Benign larygeal lesion ( voice disorder)

Anatomy: Laryngeal skeleton consist of 9 cartilages

Main laryngeal structure formed by 3 unpaired cartilages (Thyroid, cricoid, and epiglottic )

Remainder of the framework : paired cartilages (Arytenoid, corniculate, and cuneiform )

Division of Larynx

 Supraglottis - from the inlet to the false cords.

 Glottis – Space between vocal cords

 Subglottis - from the inferior aspect of the the glottis to the lower border of cricoid.
Muscles of Larynx :

1) Intrinsic muscles

• Acting on vocal cords : Abductors ,Adductors , Tensors

• Acting on laryngeal inlet :opener,closer

2) Extrinsic muscles : Elevators, Depressors

Vocal cord: Fixed to the thyroid cartilage anteriorly & arytenoid cartilage posteriorly.

a. Anterior 2/3 – membranous (vocal fold)

b. Posterior 1/3 – vocal process of arytenoid cartilage

Most benign lesions affect the membranous portion

Functions :1) Airway protection 2) Respiration 3) Phonation

Can be divided into two categories

1) Non-neoplastic : Vocal nodules , Vocal Polyp , Vocal Cyst , Reinke’s

edema ,Granuloma ,Leukoplakia ,Intracordal scars

2) Neoplastic :Papilloma
VOCAL FOLD NODULE VOCAL FOLD POLYP VOCAL FOLD CYST

• Singer’s nodes, • Formed by capillary 2 type of cyst found

screamer’s nodes break in Reinke in Reinke’s space
• Phonotrauma (vocal space with leakage
abuse) Yelling, of blood resulting in 1) Mucus retention
screaming local edema and cyst
• Common in organization with Cause: poor vocal
• Women hyalinized trauma. hygiene
• Children 2) Epidermoid cysts
(boys) -congenital,vocal
• Actors abuse
• Singers
Site: • Unilateral
• Bilateral • broad spectrum of
• Directly face appearance
each other • Hemorrhagic
• Junction to
between edematous
anterior 1/3 • Pedunculate
and posterior d to sessile
2/3 • Gelatinous
to hyalinized
CP: CP: • Hoarseness
• Decrease amplitude of • Excessive air egress • Increased effort,
mucosal wave during phonation fatigue, pain,
• Symmetric mucosal • Fatigue soreness when
wave • Frequent voice voice is used
• Decreased closure: breaks • Singers: Abrupt loss
hourglass-shape • Decreased vocal of voice or break at
glottal closure power a certain pitch,
• Chronic hoarseness • Asymmetric mass : decreased range,
• Singers : frequent produces more easy fatigability and
voice breaks, chaotic vibrations & straining.
breathiness, vocal aperiodic mucosal • Dysphonia,
fatigue. waves • Rare: Stridor,
• Larger polyps à globus sensation,
decreased wave dysphagia
amplitude
Dx: Dx: Dx:
• Physical examination • Physical • Physical
• Indirect laryngoscopy examination examination
• Laryngeal stroboscopy • Indirect • Indirect
laryngoscopy laryngoscopy
• Laryngeal - cyst may appear
 stroboscopy as a fullness in the
fold or simply as a
lucent outline
visible under the
mucosal cover

Tx: Tx : Tx:
1) Conservative voice 1) Conservative 1) Surgery
use treatment for small -Dissection in
-Speech therapy polyp submucosal plane
-Limitation of 2) Microsurgery, with complete cyst
vocally damaging Pulsed-dye laser for removal
behavior hemorrhagic polyp
- Improve vocal
hygiene/care

• 2) Microsurgery
• Through direct
laryngoscopy
• Large nodule
• Air patency
compromised
 REINKE EDEMA VOCAL GRANULOMA VOCAL PAPILLOMA

• Diffuse edematous • occur when the lining on • Aetiology: Human

changes of the vocal the cartilage in the back papilloma virus (HPV.
cords. of the larynx is injured Common: Strain 6 &
• Due to collection of Causes: 11)
oedema fluid in the - Intubation for surgery • 2% malignant
subepithelial space of - Forceful voice use transformation (HPV 16
Reinke and 18)
• Causes:
• Vocal abuse
• Chronic
irritant
exposure –
smoking,
laryngophary
ngeal reflux
• Most commonly found
at columnar and
squamous junction.
CP: CP: CP:
• Usually bilateral • Chronic hoarseness • Hoarseness
• Both vocal cords show • Pitch change in your • Difficulty breathing if it
diffuse symmetrical voice grows large.
swellings • Significantly decreased • A sensation of a foreign
• Water-balloon out range (no longer hitting body in the throat
pouching from higher notes easily) • Hearing two pitches at
membranous vocal • Inability to sing quietly the same time
fold • Inability to hold a pitch • Decreased range (no
• Ball-valving effect steady longer hitting higher
(stridor) • Throat pain notes easily)
• Patient usually have • Voice fatigue • Inability to sing quietly
low or rough voice • Throat discomfort,
pain, or tightness
Tx: Tx: Tx:
• Remove the cause • Laryngopharyngeal reflux • CO2 laser
• Surgery treatment • Microshaver
(phonomicrosurgery) • Surgery (RARE) • Cidofovir injection
- Airway compromise • Compromise (adjuvant tx)
- Preserve some voice, breathing • Vaccine
superficial lamina or swallowing
propria and overlying • Suspicion for
epithelium to malignancy
preserve mucosal
wave
 VOCAL LEUKOPLAKIA FUNGAL LARYNGITIS

 Spectrum of change in epithelium  Disease of both immunocompromised and

 HyperkeratosisàDysplasia (mild, immunocompetent hosts
moderate)àCIS/ severe dysplasia  May mimick leukoplakia or malignancy
 Pattern of growth • White or gray
 Superficial, broad pseudomembrane on
 Verrucous, exophytic with mucosa
surrounding erythema • Mucosal erythema and
 8% to 14% rate of malignant edema (focal or diffuse)
transformation surrounding white plaques
• Mucosal ulcerations
• Contact bleeding
 Risk factors: Laryngopharynx reflux,
smoking, inhaled steroids, prolonged
antibiotic use
 Diabetes mellitus, immunosuppressants,
cancer patient, nutritional deficits
 Compromise mucosal barrier

• A chronic white mucosal macule • Symptoms

which cannot be scraped off, and – Weakened voice
cannot be given another diagnosis – Loss of voice
• White lesions : leukoplakia, – Hoarse dry throat
hyperkeratosis, pachydermia and – Constant tickling or minor throat
epithelial hyperplastic lesion irritation
• Difficult to predict which white lesion – Dry cough
progresses into carcinoma • Signs
• Appearance does not correlate with – Thick white patches over vocal cord
degree of dysplasia area
Dx:
 Suspicion and response to empiric therapy
 Culture from laryngeal brushing or biopsy
• Candida species most
commonly cultured
 Dysphagia may also have esophageal
involvementà do transnasal esophagoscopy
Tx: Tx:
 CO2 laser  Fluconazole x 3wks
 Microflap excision  Nystatin oral suspension swish and swallow.
 Preservation of normal mucosal wave  Prevention
for mild dysplasia • spacers for inhaled steroids
 More aggressive excision with • oral rinse, gargle with water after
increasing dysplasia use