**4.1 Clinical features**

The most common presentation of patients harboring premalignant lesions is dysphonia which can be progressive or fluctuating. Rarely patients may even present with breathing difficulty or foreign body sensation throat.

The diagnosis is made by doing a flexible endoscopy. These lesions either appear as white keratotic patches, single, multiple or confluent (**Figures 3-5**). They are also seen as erythroplakia (red), mixed leucoerythroplakic (speckled) patches.

In general clinical appearance has shown to have poor correlation with the state of underlying epithelium [28, 29]. Still a few authors have found higher chances of malignancy and dysplasia with certain types of lesions. Following features in decreasing order of importance, ulceration, erythroplasia, surface granularity, increased keratin thickness (verrucous appearance), increased size, recurrence after excisional biopsies and long duration have all been associated with carcinoma [30].


#### **Table 3.**

*Various classifications of laryngeal precancerous conditions.*

**Figure 3.** *Single keratotic lesion seen involving the left true vocal fold.*

#### **4.2 Management**

The management of premalignant lesions is challenging for a clinician as it poses a diagnostic challenge and also because it requires close monitoring and follow up due to underlying risk of malignancy.

The laryngeal cancer represents about 1–2% of all malignant tumors. In 90% of cases carcinomas develop from precancerous epithelial lesions [31]. Prompt treatment after an early diagnosis is capable to prevent the development of an invasive neoplasm and the consequent recourse to more invasive laryngeal surgery [32, 33]. Lack of valid protocol or guidelines to manage such precancerous conditions makes it tough for an ENT surgeon to make a decision plan for their management.

*Premalignant Conditions of Larynx DOI: http://dx.doi.org/10.5772/intechopen.97870*

**Figure 4.** *Multiple Keratotic Lesion involving the bilateral arytenoids.*

The dilemma in managing premalignant conditions lies in whether to manage it conservatively with close follow up or to do a biopsy. The invasiveness of the lesion and the prediction whether a lesion has a malignant potential cannot be assessed by clinical examination. Even various investigation modalities like

#### *Pharynx - Diagnosis and Treatment*

endoscopy, stroboscopy fail to analyse the invasiveness of lesion. Newer techniques such as contact endoscopy using highly magnified images (up to 150 X) using a rigid endoscope which is placed in direct contact with vocal fold epithelium and staining is done using 1% methylene blue dye. Though it has been found to have a high sensitivity and specificity still its limitation to unable to detect the dysplasia in deeper layers and the learning curve associated with it and requiring an expertise of a pathologist has made its application limited in the field of otorhinolaryngology [28, 32, 34].

In an attempt to formulate a plan a meeting of UK otolaryngologists and pathologists involved in the care of Head and Neck cancer was held and guidance in relation to premalignant conditions was issued [35]. In case of single (**Figure 3**) and multiple foci (**Figure 4**) they should be completely excised to all visible margins, if possible and in the presence of widespread, confluent leukoplakia (**Figure 5**), histopathological mapping of the lesion with multiple biopsies should be initially performed, followed by staged resection, if feasible. Once sending the biopsy specimen proper labelling and anatomical orientation should be presented on a template to the pathologist with photo documentation prior to histological analysis.

The patient's general condition and fitness for surgery, physiological age, comorbidity and the presence of other risk factors also play a vital role in planning a surgical procedure. The most essential step to be taken before planning the surgical procedure is a detailed and vivid discussion with the patient to inform him/her about the potential risks of hoarseness and change in voice quality postoperatively and about the possibility of recurrence.

#### **4.3 Surgical treatment**

The surgical procedure options are in the form of cold steel or carbon dioxide (CO2) laser resection. Both are taken up via an endoscopic approach. If laser excision is planned, CO2 laser is a preferred laser type. The use of the laser for ablation is to be discouraged, because no specimen is provided for diagnosis and it may be Associated with a possible higher risk of damage and impact on voice production. Hence, stripping of the cord is also not recommended due to the poor quality voice issues.

There are a few vital points which should be borne in mind while dissecting these lesions and they are as following: A proper plane of dissection should be achieved and the vocal ligament should be preserved so as to attain a good postoperative voice quality. An overzealous dissection can lead to postoperative scarring and poor voice outcomes. In such cases excision biopsy is performed with special care so as to preserve the deeper layers of vocal cords and the surrounding normal mucosa.

In case of anterior commissure lesions there is a risk of recurrence and their progression to cancer is reported in literature so adequate clearance and regular follow up is required in case the disease is progressing to anterior commissure.

#### **4.4 Radiotherapy**

Role of radiotherapy in premalignant conditions is only reserved for those patients, in whom the surgical intervention is contraindicated due to morbidity. Many studies have shown that radiation therapy to be ineffective in preventing the progression of dysplastic lesions to carcinoma; in fact, it may even precipitate malignant degeneration [30]. Therefore, the application of radiation therapy should be reserved for invasive carcinoma only.
