Diseases of the larynx


Introduction

 

Very common diseases of the larynx are hyperplastic changes of laryngeal epithelium such as:

 

  • polyps
  • swelling
  • voice nodules
  • granulomas
  • precancerous lesions

 

Laryngeal polyps usually arise when the voice organ in inflammation state  is loaded with excessive vocal effort. Etiological factors are allergic, hormonal disorders, smoking. Edema occur in the upper layer of the vocal folds mucosa.

These changes are very common on both sides, asymmetrically on the voice folds, usually on their upper surface, in the front part. The etiology is not fully understood.

The main reasons is the constant and repeated stimulation of the mucous membrane of the larynx. Stimulation can be caused by exposure to tobacco smoke and inhaled industrial toxins (work in chemically contaminated and not ventilated conditions), continuous and repetitive voice strain (eg teachers).

 

Vocal fold nodules usually occur symmetrically. Their formation has much to do with the strain of the voice (excessive vocal effort) and are related to mechanical trauma of the vocal folds.

 

Granulomatous inflammation is a change of the larynx that derives from perichondrium near the arytenoid cartilage. Common causes of their formation are: gastroesophageal reflux, strain of a voice, chronic cough.

The precancerous lesions are classified as:

 

  • leukoplasia
  • chronic hyperplastic laryngitis
  • laryngeal papillomas

 

Precancerous lesions are focal morphological changes, bringing with it an increased risk of malignancy .

 

Leucoplasia, is a white to off-white stain on the mucous membrane of the larynx, especially in the vocal folds. These changes are often referred to as  pachydermia, or keratosis and hyperkeratosis. In most cases, patients with leucoplasia are smokers, often also with abuse of alcohol. Highly likely infection of different types of HPV, and gastroesophageal reflux in pathogenesis of leucoplasia are involved. Leucoplasia may be accompanied by clinical changes – chronic hyperplastic laryngitis, polyps, edema, papillomas, granulomas.

 

Hypertrophic chronic laryngitis develops on the basis of catarrhal laryngitis. In this case, the vocal folds show considerable irregularities and thickenings, especially in the anterior part of the glottis. Similar mucosal thickening can be formed in the posterior commissure, the vocal process and vestibular folds. Symmetrical vestibular fold thickening can reach such large size that completely covers vocal folds.

 

Papillomas are about 95% of the benign tumors found in the larynx, which are often regarded as precancerous lesions. They can occur in children and in adults. Pathogenesis of papillomas is closely associated with HPV infection (mainly types 6 and 11). In adults, papillomas usually appear as a single change, mostly located in the vocal folds as soft richly branched creations. Papillomas can spread to the vestibular folds, epiglottis, subglottic area, sometimes to the trachea and bronchi.

 

Symptoms

 

Hypertrophic changes in laryngeal epithelium and precancerous changes are usually accompanied by hoarseness, however, asymptomatic course is also possible. Shortness of breath is extremely rare, if it is already, rather accompanies large changes observed in the edematous changes, large polyps, chronic hypertrophic laryngitis and papillomas. Special attention need precancerous lesions. There are no clinical features that clearly indicate the presence of leucoplasia, chronic hypertrophic laryngitis, papilloma or cancer, because any change of this type should be treated as potentially malicious, radically removed and verified histologically. Very important is the fact that even a slight change in the timbre of voice or hoarseness not subsiding after 2-3 weeks, despite of adequate treatment requires consultation with otolaryngologist.

 

Diagnostics

 

The diagnosis of the nature of the changes in the larynx is possible on the basis of subjective (medical history), physical examination (ENT examination), and additional tests. An important preoperative and postoperative examination is phoniatric consultation, during which is performed videostroboscopy, videolaryngoscopy. Definitive diagnosis is based on the result of the histopathological examination of specimen taken during microdirectoscopy (direct laryngoscopy) which is usually performed under general anesthesia.

 

Directoscopy (direct laryngoscopy)

 

– view of the larynx in the operating room under general anesthesia after intubation (endotracheal anesthesia). The larynx is viewed with use of rigid endoscopes - laryngoscopes. Its more often used variety is microlaryngoscopy.

 

Mikrolaryngoscopy

 

– is performed under general anesthesia, laryngoscope is inserted through the patient's mouth in order to visualize the larynx, it is fixed on a special lever. The larynx is viewed through an operating microscope, which is set in front of the laryngoscope. The treatment is performed for diagnostic and therapeutic reasons.

During microlaryngoscopy, using the appropriate tools, you can perform biopsy for histopathological examination and remove lesions of the larynx, such as polyps, papillomas, Reinke’s edema.

Microlaryngoscopy procedure during which the biopsy is performed or leasions are removed is called microsurgery of the larynx.

 

Microsurgery of the larynx can be performed using microsurgical instruments (classic microsurgery) as well as with a laser (laser microsurgery).

 

To perform the operations it is required that each patient is  familiar with aware consent form and signed it. Detailed information about the possible course of the operation, the chances of achieving  aim of the surgery, postoperative care and the risk of complications may be obtained from your doctor and / or the head of the operating team and the course of anesthesia, from the anesthesiologist.

 

Postoperative

 

Immediately after the procedure patient needs special observation due to possible edema of the larynx, resulting in shortness of breath. In addition, depending on the extent of surgery and postoperative period steroids, antibiotics, pain killers and antireflux drugs are used. The patient is informed of a need to save the voice for about 14 days after surgery.

 

Follow up

 

All patients after microsurgery of the larynx need constant control of otolaryngologist and phoniatrician based on disease entity.

 

Prognosis

 

Forecasting for hyperplastic epithelial laryngeal changes is good. The basic condition for a full recovery, however, is the elimination of risk factors, constant care of phoniatrician and Otolaryngologist. This is particularly important in the case of patients with precancerous lesions that can lead to cancer development. Patients with changes resulting from improper voice hygiene are often referred for voice exercise and rehabilitation of voice.

 

Anthony Bruzgielewicz MD