Benign Laryngeal Lesions

Author Credentials 

Original Author:
Nadir Ahmad, MD
nadirahmad@hotmail.com

Update by:
Thomas L. Carroll, MD
Instructor, Department of Otolaryngology-Head and Neck Surgery, Harvard Medical School
Director, Brigham Women’s Voice Program
Brigham and Women’s Hospital
45 Francis St.
Boston, MA 02115
TCARROLL@bwh.harvard.edu

Module Summary

Benign laryngeal lesions are related to vocal trauma (that may or may not be due to vocally abusive behaviors), inflammatory processes, and neoplastic changes. Though hoarseness is the most common complaint with these lesions, other symptoms such as vocal fatigue, increased vocal effort, loss of range, dyspnea, frequent throat clearing, should also alert the clinician to the possibility of a benign laryngeal lesion. The evaluation of benign laryngeal lesions involves a detailed history and physical exam with special emphasis on laryngeal evaluation by various methods such as flexible and rigid laryngoscopy including videostroboscopy. The management of benign laryngeal lesions involves medical therapy targeted at reducing inflammation, behavioral therapy to reduce hyperfunctional behaviors contributing to the vocal fold changes, and surgery in selected situations depending on response to conservative therapy, occupational needs, and potential for recurrence.

Module Learning Objectives 
  1. Review the anatomy and physiology of the larynx and their relevance to benign laryngeal lesions.
  2. List the various etiologies of benign laryngeal lesions.
  3. Explain the evaluation of a patient with a benign laryngeal lesion.
  4. Develop a differential diagnosis of benign laryngeal lesions based on the evaluation.
  5. Discuss general management options for patients with benign laryngeal lesions.
  6. Describe specific benign laryngeal lesions.
  7. Describe the treatment of specific benign laryngeal lesions.

Embryology

Learning Objectives 
  1. Understand the developmental anatomy of the larynx
  2. Know that the entire respiratory system is an outgrowth of the primitive pharynx
  3. Be familiar with the laryngotracheal groove – ventral aspect of foregut
  4. Be familiar with laryngeal muscles and cartilages – mesoderm of 4th and 5th arches
  5. Understand the ossification of laryngeal skeleton
References 
  1. Lee KJ. Embryology of clefts and pouches. In Essential otolaryngology head and Neck Surgery. 8th Ed. New York: Mc-Graw Hill; 2003

Anatomy

Learning Objectives 
  1. Know the microarchitecture/layers of the vocal fold
    1. Non-keratinized stratified squamous epithelium
    2. Superficial layer of the lamina propria (Reinke’s layer or space)
    3. Intermediate and deep layers of the lamina propria (Vocal ligament)
    4. Thyroarytenoid (TA) muscle (Vocalis muscle is considered the medial portion of the thyroarytenoid muscle)
  2. Know why these layers are important in voice production and know the concepts of “cover” and “body,” pertaining to phonatory physiology
    1. Cover layer: Epithelium and superficial layer of lamina propria – critical for mucosal wave
    2. Transition zone: vocal ligament (deep layer of the lamina propria layer)
    3. Body layer: Thyroarytenoid muscle
  3. Know where and what is the “saccule”
    1. The saccule is the superior aspect of the laryngeal ventricle which extends laterally and superiorly from the space between the true and false vocal folds
  4. Understand the physiology of phonation, and be able to describe the phonatory glottic cycle
    1. The mucosal wave is passive
    2. Air flowing from the lungs towards adducted vocal folds eventually leads to high enough subglottic pressure to open the approximated covers of the opposing folds. Vocal fold oscillation then ensues and tissue elasticity and Bernoulli’s forces close the glottis. The airflow is modulated by the oscillation, creating sound. The voice is created by that sound resonating through the head and neck.
References 
  1. Cummings CW et al. Cummings Otolaryngology-Head and neck surgery. 4thth ed. Philadelphia: Elsevier Mosby, 2005.
  2. Hirano M. Clinical examination of voice. New York: Springer-Verlag; 1981.
  3. Hirano M. Phonosurgical anatomy of the larynx. In: Ford CN, Bless DM, editors. Phonosurgery: Assessment and surgical management of voice disorders. New York: Raven; 1991:25-41.
  4. Hirano M, Sato K. Histologic color atlas of the human larynx. San Diego: Singular; 1993.

Pathogenesis

Learning Objectives 
  1. Know that it is unclear if the etiology of benign subepithelial vocal fold lesions is vocal abuse or, rather, from an injury that then leads to compensatory behaviors that lead to lesion formation
  2. Know that occupational and lifestyle vocal demands also play a major role
  3. Know that cigarette smoking is an important cofactor in the development of certain lesions, primarily Reinke’s edema (also known as polypoid corditis)
  4. Know that other influences, such as acid reflux, allergy, infection, and recent intubation can increase mucosal vulnerability to injury and development of benign lesions and can also be exacerbating factors to vocal trauma
References 
  1. Benjamin B. Prolonged intubation injuries of the larynx: Endoscopic diagnosis, classification, and treatment. Ann Otol Rhinol Laryngol Suppl. 1993 Apr;160:1-15.
  2. Dixon HS. Allergy and laryngeal disease. Otolaryngol Clin North Am. 1992 Feb;25(1):239-50.
  3. Koufman JA. The otolaryngologic manifestations of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope. 1991 Apr;101(4 Pt 2 Suppl 53):1-78.
  4. Koufman JA, Amin MR, Panetti M. Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders. Otolaryngol Head Neck Surg. 2000;123:385-388.
  5. Koufman J, Aviv J, Casiano R, Shaw G. Laryngopharyngeal reflux: Position statement of Committee on Speech, Voice and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2002 July;127:32-35.

Basic Science

Learning Objectives 

Know the composition of the layers of the vocal folds (i.e. collagen, elastin, hyaluronic acid, fibroblasts, macrophages)

References 
  1. Gray SD. Cellular physiology of the vocal folds. Otolaryngol Clin North Am. 2000;33:679-697.
  2. Gray SD, Hirano M, Sato K. Molecular and cellular structure of vocal fold tissue. In Titze IR, editor. Vocal fold physiology. San Diego, CA: Singular; 1993.

Incidence

Learning Objectives 

Understand that benign laryngeal lesions are common in approximately 50 percent of patients with voice complaints

References 
  1. Kleinsasser O. Microlaryngoscopy and endolaryngeal microsurgery: Technique and typical findings. 2nd ed. Baltimore: University Park Press; 1979.

Patient Evaluation

Learning Objectives 
  1. Describe the evaluation of a patient with hoarseness or voice complaint caused by a benign laryngeal lesion
    1. Know the complaint may not be hoarseness alone but rather vocal fatigue, vocal effort or strain.
  2. Know that the three fundamental aspects of this evaluation include:
    1. A detailed history
      1. Onset and duration of vocal symptoms; whether acute, chronic, or acute on chronic
      2. Patient beliefs about the etiology as well as alleviating and exacerbating factors
        1. Does the voice get better or worse as the day goes on? Does the voice ever return to normal?
      3. Patient perception of the severity of symptoms
      4. Associated symptoms, such as dyspnea, dysphagia, heartburn, throat clearing, mucus sensation, globus sensation, post nasal drip sensation (all can be associated with laryngopharyngeal reflux)
      5. Patient vocal personality, i.e., degree of talkativeness
      6. Occupation, i.e. singer, professional voice user, etc.
      7. Associated risk factors, i.e., tobacco and alcohol use, allergies, dehydration, known gastroesophageal reflux disease
    2. Vocal analysis/Perceptual assessment of vocal capabilities and limitations
      1. No single gold standard test as intra- and inter-patient variability exists
      2. Acoustic measures (spectrograms, harmonics, noise to harmonic ration, cepstral peak prominence, etc.)
      3. Electroglottography (EGG)
      4. Aerodynamic measures (subglottic pressure, airflow, maximal phonation time)
      5. Perceptual analysis
      6. Voice outcomes (Voice handicap index)
    3. Laryngeal examination
      1. Indirect laryngoscopy
      2. Flexible laryngoscopy
        1. Fiberoptic as well as distal chip camera options
      3. Videostroboscopy
        1. Necessary for the diagnosis of hoarseness that otherwise cannot be explained by white light examination
        2. Can be performed via flexible laryngoscopy or rigid trans-oral 70 or 90 degree Hopkins rod telescope.
References 
  1. Cummings CW et al. Cummings otolaryngology-Head and neck surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005.
  2. Sataloff RT. Professional singers: The science and art of clinical care. Am J Otol. 1981;2:251.
  3. Yanagisawa E, Yanagisawa R. Stroboscopic videolaryngoscopy: A comparison of fiberscopic and telescopic documentation. Ann Otol Rhinol Laryngol. 1993;102:255-265.
  4. Yanagisawa E, Yanagisawa R. Laryngeal photography. Otolaryngol Clin North Am. 1991;24:999-1022.

Measurement of Functional Status

Learning Objectives 

Be familiar with the various voice assessment scales, such as the Voice Handicap Index (VHI), Voice Handicap Index-10 and Voice-Related Quality of Life (VRQOL) scale.

References 
  1. Benninger MS et al. Assessing outcomes for dysphonic patients. J Voice. 1998 Dec;12(4):540-550.
  2. Hogikyan ND, Sethuraman G. Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice. 1999;13:557.
  3. Jacobson GH et al. The voice handicap index (VHI): Development and validation. Am J Speech Lang Pathol. 1997;6(3):66-69.
  4. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the Voice Handicap Index-10. The Laryngoscope. 2004;114(9):1549–1556.

Pathology

Learning Objectives 

Benign laryngeal lesions:

  1. Inflammatory/Traumatic
    1. Vocal nodules
    2. Vocal fold polyp
    3. Vocal fold cyst
    4. Vocal fold hemorrhage/Hemorrhagic vocal fold polyp
    5. Vascular ectasia
    6. Scar/Sulcus Vocalis
    7. Polypoid Corditis (Reinke’s edema)
    8. Contact ulcer or granuloma
    9. Intubation granuloma
  2. Benign neoplasms
    1. Recurrent respiratory papillomatosis
    2. Laryngocele
    3. Saccular cyst
    4. Laryngeal hemangiomas
    5. Rhabdomyoma
    6. Lipoma
    7. Chondroma
    8. Granular cell neoplasms
    9. Neurofibroma
    10. Neurilemmoma
References 
  1. Abitbol J. Vocal fold hemorrhages in voice professionals. J Voice. 1988;2:261.
  2. Agarwal RK, Blitzer A, Perzin KH. Granular cell tumors of the larynx. Otolaryngol Head Neck Surg. 1979;87:807.
  3. Beafsky PC, Postma GN, Koufman JA. The association between laryngeal pseudosulcus and laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2002;126:649-652.
  4. Bouchayer M et al. Epidermoid cysts, sulci, and mucosal bridges of the true vocal fold: a report of 157 cases. Laryngoscope. 1995;95:1087-94.
  5. Cummings CW et al. Cummings otolaryngology-Head and neck surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005.
  6. Derkay CS. Recurrent respiratory papillomatosis. Laryngoscope. 2001;111:57-69.
  7. Ford CN, Inagi K, Khidr A et al. Sulcus vocalis: A rational analytic approach to diagnosis and management. Ann Otol Rhinol Laryngol. 1996;105(3):189-200.
  8. Hochman I, Sataloff R, Hillman RE, Zeitels SM. Ectasias and varices of the vocal fold: Clearing the striking zone. Ann Otol Rhinol Laryngol. 1999;108:10.
  9. Holinger LD et al. Laryngocele and saccular cysts. Ann Otol Rhinol Laryngol. 1978;87;675.
  10. Jones SR, Myers EN, Barnes L. Benign neoplasms of the larynx. Otolaryngol Clin North Am. 1984;17:151.
  11. Kambic V et al. Vocal cord polyps: incidence, histology, pathogenesis. J Laryngol Otol. 1981;95:609.
  12. Pontes P, Behlau M. Treatment of sulcus vocalis: Auditory perceptual and acoustic analysis of the slicing mucosa surgical technique. J Voice. 1993;7:365-376.
  13. Akbulut S, Gartner-Schmidt JL, Gillespie AI, et al. Voice outcomes following treatment of benign midmembranous vocal fold lesions using a nomenclature paradigm. The Laryngoscope. 2016 Feb 1;126(2):415–20.

Treatment

Learning Objectives 
  1. Know the general management options for the treatment of benign laryngeal lesions:
    1. Voice therapy to decrease primary or secondary hyperfunctional laryngeal behaviors have caused or exacerbate the lesions
    2. Vocal hygiene including avoidance of throat clearing and cough and voice rest when possible
    3. Hydration
    4. Sinonasal and allergy management
    5. Avoidance of cigarette smoking and alcohol consumption
    6. Treatment of laryngopharyngeal reflux disease if present by history, or preferably after pH Impedance testing
    7. Surgical management using microlaryngeal techniques and/or office based interventions (lesion dependent)
  2. Know the specific treatment for each of the benign laryngeal lesions:
    1. Vocal nodules
      1. Medical – hydration, treating comorbidities as above
      2. Behavioral – avoid vocal overuse or abuse
      3. Surgical – laryngeal microsurgery
      4. Postsurgical care
    2. Capillary ectasia
      1. Medical – hydration, treating comorbidities as above and avoid meds with anticoagulant effect
      2. Behavioral - avoid vocal overuse or abuse
      3. Surgical - laryngeal microsurgery, office or operative laser coagulation
    3. Vocal fold hemorrhage/Hemorrhagic vocal fold polyp
      1. Medical – hydration, treating comorbidities as above and avoid meds with anticoagulant effect
      2. Behavioral – Voice Rest with subsequent voice therapy after hemorrhage resolves
      3. Surgical –laryngeal microsurgery or office based KTP laser
    4. Vocal fold cyst
      1. Medical – hydration, treating comorbidities as above
      2. Behavioral – voice therapy
      3. Surgical – mucosal incision and cyst exposure and removal (microflap surgery)
      4. Postsurgical – voice therapy
    5. Scar or sulcus vocalis
      1. Medical – hydration, treating comorbidities as above
      2. Behavioral –voice therapy
      3. Surgical – various (see Bouchayer’s article in the references). Office steroid injections into the scar can be offered before OR.
    6. Polypoid Corditis (Reinke’s edema)
      1. Medical – smoking cessation, possible thyroid function evaluation if myxedema suspected
      2. Behavioral – voice therapy
      3. Surgical – polyp reduction with KTP laser if not large; or trimming but preserving mucosa rather than stripping
    7. Vocal process granuloma (lesions that form in face of hyperfunction from glottic insufficiency and inflammation, typically reflux disease)
      1. Medical – hydration and antireflux therapy empiric trial or pH impedance testing
      2. Behavioral – voice therapy
      3. Surgical –Consider Vocal fold injection augmentation if suspicious of glottic insufficiency. Botox injections into thyroarytenoid muscle are also common. Both will decrease contact in the posterior glottis. Surgical removal is often necessary due to frequent recurrence if underlying issues are not addressed.
    8. Intubation granuloma
      1. Often self-limited, may need surgery if large and affecting airway
    9. Laryngocele
      1. Surgical - endoscopic marsupialization versus external approach
    10. Saccular cysts
      1. Surgical – See reference articles by Abramson and Zielinski; DeSanto, Devine, and Weiland; and Holinger et al
      2. Typically false vocal fold excision on the affected side to include cyst.
    11. Recurrent respiratory papillomatosis
      1. Medical – intralesional cidofovir, bevacizumab, interferon, indole-3-carbinol, methotrexate
      2. Surgical – KTP or pulse dye laser, CO2 laser, microdebrider, cold knife excision
References 
  1. Abramson AL, Zielinski B. Congenital saccular cyst of the newborn. Laryngoscope. 1994;94:1580.
  2. Akst LM et al. Stepped-dose protocol of cidofovir therapy in recurrent respiratory papillomatosis in children. Arch Otolaryngol Head Neck Surg. 2003;129:841-846.
  3. Bouchayer M, Cornut G. Microsurgery for benign lesions of the vocal folds. Ear, Nose and Throat Journal. 1988;67:446-66.
  4. Cummings CW et al, Cummings otolaryngology-Head and neck surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005.
  5. DeSanto LW, Devine KD, Weiland LH. Cysts of the larynx: Classification. Laryngoscope. 1970;80:245.
  6. Sridharan S, Achlatis S, Ruiz R, Jeswani S, Fang Y, Branski RC, et al. Patient-based outcomes of in-office KTP ablation of vocal fold polyps. The Laryngoscope. 2014 May 1;124(5):1176–9.
  7. Carroll TL, Gartner-Schmidt J, Statham MM, Rosen CA. Vocal process granuloma and glottal insufficiency: An overlooked etiology? Laryngoscope. 2010; 120:114–120.
  8. Holinger LD et al. Laryngocele and saccular cysts. Ann Otol Rhinol Laryngol. 1978;87:675.
  9. Zeitels SM et al. Office-based treatment of glottal dyplasia and papillomatosis with the 585-nm pulsed dye laser and local anesthesia. Ann Otol Rhinol Laryngol. 2004;113(4):265-2761.
  10. Zeitels SM, Akst LM, Burns JA, Hillman RE, Broadhurst MS, Anderson RR. Office-Based 532-nm Pulsed KTP Laser Treatment of Glottal Papillomatosis and Dysplasia. Ann Otol Rhinol Laryngol. 2006 Sep;115(9):679-85.
  11. Best SR, Friedman AD, Landau-Zemer T, Barbu AM, Burns JA, Freeman MW, et al. Safety and Dosing of Bevacizumab (Avastin) for the Treatment of Recurrent Respiratory Papillomatosis. Ann Otol Rhinol Laryngol. 2012 Sep;121(9):587-93.

Medical Therapies

Learning Objectives 

List appropriate medical treatments that may be helpful in treating benign laryngeal lesions:

  1. Hydration
  2. Sinonasal and allergy management
  3. Avoidance of cigarette smoking
  4. Voice therapy including vocal hygiene, voice rest, and gentle voice use
  5. Treatment of laryngopharyngeal reflux disease if present and contributing
References 
  1. Cummings CW et al. Cummings otolaryngology-Head and neck surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005.

Pharmacology

Learning Objectives 

Be familiar with the pharmacologic treatment of laryngopharyngeal reflux disease:

  1. H2 blockers.
  2. Proton pump inhibitors (PPIs)
  3. Alginates
References 
  1. Amin MR et al. Proton pump inhibitor resistance in the treatment of laryngopharyngeal reflux. Otolaryngol Head Neck Surg. 2001;125;374-378.
  2. Koufman J, Aviv J, Casiano R, Shaw G. Laryngopharyngeal reflux: Position statement of Committee on Speech, Voice and Swallowing Disorders of the American Academy of Otolaryngology-Head and Neck Surgery. Otolaryngol Head Neck Surg. 2002 July;127:32-35.
  3. Steward D, Wilson K, Kelly D, et al. Proton pump inhibitor therapy for chronic laryngo-pharyngitis: A randomized placebo controlled trial. Otolaryngol Head Neck Surg. 2004;13:342-350.
  4. Gooi Z, Ishman SL, Bock JM, Blumin JH, Akst LM. Changing Patterns in Reflux Care 10-Year Comparison of ABEA Members. Ann Otol Rhinol Laryngol. 2015 Dec;124(12):940-6.
  5. McGlashan JA, Johnstone LM, Sykes J, Strugala V, Dettmar PW. The value of a liquid alginate suspension (Gaviscon Advance) in the management of laryngopharyngeal reflux. Eur Arch Otorhinolaryngol. 2009 Feb;266(2):243-51.

Surgical Therapies

Learning Objectives 
  1. Be familiar with the procedures that can address benign laryngeal lesions
  2. Know the various techniques of vocal fold microsurgery
References 
  1. Cummings CW et al. Cummings otolaryngology-Head and neck surgery. 4th ed. Philadelphia: Elsevier Mosby; 2005.
  2. Rosen CA and Simpson CB. Operative Techniques in Laryngology.  Berlin Heidelberg; 2008.

Rehabilitation

Learning Objectives 

Understand voice therapy, vocal rehabilitation, and speech pathology services are recommended for most patients with benign vocal fold lesions pre-operatively and/or post-operatively to both treat (avoid surgery) and prevent these lesions from recurring.

References 
  1. Benninger MS, Murray T. The performer’s voice. Plural Publishing; 2006.
  2. Sataloff RT. Professional voice. The science and art of clinical care. 2nd ed. San Diego, CA: Singular; 1997.

Case Studies

  1. A 55-year-old female presents with progressive hoarseness and complaints of frequent throat clearing and globus sensation. She also works as an elementary school teacher and states that her occupation necessitates excessive use of her voice. She also smokes 1.5 packs of cigarettes a day. On physical exam you note bilateral polypoid changes of her vocal folds with no leukoplakia or areas suspicious for malignancy. How would you further evaluate this patient? How would you counsel this patient to improve her voice? Should she try a trial of voice therapy or have these “polyps” removed surgically?
  2. An 8-year-old male singer presents with dysphonia and decrease in vocal range, including loss of higher pitch. He has noted increased effort for singing and day-to-day variability in his symptoms. He does note occasional heartburn and does frequently clear his throat and experiences a globus sensation. Indirect exam reveals bilateral vocal fold nodules. How would you further evaluate this patient? What medical and behavioral therapy would be helpful in this case? When would it be appropriate to have these nodules surgical removed?

Complications

Learning Objectives 

List the potential complications associated with the surgical treatment of benign laryngeal lesions:

  1. Vocal fold scar
  2. Oropharyngeal complications
References 
  1. Benninger MS et al. Vocal fold scarring: Current concepts and management. Otolaryngol Head Neck Surg. 1996;115(5):474-482.
  2. Rosen CA. Vocal fold scar evaluation and treatment. Otolaryngol Clin North Am. 2000;33(5):1081-1086.
  3. Rosen CA, Andrade Filho PA, Scheffel L et al. Oropharyngeal complications of suspension laryngoscopy: A prospective study. Laryngoscope. 2005;115:1681-1684.
  4. Rosen CA and Simpson CB. Operative Techniques in Laryngology. Springer Berlin Heidelberg; 2018. 

Review

Review Questions 
  1. What are the layers of the vocal fold?
  2. What risk factors play a role in the development of benign laryngeal lesions?
  3. Describe the evaluation of a patient with a suspected benign laryngeal lesion?
  4. What are the general medical and behavioral treatments of benign laryngeal lesions?
  5. Name the common benign laryngeal lesions and their specific treatments?
  6. What are some of the potential complications of vocal fold microsurgery for benign laryngeal lesions?
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