COMMON LARYNGEAL LESIONS
Vocal cord
nodules, polyps, and cysts are common causes of hoarseness in people with high
voice demands, such as teachers, singers, and young children. Excessive or
abusive voice use causes repetitive trauma and inflammation within the
superficial layer of the lamina propria (Reinke space), leading to the formation
of subepithelial lesions affecting the anterior true vocal cord. Mass effect
from these lesions impairs vocal cord vibration and disrupts air flow between
the vocal cords during phonation, leading to hoarseness. Treatment requires a
multifaceted approach, including elimination of vocally abusive behaviors;
optimization of laryngeal hygiene; and medical therapy for associated
inflammatory conditions such as allergy, infection, and laryngopharyngeal reflux.
Surgical excision using modern phonomicrosurgical techniques is indicated for
persistent lesions that do not respond to conservative measures.
Laryngeal granulomas are inflammatory lesions arising from the vocal process of the arytenoid
cartilage in the posterior larynx. They may be unilateral or bilateral. The
most common cause is endotracheal intubation, and the term intubation
granuloma has been previously used. Pressure from the endotracheal tube
causes inflammation and erosion of the thin perichondrium overlying the vocal
process of the arytenoid cartilage, leading to granuloma formation. Other
common causes include chronic cough or throat clearing, excessive voice use,
and laryngopharyngeal reflux. These lesions often regress spontaneously after
the localized trauma or underlying inflammatory condition has been addressed.
Surgical excision with cold steel or the CO2 laser is reserved for
refractory lesions or large granuloma obstructing the posterior glottic airway.
Recurrent respiratory papillomatosis (RRP) is a disease of viral origin characterized by multiple
exophytic lesions of the aerodigestive tract in both children and adults.
Laryngeal involvement is common, leading to progressive hoarseness and airway
compromise. Extralaryngeal spread to the trachea and lungs is less common but
is associated with increased morbidity and potential mortality. Onset of RRP
may occur during either childhood or adulthood, with a bimodal age distribution
demonstrating the first peak in children younger than 5 years of age and the
second peak between 20 and 30 years of age. Juvenile-onset RRP is more common
and is the most aggressive form of the disease. It is acquired through vertical
transmission of human papilloma virus from an infected mother in utero or
during childbirth. Although benign, these lesions are a source of significant
morbidity because of their location within the upper and lower airways, the
frequency with which they recur despite aggressive medical and surgical
treatment, and the potential for malignant degeneration over time.
Squamous cell carcinoma is the most common malignancy
of the larynx. These cancers range from well- differentiated, low-grade tumors
such as verrucous carcinoma, which can be treated with surgical excision alone
and carries an excellent prognosis, to poorly differentiated, high-grade
carcinomas, which have a poor prognosis despite aggressive, multimodality treatment. The location of
the tumor also has important implications. Glottic cancers, which arise from
the true vocal cords, are often diagnosed at an early stage because even small
lesions cause symptomatic hoarseness. They also have a relatively low rate of
metastasis to regional lymphatics or distant sites. In contrast, supraglottic
cancers, which arise from the epiglottis or false vocal cords, are often
diagnosed at a more advanced stage when the tumor is large enough to cause symptomatic dysphagia or airway
obstruction. Supraglottic cancers have a high rate of regional lymph node
involvement and are more likely to metastasize to the lungs or other distant
sites. Subglottic cancers are rare but carry a relatively poor prognosis.
Prolonged smoking and alcohol consumption are the most important risk factors
for laryn eal cancer, with a synergistic effect when combined.
