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.