And Hypopharyngeal Leukoplakia and Chronic Laryngitis

Squamous intraepithelial lesions appear mainly along the true vocal cords, and rarely in other parts of the larynx, such as the epiglottis. Two-thirds of vocal cord lesions are bilateral [48, 178, 181]. They can extend over the free edge of the vocal cord to its subglottic surface. An origin in, or extension along the upper surface of the vocal cord is less common [181, 194]. The commissures are rarely involved [48]. Hypopharyngeal lesions are rarely found and are poorly defined [364].

Laryngeal SILs do not have a single distinctive or characteristic clinical appearance and are variously described as leukoplakia, chronic hyperplastic laryngitis or rarely erythroplakia. A circumscribed thickening of the mucosa covered by whitish patches (Fig. 1.7), or an irregularly growing, well-defined warty plaque may be seen. A speckled appearance of lesions can also be present, caused by unequal thickness of the keratin layer.

However, the lesions are commonly more diffuse, with a thickened appearance, and occupy a large part of one or both vocal cords (Fig. 1.8). A few leukoplakic lesions are ulcerated (6.5%) or combined with erythroplakia (15%) [48]. Leukoplakic lesions, in contrast to eryth-roplakic ones, tend to be well demarcated.

The macroscopic features of hypopharyngeal and laryngeal SILs are not as well defined as their counterparts in the oral cavity and their relative importance is not generally accepted. Most patients with SILs present with a history of a few months or more of symptoms; an average duration of 7 months has been reported [48]. Symptoms depend on the location and sever-

Fig. 1.7. Leukoplakia of the left vocal cord. The microscopic diagnosis was squamous cell hyperplasia

ing system depends on the degree of accord with the biological behaviour of the lesions. Worldwide, there are no generally accepted criteria for a histological grading system in the head and neck region with regard to severity of SILs and propensity to malignant transformation. It is, therefore, not surprising to find in the literature more than 20 classifications of laryngeal SILs [39, 125, 150, 180, 181, 242]. The majority of the classifications have followed similar criteria to those in common use for epithelial lesions of the uterine cervix, such as the dysplasia or cervical intraepithelial neoplasia systems.

The World Health Organisation (WHO) has recently readopted the dysplasia system for classifying SILs of the oral cavity and larynx [381]. However, due to different standpoints concerning this important problem of oral and laryngeal carcinogenesis, the dysplasia system was reviewed simultaneously with two additional classifications: the squamous intraepithelial neoplasia system and the Ljubljana classification [381]. Here, the WHO dysplasia system and the Ljubljana classification will be reviewed.

Fig. 1.8. Chronic laryngitis. Both vocal cords are irregularly thickened and covered by whitish plaques. The microscopic diagnosis was atypical hyperplasia

ity of the disease. Patients may complain of fluctuating hoarseness, throat irritation, sore throat, and/or a chronic cough.

Traditional light microscopic examination, in spite of certain subjectivity in interpretation, remains the most reliable method for determining an accurate diagnosis of a SIL. The clinical validity of any histological grad-

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