Benign Lesions of the Larynx

Introduction

The larynx is a complex organ in the upper aerodigestive tract with multiple functions. Due to its location, any disease affecting the larynx may present with multiple symptoms, including hoarseness, difficulty breathing or swallowing, and aspiration pneumonia.

Assessment and Evaluation of Benign Lesions of the Larynx

A laryngologist and a speech therapist should ideally assess and evaluate patients with voice disorders in a multidisciplinary clinic. A voice coach may be part of the team.

Terminologies used to describe voice symptoms

1. Dysphonia: It is any impairment of the voice or difficulty speaking.
2. Dysarthria: It includes difficulty in articulating words caused by impairment of the muscles used in speech.
3. Dysarthrophonic: It is dysphonia in conjunction with dysarthria, for example, after a cerebrovascular accident, head injury, or part of a degenerative neurological condition, such as motor neuron disease.
4. Dysphasia is an impairment of the comprehension of spoken or written language or an impairment of speech or writing expression, especially when associated with brain injury.
5. Hoarseness: It is perceived as the voice's rough, harsh, or breathy quality.
6. Odynophonia: patients feel pain while talking.

Characteristics of Disordered Voice

• Disordered voice is not audible, clear, or stable in a wide range of acoustic settings.
• It is not appropriate for the gender and age of the speaker.
• It is not capable of fulfilling its linguistic and paralinguistic functions.
• It is easily associated with discomfort, pain, and fatigue.

History of Benign Lesions of the Larynx

• The Patient should be allowed to present his/her story in his/her own words without interruption at first.
• Some of the voice disorders are diagnosed entirely by listening to the patient’s voice (spasmodic dysphonia, functional dysphonia)
• Points to note in history: The following points must be observed while taking the history:

1. The nature and chronology of the voice problem.
2. Exacerbating and relieving factors.
3. Lifestyle, dietary, and hydration issues.
4. Contributing to medical conditions or the effects of their treatment.
5. The patient’s voice use and requirements.
6. The impact on their quality of life, social and psychological well-being.

Symptoms of Benign Lesions of the Larynx

• Changes in the voice quality (hoarseness, roughness, and breathiness).
• A pitch that is increased or decreased which is not appropriate for their age and sex.
• An inability to control their voice as required (pitch breaks, voice cutting out).
• An inability to raise the voice or make the voice heard in a noisy environment.
• An increased effort and/or reduced stamina of the voice or one that tired with the use.
• Difficulties or restrictions in using their voice at different times of the day or related to specific daily, social, or work-related tasks.
• Difficulty in singing for the signing professionals.
• Throat-related symptoms (soreness, discomfort, aching)

Self-administered questionnaires to assess voice

Many self–report questionnaires have been developed to measure the impact of the voice problem on the quality of life are concerned with this area of voice complaint, these are:

• GRABS (Grade, Roughness, Asthenia, Breathiness, and Strain)
• VoiSS (Voice Symptom Scale)
• VHI-10 (Voice handicap index)
• RSI (Reflux symptom index)

General Examination in Benign Lesions of the Larynx

• Physicians must give special attention to the ears, nose, and throat, for instance, when a voice problem arises.
• The neck should be inspected for any scar that may indicate previous surgery, trauma, or neck masses.
• A full neurological assessment might be necessary to assess the cranial nerve function or any sign of central neurological disease.

Laryngeal Examination of Benign Lesions of the Larynx

If there is hoarseness of voice for more than 4 weeks then, mandatory laryngeal examination is needed. Laryngeal examination can be done in the following ways:

IDL Examination is done by IDL mirror

• Warm the mirror
• Cheak the temperature on the back of the palm
• Ask the patient to protrude the tongue 

                                  ↓

        Hold the tongue with fingers 

     (Retroglossal space will increase)

Rigid laryngoscopy 

• 70⁰   or 90⁰ - Hopkins Rods Telescope 

Flexible fibreoptic laryngoscopy

• Passing a fibreoptic scope from the nose and insert it downwards till the larynx is visible  
• Topically anesthetize the nose and the pharynx (4% Xylocaine liquid  and 10% Xylocaine oral spray ) 
• Advantage – very close look at vocal cords and understanding the pathology very clearly to understand the mucosal pattern or mucosal vibration is more easily understood
• Rigid laryngoscopy  and Flexible fibreoptic laryngoscopy can be clubbed with stroboscopy

Causes of voice disorders

Causes of voice disorders could be:

• Inflammatory,
• Structural or neoplastic, 
• Neuromuscular, or 
• Muscle tension imbalance.

Benign lesions

Vocal Polyps

A true vocal polyp is a benign swelling of greater than 3 mm that arises from the free edge of the vocal fold. It is usually solitary, occasionally bilateral. It is the most common structural abnormality that causes hoarseness, and it affects men more than women. They are most frequently seen in smokers between the age of 30 and 50 years.

Aetiology Of Vocal Polyps

• Phonotrauma: It may present as a sudden onset of hoarseness or loss of voice after yelling or shouting, particularly if the vocal folds are inflamed from acute infective laryngitis or extraesophageal reflux.
• Cigarette smoking causes injury to the vocal cord, leading to hyaline degeneration in polyps.
• There appears to be disruption to the vascular basement membrane, capillary proliferation, thrombosis, minute hemorrhage, and fibrin exudation.
• Some polyps have a hemorrhagic appearance, while others are more gelatinous and grey.

Clinical Features Of Vocal Polyps

• Hoarse voice
• Lowered pitch 
• The voice cuts out in the speech
• Loss of range of the voice 
• Strain to speak
• Very rarely, large polyps can cause difficulty breathing and choking episodes.

Medical Treatment Of Vocal Polyps

• Vocal polyps generally resolve spontaneously or may be coughed up.
• Voice therapy can be done to ease symptoms, but it doesn’t resolve the polyp.
• Treatment of GERD
• Stop smoking

Surgical treatment Of Vocal Polyps

• Excision techniques can be used using laser or cold steel suspension k/a micro laryngoscopic technique.
• Surgical treatments aim to restore the smooth edge of the vocal cord to allow it to close fully and vibrate normally.

Vocal Nodules

Vocal fold nodules are small bilateral swellings (less than 3 mm in diameter) that develop on the free edge of the vocal fold at approximately the mid-membranous portion. In some cases, particularly in singers, they may be smaller, more pointed, and white, reflecting a more superficial response to trauma. They are variable in size and histologically characterized by thickening of the epithelium and a variable degree of underlying inflammation.

Higher percentages are found in teachers and singers with voice problems. In children, they are more common in boys than in girls, while in adults, they are very much more commonly found in women, particularly under the age of 30.

Aetiology of Vocal Nodules

• The most common cause of vocal nodules is vocal abuse.
• The vocal folds are thought to impact each other in such a way that the repeated trauma of the mid-membranous portions leads to localized swelling and epithelial thickening.
• Psychological factors, nasal, throat, and chest infections, allergies, and extraesophageal reflux are the contributing factors to form vocal nodules.

Clinical features of Vocal Nodules

• The voice quality is often husky and breathy, worsening with voice use.
• It is associated with peri laryngeal discomfort or throat soreness on phonation.
• The voice may become a little deeper in pitch and associated with voice breaks, particularly at the higher end of the range of the voice.

Examination of Vocal Nodules

The vocal folds are usually hourglass in appearance, with often only the nodules making contact at the mid membranous zone.

Medical Treatment of Vocal Nodules

• It includes treatment of allergies, infection and GERD
• Vocal therapy

Surgical treatment of Vocal Nodules

• Surgical treatment is reserved for those who fail voice therapy and remain symptomatic.
• Chances of reoccurrence are high if surgery is performed without voice therapy, either pre- or post-operatively.
• The aim of the surgery is to precisely excision the nodule alone without exposure or damage to the underlying ligament.

Pseudocysts

It is a lesion that differs from cysts and polyps in that it has no cyst wall and is filled with serous fluid, having an appearance similar to that of the blister. It is also defined as localized Reinke’s edema which may indicate the presence of underlying paresis.

The exact etiology is not known, but it is probably phonotrauma. A pseudocyst is initially managed by behavioral therapy. Surgical excision might be necessary in cases that were not resolved with speech therapy.

Reinke’s Edema

Reinke’s edema is a term used to describe the vocal folds when they become chronically and irreversibly swollen. Other terms for the condition include:

• Polypoid vocal cord, polypoid degeneration or polypoid hypertrophy, cordal polyposis, or polypoid corditis.
• Chronic oedema of vocal folds.
• Pseudomyxoma or pseudo myxomatous laryngitis
• Smoker’s larynx

Aetiology of Reinke’s Edema

• It occurs almost exclusively in moderate to heavy smokers
• It occurs due to voice strain, extra oesophageal reflux, and hypothyroidism can be an accompanying feature

Pathology of Reinke’s Edema

• The epithelium shows non-specific changes, and the basement membrane layer is usually thickened.
• In Reinke’s space, there are lakes of edema, extravasated erythrocytes, and thickening of the walls of the subepithelial vessels.

Symptoms  of Reinke’s Edema

The most common symptoms are the following:

• Deepening of the pitch of the voice with women often being mistaken for a man, particularly on the telephone
• Gruffness of the voice
• Effortful speaking
• An inability to raise the pitch of the voice
• Choking episodes
• Other symptoms associated with extra oesophageal reflux.

Grading of Reinke’s oedema  of Reinke’s Edema

Treatment depends on Reinke’s Edema

• Symptoms
• The severity of the edema
• Presence of the leucoplakia

Conservative measures for Reinke’s Edema

• Reassurance 
• Vocal hygiene advice
• Smoking cessation 
• Hypothyroidism, upper airway infections and allergies, and extra oesophageal reflux should be treated.

Principle of surgery for Reinke’s edema

• It reduces the bulk of the mucosa of the vocal fold.
• Obtaining a straight mucosal edge and avoiding damage to and exposure of the underlying ligament reduces the chances of scarring and web formation.
• Avoiding damage to and exposure of the underlying ligament, thereby reducing the chance of scarring and web formation

Surgical treatment of Reinke’s edema

• The myxomatous material from the superficial lamina propria layer is aspirated, removed with forceps, or vaporized, and the epithelial edges are apposed following excision of redundant mucosa as necessary.
• Phonosurgery can be done with cold instruments or one of the new generation of microspot lasers.
• KTP laser treatment can be done by local anesthesia via a channeled endoscope as an OPD procedure
• Care should be taken not to remove excised epithelium or overheat the vocal cord ligament, as this may result in a permanent scar and hoarseness.

Frequently Asked Questions:

Q: Hourglass-shaped larynx is seen in which laryngeal pathology?

Answer: Vocal Nodules

Q: Bag of Water appearance is seen in which laryngeal pathology?

Answer: Reinke’s edema

Q: What is Dysphonia?

Answer:  Dysphonia is any impairment of the voice or difficulty speaking.

Q: What is Dysarthria?

Answer: Dysarthria includes difficulty in articulating words caused by impairment of the muscles used in speech.

Q: What is Odynophonia?

Answer: Odynophobia is when a patient feels pain while talking.

Hope you found this blog helpful for your ENT residency Larynx preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.