Leukoplakia (leuko = white; plakia = plaque) is a white patch found on the mucosa anywhere in the body. In the larynx, it is most often seen on the vocal cords, either in long-time smokers or in individuals with some other cause of chronic inflammation, such as (controversially) acid reflux.

Leukoplakia is the visually descriptive term for what, on biopsy, may prove to be keratosis, carcinoma in situ, or carcinoma. Unfortunately, it is a stubborn and frustrating problem in laryngology, with a tendency to recur after removal.

Cake Icing and Spilled Milk Leukoplakia after Covid in a Former Smoker

This is a person who had smoked ½ pack per day for a little over a decade but stopped nearly 15 years ago. Voice was always normal until Covid-19 infection (despite vaccination). Laryngitis occurred during that illness and never resolved across six months to the time of this examination. He is hoarse but voice is functional for basic communication. After supportive (acid reflux, etc.) treatments failed to resolve these lesions, microlaryngoscopy with meticulous “basement membrane” peeling of these lesions will follow.

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Leukoplakia (1 of 7)

The view from a distance shows a kind of “chapped lip” leukoplakia involving almost all of both vocal cords. There are elevated “cake icing” areas. The hazy “spilled milk” type of leukoplakia is seen better in subsequent photos. Note the lack of inflammation in the false vocal cords (arrows).

Spilled milk Leukoplakia (2 of 7)

At closer range, one can see that the leukoplakia around the projecting “cake icing” component is of the spilled milk variety. See tiny arrows that indicate examples of this more hazy component.

Superficial ulceration (3 of 7)

Under narrow band (blue-green) light, an area of superficial ulceration is also outlined on the right cord (left of photo), and there is a smaller similar area on the left cord (right of photo).

Closed phase of vibration (4 of 7)

Under strobe light, here is the closed phase of vibration. There is a reasonably good match of both vocal cord margins.

Stiff mucosa limits vibration (5 of 7)

The open phase of vibration is seen here under strobe light. The mucosa only vibrates at low pitch due to stiffness of the mucosa.

Leukoplakia diminishes (6 of 7)

About 4 months after a meticulous “basement membrane” peel of the leukoplakia seen in the prior 5 photos, voice is dramatically improved and we have “won territory, but not (yet) the war.” The right vocal cord (left of photo) is particularly improved.

Residual leukoplakia (7 of 7)

At closer range, one can also see that the residual leukoplakia seems more focal and defined. Additional surgery is planned to see if further territory can be won. In some cases it can be; in others, the leukoplakia continues to recur aggressively.

More examples of Leukoplakia

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Cake-icing Leukoplakia (1 of 4)

The leukoplakia here is heaped up in three main areas, as what some might call “cake-icing” leukoplakia. With this view only, a person could easily overlook the second component of “hazy” or ” spilled milk” leukoplakia shown in the next three photos. All of this leukoplakia would be considered “bland” and non-threatening because there is no component of vascular prominence or erythema (erythroplasia). Erythroplasia would much more strongly indicate the need for biopsy.

Hazy Leukoplakia (2 of 4)

Pre-phonatory phase, showing mild bowing of the vocal cords. There is also the hazy leukoplakia component indicated by the dotted line.

Leukoplakia (3 of 4)

Vocal cords are in the nearly closed phase of vibration. The bluish light from the strobe light makes the hazy leukoplakia even more evident (indicated by the dotted line).

Closer look (4 of 4)

Open phase of vibration, shown under strobe lighting.

Example 2

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Leukoplakia (1 of 2)

Leukoplakia, left vocal cord (right of image), standard light.

Leukoplakia (2 of 2)

Same lesion, under narrow band illumination.

Leukoplakia, Before and After Surgical Removal

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Diffuse Leukoplakia (1 of 4)

Diffuse leukoplakia (seen under standard light) in a man who had undergone removal elsewhere at least twice, with rapid return of diffuse disease on both vocal cords.

HPV effect (2 of 4)

Closer view, using narrow-band illumination. Leukoplakia is accentuated, but punctate vascular markings are also accentuated. We sometimes call this “HPV effect,” though in fact this man’s HPV subtyping was negative.

Leukoplakia, after surgical removal (3 of 4)

Two years after one superficial yet intensely precise peeling of the leukoplakia, plus one follow-up thulium laser ablation of scattered residual disease. The patient, a tenor, considers his voice to be normal. Closed phase of vibration, as seen under strobe light.

Leukoplakia, after surgical removal (4 of 4)

Open phase of vibration, demonstrating that the mucosa on both vocal cords remains flexible. The shifting hazy patches seen here and in photo 3 are collections of mucus.

Leukoplakia Battled Over Time

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Leukoplakia (1 of 8)

Leukoplakia, recurrent, in a former smoker, several years after initial diagnosis. The patient has had this removed in the operating room several times elsewhere, and pathology has only shown hyperkeratosis. HPV testing is negative. Notice both the “cake icing” (green arrows) and “spilled milk” (white arrow) components of the leukoplakia. At this examination, the patient is severely hoarse.

Spilled Milk (2 of 8)

Closer view, under narrow-band illumination, which accentuates in particular the “spilled milk” component (arrows) of the leukoplakia on the left vocal cord (right of image).

Thulium laser (3 of 8)

In the midst of coagulation using the thulium laser, delivered via glass fiber (right of image).

Coagulated tissue (4 of 8)

The thulium laser session is done. On the left cord (right of image), mostly near-contact mode was used, and the coagulated tissue, which has gone from leukoplakia-white to coagulated-white, will slough off within days. On the right cord (left of image), contact mode was used, to coagulate more deeply and detach the bulkier lesion. An additional surface layer will also slough on this cord.

Leukoplakia (5 of 8)

A year and a half later, after a few interval laser treatments, there is a small persistent patch of leukoplakia.

Detachment (6 of 8)

At the conclusion of another thulium laser procedure, using brief contact mode for superficial detachment of the patch of leukoplakia.

Superficial vascular pattern (7 of 8)

Fourteen months after photos 5 and 6. After roughly a dozen treatments spanning more than a decade, the voice sounds effortless and has no syllable dropouts. It is mildly husky but entirely satisfactory to the patient. Note how well-preserved and “unscarred” the superficial vascular pattern of the mucosa is (arrows), after so many surgical procedures.

Coagulated tissue (8 of 8)

At the conclusion of thulium coagulation of this linear patch of leukoplakia. Arrows show the line of coagulated tissue.

Leukoplakia, Before, During, and After Laser Coagulation

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Leukoplakia, not yet seen (1 of 6)

A few years earlier, this patient underwent superficial laser cordectomy of the right vocal cord (left of photo) for cancer. The voice result is excellent, and the patient is being seen this day for a routine interval examination, and has no new complaints.

Leukoplakia (2 of 6)

At closer range, tiny points of leukoplakia (inside the green dotted oval) become evident. The bright white spot in the photo is just a light reflection.

Leukoplakia (3 of 6)

Still closer view, again confirming the tiny patches of leukoplakia. There is another light reflection in this view, right in the middle of the photo.

Leukoplakia, coagulated by laser (4 of 6)

Thulium laser coagulation of the leukoplakia lesions, through a glass fiber (blue-ish cylinder at top-right of photo), as seen under narrow-band illumination. The Thulium laser had been placed on stand-by prior to the routine examination, to save the patient a potential second visit. The coagulated tissue is also white, but will slough off within a few days, and along with it, the leukoplakia.

Leukoplakia, 3 months after laser treatment (5 of 6)

Three months after laser treatment, the patient has healed.

Leukoplakia, 3 months after laser treatment (6 of 6)

Three months after laser treatment, a close up view shows no signs of leukoplakia spots.

Vocal Nodules, Leukoplakia, and Capillary Ectasia

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Vocal nodules, leukoplakia, and capillary ectasia (1 of 4)

Abducted breathing position, standard light. Notice not only the margin swellings (nodules) but also the ectatic capillaries and the roughened leukoplakia. This person illustrates well the idea that vibratory injury can be manifested differently. Many express the injury more in the form of sub-epithelial edema and other changes; this person also has considerable epithelial change.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (3 of 4)

Partial resolution of mucosal injury as a result of behavioral changes directed by a speech pathologist. Strobe light, open phase of vibration.

Vocal nodules, leukoplakia, and capillary ectasia: 6 months later (4 of 4)

Strobe light, moving towards closed phase of vibration.

Glottic Furrow / Leukoplakia / Acid Reflux

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Glottic furrow / Leukoplakia / Acid reflux (1 of 4)

Panoramic view, standard light. Note general inflammatory appearance, left vocal cord leukoplakia, interarytenoid pachyderma. Some would call this a sulcus.

Leukoplakia (2 of 4)

Furrow-like groove best seen on the left vocal cord (arrow). Beneath the arrow is the leukoplakia. Notice loss of fine surface vessels in this area.

Glottic furrows (3 of 4)

Furrows seen bilaterally.

Gap during closed phase (4 of 4)

Strobe light, closed phase. Note the slight gap; this is often seen as a kind of pseudo-bowing with furrow.

Thulium Laser Surgery, With Local Anesthetic Injection, to Treat Leukoplakia

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Leukoplakia, about to be treated with laser (1 of 4)

Leukoplakia of the vocal cords in a patient radiated years earlier for glottic cancer. This disease is mostly benign, but foci of carcinoma-in-situ have also been removed twice in the operating room, yet with rapid return of leukoplakia. The patient has had no glottic voice. In an effort to avoid total laryngectomy, we are managing these visual abnormalities with the thulium laser in an outpatient videoendoscopy room.

Injection of local anesthetic (2 of 4)

Since this patient cannot tolerate aggressive laser therapy with topical anesthesia alone, we are here adding injection of local anesthetic. Note the blanching of tissue surrounding the needle.

Injection of local anesthetic (3 of 4)

Further injection of the local anesthetic.

Right after thulium laser treatment (4 of 4)

At the completion of aggressive laser coagulation of abnormal tissue. Compare with photo 1. The patient will return in a month for additional laser treatment as indicated.

Leukoplakia Biopsy

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HIV Testing (1 of 2)

2-millimeter forceps being used to scrape the area of leukoplakia to retrieve cells for HPV testing. In this case, it was negative.

Biopsy (2 of 2)

Cup forceps closed. Note that there is no biopsy, per se, but just scraping of the surface of the cords.

Narrow-band vs. Standard Light: Leukoplakia

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Narrow-band vs. standard light: leukoplakia (1 of 2)

With standard light, the leukoplakia on the right vocal cord (left of image) is visible but indistinct, as a hazy, whitish patch.

Narrow-band vs. standard light: leukoplakia (2 of 2)

With narrow-band light, not only the network of blood vessels but also the hazy leukoplakia is much more apparent.