BENIGN TUMOURS OF LARYNXBENIGN TUMOURS OF LARYNX

Benign tumours of the larynx are not as common as the malignant ones.

Divided into

I. Neoplastic

II. Non-neoplastic

NEOPLASTIC

Laryngeal fibroma and papilloma are the most frequent.

FIBROMA

Occurs with equal frequency in men and women aged 20-50 years , children are extremely rare.

Usually grow on the free edge on the upper surface of the vocal fold , have a dark cherry (sometimes lighter ) color, usually solitary, mobile.

Its size ranges from a grain of lentil to a pea.

Complaints of the patient – hoarse and whispered voice.

Treatment - surgery. Removed under local or general anesthesia , with special forceps (Moritz -Schmidt or Cordes).

SQUAMOUS PAPILLOMAS

They are viral in origin (HPV types 6 and 11)

1. Juvenile

2. Adult onset type

JUVENILE LARYNGEAL PAPILLOMA

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 PAPILLOMA

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

The other way to diagnose laryngeal papilloma is for a biopsy to be conducted and for the lesion to be tested for HPV. 

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

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

HAEMANGIOMA

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

Direct laryngoscopy , X-ray 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 TUMOUR It arises from the

Schwann cells and is often submucosal

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

Treated by surgical resection under a fine dissection laryngomicroscope

OTHER RARE TUMORS

Pleomorphic adenoma or oncocytoma are rare tumours

Other rare tumours include rhabdomyoma, neurofibroma, neurilemmomas,

NON-NEOPLASTIC

These are not true neoplasms

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

Divide into:

Solid

Cystic

NON-NEOPLASTICSOLID 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 3mm

They are results of vocal trauma

Mostly 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 edematous swelling, later becomes grayish or whitish in colour.

VOCAL NODULES- TREATMENT

Early cases of vocal nodules can be treated conservatively by educating the patient in proper use of voice. With this treatment, many nodules in children disappear completely.

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 EDEMA (BILATERAL DIFFUSE REINKE’S EDEMA (BILATERAL DIFFUSE POLYPOSIS)POLYPOSIS)

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

Usual cause is vocal abuse and smoking

Both vocal cords show diffuse symmetrical swellings

Individuals with Reinke's edema typically have low-pitched, husky voices, as they use false vocal folds for voice production.

Treatment is vocal cord stripping preserving enough mucosa for epithelization

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. The most common cause of the condition is sustained periods of

increased pressure on the vocal folds, and is commonly seen in people who use their voice excessively such as singers.

Some cases are due gastroesophageal 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 (endoscopy). There may be granuloma formation TREATMENT: Resting the vocal cords for as long as six weeks,

normally followed by vocal therapy.

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

Patient usually complains of hoarseness of voice.

Presents as smooth plaque or a pedunculated mass

Diagnosis is only on histology

Treatment is endoscopic surgical excision

NON-NEOPLASTICCYSTIC LESIONS

CYSTIC LESIONS OF LARYNXCYSTIC LESIONS OF LARYNX

There are 3 types of cysts in larynx Ductal cyst Saccular cyst Laryngocele

DUCTAL 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

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, aryepiglottic folds and may even appear in the neck.

Removed endoscopically

LARYNGOCELELARYNGOCELE

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 may cause 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 of 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 (laryngotomy) Marsupialisation of internal laryngocoele can be done by

laryngoscopy, but chances of recurrence are high Laryngocoele in an adult may be associated with carcinoma

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