal clefts

Symptoms- Proportional to length- Can be asymptomatic- Inspiratory stridor- Feeding problem aspiration- Cyanotic episodes- Recurrent pneumonia

Diagnosis- CXR- pneumonia- Barium swallow – contrasrt pill into trachea- Direct laryngoscopy- best single test

Tx- Supraglottic larynx- Conservative- Swallowing therapy- GERD evaluation- Surgical

Mortality- 11 %, 46%- Intrathoracic – 93%

SUBGLOTTIC HEMANGIOMA x- Benign vascular malformation- Histological – endothelial hyperplasia- Female 2:1- Asymptomatic at birth

Stridor at 6 monhts- Ass cutaneous hemangioma (50% - x- Rapid growth at 1 year old followed by slow

resolution- Most complete resolution 5 yr- 30-70% mortality if untreated- Priority- airway

Dx – direct laryngsocopy- Systemic steroid – dec size- Interferon alpha- Tracheostomy – in Phils- Laser co2 and KTP- Surgical excision

ALLERGIES and INFECTION- Obstructive edema due to allergic response tx

with steroids or tracheostomy- Croup- Acute laryngitis

CROUP- Pathognomonic -stipple sign in CXR at AP view

BENIGN TUMORS OF LARYNX- Main complaint is hoarseness


- Hoarseness – perceived breathiness quality of voice (bailey)

- Rough or noisy quality of voice (Dorland)- Rough, harsh voice quality (Stedman)- Benign vocal fold mucosal disorders seem to

be caused by primarily by vibratory trauma- An expressive talkative personality- Occupational and lifestyle vocal demands- Cigarette smoking and liberal use of voice- Other secondary influences (infection, allergy,

acid reflux, insufficient fluid intake, certain drying medications, systemic illnesses)

- Benign vocal fold mucosal DO are common

Anatomy and physiology- Anatomy most relevant to the benign vocal fold

mucosal DO is the microarchitecture of voca folds

- Vocalis muscle- not participant in production of mucosal wave

- reinkes space – superficial layer of L.propia – chief oscillator of phonation

Myoelastic-aryeodynamic theory- closed vocal folds- pressure build p- folds blown apart- vocal fold mucosal vibration

Evaluation of px- skillful Hx- Asses vocal capabilities and limitations- Hi quality laryngeal exam

Hx- Onset and duration of symptoms- Patient beliefs causes exacerbating influences- Common symptoms complexes- Talkativeness- Vocal commitments- Patient perception of severity of DO- Vocal aspirations- Risk factors – smoking

Benign- Polyps- Nodules- Varices- cyst

POLYPS- result of trauma to the SLP and

microvasculature- size, shape, and tissue composition is variable- commonly found at middle portion of musculo-

membranous region- not uncommon to find smaller traumatic

fibrovascular lesion on contralateral vocal fold- epi is normal

Sessile – epi microflap-sub epi resection of polyp contents

Pedunculated – retraction and amputations

Size

Small- 0-3Medium- 3-6Large - >6 mm

NODULES- occurs at boys and women- vocal overdoses- children with cleft palates develop nodules

freq. presumably form using glottal stops to compensate for velopharyngeal incompetence

vary in size.contour, symmetry, colornodules do not unilaterallypolyps- unilateral

- vibration too forceful or prolonged causes localized vascular congestion with edema

- fluid accumulation in the sub mucosa- hyalinization of renkes potential space

MNgment- good laryngeal lubrication through hydration- manage allergies and nighttime reflux of

stomach acid into larynx- behavior voice therapy- nodules regress if px not singer

Surgical – if nodules persist and voice impaired- After adequate trial of therapy- Micro dissection techniques

Post surg- Patient is asked not to speak for 4 days- After 4 days, px progress to full voice use- Early return to nonstressful voice use seems to

promote dynamic healing and preserve a degree of mucosal freedom

- As long as certain management principles are followed in the majority of cases

VArices and ectasia- Excessive blood- Happens because of idlated capillaries.- Frequent in women- Repeated vibratory micro trauma lead to

capillary angiogeneses- Inc mucosa’s vulnerability to vibratory trauma- Most often in female singers - Abn dilatation of long archades of capillaries- Cappillay lake

Medical – anticoagulant effects stops used- It increase severity of bruising

Behavioral-vocal overdoses- px warned about sudden explosive use of

voice

Surgical


- Microsurgery- Spot-coagulated lasers – routinely involutes

within a few weeks

Vibratory .. - MC in men- Hx of aspirin or other anticoagulant use

Pathophy- Capillary rupture- Resolution of the bruise may be complete

within 2 weeks- Alter the margin contour- Abrupt onset

Laryngeal exam- Unilateral lesion- Usually dark or very red

Surgical- Evacuation of blood through a tiny incision

CYST- Vocal overuse- Mucus retention or epidermoid inclusion type

Mucus retention (ductal) cysts- Mucus gland plugged

Epidermoid cysts- Accumulation of keratin

Theories- From previous injury- Or from birth and recurred

Cysts may rupture spontaneously. Opening is small in relation to the overall size of the cyst

- Mucus retention cyst may just come and go

Laryngeal eacx- Originate below the free margin of the fold- Cyst on examination

Medical mngt- Voice rest- Hydration

Beh mngt- Voice therapy

Surgery - Small incision

Glottic sulcus- Ruptured cyst

GRANULOMA- Contact grnuloma or ulceration- Due to trauma

o Intubation granuloma – MC - Most common in males

o Lawyers, ministers

Pathophy- Thin mucosa of glottis become inflamed- Overly forceful apposition (slamming together)

Hx- Caffeine and alcohol use and late-noght eating

habits- Acid reflux symptoms- Speaking voice may sound normal or slightly

husky- Held-back quality, habitual coughing or throat

clearing

Laryngeal exam- Depressed ulcerated areas with whitish

exudates

Mngt- Antireflux- Steroidal injections- Voice rest- Stop coffee

REINKER’s EDEMA- Middle-aged woman- Smoking and voice abuse- Smoker’s polyps may complain of being called

“sir”- Increasing hoarseness during the day- Phonate though the voice of a bass singer- Due to fluid retention

Mangt- Stop smoking- Thyroid function tests can be done if

hypothyroidism is suspected- Surgical: microsurgery

POSTSURGICAL DYSPHONIA- Scarred stiff vocal fold cover, phonatory

mismatch of the vocal fild margins- Degree of freedom of the mucosa from the

iunderlying vocal ligament is lost- Mucosal injury due to previous laryngeal

surgery

Impact on identity and communication and their commonness

- Good hx, vocal capability elicitation and laryngeal examination


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ENT Benign Laryngeal Disorders