Laryngeal Pathology and Benign Lesions
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Questions and Answers

What are the primary indications for performing a tracheostomy?

The primary indications for performing a tracheostomy include bypassing upper airway obstruction, assisting mechanical ventilation, enabling efficient bronchial toilet, and temporarily securing an airway during major head and neck surgery.

Describe the main surgical steps involved in performing a tracheostomy.

The main surgical steps involve making a skin incision, separating and retracting strap muscles, possibly dividing or retracting the thyroid isthmus, and opening the trachea between the 2nd and 3rd tracheal rings before inserting the tube.

List the contraindication for a tracheostomy procedure.

The only contraindication for a tracheostomy is the presence of a high innominate artery.

What types of materials are commonly used to construct tracheostomy tubes?

<p>Tracheostomy tubes can be made from metallic materials or non-metallic materials such as PVC and silicone.</p> Signup and view all the answers

Why is it important to avoid the cricoid and 1st tracheal ring when performing a tracheostomy?

<p>Avoiding the cricoid and 1st tracheal ring is important because incisions in this area can lead to subglottic stenosis.</p> Signup and view all the answers

What is the primary nerve responsible for innervating the intrinsic muscles of the larynx?

<p>The recurrent laryngeal nerve is primarily responsible for innervating the intrinsic muscles of the larynx.</p> Signup and view all the answers

Why is the left recurrent laryngeal nerve more commonly affected than the right?

<p>The left recurrent laryngeal nerve is more commonly affected due to its longer and more convoluted course.</p> Signup and view all the answers

What is the most common cause of unilateral recurrent laryngeal nerve palsy?

<p>Iatrogenic causes, especially from surgeries like thyroid or esophageal procedures, are the most common.</p> Signup and view all the answers

Describe the treatment approach for left vocal cord paralysis in idiopathic cases.

<p>Expectant therapy is advised if there's no malignancy, as compensation can occur in 6-18 months.</p> Signup and view all the answers

How does stridor vary based on the location of the airway obstruction?

<p>Inspiratory stridor indicates obstructions at the glottis or supraglottis, while expiratory stridor suggests intrathoracic obstruction.</p> Signup and view all the answers

What is the purpose of laryngeal framework surgery in treating vocal cord paralysis?

<p>Laryngeal framework surgery aims to approximate the vocal cords to improve contact during phonation and swallowing.</p> Signup and view all the answers

Identify two congenital causes of upper airway obstruction.

<p>Congenital laryngeal cyst and laryngomalacia are two congenital causes of upper airway obstruction.</p> Signup and view all the answers

What symptoms should be assessed in a patient with upper airway obstruction?

<p>History should include onset and symptoms such as hoarseness and dysphagia.</p> Signup and view all the answers

What is hoarseness and what does it indicate?

<p>Hoarseness, or dysphonia, is a change in the quality of voice indicating laryngeal pathology.</p> Signup and view all the answers

Why is the duration of hoarseness significant for clinical assessment?

<p>Persistent hoarseness lasting more than three weeks is considered alarming and requires referral to an otolaryngologist.</p> Signup and view all the answers

What is the common cause of hoarseness in adults?

<p>The most common cause of hoarseness in adults is viral laryngitis, typically associated with upper respiratory tract infections.</p> Signup and view all the answers

Describe the characteristics and common history related to vocal cord nodules.

<p>Vocal cord nodules are bilateral, pale lesions resulting from voice abuse, commonly found in children and professionals who use their voices frequently.</p> Signup and view all the answers

What differentiates vocal cord polyps from nodules?

<p>Vocal cord polyps are usually unilateral and are associated with smoking and voice abuse, occurring particularly between the anterior and middle thirds of the vocal folds.</p> Signup and view all the answers

What is a common cause of vocal cord granuloma and what is the initial treatment?

<p>Vocal cord granuloma often arises from intubation trauma and is usually treated with conservative voice therapy combined with aggressive antireflux therapy.</p> Signup and view all the answers

How can the onset of hoarseness indicate the underlying pathology?

<p>Sudden onset of hoarseness suggests an acute event like shouting, while gradual onset may indicate inflammatory or neoplastic diseases.</p> Signup and view all the answers

What is the role of microlaryngeal surgery in the treatment of benign laryngeal lesions?

<p>Microlaryngeal surgery is employed for treating certain benign lesions like vocal cord nodules and polyps, especially if voice therapy is ineffective.</p> Signup and view all the answers

What is the primary function of the introducer in tracheostomy procedures?

<p>The introducer facilitates the insertion of the tube.</p> Signup and view all the answers

How does the design of the inner tube improve tracheostomy care?

<p>The inner tube protrudes 2-3 mm beyond the outer tube to collect secretions for easy removal.</p> Signup and view all the answers

What are the two primary purposes of the cuff in a tracheostomy tube?

<p>The cuff prevents aspiration of food or blood and minimizes air leakage during ventilation.</p> Signup and view all the answers

Why are metal tracheostomy tubes less commonly used?

<p>They are less common because they have no cuff and cannot be fenestrated.</p> Signup and view all the answers

What is a key nursing practice to prevent tracheal necrosis during postoperative care?

<p>Cuff deflation should be performed intermittently to reduce pressure on the trachea.</p> Signup and view all the answers

What complication is the most common during the immediate postoperative period of tracheostomy?

<p>Haemorrhage is the most common immediate complication.</p> Signup and view all the answers

What would likely prompt a surgeon to change a non-functional tracheostomy tube after 2-3 days?

<p>Poor nursing care likely led to dysfunction requiring the surgeon to change the tube.</p> Signup and view all the answers

What complications may arise from the pressure of the cuff in a tracheostomy tube?

<p>Tracheoarterial and tracheoesophageal fistulas can occur due to necrosis from cuff pressure.</p> Signup and view all the answers

What is the primary objective of a tracheostomy?

<p>To provide a secure airway.</p> Signup and view all the answers

List two indications for performing a tracheostomy.

<p>Bypassing an upper airway obstruction and assisting mechanical ventilation.</p> Signup and view all the answers

What is the main surgical step for accessing the trachea during a tracheostomy?

<p>Opening the trachea between the 2nd and 3rd tracheal rings.</p> Signup and view all the answers

What should be avoided when performing a tracheostomy and why?

<p>Avoid the cricoid and 1st tracheal ring to prevent subglottic stenosis.</p> Signup and view all the answers

Name two types of materials used for non-metal tracheostomy tubes.

<p>PVC and silicone.</p> Signup and view all the answers

What is the primary cause of hoarseness in adults?

<p>The most common cause of hoarseness in adults is viral laryngitis.</p> Signup and view all the answers

What should be done if hoarseness persists for more than three weeks?

<p>If hoarseness persists for more than three weeks, the patient should be referred to an otolaryngologist.</p> Signup and view all the answers

Describe the physical characteristics of vocal cord nodules.

<p>Vocal cord nodules are usually bilateral, pale lesions found at the junction of the anterior one third and posterior two thirds of the vocal cords.</p> Signup and view all the answers

What condition is commonly associated with unilateral vocal cord polyps?

<p>Unilateral vocal cord polyps are often associated with smoking and voice abuse.</p> Signup and view all the answers

What initial treatment is recommended for a vocal cord granuloma?

<p>The initial treatment for a vocal cord granuloma includes conservative voice therapy along with aggressive antireflux therapy.</p> Signup and view all the answers

How can the onset of hoarseness help in diagnosing the underlying issue?

<p>Sudden onset hoarseness may indicate shouting or acute injury, while gradual onset suggests inflammatory or neoplastic diseases.</p> Signup and view all the answers

What treatment options exist for vocal cord nodules?

<p>Treatment options for vocal cord nodules include voice therapy and surgical treatment, such as microlaryngeal surgery.</p> Signup and view all the answers

What are the two main branches of the superior laryngeal nerve?

<p>The internal and external branches.</p> Signup and view all the answers

What is the typical history linked to the development of vocal cord granulomas?

<p>Vocal cord granulomas often have a history of intubation trauma.</p> Signup and view all the answers

What is the clinical presentation of left vocal cord paralysis?

<p>Dysphonia with a weak voice that tires with use.</p> Signup and view all the answers

What symptom is primarily associated with upper airway obstruction (UAO)?

<p>Stridor, or noisy respiration.</p> Signup and view all the answers

What is the most common surgical treatment for vocal cord paralysis?

<p>Injection laryngoplasty.</p> Signup and view all the answers

Which nerve supplies all intrinsic muscles of the larynx except the cricothyroid muscle?

<p>The recurrent laryngeal nerve.</p> Signup and view all the answers

What are two causes of upper airway obstruction?

<p>Congenital laryngeal cyst and epiglottitis.</p> Signup and view all the answers

How does a subglottic lesion typically present in terms of stridor?

<p>It presents with biphasic stridor.</p> Signup and view all the answers

What is one main indication for expectant therapy in vocal cord paralysis?

<p>Absence of underlying malignancy.</p> Signup and view all the answers

What is the purpose of the inner tube in a tracheostomy?

<p>The inner tube allows for cleaning of secretions or crusts without disturbing the main tracheostomy.</p> Signup and view all the answers

How often should the cuff be deflated to prevent tracheal necrosis?

<p>The cuff should be deflated every 2 hours for 10 minutes or every 1 hour for 5 minutes.</p> Signup and view all the answers

What is the most common immediate complication of tracheostomy?

<p>Haemorrhage is the most common immediate complication.</p> Signup and view all the answers

What is a critical factor in preventing complications after a tracheostomy?

<p>Proper nursing care, including wound care and fixation checking, is critical.</p> Signup and view all the answers

Why should tracheostomy tubes be changed every month?

<p>Tracheostomy tubes can be changed every month for maintenance, but can last up to 2-3 months with good care.</p> Signup and view all the answers

What does the introducer facilitate during tracheostomy tube insertion?

<p>The introducer facilitates the insertion of the tube into the trachea.</p> Signup and view all the answers

What complication can occur if the wound from a tracheostomy is closed tightly?

<p>Tightly closed wounds can lead to surgical emphysema.</p> Signup and view all the answers

What is the risk associated with a dysfunctional tracheostomy after 2-3 days?

<p>A dysfunctional tracheostomy after 2-3 days indicates poor nursing care, and the surgeon may not change it.</p> Signup and view all the answers

Study Notes

Hoarseness

  • A change in voice quality can indicate pathology in the larynx.
  • In adults, the most common cause is viral laryngitis, often associated with an upper respiratory tract infection (URTI).
  • In children, vocal cord nodules are a common cause.
  • Persistent hoarseness lasting more than 3 weeks should be referred to an otolaryngologist.

Benign Laryngeal Lesions

  • Vocal Cord Nodule: Commonly affects children and professionals who use their voice frequently. Often caused by voice abuse, commonly shouting in children. Typically bilateral and pale, located at the junction of the anterior third and posterior two thirds of the vocal cords.
    • Treatment includes voice therapy and surgical options like microlaryngeal surgery or CO2 laser.
  • Vocal Cord Polyp: Usually unilateral and pedunculated. Associated with habits like smoking and voice abuse. Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds. Treated by surgical excision.
  • Vocal Cord Granuloma: Arise posteriorly, adjacent to the vocal process. Often caused by intubation trauma. Initial treatment focuses on conservative voice therapy and aggressive antireflux therapy. Antibiotics and systemic steroids can be helpful. Microlaryngoscopy is rarely required but helps rule out malignancy.

Neurological Causes of Hoarseness

  • Nerve Supply of the Larynx:

  • Superior Laryngeal Nerve: Composed of internal and external branches.

  • Recurrent Laryngeal Nerve: Supplies all intrinsic muscles of the larynx, except the cricothyroid muscle. Also serves as a sensory nerve for the glottis and subglottis.

  • Unilateral Recurrent Laryngeal Nerve (RLN) Paralysis: The left RLN is more commonly affected than the right due to its longer and more convoluted course.

  • Aetiology of Unilateral RLN Paralysis: Iatrogenic causes, such as thyroid, esophageal, cervical spine, and thoracic surgeries, are most common.

  • Left Vocal Cord Paralysis: Presents with dysphonia and vocal fatigue. Examination reveals the cord in a paramedian position due to unopposed action of the cricothyroid muscle.

    • Treatment: Expectant therapy can be used in idiopathic cases when there is no underlying malignancy. Compensation can occur by the other normal vocal cord within 6-18 months, leading to reduced hoarseness.
    • Surgical options include:

  • Injection laryngoplasty: To approximate the vocal cord and improve phonation and swallowing.

  • Laryngeal framework surgery (medialization laryngoplasty): For similar purposes as injection laryngoplasty.

Stridor

  • Stridor (noisy respiration) is a hallmark symptom of upper airway obstruction (UAO).
  • Timing of stridor with respiration can indicate the location of the obstruction:
  • Glottis and Supraglottis: Inspiratory stridor.
  • Subglottic: Biphasic stridor.
  • Intrathoracic Airway: Expiratory stridor.
  • Causes of UAO:
  • Congenital: Congenital laryngeal cyst, laryngomalacia.
  • Inflammatory: Epiglottitis.
  • Neoplastic: Laryngeal cancer.
  • Traumatic: Maxillofacial trauma, bilateral RLN palsy.
  • Foreign Body.

Assessment of Patient with UAO

  • History: Onset, symptoms of upper airway disease (e.g., hoarseness, dysphagia), history of trauma or foreign body ingestion or inhalation.
  • Examination: Observe for dyspnea, tachypnea, restlessness, cyanosis, vital signs, neck examination for bruises, subcutaneous emphysema, or hematoma.

Treatment of UAO

  • ABC (Airway, Breathing, Circulation):
  • Medical: IV line, humidified oxygen, steroids, antibiotics.
  • Alternative Airway (Nonsurgical): Oral airway, nasopharyngeal airway, endotracheal intubation.
  • Alternative Airway (Surgical): Cricothyroidotomy, Tracheostomy.

Tracheostomy

  • Definition: Creation of an opening in the anterior wall of the trachea through a neck incision.
  • Primary Objective: To provide a secure airway.
  • Contraindication: High innominate artery.
  • Indications:
  • Bypassing an upper airway obstruction (e.g., laryngeal foreign body, edema, tumor, epiglottitis, maxillofacial trauma).
  • Assisting mechanical ventilation (e.g., chronic ventilator dependence > 3 weeks).
  • Facilitating bronchial toilet.
  • Temporarily securing an airway during head and neck surgery.

Surgical Technique of Tracheostomy

  • Incision: Through the skin.
  • Muscle Separation: Strap muscles separated and retracted laterally.
  • Thyroid Isthmus: Either retracted or divided.
  • Trachea Opened: Between the 2nd and 3rd tracheal rings, tube is inserted.
    • Avoid cricoid and 1st ring to prevent subglottic stenosis.

Types of Tracheostomy Tubes

  • Metal: Less commonly used (e.g., silver or gold). No cuff, cannot be fenestrated. Comes as a set with outer tube, inner tube, and introducer.
  • Non-Metallic: Made from various materials like PVC and silicon. Includes an outer tube, inner tube, and an introducer without a cuff.
    • Introducing without a cuff helps facilitate insertion.

Features of Non-Metallic Tube

  • Inner Tube Projection: Projects 2-3 mm beyond the outer tube allowing secretions or crusts to collect in the inner tube.
  • Inner Tube Removal: Can be removed for cleaning without disturbing the main tracheostomy.
  • Cuff: Prevents aspiration of food or blood and air leakage during anesthesia or prolonged mechanical ventilation.

Tracheostomy Care

  • Postoperative Care: Requires good nursing care. Includes wound care, tube fixation checks, intermittent cuff deflation (every 2 hours for 10 minutes or every 1 hour for 5 minutes) to prevent tracheal necrosis, and suctioning secretions under aseptic technique (every 15 minutes on the first day).
  • Tube Change: Every 1 month. Tubes can remain in place for 2-3 months with good wound care.
  • Dysfunctional Tube: If dysfunctional after 2-3 days, it indicates poor nursing care, requiring surgeon intervention. Tube can be changed easier after 5-7 days.

Complications of Tracheostomy

  • Immediate:
  • Anesthetic Complications:
  • Hemorrhage: Common, affecting thyroid veins, jugular veins (potentially fatal), and arteries.
  • Air Embolism: Can occur if large neck veins are opened during the procedure, air can be sucked into the venous system.
  • Apnea, Cardiac Arrest.
  • Local Damage: To thyroid cartilage, cricoid cartilage, RLN.
  • Intermediate:
  • Tube Displacement: Can be avoided by proper selection, fixation with sutures and tapes.
  • Surgical Emphysema: Wound should not be closed tightly, just approximation is needed.
  • Pneumothorax/Pneumomediastinum:
  • Infection: Perichondritis, antibiotics are given if there is infection of the lower airway.
  • Tube obstruction: Caused by secretions or crusts.
  • Tracheal necrosis.
  • Tracheoarterial fistula: Most common in irradiated neck due to pressure of cuff or tip of tube.
  • Tracheo-oesophageal fistula: Due to necrosis of the posterior wall of the trachea.
  • Dysphagia: Presence of tube impairs larynx movement and cuff pressure on the esophagus.

Hoarseness

  • Hoarseness is a change in voice quality and indicates a laryngeal issue.
  • Common cause in adults: viral laryngitis, often with upper respiratory tract infection (URTI).
  • Common cause in children: vocal cord nodule.
  • Persistent hoarseness for over 3 weeks should be evaluated by an otolaryngologist.

Benign Laryngeal Lesions that cause Hoarseness

  • Vocal cord nodule:
    • Affects children and professionals who use their voice extensively.
    • History of voice abuse is common, such as frequent shouting.
    • Bilateral, pale lesions at the junction of the anterior one-third and posterior two-thirds of the vocal cords.
    • Treatment: voice therapy and surgical treatment (microlaryngeal surgery or CO2 laser).
  • Vocal cord polyp:
    • Usually unilateral and pedunculated.
    • Associated with smoking and voice abuse.
    • Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds.
    • Treatment: surgical excision.
  • Vocal cord granuloma:
    • Arise posteriorly, adjacent to the vocal process.
    • Often caused by intubation trauma (intubation granuloma).
    • Initial treatment: conservative voice therapy and aggressive antireflux therapy.
    • Antibiotics and systemic steroids can be helpful.
    • Microlaryngoscopy may be required to exclude malignancy.

Neurological Diseases of the Larynx

  • Nerve supply of the larynx:
    • Superior laryngeal nerve:
      • Internal branch: sensory to the larynx above the vocal folds.
      • External branch: motor to the cricothyroid muscle.
    • Recurrent laryngeal nerve:
      • Supplies all intrinsic muscles of the larynx (except the cricothyroid).
      • Sensory nerve for the glottis and subglottis.

Unilateral Recurrent Laryngeal Nerve (RLN) Paralysis

  • The left RLN is more commonly affected than the right due to its longer and more convoluted course.

Aetiology (Causes) of Unilateral RLN Paralysis

  • Iatrogenic (caused by medical intervention) is the most common cause, often due to surgeries involving:
    • Thyroid
    • Esophagus
    • Cervical Spine
    • Thorax

Left Vocal Cord Paralysis

  • Symptoms:
    • Dysphonia (weak voice) that becomes tired with use.
  • Examination:
    • The vocal cord is in a paramedian position due to the unopposed action of the cricothyroid muscle.
  • Treatment:
    • Expectant therapy: if there is no underlying malignancy (in idiopathic cases).
      • Compensation can occur by the other normal vocal cord, decreasing hoarseness within 6-18 months.
    • Surgical treatment:
      • Aims to approximate the vocal cords to allow contact during phonation and swallowing, improving coughing ability.
      • Injection laryngoplasty:
      • Laryngeal framework surgery (medialization laryngoplasty)

Stridor

  • Stridor (noisy respiration) is a hallmark sign of upper airway obstruction (UAO).
  • Timing of stridor with respiration can indicate the location of obstruction:
    • Inspiratory stridor: lesion at the glottis or supraglottis.
    • Biphasic stridor: subglottic lesion.
    • Expiratory stridor: intrathoracic airway obstruction.

Causes of Upper Airway Obstruction

  • Congenital:
    • Congenital laryngeal cyst
    • Laryngomalacia
  • Inflammatory:
    • Epiglottitis
  • Neoplastic:
    • Laryngeal cancer
  • Traumatic:
    • Maxillofacial trauma
    • Bilateral RLN palsy
  • Foreign body

Assessment of Patient with UAO

  • History:
    • Onset of symptoms
    • Signs of upper airway disease (e.g., hoarseness, dysphagia)
    • History of trauma, foreign body ingestion, or inhalation
  • Examination:
    • Observation: dyspnea, tachypnea, restlessness, cyanosis
    • Vital signs: check blood pressure, heart rate, and respiratory rate
    • Neck examination: look for bruises, subcutaneous emphysema, or hematoma

Treatment of UAO

  • ABC (Airway, Breathing, Circulation): First priority
  • Medical:
    • IV line
    • Humidified oxygen
    • Steroids
    • Antibiotics
  • Alternative airway (nonsurgical):
    • Oral airway
    • Nasopharyngeal airway
    • Endotracheal intubation
  • Surgical:
    • Cricothyroidotomy
    • Tracheostomy

Tracheostomy

- **Definition:**  A surgical procedure that creates an opening in the anterior wall of the trachea through a neck incision. 
- **Purpose:** To provide a secure airway. 
- **Contraindication:** High innominate artery. 
- **Indications:**
    - Bypassing an upper airway obstruction (e.g., laryngeal foreign body, edema, tumor, epiglottitis, maxillofacial trauma).
    - Providing mechanical ventilation assistance for chronic ventilator dependence (>3 weeks).
    - Enabling efficient bronchial toilet (removal of secretions).
    - Temporarily securing an airway during major head and neck surgery.

Surgical Technique of Tracheostomy

- **Skin incision:** 
- **Strap muscles:** Separated and retracted laterally. 
- **Thyroid isthmus:** Retracted or divided.
- **Trachea opened:** Between the 2nd and 3rd tracheal rings, tube inserted. 
- **Avoid cricoid and 1st ring:** Prevents subglottic stenosis.

Types of Tracheostomy Tubes

- **Metal tube:** Less common; made of silver or gold; no cuff; cannot be fenestrated (no opening).
- **Non-metal tube:** More common; various materials (e.g., PVC, silicone).

Non-Metallic Tracheostomy Tubes

- **Components:** 
    - **Outer tube:**
    - **Inner tube:** Can be removed for cleaning without disturbing the main tube.
    - **Introducer without cuff:** Facilitates tube insertion.
- **Cuff:** Used to prevent aspiration and air leakage during anesthesia or prolonged ventilation.

Metal Tracheostomy Tubes

- **Components:** 
    - **Outer tube:** 
    - **Inner tube:**
    - **Introducer:**

Tracheostomy Care

- **Wound care:**
- **Tube fixation:** Check tube security. 
- **Cuff deflation:** Intermittently deflate to prevent tracheal necrosis (every 2 hours for 10 minutes or every hour for 5 minutes).
- **Secretion suction:** Under aseptic technique, suction every 15 minutes on the first day.
- **Tube change:**  Can be changed every month, however, it is not necessary if good wound care is maintained. It can last up to 2-3 months.
- **Changing a dysfunctional tube:** If the tube malfunctions after 2-3 days, it is a sign that the nurse has not taken good care of it. It is difficult for the surgeon to change. After  5-7 days, the surgeon can change it more easily.

Complications of Tracheostomy

- **Immediate:**
    - **Anesthetic complications:**
    - **Hemorrhage:** Most common; thyroid veins, jugular veins (fatal), arteries.
    - **Air embolism:** Can occur if large neck veins are opened during the procedure.
    - **Apnea:**
    - **Cardiac arrest:** 
    - **Local damage:** Thyroid cartilage, cricoid cartilage, RLN.
- **Intermediate:**
    - **Tube displacement:**  Can be avoided by proper selection, fixation, and taping. 
    - **Surgical emphysema:** Wound should not be closed tightly (just approximation).
    - **Pneumothorax / pneumomediastinum:** Air in the chest cavity or around the heart.
    - **Infection:** Perichondritis: antibiotics are given if there is lower airway infection at the time of tracheostomy.
    - **Tube obstruction:**  Secretions or crusts.
    - **Tracheal necrosis:**  Tissue death of trachea; due to cuff pressure.
    - **Tracheoarterial fistula:** Most common in irradiated necks, due to cuff or tube tip pressure.
    - **Tracheo-esophageal fistula:**  Due to tracheal wall necrosis.
    - **Dysphagia:**  Tracheostomy tube interferes with larynx movement; cuff pressure on the esophagus.

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Hoarseness, Stridor & Tracheostomy (2022-2023) PDF

Description

This quiz explores hoarseness and its association with laryngeal conditions. It covers common causes such as viral laryngitis in adults and vocal cord nodules in children. Additionally, the quiz discusses benign lesions like vocal cord nodules and polyps, including their treatment options.

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