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

5. Intubation granuloma 3. Ductal cyst

Vocal nodules
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

 Pathogenesis
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
 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

 Vocal nodules

Spindle shaped nodules Often asymmetrical nodules

 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)

 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

Excision of vocal nodule
 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

Vocal polyp
 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

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
 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
 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

Vocal polyp
 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

Elevation of micro-flap
Excision of polyp
Trimming of excess mucosa
Redraping of mucosa
Truncation approach
Reinke’s edema
 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
Reinke’s space
 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

 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

Reinke’s edema
 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

Vocal cord stripping
Removal of edematous tissue
Trimming & re-draping
Pre-op vs. post-op
Contact ulcer
 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

Contact ulcer in voice abuse
Contact granuloma in GERD
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

 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

Intubation granuloma
Intubation granuloma
 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
Vocal cord leukoplakia
Incision & dissection
Excision of leukoplakia
Laryngocoele
 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

Swelling enlarges on Valsalva
 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.

 Types of laryngocoele

Internal External Combined

 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

Flexible laryngoscopy
 Swelling of false vocal

folds & ary-epiglottic

fold

 Swelling easily emptied

 Escape of purulent fluid

into airway = pyocoele

X-ray neck AP view

X-ray soft tissue neck AP

view during Valsalva

maneuver shows air-

filled radiolucent

swelling
CT scan: mixed laryngocoele
 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.

Endoscopic marsupialization
External approach
 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

 Anterior saccular cyst
Smaller in size, project into laryngeal lumen in
anterior ventricular region
 Lateral saccular cyst
Larger, present as bulge in false vocal fold or
ary-epiglottic fold, extend into neck
C.T. scan
 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

Incision & exposure

Cyst exposed after incision

Dissection of cyst

Final cut of cyst with false vocal cord

 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

Ductal cysts
Excision of ductal cyst
Neoplastic lesions
 Classification
1. Squamous papilloma: commonest
2. Chondroma

3. Haemangioma

4. Rhabdomyoma
5. Schwannoma

6. Paraganglioma
7. Lipoma
8. Fibroma & neurofibroma
 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

 Clinical Features
Symptoms:
 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.
Adult onset papilloma
Tracheal involvement
 Treatment
1. 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

 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
Micro-flap removal
Cup forceps & microdebrider
removal
Thank You