Benign laryngeal lesions

Common benign lesions of the larynx include vocal fold polyps, vocal fold nodules, vocal fold cysts, vocal fold granulomas, Reinke edema, and laryngeal papillomatosis. Most of these lesions develop as a consequence of chronic irritation of the vocal cords (e.g., smoking, voice overuse, GERD), while laryngeal papillomatosis is caused by HPV. The cardinal symptom of these conditions is hoarseness. Laryngoscopy with or without biopsy is usually indicated for diagnosis. Management depends on the clinical findings and includes conservative management of underlying causes (e.g., smoking cessation, vocal rest) and surgical approaches. Laryngeal papillomatosis, leukoplakia, and pachyderma are all lesions of the larynx that are considered precancerous.

• Definition: benign lesion that develops in response to vocal fold irritation in the anterior one-third of the vocal fold
• Epidemiology
  • Most common benign lesion of the vocal cords
  • Peak incidence between 30 and 50 years
  • ♂ > ♀
• Etiology
  • Voice overuse (e.g., teachers, professional singers)
  • Smoking, GERD
  • Anticoagulant use
• Clinical features: low-pitched, whispery voice; hoarseness ^[1]
• Diagnostics: laryngoscopy
  • Unilateral spherical lesion
  • Located at the junction of the anterior one-third and posterior two-thirds of the vocal folds
• Pathology: fluid and fibrin filled lesion in the superficial lamina propria of the vocal fold
• Management: microsurgical removal

• Definition: benign lesion that are caused by frequent microtrauma (e.g., voice overuse) to the vocal cords, which leads to edematous swelling and development of fibrotic scars
• Epidemiology
  • Peak incidence between 20 and 50 years
  • Most common cause of persistent hoarseness in school-aged children
  • ♀ > ♂
• Etiology: voice overuse (e.g., teachers, professional singers) or abuse (e.g., children who scream/cry a lot)
• Pathophysiology: microtrauma to the vocal cords → edematous swelling → fibrotic scar (vocal fold nodule) of the superficial lamina propria
• Clinical features: low-pitched, whispery voice; hoarseness, altered vocal range ^[1]
• Diagnostics: laryngoscopy
  • Bilateral lesions at the junction of the anterior one-third and posterior two-thirds of the vocal folds
  • Symmetric, pinhead-sized, pale nodules
  • Variable color, contour, and/or shape
• Management
  • Conservative management: treat underlying cause
    • Vocal rest and voice therapy
    • Treatment of GERD
    • Smoking cessation
  • Vocal fold steroid or botulinum toxin injection
  • Microsurgical removal in persistent or severe cases
• Prognosis: good prognosis (especially in children and adolescents) with appropriate treatment

• Definition: benign, sac-like structure in the lamina propria of the vocal cords due to obstruction of mucus-secreting glands
• Epidemiology: Occurs in all ages; often in children
• Etiology: obstruction of laryngeal mucus-secreting glands
  • Retention cysts: obstruction caused by inflammation due to high vocal stress (e.g., occupational)
  • Epidermoid cysts: obstruction caused by congenital anomaly or secondary to a vocal trauma
    • In children: typically a congenital anomaly
• Classification:
  • Retention or epidermoid cyst
  • Intracordal or saccular cyst
• Clinical features
  • Intracordal cyst: hoarseness
  • Saccular cyst: airway obstruction, voice change
• Diagnostics: laryngoscopy typically shows unilateral yellow-white lesion with distinct border
  • Saccular cyst: supraglottic mass
  • Intracordal cyst: middle third of the vocal cord associated with an area of hyperkeratosis on the opposite cord
• Treatment: microsurgical removal

• Definition: lesion on both vocal folds caused by trauma (e.g., endotracheal intubation) and subsequent inflammation and ulceration
• Epidemiology: ♂ > ♀
• Etiology: trauma to the vocal cords
  • Endotracheal intubation
  • Voice overuse (e.g., teachers, professional singers)
  • Chronic cough
  • GERD
• Clinical features: hoarseness, cough
• Diagnostics: laryngoscopy with biopsy to exclude cancerous cells or tuberculosis
  • Mostly bilateral lesion
  • Mushroom-shaped appearance of the granulomas, whitish shimmering fibrin coating
  • Located in the dorsal third of vocal folds, adjacent to the arytenoids
• Pathology: usually ulceration → granuloma
• Management
  • Conservative management: treat underlying cause
    • Vocal rest and voice therapy
    • Treatment of GERD
    • Smoking cessation
  • Microsurgical removal: if symptoms persist or malignancy is suspected

• Definition: a benign buildup of fluid in the superficial lamina propria of the true vocal cords caused by chronic inflammation and irritation secondary to smoking
• Epidemiology: ♀ > ♂
• Etiology ^[2]
  • Major risk factor: smoking
  • Minor risk factors
    • Voice overuse (e.g., teachers, professional singers)
    • Allergy
    • Chronic URIs
    • GERD
• Clinical features: hoarseness; low-pitched, rough voice ; vocal fatigue
• Diagnostics: laryngoscopy shows bilateral swelling of the true vocal cords
• Pathology: edema within the superficial lamina propria between the epithelium and vocal ligament (Reinke's space) ^[2]
• Management ^[3]
  • Controlling risk factors
    • Smoking cessation
    • Reflux management
    • Avoidance of voice overuse
  • Restoring normal voice function
    • Voice therapy
    • Microsurgical removal in cases in which voice function is dissatisfactory despite conservative treatment

Significant smoking history is also a risk factor for vocal fold leukoplakia and laryngeal cancer, so it is important to clearly visualize the vocal cords during diagnosis of Reinke edema and evaluate for other lesions in the area as well.

• Definition: benign tumor of the laryngeal stratified squamous epithelium caused by human papillomavirus (HPV) infection of the throat
• Classification
  • Juvenile onset recurrent respiratory papillomatosis (JORRP): < 20 years of age
    • Peak onset < 5 years of age
  • Adult onset recurrent respiratory papillomatosis (AORRP)
• Etiology: HPV infection (especially HPV6 and HPV11; followed by HPV subtypes 16, 18, 31, and 33) ^[4]
  • In children: usually due to vertical transmission during birth
  • In adults: potentially via sexual activity or reactivation of the dormant virus
• Clinical features: disease extent is highly variable
  • Hoarseness, dysphonia/aphonia
  • Stridor, chronic cough, dyspnea due to airway obstruction
  • Dysphagia in advanced disease
• Diagnostics: laryngoscopy
  • Multiple raspberry-like swellings
  • Usually located on vocal cords
  • Can be unilateral or bilateral
• Management: no definitive cure, goal is to limit disease spread
  • Surgical removal (e.g., microdebridement, carbon dioxide lasers) of symptomatic lesions
  • Potentially adjuvant treatment with antivirals (e.g., acyclovir, ribavirin, cidofovir)
• Complications
  • Malignant transformation into squamous cell carcinoma in up to 4% of cases ^[5]
  • Airway obstruction and life-threatening respiratory distress
• Prognosis
  • Frequently recurring
  • Often regresses spontaneously in puberty

Papillomas that remain till adulthood are potential precancerous lesions. Although it rarely occurs, papillomas can undergo malignant transformation and become squamous cell carcinoma.

• Laryngeal papillomatosis: squamous cell carcinoma in up to 4% of cases ^[5]
• Leukoplakia: hyperkeratosis of the epithelium and mucous membranes that most commonly affects the oral cavity
  • High risk of malignant transformation into laryngeal cancer (up to 20% within 5 years of diagnosis) ^[6]
  • See “Leukoplakia” for details.
• Pachyderma: rough and/or thickened mucosa that may be accompanied by swelling
  • Associated with GERD or chronic bacterial infection, as well as some cancers and pachydermoperiostosis
  • Malignant transformation into laryngeal cancer is possible

The differential diagnoses listed here are not exhaustive.