Inkesi, Infiltrasi, Laring

8/16/2019 Inkesi, Infiltrasi, Laring

1/17

Craig R. Villari Melissa M. Statham

Multiple infectious and benign conditions can affect

laryngeal biomechanics and detrimentally affect laryngeal function and vocal performance. A variety of clini

cal presentations is possible ranging from dysphonia or

dysphagia to airway compromise depending on pathol

ogy, the affected laryngeal subsite(s), and premorbid

laryngeal anatomy. Treatment is targeted to the specific

pathology, which is usually diagnosed from a thorough

history, physical examination, and detailed laryngoscopy,

but may also require more specific laboratory or radio

logic examination .

INFECTIONS OF THE LARYNX

Viral Laryngitis

The most common cause of infectious laryngitis isviral

(). !iral laryngitis is typically self "limited with a normal

dura tion of # to $ days (%). &atients are usually

dysphonic but may also present with odynophagia.

'istory may include a viral prodrome with upper

respiratory tract symptoms and physical examination

usually demonstrates edema tous, erythematous vocal

folds (ig. $.) with loss of normal vibratory

pliability.Treatment includes supportive care with

hydration and removal of laryngeal phonotory trauma

(phonation and coughing, pollutants). The most common

viral pathogens in the upper respiratory tract include

rhinovirus, influen*a A, +, , and parainfluen*a viruses.

&atients with substantive vocal fold edema from viral

laryngitis are at increased ris- of repetitive phono trauma

leading to more significant vocal fold inury, such as

midmembranous vocal fold lesions, epithelial and sub

epithelial trauma/ulceration, and scar (0). As such , these

patients should ideally be limited to relative or absolute

voice rest. 1vidence suggests that anti"inflammatory

medi cation may decrease subective discomfort and

decrease odynophagia, but one would not expect such

treatment to decrease duration of illness as it could notaffect the

978


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erlying viral etiology (2). 3ystemic corticosteroids may be

*ed udiciously to treat moderate to severe laryngeal edema

ciated with very substantial symptoms, espe cially in patients

h significant vocal demands that can not be mitigated with

avioral modification. Antibiotics are not indicated in patients

enting with symptoms typical of viral laryngitis (). Acute

phonia lasting lon ger than % wee-s is unli-ely to result from

l laryngitis, and other etiologies should be investigated,

uding a detailed laryngoscopy.

cterial Laryngitis

ough rare, the physician should begin to consider a

erial etiology when the supportive measures dis cussed above

to decrease symptoms or if symptoms worsen after an initial

eau of symptoms. 4nitial clini cal presentation may be similar to

of viral laryngitis, but supraglottitis and epiglottitis may result.

with the pediatric population, these conditions require escalated

care, given the potential for airway demise. The causative

bacteria are also similar to those in the pediatric popu

lation and include Haemophilus influen z ae , Streptococcus

species, and Staphyloco ccus species. Haemophilus spe cies

remain the most common but methicillin"resistant

Staphylococcus aureus infections have been reported (,#"

$).

5iagnosis relies on endoscopic examination (ig.

$.%) of the larynx. 6adiologic imaging may be used to

supple ment endoscopic evaluation, and findings can

include the classic 7thumb"print7 sign of supraglottic

inflamma tion. Tr eatment depends on the clinical

presentation with attention focused on airway

competence. 4n a recent study, only % of 8 adult patients

with supraglottitis evaluated over a "month period

requir ed airway intervention (9). 5espite the maority of

patients not needing airway pro tection, incr eased wor-

of breathing and/or stridor must


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3 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' ("(

Fig)re !"*+ Acute laryngitis: note global laryngeal edema anderythema.

be given proper credence. Medical treatment is targeted

to the pathogen identified by culture. Additionalsupportive measures such as hydration and steroids are

indicated (;). Though not common in the


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4 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' ("(

Fig)re !"*/ ungal laryngitis: note white fungal plaques withmarginal erythema on midmembranous vocal folds.


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M . tuberculosis infections follow similar natural history

to pulmonary tuberculosis and most commonly present

as lesions in the posterior glottis. &atient factors include

increased prevalence in underdeveloped countries, areas of

over"crowding and communal living, and immunocom

promised populations. hile laryngeal infections present

with similar symptoms as pulmonary infections (cough,

hemoptysis, unintentional weight loss, fever, night sweats), patients may also present with laryngopharyngeal symp

toms such as dysphonia, dysphagia, and odynophagia.

&hysical examination can demonstrate exophytic masses

that mimic malignancy (;,%8). &athologic examination

demonstrates caseating granulomas that are pathogno

monic to M . tuberculosis infection. Treatment is targeted

with multidrug regimens with culture guidance, as multi

drug resistant M . tuberculosis strains are on the rise.

Other In#ections

@ess common infections of the larynx include leprosyand syphilis. M ycobacterial leprae and M ycobacterium lep

romatosis, the causative infectious agents of leprosy, cause

dramatic systemic and laryngeal epithelial changes. As

with the other laryngeal infections, patients can present

with variable severity in symptoms, with the most severe

being occult aspiration or complete upper airway obstruc

tion requiring tracheotomy (%,%%). The orld 'ealth

>rgani*ation recommends multidrug treatment with com

binations of dapsone and rifampin with possible adunc

tive clofa*imine.

3yphilis is caused by Treponema pallidum infection and

generally presents in stages. The primary stage generally

presents to the otolaryngologist as a painless oropharyngeal chancre. 5uring the secondary stage, patients can

present with laryngeal manifestations, including leu-o

pla-ia, exophytic mass( es), and very rarely, decreased

vocal fold mobility (%0,%2). 5iagnosis involves serologic

studies (venereal disease research laboratory or rapid

plasma regain) and/or dar-"field microscopy to visuali*e

the pathopneumonic spirochetes sampled from suspect

mucosa= lesions. The mainstay of treatment is penicillin.

or those patients with penicillin sensitivities, definitive

allergy testing and desensiti*ation may be required prior

to treatment.

I%ioathic 0lcerati1e Laryngitis

4diopathic ulcerative laryngitis (4


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frequency phonation, generali*ed dysphonia, decreased

vocal fold mobility, and


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7 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' (4+

laryngeal edema (08). These symptoms are modulated by

the active status of the patientDs disease. Active rheuma

toid arthritis tends to present with a substantial laryngitis

with erythematous arytenoid mucosa (08"0%). hronic

rheumatoid arthritis also selectively targets the arytenoid

cartilages, but more specifically seems to affect the

cricoar ytenoid oint causing an-ylosis and possible oint

fixation (%). &atients may also present with rheumatoid

nodules, also -nown as bamboo nodes, which are focal

subepithe lial lesions, typically on the superior surface of

the mem branous vocal fold. Treatment of rheumatoid

arthritis relies upon medical management with

immunomodular and anti"inflammatory treatments.

Although outcomes data are sparse, surgical management

may be indicated to man age airway symptoms or to

udiciously remove rheumatoid nodules to improve

phonation (0%,00). (3ee hapter 9) Alternatively, serial

vocal fold steroid inections are a less invasive treatment

that may improve vocal outcome (02).

A&yloi%osis

Amyloidosis is an autoimmune condition characteri*ed

by extracellular deposition of fibrillar proteins in affected

tissue. @aryngeal involvement is rare and may not be

asso ciated with primary systemic amyloidosis. 'owever,

laryn geal amyloidosis may be present in conunction

with other systemic conditions such as multiple myeloma

(0#,0). &atients usually present with bul-y deposition of

amyloid protein with variable degrees of infiltration of

the vocal fold, paraglottic space, and the supraglottis.

&resenting fea tures include cough, dysphonia,dysphagia, and possible stridor. +iopsy is required for

diagnosis as amyloid has a pathognomonic apple green

birefringence after staining with ongo red (ig. $.2).

6eferral is needed to examine for underlying secondary

causes, such as systemic amyloi dosis. There are reports

of complete resolution with radia tion therapy, but this

treatment modality has not gained

Fig)re !"*5 Amyloidosis after ongo red staining: note applegreen birefringence with polarimetric filtered microscopy.


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8 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' (4+

mainstream acceptance (0$). 3urgical intervention is

usu ally underta-en to address specific symptoms and

can improve vocal deficits. 6ecurrence is quite common

(09).

Relasing 6olychon%ritis

6elapsing polychondritis is characteri*ed by intermittentrecurrent episodes and inflammation of cartilaginous

struc tures. hile the ears and nose are most commonly

affected, the larynx can also become involved. 1arly

studies demon strate 2C of patients have laryngeal

involvement at pre sentation but that up to half of

patients eventually develop airway symptoms (0;).

6adiographic studies, such as mag netic resonance

imaging (M64) and computed tomography (T) can

identify cartilaginous changes. &atients may pres ent to

the otolaryngologist with ear, nasal, and/or airway

complaints such as exertional dyspnea or stridor.

&urulent chondritis of the laryngeal framewor- has been

described as a sequela of superimposed infection (28).

Medical man agement is paramount as maintenance

includes low dose corticosteroids and/or methotrexate.

5apsone has also shown to be beneficial (2). 3urgical

intervention may be indicated to secure the airway with

tracheotomy. A small case series of patients underwent

airway reconstruction to provide more long"term airway

stability (2%).

Syste&ic L))s Erythe&ato)s

@i-e rheumatoid arthritis, systemic lupus erythematous

(3@1) has a predilection for females. 4ts effects are not usu

ally limited to the larynx as roughly two"thirds of patients

never experience laryngeal symptoms. &atients can pres ent

with a wide variety of laryngopharyngeal complaints, which

include dysphonia and dyspnea. A study including %

patients with 3@1 found that had laryngeal abnormal ities

(20). &hysical signs ranging from edema or ulceration to

vocal fold paralysis can be seen on examination (22).

'owever, a direct causal relationship between 3@1 and the

above laryngeal pathology has yet to be demonstrated.

6e&hig)s an% 6e&higoi%

&emphigus and pemphigoid are related autoimmune con

ditions differentiated by the target of their autoantibod

ies. hile both conditions lead to a robust inflammatory

reaction that can possibly lead to epithelial inury, pem

phigus autoantibodies are directed against intraepithelialtargets while pemphigoid autoantibodies target subepithe

lial antigens. 4mmunofluorescence of tissue biopsy is

used to identify the characteristic autoantibodies for

definitive diagnosis.

&atients may pr esent with signs of disease within the

nasal cavity or the larynx. The prevalence of laryngeal

involvement seems to differ between the diseases for

un-nown reasons. >ne study demonstrated that % of

#0 (28C) patients with head and nec- manifestations of


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Fig)re !"*7 @aryngeal pemphigus in typical supraglottic location.

pemphigus had laryngeal involvement (2#). 'owever , a

separate study of pemphigoid patients demonstrated that

8 of 09 (%C) patients with head and nec- symptoms

had laryngeal involvement (2). >ther studies have dem

onstrated relatively similar prevalence in pemphigus

(2$). +oth pemphigus and pemphigoid appear to have a

predi lection for supraglottic mucosa (ig. $.#). 'igh"

dose cor ticosteroids are utili*ed to control active disease

and are decreased for maintenance therapy. >ther

immunomodu lators, such as a*athioprine,

cydophosphamide, and cydo sporine, have also been

utili*ed for medical management. 3urgical intervention is

limited to diagnostic biopsy and/ or airway intervention,such as tracheotomy or less invasive airway surgery

(dilation) to provide a stable airway.

Sarcoi%osis

3arcoidosis is an autoimmune condition defined patho

logically by noncaseating granulomas. &atients most

com monly affected are young adult African American

women. @aryngeal involvement is seen in 0C to #C of

cases and

Fig)re !"*! 3arcoidosis in typical supraglottic location.


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usually affects the supraglottis (ig. $.) (29).

@aryngeal complaints from sarcoidosis, such as

nonproductive cough and dyspnea, may be difficult to

differentiate from the pulmonary manifestations of the

disease. 5iagnosis of sarcoidosis relies on multiple

modalities as there are usu ally multiple organ systems

involved. The establishment of laryngeal sarcoidosis

relies on laryngoscopic evaluation, with hallmar- exam

findings of submucosal infiltration in the infraglottic, paraglottic space, and the supraglot tis. 4nvolvement of

the epiglottis leads to a distortion and thic-ening and

has been commonly referred to as a tur ban epiglottis.

3arcoidosis remains an elusive diagnosisE however,

biopsy of lesions classically reveals noncaseating

granulomas.

Treatment mainly relies on corticosteroids, but other

immunomodulators, such as a*athioprine, have also

been administered with good treatment success (2;).

3urgical intervention is limited to diagnostic biopsy,

excision of symptomatic lesions, or management of

obstructive airway lesions.

E'ternal Bea& Ra%iation

As the role of external beam radiation has increased for the

treatment of head and nec- malignancies, many of these

patients later present with laryngopharyngeal complaints,

such as dysphonia, dysphagia, and globus sensation post

treatment. 1lectron beam radiation induces gradual, dose

dependent fibrotic changes to include muscle atrophyand fibrosis in the larynx as well as desiccation of mucosa

(ig. $.$). ibrosis within the lamina propria can be

appreciated as decreased mucosa= pliability on strobos copy.

&atients will exhibit atrophy that is disproportionate to

their expected age"related vocal fold volume loss. !ocal fold

hypervascularity is a common finding due to prior vasculitis

incurred during radiation therapy. 4mprovement in voice is

commonly reported following laryngeal radia tion for early

laryngeal cancer, but voice outcomes associ ated with late

radiation fibrosis of the vocal folds remains


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11 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' + + (4"

Fig)re !"*" 6adiation effects on the larynx: note global erythema, slight atrophy of muscular anatomy, and limited light reflexindicating decreased secretory function of the mucosa.

uncertain (#8,#). A prior report of postradiation vocal

quality suggests that vocal fold stripping or excisional

biopsy rather than limited biopsy for initial diagnosis and

continued tobacco smo-ing after treatment are signifi

cantly associated with an increased ris- of perceived

worse voice quality after treatment (#%).

As radiation oncologists develop more sophisticated

techniques to avoid collateral damage to uninvolved

struc tures, the extent of radiation changes may decrease.

BENI3N NEO6LASIA OF THE LARYNX

hen one excludes nonneoplastic vocal fold lesions,

such as vocal fold polyps, nodules, and cysts (see

hapter 9), benign tumors of the larynx are varied and

quite rare. 5iagnosis relies on thorough history with

appropriate examination and imaging.

Ha&arto&a

'amartomas are rare, benign lesions that can present as

congenital malformations or lesions later in life. They are

generally loosely organi*ed neoplasms with multiple

types of tissue, all of which are native to the affected

subsite of the larynx. 'amartomas can be incidentallyidentified or cause significant airway symptoms,

especially in a young child. &resentation and

symptomatology are related to the location of the

neoplasm, and hamartomas have been mostly commonly

identified in the supraglottis and sub glottis (#0,#2).

1xcisional biopsy is both diagnostic and curative if

resection is complete (##).

Chon%ro&a

hondromas are benign tumors consisting of

cartilaginous cells. They are slow"growing lesions that

do not metasta si*e, and they generally present as a

smooth, submucosal


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12 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' + , (4"

lesion. @aryngeal chondromas may be difficult to differ

entiate from low"grade chondrosarcomas and clinically

follow a similar course. hile the bul- of these tumors

present within the posterior cricoid cartilage, lesions

have been found within other subsites of the larynx as

well as the hyoid bone (#,#$). &atients may be

relatively asymp tomatic, but lesions can cause airway

obstruction or exter nal nec- masses (#). T isgenerally the preferred imaging modality to define the

extent of the lesion (#9). 3urgical excision is the

treatment of choice for chondromas. 3urgery has been

traditionally performed via open procedures involving

laryngofissure, but, more recently, endoscopic ablation

techniques have been shown to be successful (#;).

omparative efficacy between open and endoscopic

surgical excision is un-nown.

Rha.%o&yo&a

6habdomyomas of the larynx are benign tumors

compris ing striated muscle. @aryngeal involvement is

the most common location for rhabdomyomas of the

head and nec- (8). These tumors present in variable

locations within the larynx and have been documented to

involve both intrinsic and extrinsic laryngeal

musculature (,%). 5iagnosis with biopsy or magnetic

resonance is indicated, and complete resection is

curative.

Resiratory 6aillo&atosis

Though primarily seen in the pediatric population, adult

onset recurrent respiratory papillomatosis (66&) is not an

uncommon presentation. or further information regard

ing uvenile onset 66&, please refer to hapter ;2.

aused by human papillomavirus ('&!) subtypes

and , 66& occurs most commonly at the level of

thevocal folds. The virus can be transmitted vertically or

by sexual transmission. 66& can present anywhere withinthe upper aerodigestive tract from the nasal vestibule to

the bronchi oles with a predilection for areas of transition

from pseu dostratified columnar to stratified squamous

epithelium.

@esions can be relatively small, noticeable only

because of resultant dysphonia from decreased vocal fold

muco sal wave propagation, dysphonia related to mass"

effect that impairs glottal closure, or variable degrees of

airway obstruction (igs. $.9 and $.;). Though benign,

they do have significant morbidity and have the potential

for malignant transformation (0,2). A recent study

includ ing #2 adults demonstrated that dysplasia was

identi fied in #8C of patients, and dysplasia was

diagnosed on biopsy specimens at an average of .%

months from initial diagnosis. >f the initial #2 patients, 0

progressed to carci noma in situ while patient

progressed to squamous cell carcinoma (2).


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13 Section IV: Laryngology Chater !": In#ection$ In#iltration$ an% Benign Neolas&s o# the Laryn' + / (4"

Fig)re !"*4 Adult 66& occluding anterior glottis, limiting phonation.

radiation therapy, cigarette smo-ing, and systemic immunosuppression have been implicated in malignant trans

formation ().

The verrucous papillomatous growth of the lesions are

pathognomonic. Though multiple treatment modalities

are available, conservative removal of disease is the first

line treatment. If cold instrumentation is to be utili*ed,

careful attention must be dedicated to only removing the

papilloma and leaving the superficial lamina propria undis

turbed. Ablation with >% or potassium titanyl phosphate

(FT&) lasers has also been shown to be a successful treat

ment modality for both initial and subsequent treatments

($). A great benefit of fiber"based laser treatment is that it

can be performed in an awa-e patient using a channeled

endoscope through which the fiber can be advanced. Awa-e

procedures decrease use of operative resources and elimi

nate the need and dangers of general anesthetic. 6egardless

of the surgical technique utili*ed, the physician must avoid

deepitheliali*ed surfaces in uxtaposition to avoid anterior

glottic webbing and/or posterior glottic stenosis.

Fig)re !"*( Adult 66& nearly occluding entire glottis.

hile surgical removal of lesions remains the first"line

treatment for 66&, other aduvant therapies have been

developed. idofovir is an antiviral shown to decrease

dis ease burden in both intralesional inection and inhaled

forms (9,;). +oth treatment modalities have been

shown safe, but hepatotoxicity has been identified with

the inected form. 4nterferon"alpha and indole"0"carbinol

(an extract found in cruciferous vegetables) have both

been used to control disease propagation ($8).

The


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Fig)re !"*+8 Adult supraglottic hemangioma. obblestone"appearing lingual tonsils are visibleat the inferior aspect of this image.The epiglottis is completely obscured by this hemangioma.

paucicellular areas, and the extracellular matrix tends to

be composed of 7cytologically bland spindle cells.7 The

reported cases all appear to be isolated lesions that pre

sented with dysphonia and cough ($$).6adiographicimag ing (er and M64) can delineate the full extent of the lesionin planning for surgical resection. 1xcision with margins is

advocated to minimi*e chance of recurrence ($9).

Sch9anno&a

3chwannomas arise from nerve sheath fibers and account

for less than % of all laryngeal tumors. The endoscopic

appearance may be mista-en for a laryngocele and com

monly appear as smooth submucosal mass within the

pyri form sinus or aryepiglotticspace ($;). &atients may

present

with globus sensation, dysphagia, dysphonia, and if large,airway obstruction (98). 4maging with er and/or M64help

to plan surgical resection. 'istopathologic examinationdemonstrates the classic Antoni A and Antoni + areas

seen with other schwannomas. The associated nerve was

not identified in the available case reports. 3ome patients

have postoperative dysphonia and vocal fold paresis,

possibly implying recurrent laryngeal involvement ($;).

3ran)lar Cell T)&or

Granular cell tumors can occur anywhere within the

body but are often seen within the head and nec- (9).

The larynx, however , is a rare location for these neo

plasms. They are neural in derivation and, within the

larynx, tend to grow slowly and isolate within the

vocal folds themselves. &resenting symptoms include

hoarse ness, strider , dysphagia, and cough. +iopsy

must be com pleted to evaluate for malignant neoplasm

as there is an association with pseudo"epitheliomatous

hyperplasia, which can mimic squamous cell

carcinoma. 3erologic staining of biopsy specimens will

yield positive results for 3"88, neuron"specific

enolase, vimentin, and 5 9 (9). omplete resection

with microlaryngeal phono surgical instruments and

principles can yield cure with good vocal outcome.

LARYN3OCELES AN SACC0LAR CYSTS

hile laryngoceles and saccular cysts are not neoplasms,

they present as benign appearing masses in the larynx.

The laryngeal saccule is a mucous gland containing

appendage that lies between the false vocal fold and the

thyroid carti lage. 4t is an out pouching of the normal

laryngeal ventricle and extends as a blind"ended sac posterolateral to the edge of the laryngeal surface of the

epiglottis. The function of the saccule is un-nown

although ithas been theori*ed that it may represent a

vestigial air sac. +oth laryngoceles and saccular cysts

involve expansion of the saccule to form a mass.

@aryngoceles by definition must have air contained

within their lumen, while saccular cysts are strictly fluid

filled masses.

@aryngoceles contain air due to patent communication

with the laryngeal lumen. urther classification of laryn

goceles depends on their location. They can be defined as


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Fig)re !"*++ ombined laryngocele. Axial T showing air"filleddilation of the saccule extending through the thyrohyoid mem

brane into the nec-.

internal, external, or combined. 4nternal laryngoceles are

strictly confined within the thyroid cartilage, external laryn

goceles lie exclusively outside the cartilaginous laryngeal

framewor-, and combined laryngoceles spanboth the inside

and outside of the thyroid cartilage (9%,90) (ig. $.).

3accular cysts are also classified according to their

loca tionE anterior and lateral. Anterior saccular cysts

appear as rounded fluid"filled masses emanating from

the ante rior portion of the ventricle and extend medially

into the lumen of the larynx (ig. $.%). They liesuperior to the glottal level at or near the anterior

commissure, and inter fere with phonation or airway

depending on their si*e. @ateral saccular cysts expand

within the paraglottic space and appear similar to internal

laryngoceles as a submuco sal fullness in the ventricular

fold.

Although the etiology of saccular masses is unclear,

they result from abnormal dilation of the saccule. 4t has

been suggested that those who routinely develop high

trans glottic pressures (glass blowers, trumpet players)

are at a higher ris- of developing laryngoceles. It is

thought that saccular cysts arise secondary to obstruction

of the saccular orifice as they have been found in patients

with laryngeal carcinoma or following an upper

respiratory tract infection (92). ongenital saccular cysts

can occur in infants and present as a wea- cry, stridor, or

cyanosis (90).

&atients with laryngoceles and saccular cysts report

symptoms consistent with a laryngeal mass: dysphonia,

stridor , chronic cough, a nec- mass, and occasionally

dys phagia. 3everity of symptoms depends on the si*e

and location of the lesion. 3mall or nonobstructing

lesions may be asymptomatic. The diagnosis is most

commonly made by physical examination including

transnasal or transoral laryngeal imaging and nec- exam.4n the case of


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Fig)re !"*+, Anterior saccular cyst. luid"filled mass arisingfrom the saccule and protruding into the laryngeal lumen.

anterior saccular cysts, a mass can be seen emanating from

the vestibule to the laryngeal lumen while lateral saccular

cysts and laryngoceles present as a submucosal mass in the

false vocal fold. 1xternal and combined laryngoceles can

present as a nec- mass that enlarges with valsalva. +oth

laryngoceles and saccular cysts can become acutely infectedto form a laryngopyocele or an infected saccular cyst.

3uper"infection can lead to rapid expansion and acute pre

sentation with worsening symptoms, fever, and occasion

ally, airway obstruction.

ine"cut T is a useful adunctive tool diagnostically.

The presence of air within the lesion differentiates laryn

goceles from saccular cysts. The location and extent of

the lesion can be accurately assessed with a fine"cut T

scan. 1ndoscopic excision of these lesions is the mainstay

of treatment and the recurrence rate is very low with

long term follow up (92).

S0--ARY

The larynx can be subect to infectious agents, inflamma

tory conditions, and neoplasia. The initial management

of the patient must be to ensure a stable, secure airway.

>nce the airway is ensured, a thorough history and physi

cal examination, followed by detailed laryngeal

endoscopy


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and directed biopsy, can usually narrow the differential

diagnosis and guide the physician to appropriate diagnos

tic testing. Treatment should address the patientDs symp

toms and ideally ensure both airway stability and future

vocal performance.

I Multiple infections, inflammatory, and benign

processes can affect the larynx. 1ach has its own

unique presentation and treatment considerations.

I 4nfectious laryngitis is most commonly viral in eti

ology, and should be initially treated with voice

rest and supportive measures in most cases.

+acterial, fungal, and mycobacterial infection is

considerably more rare.

I 4nflammatory and infiltrative processes of the lar

ynx can occur from egener granulomatosis (typi

cally subglottic involvement), sarcoidosis(typically supraglottic involvement), amyloidosis,

and auto immune processes (such as rheumatoid

arthritis, 3@1, and pemphigus/pemphigoid)

I The most common benign neoplasm of the larynx

is laryngeal papillomatosis. @aryngeal

chondromas, hamartomas, schwannomas,

fibromas, pleomor phic adenomas, and granular

cell tumors are far more rare.

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2. &ochini 3obrinho , 5ella Begra M, Jueiro* , et al.'istoplasmosis of the larynx. Braz J Owrhinolarynol %88$E$0:9#$"9.

#. +oyle H>, oulthard 3, Mandel 6M. @aryngeal involvement indisseminated coccidioidomycosis. !rch Otolarynol Head "ec# Sur ;;E$:200"209.

. 1beo T, >live F, +yrd 6& Hr, et al. +lastomycosis of the vocalfolds with life"threatening upper airway obstruction: a casereport. $ar "ose Throat % %88%E9:9#%"9##.

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