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    Benign Laryngeal Lesions Presentation TDuong 11-12-08

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    Aliyah Tofani Pawelloi
    This document summarizes benign laryngeal lesions including vocal fold nodules, polyps, cysts, scarring, edema, papillomas, leukoplakia, and fungal laryngitis. It describes the etiology, pathophysiology, clinical presentation, diagnostic evaluation including stroboscopy, and treatment options for each condition.

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    Benign Laryngeal Lesions Presentation TDuong 11-12-08

    Uploaded by

    Aliyah Tofani Pawelloi
    17 views54 pages
    This document summarizes benign laryngeal lesions including vocal fold nodules, polyps, cysts, scarring, edema, papillomas, leukoplakia, and fungal laryngitis. It describes the etiology, pathophysiology, clinical presentation, diagnostic evaluation including stroboscopy, and treatment options for each condition.

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    This document summarizes benign laryngeal lesions including vocal fold nodules, polyps, cysts, scarring, edema, papillomas, leukoplakia, and fungal laryngitis. It describes the etiology, pathophysiology, clinical presentation, diagnostic evaluation including stroboscopy, and treatment options for each condition.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    17 views54 pages

    Benign Laryngeal Lesions Presentation TDuong 11-12-08

    Uploaded by

    Aliyah Tofani Pawelloi
    This document summarizes benign laryngeal lesions including vocal fold nodules, polyps, cysts, scarring, edema, papillomas, leukoplakia, and fungal laryngitis. It describes the etiology, pathophysiology, clinical presentation, diagnostic evaluation including stroboscopy, and treatment options for each condition.

    Copyright:

    © All Rights Reserved
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    Benign Laryngeal Lesions

    Factors contributing to vocal


    fold lesions

    voice overuse or misuse


    smoking
    etoh
    Laryngopharyngeal reflux
    History

    medical conditions
    AR, GERD, asthma, bronchitis, sinusitis
    medications
    Environmental exposure: smoke,
    allergens, particulates (dust)
    LPR

    baseline inflammation predisposes


    VF to other stresses
    78% w/ nodules had LPR
    Allergy

    pts treated for AR had better


    outcome for treatment of laryngitis
    hypersensitivity makes laryngeal
    mucosa more susceptible to stress
    Pathophysiology
    mech stress least at midpoint of membranous VF
    during phonation

    during hyperfunctioning dysphonia increased


    stress at midpoint

    increased stiffness in body of VF at midpoint


    results in higher shearing stresses, worse if
    nodule or mass present

    mass adds wt to VF decreasing vibratory qualities


    and frequency on stroboscopy
    Pathophysiology

    decrease in pitch range and impaired closure


    leads to breathy voice and fatigue.

    Asymmetry adds grainy quality to voice

    once initiated, can cause compensatory


    muscle tension to reduce air flow through
    glottis
    Anatomy of vocal fold
    Nodules
    Nodules

    bilateral symmetric epithelial


    swelling of ant/mid third of TVF
    More prevalent in children,
    adolescents, females
    softer intensity of voice causes
    hyperfunction
    Result of abuse or misuse
    Nodule formation
    junction of anterior to middle VF experience
    maximal shearing and collision forces.
    vascular congestion and edema
    hyalinization of Reinke space and thickening
    of epithelium with epithelial hyperplasia
    nodules are acellular with thick epithelium
    over matrix of abundant fibrin and organized
    collagen IV in BM
    Symptoms

    decreased amplitude mucosal wave


    Symmetric mucosal wave
    decreased closure: hourglass-shape
    glottal closure
    chronic hoarseness
    singers: frequent voice breaks,
    breathiness, vocal fatigue
    Treatment of Nodules

    conservative voice use


    speech therapy to address
    technique
    Microsurgery when speech tx and
    other contributing factors optimized
    Vocal fold polyps
    Polyps

    Unilateral
    Broad-based vs. Pedunculated
    Formed by capillary break in Reinke
    space with leakage of blood resulting
    in local edema and organization with
    hyalinized stroma
    Hemorrhagic (feeding vessel) vs.
    nonhemorrhagic (pseudocyst)
    Vocal fold polyps
    Effect of polyps on mucosal
    wave
    Asymmetric mass produces more chaotic
    vibrations and aperiodic mucosal waves
    Larger polyps cause decreased wave
    amplitude
    Excessive air egress during phonation
    Fatigue
    Frequent voice breaks
    decreased vocal power
    Treatment

    Conservative for small polyps


    Microsurgery mainstay of therapy
    Hemorrhagic polyps
    Pulsed-dye lasers absorbed by
    hemoglobin (585 nm)
    Lasers more effective for smaller polyps
    Vocal fold cysts
    Vocal fold cysts

    Subepidermal epithelial-lineds sacs


    within lamina propria
    Mucus retention cysts
    Epidermoid cysts congenital cell rests
    in the subepithelium of 4th and 6th
    branchial arch or healing injured
    mucosa burying epithelium
    Vocal fold cysts

    Ruptured cyst may result in LP


    scarring or in a sulcus
    May cause reactive lesion on
    contralateral VF
    Size may vary with menstrual cycle
    Caution when operating on
    premenstrual females
    Strobolaryngoscopy
    Asymmetric vocal fold
    Decreased or absent mucosal wave on cyst
    side
    Diplophonia
    Glottic closure depends on cyst size and
    reactive lesion on contralateral side
    Mucosal wave
    present in 80% of polyps BUT
    absent in almost 100% of cysts
    Treatment of cysts

    Does not resolve with conservative


    management
    Surgery
    Dissection in submucosal plane with
    complete cyst removal
    Prolonged mucosal wave recovery
    Discuss risks with pt
    Reactive Lesions
    Reactive lesions

    Reaction to unilateral VF lesion


    Contralateral VF reactive callus with
    epithelial hyperplasia
    Bilateral like nodules
    Strobe: asymmetry not seen in nodules
    Tx: treatment of primary lesion, may
    resolve with conservative management
    Before and After
    Intracordal Scarring
    Scarring in Reinke space after repeated
    inflammation, trauma or vocal hemorrhage
    Subepithelial scar
    Disorganized collagen
    Loss of ECM
    Distinguish from epithelial scarring or vocal
    sulcus
    VF appears stiff, white or opaque
    Hoarseness, vocal fatigue, breathiness, loss
    of projection
    Sulcus Vocalis
    Causes of Intracordal
    scarring
    Cysts predispose to scar formation (ruptured,
    epidermoid origin)
    Trauma
    Vocal fold surgery involving lamina propria
    Repeated epithelial procedures
    Biopsy, stripping
    Inhalational
    Intubation
    CO2 laser
    Radiation
    Rheumatologic disease
    Stroboscopy
    Markedly reduced
    or absent mucosal
    wave
    Asymmetry affects
    phase closure
    Treatment of vocal scar

    Microflap to remove cyst elements and


    adynamic fibrous components
    Medialization thyroplasty for glottic
    gaps
    Replacement soft tissue (Fillers)
    Collagen
    Fat
    Hyaluronic acid
    Reinke Edema
    Reinke edema

    polypoid corditis
    proliferation of superficial lamina propria
    chronic irritant exposure
    Smoke, LPR, occupational exposures
    water-balloon outpouching from
    membranous VF
    ball-valving effect
    Treatment
    Surgery
    Airway compromise
    Preserve some superficial lamina propria
    and overlying epithelium to preserve
    mucosal wave
    Stage for bilateral disease to prevent
    anterior web
    Remove irritants and treat LPR
    Feeding varices and
    hemorrhage
    Aberrant microvessels in superficial
    lamina propria
    Result of shearing forces and trauma
    Predispose to formation of polyps
    and hemorrhage
    Treatment
    Microdissection and CO2 laser
    Risks of scarring and sulcus
    Pulsed lasers (KTP, 585nm PDL)
    No adverse scarring or reduction in mucosal
    wave
    Vocal Process Granuloma
    Granulomas

    Response to trauma
    LPR, throat clearing, chronic cough
    Intubation
    Compensatory forceful glottic closure
    VF paresis
    Presbylarynges
    Does not affect mucosal wave or
    phase closure
    Treatment

    LPR treatment
    Speech therapy
    Botox to thyroarytenoid muscle
    Surgery
    Compromise voice, breathing or swallowing
    Suspicion for malignancy
    High recurrence rate
    Papillomas
    Papillomas
    HPV (Strain 6 and 11 most common)
    2% malignant transformation (HPV 16 and 18)
    10% rate of spread to other sites (trachea,
    supraglottis, NP)
    Most commonly found at columnar and
    squamous junction
    Host immune recognition
    HPV 11 growth more aggressive during pregnancy
    40% HPV+ larynx without RRP
    Treatment

    CO2 laser
    Controversy: depth risks scarring and
    implantation of HPV
    Avoided in most centers
    Microshaver
    Cidofovir injection (adjuvant tx)
    Vaccine
    Cidofovir
    Acyclic nucleoside
    phosphonate
    Once phosphorylated,
    resembles nucleotide
    incorporated into DNA,
    halting DNA synthesis
    ANPs have greater
    affinity for viral DNA
    polmerase and reverse
    transcriptase than
    host DNA polymerase
    Off-label use
    Cidofovir studies limited
    Leukoplakia
    Leukoplakia
    Spectrum of change in epithelium
    HyperkeratosisDysplasia (mild,
    moderate)CIS/ severe dysplasia
    Pattern of growth
    Superficial, broad
    Verrucous, exophytic with surrounding erythema
    Appearance does not correlate with degree
    of dysplasia
    8% to 14% rate of malignant transformation
    Treatments

    CO2 laser
    PDL
    microflap excision
    Preservation of normal mucosal wave
    for mild dysplasia
    More aggressive excision with
    increasing dysplasia
    Fungal Laryngitis

    Disease of both immunocompromised


    and immunocompetent hosts
    May mimick leukoplakia or malignancy
    White or gray pseudomembrane on
    mucosa
    Mucosal erythema and edema (focal or
    diffuse) surrounding white plaques
    Mucosal ulcerations
    Contact bleeding
    Fungal laryngitis
    Risk factors

    Risk factors: LPR, smoking, inhaled


    steroids, prolonged antibiotic use,
    XRT
    DM, immunosuppressants, CA,
    nutritional deficits
    Compromise mucosal barrier
    Diagnosis

    Suspicion and response to empiric


    therapy
    Any question can culture by
    laryngeal brushing or biopsy
    Dysphagia may also have
    esophageal involvementTNE
    Candida species most commonly
    cultured
    Blastomyces (Eastern US and Midwest)
    Histoplasma (Ohio and Mississippi River
    Valleys)
    Coccidioides (Southwestern US)
    Bacterial superinfection
    Honey-colored crusts
    Treatment of fungal
    laryngitis
    Fluconazole x 3wks
    Nystatin swish and swallow (100,000
    units/ml, 10ml tid)
    Prevention
    spacers for inhaled steroids
    oral rinse, gargle with water after use

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