What is the diagnosis and treatment for a patient with a whitish plaque over the vocal cords on endoscopy?

Whitish Plaque Over Vocal Cords: Diagnosis and Treatment

Primary Differential Diagnosis

The most critical first step is to distinguish between infectious candidiasis and premalignant/malignant laryngeal leukoplakia, as these require fundamentally different management approaches.

Candida Esophagitis/Laryngitis

• Whitish plaques that are painless, creamy white, and can be easily scraped off with an instrument are characteristic of oropharyngeal candidiasis 1
• These lesions appear as cotton-like exudates that cannot be washed off during endoscopy 2
• Most commonly occurs in immunosuppressed patients (CD4+ count <200 cells/µL), those on chronic corticosteroids, antibiotics, or proton pump inhibitors 1, 2
• Diagnosis can be confirmed with KOH preparation showing yeast forms or culture 1

Laryngeal Leukoplakia (Premalignant Lesion)

• Leukoplakia represents a white patch that cannot be removed and cannot be explained by another disease process 3, 4
• These lesions are keratotic and do NOT scrape off easily, distinguishing them from candidiasis 1
• Even lesions without dysplasia carry a 3.7% malignancy risk, while those with severe dysplasia have an 18.1% risk of malignant transformation 5
• Heavy smoking and male gender are significant risk factors for malignant transformation 6

Eosinophilic Esophagitis

• Presents with whitish exudates along with longitudinal furrowing, circular rings, edema, and "crêpe paper" mucosa 1, 2
• Requires multiple biopsies from proximal and distal locations, as 30% have normal-appearing mucosa 2
• Less likely if isolated to vocal cords without esophageal involvement

Diagnostic Algorithm

Immediate Assessment Required

1. Attempt to scrape the lesion during endoscopy - if it easily removes, suspect candidiasis; if it does not remove, suspect leukoplakia 1, 3

2. Assess patient risk factors:

   • Immunosuppression status (HIV, medications, transplant) 1
   • Age >60 years 7, 6
   • Tobacco use history (especially heavy smoking) 6, 5
   • Recent intubation (94% develop laryngeal injury if intubated >4 days) 8

3. Evaluate lesion characteristics:

   • Increased vasculature, ulceration, or exophytic growth suggests malignancy 7
   • Multiple or extensive lesions may indicate proliferative verrucous leukoplakia 9

Biopsy Indications

Perform immediate surgical biopsy with histopathologic evaluation if:

• Age >60 years with tobacco history (28% malignancy rate) 8
• Lesion has increased vascularity, ulceration, or exophytic features 7
• Lesion cannot be scraped off (suggesting leukoplakia rather than candidiasis) 1, 3
• Any suspicion of malignancy 1, 8

Biopsy is mandatory for definitive diagnosis of laryngeal pathology 1

Treatment Based on Diagnosis

If Candidiasis is Confirmed

• Oral fluconazole is superior to topical therapy and is the preferred first-line treatment 1
• Itraconazole oral solution for 7-14 days is equally effective but less well tolerated 1
• For esophageal involvement, systemic therapy with fluconazole or itraconazole for 14-21 days is required 1

If Leukoplakia is Confirmed (Without Malignancy)

Conservative management is the primary approach:

1. Voice rest and voice therapy - refer to certified speech-language pathologist for 1-2 sessions weekly for 4-8 weeks 7, 8

2. Antireflux medications - address potential laryngopharyngeal reflux contributing to lesion 7

3. Vocal hygiene:

   • Adequate hydration 8
   • Strict smoking cessation (critical given malignancy risk) 8, 6
   • Avoid alcohol 8

4. Close surveillance:

   • Patients with severe dysplasia can develop squamous cell carcinoma within 19 months 6
   • Regular follow-up laryngoscopy is essential, as recurrent leukoplakia has a 19.2% malignant transformation rate 6

Surgery is reserved only for:

• Cases where malignancy cannot be excluded 7
• Lesions refractory to conservative management 8
• Confirmed malignancy on biopsy 1, 8

Critical Pitfalls to Avoid

• Never treat empirically without laryngoscopy if hoarseness persists >2 weeks 8
• Do not delay biopsy in high-risk patients (age >60, tobacco use, suspicious features) as this leads to higher cancer staging and reduced survival 8
• Do not proceed directly to surgery for benign-appearing lesions without attempting conservative management first 7, 8
• Do not assume a scrapable white lesion is always benign - confirm with KOH prep or culture if suspecting candidiasis 1
• Recognize that 53% of laryngeal leukoplakia shows no dysplasia on initial biopsy, but still carries malignancy risk 5