Vocal cord either on a pedicle or sessile. It is seroedematous and occasionally

hemorrhagic. Older fibromas appear firm due to fibrosis and thickening of the

overlying epithelium.

Treatment. The fibroma is removed by endolaryngeal microsurgery, with

preservation of the vocal ligament and vocalis muscle. The patient is advised to

rest his voice until the defect epithelializes.

The fibroma may be removed by direct or indirect laryngoscopy after

premedication to inhibit reflexes and topical anesthesia.

The fibroma should always be examined histologically to establish the diagnosis.

Papillomas

Symptoms. Depending on the site and extent of the lesions, these include

hoarseness which is often severe and respiratory obstruction.

Pathogenesis. This disease has etiologic and morphologic similarities to the

common wart which occurs on the skin. A viral cause has been suggested. Some

juvenile papillomas resolve spontaneously about the time of puberty due to

hormonal influences. Many adult patients have suffered papillomas since early

childhood.

Diagnosis. This is made by indirect laryngoscopy, direct laryngoscopy and

histologic examination. Papillomas may be pedicled, solitary, or widespread.

Their surface is pale-yellow to red, granular, villous, and often has a

raspberry appearance.

Other areas of papillomatosis may lie in the oropharynx and the subglottic

space.

Treatment. Spontaneous regression rarely occurs. Treatment is combined. The

Immunologic and antiviral treatment are used. Today there is no alternative to

surgery. Microsurgery is being progressively replaced by the laser. The problem

of surgery is the marked tendency of papillomas to recur, the appearance of new

foci, and the interference with the function of the vocal cords caused by

defects and scars due to repeated operations.

MALIGNANT TUMOURS

Laryngeal Carcinoma

Laryngeal carcinoma forms about 45% of carcinomas of the head and neck. It is

most common between the ages of 45 and 75 years. At the present time men are ten

times more frequently affected than women, although in the last few decades the

number of female patients has increased due to increased incidence of smoking in

women.

TNM-system for the Larynx

T – Tumor

T1 - Tumor is confined one anatomical site within the larynx

T2 – Tumor is confined one region of the larynx

T3 – Tumor extend beyond one region but it still confined to the larynx

(fixation of the vocal cord)

T4 – Tumor extend beyond the larynx

N – Regional lymph nodes metastases (for nose, pharynx and larynx)

N0 – none

N1 – mobile homolateral nodes

N2 – mobile contralateral or bilateral nodes

N3 – fixed nodes

M – Distant metastases

M0 – none

M1 – present

Regions Sites

Supraglottic lower part epiglottis

false cords

Ventricles

arytenoids

Glottic vocal cords

anterior and posterior commissures

Subglottic walls of subglottis

Symptoms. Hoarseness is the first and main symptom when the tumor affects the

glottis. Further symptoms, which may occur alone or in combination depending

upon site and extent, include a feeling of a foreign body, clearing the throat,

pain in the throat or referred elsewhere, dyspnea, dysphagia, cough, and

hemoptysis. Regional lymph node metastases may also occur.

Hoarseness persisting for more than 2 to 3 weeks must always be investigated by

a specialist, and omission of this step is dangerous.

Pathogenesis. Invasive carcinoma may develop from epithelial dysplasia

especially from carcinoma in situ. More than 90% of laryngeal carcinomas are

keratinizing or nonkeratinizing squamous cell carcinomas. Unusual forms include

verrucous carcinoma, adenocarcinoma, carcinosarcoma, fibrosarcoma, and

chondrosarcoma.

Most patients with squamous carcinoma of the larynx were or are heavy cigarette

smokers and, in addition, often heavy drinkers. Chronic exposure to irritation

with heavy metals such as chromium, nickel, uranium, or asbestos, and

irradiation are rarer causes.

Laryngeal carcinoma infiltrates locally in the mucosa and beneath the mucosa and

metastasizes via the lymphatics and the bloodstream. The limits of vascular

spread are embryologically determined. Thus, supraglottic carcinomas usually

remain confined to the supraglottic space and spread anteriorly into the

preepiglottic space, whereas glottic carcinomas seldom spread into the

supraglottic area but rather into the subglottic space. A transglottic carcinoma

is a glottic carcinoma involving the ventricle and the vestibular folds in which

the site of origin can no longer be recognized. The characteristics of the

intralaryngeal lymphatics influence the frequency of regional lymph node

metastases. Other factors influencing the frequency of metastases are the

duration of the symptoms, the histologic differentiation, and the size and site

of the tumor. Lymph node metastases at the time of presentation are very rare in

carcinomas of the vocal cord, but are found in about 20% of subglottic

carcinomas, about 40% of supraglottic carcinomas, and in about 40% of

transglottic carcinomas.

Contralateral metastases are unusual in unilateral glottic tumors. Bilateral

metastases become more common if the carcinoma crosses the midline, e.g., at the

anterior or posterior commissure or in the trachea, or if the tumor arises

primarily in the supraglottic space.

Distant hematogenous metastases are relatively unusual in laryngeal carcinoma at

the time the patient is first seen. Second primary carcinomas of the respiratory

and digestive tracts also occur.

Diagnosis. The clinical diagnosis rests initially on the findings of indirect

laryngoscopy and telescopic laryngoscopy. The site and extent of the tumor and

the mobility of the vocal cord must be assessed. It is very important to carry

out microlaryngoscopy. This allows accurate evaluation of the site and extent of

the tumor, provides a view of hidden angles such as the ventricle and the

piriform sinus, and allows assessment of the superficial characteristics such as

nodular, exophytic, granulomatous, ulcerating, etc. Biopsy and histological

examination should be carried out.

Differential diagnosis. It includes chronic laryngitis and its specific forms,

and benign laryngeal tumors.

Treatment. If untreated, laryngeal carcinoma leads to death within an average of

12 months by asphyxia, bleeding, metastases, infection, or cachexia. The

existence of cardiovascular or pulmonary diseases and diabetes mellitus

determines the course of treatment and the course of the disease. The

indications for radiotherapy or surgery for laryngeal carcinoma vary depending

on the site and stage of the tumor. They are often used in combination.

Chemotherapy alone has so far proved to be useless for this type of tumor.

Radiotherapy achieves similar results to surgery for T1N0 glottic tumors and for

some T2N0 tumors. Radiotherapy must also be used for patients with inoperable

tumors or those unwilling to undergo surgery.

For all other sites and stages of tumor, especially if lymph node metastases are

present, surgery is clearly superior to radiotherapy.

Both methods of treatment may be combined, e.g., pre- or postoperative

radiotherapy or sandwich radiotherapy. This latter form of treatment gives the

best result for selected patients in advanced stages.

Complications after radiography include persistent edema which makes it

difficult to assess the local appearances and detect a recurrence. The edema is

usually due to chondroradionecrosis leading to cartilaginous necrosis and which

may require laryngectomy. Other complications include dysphagia, ageusia,

xerostomia and the sicca syndrome, recurrent tumor, or lymph node metastases. if

surgery must be undertaken after a full course of radiotherapy, the wound

healing and prognosis are considerably worse.

Surgical Procedures for Laryngeal Carcinoma

If larynx stenosis take place (3 or 4 stage) tracheostomy should be done.

1. Microsurgical decortication of the vocal cord is indicated for severe

dysplasia and some carcinomas in situ.

2. Cordectomy is indicated for a vocal cord carcinoma with a mobile vocal cord.

The breathing is normal after this operation. The voice is rough or hoarse

postoperatively, but may return to normal after several months as scar tissue

forms a pseudocord. Cordectomy can be carried out during direct laryngoscopy

also.

3. Vertical or horizontal partial laryngectomies are used for carcinomas for

which a cordectomy is not suitable because of the extent or site of the tumor,

but for which total laryngectomy is not necessary. Partial laryngectomies

preserve the vocal function and a normal airway. The prerequisites for success

are careful assessment and good surgical judgment to ensure that the tumor is

removed completely.

4. Total laryngectomy may on occasion be combined with removal of the

hypopharynx. This technique is indicated for tumors that cannot be removed by

cordectomy or partial laryngectomy and for tumors that have spread to

neighboring structures such as the tongue, the hypopharynx, the thyroid gland

and the trachea. Total laryngectomy is also indicated for tumors that have

recurred after radiotherapy or partial procedures.

SCLEROMA

Scleroma of the Nose

Scleroma is found in certain parts of Eastern Europe, Indonesia and Central and

Southern America, and is due to Klebsiella rhinoscleromatosis (bacilli of

Volcovich-Frich). It consists of a hard rubbery nodular infiltration of the

mucous membrane, reddish-brown in colour at first, but becoming pale pink later

when fibrosis occurs. There is nasal obstruction, crusted discharge and a slowly

progressive, but painless, stenosis of the nasal cavity. Prolonged antibiotic

treatment by ampicillin, streptomycin or tetracycline may be helpful. Local

excision of the lesions tends to destroy healthy tissue, and stenosis may be

treated by dilatation of the nasal cavities and the insertion of polythene tubes

which are retained for up to 2 months.

Scleroma of the Larynx

This disease starts in the nose and oral cavity and spreads downwards to involve

the pharynx and larynx. The typical lesion is in the subglottic region and takes

the form of a smooth red swelling covered by crusts. The patient complains of

nasal obstruction followed later by hoarseness, wheezing and stridor. Diagnosis

is made by biopsy when plasma cells and hyaline bodies are seen in granulation

tissue together with the diagnostic Mikulicz cells which are large cells looking

like enormous fat deposits. If it is untreated the condition progresses to

laryngotracheal stenosis. The first line of treatment is streptomycin with

steroids added if there is a danger of stenosis.

SYPHILIS

Laryngeal Syphilis

Isolated laryngeal syphilis is unusual, and it is much more often a

manifestation of oropharyngeal syphilis in the secondary generalized stage of

the disease.

Mucous plaques or hazy, smoke-colored mucosal lesions occur in the larynx

similar to those of syphilitic pharyngitis. The patient is also hoarse. The

disease is reportable.

Respiratory obstruction only occurs in the presence of marked mucosal swelling.

The cartilage is destroyed in a gumma in stage III. The differential diagnosis

from carcinoma is difficult to make. Diagnosis is by biopsy, but this must be

confirmed by the appropriate serological tests. Treatment should be supervised

by appropriate specialist.

Nasal Syphilis