45

LARYNGOSCOPY
Ellen S. Deutsch, MD
Jane Y. Yang, MD
James S. Reilly, MD

The larynx comprises the supraglottis, consisting of the

epiglottis, aryepiglottic folds, false vocal folds, and laryngeal
ventricle; the glottis or true vocal folds; and the subglottis,
including the cricoid cartilage. Laryngeal disease generally
presents with pain, stridor, or hoarseness. Hoarseness indi-
cates that the abnormality involves, but is not necessarily lim-
ited to, the free margin of the vocal folds.

BENIGN MASSES
Vocal fold nodules, polyps, and cysts generally occur at the
junction of the anterior and middle third of the vocal fold and
involve the epithelial and superficial layers of the lamina pro-
pria. Vocal fold nodules, generally bilateral, are small, white,
firm, sessile masses containing collagenous fibers and edema.
Vocal fold cysts, usually unilateral, comprise epithelial
cysts and mucous retention cysts. Polyps, caused by vocal
trauma, are usually unilateral, pedunculated, or sessile and
may have evidence of preceding hemorrhage.
Reinke’s edema, also known as polypoid corditis or poly-
poid degeneration of the vocal folds, is most commonly
associated with tobacco use, although vocal misuse and extra-
esophageal reflux disease may contribute to this condition.

536
 Laryngoscopy 537

Granulomas commonly occur on the vocal process or

inner surface of the body of the arytenoid cartilage and can be
large enough to obstruct the airway. Primary etiologic fac-
tors include traumatic or prolonged intubation, vocal abuse,
or extraesophageal reflux disease.
Benign neoplasms, including laryngeal rhabdomyomas,
are less frequent causes of hoarseness.
Cartilaginous laryngeal neoplasms, such as chondromas,
have a 5 to 1 male predominance; most occur in patients
between the ages of 40 and 60 years. Granular cell tumor, pre-
viously referred to as granular cell myoblastoma, is a benign,
slow-growing neoplasm that can often be removed endoscop-
ically. Neurofibromas and neurilemomas or schwannomas are
histologically similar, benign neurogenic tumors of the lar-
ynx originating from the aryepiglottic fold or from the false
vocal folds. Paragangliomas and atypical carcinoids may have
similar clinical appearances. Paragangliomas are the only
laryngeal neoplasm with a female predominance. Both are of
neuroendocrine origin, contain neurosecretory granules, and
are distinguished by careful immunocytochemical and/or
ultrastructural investigation. In contrast to other head and neck
paragangliomas, such as chemodectomas, laryngeal paragan-
gliomas do not secrete catecholamines.
Hemangiomas occur in both adult and infantile types.
Infantile subglottic hemangiomas generally increase in size
and symptom severity until 6 months of age, after which
spontaneous regression occurs. The adult form occurs on or
above the vocal folds and is often pedunculated, well demar-
cated, and reddish blue in color. Lipomas are usually solitary
lesions, found in men during the seventh decade of life; most
can be removed endscopically. Extralaryngeal lesions, such
as retropharyngeal abscesses, adjacent tumors, or postcricoid
foreign bodies, may compress the airway and cause stridor by
exerting a mass effect.
538 Otorhinolaryngology

Autoimmune, immune, and idiopathic diseases may have

laryngeal manifestations. Sarcoidosis is an idiopathic,
chronic, noncaseating granulomatous disease that most com-
monly involves the supraglottis, particularly the epiglottis,
and presents with dysphonia, dysphagia, globus sensation,
and dyspnea.
Scleroma (rhinoscleroma) is a chronic granulomatous
infectious disease caused by Klebsiella rhinoscleromatis,
which primarily occurs in the nose and nasopharynx but may
involve the larynx.
Wegener’s granulomatosis is a necrotizing vasculitis typ-
ically involving a triad of organs: the sinuses, lungs, and kid-
neys. Glomerulonephritis may present with microhematuria,
proteinuria, and red cell casts. Laryngeal involvement gener-
ally causes subglottic stenosis with dyspnea and stridor.
Elevated cytoplasmic antineutrophil cytoplasmic antibodies
(c-ANCA) are highly specific for Wegener’s granulomatosis.
Amyloidosis is a disease of unknown etiology characterized
by deposition of extracellular, fibrillar protein. It is classified by
the name of the fibrillar protein (AL, AA, ATTR, or AB2M),
the precursor protein (kappa or lambda light chain, apoSSA,
transthyretin, or β2-microglobulin), and the clinical presenta-
tion (primary, secondary multiple myeloma associated, famil-
ial, or hemodialysis associated). The larynx is the most
common site of involvement in the upper aerodigestive tract.
Rheumatoid arthritis is an autoimmune disorder affecting
2 to 3% of the adult population. Both adult and juvenile
rheumatoid arthritis may involve the cricoarytenoid joint.
Relapsing polychondritis is a multisystemic autoimmune
inflammatory disorder of obscure etiology characterized by
progressive inflammation and degeneration of cartilaginous
structures and connective tissues. Respiratory tract involve-
ment may be the presenting symptom in as many as 26% of
patients, and up to 50% of patients will eventually develop
respiratory complications. Laryngotracheobronchial involve-
 Laryngoscopy 539

ment may cause life-threatening airway obstruction from

acute inflammation, scarring, or airway collapse from carti-
lage dissolution. Medical management in the acute phases
includes corticosteroids; dapsone and immunosuppresant
agents, such as cyclophosphamide, may be helpful.
Examination of supraglottic allergic edema reveals pale,
watery swelling of the epiglottis and aryepiglottic folds.
Treatment may include subcutaneous epinephrine, intramus-
cular or intravenous corticosteroids, antihistamines, and
inhaled racemic epinephrine. Fatal airway obstruction can
occur when the larynx is affected; insertion of an oro- or
nasopharyngeal airway, endotracheal intubation, or tra-
cheostomy may be necessary.
Hereditary angioedema results from an autosomal domi-
nant deficiency of active C1 esterase inhibitor leading to
recurrent attacks of localized edema or severe abdominal
pain, precipitated by trauma or stress. Airway occlusion is
the most common cause of mortality. The deficiency of C1
esterase inhibitor protein is usually quantitative but can
be qualitative. Standard therapies for allergy-mediated angio-
edema, such as epinephrine, antihistamines, and cortico-
steroids, are less successful; C1 inhibitor (C1-INH) con-
centrate is used for acute management, and mechanical
control of the airway may be needed. Long-term prophylac-
tic treatment may include attenuated androgens such as dana-
zol or stanozolol; antifibrinolytic medications such as
ε-aminocaproic acid and tranexamic acid; and C1-INH con-
centrate. Antifibrinolytic medications are the drugs of choice
for children. Acquired angioneurotic edema is less common
and generally begins during adulthood. Drug-induced
angioedema most commonly occurs in patients taking
angiotensin converting enzyme inhibitors.
Acute spasmodic laryngitis or nocturnal croup typically
presents as a mild viral upper respiratory tract infection with
nocturnal episodic wakening accompanied by inspiratory
540 Otorhinolaryngology

stridor and croupy cough in a toddler; it invariably subsides

during the day.
Epiglottitis, or acute supraglottitis, is an acute bacterial
infection of the epiglottis, aryepiglottic folds, and soft tissues
of the arytenoid cartilages. Features include the dangerously
rapid onset of sore throat, high fever, muffled voice, and signs
and symptoms of airway obstruction, including inspiratory
stridor, inability to swallow, respiratory distress, and restless-
ness. The classic presentation is a pale, shocky, restless, drool-
ing child in an upright position with head forward and tongue
protruding. Examination, which is deferred until equipment
and personnel are available to secure the airway, reveals fiery
red edema of epiglottis and aryepiglottic folds. Pediatric acute
supraglottitis, now uncommon, was previously caused pre-
dominantly by Haemophilus influenzae. The disease is now
more common in adults and may be life-threatening but is
usually less severe, with slower onset and progression.
“Croup,” or laryngotracheobronchitis, refers to a con-
stellation of viral infections that may affect any or all seg-
ments of the pediatric airway and is the most common cause
of airway obstruction in children; the majority of patients are
between the ages of 6 months and 4 years. Patients usually
have a characteristic “barking” cough, 60% have inspiratory
stridor, and the voice may be hoarse but not muffled. Most
patients respond to medical and supportive therapy includ-
ing humidification, nebulized racemic epinephrine, and sys-
temic glucocorticoids. Anterior-posterior airway radiographs
may demonstrate subglottic swelling, which changes the
appearance of the square-shouldered space below the vocal
folds to that of a steeple or pencil; lateral neck radiographs
may show subglottic haziness. Endoscopy is avoided during
the acute phase of the illness but is indicated if the patient
fails two extubation attempts or does not improve as
expected. Interval endoscopy is indicated if the patient has
other risk factors for subglottic stenosis, more than three
 Laryngoscopy 541

episodes of croup, onset of croup prior to 6 months of age, or

an atypical course.
Recurrent respiratory papilloma is a benign but very
rapidly proliferating tumor that usually presents within the
first few years of life with hoarseness, inspiratory stridor, and
respiratory distress progressing over a period of weeks or
months. Human papillomavirus (HPV) subtypes 6 and 11 are
most commonly found in juvenile recurrent respiratory papil-
loma. Treatment consists of repeated excision using carbon-
dioxide laser or a microdébrider. Recent trials of cidofovir
appear promising. Malignant degeneration of recurrent res-
piratory papilloma is uncommon, but the risk is greater for
patients with subtypes 16/18 and 31/33 and those treated with
radiation therapy.
Bacterial or fungal laryngitis and tracheitis can cause sud-
den airway obstruction.
Laryngopharyngeal reflux, or extraesophageal reflux,
denotes the entry of gastric contents above the upper
esophageal sphincter. Otolaryngologic manifestations and
sequelae of extraesophageal reflux include chronic intermit-
tent hoarseness, vocal fatigue, sore throat, dysphagia, chronic
cough, stridor, croup, subglottic stenosis, excessive mucus
production, postnasal drip, globus sensation, a choking sen-
sation resulting from laryngospasm, and frequent throat clear-
ing. Laryngeal examination may reveal edema, which may
be diffuse or limited to the vocal folds, obliteration of the
ventricles, interarytenoid thickening, pseudosulcus, or vocal
process granuloma. Effects within the posterior part of the
larynx or trachea include erythema, edema, “cobblestoning,”
blunting of the carina, and friable mucosa.
Two mechanisms of injury may coexist: reflex mecha-
nisms may cause laryngospasm, bronchospasm, or apnea, and
prolonged direct contact with the gastric fluid may cause
mucosal damage. Twenty-four-hour multichannel ambulatory
esophageal pH monitoring is the most sensitive study for
542 Otorhinolaryngology

extraesophageal reflux; esophagoscopy with biopsy, barium

esophagram, nuclear medicine scintiscan, and bronchoscopy
with washings for fat-laden macrophages may be supportive.
Treatment options include antireflux behavioral and dietary
modifications; acid-suppressive medications, including hist-
amine H2-receptor antagonists and proton pump inhibitors; or
surgical therapy such as Nissen fundoplication.
Acute airway obstruction from laryngeal or tracheal edema
is possible after ingestion of acid, alkali, or corrosive sub-
stances; following inhalation of hot air, smoke, steam, or
chemical fumes; or following direct mechanical trauma.
Traumatic epiglottitis may be treated with fluids, humidified
supplemental oxygen, nebulized epinephrine, and parenteral
administration of corticosteroids; intubation may be neces-
sary. Intraluminal trauma may occur from intubation or other
causes and can result in acquired glottic or subglottic stenoses,
subglottic cysts, synechiae, and webs. Pressure from endotra-
cheal or tracheostomy tube cuffs may cause tracheomegaly.
External causes of laryngeal injury include blunt or
penetrating trauma from motor vehicle crashes, falls, sporting
injuries including “clothesline” injuries, or assaults. Pene-
trating injuries are most commonly caused by knives or bul-
lets. Minor injuries may consist of edema, hematoma,
contusion, abrasion, and small lacerations; major injuries
may result in loss of soft tissue, large lacerations without
approximation, fracture or dislocation of cricoid or thyroid
cartilages, displacement of the arytenoid cartilages or epi-
glottis, and impaired vocal fold mobility. Airway obstruc-
tion may occur instantly, gradually over hours, or with great
rapidity hours after the injury has occurred. Computed
tomography is the radiologic modality of choice. Laryn-
goscopy is indicated when evidence of airway injury or
obstruction occurs following trauma to the neck, even with
minimal symptoms. Tracheostomy or intubation may be
needed to maintain the airway.
 Laryngoscopy 543

Congenital laryngeal abnormalities include teratomas or

hamartomas, laryngomalacia, subglottic stenosis, complete
or partial laryngeal atresia including congenital laryngeal
webs, laryngotracheoesophageal clefts, hemangiomas, and
lymphangiomas.
Vocal fold paralysis may be congenital or acquired.
Central bilateral vocal fold paralysis may result from
increased intracranial pressure or congenital nerve compres-
sion. Peripheral causes of paralysis are usually associated
with injury to the recurrent laryngeal nerves, particularly dur-
ing cardiovascular, thoracic, or neck surgery; the left recur-
rent laryngeal nerve is more frequently injured.
Speech and swallowing disorders, including dysarthria,
dysphagia, or aspiration, may result from a combination of
neurologic, structural, cardiorespiratory, metabolic, and/or
behavioral abnormalities.

MALIGNANCIES
The larynx is the second most common site of cancer in the
upper aerodigestive tract. Each year, 12,500 new cases are
diagnosed in the United States, with an estimated 5-year sur-
vival rate of 68% overall. Squamous cell carcinoma accounts
for over 95% of all laryngeal malignancies, with a peak inci-
dence in the sixth and seventh decades. Tobacco is the sin-
gle most significant risk factor; ethanol is believed to have a
synergistic effect with tobacco. Palliation and cure of laryn-
geal squamous cell carcinomas may be accomplished using
radiation therapy, chemotherapy, laser, or open surgical
resection, singly or in combination. Verrucous carcinoma,
an exophytic, highly differentiated variant of squamous cell
carcinoma, rarely metastasizes; surgical resection is the
treatment of choice.
Pleomorphic carcinoma may histologically resemble
other laryngeal supporting tissue neoplasms.
544 Otorhinolaryngology

Rhabdomyosarcomas, usually of the embryonal type, are

the most common type of laryngeal tumor in children and
adolescents. Treatment may include chemotherapy alone or
with radiation therapy. Surgery is usually reserved for diag-
nostic biopsy or for debulking lesions; extensive debilitating
surgery is usually not indicated.
Well-differentiated laryngeal fibrosarcomas have a low
mortality rate, whereas poorly differentiated laryngeal fibrosar-
comas are fatal in more than half of the reported instances.
Primary tumors including adenocarcinoma, malignant
fibrous histiocytoma, non-Hodgkin’s lymphoma, malignant
schwannoma, mucoepidermoid carcinoma, and primitive
neuroectodermal tumor, as well as other sarcomas, such as
synovial sarcoma, Ewing’s sarcoma, chondrosarcoma, and
“mixed” sarcoma, are rare. Metastases to the larynx are
also rare.

RADIOLOGIC EVALUATION
OF THE LARYNX
Routine radiologic evaluation comprises anterior-posterior
and lateral neck images. The lateral view of the neck pro-
vides useful information about the base of the tongue, val-
lecula, thyroid and cricoid cartilages, posterior pharyngeal
wall, prevertebral cervical soft tissues, and intralaryngeal
structures including the epiglottis, aryepiglottic folds, ary-
tenoid cartilages, false and true vocal folds, laryngeal ventri-
cles, and subglottic space.
Fluoroscopy may be useful in assessing dynamic lesions.
Adding radiologic contrast agents such as barium, or iohexol
for tracheobronchography, may enhance visualization and
further define airflow dynamics and distal anatomy. Spiral
computed tomography and fast magnetic resonance tech-
niques allow rapid acquisition of enhanced images of laryn-
geal structures, minimizing motion artifact. Direct spiral
 Laryngoscopy 545

computed tomography of the neck is performed in the axial

plane; coronal, sagittal, and three-dimensional reconstruction
can be computer generated. Magnetic resonance has the
advantage of multiplanar high-resolution imaging, with an
increased ability to separate various soft tissues, and may be
more sensitive for identifying early cartilage invasion.