Vocal nodules and Vocal nodules and polyppolyp

Rohit Kumar

128/06

Normal Larynx

Normal resting anatomy

Normal phonation

Histology of the Vocal Histology of the Vocal FoldsFolds

The true vocal folds have an epithelial lining that is composed of respiratory epithelium (pseudostratified squamous) on the superior and inferior aspects of the fold and nonkeratinizing squamous epithelium on the medial contact surface. 

The subepithelial tissues are composed of a three-layered lamina propria based on the amount of elastin and collagen fibers. 

Deep to the lamina propria is the thyroarytenoid (or vocalis) muscle.

Nodules Nodules • Definition: VFNs are localized,

benign, superficial growths on the medial surface of the true vocal folds that are commonly believed the result of phonotrauma; commonly affecting singers,actors vendors,teachers,children(who are prone to shouting)etc

• Small benign lesions:size<3mm

Teacher’s NodulesSinger’s Nodules

Location: Nodules are bilateral with a classic location at the junction of the anterior one third and posterior two thirds of the true vocal fold.

.

Etiology: Vocal abuse and misuse (screamer’s or singer’s nodes

Pathogenesis:Vocal abuse hemorrhage and submucosal edema hyalinisation and fibrosis.

Epithelium undergoes hyperplasia nodule

SymptomsSymptoms

Hoarseness of voice

Vocal fatigue Pain in the neckSoreness in

throat on long phonation

Voice breaks at higher range

Vocal PolypVocal PolypDefinition –polyp is a well

differentiated,hyperplastic,benign pathological structure of mucous membrane;size >3mm

Etiology-Phonotrauma-Smoking

-AllergyMales b/w 30 and 50yrs.pathogenesis-sudden shouting

hemorrhage submucousal edema.

Vocal PolypVocal Polyp• Location:VFPs typically involve the

free edge of the vocal fold mucosa, although they may also be found along the superior or inferior borders

• VFPs generally are unilateral and have a broad spectrum of appearances, from hemorrhagic to edematous, pedunculated to sessile, and gelatinous to hyalinized

• .

Vocal Fold Polyp•.

symptomssymptomsHoarseness of voiceBreak in speechLowered pitchLoss of part of voice rangeStrain during phonationdiplophoniaStridor and choking(rarely)

Nodules vs PolypsNodules vs Polyps

A nodule differs from a polyp in that it is a growth of the epithelium that covers the mucous membrane, not of the mucous membrane itself.

Nodules are most frequently caused by vocal abuse or misuse.

Polyps are lesions that develop from voice abuse, chronic laryngeal allergic reactions and chronic inhalation of irritants, such as industrial fumes and cigarette smoke. It may also be seen in hypothyroidism.

Nodules in children frequently regress in puberty.

Differential diagnosisDifferential diagnosisReinke’s edema

Intubation granuloma

Leucoplakia

Contact ulcerAmyloid tumour

ExaminationExaminationIndirect laryngoscopyRigid laryngoscopyFlexible laryngoscopyStroboscopymicrolaryngoscopy

Indirect Indirect laryngoscopylaryngoscopy

• The indirect mirror exam is the initial procedure used to view the larynx.  It is quick, inexpensive, and only requires a mirror and external light source. 

• Gross abnormalities may be detected quickly, but subtle abnormalities may be missed. 

• Disadvantages include the larynx not being in physiologic phonation position (the tongue is extended and the larynx is elevated), some anatomic features limit the exam, and a hyper-reflexive gag is present in 5-10% of patients.  

Rigid LaryngoscopyRigid Laryngoscopyperformed using 70 or 90 degree

telescopes passed through the mouth to obtain images of the larynx and pharynx.  These are the highest quality images obtainable and offer excellent magnification.   

The patients are viewed in a nonphysiologic phonation position similar to the indirect examination.  Anatomic factors and hyper-reflexive gags can limit the results. 

Flexible Flexible LaryngoscopyLaryngoscopyMost relied upon in the evaluation of

the dysphonic patient.

allows examination of the nasopharynx, palate, larynx, and pharynx in a near physiologic position.

can be performed relatively easily even in patients with hyper-responsive gags and pediatric patients. 

Video StroboscopyVideo Stroboscopy

a stroboscopic light is used in conjunction with a laryngoscope to electronically slow down the motion of the vocal folds in order to identify subtle changes in vibratory patterns that are diagnostically significant.

Video stroboscopy is used to differentiate vocal fold nodules from vocal fold polyps.

Videostroboscopy provides a highly detailed view of the vocal folds. It can be performed via a nasal or oral pathway. Stroboscopic examination of the vocal fold lesion is essential for accurate diagnosis and successful treatment.

MicrolaryngoscopyMicrolaryngoscopy

• A procedure conducted under general anesthesia which allows the physician to examine the vocal folds of the larynx with magnification tools. Microsurgical and laser removal of lesions is done at this time.

TreatmentTreatmentVoice therapy(vocal hygeine &

behavioral treatment)

Medical treatment

Surgical treatment

Voice Therapy Voice Therapy • Aim: to help the patient find a better voice

quality which is stable,relaible and less effortful.

• Vocal hygiene.:1.maintaining adequate hydration (6-8 glasses

of water per day), 2.minimizing exposure to noxious chemicals, no

smoking, and 3.avoiding excessive shouting, screaming or

other loud voice use. Voice therapy : a behavioral intervention technique that

makes use of vocal exercises, speaker awareness and proper postures and alignment when using the voice.

Medical TreatmentMedical Treatment• Reflux may be a contributing factor and a

two week trial of medication, dietary and life-style adjustments and perhaps bed positioning may be appropriate to determine reflux’s contribution.

• Steroid treatment reduces the overlying and

sometimes camouflaging inflammation and swelling, thus making its diagnosis easier.

• Patients may be placed on a 2-week period of vocal rest, perhaps accompanied by a high-dose corticosteroid.

Surgical TreatmentSurgical Treatment• Aim: removing only the mucosal lesion and preserving as

much of the intermediate and deep layers of the vocal fold as possible.

• Indications: when the nodules or polyps are very large or

have existed for a long time and if the lesion extends deeper into the layers of the vocal fold.

• rarely done in children.

• Patients experience a substantial improvement. If deep lesions are present bilaterally, the physician needs to be extremely prudent. Waiting to see if stiffness develops from a deep dissection on one side.

Surgical Surgical ComplicationsComplications

• Related either to laryngoscopy or to vocal fold mucosal injury.

• Pressure effects from suspension laryngoscopy may result in tongue numbness, altered taste, and oropharyngeal, mucosal, and dental injuries.

• Deep-plane dissection or exposure of the vocal ligament can result in scarring and fibrosis of the mucosa with loss of mucosal wave and glottal insufficiency.

• Injudicious use of the laser can result in a wide zone of thermal damage with mucosal scarring and fibrosis, unintended burn injuries, and endotracheal tube fires.

Thank you!!!