Non-Neoplastic Lesions of the Larynx, Hypopharynx, and Trachea

Clinical Features

A nodule and a polyp are not clinically synonymous terms, although they are frequently used interchangeably in the pathology community. Approximately 1.5% of the general population has hoarseness, and the presence of polyp/nodule is one of the most frequent significant causes. Nearly 2.5% of children have nodules, with boys affected more often than girls (2 : 1), with attention-deficit/hyperactivity disorder (ADHD) associated with increased frequency of polyps or nodules. Among young adults, nodules are more frequent in young women. By contrast, polyps occur in any age group, with an equal sex distribution. Both lesions characteristically produce hoarseness, discomfort, vocal changes, and unstable voice. The speaking voice of singers, actors, public speakers, lecturers, and coaches is affected by excessive (overuse) and improper (abuse) use of voice. Interestingly, extroverted patients and patients who are talkative or excessively loud (vocal overdoers) are more likely to develop vocal cord polyps and nodules than quiet people who are not talkative (i.e., not me).

Pathologic Features

Gross Findings

Grossly, nodules are almost always bilateral, affecting the anterior to midportion of the true vocal cord, and presenting as an edematous, hemorrhagic, or callous-like mass, typically a few millimeters in size ( Fig. 4.1 ). By contrast, a polyp is unilateral (>90%), affecting the aryepiglottic fold, ventricular space, vocal fold, or Reinke space, as a sessile, raspberry-like to pedunculated soft, rubbery, translucent (edematous) to erythematous mass ( Fig. 4.2 ) up to a few centimeters in greatest dimension.

Microscopic Findings

There is usually no definitive histologic distinction between laryngeal nodules and polyp because they represent different stages within an arc of development. In the early stages, there is edema and deposition of proteinaceous material in the subepithelium and interstitium ( Fig. 4.3 ). There is increased vascularization with subsequent hemorrhage ( Fig. 4.4 ). Vascularity is much higher in polyps than nodules, and a thickened basement membrane is seen in nodules and not in polyps. Inflammation is scant to absent, but dilated vessels (telangiectasia) and granulation-type tissue may occasionally be seen. Myxoid stroma (pale blue-pink matrix material; Fig. 4.5 ) tends to be intermediate in the progression to a hyaline type, with fibrin-type material closely opposed to vascular spaces ( Fig. 4.6 ) or a fibrous type, with spindle cells in a dense fibrous stroma ( Fig. 4.7 ). However, any or all of these changes may be seen within the same polyp. Therefore the designations of edematous, vascular, myxoid, hyaline, or fibrous types are not important, as they represent degrees of development. However, by convention, the dominant histologic pattern determines the type. The surface epithelium may become metaplastic, atrophic, keratotic, and hyperplastic. Crystals may be seen in a few polyps.

Differential Diagnosis

The differential diagnosis includes amyloidosis, myxoma, contact ulcer, ligneous conjunctivitis, and, rarely, neoplasms (granular cell tumor, spindle cell [sarcomatoid] squamous cell carcinoma [SCSCC]). Amyloidosis shows a perivascular or periglandular accentuation of an acellular, extracellular eosinophilic matrix material. Myxoma , uncommon at this site, is an avascular, hypocellular lesion with occasional stellate spindle cells in an abundant basophilic, gelatinous matrix. Contact ulcer shows surface ulceration with fibrinoid necrosis and primarily affects opposing surfaces of the posterior true vocal cords. Ligneous (“woody”) conjunctivitis, a rare chronic condition affecting mucous membranes, results in firm, clotted fibrin-rich matrix material deposition that creates a hard, subepithelial nodule. In general, neoplasms may be easily distinguished by their unique histologic findings.

Prognosis and Therapy

Voice or speech therapy, behavior modification, and vocal hygiene are first line treatments for polyps and nodules. Drug therapy may also help certain underlying conditions, such as hypothyroidism. Surgery usually has limited value because it is the underlying cause that needs to be managed.

Clinical Features

Contact ulcer is a frequent benign reactive epithelial response to injury, generally associated with acid regurgitation, vocal abuse, and/or intubation. Gastric-laryngeal reflux or gastroesophageal reflux disease (GERD) is frequently missed because the patient is unaware of the underlying cause (hiatal hernia), although they may report heartburn and/or belching as a result of the acid reflux, with pepsin thought to be the injurious agent rather than hydrochloric acid. When a result of intubation, females are affected more commonly, especially in the urgent setting when an inappropriately sized endotracheal tube has been selected. Otherwise, contact ulcer develops more frequently in adult men, who present with hoarseness, cough, sore throat, chronic throat clearing, habitual coughing, or pain.

Pathologic Features

Gross Findings

Contact ulcer usually presents as a bilateral, polypoid, or nodular mass ( Fig. 4.8 ), up to 3 cm in size, most frequently affecting the posterior larynx. There is usually a “kissing ulcer” on the contralateral cord, with a red to beefy appearance.

Microscopic Findings

Histologic sections reveal extensive surface ulceration, covered by fibrin and/or fibrinoid necrosis, overlying exuberant granulation tissue ( Figs. 4.9 and 4.10 ). Vessels in the granulation tissue, often arranged perpendicular to the surface, are lined by plump reactive endothelial cells without atypia, and surrounded by marked acute and chronic inflammation, including plasma cells, histiocytes, and giant cells ( Fig. 4.10 ). Hemosiderin-laden macrophages may be seen at the base of the polyp, especially in lesions of long clinical duration ( Fig. 4.9 ). Surface bacterial or fungal colonization is frequently seen. In the early stages, surface ulceration without granulation tissue may be identified. Over time, the lesion may demonstrate an irregular hyperplastic epithelium secondary to regenerative surface reepithelialization, although a residuum of fibrinoid necrosis is usually identified below the new surface ( Fig. 4.11 ). These changes characterize the chronic phase of the disease, which may also show prominent stromal fibrosis.