What causes white patches on the vocal cords?

White Patches on the Vocal Cords: Causes and Clinical Approach

White patches (leukoplakia) on the vocal cords represent a spectrum of pathology ranging from benign keratosis to invasive squamous cell carcinoma, and require histopathologic confirmation through biopsy to determine the underlying diagnosis. 1, 2

Primary Diagnostic Categories

Premalignant and Malignant Lesions

Laryngeal malignancy is the most critical diagnosis to exclude, as delayed diagnosis results in higher staging, more aggressive treatment requirements, and reduced survival rates. 1

• White patches may represent keratosis overlying dysplasia, carcinoma in situ, or invasive squamous cell carcinoma 1, 2, 3
• Keratosis is a histological term denoting pathological keratin accumulation that can mask various epithelial changes from simple hyperplasia to invasive carcinoma 2
• Highly suspicious lesions with increased vasculature, ulceration, or exophytic growth require prompt biopsy 1
• A trial of conservative therapy with avoidance of irritants may be employed prior to biopsy for superficial white lesions on otherwise mobile vocal folds 1

Risk factors requiring immediate concern: 1

• Tobacco use (increases cancer risk 2-3 fold) 1
• Alcohol abuse 1
• Age over 60 years (malignancy observed in 28% of hoarse patients over 60 after self-limited disease excluded) 1
• Progressive hoarseness 1
• Associated symptoms: hemoptysis, dysphagia, odynophagia, otalgia, unexplained weight loss, or neck mass 1

Benign Keratotic Lesions

• Simple keratosis or hyperkeratosis represents benign keratin accumulation on normal squamous epithelium 2, 3
• These lesions appear as white patches but lack underlying epithelial atypia on histology 2
• Keratosis, atypia, carcinoma in situ, and microinvasive cancer represent a sequential continuum and are part of the diathesis of aerodigestive tract cancer 3

Infectious Causes

Fungal laryngitis (candidiasis) can present as white hyperplastic lesions mimicking malignancy. 4

• Laryngeal candidiasis is rare but may show pseudoepitheliomatous hyperplasia or acanthosis that can be confused with cancer 4
• More common in patients using inhaled corticosteroids (dose-dependent mucosal irritation and fungal infection) 1
• Risk factors include immunosuppression, chronic steroid use, and antibiotic use 4
• Responds to systemic antifungal therapy (fluconazole or amphotericin) 4

Benign Vocal Fold Lesions

• Vocal nodules rarely present as white patches but may have associated keratotic changes 1, 5
• Polypoid degeneration (Reinke's edema), polyps, and other benign soft tissue lesions typically do not appear white unless secondarily keratinized 1

Clinical Approach Algorithm

Immediate Laryngoscopy Indications (Regardless of Duration)

Perform or refer for laryngoscopy immediately if: 1, 6

• History of tobacco or alcohol use 1
• Concomitant neck mass 1
• Associated hemoptysis, dysphagia, odynophagia, otalgia, or airway compromise 1
• Unexplained weight loss 1
• Progressive worsening of hoarseness 1
• Immunocompromised host 1

Laryngoscopy Within 4 Weeks

• Hoarseness persisting beyond 4 weeks requires laryngoscopy or referral 1, 6
• Professional voice users (singers, teachers, clergy) warrant earlier evaluation 1

Biopsy Decision-Making

For white patches identified on laryngoscopy: 1

1. Highly suspicious features (immediate biopsy required):

   • Increased vasculature 1
   • Ulceration 1
   • Exophytic growth 1
   • Fixed or immobile vocal fold 1

2. Superficial white lesions on mobile vocal folds:

   • May trial conservative therapy with avoidance of irritants (tobacco, alcohol) 1
   • If no improvement or progression, proceed to biopsy 1

3. All biopsies require histopathologic evaluation to distinguish:

   • Simple keratosis (benign) 2
   • Dysplasia (mild, moderate, severe) 3
   • Carcinoma in situ 3
   • Invasive carcinoma 1, 2

Critical Clinical Pitfalls

• Never empirically treat white patches without visualization and histologic diagnosis 1, 6
• Do not prescribe antibiotics, antireflux medications, or corticosteroids prior to laryngoscopy 1, 6
• Leukoplakia is only a descriptive clinical term and must be complemented by histology 2
• Keratosis can mask underlying malignancy and is not a distinct pathological entity 2
• Cessation of smoking does not remove the potential for disease progression; indefinite follow-up is required 3
• Do not delay laryngoscopy beyond 4 weeks in persistent hoarseness, as this more than doubles healthcare costs and risks missing critical diagnoses 6

Management Based on Histology

Benign Keratosis

• Voice therapy and vocal hygiene 1, 6
• Avoidance of tobacco and alcohol 1, 3
• Close surveillance with repeat laryngoscopy 3

Dysplasia or Carcinoma in Situ

• Excisional biopsy is the preferred treatment for identification and potential cure 3
• If margins inadequate, options include reexcision or radiotherapy 3
• Radiotherapy reserved for cases where voice conservation is paramount 3

Invasive Carcinoma

• Surgical management or radiotherapy based on staging 1
• Multidisciplinary oncologic evaluation 1