Laryngology benign disorders

Question 1

Damage to the vocal folds resulting from voice
abuse, misuse, and overuse can give rise to various
vocal-fold lesions. This type of damage is called
_____?

Answer 1

Phonotrauma

Question 2

What is the most common location of true vocal

fold lesions resulting from voice abuse?

Answer 2

Mid-membranous vocal fold

Question 3

What is the term for benign growths in the
superficial layer of the anterior and middle third of
the true vocal fold, which can be either acute
(edematous, erythematous, more vascular) or
chronic (firm, nonvascular, thickened due to scar
deposition and fibrosis)?

Answer 3

Vocal-fold nodules

Question 4

What is the most common cause of vocal fold

nodules?

Answer 4

Phonotrauma (ex: singing, screaming)

Question 5

Before any surgical intervention for vocal-fold nodules, what is the first line of management?

Answer 5

Voice therapy

Question 6

In addition to voice therapy, what two contribu-
ting medical conditions should be optimized when

treating a patient with vocal fold nodules?

Answer 6

● Laryngopharyngeal reflux

● Allergies

Question 7

Describe the pathophysiologic sequence that gives

rise to vocal fold nodules.

Answer 7

Excessive vibration causes trauma leading to vascular
congestion and submucosal edema at the midmembranous
cord. If the vocal trauma continues, hyalinization of the
superficial lamina propria and epithelial thickening may
occur.

Question 8

When is it appropriate to consider surgical removal

of vocal-fold nodules?

Answer 8

When vocal impairment persists after an appropriate trial of

voice therapy

Question 9

Describe the difference between a vocal-fold

nodule and a vocal fold polyp.

Answer 9

Nodules are always bilateral, are composed of inflammatory
tissue, and respond to voice rest. They have a broad range
of appearances (hemorrhagic/edematous, pedunculated/
sessile, gelatinous/hyalinized). Polyps may be unilateral or
bilateral, are full of either gelatinous material or blood, and
typically do not respond to voice rest.

Question 10

What are the two most common etiologies for

vocal fold polyps?

Answer 10

Phonotrauma and hemorrhage

Question 11

What is the treatment of choice for a symptomatic

unilateral true vocal-fold polyp?

Answer 11

Voice therapy may be offered initially as a means of
optimizing voice use. However, polyps only rarely respond
to therapy alone, and microsurgical excision is usually
necessary. Dissection should be subepithelial and just deep
to the lesion within the involved SLP.

Question 12

After a patient undergoes microsurgical excision of a vocal-fold polyp, what amount of voice use is typically recommended in the immediate post-
operative period?

Answer 12

Complete voice rest

Question 13

Sudden voice loss during maximal voice effort is most

likely associated with what type of vocal-fold lesion?

Answer 13

Vocal-fold hemorrhage or unilateral hemorrhagic polyp

Question 14

What is the treatment of choice for vocal-fold hemorrhage?

Answer 14

This is a laryngologic emergency, and the treatment of
choice is 7 to 14 days of total voice rest with follow-up to
ensure resorption of blood and to identify a varix that could
be treated. If the blood has not resorbed, cordotomy and
evacuation of the blood are indicated.

Question 15

Describe the difference between vocal-fold scar

and sulcus vocalis.

Answer 15

In vocal-fold scar, the lamina propria is replaced with
abnormally fibrous and disorganized tissue. In sulcus vocalis,
the lamina propria has degenerated or disappeared, leaving
an epithelial-lined depression down to the vocal ligament or
deeper.

Question 16

Describe the different types of sulcus vocalis.

Answer 16

● Type I (physiologic sulcus): Longitudinal depression of the
epithelium into the superficial lamina propria but not to
the vocal ligament
● Type II: Longitudinal depression of the epithelium down
to the level of the vocal ligament or farther
● Type III: Focal depression of the epithelium to or through
the vocal ligament

Question 17

Describe the common surgical procedures used in

the management of sulcus vocalis.

Answer 17

● Cold instrument undermining and release of the base of the sulcus with redraping of the epithelium and superficial lamina propria
● Laser undermining and redraping
● Cold instrument excision
● Coronal slicing to release the scar band
● Fat, fascia, or alloderm implant
● KTP (potassium-titanyl-phosphate) or PDL (pulsed dye
laser) treatment
Note: Surgical excision may improve symptoms, but
techniques and results are highly variable.

Question 18

What is the cause of dysphonia secondary to vocal-

fold scar or sulcus vocalis?

Answer 18

Stiffening of the superficial lamina propria of the true vocal fold

Question 19

What benign lesion often occurs on the posterior
vocal fold, near the vocal process, as either an
ulcerative or nodular polypoid process?

Answer 19

Vocal-fold granuloma

Question 20

Vocal-fold granuloma/contact ulcer results from
chronic irritation and inflammation of what
structure?

Answer 20

Arytenoid perichondrium

Question 21

Describe the difference between vocal-fold granuloma related to intubation and vocal-fold granuloma not related to intubation.

Answer 21

● Intubation-related granuloma tends to resolve sponta-
neously within a few months of extubation.
● Vocal-fold granulomata not related to intubation are typically difficult to treat, requiring thorough evaluation
to identify and eliminate causative factors such as reflux,
voice abuse, chronic cough, or allergies.

Question 22

What is the treatment of choice for vocal-fold granuloma?

Answer 22

● Intubation-related granulomas will likely resolve sponta-
neously.
● Non–intubation-related granulomas should be treated
conservatively with primary voice therapy in addition to
elimination of contributing factors (e.g., antireflux medi-
cation, possibly steroids to limit inflammatory response).
● Surgery is a last resort in both cases (e.g., large, pedunculated lesion).

Question 23

You are performing an interval airway examination on a 21-year-old man who survived a motor-
vehicle accident 10 days earlier. He suffered a tracheal laceration and polytrauma and has
required ongoing sedation because of the extent of his neurologic injuries. He has an 8–0 endo-
tracheal tube in place, and although his tracheal repair has healed nicely, you note the growth of a
pedunculated lesion on his posterior true vocal fold and vocal process. What immediate intervention should you recommend?

Answer 23

Downsize his endotracheal tube (ETT).

Question 24

A patient has dysphonia. Laryngoscopy reveals
bilateral pale, watery, sessile, mobile collections of
fluid on the superior surface and margins of the true vocal folds. What is the most likely diagnosis?

Answer 24

Reinke edema (also called bilateral diffuse polyposis or
smoker's polyps)

Question 25

What is the mechanism leading to the voice changes observed in bilateral diffuse polyposis (Reinke edema) of the true vocal folds?

Answer 25

Accumulation of gelatinous material in the superficial | lamina propria leading to increased vocal-fold mass

Question 26

What risk factors have been associated with the severity of Reinke edema?

Answer 26

Age, laryngopharyngeal reflux, vocal abuse, vocal hyperfunction, smoking, and hypothyroidism

Question 27

True or False. The polypoid changes associated | with Reinke edema are permanent.

Answer 27

True. However, the degree of edema and turgidity may | fluctuate with voice use and exacerbating factors.

Question 28

What is the initial treatment of choice for a patient with bilateral diffuse polyposis (Reinke edema) of the true vocal folds?

Answer 28

Smoking cessation, management of reflux, and reduction of phonotrauma

Question 29

If conservative therapy for a patient with Reinke edema fails, what is the primary surgical intervention?

Answer 29

Mucosal sparing microflap polyp reduction, which results in decreased postoperative voice dysfunction compared with vocal cord stripping

Question 30

What are the two mechanisms by which upper | airway angioedema may occur?

Answer 30

Mast cell mediated and bradykinin induced

Question 31

What laboratory test should be ordered if you suspect a diagnosis of hereditary angioedema?

Answer 31

C1 esterase inhibitor level

Question 32

Describe three types of laryngeal cysts.

Answer 32

● Saccular cysts ● Ductal cysts ● Intracordal vocal fold cysts

Question 33

Intracordal vocal-fold cysts generally arise within the superficial lamina propria (although they may arise from the vocal ligament or epithelium). They may be open to the epithelium of the vocal fold and can be associated with a sulcus, and they are also commonly associated with a contralateral nodule. What are the two most common subtypes?

Answer 33

● Mucus-retention cysts (wax and wane) | ● Epidermoid/keratin cysts (fairly stable, more white)

Question 34

What is the preferred management for intracordal | cysts?

Answer 34

For lesions that persist after conservative therapy, including a trial of voice therapy, microflap resection with preserva- tion of the epithelium and superficial lamina propria, possibly followed by infusion of saline (or other substance, such as collagen) into the SLP

Question 35

A cyst arising from which branchial cleft may involve the larynx?

Answer 35

Third branchial cleft

Question 36

A large cyst is noted along the laryngeal surface of the epiglottis, resulting in partial obstruction. The cyst is covered in smooth mucosa and is round and slightly translucent. What is the best treatment?

Answer 36

Endoscopic incision and drainage followed by marsupiali- | zation (mucus-retention cyst)

Question 37

A patient with a history of having been intubated for less than 24 hours develops stridor and respiratory difficulty. A subglottic cyst is identified. What is the most likely cause for development of this lesion?

Answer 37

``` Acquired subglottic (ductal) cysts develop as a result of mucosal damage, which obstructs the duct of a mucous gland ```

Question 38

What structure consists of a blind sac between the false vocal fold and the thyroid cartilage, which opens into the anterior third of the laryngeal ventricle, is lined with ciliated respiratory epithelium and mucous glands, and is responsible for lubricating the vibrating vocal folds?

Answer 38

Laryngeal saccule (laryngeal appendix)

Question 39

When the saccular opening becomes blocked resulting in a mucous filled dilation within the false vocal fold, what pathologic condition results?

Answer 39

Saccular cyst

Question 40

What are the most common reasons for saccular cyst formation (obstruction of the saccular open- ing)?

Answer 40

Infection, recent intubation, cancer, or mass effect

Question 41

What type of saccular cyst extends posteriorly and | superiorly to involve the aryepiglottic fold?

Answer 41

Lateral saccular cyst

Question 42

What type of saccular cyst extends medially into the laryngeal lumen between the true and false vocal folds?

Answer 42

Anterior saccular cyst

Question 43

What is the difference between an anterior and a lateral saccular cyst?

Answer 43

An anterior saccular cyst lies between the true and false vocal folds. A lateral saccular cyst lies between the false vocal fold and the aryepiglottic fold.

Question 44

What are the most common initial signs and symptoms associated with saccular cysts?

Answer 44

● Infants: Respiratory distress, cyanosis, stridor, difficulty feeding ● Adults: Dysphonia, dyspnea, dysphagia, pain, neck mass

Question 45

What is the treatment of choice for saccular cysts?

Answer 45

Marsupialization or complete excision | Biopsy should be performed in adults to rule out cancer.

Question 46

What are the medial and lateral boundaries of the | laryngeal saccule?

Answer 46

The saccule is bordered medially by the false vocal cord and | laterally by the thyroid cartilage.

Question 47

What results when the saccule becomes dilated or herniated, is filled with air, and maintains a patent orifice?

Answer 47

Laryngocele

Question 48

Describe the similarities and differences between a | laryngocele and a saccular cyst.

Answer 48

Both laryngoceles and saccular cysts are dilations of the saccule. A laryngocele is an air-filled dilation that communicates with the laryngeal lumen. A saccular cyst is a fluid-filled dilation that does not communicate with the laryngeal lumen.

Question 49

What type of laryngocele is confined to the larynx?

Answer 49

Internal laryngocele

Question 50

What type of laryngocele extends through the | thyrohyoid membrane, laterally into the neck?

Answer 50

External or combined laryngocele

Question 51

Describe the difference between an internal laryngocele and an external or combined laryngocele.

Answer 51

● Internal laryngocele: Contained within the thyroid cartilage ● Combined (external) laryngocele: Extends through the thyrohyoid membrane

Question 52

What are the most common symptoms associated | with a laryngocele?

Answer 52

Most are asymptomatic. However, symptoms can include dysphonia, dyspnea, weak cry, and aphonia. External laryngoceles may manifest with an intermittent lump in the neck.

Question 53

How are internal laryngoceles treated?

Answer 53

Complete excision, either via endoscopic or external | approaches. Marsupialization is not recommended.

Question 54

How should a large combined or external laryngocele be treated?

Answer 54

Generally, external approaches are recommended with complete excision through the thyrohyoid membrane and transection close to the orifice of the saccule. However, complete endoscopic excision has been successfully re- ported even for large lesions.

Question 55

What is the greatest risk associated with surgical | repair of bilateral combined laryngoceles?

Answer 55

Aspiration secondary to bilateral injury to the internal | branch of the superior laryngeal nerve

Question 56

When a saccular cyst is filled with purulent debris, what is it called?

Answer 56

Laryngopyocele

Question 57

How are laryngopyoceles managed?

Answer 57

A laryngopyocele can be a surgical emergency. Secure an airway, drain endoscopically, and culture. Either at the time of drainage or after resolution of the acute infection, complete excision either endoscopically or externally is indicated. Medical management of the acute episode includes IV antibiotics, antipyretics, and steroids.

Question 58

Describe the normal effect of advancing age on | the fundamental frequency of the speaking voice.

Answer 58

In both men and women, the speaking pitch decreases with | age to a point and then begins to increase.

Question 59

Describe the changes that occur in the larynx with | age.

Answer 59

Muscle atrophy, thinning of the vocal ligament, mucous glad degeneration, cartilage ossification and epithelial thickening.

Question 60

Name three physiologic changes that contribute to | the perception of a voice as sounding “elderly.”

Answer 60

● Air escape ● Laryngeal tension ● Tremor

Question 61

In a patient with paresis of the external branch of the left superior laryngeal nerve, which direction will the petiole of the epiglottis deviate during high-pitched phonation?

Answer 61

Left. Toward the side of the weak cricothyroid muscle

Question 62

True or False. Presbylaryngis is likely to be the sole | cause of a voice complaint in an elderly patient.

Answer 62

False. Voice disorders in elderly patients are much more likely to be caused or confounded by diseases of aging and associated medications than by presbylaryngis alone. Presbylaryngis is a diagnosis of exclusion after all possible causes have been ruled out.

Question 63

How does chronic laryngitis differ from acute laryngitis?

Answer 63

Chronic laryngitis results in chronic dysfunction.

Question 64

What three habits should be limited or eliminated | to improve laryngeal hygiene?

Answer 64

● Tobacco use ● Alcohol use ● Caffeine consumption

Question 65

What are the most common symptoms associated | with reflux laryngitis?

Answer 65

``` ● Hoarseness ● Cough ● Globus ● Throat clearing Notably, fewer than 50% have gastrointestinal symptoms of reflux. ```

Question 66

``` Describe the key difference between laryngophar- yngeal reflux (LPR) and gastroesophageal reflux. ```

Answer 66

Patients with LPR are less likely to have esophagitis (25%) or heartburn (< 40%) and are less likely to have prolonged periods of esophageal acid exposure or dysmotility. Patients are more often "daytime" refluxers, and the cause is thought to be upper esophageal sphincter dysfunction.

Question 67

How is LPR diagnosed?

Answer 67

There is significant controversy regarding the best diag- nostic criteria and tests to use. However, diagnosis is commonly made based on the following: ● Clinical history: Reflux symptoms while upright, dyspho- nia/hoarseness, cough, globus pharyngeus, throat clear- ing, and dysphagia ● Symptomatic improvement with empiric treatment with PPIs as indicated by a patient’s reflux findings score ● Laryngoscopy: Mucosal edema, injury, inflammation ● Reflux events identified by use of a dual pH probe, oropharyngeal probe or impedence probe.

Question 68

What is the treatment for LPR?

Answer 68

A combination of diet and behavior modifications is recommended. The use of PPIs and H2 blockers, although recommended by the American Academy of Otolaryngol- ogy–Head and Neck Surgery (AAO-HNS) consensus state- ment, is still somewhat controversial for isolated LPR.

Question 69

What are the most common risk factors for developing laryngeal chondronecrosis (radionec- rosis)?

Answer 69

Radiation dose/timing, infection, poor vascular health (i.e., smoker, diabetic, and such conditions)

Question 70

Describe the Chandler classification system for laryngeal radionecrosis and the corresponding treatment recommendations.

Answer 70

● Grade I: Slight hoarseness/dryness; slight edema, telan- giectasias; symptomatic care: humidification, antireflux medication, smoking cessation ● Grade II: Moderate hoarseness/dryness; similar signs and treatment ● Grade III: Severe hoarseness with dyspnea, moderate odynophagia, and dysphagia; Severe impairment of vocal-cord mobility or fixation of one cord, marked edema, skin changes; symptomatic care, steroid, anti- biotics, tracheostomy or laryngectomy, if necessary ● Grade IV: Respiratory distress, severe odynophagia, weight loss, dehydration; fistula, fetor oris, fixation of the skin to the larynx, airway obstruction, fever; tracheos- tomy, laryngectomy

Question 71

In addition to symptomatic care, antibiotics, and steroids, what additional conservative measure can be tried before laryngectomy for laryngeal chondronecrosis and radionecrosis?

Answer 71

Hyperbaric oxygen therapy