Benign Laryngeal Lesions PDF

Benign laryngeal lesions [email protected]  Pathological Classification of Benign Laryngeal Tumours Epithelia Nonepitheli l al Glandula Vascula Hemangioma r...

Benign laryngeal lesions [email protected]  Pathological Classification of Benign Laryngeal Tumours Epithelia Nonepitheli l al Glandula Vascula Hemangioma r r Lymphangioma Pleomorphic adenoma Oncocytic tumor Cartilage & Chondroma Bone Squamous Muscle Leimyoma Epithelium Rhabdomyoma Recurrent respiratory papillomatosis Angiomyoma Keratinized papilloma Adipose Lipoma Neura Neurilemoma Paraganglio l ma Remacle M,Eckel H.E. Neurofibroma Granular cell Pseudotumou Fibroma Surgery of Larynx & Trachea. 2010, Heidelberg : Springer (1) rs Amyloidosis Laryngeal cyst & laryngoceles Benign vocal fold lesions Benign lesions of the vocal folds are epithelial lesions arising from epithelium and lamina propria. Vocal nodule, polyps, superficial cyst are histologically confined to superficial layer of lamina propria. Mahesh et al, 2005: – A male preponderance with M:F ratio 3:1 – Vocal polyps were the most commonest type of lesions. – The most common symptoms of presentation are hoarseness, cough , FB sensation and throat pain. Vocal nodule  Bilateral & symmetric swelling Epidemiology Site of maximal VF vibration ie : midmembranous portion VF Repeated shearing causes thickening BM Edge and undersurface Common in – school-age children. – In Peadiatric: boy > girl ( habitual screaming) – In adult: female > than male – Professional voice users eg teacher, singer, telephone operators are susceptible group. (Evelyne et al, 2009)  Pathophysiology The histological findings are Localized - Hyperplasia of the epithelial layer submucosal - Thickening of the basement oedema membrane +-keratin formation. - Presence of fibroblasts, fibrous tissue, Progression of BM hyalinization changes - Minimal inflammation - Absence of haemorrhage Submucosal fibrosis Immunohistochemical findings: - Fibronectin deposition in the Submucosal superficial layer of lamina propria scarring with thick collagen type IV. Mucosal thickening  Treatment Medical - Treat LPR, AR, comorbids - Voice rest - Voice therapy (12 weeks) – aim of modification of lifestyle and vocal behaviour – providing information and guidance on voice care – produce voice more effectively with less strain and coping strategies.  Treatment If the vocal nodule not responding to medical therapy and other contributing factors are optimized, it can be removed with microlaryngeal surgery. – persistent & significant dysphonia with functional limitations – hard fibrotic nodules – presence of atypical features suggestive of malignant changes  Surgical complications Create more scar & synechiae Submucosal haemorrhage Residual VF pathology Excessive removal of VF tissue causing “cookie bite” defect of VF Vocal cord polyp  Epidemiology Male : female =2:1 80% of vocal cord polyps are unilateral Edge of the VF Ant 1/3 of VF Risk factors: – Overuse or abuse of voice – Smoking  Pathophysiology Phonotrauma Histologically 3 types: VF microhaemorrhage & 1. Gelatinous polyps : vessel leakage of serum/protein into SLP oedematous stroma, collagen fibres, fibrocytes, small vessel 2. Telangiectatic polyps : homogenous eosinophilic Formation of organized deposits with fibrin collection soft tissue in SLP 3. Mixed type : most common type of polyp Site :localized of diffussed involve Seth et al, 2007: – Patient with translucent polyps (81.8%) > whole SLP commonly responded to voice therapy than fibrotic (15.4%) and hemorrhagic polyps (25%).  Clinical feature Abrupt onset of hoarseness: can identify loss of voice at specific time – eg : shouting during sports /scream/ severe cough Size matters: – Small : dysphonia – Large : airway obstruction, cough – Pedunculated : ball-valve effect on voice & airway flip down – voice good flip up – severe dysphonia Can cause contralateral VF reactive lesions  Treatment Most of vocal polyps do not improve with medical therapy or speech therapy Remove irritants Mainstay of treatment is Endolaryngeal Microsurgery – 2 techniques – depends on amount healthy mucosa associated with polyp phonomicrosurgery using microflap technique truncation of VF polyp – fibrotic, involve VF epithelium – Manage small ectatic vessels (laser, microcautery)  Redrape Palpate After excision Vocal cord cyst  Types of vocal cord cyst Mucus retention cyst Epidermoid cyst - Arise from blocked minor - Lined by squamous epithelium & filled salivary gland, possibly with keratin and cholesterol debris. secondary to phonotrauma - Inflammatory exudate in the Reinke’s or inflammation. space. Content: Cheese like epidermal debris - Lined by cuboidal or low columnar Appearance : white pearl-like epithelium. - Usually unilateral & found at the free - Theories: – Metaplasia in a longstanding mucus edge of vocal fold or false cord retention cyst Content :mucous/serous – Microinclusion of epithelium from the Appearance : more transluscent & surface trauma. yellowish – Congenital cell rests in the subepithelium - Associated with edema and fibrosis in of 4th and 6th branchial arch. Reinke’s space.  Treatment Mainstay of treatment is microsurgery: – Precisely preserve the underlying deeper LP and overlying epithelium – Avoid leaving part of the cyst wall behind which result in recurrence or causing localized scarring and poor voice. Vocal granuloma  Vocal granuloma is classified according to etiology – Intubation granuloma – Contact granuloma – Hyperfunctioning granuloma  Pathogenesis Voice abuse, shouting, chronic cough, chronic throat clearing Thin mucoperichondrium over the medial side of vocal process become inflamed or acutely ulcerated Local inflammation lead to perichondritis and chondritis in the arytenoid cartilage Formation of vocal granuloma  Treatment Medical management – PPI – Reassurance that granuloma is not malignant and that eventually resolved. – Voice therapy  Upper airway obstruction /significant voice impairment despite therapy/medical management/ suspect malignancy: – Do not excise – Leave some tissue covering the perichondrium – Consider SIILSI  SIILSI Serial In-Office Intralesional Steroid Injection 63/Malay/ Female ITU for COVID pneumonia, pericarditis 1/12 after one inj The exotic ones  Microflap technique Microflap concept was developed by Sataloff et al. and Courey et al. By identifying normal histologic plane without extensive dissection, the benign vocal cord lesion can be excised with minimal interruption of vibratory mechanics.  Lateral microflap.  Medial microflap.  Summary Most vocal fold lesions require microlaryngoscopic biopsy – To differentiate benign and malignant TB and SCC difficult to differentiate – Except vocal nodule – Aim excision provided Spare anterior commisure Spare vocal ligament Spare posterior commisure THANK YOU