Benign Laryngeal Lesions

Benign laryngeal lesions are a group of non-malignant structural abnormalities of the vocal folds and surrounding laryngeal structures. They arise predominantly from chronic vocal misuse, mechanical trauma or reflux related irritation.

The group comprises vocal cord nodules, vocal cord polyps and Reinke oedema, with laryngeal granuloma and vocal cord cyst as further related benign lesions.

The shared clinical priority is accurate distinction from laryngeal malignancy, as presenting features overlap, particularly persistent hoarseness. The three week hoarseness rule mandates laryngoscopic assessment of any hoarseness persisting beyond this duration.

Classification

• Vocal cord nodules, vocal cord polyps and Reinke oedema are the commonest benign laryngeal lesions in clinical practice. They share a pathophysiological spectrum of chronic vocal fold mechanical stress and trauma.
• The lesion type and location reflect differences in the pattern, chronicity and severity of the underlying vocal misuse or trauma.
• Laryngeal granuloma (contact granuloma) arises predominantly at the posterior vocal fold. It most commonly reflects chronic mechanical trauma from forceful vocal fold contact, associated with vocal misuse patterns such as excessive throat clearing or a harsh, glottal vocal attack.
• Laryngopharyngeal reflux related mucosal irritation is another important cause of granuloma.
• After recent intubation, granuloma can follow direct mechanical trauma to the posterior vocal fold or arytenoid region during intubation, or prolonged endotracheal tube contact during mechanical ventilation.
• Vocal cord cyst is a discrete, fluid or mucus filled lesion within the substance of the vocal fold. It arises either from obstruction of a submucosal gland duct (a mucus retention cyst) or from entrapment of epithelial tissue (an epidermoid cyst).
• The mass effect disrupts normal vocal fold vibration and closure. Because of its discrete, structural nature, a cyst is generally more resistant to voice therapy alone than the other benign lesions in this group.

• The core presenting symptom across this group is hoarseness or other voice change. Its character varies somewhat with the underlying lesion.
• Clinical overlap is substantial. Laryngoscopic visualisation, rather than the character of the voice symptom alone, is generally required to distinguish the lesion types reliably.
• Vocal fatigue, a sense of increasing vocal effort or voice deterioration with sustained use through the day, commonly accompanies hoarseness. So do reduced vocal range and, in some patients, a sensation of a lump or foreign body in the throat.
• Globus sensation is particularly relevant where laryngopharyngeal reflux is a significant contributing factor.
• Laryngeal granuloma frequently presents with throat discomfort and a sensation of a foreign body or lump.
• Recurrent throat clearing is both a symptom and a perpetuating factor in granuloma. The mechanical irritation of repeated throat clearing exacerbates the granuloma, which provokes further throat clearing.
• This self-reinforcing behavioural pattern is important to understanding the pathophysiology and directing management.
• Explore an occupational or lifestyle history of significant vocal demand, including professional voice users such as teachers, singers and public speakers.
• Also explore symptoms or risk factors for laryngopharyngeal reflux, and any recent endotracheal intubation or prolonged mechanical ventilation. These identify likely contributing factors and inform targeted management.

• Laryngoscopy is the essential diagnostic investigation for any patient with hoarseness persisting beyond the standard three week threshold, or with any other red flag feature warranting more urgent assessment. It allows direct visualisation and characterisation of the lesion.
• Options are flexible nasendoscopy or, for more detailed assessment, videostroboscopy. Videostroboscopy gives slow motion assessment of the vocal fold mucosal wave and vibratory pattern, showing the functional impact of the lesion on vibration.
• Lesion type and location, and any associated mucosal changes, support accurate classification and targeted management. Features suggesting associated laryngopharyngeal reflux include posterior laryngeal erythema and oedema.
• Biopsy is generally not required for clearly benign appearing lesions with a typical appearance and clinical context.
• Consider biopsy where the lesion looks atypical, where any feature raises concern for malignancy (irregular surface, mucosal ulceration, or fixation of the vocal fold), or where there is significant diagnostic uncertainty. Malignancy must be confidently excluded in any persistent laryngeal lesion.

• Voice therapy is first line for the great majority of benign laryngeal lesions. It is delivered by a specialist speech and language therapist with expertise in voice disorders, and addresses the vocal misuse patterns and techniques contributing to lesion development and persistence.
• This conservative approach resolves or significantly improves lesions in a substantial proportion of patients. It is particularly effective for vocal cord nodules and, to a somewhat lesser extent, vocal cord polyps and Reinke oedema.
• Manage any contributing factor alongside formal voice therapy. This includes treating laryngopharyngeal reflux where present.
• Smoking cessation is particularly relevant to Reinke oedema, given its strong, well established association with chronic smoking.
• Modify problematic vocal behaviour, including excessive throat clearing, which is particularly relevant to laryngeal granuloma.
• Surgery, typically microlaryngoscopy with precise, targeted excision, is reserved for lesions not adequately responding to a trial of voice therapy and management of contributing factors.
• Surgery is also used for lesions with a structural character less amenable to voice therapy alone. Vocal cord cyst, given its discrete, structural nature, frequently requires surgical excision as first line, or at least early, treatment.
• Laryngeal granuloma is managed with voice therapy addressing the contributing vocal behaviour, together with aggressive treatment of any associated laryngopharyngeal reflux.
• If these measures are inadequate, options include intralesional corticosteroid injection or, for persistent, refractory lesions, surgical excision.
• Excision carries a relatively high risk of recurrence if the behavioural and reflux related causes are not concurrently and effectively addressed. A multi-component approach is therefore particularly important.
• Regular, structured follow up with repeat laryngoscopy monitors symptomatic and visualised lesion response.
• Keep a low threshold for biopsy or further investigation where the clinical or laryngoscopic response deviates from that expected for a straightforward, benign lesion.