Laryngology benign disorders Flashcards
Damage to the vocal folds resulting from voice
abuse, misuse, and overuse can give rise to various
vocal-fold lesions. This type of damage is called
_____?
Phonotrauma
What is the most common location of true vocal
fold lesions resulting from voice abuse?
Mid-membranous vocal fold
What is the term for benign growths in the
superficial layer of the anterior and middle third of
the true vocal fold, which can be either acute
(edematous, erythematous, more vascular) or
chronic (firm, nonvascular, thickened due to scar
deposition and fibrosis)?
Vocal-fold nodules
What is the most common cause of vocal fold
nodules?
Phonotrauma (ex: singing, screaming)
Before any surgical intervention for vocal-fold nodules, what is the first line of management?
Voice therapy
In addition to voice therapy, what two contribu-
ting medical conditions should be optimized when
treating a patient with vocal fold nodules?
● Laryngopharyngeal reflux
● Allergies
Describe the pathophysiologic sequence that gives
rise to vocal fold nodules.
Excessive vibration causes trauma leading to vascular
congestion and submucosal edema at the midmembranous
cord. If the vocal trauma continues, hyalinization of the
superficial lamina propria and epithelial thickening may
occur.
When is it appropriate to consider surgical removal
of vocal-fold nodules?
When vocal impairment persists after an appropriate trial of
voice therapy
Describe the difference between a vocal-fold
nodule and a vocal fold polyp.
Nodules are always bilateral, are composed of inflammatory
tissue, and respond to voice rest. They have a broad range
of appearances (hemorrhagic/edematous, pedunculated/
sessile, gelatinous/hyalinized). Polyps may be unilateral or
bilateral, are full of either gelatinous material or blood, and
typically do not respond to voice rest.
What are the two most common etiologies for
vocal fold polyps?
Phonotrauma and hemorrhage
What is the treatment of choice for a symptomatic
unilateral true vocal-fold polyp?
Voice therapy may be offered initially as a means of
optimizing voice use. However, polyps only rarely respond
to therapy alone, and microsurgical excision is usually
necessary. Dissection should be subepithelial and just deep
to the lesion within the involved SLP.
After a patient undergoes microsurgical excision of a vocal-fold polyp, what amount of voice use is typically recommended in the immediate post-
operative period?
Complete voice rest
Sudden voice loss during maximal voice effort is most
likely associated with what type of vocal-fold lesion?
Vocal-fold hemorrhage or unilateral hemorrhagic polyp
What is the treatment of choice for vocal-fold hemorrhage?
This is a laryngologic emergency, and the treatment of
choice is 7 to 14 days of total voice rest with follow-up to
ensure resorption of blood and to identify a varix that could
be treated. If the blood has not resorbed, cordotomy and
evacuation of the blood are indicated.
Describe the difference between vocal-fold scar
and sulcus vocalis.
In vocal-fold scar, the lamina propria is replaced with
abnormally fibrous and disorganized tissue. In sulcus vocalis,
the lamina propria has degenerated or disappeared, leaving
an epithelial-lined depression down to the vocal ligament or
deeper.
Describe the different types of sulcus vocalis.
● Type I (physiologic sulcus): Longitudinal depression of the
epithelium into the superficial lamina propria but not to
the vocal ligament
● Type II: Longitudinal depression of the epithelium down
to the level of the vocal ligament or farther
● Type III: Focal depression of the epithelium to or through
the vocal ligament
Describe the common surgical procedures used in
the management of sulcus vocalis.
● Cold instrument undermining and release of the base of the sulcus with redraping of the epithelium and superficial lamina propria
● Laser undermining and redraping
● Cold instrument excision
● Coronal slicing to release the scar band
● Fat, fascia, or alloderm implant
● KTP (potassium-titanyl-phosphate) or PDL (pulsed dye
laser) treatment
Note: Surgical excision may improve symptoms, but
techniques and results are highly variable.
What is the cause of dysphonia secondary to vocal-
fold scar or sulcus vocalis?
Stiffening of the superficial lamina propria of the true vocal fold
What benign lesion often occurs on the posterior
vocal fold, near the vocal process, as either an
ulcerative or nodular polypoid process?
Vocal-fold granuloma
Vocal-fold granuloma/contact ulcer results from
chronic irritation and inflammation of what
structure?
Arytenoid perichondrium
Describe the difference between vocal-fold granuloma related to intubation and vocal-fold granuloma not related to intubation.
● Intubation-related granuloma tends to resolve sponta-
neously within a few months of extubation.
● Vocal-fold granulomata not related to intubation are typically difficult to treat, requiring thorough evaluation
to identify and eliminate causative factors such as reflux,
voice abuse, chronic cough, or allergies.
What is the treatment of choice for vocal-fold granuloma?
● Intubation-related granulomas will likely resolve sponta-
neously.
● Non–intubation-related granulomas should be treated
conservatively with primary voice therapy in addition to
elimination of contributing factors (e.g., antireflux medi-
cation, possibly steroids to limit inflammatory response).
● Surgery is a last resort in both cases (e.g., large, pedunculated lesion).
You are performing an interval airway examination on a 21-year-old man who survived a motor-
vehicle accident 10 days earlier. He suffered a tracheal laceration and polytrauma and has
required ongoing sedation because of the extent of his neurologic injuries. He has an 8–0 endo-
tracheal tube in place, and although his tracheal repair has healed nicely, you note the growth of a
pedunculated lesion on his posterior true vocal fold and vocal process. What immediate intervention should you recommend?
Downsize his endotracheal tube (ETT).
A patient has dysphonia. Laryngoscopy reveals
bilateral pale, watery, sessile, mobile collections of
fluid on the superior surface and margins of the true vocal folds. What is the most likely diagnosis?
Reinke edema (also called bilateral diffuse polyposis or smoker's polyps)
What is the mechanism leading to the voice
changes observed in bilateral diffuse polyposis
(Reinke edema) of the true vocal folds?
Accumulation of gelatinous material in the superficial
lamina propria leading to increased vocal-fold mass
What risk factors have been associated with the severity of Reinke edema?
Age, laryngopharyngeal reflux, vocal abuse, vocal hyperfunction, smoking, and hypothyroidism
True or False. The polypoid changes associated
with Reinke edema are permanent.
True. However, the degree of edema and turgidity may
fluctuate with voice use and exacerbating factors.
What is the initial treatment of choice for a patient with bilateral diffuse polyposis (Reinke edema) of the true vocal folds?
Smoking cessation, management of reflux, and reduction of phonotrauma
If conservative therapy for a patient with Reinke edema fails, what is the primary surgical intervention?
Mucosal sparing microflap polyp reduction, which results in decreased postoperative voice dysfunction compared with
vocal cord stripping
What are the two mechanisms by which upper
airway angioedema may occur?
Mast cell mediated and bradykinin induced
What laboratory test should be ordered if you suspect a diagnosis of hereditary angioedema?
C1 esterase inhibitor level
Describe three types of laryngeal cysts.
● Saccular cysts
● Ductal cysts
● Intracordal vocal fold cysts
Intracordal vocal-fold cysts generally arise within the superficial lamina propria (although they may
arise from the vocal ligament or epithelium). They
may be open to the epithelium of the vocal fold and
can be associated with a sulcus, and they are also commonly associated with a contralateral nodule. What are the two most common subtypes?
● Mucus-retention cysts (wax and wane)
● Epidermoid/keratin cysts (fairly stable, more white)
What is the preferred management for intracordal
cysts?
For lesions that persist after conservative therapy, including a trial of voice therapy, microflap resection with preserva-
tion of the epithelium and superficial lamina propria, possibly followed by infusion of saline (or other substance,
such as collagen) into the SLP
A cyst arising from which branchial cleft may involve the larynx?
Third branchial cleft
A large cyst is noted along the laryngeal surface of
the epiglottis, resulting in partial obstruction. The
cyst is covered in smooth mucosa and is round and
slightly translucent. What is the best treatment?
Endoscopic incision and drainage followed by marsupiali-
zation (mucus-retention cyst)
A patient with a history of having been intubated
for less than 24 hours develops stridor and
respiratory difficulty. A subglottic cyst is identified.
What is the most likely cause for development of
this lesion?
Acquired subglottic (ductal) cysts develop as a result of mucosal damage, which obstructs the duct of a mucous gland
What structure consists of a blind sac between the
false vocal fold and the thyroid cartilage, which opens into the anterior third of the laryngeal ventricle, is lined with ciliated respiratory epithelium and mucous glands, and is responsible for lubricating the vibrating vocal folds?
Laryngeal saccule (laryngeal appendix)
When the saccular opening becomes blocked resulting in a mucous filled dilation within the false
vocal fold, what pathologic condition results?
Saccular cyst
What are the most common reasons for saccular cyst formation (obstruction of the saccular open-
ing)?
Infection, recent intubation, cancer, or mass effect
What type of saccular cyst extends posteriorly and
superiorly to involve the aryepiglottic fold?
Lateral saccular cyst
What type of saccular cyst extends medially into the laryngeal lumen between the true and false
vocal folds?
Anterior saccular cyst
What is the difference between an anterior and a lateral saccular cyst?
An anterior saccular cyst lies between the true and false
vocal folds. A lateral saccular cyst lies between the false
vocal fold and the aryepiglottic fold.
What are the most common initial signs and symptoms associated with saccular cysts?
● Infants: Respiratory distress, cyanosis, stridor, difficulty
feeding
● Adults: Dysphonia, dyspnea, dysphagia, pain, neck mass
What is the treatment of choice for saccular cysts?
Marsupialization or complete excision
Biopsy should be performed in adults to rule out cancer.
What are the medial and lateral boundaries of the
laryngeal saccule?
The saccule is bordered medially by the false vocal cord and
laterally by the thyroid cartilage.
What results when the saccule becomes dilated or
herniated, is filled with air, and maintains a patent
orifice?
Laryngocele
Describe the similarities and differences between a
laryngocele and a saccular cyst.
Both laryngoceles and saccular cysts are dilations of the saccule. A laryngocele is an air-filled dilation that communicates with the laryngeal lumen. A saccular cyst is a fluid-filled dilation that does not communicate with the laryngeal lumen.
What type of laryngocele is confined to the larynx?
Internal laryngocele
What type of laryngocele extends through the
thyrohyoid membrane, laterally into the neck?
External or combined laryngocele
Describe the difference between an internal
laryngocele and an external or combined
laryngocele.
● Internal laryngocele: Contained within the thyroid cartilage
● Combined (external) laryngocele: Extends through the
thyrohyoid membrane
What are the most common symptoms associated
with a laryngocele?
Most are asymptomatic. However, symptoms can include
dysphonia, dyspnea, weak cry, and aphonia. External
laryngoceles may manifest with an intermittent lump in the neck.
How are internal laryngoceles treated?
Complete excision, either via endoscopic or external
approaches. Marsupialization is not recommended.
How should a large combined or external laryngocele be treated?
Generally, external approaches are recommended with
complete excision through the thyrohyoid membrane and
transection close to the orifice of the saccule. However,
complete endoscopic excision has been successfully re-
ported even for large lesions.
What is the greatest risk associated with surgical
repair of bilateral combined laryngoceles?
Aspiration secondary to bilateral injury to the internal
branch of the superior laryngeal nerve
When a saccular cyst is filled with purulent debris, what is it called?
Laryngopyocele
How are laryngopyoceles managed?
A laryngopyocele can be a surgical emergency. Secure an airway, drain endoscopically, and culture. Either at the time of drainage or after resolution of the acute infection,
complete excision either endoscopically or externally is
indicated. Medical management of the acute episode
includes IV antibiotics, antipyretics, and steroids.
Describe the normal effect of advancing age on
the fundamental frequency of the speaking voice.
In both men and women, the speaking pitch decreases with
age to a point and then begins to increase.
Describe the changes that occur in the larynx with
age.
Muscle atrophy, thinning of the vocal ligament, mucous
glad degeneration, cartilage ossification and epithelial
thickening.
Name three physiologic changes that contribute to
the perception of a voice as sounding “elderly.”
● Air escape
● Laryngeal tension
● Tremor
In a patient with paresis of the external branch of
the left superior laryngeal nerve, which direction
will the petiole of the epiglottis deviate during
high-pitched phonation?
Left. Toward the side of the weak cricothyroid muscle
True or False. Presbylaryngis is likely to be the sole
cause of a voice complaint in an elderly patient.
False. Voice disorders in elderly patients are much more likely to be caused or confounded by diseases of aging and associated medications than by presbylaryngis alone. Presbylaryngis is a diagnosis of exclusion after all possible
causes have been ruled out.
How does chronic laryngitis differ from acute laryngitis?
Chronic laryngitis results in chronic dysfunction.
What three habits should be limited or eliminated
to improve laryngeal hygiene?
● Tobacco use
● Alcohol use
● Caffeine consumption
What are the most common symptoms associated
with reflux laryngitis?
● Hoarseness ● Cough ● Globus ● Throat clearing Notably, fewer than 50% have gastrointestinal symptoms of reflux.
Describe the key difference between laryngophar- yngeal reflux (LPR) and gastroesophageal reflux.
Patients with LPR are less likely to have esophagitis (25%) or
heartburn (< 40%) and are less likely to have prolonged
periods of esophageal acid exposure or dysmotility. Patients
are more often “daytime” refluxers, and the cause is thought
to be upper esophageal sphincter dysfunction.
How is LPR diagnosed?
There is significant controversy regarding the best diag-
nostic criteria and tests to use. However, diagnosis is
commonly made based on the following:
● Clinical history: Reflux symptoms while upright, dyspho-
nia/hoarseness, cough, globus pharyngeus, throat clear-
ing, and dysphagia
● Symptomatic improvement with empiric treatment with
PPIs as indicated by a patient’s reflux findings score
● Laryngoscopy: Mucosal edema, injury, inflammation
● Reflux events identified by use of a dual pH probe,
oropharyngeal probe or impedence probe.
What is the treatment for LPR?
A combination of diet and behavior modifications is
recommended. The use of PPIs and H2 blockers, although
recommended by the American Academy of Otolaryngol-
ogy–Head and Neck Surgery (AAO-HNS) consensus state-
ment, is still somewhat controversial for isolated LPR.
What are the most common risk factors for
developing laryngeal chondronecrosis (radionec-
rosis)?
Radiation dose/timing, infection, poor vascular health (i.e.,
smoker, diabetic, and such conditions)
Describe the Chandler classification system for
laryngeal radionecrosis and the corresponding
treatment recommendations.
● Grade I: Slight hoarseness/dryness; slight edema, telan-
giectasias; symptomatic care: humidification, antireflux medication, smoking cessation
● Grade II: Moderate hoarseness/dryness; similar signs and
treatment
● Grade III: Severe hoarseness with dyspnea, moderate
odynophagia, and dysphagia; Severe impairment of
vocal-cord mobility or fixation of one cord, marked edema, skin changes; symptomatic care, steroid, anti-
biotics, tracheostomy or laryngectomy, if necessary
● Grade IV: Respiratory distress, severe odynophagia,
weight loss, dehydration; fistula, fetor oris, fixation of the skin to the larynx, airway obstruction, fever; tracheos-
tomy, laryngectomy
In addition to symptomatic care, antibiotics, and
steroids, what additional conservative measure
can be tried before laryngectomy for laryngeal
chondronecrosis and radionecrosis?
Hyperbaric oxygen therapy
