Case histories: Foreign body in laryngeal ventricle

Stroboscopic Examination

• I really could not visualize the vocal cords during ADduction.

Initial Exam

View during ADduction: There is a mass involving or obliterating the right false vocal cord and it obscures the view of both vocal cords during phonation.

View during ABduction: The mass is multilobulated and it is difficult to tell from above whether the right true vocal cord is involved or not.

I anesthetized the vocal cords with lidocaine so that I could see beneath the mass. I could at least see that the right anterior vocal cord was not involved with the mass and it suggested to me that the mass was coming from the ventricle or from within the false vocal cord. The mass rested on or included the right posterior vocal cord.

Surgery

This is the view with a 70 degree angled endoscope at the time of surgery. The white at the bottom of the photo is a laser resistant endotracheal tube. The multilobulation of the right sided mass is even more apparent. It has a granulation tissue appearance, though it still vaguely resembles papilloma. It is firm to touch and bleeds easily.

This is the medial surface of the mass. The anterior portion is at the top of the photo. It is "hard as a rock". It is enlarged compared to the other photos in this series. It occupied perhaps about 25% of the ventricle.

This is the lateral surface of the mass. The anterior portion is at the top of the photo. The "spicules" were indented into the lateral wall of the right laryngeal ventricle.

Post-operative

Six weeks post removal of the mass, there is no longer any effort speaking and there is a tiny residual amount of granulation tissue hanging from the right false vocal cord

Treatment

Medical

Behavioral

No therapy was recommended.

Surgical

My primary differential at the conclusion of the initial exam was a cystic mass (though it seemed too posterior for a saccular cyst), a tumor (benign or malignant), an infection such as laryngeal papilloma (usually it has a slightly different appearance) or an unusual fungus (I have seen coccidiomycosis resemble this) or some purely inflammatory process. Excision was performed gradually and the mass was firm enough to be a tumor, but also resemble granulation tissue quite strongly. It bleed easily, but not really easily enough to be a hemangioma. When I excise or biopsy something unknown I cut as close to the abnormal tissue as possible to preserve normal tissue. I can always come back for additional treatment, even if it is cancerous or malignant. At the bottom of the excision, in the posterior aspect of the ventricle I found the hard object above and after its removal, I didn't remove any additional granulation tissue.