Benign tumours of the larynx

Benign tumours of the larynx

 

1. Vocal Nodules

Vocal nodules, also known as singer’s or screamer’s nodules. They are small, bilateral swellings, usually less than 3 mm, located on the free edge of the vocal cord. They resemble peas in size and shape. Vocal nodules typically occur at the junction between the anterior one-third and posterior two-thirds of the vocal cords—the area experiencing the maximum vibration and mechanical stress. Often affecting voice professionals such as teachers, singers, actors, and public speakers, vocal nodules are a common cause of hoarseness and voice fatigue.

Causes of Vocal Nodules

1. Vocal abuse. Although the exact cause of vocal nodules remains unclear, most experts agree that voice abuse plays a critical role. This includes speaking for prolonged periods at high volume, yelling, singing outside one’s natural range, and frequently clearing the throat.
2. Additionally, poor vocal hygiene, respiratory infections, allergies, laryngopharyngeal reflux, and psychological stress may contribute to the formation of these nodules.
3. Boys are more commonly affected during childhood, while adult cases are seen predominantly in women under 30.

Clinical Features and Symptoms

1. Hoarseness
2. Vocal fatigue
3. Breathy or husky voice.
4. Neck pain or throat discomfort.
5. In some cases, the voice becomes deeper with noticeable pitch breaks, especially at higher frequencies. These symptoms can hinder both personal and professional communication, particularly in individuals who rely heavily on their voice.

Diagnosis. Diagnosis can be done by indirect laryngoscopy, 90-degree telescopic examination, and flexible fiberoptic laryngoscopy provides direct visualisation of the vocal cords. The nodules appear symmetrically on both vocal cords and are usually less than 3 mm in size. Initially soft, red, and swollen due to inflammation, they can later become white, firm, and fibrotic with chronic misuse. Despite their small size, these lesions can significantly impair vocal performance. On videostroboscopy, the vocal folds appear like an hourglass configuration with a break in the mucosal wave in the middle.

Treatment

• Conservative Management. Most early-stage vocal nodules respond well to conservative measures. In many paediatric cases, vocal nodules resolve spontaneously with proper voice rest and growth of the larynx. However, in adults, long-standing nodules typically persist and can significantly impact vocal function over time. Early intervention leads to better outcomes and minimises the need for surgical management.

1. 1. Speech therapy remains the cornerstone of treatment, focusing on voice modulation, breath support, posture correction, and eliminating abusive vocal behaviours.
   2. Lifestyle changes – such as adequate hydration, vocal rest, and avoiding smoking and alcohol – also enhance healing.
   3. Treating underlying conditions like allergies, infections, or acid reflux helps reduce recurrence.

• Surgical management. Micro laryngeal surgery (MLS), either with cold instruments or laser, under an operating microscope, is done for vocal nodules. Surgery should be done carefully without damaging the underlying vocal ligament. It is usually considered only when conservative therapy fails. Pre- and post-operative voice therapy is essential to prevent recurrence. Recovery requires strict voice rest and structured speech therapy, with most patients regaining normal voice quality within weeks.

 

2. Vocal Polyp

A vocal polyp is a benign, soft swelling greater than 3 mm located on the free edge of the vocal cord. While usually solitary, it may occasionally appear on both cords. The condition most often affects men aged 30 to 50 years.

Causes of Vocal Polyp

1. Vocal abuse: This condition primarily occurs from vocal abuse, especially from sudden shouting, which causes intense shearing forces in the vocal cords. These forces lead to capillary rupture, followed by subepithelial haemorrhage, disruption of the vascular basement membrane, and ultimately the development of a polyp.
2. Allergy and smoking: Contributing factors such as smoking and allergies further increase the risk. Smoking damages the vocal cord’s surface and promotes hyaline degeneration, creating an ideal environment for polyp formation.
3. Pre-existing disease: Patients experience sudden hoarseness or voice loss, especially after shouting while already suffering from acute laryngitis or reflux.

Clinical Features and Symptoms. Common symptoms include hoarseness, and in larger polyp cases, dyspnoea, stridor, or even intermittent choking may occur. A few patients report diplophonia, where the two vocal cords vibrate at different frequencies, causing a double voice.

Diagnosis is straightforward and can be confirmed through indirect laryngoscopy, 90-degree telescopic examination, or flexible laryngoscopy. A typical vocal polyp is unilateral and occurs at the junction between the anterior one-third and posterior two-thirds of the vocal cords (same location as a vocal nodule) – the area experiencing the maximum vibration and mechanical stress. It appears soft, smooth, and is often pedunculated. Some present as haemorrhagic, while others appear gelatinous and grey. During breathing or speaking, the polyp may flop across the glottis.

Treatment. It involves MLS (Micro Laryngeal Surgery) under general anaesthesia using either cold steel instruments or CO₂ laser, depending on the case. The objective is to restore the smooth contour of the vocal fold, allowing for normal closure and vibration during phonation. After surgery, speech therapy is crucial to prevent recurrence and promote vocal recovery.

Table: Differences between Vocal Nodules and Vocal Polyp

3. Leukoplakia/ Hyperkeratosis/ Keratosis Laryngis

Leukoplakia, also known as vocal cord keratosis, refers to abnormal thickening (hyperkeratosis) of the vocal cord epithelium. It mainly affects the upper surface of one or both vocal cords. Unlike arytenoid granuloma, keratosis is considered a premalignant lesion.

Aetiology. It usually arises from chronic laryngeal irritation, most often due to smoking. Additionally, alcohol consumption and laryngopharyngeal reflux may contribute.

Symptoms. The predominant symptom is hoarseness.

Diagnosis. Indirect laryngoscopy or 90-degree telescope examination or flexible laryngoscopy examination reveals, white patches or a warty lesion over the upper surface of one or both vocal cords that does not impair vocal cord mobility.

Treatment. Importantly, leukoplakia carries a risk of malignant transformation, frequently progressing to carcinoma in situ. Biopsy is done to rule out malignancy. Despite this, treatment should aim to preserve voice quality while ensuring oncological safety. The mainstay of treatment includes conservative surgical excision through suspension microlaryngoscopy (MLS). Cold steel instruments or LASER may be used. The excised tissue must be sent for histopathological examination. Furthermore, eliminating chronic irritants like smoking or reflux is essential to prevent recurrence.

 

4. Recurrent respiratory papillomatosis (RRP)

Recurrent respiratory papillomatosis (RRP) is a rare yet potentially life-threatening disease characterised by the repeated growth of wart-like lesions, known as papillomas, within the respiratory tract. These wart-like lesions can appear anywhere from the nasal vestibules to the terminal bronchi. Predominant sites are where there is a change of epithelium (e.g. from squamous to ciliated) and especially the tonsillar pillars, uvula, vocal folds and laryngeal commissure. These growths can obstruct the airway and, in severe cases, become life-threatening. The disease tends to recur, requiring multiple interventions over time. Fortunately, malignant transformation remains rare.

RRP appears in two forms:

1. Juvenile-onset RRP (JORRP)
2. Adult-onset RRP.

Juvenile-onset recurrent respiratory papillomatosis (JORRP)

JORRP usually begins around the ages of 3 to 4. The estimated prevalence is around 4 cases per 100,000 children. When symptoms begin before the age of 3, the prognosis tends to be worse. Children with JORRP often need surgery every 2 to 3 months to remove papillomas. However, many cases improve by puberty, likely due to hormonal changes that reduce disease activity. About one-third of JORRP cases spread beyond the larynx, often to the trachea, especially if there is papilloma in the subglottis or tracheostomy is present.

Causes and Risk Factors

1. Human Papillomavirus (HPV). RRP is caused by the Human Papillomavirus (HPV), most commonly types 6 and 11. These are the same low-risk HPV strains that cause genital warts. However, in rare cases, types 16 and 18—linked to cancer—may be involved, especially in more aggressive or malignant forms. A common pattern seen in JORRP includes young maternal age, vaginal delivery, and low maternal socioeconomic status. During birth, babies may come into contact with the mother’s HPV-infected birth canal, leading to infection in the throat and airway.
2. GERD. Additionally, acid reflux can worsen laryngeal damage post-surgery, so surgeons often prescribe medications like proton pump inhibitors for 48 hours after procedures.

Microscopic Features. Under the microscope, papillomas display finger-like projections. These structures consist of a keratinised squamous epithelial covering and a fibrovascular core. Viral changes, such as the presence of koilocytes—cells with clear halos surrounding their nuclei—are common. These changes confirm HPV infection. The virus remains dormant in the mucosa, explaining why recurrence is so frequent.

Clinical features. Papillomas mostly affect supraglottic and glottic regions of the larynx but can also involve subglottis, trachea and bronchi. Children who had tracheostomy for respiratory distress due to laryngeal papillomas have a higher incidence of tracheal and stomal involvement due to seeding. DNA virus particles have been found in the cells of the basement membrane of the respiratory mucosa and may account for widespread involvement and recurrence.

The most noticeable symptom of RRP is persistent hoarseness. In young children, this may progress to stridor, a high-pitched wheezing caused by airway obstruction. Some children may also have chronic cough, choking spells, repeated respiratory infections, or failure to gain weight. Because the symptoms overlap with other respiratory disorders, early diagnosis is essential to avoid complications.

Diagnosis. Fiberoptic laryngoscopy is the primary diagnostic tool for RRP. It provides a clear view of the larynx and upper airway. During the exam, papillomas appear as grape-like clusters or frond-like lesions. They may be pedunculated (on a stalk) or sessile (flat-based), and they can spread across the larynx and down the trachea.

A detailed history and examination help rule out other conditions. In severe or recurring cases, imaging and biopsy may also be performed to assess lesion depth or rule out malignancy. Papillomas are known for recurrence but rarely undergo malignant change.

Treatment Options for Juvenile-onset recurrent respiratory papillomatosis

1. Surgical Management

The main goal of surgery is to remove papillomas, secure a safe airway, and preserve normal vocal function by avoiding injury to the mucosa and vocal ligament. Several surgical techniques are available:

• Cold steel instruments: Using precise dissection, surgeons remove lesions manually. However, bleeding is a concern.
• Microdebrider: This powered tool gently shaves and suctions papillomas, causing less damage to nearby tissues. It is currently the gold standard.
• CO₂ Laser: Offers both removal and coagulation. Many surgeons prefer this method due to its dual action.
• Coblation: A low-heat (40–70 °c) plasma technology that minimises surrounding tissue damage.
• Photodynamic therapy, which uses light-activated intravenous drugs to destroy rapidly proliferating cells. But its results are comparable.
• Tracheostomy: Reserved for emergency airway access. However, it increases the risk of spreading the disease to the lower airways. A low tracheostomy is recommended if necessary.

2. Adjuvant Medical Therapy

In cases where surgery alone is insufficient, adjuvant medical therapy plays a role. Adjuvant medical therapies can be broadly divided into antiviral therapies and drugs with antiproliferative or immunomodulatory properties.

• Cidofovir: An antiviral agent injected directly into lesions; inhibits viral DNA replication
• Bevacizumab: A VEGF inhibitor that reduces blood supply and slows the growth of papillomas.
• Interferon-alpha, ribavirin, acyclovir, indole-3-carbinol, and cimetidine have been tested with mixed results.

Among all, intralesional bevacizumab and cidofovir show the most promise in improving disease control.

3. Prevention Through HPV Vaccination

HPV vaccination can significantly reduce the risk of RRP. Two vaccines are available:

• Cervarix®: Protects against HPV types 16 and 18.
• Gardasil®: Covers HPV types 6, 11, 16, and 18.

Because types 6 and 11 cause most RRP cases, Gardasil® is preferred for prevention. The vaccine should be given before sexual activity begins—ideally in early adolescence—to provide the best protection.

Adult-onset RRP

Adult-Onset RRP (AORRP) differs significantly from the juvenile form. This type usually results from sexual transmission or indirect contact with genital HPV lesions.

• Typically affects individuals between ages 20 and 30
• More common in males (3:2 ratio)
• Usually involves a single lesion, most often on the anterior vocal cord or anterior commissure
• Less aggressive and rarely recurs after treatment

Treatment is the same as JORP.

 

5. Chondroma of the Larynx

Chondromas are rare, benign cartilaginous tumours predominantly arising from the cricoid cartilage, though they can also originate from the thyroid or arytenoid cartilages. These tumours are more prevalent in men (4:1) aged 40–60 years.

Symptoms. Patients often present with subglottic masses leading to symptoms such as dyspnoea, a sensation of a lump in the throat, and dysphagia.

Diagnosis. Computed tomography (CT) scans are instrumental in delineating the extent of the tumour, while biopsies, often facilitated by CO₂ lasers, are essential for definitive diagnosis.

Treatment typically involves surgical excision via laryngofissure or lateral pharyngotomy, depending on the tumour’s location. In cases of large or recurrent tumours, total laryngectomy may be necessary.

 

6. Haemangioma: Infantile and Adult Forms

• Infantile haemangiomas commonly affect the subglottic area, presenting with stridor within the first six months of life. Approximately half of these patients have haemangiomas elsewhere, particularly in the head and neck region. While many of these lesions involute spontaneously, severe cases may require interventions such as tracheostomy to alleviate airway obstruction. Infantile haemangiomas are mainly capillary type and can be vaporised with a CO₂ laser. Oral propranolol also offers a safe and effective first-line therapy.
• Adult haemangiomas are found on the vocal cords or supraglottic larynx. Adult haemangiomas are mainly cavernous type and cannot be vaporised with a CO₂ laser. Asymptomatic haemangiomas are often monitored without intervention. However, symptomatic haemangiomas may require treatments such as corticosteroids or radiation therapy.

 

7. Bamboo Nodes and Autoimmune Associations

Bamboo nodes are pale yellowish lesions located in the mid-third of the membranous vocal cords. The disease is often associated with autoimmune diseases, including rheumatoid arthritis, systemic lupus erythematosus (SLE), Sjögren’s syndrome, Hashimoto’s thyroiditis, and systemic sclerosis.

Symptoms. Patients typically present with hoarseness.

Diagnosis involves a combination of clinical examination, videolaryngostroboscopy, and blood tests to identify underlying autoimmune conditions.

Treatment.

• Speech therapy.
• Systemic corticosteroids
• Steroid injections
• Phonosurgical excision. Done in resistant cases and should be performed under high magnification (MLS) to prevent damage to the vocal ligament and preserve vocal function.

 

8. Vocal Fold Cysts

Vocal fold cysts, including mucus retention and epidermoid cysts, are less common than polyps and nodules. These cysts cause persistent hoarseness, which may worsen with vocal use.

• Mucus retention cysts are usually unilateral and arise from blocked minor salivary glands and vocal abuse.
• Epidermoid cysts are lined by squamous epithelium, contain keratin and cholesterol debris and are often associated with voice misuse. They appear as a yellowish/white bulge in the vocal fold.

Diagnosis often requires videostroboscopy and may necessitate microlaryngoscopy with cordotomy for confirmation.

Treatment includes voice therapy, and in cases where symptoms persist, surgical excision (MLS) is considered.

 

9. Sulci. Sulcus vocalis refers to a localised longitudinal invagination or groove along the free edge of the vocal fold and is categorized into three types:

• Type 1 (Physiologic Sulcus): A superficial depression not affecting the vocal ligament. Voice is not affected and treated with speech therapy and antireflux medication.
• Type 2a (Sulcus Vergeture): An invagination extending into the vocal ligament with some loss of superficial lamina propria. It occurs due to a congenital failure in the development of Reinke’s space. The patient has moderate dysphonia.
• Type 2b (Classic Sulcus Vocalis): A focal pit extending beyond the vocal ligament into the thyroarytenoid muscle with marked loss of superficial lamina propria. The patient has severe dysphonia.

———— End of the chapter ————

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Benign tumours of the larynx Best Lecture Notes Dr Rahul Bagla ENT Textbok

Reference Textbooks.

• Scott-Brown, Textbook of Otorhinolaryngology-Head and Neck Surgery.
• Cummings, Otolaryngology-Head and Neck Surgery.
• Stell and Maran’s, Textbook of Head and Neck Surgery and Oncology.
• Ballenger’s, Otorhinolaryngology Head And Neck Surgery
• Susan Standring, Gray’s Anatomy.
• Frank H. Netter, Atlas of Human Anatomy.
• B.D. Chaurasiya, Human Anatomy.
• P L Dhingra, Textbook of Diseases of Ear, Nose and Throat.
• Hazarika P, Textbook of Ear Nose Throat And Head Neck Surgery Clinical Practical.
• Mohan Bansal, Textbook of Diseases of Ear, Nose and Throat Head and Neck Surgery.
• Hans Behrbohm, Textbook of Ear, Nose, and Throat Diseases With Head and Neck Surgery.
• Logan Turner, Textbook of Diseases of The Nose, Throat and Ear Head And Neck Surgery.
• Arnold, U. Ganzer, Textbook of  Otorhinolaryngology, Head and Neck Surgery.
• Ganong’s Review of Medical Physiology.
• Guyton & Hall Textbook of Medical Physiology.

Author:

Dr. Rahul Bagla
MBBS (MAMC, Delhi) MS ENT (UCMS, Delhi)
Fellow Rhinoplasty & Facial Plastic Surgery.
Renowned Teaching Faculty
Mail: msrahulbagla@gmail.com
India

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• Please read. Juvenile Angiofibroma. https://www.entlecture.com/juvenile-angiofibroma/
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• Please read. Anatomy of Oesophagus. https://www.entlecture.com/anatomy-of-oesophagus/

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