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Questions and Answers
What is the most common type of vocal polyp?
Which of the following clinical features is associated with large vocal polyps?
Which technique is the primary approach for treating vocal polyps?
What type of vocal cord cyst arises from blocked minor salivary glands?
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What content is typically found in an epidermoid cyst?
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Which factors influence the choice of technique during endolaryngeal microsurgery for polyps?
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What type of appearance is typically associated with mucus retention cysts?
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Which clinical manifestation can result from contralateral vocal fold reactive lesions?
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What is the most common type of benign vocal fold lesion?
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What is the male to female ratio for vocal fold lesions in adults based on the provided information?
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Which benign laryngeal lesion is most likely to affect professional voice users?
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Which of the following is NOT classified as a benign laryngeal lesion?
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In which demographic are vocal nodules most commonly found among children?
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What is a common symptom presentation in patients with benign vocal fold lesions?
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What is the primary reason for thickening of the basement membrane in vocal fold lesions?
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Which of the following benign lesions is primarily found in the adipose tissue?
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What is the primary approach used in the treatment of vocal granuloma to avoid recurrence?
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Which type of vocal granuloma is primarily caused by mechanical irritation from intubation?
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What is the recommended management approach for upper airway obstruction associated with vocal granuloma?
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What is the primary goal when performing a microflap technique in vocal fold surgery?
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Which condition makes it particularly challenging to differentiate between tuberculosis (TB) and squamous cell carcinoma (SCC) in vocal fold lesions?
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What is a common histological finding associated with vocal cord nodules?
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Which treatment method aims to modify vocal behavior for vocal cord issues?
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What is the male-to-female ratio for vocal cord polyps?
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What type of polyp is characterized by homogenous eosinophilic deposits?
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Which of the following is a risk factor for developing vocal cord polyps?
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Which complication can result from surgical intervention on vocal cords?
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What histological characteristic is commonly observed in vocal cord microhaemorrhage?
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What is a recommended approach for managing persistent dysphonia due to vocal nodules?
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Study Notes
Benign Laryngeal Lesions
- Benign laryngeal lesions are growths in the larynx that are not cancerous.
- Epithelial lesions arise from the lining of the larynx, while nonepithelial lesions arise from other tissues like cartilage, blood vessels, or muscle.
- Some common types of benign laryngeal lesions include:
- Vocal nodules: These are small, benign growths on the vocal folds that are usually caused by overuse or misuse of the voice.
- Vocal polyps: These are larger, fluid-filled growths on the vocal folds that can also be caused by overuse or misuse of the voice.
- Vocal cysts: These are fluid-filled sacs on the vocal folds that can be caused by obstruction of a minor salivary gland or inflammation.
- Vocal granulomas: These are small, irritated growths on the vocal folds that can be caused by intubation, voice abuse, or chronic cough.
Vocal Nodules
- Vocal nodules are more common in males with a 3:1 male:female ratio.
- Usually occur bilaterally and symmetrically at the midmembranous portion of the vocal folds.
- Commonly seen in school-age children, particularly boys due to habitual screaming.
- More common in adults with a female predominance.
- Professional voice users are at higher risk (e.g., teachers, singers, telephone operators).
Vocal Nodule Pathophysiology
- Histopathology:
- Hyperplasia of the epithelial layer
- Thickening of the basement membrane with potential keratin formation
- Increased fibroblasts, fibrous tissue, hyalinization, and minimal inflammation
- Absence of hemorrhage
- Immunohistochemical findings:
- Fibronectin deposition in the superficial layer of lamina propria
- Thick collagen type IV
Vocal Nodule Treatment
-
Medical Treatment:
- Treat any underlying conditions like gastroesophageal reflux, allergies, or other comorbidities.
- Rest the voice.
- Voice therapy (12 weeks) for voice care education, vocal behavior modification, and coping strategies.
-
Surgical Treatment:
- Considered when medical therapy fails, contributing factors are optimized, and the patient experiences persistent dysphonia with limitations, hard fibrotic nodules, or atypical features suggestive of malignancy.
- Microlaryngeal surgery involves removing the nodule.
Vocal Cord Polyp
- 2:1 male to female prevalence.
- 8o% of vocal cord polyps are unilateral.
- Located on the edge of the vocal fold, typically in the anterior 1/3.
- Risk factors:
- Voice overuse or abuse
- Smoking
Vocal Cord Polyp Pathophysiology
-
Phonotrauma (voice overuse) leads to:
- Microhemorrhage and vessel leakage in the superficial lamina propria (SLP)
- Release of serum and protein into the SLP
- Formation of organized soft tissues (gelatinous, telangiectatic, or mixed).
-
Histological types:
- Gelatinous polyps: characterized by edematous stroma, collagen fibers, fibrocytes, and small vessels.
- Telangiectatic polyps: have homogenous eosinophilic deposits with fibrin collection.
- Mixed type: the most common type, combines features of gelatinous and telangiectatic polyps.
Vocal Cord Polyp Clinical Features
- Abrupt onset of hoarseness, often linked to specific events like shouting during sports or a severe cough.
- Polyp size matters:
- Small polyps cause dysphonia.
- Large polyps can obstruct the airway and lead to coughing.
- Pedunculated polyps (attached by a stalk) can cause a "ball-valve" effect on the voice and airway (voice is good when polyp is down, but severely impaired when up).
Vocal Cord Polyp Treatment
- Most polyps don't improve with medical or speech therapy.
- Focus on removing voice irritants.
- Endolaryngeal microsurgery is the main treatment.
- Two techniques are utilized depending on the amount of healthy mucosa associated with the polyp:
- Phonomicrosurgery with a microflap technique.
- Truncation of the vocal fold polyp (for fibrotic polyps involving the VF epithelium).
Vocal Cord Cyst
-
Mucus retention cyst:
- Arises from a blocked minor salivary gland, potentially secondary to phonotrauma or inflammation.
- Lined by cuboidal or low columnar epithelium.
- Unilateral and commonly found at the free edge of the vocal fold or false cord.
- Content is mucous or serous.
- Appearance is translucent and yellowish.
- Often associated with edema and fibrosis in the Reinke's space.
-
Epidermoid cyst:
- Lined by squamous epithelium filled with keratin and cholesterol debris.
- Contains inflammatory exudate in the Reinke's space.
- Content is cheesy epidermal debris.
- Appearance is pearl-like white.
- Theories for its formation include:
- Metaplasia within a longstanding mucus retention cyst.
- Microinclusion of epithelium from surface trauma.
- Congenital cell rests from the subepithelium of the fourth and sixth branchial arches.
Vocal Cord Cyst Treatment
- Microsurgery is the main treatment.
- Emphasize precise preservation of the underlying deep lamina propria and overlying epithelium.
- Avoiding leaving any part of the cyst wall behind, which can lead to recurrence, localized scarring, and poor voice.
Vocal Granuloma
- Classified according to etiology:
- Intubation granuloma: caused by the insertion of a breathing tube.
- Contact granuloma: arises from irritation or pressure from the vocal folds rubbing together.
- Hyperfunctioning granuloma: caused by overuse or abuse of the voice.
Vocal Granuloma Pathogenesis
- Voice abuse, shouting, chronic cough, or throat clearing can lead to inflammation or ulceration on the medial side of the vocal process, which is thinly covered by mucoperichondrium.
- Local inflammation can lead to perichondritis and chondritis in the arytenoid cartilage.
- This inflammation contributes to vocal granuloma formation.
Vocal Granuloma Treatment
-
Medical management:
- Proton Pump Inhibitors (PPIs) to treat gastroesophageal reflux.
- Reassurance that the granuloma is benign and will eventually resolve.
- Voice therapy.
-
Surgical treatment:
- Considered when there is upper airway obstruction, significant voice impairment despite therapy and medical management, or suspicion of malignancy.
- Excision should avoid completely removing tissue covering the perichondrium to minimize scarring.
- Serial in-office intralesional steroid injection (SIILSI) might be considered.
Microflap Technique
- Developed by Sataloff et al. and Courey et al.
- Involves identifying normal tissue planes to excise benign vocal cord lesions with minimal disturbance to vocal mechanics.
- Two types: lateral microflap and medial microflap.
Summary
- Most vocal fold lesions require microlaryngoscopic biopsy to distinguish benign from malignant lesions, particularly to differentiate tuberculosis and squamous cell carcinoma.
- Exceptions include vocal nodules, where biopsy may not be needed.
- Surgical excision aims to spare the anterior commissure, vocal ligament, and posterior commissure.
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Description
Test your knowledge on benign laryngeal lesions, including their types and characteristics. This quiz covers various conditions like vocal nodules, polyps, cysts, and granulomas, focusing on their causes and effects. Perfect for students in speech-language pathology or otolaryngology.
