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Calcium hydroxylapatite (CaHA) Fat Teon is no longer used due to granuloma formation

– Laryngeal framework surgery

Medialization laryngoplasty (Isshiki type I thyroplasty) Carved silastic block, pre-formed implants, and Gore-Tex Arytenoid adduction or adduction arytenopexy Cricothyroid subluxation

– Laryngeal reinnervation

RLN direct reanastomosis or cable graft Ansa cervicalis to RLN

• Bilateral vocal fold immobility

– Surgical management

Tracheostomy Endoscopic approach:

• Transverse cordotomy

• Arytenoidectomy (partial or total)

• VF lateralization

A. Shahangian and C. K. Sung

Open arytenoidectomy

Neurolaryngology

• Signs suggestive of neurologic laryngeal disorder:

– Vocal fatigue – Vocal tremor – Weak or breathy voice – Vocal strain – Dysarthria – Dysphagia

• Parkinsonism

– Weak breathy voice, sluggish articulation, dysphagia, and drooling – Thin, bowed TVFs due to atrophy – Lee Silverman Voice Treatment (LSVT)—intensive voice therapy stimulating

loud voice with maximum effort

– Injection laryngoplasty may be considered

• Essential tremor

– Characteristic hand and voice tremor at 6–8Hz – Muscles of the larynx, pharynx, soft palate, and strap muscles involved

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– Treatment

Propranolol and primidone Botox (botulinum toxin A) can be considered, but may lead to excessive breathiness Injection laryngoplasty may be considered

• Spasmodic dysphonia (SD) or laryngeal dystonia (LD)

– Idiopathic focal dystonia of the larynx – Adductor SD (ADSD)—85–90% of SD

Intermittent voice breaks in the middle of vowels, strangled voice Test sentences: “We eat eels every day.” “We mow our lawn all year.” Count from 80 to 90 Treatment:

• Botox injection to the TA muscles with or without EMG guidance

– Dosage varies: 0.1–3.5 units bilaterally

• Surgical: RLN sectioning; selective laryngeal adductor denervationreinervation; type II thyroplasty.

– Abductor SD (ABSD)—~15% of SD

Prolonged voiceless consonants, occasional breathy voice Test sentences: “The puppy bit the tape.” “Harry’s happy hat.” Count from 60 to 70 Treatment

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• Botox injection to the PCA muscle 0.5–5 units

– Mixed SD—combination of ADSD and ABSD

Difcult to treat with Botox due to side effects

• Muscle tension dysphonia (MTD)

– Voice with constant strain, but no discernible voice

breaks; can also be constantly breathy

– Anterior–posterior squeezing of the supraglottis, hyperconstriction of the

false VFs

– Treatment: voice therapy

Miscellaneous laryngology

• Classication of laryngeal framework (Isshiki thyroplasty) procedures

– Type I: vocal fold medialization – Type II: vocal fold lateralization – Type III: vocal fold shortening – Type IV: vocal fold lengthening

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A. Shahangian and C. K. Sung

Subglottic andtracheal stenosis

• Etiologies:

– Trauma—blunt or penetrating; burns – Iatrogenic—prolonged intubation, tracheostomy, radiation, surgical trauma – Inammatory disease/collagen vascular disease

Granulomatosis with polyangiitis (Wegener’s) Sarcoidosis Amyloidosis Relapsing polychondritis

– Idiopathic

• Cotton-Meyers Classication

– Grade I: 0–50% obstruction – Grade II: 51–70% obstruction – Grade III: 71–99% obstruction – Grade IV: 100% obstruction

• Preoperative assessment:

– Flexible laryngoscopy and bronchoscopy

Identify location, dimension, quality of stenosis, vocal fold movement

– High-resolution CT scan – Pulmonary function test

Objective testing of impairment Flattened inspiratory and expiratory curves on ow-volume loop

• Endoscopic management:

– Microdirect laryngoscopy with:

CO2 laser and dilation

• Indications: Cotton-Meyers Grade I–II, stenosis length <1.5cm

• Risks: Airway re, laser smoke plume, thermal injury, perioperative edema

Balloon dilation—for soft tissue stenosis Microdebrider

• Indications: bulky, exophytic lesions, brous scar, and granulation tissue

• Benets: no risk of airway re and shorter operative time

Application of Mitomycin C

• Antineoplastic, antibiotic, and alkylating agent

• Inhibits broblast proliferation, allowing re-epithelialization before scar formation

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• Open surgical management:

– Indications: high-grade stenosis, failed endoscopic treatment, circumferential

scarring, loss of cartilaginous support, exposure of cartilage, long segment stenosis, and combined laryngotracheal stenosis

– Laryngotracheal reconstruction (LTR)

With anterior cartilage graft +/− posterior cartilage graft

– Cricotracheal resection and primary anastomosis – Segmental tracheal resection and primary anastomosis – Stents: silicon roll, Montgomery stent, T-tube, and nger cot

Provide support for cartilage grafts Approximate skin or mucosal grafts to a recipient site Separate opposing raw surfaces during healing Maintain lumen in a reconstructed area that lacks adequate cartilaginous support

Tracheal neoplasms

Benign

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• Epithelial

– Squamous papilloma

In children caused by HPV 6 and 11. Vertical transmission during childbirth

– Mucoepidermoid adenoma

• Mesynchemal

– Chondroma

Covered with normal mucosa Found commonly on posterior trachea/cricoid region but can be anywhere Affects elderly men Can recur after resection

– Leiomyoma

Typically arise from the distal third Can be pedunculated Signicant bleeding with bronchoscopic excision of nonpedunculated lesions

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A. Shahangian and C. K. Sung

– Hemangioma – Lymphangioma (cystic hygroma)

Soft solitary compressible mass >60% present at birth and the rest declare themselves by 3 years increased mast cells during proliferation

– Granular cell tumor – Others include Schwannoma, neurobroma, brous histiocytoma, chondro-

blastoma, lipoma, and pseudosarcoma

Malignant

• See Chap. 20. Head and Neck Section

Further Reading

1. Denlinger C, Patterson GA.Chapter 114. Diagnosis and management of tracheal neoplasms. In: Cummings CW, editor. Otolaryngology: head & neck surgery. 5th ed. Philadelphia: Mosby Elsevier; 2010.

2. Jalisi S, Zoccoli M. Management of laryngeal fractures—a 10-year experience. J Voice. 2011;25(4):473–9.

3. Kearney PR, Mann EA, Ludlow CL.Chapter 32. Management of the spasmodic dysphonias. In: Rubin JS, Sataloff RT, Korovin GS, editors. Diagnosis and treatment of voice disorders. 3rd ed. San Diego: Plural Publishing; 2006.

4. Khalid AN, Goldenberg D.Chapter 71. Surgical management of upper airway stenosis. In: Cummings CW, editor. Otolaryngology: head & neck surgery. 5th ed. Philadelphia: Mosby Elsevier; 2010.

5. Koufman JA.The otolaryngologic manifestations of gastroesophageal reux disease (GERD): a clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991;101(4 Pt 2 Suppl 53):1.

6. Koufman JA, Wright SC Jr. Chapter 28. Laryngopharyngeal reux and voice disorders. In: Rubin JS, Sataloff RT, Korovin GS, editors. Diagnosis and treatment of voice disorders. 3rd ed. San Diego: Plural Publishing; 2006.

7. Lebovics RS, Neel HB III.Chapter 29. Infectious and inammatory disorders of the larynx. In: Rubin JS, Sataloff RT, Korovin GS, editors. Diagnosis and treatment of voice disorders. 3rd ed. San Diego: Plural Publishing; 2006.

8. Merati AL. Chapter 63. Acute and chronic laryngitis. In: Cummings CW, editor. Otolaryngology: head & neck surgery. 5th ed. Philadelphia: Mosby Elsevier; 2010.

9. Weinberger PM, Terris DJ.Chapter 15. Otolaryngology—head & neck surgery. In: Doherty GM, editor. Current diagnosis & treatment: surgery. 13th ed. NewYork: McGraw-Hill; 2010.

10. Woodson G.Management of neurologic disorders of the larynx. Ann Otol Rhinol Laryngol. 2008;117(5):317–26.

Chapter 28

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Benign Lesions oftheLarynx

AhmedSalamaAbdelmeguid, MelyndaBarnes, andC.KwangSung

Pearls

• The mucosal wave is the most important parameter in differentiating cysts from

polyps (diminished or absent in cysts compared to present in 80% of polyps)

• Respiratory papillomas are most common at the transition between columnar

and squamous epithelium

Differential diagnosis of benign vocal fold lesions

• Polyp (most common): mucoid and angiomatous

• Nodules

• Cyst: mucus retention and dermoid

• Vocal process granuloma

• Scar

• Sulcus vocalis

• Recurrent respiratory papilloma

• Polypoid corditis (Reinke’s edema)

A. S. Abdelmeguid Department of Otolaryngology Head and Neck Surgery, Mansoura University Hospital, Mansoura, Dakahlia, Egypt

M. Barnes Ro’s Women’s Health Vertical, New York, NY, USA

C. K. Sung (*) Department of Otolaryngology - Head & Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA e-mail: kwang.sung@stanford.edu; kwangs@stanford.edu

https://doi.org/10.1007/978-3-031-26048-3_28

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A. S. Abdelmeguid et al.

• Leukoplakia/keratosis

• Fungal laryngitis

(Note: Two systemic diseases that should be considered in the differential of a

vocal cord lesion are hypothyroidism and acromegaly)

• Polyps

– Unilateral, broad-based vs. pedunculated, hemorrhagic vs. non-hemorrhagic

outpouching of inamed and organized Reinke’s space of true vocal fold

– Seen mostly in males, after intense intermittent voice abuse, aspirin use, anti-

coagulant use, vocal trauma or endotracheal intubation

– Pathophysiology: breakage of capillaries in Reinke’s space (SLP) with extrav-

asation of blood→edema→blood organization with hyalinized stroma

– Histology: acellular with thickened epithelium, increased vascularity, clus-

tered bronectin, and disruption of laminar pattern

– Symptoms: breathy and/or rough voice, vocal fatigue, frequent voice breaks,

and worsening hoarseness with high-pitched soft phonation

– Stroboscopy: small polyps have intact mucosal waves but phase asymmetry

because of impaired phase closure and mass effect of the polyp; large polyps have prominent decreased amplitude

– Treatment options: voice therapy, microsurgical, or laser excision for hemor-

rhagic polyps

• Nodules

– Bilateral, symmetric epithelial swelling of the anterior/mid third of the true

vocal folds

– Seen mostly in children, adolescents, women, and professionals with high-

voice demands

– Pathophysiology: mid-membranous (junction of anterior and middle third)

vocal fold undergoing maximal shearing and repeated collision forces resulting inlocalized vascular congestion and edema. Reinke’s space hyalinization and thickened overlying epithelium occurs with epithelial hyperplasia

– Histology: acellular with thickening of epithelium over matrix of brin and

collagen

– Symptoms: chronic hoarseness and repeated episodes of progressively severe

voice loss. Professional singers have inability to sing high notes softly, frequent voice breaks, increased breathiness, and vocal fatigue

– Stroboscopy: symmetric supercial swelling of vocal folds at strike zone

(junction of anterior and middle cord) with decreased amplitude, hour-glass glottal closure, and open phase dominance

– Treatment options: vocal hygiene, adquate hydration, traet allergy and reux

if present, voice rest, voice therapy, and microsurgery

– Microsurgical indications: longstanding nodules, voice therapy failure, reac-

tive callus with primary lesion on opposite vocal fold

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– Voice rest should be implemented after surgery (duration of 3–14days after

surgery is controversial)

– Botulinium toxin injection for induced voice rest in patients with recalcitrant

vocal fold nodules has shown efcacy

• Cysts

– Subepidermal epithelial-lined sacs within lamina propria

Mucus retention—obstructed mucous gland duct (usually during URI or voice overuse). Can be spontaneous without relation to amount and manner of voice use Epidermoid—congenital cell rests in subepithelium from fourth or sixth branchial arch or buried epithelium from healing injured mucosa. Can be related to voice oveuse like nodules

– Ruptured cyst may result in scar within lamina propria or a sulcus – The cyst can also irritate the contralateral vocal fold, producing a reactive

lesion on the opposite vocal fold

– Occurs in similar population as polyps and nodules, slight female

predominance

– Exam: rough, diplophonic voice, pitch instability, splitting of frequency over-

tones, and vocal hyperfunction. Vocal limitations are more in epidermal inclusion cyst than in mucous retention cyst

– Stroboscopy: phase asymmetry, signicantly decreased or absent mucosal

wave, glottic closure depends on cyst size and whether there is a contralateral reactive callus

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Mucosal wave is the most important parameter in differentiating cysts from polyps (diminished or absent in cysts compared to present in 80% of polyps)

– Treatment: Multidisciplinary approach but usually needs microsurgery com-

bined with vocal hygene, acid reux control, and voice therapy – Cyst recurs if epithelium left behind during surgical excision – Longer post-operative recovery compared to polyps and nodues. Required

longer vocal rehabilitation with speech language pathologist or singing teacher

• Vocal process granulomas

– Occur at vocal process of the arytenoid, not on the membranous vocal fold.

May or may not cause dysphonia – Male predominance – Etiology: intubation injury most common; prolonged or repetitive contact

trauma leads to mucosal ulceration, cartilage exposure, and inammation – Risk factors: trauma, laryngopharyngeal reux (LPR), severe or chronic

cough, throat clearing, post-endotracheal intubation (contact ulceration),

forceful glottal closure (compensation for vocal fold paresis or

presbylaryngis)

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A. S. Abdelmeguid et al.

– Stroboscopy: granuloma appears solitary or bilobed, normal mucosal wave,

glottic closure may be impeded by large granuloma

If abnormal mucosal wave or phase closure rule out underlying vocal paresis, presbylaryngis, or sulcus

– Conservative treatment: treat LPR, cough, underlying condition, voice ther-

apy, Botox to thyroarytenoid muscle, and intralesional corticosteroids – Indications for surgery (CO2 laser excision or cold knife): enlarging granu-

loma, compromised voice, breathing, or swallowing or to rule out

malignancy

• Scar

– Repeated inammation, vocal trauma, vocal hemorrhage, presence of intra-

cordal cyst (ruputered epidermoid) leads to intracordal scar – May occur after vocal surgery involving lamina propria, use of CO2 laser,

repeated epithelial procedures – Stroboscopy: markedly reduced or absent mucosal wave (asymmetric) – Treatment: excision vs. steroid injections

• Sulcus vocalis

– Epithelial scar with loss of supercial lamina propria – Etiology: unknown but usually acquired by vocal trauma. May be congenital

due to ruptured epidermoid cyst – Three types:

Type I: a depression of the epithelium into only the SLP.In general, it has limited to no functional impact and is not considered pathologic (physiologic sulcus) Type II: loss of the SLP with extension to the vocal ligament (sulcus vergeture) Type III: a focal indentation that extends into the vocal ligament or deeper

– Vocal impairment usually due to stiffness of vocal fold and glottic

insufciency – Symptoms: hoarseness with strained, breathy voice. Upper voice limitations,

particularly diplophonia – Stroboscopy: restriction of mucosal wave – Treatment: difcult to treat with unreliable outcomes. Options include:

Excision, collagen or steroid injection, mucosal “slicing” technique, elevation with submucosal grafting, endoscopic fat injection, Gray’s minithyrotomy

– Tissue engineering experiments and animal studies have shown promising

results with using certain growth factors like hepatocyte growth factor and

transforming growth factor beta1

28 Benign Lesions oftheLarynx

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• Recurrent respiratory papilloma

– One of the most common laryngeal neoplasms—cauliower exophytic. Most

common at transition between columnar and squamous epithelium – Second most common cause of hoarseness in children

2/3 present before age 15, usually regress by puberty

– Risk factors: rst-time mother (longer second stage of delivery in birth canal),

lower socioeconomic status, 50% born from mothers with maternal condy-

loma acuminata, oral sex, and multiple sexual partners

– Etiology: Human papilloma virus (HPV) infection (subtypes 6 and 11 most

common); HPV 11 runs the most aggressive coure. 2% likelihood of malig-

nant degeneration (subtypes 16 and 18) – 10% likelihood of tracheal spread, depending on the number of surgical

procedures – Types:

Juvenile-onset—children, multiple sites of involvements, more aggressive, rapid recurrence Adult-onset—often single site, recurrence less likely

– Symptoms: rough voice, voice may become strained due to scarring from

surgical procedures, stridor (inspiratory or biphasic), dyspnea, and dysphagia – Stroboscopy: vascular stippling on the mass, decreased mucosal wave due to

mass effect – Treatment: surgical—microdebrider, CO2 laser (greater depth of penetration

increases risk of scarring and implantation of virus into deeper tissues), pulsed

dye laser (PDL), KTP or blue light laser. Avoid tracheostomy

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Adjuvant therapy—HPV vaccine (preventative), cidofovir injections, bevacizumab (local injection or systemic for pulmonary disease), indole- 3carbinol (I3C)

– The angiolytic KTP and blue light lasers may cause less thermal damage than

CO2 laser without disruption of the basement membrane – Some studies have shown that effective management of laryngopharyngeal

reux disease LPRD can improve the control of RRP

• Ectasias

– Vascular lesion of the true vocal fold with a hemangiomatous appearance – Seen in voice professionals or post-radiotherapy – Etiology: vocal use, vocal abuse, and trauma

Repeated trauma leads to new blood vessel formation and weakened blood vessel walls

– Symptoms: hoarseness; can be episodic in menstruating women and patients

with recurrent trauma

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