The PPT note provide an overview of benign laryngeal tumors, highlighting their anatomy, types, causes, symptoms, and treatments. Key categories include cystic lesions (ductal and saccular cysts, laryngocele), granulomas (specific and nonspecific), and papillomas caused by human papillomavirus (HPV). Cystic lesions vary by location and symptoms, with treatments like micro-laryngoscopic removal or CO2 laser excision. Granulomas, such as amyloidosis and intubation-related granulomas, are managed via surgical excision or medical interventions depending on the extent and type. Recurrent respiratory papillomatosis, linked to HPV-6 and HPV-11, is particularly significant for its potential malignant transformation and requires repeated surgeries with adjunct medical therapies.
Additional benign tumors include cartilaginous, vascular (hemangiomas), and mesodermal types like rhabdomyoma and lipoma. Vocal cord nodules and polyps, common in voice abuse cases, are treated with speech therapy or microsurgery. Other rare conditions, such as tuberculosis, syphilis, and sarcoidosis of the larynx, are addressed with a combination of medical and surgical approaches. The presentation underscores the importance of precise diagnosis using imaging, laryngoscopy, and biopsy, followed by tailored treatment to preserve function and prevent malignancy.
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SLIDES OUTLINE
BENIGN NEOPLASTIC LESIONS OF LARYNX
Surgical anatomy
Cystic lesions
Granuloma
Papilloma: JORRP and adult papilloma
Vocal nodule and polyps
Benign Ectodermal and Mesodermal tumour
SURGICAL ANATOMY
Blood, nerve supply and lymphatic drainage
CYSTIC LESION
Ductal cyst
Saccular cyst
Laryngocele
DUCTAL CYST
most common cyst
Cause: Blockage of ducts of seromucinous gland larynx
SITE
TrueVC, Ventricle, FalseVC, AE fold, Epiglottis , Vallecula, Pyriform fossa
SYMPTOMS
Depend on size and site
Small: Asymptomatic
Large: Hoarseness, cough, sore throat
TREATMENT
Micro laryngoscopic removal
SACCULAR CYST
Mucous filled dilation of laryngeal saccule
Location: Submucosal
Cause: Obstruction of orifice of saccule
TYPES;
Anterior: Anterior part of ventricle and obscure
part of VC
Lateral: Larger, extend into false cord, AE fold
laryngoscopy
SYMPTOMS
Depend upon size of tumour
Hoarseness, breathing difficulty/stridor
INVESTIGATION
CT scan: Extend of lesion
TREATMENT
Micro laryngeal surgery
Endoscopic excision of cyst
Marsupilization: CO2 laser or endoscopically
External approach: large lateral cyst
LARYNGOCELE
Air filled dilatation of laryngeal saccule
TYPE
Internal
External
Mixed
INTERNAL
Sac confined within larynx
Presents as distension of false
cord and AE fold
EXTERNAL
Sac extend beyond the limit of
thyroid cartilage as presents as
neck mass
MIXED
Both external and internal
component present
PRECIPITATING FACTOR
Raised transglottic pressure
E.g. in trumpet player and weight lifter
SYMPTOMS
Hoarseness
Cough
Resp obstruction
Neck swelling
Increases on crying or straining
DIAGNOSIS
Compression : hissing sound
IL :submucosal mass
Flexible endoscope : mass enlarge during valsalva maneuver
X-ray soft tissue neck: Air filled sac
CT scan: Extend of lesion
TREATMENT
Small lesion; Endoscopic excision or
Marsupilization
External or large internal : excision via external approach
GRANULOMA
Amyloidosis
Specific granuloma
Non specific granuloma
SPECIFIC GRANULOMA
Tuberculosis, Sarcoidosis, Syphilis,
Scleroma of larynx, Wegener’s granuloma,
Leprosy, Fungal granuloma
AMYLOIDOSIS
Extracellular deposits of proteinaceous substance
TYPE
1. Generalized: primary , secondary
2. Localized
LARYNGEAL AMYLOIDOSIS
Primary
M>F
Age: 40-60yrs
Solitary / diffuse swelling
SITE
False VC
AE fold
Subglottis
TVC
SYMPTOMS
Depend upon site
VC: Hoarseness
Subglottic: Resp obstruction
Supraglottic: Uncharacteristic and vague symptoms
DIAGNOSIS
Biopsy: Congo Red staining: Bright red color : microscopy
TREATMENT
Surgical
Localized /solitary: Endoscopic removal
Diffuse: repeated excision
Extensive lesion: external approach
Medical;
Immunological origin: immunosuppressive
NON SPECIFIC GRANULOMA: Trauma
Post operative granuloma
Intubation granuloma
Foreign body granuloma
POST OPERATIVE GRANULOMA
Laryngeal Endoscopic procedure
Partial laryngectomies
Laser surgery ( for Rx of malignancy) ;excessive granuloma formation during healing process
INTUBATION GRANULOMA
(contact granuloma)
Long term intubation
Ulceration of mucosa overlying vocal process
Influencing factor
Duration of intubation
Type of tube
Degree of relaxation of pt
FEATURES
Unilateral/bilateral
Location : Medially or Superiorly on vocal process of
arytenoid
Appearance : Polypoid
Color : Red
SYMPTOMS
Dx within a few weeks (~ 4 – 5) of extubation
Hoarseness
Irritation
Sore throat
TREATMENT:
Endoscopic excision: Recurrence may occur
Repeated treatment is necessary
CONTACT ULCER
(CONTACT PACHYDERMIA)
Misnomer: No epithelial defect
Location : medial edge of vocal cord
B/L & symmetrical
Saucer shaped
nearly exclusively in men> 30 yrs
ETIOLOGY
Vocal abuse
Emotional stress
GERD
SYMPTOMS
Low pitched voice ☼
Irritation and sore throat
Cough and frequent clearing of throat
TREATMENT
Biopsy should be done to R/O malignancy,
Voice rest
Voice rest plus surgical resection
Speech therapy
No difference speech therapy Vs speech therapy +surgery
Excessive granuloma should be excised to facilitate voice therapy
RESPIRATORY PAPILLOMATOSIS
Human papilloma virus (HPV), HPV-6 and HPV-11
TYPES
Juvenile-onset recurrent respiratory papillomatosis [JORRP): children < 5 years
Adult-onset respiratory papillomatosis [AORP]): fourth decade of life
HPV-11 more severe; 70% require tracheostomy,
HPV-6 less severe <20% tracheostomy,
PATHOPHYSIOLOGY
After infection, the virus may remain in basal layer of mucous mem (episomal maintenance},
As cells of basal layer differentiate
Changes in host cell allow the viral genes to be switched on (transcribed) and viral particle can be identified in stratum granulosum and corneum
JORRP
TRANSMISSION : Peripartum
Risk factors
Vaginal delivery
Firstborn
Mother younger than 20 years
SITES
Anywhere in the mucous mem of respiratory tract (nose to the lung) and upper food passage
Larynx: 95% (anterior glottis, anterior commisure)
Trachea : usually following tracheostomy
About 2% of tracheal involvement develops bronchial involvement
31% outside of the trachea and larynx (e.g., oropharynx, nasopharynx, mouth, bronchi, lung parenchyma)
CHARACTERISTIC OF DISEASE
Occurs in cluster on involved mucosa
Fronds of papilloma; sessile/
Pedunculated
Number : multiple ( usually)
Single: at onset
Recurrent:
FEATURES
Epidemiology
In US: < 14 years :4.3 per 100,000
>15 years):1.8 per 100,000
Internationally: as in the United States.
Malignant degeneration : 3-5% sq cell carcinoma.
Use of radiotherapy to control the disease
Smokers
Sex:
JORRP : M:F=1:1
AORP M>F.
Age: Mean age at diagnosis
JORRP: 3.8 years.
AORP:3rd to 4th decade of life
SYMPTOMS
Hoarseness ☼
Other symptoms
Voice change
Weak cry
Choking episodes
Foreign body sensation in the throat
Cough
Dyspnoea
Stridor
INVESTIGATION
Laryngoscopy or bronchoscopy: characteristic warty growths
2. Lab investigation : Typing of the virus(PCR).
HPV-11 : Severe disease
Risk of malignant transformation.
3. Imaging Studies:
CXR: multiple /single cyst containing fluid or air .
CT scans (upper airway) :tumor like papillomatous growths in larynx or trachea.
4. Biopsy
Confirmation.
viral typing
R/O malignant transformation
TREATMENT
SURGERY
Primary Rx involve repeated debulking
CO2 laser
Microspot laser
Microdebrider
Use of 585nm pulse dye laser
MEDICAL
These appear to increase the interval between the need for resection
Intralesion cidofovir
Indole-3-carbinol
Interferon
Ribavirin
DIET: Cruciferous vegetables
Cabbage, cauliflower, broccoli which
contains indole -3 -carbinol
REMISSION
Related to age and site of presentation of disease
Age:
6-10 yrs: highest
<16yrs: 46%
> 16yrs: 26%
Site:
Larynx: 48%
Tracheobronchial: 27%
Lungs: 0%
ADULT PAPILLOMA
Transmission :
Unknown,
Sexual transmission is probable
Occurs as solitary or more localized than JORRP
less aggressive
Single removal produces cure, sometimes recurrent but interval are long
Ca has been reported in adult papilloma
CARTILAGINOUS TUMOUR
No clear cut histological or clinical distinction between chondroma & chondrosarcoma
CHONDROMA
Age: 40-70
M: F: 4:1
Site:
Cricoid cartilage: 70%
Thyroid: 20%
Arytenoid: 10%
SYMPTOMS
Non specific
Hoarseness, dyspnoea ,dysphagia and neck swelling
Depend on site and size of tumour
Dyspnoea: Tumour from cricoid cartilage extend into subglottic space
Hoarseness : If vocal cord mobility is impaired
Dysphagia: Extension of tumour posteriorly to
hypopharynx
Neck swelling: Tumour is located in cricoid ring
or in thyroid cartilage
DIAGNOSIS
IL examination: Smooth encapsulated mass covered by intact mucosa
Radiology : Peripheral or Central calcific stippling
(mottled calcification)
Biopsy ; Unrepresentative
Histopathology:
Difficulty in distinguishing between chondroma and highly differentiated chondrosarcoma as pronounced cellurality and polymorphism occur in small foci
DNA measurement may assist in a correct diagnosis
TREATMENT
Surgery treatment of choice
Conservative surgery; recommended on account of the slow growth rate and low incidence of metastasis
If more than 50% of cricoid is involved it needs to be reconstructed
HAEMANGIOMA
1. Infantile
2. Adult
INFANTILE HAEMANGIOMA
Site: Subglottis
5% have other congenital abnormalities and half of them are cutaneous haemangioma
SYMPTOMS
Dyspnoea betw 3-16th week of life
Resp distress: fluctuating character
LARYNGOSCOPIC EXAMINATION
Mucosa covered mass (blue or red) in subglottic region
TREATMENT
CO2 laser superior to steroid
If laser not available: tracheostomy and wait for resolution
Other options: excision via laryngofissure or laser or cryotherapy
Oral Propanolol
ADULT HAEMANGIOMA
Site: at or above level of vocal cord
SYMPTOMS
Hoarseness
LARYNGOSCOPIC EXAMINATION
Mucosa covered bluish mass
TREATMENT
Asymptomatic: no treatment
Corticosteroid or RT when haemangioma progressively involve additional part of larynx
MYOGENIC TUMOUR
Leiomyoma
Rhabdomyoma
Granular cell myoblastoma
LEIOMYOMA
Common in adults
Site: supraglottic
Size : pea to pigeon egg size
TREATMENT
Surgical excision,
Endoscopic or an external approach depending on tumour size
RHABDOMYOMA
Adult rhabdomyoma
Fetal rhabdomyoma
ADULT TYPE
True adult type : extremely rare
Around 80% of non cardiac lesion occur in head and neck , principally in larynx
Site: most common : vocal cord region
/ extend above and below cords
They appear as polypoid mass
FETAL RHABDOMYOMA
Extremely rare
It usually presents shortly after birth but may occur in adult and present as vocal cord polyp
The precise nature of this tumour is unknown; (may be hamartoma)
TREATMENT
Surgical through Endoscopic route
GRANULAR CELL TUMOUR
(GRANULAR CELL MYOBLASTOMA)
Uncommon
Once thought not a true tumour but a degenerative disease of mature striated muscle
Evidence now suggest origin from neural tissue; (Schwann cell)
SITE
Commonly in tongue
Laryngeal <10%
(Mostly True cord)
TREATMENT:
Endoscopic excision
Overlying epithelium may show the appearance of pseudoepitheliomatous hyperplasia, which are confused with squamous cell carcinoma
FIBROMA
Rare
Composed of fibrillar connective tissue
Appearance :
Pedenculated/sessile
Round
smooth
TREATMENT
Endoscopic removal
LIPOMA
Site : Adipose tissue of false cord
Lipoma form hypopharynx and extended into larynx
Macroscopic: light coloured, encapsulated and lobulated tumour
Microscopically: composed of fat cell of varying size and fibroreticular stroma
TREATMENT
Endoscopic removal or by external approach depending on the size and location
BENIGN ECTODERMAL TUMOUR
1. Epithelial tumour :
Adenoma
2. Neurogenic tumour
Schwannoma
Neurofibroma
ADENOMA
Rare
Origin: seromucinous glands of larynx
Site: subglottic larynx
Symptoms
Small: non specific
Large : respiratory obstruction
TREATMENT
Biopsy to R/O malignancy
Surgery
Approach depend on size and location of adenoma within the larynx
SCHWANNOMA
Rare
Well encapsulated slowly growing tumour
Origin: Schwann cell of axon sheath
Site: AE fold close to apex of arytenoid cartilage,
internal branch of superior laryngeal nerve
Incidence
4-5th decade, F>M
Symptoms
Insidious, tumour are usually small
TREATMENT
Surgical depending on size and location
Endoscopically
Laryngofissure
NEUROFIBROMA
Part of Von Recklinghausen’s syndrome (neurofibromatosis type1)
Common in : children and adolescent
SITE: Supraglottis but they can occur as far down as
subglottis
LARYNGOSCOPIC
Pink or yellow submucosal masses along AE fold
TREATMENT
Not suitable for Endoscopic resection because of indistinct border and lateral pharyngotomy or thyrotomy is necessary
Vocal Cord Nodules
Appear on the junction of the anterior
and middle two-thirds of the vocal fold,
where contact is most forceful.
- The nodules appear as
symmetrical swellings on
both sides of the vocal cords.
Risk factors : Persons who are
in a loud environment. Examples include teachers, cheerleaders, politicians, actors. And female .
Treatment
- Speech therapy
Speech therapy should be used as a first-line treatment. It is the mainstay of treatment in both children and adults.
- Microlaryngoscopy
Nodules may be excised using appropriate microsurgical instruments, or vaporized using a pulsed CO2 laser
Vocal Cord Polyps
Usually unilateral, pedunculated lesions.
Associated with smoking and voice abuse.
Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds
Treatment
Microsurgery :mainstay of therapy
Hemorrhagic polyps
Pulsed-dye lasers absorbed by hemoglobin (585 nm)
Lasers more effective for smaller polyps
Thank you
REINKE'S OEDEMA(bilateral diffuse polyposis)
Collection of oedema fluid in subepithelial space of reinke
Caused due to vocal abuse and smoking.
Both vocal cords show diffuse symmetrical swellings.
Treatment: Vocal cord stripping, preserving enough mucosa for epithelialisation.
ONLY ONE CORD IS OPERATED AT A TIME
Re-education in voice production and cessation of smoking are essential to prevent recurrence.
SPECIFIC GRANULOMATOUS
TUBERCULOSIS OF LARYNX
Almost always associated with open pulmonary Tuberculosis
Due to contamination of sputum containing acid fast bacilli
May rarely develop by blood borne infections which causes extensive ulceration of mucosa
Common age group : 20-40 yrs
Incidence increasing due to emergence of AIDS
TUBERCULOSIS OF LARYNX PATHOLOGY
Posterior part of larynx affected than anterior
Formation of submucosal tubercles which later may caseate and ulcerate producing undermined ulcers
There may be infiltration of epiglottis and arytenoids
Self limiting to some extent –> heals with fibrosis-> stenosis of larynx
With reparative process tumor like swellings are found called Tuberculomas
there may be diffuse oedematous reaction consistent to allergic response to AFB
TUBERCULOSIS OF LARYNX SYMPTOMS
Throat pain
Referred otalgia
Hoarseness with weakness of voice (earliest symptom)
Painful speech
dysphagia
TUBERCULOSIS OF LARYNX SIGNS
Mucosal hyperemia and oedema
Inter-arytenoid mamillations
Undermined ulcers- mouse nibbled appearance
Turban epiglottis
Ragged ulcerations on arytenoids and inter-arytenoid region
Pale granulation tissue in inter-arytenoid region
Pale laryngeal mucosa
Monocorditis
TUBERCULOSIS OF LARYNX DIAGNOSIS
Chest X-ray
Sputum examination for AFB
Laryngoscopic examination
Biopsy of laryngeal lesion
TUBERCULOSIS OF LARYNX TREATMENT
Anti tubercular drug regimen
Vocal rest
Nutritional supplements
SCLEROMA OF LARYNX
Klebsiella rhinoscleromatis is the causative organism
Laryngeal involvement is seen with or without nasal lesion
Subglottic region is commonly involved
SCLEROMA OF LARYNX- SYMPTOMS AND SIGNS
Non specific symptoms as seen in other chronic laryngeal infections like hoarseness, wheeze
Dyspnoea may be presenting symptom in addition to nasal lesion
Presents as smooth red swelling in subglottic region
SCLEROMA OF LARYNX- DIAGNOSIS
Biopsy of the lesion
Histopathology -> specimen shows Mikulicz cells, Russell bodies, gram negative organism within the Mikulicz cell
Culture of organism from biopsy material
SCLEROMA OF LARYNX- TREATMENT
Medical combination of an aminoglycoside such as gentamycin with an anti-metabolite such as tetracyclin
Steroids to reduce fibrosis
Surgical
Endoscopic removal of granulomatous tissue
Mild stenosis dilatation
Severe subglottic stenosis tracheostomy
SYPHILIS OF LARYNX
Now rarely seen
All stages can manifest in larynx
Primary lesion described rarely
Tertiary stage is most important gumma are seen
Peri arterial infiltration and obliterative endarteritis
Prediliction for anterior part of larynx epiglottis and AE folds
SYPHILIS OF LARYNX
Oedematous mucosa with infiltration of plasma cells, lymphocytes and giant cells
Deep ulceration with central sloughing
Abundant necrotic tissue reaches and penetrates laryngeal cartilages
Considerable destruction after healing leaves deformity of larynx and often stenosis
SYPHILIS OF LARYNX- CLINICAL FEATURES AND MANAGEMENT
Hoarseness, sometimes dysphagia, pain is rare
Oedema of mucosa leading to stridor
Diagnosis only on biopsy and serological tests
Treatment Prolonged treatment with high doses of penicillin
Local treatment by inhalation
Endoscopic removal of necrotic tissue to maintain airway
tracheostomy
LEPROSY OF LARYNX
Caused by mycobacterium leprae (Hansen's bacillus)
Both lepromatous and tuberculoid can arise in larynx
Epiglottis and AE fold most commonly affected
Granulomatous swelling and often ulceration and destruction in supraglottic region
Epiglottis may be curled
Mucosa may be studded with nodules
Virchow cells ( foamy histiocytes) and mucosal thickening seen on HPE
LEPROSY OF LARYNX- TREATMENT
Medical Dapsone, Clofazimine, Rifampicin
Surgical tracheostomy in cases of stenosis
WEGENER’S GRANULOMATOSIS
Diffuse systemic disease of unknown cause
Includes triad of necrotizing granulomatous lesion in upper and lower respiratory tract (sinusitis, rhinitis), vasculitis involving pulmonary arteries and veins and necrotizing glomerulonephritis
Larynx is rarely source of primary manifestation
Lesion usually lies in subglottis laryngeal obstruction
Edematous mucosa with granular appearance which bleeds easily and sometimes ulcerates
If untreated can be rapidly fatal
Immunosuppressive drugs especially cyclophosphamide are very active
Steroids should be started early
SARCOIDOSIS OF LARYNX
Chronic idiopathic granulomatous disease also called Besnier-Boeck disease
Head and neck manifestations in 10% of whom only minor proportion have laryngeal disease
Disease is usually self limiting
Pathology non specific granuloma later fibrosis and hyalinization
Main site involved is supraglottis
SARCOIDOSIS OF LARYNX- CLINICAL FEATURES AND MANAGEMENT
Hoarseness, dysphagia and dyspnoea
Epiglottis and false vocal cords are swollen and pale
True cords and subglottis rarely affected
Lesion can progress rapidly leading to life threatening airway obstruction
Diagnosis biopsy
Positive Kveim’s test, elevated serum angiotensin converting enzyme is highly suggestive
Treatment high dose corticosteroids, tracheostomy
LUPUS OF LARYNX
Indolent tubercular infection associated with lupus of nose and pharynx
Involves anterior part of larynx.
Epiglottis is involved first and may be completely destroyed. disease spreads to AE fold and ventricular bands.
Painless asymptomatic condition may be discovered incidentally
Prognosis is good
Treatment is anti tubercular drugs
MYCOSIS OF LARYNX
Following mycosis can occur in the larynx
Candidiasis
Coccidioidmycosis
Paracoccidioidmycosis
Histoplasmosis
Blastomycosis
Cryptococcosis
aspergillosis
Leukoplakia (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
Leukoplakia (keratosis) larynx
Hoarseness is common presenting symptom
Treatment is stripping of the vocal cords and histopathological examination to rule out malignancy.
