Non-Neoplastic Lesions of the Larynx and Trachea

Clinical

• No gender predilection; may be seen in all age groups but most common from the third to sixth decades

• Clinicians distinguishing between nodules and polyps based on whether the lesion(s) is (are) sessile (nodule) or pedunculated (polyp)

• Regardless of terminology, the symptoms related to vocal cord polyps and nodules are similar and include hoarseness or voice changes (“breaking” of the voice).

• May be a single lesion arising from the true vocal cord or bilateral lesions involving the anterior or middle third of the true vocal cord:

  • May occur anywhere along the vocal cord but most occur on the free edge at the junction of the anterior and middle thirds

  • Point of maximal vibratory impact in the vocal cord is in the middle third of the true vocal cord (membranous cord), representing the most common site for polyps or nodules to occur.

• Follows voice abuse (phonatory trauma), infection (laryngitis), alcohol, smoking, or endocrine dysfunction (hypothyroidism):

  • Phonatory trauma is a central cause of nodule/polyp formation.

  • Infrequently, hypothyroidism may cause vocal cord edema, which may progress to formation of a myxoid polyp.

• Helicobacter pylori (HP), a common cause of gastritis and/or gastroespohageal reflux disease, may be associated with vocal fold minimal lesions (VFML) (e.g., polyps, nodules, contact ulcers):

  • HP can be detected by immunohistochemical staining or reverse transcriptase polymerase chain reaction (RT-PCR) in biopsies from patients with VFML.

  • Direct cause and effect between presence of HP and polyps/nodules not established

• Videostroboscopic examination of the glottal cycle is useful in the differential diagnosis of small lesions of the vocal fold cover that cannot be easily visualized:

  • An isolated lesion shows:

    • –

      Irregular, incomplete closure

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      Reduced amplitude of vibration and mucosal wave on the vocal fold on the side of the lesion

  • Bilateral lesions of longer duration show:

    • –

      Greater reduction in vibratory amplitude and mucosal wave due to increased submucosal fibrosis and perhaps presence of surface keratinization

Pathology

Differential Diagnosis

• Myxoma:

  • True myxomas are rarely encountered in the larynx.

  • Typically occurs in supraglottic larynx rather than vocal cord (i.e., gottis) where polyps/nodules occur

  • Typically large (≥3 cm or larger) rather than small size of polyps/nodules

  • Tend to be avascular as compared with well-vascularized nature of polyps/nodules

  • Typically are not covered by surface epithelium as compared with polyps/nodules that typically include overlying surface (squamous) epithelium

• Amyloidosis:

  • Hyaline-type vocal cord nodule may be misinterpreted as amyloid deposition; however, staining for amyloid differentiates between these entities.

• Hemangioma

• Fibroma

• Neurofibroma:

  • Neurofibromas are S100 protein and Sox10 positive.

  • Vocal cord polyps/nodules S100 protein and Sox10 negative

• In rare examples showing atypical stromal cells the differential diagnosis may include a malignant neoplasm, including sarcoma (e.g., rhabdomyosarcoma) and carcinoma (e.g., spindle cell squamous carcinoma):

  • Laryngeal sarcomas are rare; the most common type of sarcoma of the larynx is a chondrosarcoma (see Chapter 16 ).

  • Atypical stromal cells in a polyp/nodule tend to be localized as compared with diffuse cellularity and nuclear atypia, including increased mitotic activity seen in association with a sarcoma.

Treatment and Prognosis

• Surgery:

  • Laser surgery can be used safely in the larynx to remove benign superficial laryngeal lesions.

• Voice therapy:

  • Postoperative voice therapy decreases the risk of recurrence.

• Vocal cord nodules/polyps can recur up to 5 years after diagnosis/therapy.

Clinical

• No gender predilection; most common in the fifth through eighth decades of life:

  • May occur in pediatric ages

• Majority are unilateral but may be bilateral in up to 25% of patients.

• Three types of laryngoceles identified:

  • Internal laryngocele: dilatation confined to the intrinsic larynx:

    • –

      Reported incidence of 30%

  • External laryngocele: dilated sac projects upward between the false vocal cord and the thyroid cartilage and laterally through the thyrohyoid ligament into the neck:

    • –

      Reported incidence of 26%

  • Mixed (combined) laryngocele is a combination of internal and external laryngoceles:

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      Reported incidence of 44%

• Symptoms include:

  • Hoarseness, coughing, dyspnea, dysphagia, and sensations of foreign body or mass in the throat

  • External or mixed laryngoceles may present as:

    • –

      Lateral neck mass that fluctuates with changes in intralaryngeal pressure and is compressible

    • –

      Subcutaneous emphysema

  • Infected laryngoceles (laryngopyocele) associated with pain and tenderness

• Diagnosis of laryngocele is a clinical one:

  • Despite clinical assurance of a diagnosis of a laryngocele, prudent therapy would include additional examination to rule out the presence of a neoplasm.

• Radiology:

  • Thin-walled air-filled cystic lesion communicating with laryngeal ventricle

  • CT (non–contrast-enhanced):

    • –

      Internal laryngocele:

      • ▪

        Low-density mass in supraglottic space

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      Mixed laryngocele:

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        Low-density, thin-walled mass seen in the low submandibular space

      • ▪

        Can be followed into larynx through thyrohyoid membrane

      • ▪

        Internal component may be collapsed or dilated.

  • Infected laryngoceles by contrast-enhanced CT have a thick, enhancing wall surrounding the laryngocele.

• Cause:

  • Laryngoceles can be congenital or acquired:

    • –

      Acquired laryngoceles are related to occupation and include professions in which there is a tendency to excessively increase intrala­ryngeal pressures, which may result in the development of a laryngocele (e.g., glassblowers, musicians, and weight lifters).

    • –

      Laryngoceles may have a coexistent (squamous cell) carcinoma:

      • ▪

        Laryngoceles associated with carcinoma tend to be of the internal type.

Pathology

Differential Diagnosis

• Branchial cleft cyst

• Oncocytic papillary cystadenoma

• Laryngeal cysts:

  • Ductal cysts and saccular cysts (see below)

Treatment

• Asymptomatic cases require no treatment.

• Surgery may be necessary in those cases that become large and symptomatic.

  • Microlaryngoscopy involving use of CO ₂ laser has become the main therapeutic procedure for the treatment of internal laryngoceles.

  • An external approach is main therapeutic approach for the treatment of combined laryngocele.

• Complications associated with laryngoceles in­­clude airway obstruction and infection (laryngopyocele):

  • For laryngopyoceles the initial treatment is by incision and drainage followed by antibiotic therapy and then surgical excision after the infection has been controlled.

• Rare complications include vocal cord paralysis and death due to asphyxia.

Classification

• Laryngeal cysts have been divided into two categories:

  • Ductal cysts:

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      Due to obstruction of the mucous gland ducts

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      Represent 75% of all laryngeal cysts

  • Saccular cysts:

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      Due to obstruction of the orifice of the laryngeal saccule

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      Represent 25% of all laryngeal cysts

Clinical

• No gender predilection; occur over a wide age range but tend to be most common in individuals older than the sixth decade of life

  • May occur in pediatric ages

• Majority of cysts occur in the supraglottic larynx; less frequently, glottic and subglottic cysts occur.

  • Ductal cysts:

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      Majority occurs in the area of the true vocal cords but not in the region of the free margin, which lacks glands.

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      Next most common site is epiglottis

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      Less frequent sites include false vocal cords, ventricles, aryepiglottic folds, arytenoids, piriform sinus, anterior commissure, and subglottis.

  • Saccular cysts:

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      Occur in the supraglottic larynx:

      • ▪

        Majority occurs in the region of the ventricles

      • ▪

        Less often occur in the region of the aryepiglottic folds, lateral larynx

  • Saccular cysts can be further subdivided into anterior and lateral cysts, depending on the location, level of obstruction, and length of the saccule:

    • –

      Anterior:

      • ▪

        Develop near the orifice of the ventricle overhanging the anterior glottis

      • ▪

        Represent the majority of cases

    • –

      Lateral:

      • ▪

        Bulge into the aryepiglottic folds, false vocal cords, or epiglottis

      • ▪

        Rarely present as a neck mass with the cyst extending through the thyrohyoid membrane.

  • Other cysts types include tonsillar-type, epithelial, and oncocytic (require histologic confirmation—see below):

    • –

      Tonsillar-type cyst:

      • ▪

        Occurs primarily in the epiglottis, vallecula, or piriform sinus

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      Epithelial cyst:

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        Occurs primarily in the piriform sinus or vallecula

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      Oncocytic cyst:

      • ▪

        Occurs primarily in the false vocal cords and ventricles

• In general, laryngeal cysts may be solitary or multiple.

• Symptoms include:

  • Asymptomatic and identified incidentally

  • Hoarseness, coughing, dyspnea, dysphagia, sensation of foreign body in the throat, neck mass, pain

  • Infants may present with feeding problems.

• Radiology:

  • Fluid-filled cystic lesion in supraglottic larynx

• Cause:

  • Laryngeal cysts can be congenital or acquired:

    • –

      Supraglottic cysts are due to obstruction of the orifice of the laryngeal saccule or obstruction of the mucous gland ducts of the laryngeal saccule with subsequent accumulation of secretions.

    • –

      Glottic cysts may be due to vocal cord abuse.

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      Subglottic cysts may occur after intubation.

    • –

      Congenital cysts may associated with other congenital or developmental abnormalities, including:

      • ▪

        Down syndrome, cystic fibrosis, cardiac anomalies, laryngomalacia, conductive hear­ing loss, hydrocephalus, microcephalus, micrognathia, others

Pathology

Differential Diagnosis

• Branchial cleft cyst

• Laryngocele

Treatment

• Conservative management is often advocated to include needle aspiration, deroofing of the cyst, laser marsupialization, or endoscopic removal:

  • Especially for infants and children to avoid stenosis

• Smaller anterior saccular cysts can be managed by endoscopic excision.

• Saccular cysts can be managed endoscopically in many cases, but if persistent after two or three endoscopic procedures, a prolonged course can be anticipated.

• Larger saccular cysts tend to recur repeatedly.

• Complete excision, endoscopically or through an external surgical approach, may shorten the clinical course.

• Tracheotomy may be required, some under emergent conditions.

Clinical

• More common in men than women; occur over a wide age range:

  • Generally seen in the adult population

  • Uncommon in children but not restricted to any specific age group

• Most common site of occurrence is along the posterior aspect of one or both vocal cords primarily in the area of the vocal cord process of the arytenoid cartilage:

  • Propensity for contact ulcers to occur along the posterior vocal cords includes:

    • –

      Posterior vocal cord experiences the greatest excursion during opening and closing of the glottis.

    • –

      Mucoperichondrium overlying the posterior vocal cord is extremely thin and more susceptible to injury.

    • –

      Additionally, the subepithelial connective tissue in this area is relatively sparse.

  • Although the majority occurs along the posterior vocal cords, other vocal cord sites may be affected.

• Symptoms include:

  • Hoarseness most common

  • Less commonly, may include dysphagia, sore throat, dysphonia, difficulty breathing, choking, foreign body sensation in the throat, and pain

  • Duration of symptoms may be from weeks to years.

• Etiologic factors include:

  • Gastroesophageal reflux disease (GERD) with acid regurgitation

    • –

      Not infrequently patients may be unaware of their condition and while supine during sleep the refluxed acid injures the posterior cord resulting in contact ulcer

    • –

      Tends to be more common in men

    • –

      Helicobacter pylori (HP) may be detected by immunohistochemical staining or reverse transcriptase polymerase chain reaction (RT-PCR):

      • ▪

        HP also may be identified in oral cavity, sinonasal tract, pharynx, and middle ear mucosa.

      • ▪

        Direct cause and effect between HP and development of contact ulcer and/or other upper aerodigestive tract lesions (non-neoplastic and neoplastic) not established

  • Vocal abuse:

    • –

      Shouting, persistent coughing, or throat clearing

    • –

      Tends to be more common in men

  • Postintubational trauma:

    • –

      Postintubational contact ulcers tend to occur more frequently in women as a result of the smaller luminal diameter seen in women.

    • –

      Lesions may not become manifest until weeks to months after intubation injury.

Pathology