1. Benign Laryngeal LesionsBenign Laryngeal Lesions

2. Factors contributing to vocal foldFactors contributing to vocal fold
lesionslesions
• voice overuse or misusevoice overuse or misuse
• smokingsmoking
• etohetoh
• Laryngopharyngeal refluxLaryngopharyngeal reflux

3. HistoryHistory
• medical conditionsmedical conditions
– AR, GERD, asthma, bronchitis, sinusitisAR, GERD, asthma, bronchitis, sinusitis
• medicationsmedications
• Environmental exposure: smoke,Environmental exposure: smoke,
allergens, particulates (dust)allergens, particulates (dust)

4. LPRLPR
• baseline inflammation predisposes VF tobaseline inflammation predisposes VF to
other stressesother stresses
• 78% w/ nodules had LPR78% w/ nodules had LPR

5. AllergyAllergy
• pts treated for AR had better outcome forpts treated for AR had better outcome for
treatment of laryngitistreatment of laryngitis
• hypersensitivity makes laryngeal mucosahypersensitivity makes laryngeal mucosa
more susceptible to stressmore susceptible to stress

6. PathophysiologyPathophysiology
• mech stress least at midpoint of membranous VF duringmech stress least at midpoint of membranous VF during
phonationphonation
• during hyperfunctioning dysphonia increased stress atduring hyperfunctioning dysphonia increased stress at
midpointmidpoint
• increased stiffness in body of VF at midpoint results inincreased stiffness in body of VF at midpoint results in
higher shearing stresses, worse if nodule or masshigher shearing stresses, worse if nodule or mass
presentpresent
• mass adds wt to VF decreasing vibratory qualities andmass adds wt to VF decreasing vibratory qualities and
frequency on stroboscopyfrequency on stroboscopy

7. PathophysiologyPathophysiology
• decrease in pitch range and impaired closuredecrease in pitch range and impaired closure
leads to breathy voice and fatigue.leads to breathy voice and fatigue.
• Asymmetry adds grainy quality to voiceAsymmetry adds grainy quality to voice
• once initiated, can cause compensatory muscleonce initiated, can cause compensatory muscle
tension to reduce air flow through glottistension to reduce air flow through glottis

8. Anatomy of vocal foldAnatomy of vocal fold

9. NodulesNodules

10. NodulesNodules
• bilateral symmetric epithelial swelling ofbilateral symmetric epithelial swelling of
ant/mid third of TVFant/mid third of TVF
• More prevalent in children, adolescents,More prevalent in children, adolescents,
femalesfemales
– softer intensity of voice causes hyperfunctionsofter intensity of voice causes hyperfunction
• Result of abuse or misuseResult of abuse or misuse

11. Nodule formationNodule formation
• junction of anterior to middle VF experiencejunction of anterior to middle VF experience
maximal shearing and collision forces.maximal shearing and collision forces.
• vascular congestion and edemavascular congestion and edema
• hyalinization of Reinke space and thickening ofhyalinization of Reinke space and thickening of
epithelium with epithelial hyperplasiaepithelium with epithelial hyperplasia
• nodules are acellular with thick epithelium overnodules are acellular with thick epithelium over
matrix of abundant fibrin and organized collagenmatrix of abundant fibrin and organized collagen
IV in BMIV in BM

12. SymptomsSymptoms
• decreased amplitude mucosal wavedecreased amplitude mucosal wave
• SymmetricSymmetric mucosal wavemucosal wave
• decreased closure: hourglass-shapedecreased closure: hourglass-shape
glottal closureglottal closure
• chronic hoarsenesschronic hoarseness
• singers: frequent voice breaks,singers: frequent voice breaks,
breathiness, vocal fatiguebreathiness, vocal fatigue

13. Treatment of NodulesTreatment of Nodules
• conservative voice useconservative voice use
• speech therapy to address techniquespeech therapy to address technique
• Microsurgery when speech tx and otherMicrosurgery when speech tx and other
contributing factors optimizedcontributing factors optimized

14. Vocal fold polypsVocal fold polyps

15. PolypsPolyps
• UnilateralUnilateral
• Broad-based vs. PedunculatedBroad-based vs. Pedunculated
• Formed by capillary break in Reinke spaceFormed by capillary break in Reinke space
with leakage of blood resulting in localwith leakage of blood resulting in local
edema and organization with hyalinizededema and organization with hyalinized
stromastroma
• Hemorrhagic (feeding vessel) vs.Hemorrhagic (feeding vessel) vs.
nonhemorrhagic (pseudocyst)nonhemorrhagic (pseudocyst)

16. Vocal fold polypsVocal fold polyps

17. Effect of polyps on mucosal waveEffect of polyps on mucosal wave
 Asymmetric mass produces more chaoticAsymmetric mass produces more chaotic
vibrations and aperiodic mucosal wavesvibrations and aperiodic mucosal waves
 Larger polyps cause decreased waveLarger polyps cause decreased wave
amplitudeamplitude
 Excessive air egress during phonationExcessive air egress during phonation
 FatigueFatigue
 Frequent voice breaksFrequent voice breaks
 decreased vocal powerdecreased vocal power

18. TreatmentTreatment
• Conservative for small polypsConservative for small polyps
• Microsurgery mainstay of therapyMicrosurgery mainstay of therapy
• Hemorrhagic polypsHemorrhagic polyps
– Pulsed-dye lasers absorbed by hemoglobinPulsed-dye lasers absorbed by hemoglobin
(585 nm)(585 nm)
– Lasers more effective for smaller polypsLasers more effective for smaller polyps

19. Vocal fold cystsVocal fold cysts

20. Vocal fold cystsVocal fold cysts
• Subepidermal epithelial-lineds sacs withinSubepidermal epithelial-lineds sacs within
lamina proprialamina propria
• Mucus retention cystsMucus retention cysts
• Epidermoid cysts congenital cell rests inEpidermoid cysts congenital cell rests in
the subepithelium of 4th and 6th branchialthe subepithelium of 4th and 6th branchial
arch or healing injured mucosa buryingarch or healing injured mucosa burying
epitheliumepithelium

21. Vocal fold cystsVocal fold cysts
• Ruptured cyst may result in LP scarring orRuptured cyst may result in LP scarring or
in a sulcusin a sulcus
• May causeMay cause reactive lesionreactive lesion on contralateralon contralateral
VFVF
• Size may vary with menstrual cycleSize may vary with menstrual cycle
– Caution when operating on premenstrualCaution when operating on premenstrual
femalesfemales

22. StrobolaryngoscopyStrobolaryngoscopy
• Asymmetric vocal foldAsymmetric vocal fold
• Decreased or absent mucosal wave on cyst sideDecreased or absent mucosal wave on cyst side
• DiplophoniaDiplophonia
• Glottic closure depends on cyst size andGlottic closure depends on cyst size and
reactive lesion on contralateral sidereactive lesion on contralateral side
• Mucosal waveMucosal wave
– present in 80% of polyps BUTpresent in 80% of polyps BUT
– absent in almost 100% of cystsabsent in almost 100% of cysts

23. Treatment of cystsTreatment of cysts
• Does not resolve with conservativeDoes not resolve with conservative
managementmanagement
• SurgerySurgery
– Dissection in submucosal plane with completeDissection in submucosal plane with complete
cyst removalcyst removal
– Prolonged mucosal wave recoveryProlonged mucosal wave recovery
– Discuss risks with ptDiscuss risks with pt

24. Reactive LesionsReactive Lesions

25. Reactive lesionsReactive lesions
• Reaction to unilateral VF lesionReaction to unilateral VF lesion
• Contralateral VF reactive callus withContralateral VF reactive callus with
epithelial hyperplasiaepithelial hyperplasia
• Bilateral like nodulesBilateral like nodules
• Strobe: asymmetry not seen in nodulesStrobe: asymmetry not seen in nodules
• Tx: treatment of primary lesion, mayTx: treatment of primary lesion, may
resolve with conservative managementresolve with conservative management

26. Before and AfterBefore and After

27. Intracordal ScarringIntracordal Scarring
• Scarring in Reinke space after repeatedScarring in Reinke space after repeated
inflammation, trauma or vocal hemorrhageinflammation, trauma or vocal hemorrhage
• Subepithelial scarSubepithelial scar
– Disorganized collagenDisorganized collagen
– Loss of ECMLoss of ECM
– Distinguish from epithelial scarring or vocal sulcusDistinguish from epithelial scarring or vocal sulcus
• VF appears stiff, white or opaqueVF appears stiff, white or opaque
• Hoarseness, vocal fatigue, breathiness, loss ofHoarseness, vocal fatigue, breathiness, loss of
projectionprojection

28. Sulcus VocalisSulcus Vocalis

29. Causes of Intracordal scarringCauses of Intracordal scarring
• Cysts predispose to scar formation (ruptured, epidermoidCysts predispose to scar formation (ruptured, epidermoid
origin)origin)
• TraumaTrauma
– Vocal fold surgery involving lamina propriaVocal fold surgery involving lamina propria
– Repeated epithelial proceduresRepeated epithelial procedures
– Biopsy, strippingBiopsy, stripping
– InhalationalInhalational
– IntubationIntubation
• CO2 laserCO2 laser
• RadiationRadiation
• Rheumatologic diseaseRheumatologic disease

30. • StroboscopyStroboscopy
– Markedly reduced orMarkedly reduced or
absent mucosal waveabsent mucosal wave
– Asymmetry affectsAsymmetry affects
phase closurephase closure

31. Treatment of vocal scarTreatment of vocal scar
• Microflap to remove cyst elements andMicroflap to remove cyst elements and
adynamic fibrous componentsadynamic fibrous components
• Medialization thyroplasty for glottic gapsMedialization thyroplasty for glottic gaps
• Replacement soft tissue (Fillers)Replacement soft tissue (Fillers)
– CollagenCollagen
– FatFat
– Hyaluronic acidHyaluronic acid

32. Reinke EdemaReinke Edema

33. Reinke edemaReinke edema
• polypoid corditispolypoid corditis
• proliferation of superficial lamina propriaproliferation of superficial lamina propria
• chronic irritant exposurechronic irritant exposure
– Smoke, LPR, occupational exposuresSmoke, LPR, occupational exposures
• water-balloon outpouching fromwater-balloon outpouching from
membranous VFmembranous VF
• ball-valving effectball-valving effect

34. TreatmentTreatment
• SurgerySurgery
– Airway compromiseAirway compromise
– Preserve some superficial lamina propria andPreserve some superficial lamina propria and
overlying epithelium to preserve mucosaloverlying epithelium to preserve mucosal
wavewave
• Stage for bilateral disease to preventStage for bilateral disease to prevent
anterior webanterior web
• Remove irritants and treat LPRRemove irritants and treat LPR

36. Feeding varices and hemorrhageFeeding varices and hemorrhage
• Aberrant microvessels in superficialAberrant microvessels in superficial
lamina proprialamina propria
• Result of shearing forces and traumaResult of shearing forces and trauma
• Predispose to formation of polyps andPredispose to formation of polyps and
hemorrhagehemorrhage

37. • TreatmentTreatment
– Microdissection and CO2 laserMicrodissection and CO2 laser
• Risks of scarring and sulcusRisks of scarring and sulcus
– Pulsed lasers (KTP, 585nm PDL)Pulsed lasers (KTP, 585nm PDL)
• No adverse scarring or reduction in mucosal waveNo adverse scarring or reduction in mucosal wave

38. Vocal Process GranulomaVocal Process Granuloma

39. GranulomasGranulomas
• Response to traumaResponse to trauma
• LPR, throat clearing, chronic coughLPR, throat clearing, chronic cough
• IntubationIntubation
• Compensatory forceful glottic closureCompensatory forceful glottic closure
– VF paresisVF paresis
– PresbylaryngesPresbylarynges
• Does not affect mucosal wave or phaseDoes not affect mucosal wave or phase
closureclosure

40. TreatmentTreatment
• LPR treatmentLPR treatment
• Speech therapySpeech therapy
• Botox to thyroarytenoid muscleBotox to thyroarytenoid muscle
• SurgerySurgery
– Compromise voice, breathing or swallowingCompromise voice, breathing or swallowing
– Suspicion for malignancySuspicion for malignancy
– High recurrence rateHigh recurrence rate

41. PapillomasPapillomas

42. PapillomasPapillomas
• HPV (Strain 6 and 11 most common)HPV (Strain 6 and 11 most common)
• 2% malignant transformation (HPV 16 and 18)2% malignant transformation (HPV 16 and 18)
• 10% rate of spread to other sites (trachea,10% rate of spread to other sites (trachea,
supraglottis, NP)supraglottis, NP)
• Most commonly found at columnar andMost commonly found at columnar and
squamous junctionsquamous junction
• Host immune recognitionHost immune recognition
– HPV 11 growth more aggressive during pregnancyHPV 11 growth more aggressive during pregnancy
– 40% HPV+ larynx without RRP40% HPV+ larynx without RRP

43. TreatmentTreatment
• CO2 laserCO2 laser
– Controversy: depth risks scarring andControversy: depth risks scarring and
implantation of HPVimplantation of HPV
– Avoided in most centersAvoided in most centers
• MicroshaverMicroshaver
• Cidofovir injection (adjuvant tx)Cidofovir injection (adjuvant tx)
• VaccineVaccine

44. CidofovirCidofovir
• Acyclic nucleosideAcyclic nucleoside
phosphonatephosphonate
• Once phosphorylated,Once phosphorylated,
resembles nucleotideresembles nucleotide
• incorporated into DNA,incorporated into DNA,
halting DNA synthesishalting DNA synthesis
• ANP’s have greaterANP’s have greater
affinity for viral DNAaffinity for viral DNA
polmerase and reversepolmerase and reverse
transcriptase than hosttranscriptase than host
DNA polymeraseDNA polymerase
• Off-label useOff-label use

45. Cidofovir studies limitedCidofovir studies limited

46. LeukoplakiaLeukoplakia

47. LeukoplakiaLeukoplakia
• Spectrum of change in epitheliumSpectrum of change in epithelium
• HyperkeratosisHyperkeratosisDysplasia (mild,Dysplasia (mild,
moderate)moderate)CIS/ severe dysplasiaCIS/ severe dysplasia
• Pattern of growthPattern of growth
– Superficial, broadSuperficial, broad
– Verrucous, exophytic with surrounding erythemaVerrucous, exophytic with surrounding erythema
• Appearance does not correlate with degree ofAppearance does not correlate with degree of
dysplasiadysplasia
• 8% to 14% rate of malignant transformation8% to 14% rate of malignant transformation

48. TreatmentsTreatments
• CO2 laserCO2 laser
• PDLPDL
• microflap excisionmicroflap excision
• Preservation of normal mucosal wave forPreservation of normal mucosal wave for
mild dysplasiamild dysplasia
• More aggressive excision with increasingMore aggressive excision with increasing
dysplasiadysplasia

49. Fungal LaryngitisFungal Laryngitis
• Disease of both immunocompromised andDisease of both immunocompromised and
immunocompetent hostsimmunocompetent hosts
• May mimick leukoplakia or malignancyMay mimick leukoplakia or malignancy
– White or gray pseudomembrane on mucosaWhite or gray pseudomembrane on mucosa
– Mucosal erythema and edema (focal orMucosal erythema and edema (focal or
diffuse) surrounding white plaquesdiffuse) surrounding white plaques
– Mucosal ulcerationsMucosal ulcerations
– Contact bleedingContact bleeding

50. Fungal laryngitisFungal laryngitis

51. Risk factorsRisk factors
• Risk factors: LPR, smoking, inhaledRisk factors: LPR, smoking, inhaled
steroids, prolonged antibiotic use, XRTsteroids, prolonged antibiotic use, XRT
• DM, immunosuppressants, CA, nutritionalDM, immunosuppressants, CA, nutritional
deficitsdeficits
• Compromise mucosal barrierCompromise mucosal barrier

52. DiagnosisDiagnosis
• Suspicion and response to empiricSuspicion and response to empiric
therapytherapy
• Any question can culture by laryngealAny question can culture by laryngeal
brushing or biopsybrushing or biopsy
• Dysphagia may also have esophagealDysphagia may also have esophageal
involvementinvolvementTNETNE

53. • Candida species most commonly culturedCandida species most commonly cultured
• Blastomyces (Eastern US and Midwest)Blastomyces (Eastern US and Midwest)
• Histoplasma (Ohio and Mississippi RiverHistoplasma (Ohio and Mississippi River
Valleys)Valleys)
• Coccidioides (Southwestern US)Coccidioides (Southwestern US)
• Bacterial superinfectionBacterial superinfection
– Honey-colored crustsHoney-colored crusts

54. Treatment of fungal laryngitisTreatment of fungal laryngitis
• Fluconazole x 3wksFluconazole x 3wks
• Nystatin swish and swallow (100,000Nystatin swish and swallow (100,000
units/ml, 10ml tid)units/ml, 10ml tid)
• PreventionPrevention
– spacers for inhaled steroidsspacers for inhaled steroids
– oral rinse, gargle with water after useoral rinse, gargle with water after use