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Questions and Answers
Which type of benign laryngeal tumor is characterized by its glandular origin?
What category of lesions does vocal polyps belong to?
What is the most common symptom presented by individuals with benign vocal fold lesions?
In which population is the male-to-female ratio for vocal nodules typically 3:1?
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What is a notable trait of vocal nodules compared to polyps?
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What is a common cause of thickening in the basement membrane related to vocal fold lesions?
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Which of the following benign lesions is not classified under epithelial lesions?
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Which group of individuals is particularly susceptible to developing vocal fold lesions?
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What is the main focus of microsurgery in the treatment of vocal granulomas?
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Which granuloma is associated with voice abuse or shouting?
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What treatment is recommended for significant voice impairment despite therapy in vocal granuloma cases?
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Which technique is used to minimize disruption of vibratory mechanics during vocal cord lesion excision?
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What should be avoided during the surgical treatment of vocal granulomas to prevent recurrence?
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What is a common histological finding in the presence of vocal cord nodules?
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Which of the following treatments is part of the medical management for vocal cord nodules?
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What risk factor is closely linked to the development of vocal cord polyps?
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Which type of vocal cord polyp is characterized by an edematous stroma and small vessel leakage?
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Which complication is associated with surgical intervention for vocal cord nodules?
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What is the typical male to female ratio for vocal cord polyps?
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Which histological feature is expected in telangiectatic polyps?
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What is one of the primary aims of voice therapy for vocal cord disorders?
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What is the most common treatment approach for vocal polyps?
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Which type of vocal cord cyst is filled with keratin and cholesterol debris?
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What clinical feature can help identify vocal fold polyps?
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What effect does a large vocal polyp typically have?
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What is the appearance of a mucus retention cyst?
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What kind of reactive lesions can contralateral vocal fold polyps cause?
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Which vocal fold characteristic differentiates pedunculated polyps from others?
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What is a common cause of mucus retention cysts?
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Study Notes
Benign Laryngeal Lesions: A Classification
- Benign laryngeal tumors are classified into epithelial and nonepithelial categories.
- Epithelial tumors include:
- Glandular tumors: Pleomorphic adenoma and Oncocytic tumor
- Squamous epithelium: Recurrent respiratory papillomatosis and Keratinized papilloma
- Nonepithelial tumors include:
- Vascular tumors: Hemangioma and Lymphangioma
- Cartilage and Bone: Chondroma
- Muscle: Leiomyoma and Rhabdomyoma
- Adipose: Lipoma
- Neural tumors: Neurilemoma, Paraganglioma, Neurofibroma, and Granular cell pseudotumors
- Fibroma and Amyloidosis
- Laryngeal cysts and laryngoceles
Benign Vocal Fold Lesions: An Overview
- Benign lesions of the vocal folds are epithelial lesions originating from the epithelium and lamina propria.
- Vocal nodules, polyps, and superficial cysts are histologically confined to the superficial layer of the lamina propria.
- Vocal nodules are bilateral and symmetrical swellings located in the midmembranous portion of the vocal folds.
- Vocal nodules occur more frequently in school-age children, especially boys.
- In adults, women are more susceptible to vocal nodules than men.
- Professional voice users, such as teachers, singers, and telephone operators, are more prone to developing vocal nodules.
Vocal Nodule: Pathophysiology
- The histological findings of vocal nodules include:
- Hyperplasia of the epithelial layer
- Thickening of the basement membrane with potential keratin formation
- Presence of fibroblasts, fibrous tissue, and hyalinization
- Minimal inflammation
- Absence of hemorrhage
- Immunohistochemical findings show fibronectin deposition in the superficial layer of the lamina propria with thick collagen type IV, resulting in mucosal thickening.
Vocal Nodule: Treatment
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Medical treatment includes:
- Management of laryngopharyngeal reflux (LPR), asthma, and other underlying conditions
- Voice rest
- Voice therapy (12 weeks) focusing on:
- Lifestyle and vocal behavior modification
- Voice care information and guidance
- Producing voice more effectively with less strain and coping strategies
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Surgical treatment is considered when:
- Vocal nodules do not respond to medical therapy after optimization of contributing factors
- Persistent and significant dysphonia with functional limitations
- Hard fibrotic nodules
- Presence of atypical features suggesting malignant changes
Vocal Nodule: Surgical Complications
- Surgical interventions can lead to complications such as:
- Increased scar formation and synechiae
- Submucosal hemorrhage
- Residual vocal fold pathology
- Excessive removal of vocal fold tissue causing a "cookie-bite" defect
Vocal Cord Polyp: Epidemiology
- Males are more likely to develop vocal cord polyps than females with a 2:1 ratio.
- 80% of vocal cord polyps are unilateral.
- They are typically found at the edge of the vocal fold, especially in the anterior one-third.
- Risk factors include:
- Overuse or abuse of voice
- Smoking
Vocal Cord Polyp: Pathophysiology
- Vocal cord polyps develop due to phonotrauma, which causes:
- Microhemorrhage and vessel leakage of serum/protein into the superficial lamina propria (SLP)
- Formation of organized soft tissue in the SLP
- Histologically, there are three types of vocal cord polyps:
- Gelatinous polyps: Oedematous stroma, collagen fibers, fibrocytes, and small vessels
- Telangiectatic polyps: Homogenous eosinophilic deposits with fibrin collection
- Mixed type: Most common type, combining characteristics of gelatinous and telangiectatic polyps
- The location of vocal cord polyps can be localized or involve the entire SLP.
Vocal Cord Polyp: Clinical Features
- Vocal cord polyps often present with an abrupt onset of hoarseness, which can be traced back to a specific event like shouting during sports or a severe cough.
- The size of the polyp influences symptoms:
- Small polyps: Dysphonia
- Large polyps: Airway obstruction, cough
- Pedunculated polyps: Ball-valve effect on voice and airway (good voice when polyp flips down, severe dysphonia when it flips up)
- Vocal cord polyps can cause reactive lesions on the contralateral vocal fold.
Vocal Cord Polyp: Treatment
- Vocal cord polyps generally do not improve with medical therapy or speech therapy.
- Removing irritants is essential.
- The mainstay of treatment is endolaryngeal microsurgery, employing two techniques based on the amount of healthy mucosa associated with the polyp:
- Phonomicrosurgery using a microflap technique: Used for smaller polyps with minimal involvement of the vocal fold epithelium
- Truncation of the vocal fold polyp: Suitable for larger polyps involving the vocal fold epithelium
- Small ectatic vessels can be managed with laser or microcautery.
Vocal Cord Cyst: Types
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Mucus retention cysts:
- Arise from blocked minor salivary glands, possibly secondary to phonotrauma or inflammation
- Lined by cuboidal or low columnar epithelium
- Contain mucous/serous fluid
- Appear more translucent and yellowish
- Typically unilateral and found at the free edge of the vocal fold or false cord
- Associated with edema and fibrosis in Reinke’s space
-
Epidermoid cysts:
- Lined by squamous epithelium and filled with keratin and cholesterol debris
- Inflammatory exudate in Reinke’s space
- Content: Cheese-like epidermal debris
- Appear white and pearl-like
- Theories for their development include:
- Metaplasia in a longstanding mucus retention cyst
- Microinclusion of epithelium from surface trauma
- Congenital cell rests in the subepithelium of the 4th and 6th branchial arch
Vocal Cord Cyst: Treatment
- The mainstay of treatment is microsurgery:
- Precise preservation of the underlying deeper lamina propria and overlying epithelium
- Avoiding leaving part of the cyst wall behind, which can lead to recurrence, localized scarring, and poor voice
Vocal Granuloma: Etiology
- Vocal granulomas are classified based on their etiology:
- Intubation granuloma
- Contact granuloma
- Hyperfunctioning granuloma
Vocal Granuloma: Pathogenesis
- Voice abuse, shouting, chronic cough, and chronic throat clearing can contribute to the development of vocal granulomas.
- The thin mucoperichondrium over the medial side of the vocal process becomes inflamed or acutely ulcerated.
- Local inflammation leads to perichondritis and chondritis in the arytenoid cartilage.
- These factors ultimately lead to the formation of a vocal granuloma.
Vocal Granuloma: Treatment
-
Medical management includes:
- Proton pump inhibitors (PPIs)
- Reassurance that the granuloma is not malignant and will eventually resolve
- Voice therapy
-
Surgical intervention is considered when:
- Upper airway obstruction or significant voice impairment persists despite therapy and medical management
- Suspicion of malignancy
- Do not excise the entire granuloma
- Leave some tissue covering the perichondrium
- Consider serial in-office intralesional steroid injection (SIILSI)
Microflap technique
- The microflap technique was developed by Sataloff et al. and Courey et al.
- This technique involves identifying normal histologic planes without extensive dissection, allowing for excision of benign vocal cord lesions with minimal interruption of vibratory mechanics.
- Microflaps can be lateral or medial.
Summary
- Most vocal fold lesions require microlaryngoscopic biopsy to differentiate benign from malignant conditions, especially TB and SCC, which can be difficult to distinguish.
- Exceptions include vocal nodules, which typically do not require biopsy.
- The goal of vocal fold lesion excision is to spare the anterior commissure, vocal ligament, and posterior commissure.
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Description
Explore the various categories of benign laryngeal lesions including epithelial and nonepithelial tumors. This quiz covers glandular tumors, squamous lesions, vascular tumors, and more. Test your knowledge on benign vocal fold lesions and their characteristics.
