Inflammatory Disorders and Autoimmune Diseases of Larynx

Inflammatory Disorders of the Larynx

• Inflammation of the larynx can be broadly classified into infective and non-infective causes.
• Sometimes, the aetiological factors are easily identified in history (like hoarseness).
• In many other cases, the cause may be less clear. It may be multifactorial and may require empirical treatment or a biopsy and microbiological culture.

Laryngitis

Laryngitis is a descriptive term indicating a variable degree of erythema, edema, and epithelial change which may include ulceration and stiffness of the mucosa of the vocal fold. There is often an increased amount of thick mucus present, which may be white, grey, yellow, or green.

There may be associated inflammation of the rest of the subglottic, supraglottic, and interarytenoid regions of the larynx and the pharynx.

Severe cases of laryngitis are associated with shortness of breath and stridor. Voice is usually hoarse, which may be due to impaired vocal fold vibration due to stiffness from the inflammatory process and/or secondary to muscle tension imbalance. Patients with laryngitis may suffer from peri-laryngeal pain or discomfort. Accurate diagnosis may require a diagnostic mico laryngoscopy with biopsy.

Treatment of Laryngitis

Treatment of laryngitis consists of:

• Reduced voice use and abuse
• Voice rest
• Vocal hygiene
• Lifestyle and dietary advice
• Appropriate medical or surgical treatment.

Arytenoid Granuloma

Arytenoid granuloma are benign inflammatory lesions that arise from the medial surface of the arytenoid cartilages, and in particular the vocal processes. Arytenoid granuloma is also termed as the following:

• Contact ulcer or granuloma
• Vocal process granuloma
• Intubation granuloma
• Contact pachydermia
• Peptic granuloma

Pathophysiology of Arytenoid Granuloma

• The pathophysiology includes a proliferation of granulation tissue with epithelial hyperplasia
• They result from injury to the mucoperichondrium over the vocal processes from mechanical trauma, either following intubation or extra gastro reflux.

Etiology of Arytenoid Granuloma

Etiology consists of the following factors such as:

• Voice abuse
• Intubations
• Laryngopharyngeal reflux
• Idiopathic

Contributory factors to Arytenoid Granuloma

• Smoking
• Allergy
• Infection
• Post-nasal discharge
• Less water intake
• Psychiatric illness 
• Dietary habits

Clinical features of Arytenoid Granuloma

• Hoarseness
• Low-pitched voice 
• Cough 
• Pain
• Foreign body sensation
• Gastroesophageal reflux

On examination Features of Arytenoid Granuloma

• Pale, pedunculated mass over the sup-medial surface of the vocal process. 
• It can be unilateral or bilateral. 
• The lesions can be deep red, sessile, and may be two-lipped.

Medical Treatment of Arytenoid Granuloma

• Stop smoking
• Improve vocal hygiene
• Treatment of URTI/allergies
• Treatment of extra-gastro-esophageal reflux
• Voice therapy
• Botulinum toxin injections into the thyroarytenoid muscle can be useful as an adjunct treatment to surgery in resistant cases as they help reduce the impact of vocal processes against each other, allowing the epithelium to heal.

Surgical Treatment of Arytenoid Granuloma

Surgical treatment includes:

• Excision biopsy with steroid injection
• Cold knife excision
• Coblation excision
• Laser excision

Autoimmune Diseases of the Larynx                                         

• Laryngeal manifestation of autoimmune diseases is not uncommon.
• Examples include:
  • Cricoarytenoid fixation
  • Mucous inflammation
  • Subglottic stenosis
  • Vasculitis
  • Laryngeal oedema
  • Vocal fold paralysis, infection.

Bamboo Nodes                                          

• Bamboo nodes are round, pale yellowish lesions in the mid-third of the membranous vocal cords.
• These patients usually present with hoarseness
• A blood test to exclude an autoimmune disease is mandatory if the patient has not already been diagnosed with one.
• Rheumatoid arthritis, systemic lupus erythematosus, Hashimoto thyroiditis, and systemic sclerosis are examples of autoimmune diseases associated with bamboo nodes.

Vocal Cysts

• Cysts, sulci, and mucosal bridges are less frequent than nodules and polyps.
• Types of cysts are:
  • Mucus retention cysts
  • Epidermoid cyst
• Both cause the voice to be constantly hoarse with varying degrees of roughness and breathiness depending on the vocal fold vibration and closure interferences. The singing voice is affected.
• Mucous retention cyst
  • Arise from a blocked minor salivary gland
  • Secondary to phonotrauma or inflammation
  • It is lined by cuboidal or low columnar epithelium and can be associated with edema and fibrosis in Reinke's space.
  • It is usually unilateral and is found on the free edge of the vocal fold or can arise in the ventricular fold (false cord)
  • Stroboscopy can help differentiate polyps from cysts
  • Definitive diagnosis: Microlaryngoscopy and by performing a cordotomy.

Epidermal cyst 

• They are lined by squamous epithelium and are filled with keratin and cholesterol debris.

Aetiology of Epidermal cyst

• Metaplasia in a long-standing mucus retention cyst, microinclusion of epithelium from surface trauma, or some defect in epithelialization during development (congenital or dysembryoplastic theory).

Cause of Epidermal cyst

• Result of voice abuse and misuse.
• Large cysts cause a yellowish/white bulge within the vocal fold, but smaller, deeper cysts may be identified on stroboscopy.

Diagnosis and treatment of Epidermal cyst

• It may only be confirmed at micro-laryngoscopy and cordotomy in these cases.

Vocal sulcus

A sulcus vocalis is best used to describe a localized invagination of the mucosa of varying depth.

A mucosal bridge may also be found in the presence of sulci, and epidermoid cysts are thought to arise by the rupture through of the deep aspects of two sulci or cysts to form a tubed pedicle of the mucosa.

Treatment of Sulcus

• Surgical treatment: Careful dissection of the pocket of the ligament is required. The difficulty is in defining the plane between the base of the sulcus and the ligament and avoiding excessive resection of the mucosa and damage to the ligament.
• Sulcus vergeture may be best treated by bilateral medialization procedures rather than attempted resection of the vergeture.

Microvascular Lesions (Varices or Ectasias)

• They are the collection of abnormally large and weekend vessels.
• The most common site is the superior or medial aspect of the mid-membranous portion of the vocal folds.
• It is most frequently seen in professional vocalists.
• They arise secondary to repetitive trauma, hormonal variations, or repeated inflammation.
• They result in vocal fold hemorrhage, care, and polyp formation, which interfere with the vibratory pattern of the vocal folds, causing a lack of clarity of the voice.

Also Read: Benign Lesions of the Larynx

Frequently Asked Questions: 

Q: What is the most common site of microvascular lesions?

Answer: The most common site is the superior or medial aspect of the mid-membranous portion of the vocal folds.

Q: What are Bamboo Nodes?

Answer: Bamboo nodes are round, pale yellowish lesions in the mid-third of the membranous vocal cords.

Q: What is the main presentation of bamboo Nodes?

Answer: These patients usually present with hoarseness

Hope you found this blog helpful for your ENT residency Larynx preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.