60 Benign Vocal Fold Mucosal Disorders.pdf

60 Benign Vocal Fold Mucosal Disorders Robert W. Bastian, Melissa L. Wingo KEY POINTS The two most common risks for vocal fold mucosal vibratory injury are a high intrinsic tendency to use the voice (talkativeness, extroversion) and a high extrinsic opportunity or necessity to use the voice, driven by occupation, family needs, social activities, and avocations. Visible vocal fold lesions from overuse may not cause an audible change in the speaking voice. Visible vocal fold lesions that cause phonatory mismatch at the free margin or mucosal stiffness are always detectable audibly in the singing voice provided that the examiner knows how to elicit upper-range vocal tasks. Singing-voice symptoms of mucosal injury are loss of the ability to sing softly at high pitches, increased day-to-day variability of singing-voice capabilities, phonatory onset delays, reduced vocal endurance, and a sense of increased effort. Small or subtle vocal fold lesions may escape visual detection unless the larynx is viewed with high magnification; vocalization in the upper range sometimes requires topical anesthesia. With few exceptions, brief initial speech pathology evaluation and treatment are indicated when vocal fold injury is clearly due to overuse, misuse, or abuse of the voice. Speech therapy alone may suffice if the vocal improvement that follows is adequate for the patient’s needs; otherwise speech therapy will serve as preparation for vocal fold microsurgery. Key requirements for successful vocal fold microsurgery are (1) detailed knowledge of vocal fold microarchitecture Benign vocal fold mucosal disorders—vocal nodules, laryngeal polyps, mucosal hemorrhage, intracordal cysts, glottic sulci, and mucosal bridges—seem to be caused primarily by vibratory injury from an excessive amount or aggressive manner of voice use. Review of thousands of patients reveals that an expressive, talkative personality correlates best with most of these disorders. Occupational and lifestyle vocal demands appear to be additional but lesser risks unless these demands are extreme. Occasionally, injury can occur as a fluke based on one episode of vocal strain in an otherwise moderate voice user. Cigarette smoking is a cofactor for smoker’s polyps (Reinke edema). Infection, allergy, and acid reflux may also potentiate vibratory injury. Nonsingers with benign vocal fold mucosal disorders come to medical attention because of change in the sound or capabilities of the speaking voice. By contrast, singers may have no issues with their speaking voices but may seek help because of singing voice limitations, usually in the upper range. Benign vocal fold mucosal disorders are significant because spoken or sung communication is important and a person’s voice is a part of his or her identity. and vibratory physiology to guide surgical precision; (2) proven technical ability of the surgeon; (3) preoperative and postoperative laryngeal videostroboscopy examination to diagnose clearly at the initial presentation and after surgery to assess results; and (4) access to voice-qualified behavioral (speech pathology) support. Capillary ectasia can be an incidental finding that does not necessarily require treatment. Surgical intervention may be indicated, on the other hand, when the ectasia causes one or more of the following: a tendency to decreased vocal endurance (reduced voice use time before huskiness results), intermittent bruising, or a hemorrhagic polyp. Contact ulcers and granulomas are best thought of as exuberant healing responses to injury, which can be from aggressive chronic throat clearing, aggressive coughing, or endotracheal tube injury. Some believe that acid reflux is a contributor. Treatment is generally supportive over many months during the wait for maturation, pedunculation, and spontaneous detachment; surgical removal is nearly always followed by recurrence. Marsupialization of saccular cysts is sometimes followed by recurrence; therefore, when possible, complete removal of saccular cysts appears to be preferred. Even large ones can often be removed endoscopically. Recurrent respiratory papillomatosis is caused by the human papillomavirus. Currently optimal management includes careful serial laser laryngoscopic treatment with consideration of various adjuvant medications. Benign vocal fold mucosal disorders are common. More than 50% of patients who seek medical attention because of a voice change have a benign mucosal disorder. Even before the laryngeal videostroboscopy era, when subtle and small lesions may have been missed, Brodnitz1 reported that 45% of 977 patients had a diagnosis of nodules, polyps, or polypoid thickening. From the same era (1964–1975), Kleinsasser2 reported that slightly more than 50% of 2618 patients seen for a voice complaint had one of these benign entities. ANATOMY AND PHYSIOLOGY The anatomy most relevant to the benign vocal fold mucosal disorders is the microarchitecture of the vocal folds as seen on whole-organ coronal sections in a study of cancer growth patterns3,4 and in the work of Hirano.5 Medially to laterally, the membranous vocal fold is made up of squamous epithelium, Reinke’s potential space (superficial layer of the lamina propria), the vocal ligament (elastin and collagen fibers), and the thyroarytenoid muscle. 868 Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders Abstract Keywords Most commonly, benign vocal fold mucosal disorders are caused by vibratory injury in “vocal overdoers.” Exceptions include mucous retention cyst, papillomas due to human papillomavirus (HPV) infection, granulomas, uncommon benign tumors, and other lesions. Accurate diagnosis and management require a skillful history; a perceptual assessment of the patient’s vocal capabilities, limitations, and aberrations (if present); and a high-quality laryngeal examination. A voice-qualified speech pathologist is often part of the patient’s care to improve vocal hygiene and optimize voice production. Lesions found to be otherwise irreversible may be addressed with vocal fold microsurgery. This chapter discusses in detail the diagnosis and management of various benign vocal fold mucosal disorders, including vocal nodules, capillary ectasia, intracordal cysts, glottic sulcus, bilateral diffuse polyposis, postoperative dysphonia, contact ulcer/granuloma, intubation granuloma, saccular disorders, benign mesenchymal neoplasms, recurrent respiratory papillomatosis, vascular neoplasms, muscle neoplasms, neoplasms of adipose origin, benign neoplasms of glandular origin, oncocytic neoplasms of the larynx, cartilaginous neoplasms, and neoplasms of neural origin. Vibratory injury vocal capability battery flexible chip-tip video-endoscope videostroboscopy microlaryngoscopy Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 868.e1 60 CHAPTER 60 Benign Vocal Fold Mucosal Disorders Perichondrium and thyroid cartilage provide the lateral boundary of the vocal fold (Fig. 60.1). The vocal folds move as a whole between abducted and adducted positions for breathing and phonation, respectively. The mucosa— that is, the epithelium and superficial layer of the lamina propria (Reinke’s potential space), which covers the vocal folds—is the chief oscillator during phonation (continuous adduction of the folds during expiratory flow of pulmonary air). Thus it is correct to speak of vocal fold mucosal vibration rather than vocal fold vibration. In a canine study supporting this idea, Saito and associates6 placed metal pellets at varying depths within the vocal fold (e.g., epithelially, subepithelially, intramuscularly) and used radiographic stroboscopy to trace their coronal plane trajectories during vibration. Pellet trajectories of the mucosa were far wider than those of the ligament or the muscle; thus it is primarily the vocal fold mucosa that oscillates to produce sound. The work of Hirano7 provides an explanation for these observations. Hirano described the vocal fold muscle as the body of the fold, the epithelium and superficial layer of the lamina propria (Reinke’s potential space) as the cover, and the intermediate layers of collagenous and elastic tissue (vocal ligament) as the transitional zone (see Fig. 60.1). Because of the different physiologic stiffness Vocal ligament Stratified squamous epithelium 869 characteristics of these layers, they decouple mechanically from each other somewhat during phonation. Graphically illustrated in Fig. 60.2 (mucosa being stretched), decoupling allows the mucosa to oscillate with some freedom from the ligament and muscle. Imagine the vocal fold as a child’s paddleball toy: as the red rubber ball and elastic band move with relative freedom apart from the paddle, so the mucosa moves with a degree of freedom from the ligament and muscle. During phonation, pulmonary air power supplied to adducted vocal folds is transduced into acoustic power. To accomplish this, pulmonary air is passed between appropriately adducted vocal folds. At this point, the vocal fold mucosa vibrates passively according to the length, tension, and edge configuration determined by the intrinsic muscles and elastic recoil forces of the vocal fold tissues. Fig. 60.3 shows the maximum open and closed phases of one vibratory cycle, as seen during laryngeal videostroboscopy. Further details concerning the mucosa’s vibratory behavior can be found in the works of Baer8 and Hirano5 and in Chapter 56. Other important microanatomy includes glands in the supraglottic, saccular, and infraglottic areas, which produce secretions that bathe the vocal folds during vibration. Respiratory epithelium Thyroarytenoid muscle (vocalis) Superficial layer, lamina propria (Reinke’s space) Fig. 60.1 Cross-section of the vocal fold. A Fig. 60.2 Gentle medial retraction shows the relative decoupling of the mucosa from the underlying nondeformed vocal ligament. B Fig. 60.3 The maximum open (A) and closed (B) phases of an apparent single vibratory cycle as seen during videostroboscopy. The moving part is primarily mucosa; participation of ligament or muscle is slight. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 60 870 PART V Laryngology and Bronchoesophagology EVALUATION OF THE PATIENT: GENERAL PRINCIPLES The scientific method demands that hypotheses be tested using observation or measurement. In the clinical realm of voice disorders, an unresolved issue is how important are observation and measurement, respectively, for diagnosis. In this author’s view, the necessary and sufficient elements for diagnosis and management of benign mucosal disorders are (1) a skillful history; (2) a perceptual assessment of vocal capabilities, limitations, and aberrations (when present), particularly through elicitation of vocal tasks designed to detect mucosal disturbances; and (3) a high-quality laryngeal examination, which often includes laryngeal videostroboscopy. Although not particularly useful for diagnosis, certain measures of phonatory function (aerodynamic, acoustic) may be of interest for research and publication, documentation of the disorder’s physiologic effects, and as an adjunct to observational assessment of improvement after treatment. History Besides the usual items in the general medical history, the voice history should focus in particular on the following items, which may be best captured by using a questionnaire9,10: 1. 2. 3. 4. 5. 6. 7. 8. Onset and duration of vocal symptoms Patient’s beliefs about causes or exacerbating influences Common symptom complexes Talkativeness profile (intrinsic, personality-based tendency to use the voice) Vocal commitments or activities (extrinsic requirement, invitation, or opportunity to use the voice), including voice type and training if the patient is a performer Other risk factors Patient’s perception of the severity of the disorder Vocal aspirations and consequent motivation for rehabilitation Onset It is appropriate during history taking to test the hypothesis that a patient who complains of frequently recurring bouts of vocal dysfunction may be experiencing exacerbations of a more chronic overuse disorder. Based on an assessment of vocal personality, lifestyle, vocal commitments, and voice production, such a patient is often found to be “living on the edge” vocally and may have been pushed over that edge by only a small increase in vocal activity or by an upper respiratory infection. In this situation, without sophisticated insight, both the patient and the clinician may tend to focus on the recent or current upper respiratory infection (e.g., providing supportive treatments or antibiotics) rather than seeing past this acute issue to recognize the need for the more sophisticated behavioral therapy appropriate for a chronic “vocal overdoer.” Patient’s Beliefs Regarding Causes A clinician is prudent to remain open and curious about cause, even when the patient is already convinced of a certain explanation. For example, a patient may insist that the voice disorder results from allergies or acid reflux. After thorough consideration, the clinician may instead find that the patient’s vocal overdoer status (see the following section) is primary and that allergy and acid reflux in that patient actually happen to be inconsequential by comparison if they are present at all. Of course, in this instance, considerable time is required at the conclusion of the consultation for teaching to help the patient redirect his or her thinking, to meet objections, and so on. Common Symptom Complexes As in the case of many other types of voice disorders, a characteristic symptom complex usually accompanies benign mucosal disorders. Nonsingers, who often experience moderate to large mucosal disturbances before they seek medical attention, usually describe chronic hoarseness with exacerbations at times of increased voice use. Singers may not note speaking-voice symptoms but rather often describe (1) exaggeration of day-to-day variability of singing capabilities; (2) increased effort necessary for singing; (3) reduced vocal (mucosal) endurance; (4) deterioration of high, soft singing; and (5) delayed phonatory onset and air wastage (breathiness). Talkativeness Profile: Vocal Overdoer Syndrome The factor that correlates most strongly with the formation and maintenance of many benign vocal fold mucosal disorders appears to be personality. A simple and even rudimentary but nevertheless powerful way to assess this issue is to ask the patient to self-rate talkativeness on a 7-point scale; a score of 1 is very untalkative, a person with a score of 4 is average, and a person with a score of 7 is unusually talkative. (In asking this question, the clinician must stress that this scale deals with innate predisposition, not the demands of work or lifestyle.) Virtually all patients with nodules and polyps and even those with cysts and sulci rate themselves at 6 or 7, except for those less talkative individuals who work in vocally extreme occupations (e.g., financial trading). Vocal Commitments To assess vocal commitments and activities, the clinician or questionnaire should inquire briefly about occupation, voice type and level of training, and the nature and extent of vocal activities related to family life, child care, politics, religion, hobbies, athletics, and musical rehearsal and performance. Other Risk Factors Other risk factors are tobacco and alcohol use, acid reflux, insufficient fluid intake, certain drying medications, systemic illnesses, and allergies. Even when the history is positive for one of these factors, it is usually a secondary issue in comparison with “sevenness.” Patient Perception of Severity and Vocal Aspirations and Consequent Motivation for Rehabilitation It is important to explore how severe the patient perceives the voice problem to be as well as his or her vocal aspirations and motivations for rehabilitation. For example, the clinician may be confronted by a patient who only wants to be reassured that the problem is not cancer. Even with a diagnosis of large smokers’ polyps with severe range virilization and dysphonia, the management of such a patient might appropriately be short term and supportive, consisting primarily of counseling about smoking cessation. Another patient, a professional singer, may have a normal speaking voice but have upper limitations to the singing voice caused by small nodules. To help this patient pursue a competitive singing career, rehabilitation might be intense and might include significant behavioral therapy by a speech pathologist. It might also eventually include surgery. Vocal Capability Battery The vocal capability battery is an auditory-perceptual assessment of vocal capabilities, limitations, and aberrations (if present). It macrophenomenologically assesses two crucial questions, the first relating to limitation (“What can’t this voice do that it should be Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders able to?”) and the second to aberration (“What does this voice do that it should not?”). This process involves elicitation of a variety of vocal tasks followed by an auditory-perceptual assessment of the voice. The vocal capability battery is an often neglected part of the diagnostic process, although it provides the best means of understanding the nature and severity of the voice disorder. To be most efficient, this part of the diagnostic process is performed by the same clinician who takes the history and performs the laryngeal examination. Alternatively, a second clinician can perform this assessment, but for best results, the findings of vocal capability elicitation are immediately correlated with the other two components of the diagnostic process. Vocal elicitation and interpretation require that the examiner have good pitch-matching abilities; a reasonably normal voice; extensive familiarity with his or her own vocal capabilities (and limitations, if any); intimate familiarity with normal singing-voice capabilities according to age, sex, and voice classification; and the willingness to model and elicit a response with his or her own voice. Also needed is a frequency reference, such as a small electronic keyboard. These elements are straightforward and can be acquired by motivated clinicians with reasonably “aware and insightful” auditory perception. In voice clinics where expert vocal capability elicitation and assessment are not available or are not immediately correlated with history and laryngeal examination, clinicians may overlook or reject the power and centrality of this part of the evaluation. They may instead rely on various items of equipment that measure components of vocal output (e.g., acoustic, aerodynamic). Although useful for quantification, documentation, and some biofeedback applications, this equipment is cumbersome and expensive, and the data it collects are time consuming to interpret. Most importantly, instrumented measures of phonation are diagnostically weak in comparison with the insights provided by the vocal capability battery, which can answer far more quickly, powerfully, and synthetically the question, What’s wrong with this voice? The basic vocal capabilities and phenomena to be tested are (1) average or anchor speech frequency; (2) maximum frequency range; (3) projected voice and yell; (4) very-high-frequency, verylow-intensity tasks that detect mucosal disturbances11; (5) register use and phenomena; (6) maximum phonation time; and (7) instability and tremors. The ability to perform high-frequency, low-intensity tasks (e.g., singing “Happy Birthday” at the extreme upper range and in a tiny voice) is the single most important part of the vocal capability battery in people with benign mucosal disturbances. If a patient’s voice loses its expected upper range under these performance constraints or if it suffers from onset delays, air escape, diplophonia, or lack of tonal clarity, the clinician may expect to find a mucosal disorder. The clinician should also search for inconsistencies between spoken and sung capabilities and should informally note the patient’s sincerity of effort and skill. Basic vocal capability testing requires only a few minutes to perform because the examiner focuses primarily on the extremes of physical capability and secondarily on vocal skill. As stated, the vocal capability battery, combined with the initial voice history and then subsequent laryngeal examination, is crucial in diagnosing a voice disorder and in directing subsequent management. For example, if, during history taking, the patient’s speaking voice sounds normal, then—even if he or she actually has (perhaps small) vocal nodules—the clinician might, due to confirmation bias and selective perception “see” “normal” vocal folds during visual examination; however, if the patient also performs some high-frequency, low-intensity vocal tasks and the clinician detects signs of a mucosal disturbance (e.g., escaping air, onset delays, diplophonia, loss of clarity and range), the clinician will be more prepared to find any nodules that may be present.12 The vocal capability battery also provides insight into the severity of the patient’s vocal limitations, which can then be correlated with 871 the visual examination to help determine, along with the patient’s needs and motivation, the intensity and direction of management. Office Examination of the Larynx The larynx can be examined in several ways (Fig. 60.4). The laryngeal mirror should provide three-dimensional viewing and good color resolution; however, in practice it offers poor visualization in many cases. In other cases, visualization is good but only during phonation, because the view is obstructed by the epiglottis during respiration. In addition, no permanent image of the larynx results from this examination technique. Because the physician must therefore remember the lesion or document it with a simple sketch, precise critique of the effectiveness of the therapy chosen may not be possible. Rigid and also flexible laryngeal scopes often allow a clearer view, particularly during respiration. When used with the naked eye, however, they have disadvantages similar to those of the mirror. The fiberoptic nasolaryngoscope or a newer “chip-tip” videoendoscope is especially important in a patient who is difficult to examine because of unusual anatomy or an exceptional gag reflex. Even with these technologies, however, it is possible to overlook subtle to small mucosal changes unless the larynx is topically anesthetized to allow a close approach of the tip of the fiberscope to the vocal folds. With topical anesthesia, the vocal folds, subglottis, and trachea can be examined easily (Fig. 60.5).13,14 Fig. 60.4 Three of the most commonly used tools for viewing the larynx: a mirror, a 90-degree telescope, and a flexible distal-chip endoscope. Fig. 60.5 Extreme closeup of the larynx with adequate resolution of the vocal folds, subglottis, and even high trachea. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 60 872 PART V Laryngology and Bronchoesophagology Strobe illumination added to any of these examining instruments allows mucosal vibratory dynamics to be evaluated in apparent slow motion (e.g., to understand mucosal scarring and to distinguish cysts from nodules). Adding a video camera and recording device, typically a computer hard drive, to the rigid or flexible scopes brings additional advantages; for example, showing a video of the examination to a patient can help him or her to understand and be motivated. Also, such recordings enable other clinicians— otolaryngologists, speech pathologists, voice teachers—to participate more easily in assessment and management, and these recordings serve as permanent records that document the result of voice therapy or surgery and enhance the teaching of residents. Objective Measures of Vocal Output Skillful “triangulation” on the voice problem through the use of the voice history, auditory-perceptual evaluation of vocal capabilities, limitations and aberrations, and a high-quality laryngeal examination is sufficient for a clear diagnosis and description of the problem. Aerodynamic and acoustic information, although weak diagnostically because of its nonspecificity, may be useful to quantify and document severity and change in response to treatment, to deepen understanding in the research arena, and to assist in some helpful biofeedback applications. Direct Laryngoscopy and Biopsy When videostroboscopy with magnified viewing is available, lesions suspicious for cancer or papillomatosis can nearly always be distinguished easily from nodules, polyps, and cysts. Therefore removal of the latter entities is appropriate only within a comprehensive plan for treatment or voice restoration and rarely if ever for preliminary tissue diagnosis. GENERAL MANAGEMENT OPTIONS Hydration Adequate hydration promotes the free flow of lubricating secretions, which helps the vocal fold mucosa withstand the rigors of vibratory collisions and shearing forces. A consistent, rather than episodic, supply of fluids seems to be particularly important. An expectorant, such as guaifenesin, may also help when secretions are viscid. Sinonasal Management Patients often incorrectly attribute chronic hoarseness to sinonasal conditions. Existing sinonasal problems should be managed on A their own merits; however, the clinician may need to help diminish the patient’s perception of how much these problems contribute to a voice disorder in favor of more likely behavioral causes. When optimal laryngeal function is of concern, as in a vocal performer, nasal conditions should be managed locally (topically) when possible. The reason is that many systemic drugs (e.g., oral decongestants, antihistamine-decongestant combinations) dry not only nasal secretions but also secretions in the larynx, where a continuous secretional flow is important for proper vibratory function and mucosal endurance, particularly under demanding phonatory conditions. Medications that affect the voice minimally are the topical nasal decongestants, which should be used for only a few days before the nasal mucosa is allowed to rest so as to avoid rhinitis medicamentosa. The profuse rhinorrhea that accompanies the common cold can also be managed with ipratropium bromide inhalations,15,16 and corticosteroid inhalers are invaluable for the management of nasal allergies. Activating pump-action nasal inhalers without any inspiratory airflow avoids the alleged risk of the effects of nasally applied corticosteroid on the vocal folds. Management of Acid Reflux Laryngopharyngitis In a person with an incompetent lower esophageal sphincter or hiatal hernia, acid reflux into the pharynx and larynx during sleep can lead to chronic laryngopharyngitis. Such persons may or may not experience one or more of the following symptoms: exaggerated “morning mouth,” excessive phlegm, scratchy or dry throat irritation that is usually worse in the morning, habitual throat clearing, and huskiness or lowered pitch of the voice in the morning. The larynx may show characteristic erythema of the arytenoid mucosa, interarytenoid pachyderma, or contact ulcers; however, laryngeal findings may be subtler than those in Fig. 60.6. Careful attention to patient history, laryngeal examination, and a commonsense empiric trial in a thoroughly educated patient is sufficient for virtually everyone in whom this diagnosis is being considered. Ford17 suggests that the most reliable way to confirm the diagnosis is using ambulatory multichannel intraluminal impedance and pH-monitoring studies; this could be considered in the small number of patients for whom empiric trials combined with careful patient history and laryngeal examination do not suffice. Basic management of this condition consists of avoiding caffeine, alcohol, and spicy foods; eating the last meal of the day, preferably a light one, no fewer than 3 hours before retiring; using bed blocks to place the bed on a mild head-to-foot slant; and taking an antacid at bedtime, a histamine H2-receptor antagonist (H2 blocker) 2 or 3 hours before bed, or a proton pump inhibitor 30 to 60 minutes before dinner. B Fig. 60.6 (A) Acid reflux–associated findings of interarytenoid pachyderma and swelling just below the margin of the folds (blue arrows) and erythema of the mucosa that covers the anterior face of the arytenoid cartilages (green arrows). (B) Different patient with the same disorder, during phonation. Accumulation of excess inflammatory and viscous mucus is shown. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders Acute Mucosal Swelling of Overuse Public speakers or singers may sometimes perform of necessity despite acute noninfectious mucosal swelling resulting from recent overuse of the voice. A careful strategy of relative vocal rest in context is needed (e.g., interspersing high-intensity songs with low-intensity songs, avoiding conversation during intermission, etc.) along with preperformance warm-up and solid vocal technique; these may be sufficient for the patient to “get through.” A shortterm, high-dose tapering regimen of corticosteroids can also be useful in this context as part of a larger strategy to help the patient through a performance. Laryngeal Instillations for Mucosal Inflammation In past years more so than currently, laryngologists have used drugs such as mono-p-chlorophenol, topical anesthetics, mild vasoconstrictors, sulfur vapors, certain oils, and other substances for the reduction of swelling, a soothing effect, or promotion of healing. Some physicians and patients believe in the efficacy of such management, although it is supported only by anecdotal reports. Systemic Medicines That May Affect the Larynx Medicines that patients take for other reasons—such as antidepressants, decongestants, antihypertensives, and diuretics—may dry and thicken normal secretions, which thereby reduces their protective lubricating effect on the vocal folds and conceivably makes the vocal fold mucosa more vulnerable to the development of benign disorders. The clinician should inquire about these medicines during history taking. VOICE THERAPY A course of therapy by a voice-qualified speech pathologist is frequently appropriate in patients with benign vocal fold mucosal disorders, given the common relationship of such disorders with vocal overuse, abuse, or misuse. Vocal nodules in particular are expected to resolve, regress, or at least stabilize under a regimen of improved voice hygiene and optimized voice production. In some cases, however, success is defined as having achieved a more consistent voice, without the exacerbations of hoarseness and even aphonia, even if that now-more-reliable voice remains somewhat husky. In other cases, the definition of success may mean resolution of all upper singing voice limitations. If surgery becomes an option—because the mucosal disorder has not resolved completely, and the patient regards residual symptoms and vocal limitations as unacceptable—voice therapy will have optimized the patient’s surgical candidacy by educating him or her additionally about the surgical process, and it will have decreased the risk of postoperative recurrence. During evaluation, the speech pathologist gathers information on behavior that may adversely affect the voice and establishes a program to eliminate injurious behavior. Voice-qualified speech pathologists also model and elicit a battery of spoken and sung vocal tasks to make plain to themselves and patients the type and degree of impairment that has resulted from the lesion. They also assess the skill and appropriateness of voice production for both speaking and singing. Depending on the results of this second part of the evaluation, the speech pathologist may help the patient optimize the intensity, average pitch, registration, resonance characteristics, overall quality, general and vocal tract posture, and respiratory support for voice production. For singers, the singing teacher plays an invaluable role in this process, particularly with respect to the production of singing voice. Finally, in this technologic era, voice clinicians increasingly document various aspects of vocal tract output using acoustic 873 analysis, spirometric measures to test respiratory adequacy, frequency and loudness measures, translaryngeal airflow rates, and other measures under various conditions. Speech pathologists may use this equipment for biofeedback (e.g., using a visual electronic frequency readout to modify average pitch for speech in a tone-deaf patient). For obligate false vocal fold phonation and intractable psychogenic disorders of voice production with visible vocal fold posture abnormalities, therapy room videoendoscopy can also be converted into an effective biofeedback tool.11,18 SURGERY Some lesions are known at diagnosis to be irreversible except via surgery. Aside from these exceptions, vocal fold microsurgery should follow an appropriate trial of voice therapy. Individualization is the rule, but patients are typically reexamined with the vocal capability battery and videostroboscopy at 16-week intervals after diagnosis. When a compliant patient does not improve after two or more successive examinations and remains unhappy with the voice’s capabilities, surgery may be considered. Good surgical results are directly related to diagnostic accuracy, surgical judgment and precision, and the patient’s compliance with proper voice care. Although specific techniques vary for each disorder, the basic requirements for successful laryngeal microsurgery for all benign vocal fold mucosal disorders are the same. An understanding of vocal fold microarchitecture and vibratory dynamics (see previous discussion) is a prerequisite, and preoperative and postoperative videostroboscopic evaluation is necessary so that the patient and surgeon can see the results together. The first principle of surgery is that microlaryngoscopy, not direct laryngoscopy with the unaided eye, and extreme technical precision are required so as to disturb the mucosa as minimally as possible. Because the disorder is benign and confined to the mucosa, including Reinke’s potential space, the cancer concept of surgical margins does not apply. Every case should be approached with the awareness that overly aggressive or imprecise surgery of the vocal fold mucosa can result in regenerated or surgically manipulated mucosa that scars and thus adheres to the underlying vocal ligament, which will cause severe dysphonia. A set of laryngoscopes, microlaryngeal forceps, scissors, dissectors, and knives should be on hand. In the face of the plethora of instruments currently available, the comment by Kleinsasser2 that a relatively simple set suffices the experienced surgeon remains true (Fig. 60.7). The carbon dioxide (CO2) laser has become an important part of the surgeon’s armamentarium, and many have discussed its application to benign laryngeal disorders. Tissue effects of the laser depend on spot size and focus, wattage, duration of beam activation, waveform mode (pulsed vs continuous), and perhaps most important, surgical precision. Cold microdissection may be safer than laser techniques, provided that the surgeon is equally proficient in both. In the days before diminished spot size permitted increased precision, Norris and Mullarky,19 comparing a continuous-mode CO2 laser with the cold scalpel for incising pig skin, reported that a short-term advantage resulted after laser incision with regard to the speed of reepithelialization; no long-term difference in healing was noted. However, although the fact was not noted in their report, these investigators’ histologic sections clearly showed a wider zone of tissue destruction beneath the epithelium with the laser than with the scalpel. Duncavage and Toohill20 compared healing response in dogs after traditional fold stripping and after CO2 mucosal vaporization. They concluded that, until late in healing, more edema and giant-cell reactions to bits of charred debris and greater subepithelial fibrosis occurred with the laser technique than with the cup forceps alone. Manipulation of wattage, focus, and mode of laser irradiation of tissues may decrease thermal injury, charring, and other adverse effects of the laser. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 60 874 PART V Laryngology and Bronchoesophagology A C B Fig. 60.7 (A) The viewing ends (left to right) of the Jackson, Hollinger, Zeitels, and Bouchayer operative laryngoscopes. (B) The distal ends of these laryngoscopes shown in reverse order: Bouchayer, Zeitels, Hollinger, and Jackson. Each scope has its advantages, and this set meets virtually every challenge, from the difficult airway to the excision of large tumors. (C) A simple set of microsurgical instruments is often sufficient for the experienced laryngeal microsurgeon. From left, Dissection spatula (e.g., for cysts), scissors, alligator forceps, microring (heart-shaped) forceps, and cup forceps. The preceding studies date from the early era of the CO2 laser. The microspot CO2 laser appears to diminish these disadvantages,21,22 and Geyer and colleagues23 reported a more recent series of 235 patients for whom the CO2 laser achieved good results. However, a systematic comparison of functional results, including vocal capabilities and videostroboscopy, is not available to guide the surgeon in choosing between laser and microdissection methods. With a caseload of more than 1000 singers and at least triple that number of nonsingers, for whom laser and nonlaser methods have been used on an individualized basis, it appears that surgical technique and skill are preeminent over the specific tools used. After surgery, vocal quality and capabilities should show good to excellent improvement; however, patients should be counseled preoperatively as to what the risk of worsening the voice is predicted to be. For nodules it may be appropriate to say, “This surgery typically restores the voice to ‘original equipment status,’ but there is a small risk that you will experience a large improvement but not to fully normal; and there is a remote, rare risk that your voice will be worse after surgery.” By contrast, you may say to the person with bilateral sulci in whom the mucosa is thin, “I am expecting at best a modest improvement of your voice, but it will take many months to achieve this improvement, and there is a quite significant chance your voice will be no better, and it may possibly be worse.” For the experienced surgeon who uses dissection rather than microavulsion techniques along with preoperative and postoperative videostroboscopy as his or her “teacher,” the question in the general case becomes not so much one of possibly making the voice worse but rather of “Can I make this patient’s speaking and singing capabilities normal, and if not, how close can I come?” Cornut and Bouchayer’s24 experience of operating on 101 singers and Bastian’s25 experience in the same population established a role for laryngeal microsurgery in restoring vocal capabilities and in abolishing or diminishing limitations. More recently, in a series of 47 patients with various benign mucosal lesions, van Dinther and colleagues26 concluded, “Voice quality and voice handicap improve significantly after vocal fold surgery.” SPECIFIC BENIGN VOCAL FOLD MUCOSAL DISORDERS Vocal Nodules The term nodules should be reserved for lesions of proven chronicity. Recent or acute mucosal swellings, which disappear quickly in response to simple voice rest and perhaps supportive medical management, are thus excluded when one is referring to nodules. Epidemiology Vocal nodules occur most commonly in boys and women. Such persons are almost always vocal overdoers (i.e., rating 6 or 7 on the 7-point talkativeness scale). Intrinsic talkativeness correlates more consistently than occupation unless the occupation is extraordinarily demanding vocally (e.g., rock singer, stock trader). Comparatively, nodules frequently develop in children with cleft palates, presumably from their use of glottal stops to compensate for velopharyngeal incompetence. Pathophysiology and Pathology Only the anterior two-thirds (membranous portion) of the vocal folds participates in vibration because the arytenoid cartilages lie within the posterior third of the glottic aperture. Vibration that is too forceful or prolonged causes localized vascular congestion with edema at the midportion of the membranous (vibratory) portion of the vocal folds, where shearing and collisional forces are greatest. Fluid accumulation in the submucosa from acute abuse or overuse results in submucosal swelling, sometimes unwisely called incipient or early nodules. Long-term voice abuse leads to some hyalinization of Reinke’s potential space of and, in a subset of cases, to some thickening of the overlying epithelium. This pathophysiologic sequence explains the easily reversible nature of most acute, nonhemorrhagic swellings in contrast to the slower, incomplete, or failed resolution of chronic vocal nodules. Whether acute edema or more chronic nodules are present, it is the change in mucosal mass, lessened ability to thin the free margin, and incomplete glottic closure caused by the nodules that together account for a constellation of vocal symptoms and limitations characteristic of mucosal swelling.11,25 Diagnosis History. A pediatric patient with vocal nodules is usually described by the parent as “vocally exuberant.” An adult patient, virtually always a woman who rates herself as a 6 or 7 on the talkativeness scale (discussed earlier), describes experiencing chronic hoarseness or repeated episodes of acute hoarseness. Sometimes the initial onset is associated with an upper respiratory infection or acute laryngitis, after which the hoarseness never clears completely, leading the patient to incorrectly attribute the voice problem to the infection and to neglect more relevant ongoing behavioral causes. Singers with chronic nodules are usually relatively unaware of speaking-voice limitations unless the nodules are at least Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders moderate in size. More sensitive symptoms of vocal nodules, including very small ones, are as follows: Loss of the ability to sing high notes softly Delayed phonatory onset, particularly with high, soft singing Increased breathiness (air escape), roughness, and harshness Reduced vocal endurance (“my voice gets husky easily”) A sensation of increased effort for singing A need for longer warm-ups Day-to-day variability of vocal capabilities that is greater than expected for the singer’s level of vocal training Vocal Capability Battery. In patients with moderate to large vocal nodules, the speaking voice is usually lower than expected and may be husky, breathy, or harsh. Patients with subtle to moderate swellings often have speaking voices that sound normal, so the speaking voice is an insensitive indicator of mucosal disorders in comparison with the singing voice. In patients with subtle or small swellings (usually only singers come to medical attention with small mucosal disturbances), vocal limitations such as delayed phonatory onset with preceding momentary air escape, diplophonia, and inability to sing softly at high frequencies may become evident only when high-frequency, low-intensity vocal tasks for detecting swelling are elicited.12 At high frequencies, short-segment vibration may occur; in other words, the nodules stop vibrating, and the short segments of mucosa anterior or posterior to them, or both, vibrate. Many patients with nodules may have undergone indirect laryngoscopy and may have been told that their vocal folds were normal, or they have been given a nonspecific diagnosis such as “laryngeal irritation.” Use of vocal tasks that detect swellings and videostroboscopy when indicated (see Figs. 60.3–60.5) protect the laryngologist from missing the most subtle vocal fold swellings. The ability to diagnose tiny nodules is crucial, because failure to make such a diagnosis can have serious consequences for the professional voice user. Laryngeal Examination. Nodules can vary in size, contour, symmetry, and color, depending on how long they have been A B 875 present, the amount of recent voice use, and interindividual differences in mucosal response to voice abuse. Also, some variability exists in the correlation between size of nodules and their effect on vocal capabilities. Nodules do not occur unilaterally, although one may be larger than the other. It is important to distinguish between nodules and cysts, because management of these entities differs. The correlation between nodule appearance and reversibility with voice therapy is imperfect. The larynx should be examined at high frequency (500 to 1000 Hz) to visualize subtle to small swellings, which can be poorly appreciated at lower frequencies. Management Medical. Good laryngeal lubrication should be ensured through general hydration. Allergy and reflux, when present, should also be treated. Behavioral. Vocal nodules arise from the vocal overdoer profile, so initially speech (voice) therapy plays a primary role. Typically, the nodules and their more obvious symptoms regress, particularly if the patient is not a singer. However, the most skilled behavioral (voice) therapy sometimes fails to achieve complete visual resolution of nodules that have been present for many months to years. Sensitive singing tasks that detect impairment, and not the size of persistent swellings, are generally more helpful in the decision as to whether to consider surgical removal of the nodules.11,25 Surgical. Surgical removal becomes an option when nodules of any size persist and when the voice remains unacceptably impaired from the patient’s perspective after an adequate trial of therapy, generally a minimum of 3 months. Some writers prefer precise removal using microexcision techniques (Fig. 60.8); regardless, vocal fold stripping has no place in the surgery of nodules. The proper duration of voice rest is controversial, and some writers prefer a relatively short period. In the author’s practice, the patient is asked not to speak for 4 days, although sighing sounds begin 1 day after surgery. Beginning on the fourth day, the patient gradually progresses over 4 weeks to full voice use under a speech pathologist’s supervision. Early return to nonstressful voice use, as C Fig. 60.8 The operative sequence in a professional actress specializing in musical theater who, for more than 2 years, had been experiencing vocal symptoms and limitations compatible with fusiform vocal nodules. (A) The operative view after many months of conservative management. Not all fusiform swellings are reversible with conservative measures alone. (B) A polypoid nodule is grasped superficially and tented medially with Bouchayer forceps. Scissors that curve away from the vocal fold are used for removal. The nodule is thus removed in a very superficial plane, which minimizes the risk of scar between the remaining and regenerated mucosa and the underlying vocal ligament. (C) Vocal fold appearance after excision. The patient experienced dramatic normalization of her vocal capabilities, and no evidence of scarring was found on postoperative stroboscopic examination. The dilated capillaries may predispose to recurrent nodule formation and can be spot-coagulated with a microspot laser. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 60 876 PART V Laryngology and Bronchoesophagology TABLE 60.1 General Guidelines for Initial Voice Use After Vocal Fold Microsurgery Time After Surgerya Talking Scoreb Singing (for Singers) Days 1–4 Week 2 (begins day 5) Week 3 Week 4 Week 5 Weeks 6–8 None 3 4 5 4 or 5 4 or 5 Gentle attempts at yawn or sigh for approximately 30 s 6–8 times dailyc Singing-voice warmup exercises for 5 min twice daily (after first postoperative exam) Same exercises for 10 min twice dailyd Same exercises for 15 min twice dailyd (after second postoperative exam) Same exercises for 20 min twice dailyd Same exercises for up to 20 min three times dailye a After the fourth examination, return to performance should be considered. Based on a 7-point talkativeness scale, in which 1 is very untalkative, 4 is average, and 7 is extremely talkative. c Accept what comes out, even if it is only air or is very hoarse. d With emphasis on ease, clarity, and agility, not voice building. The entire expected range should be practiced in each session with gentle insistence on high notes, which are difficult to elicit. In general, practice mostly a mezzo piano dynamic and only occasionally mezzo forte. e Same as the preceding footnote, with the addition of gradually increasing the dynamic range and insistence. b A B C Fig. 60.9 (A) The abducted breathing position with standard light. This is called a “capillary lake.” (B) Prephonatory instant with standard light in the same patient shows a slight projection from the free margin. (C) After surgical ablation, the condition resolved, the voice normalized, and mucosal oscillation was preserved to the highest vocal range. described in Table 60.1, seems to promote dynamic healing. The results of precision surgery are typically remarkably good, even in singers. In their study of approximately 160 singers treated with surgery, Cornut and Bouchayer24 stated, “As long as certain management principles are followed in a majority of cases, laryngeal microsurgery enables the singing voice to regain the whole of its functioning.” Capillary Ectasia Epidemiology Capillary ectasia seems to happen most often in vocal overdoers (Figs. 60.9 and 60.10). Because of the female preponderance of this disorder, some writers have speculated about an estrogen effect. Pathophysiology and Pathology Repeated vibratory microtrauma can lead to capillary angiogenesis. In a circular fashion, abnormally dilated capillaries seem to increase the mucosa’s vulnerability to further vibratory trauma. When present with capillary ectasia, mucosal swelling appears to be larger on the side with greater ectasia. It seems that capillary ectasia predisposes to one or more of the following: increased vulnerability to mucosal swelling (reduced vocal endurance), a small incidence of vocal fold hemorrhage, and hemorrhagic polyp formation. Diagnosis History. Capillary ectasia is diagnosed most often in female singers who complain that they become a little hoarse after relatively Fig. 60.10 Ectatic capillaries need not be ablated in their entirety. Instead, flow is stopped with spot coagulations (arrows) along the course of the capillary. Within 3 weeks, capillary “segments” disappeared. short periods of singing (reduced vocal/mucosal endurance). When this complaint is associated with mucosal swelling, additional symptoms reminiscent of nodules—delayed phonatory onset; loss of high, soft singing; increased effort—may also be noted. The occasional singer with capillary ectasia may have experienced one or more episodes of acute vocal fold hemorrhage, which may have precipitated the patient’s first visit; capillary ectasia may be discerned only after the bruising has resolved. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders 877 Vocal Capability Battery. Without mucosal swelling, the voice capabilities in a patient with capillary ectasia may be entirely normal. With swelling, vocal limitations may be similar to those detected in the patient with nodules. If mucosal hemorrhage is recent, the speaking voice and the singing voice may be very hoarse. 60 Laryngeal Examination. Capillary ectasia may manifest as abnormal dilation of the long arcades of capillaries that proceed mostly from anterior to posterior (see Figs. 60.9 and 60.10). However, aberrant clusters of dilated capillaries may also be seen. Occasionally, a vascular dot may appear when a loop comes from within Reinke’s space to the surface and doubles back down into the submucosa. Finally, some dilated capillaries are confluent or become large enough to almost resemble a chronic hemorrhage; this variant can be termed a capillary lake. Management Medical. The use of drugs that have anticoagulant effects, such as aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs), should cease if medically appropriate. These drugs do not appear to increase the incidence of hemorrhage but may increase the severity of bruising when it does occur. In addition, acid reflux may have an amplified effect on the mucosa when capillary ectasia is visible; thus management of reflux is particularly important. Behavioral. Many persons with capillary ectasia are vocal overdoers; therefore the behavioral changes appropriate for individuals with nodules are advocated. In particular, patients are warned about sudden explosive use of the voice. The duration of voice use per practice session should also be reduced (e.g., three 20-minute sessions per day vs a single 1-hour session). Surgical. If the patient cannot accept residual vocal symptoms and limitations (e.g., decreased vocal endurance) after medical and behavioral management, laryngeal microsurgery is an excellent option.25,27 Dilated capillaries are spot-coagulated to interrupt blood flow every few millimeters (see Fig. 60.10), and capillaries proximal to each interrupted segment may subsequently dilate. Even so, not all visible dilations should be ablated; those that remain visible at the end of the procedure, and even at the first postoperative visit, routinely involute within a few weeks. If the mucosal edema accompanying ectatic capillaries is minimal, management of the capillaries alone often leads to resolution of the edema. Vocal Fold Hemorrhage and a Unilateral (Hemorrhagic) Vocal Fold Polyp Epidemiology The occurrence of vocal fold hemorrhage (Fig. 60.11) and unilateral hemorrhagic vocal fold polyp is more common in men, particularly those who engage in intermittent severe voice abuse or who work in noisy environments. Surprisingly few patients have a history of using aspirin or other anticoagulants. Pathophysiology and Pathology Shearing forces that act on capillaries within the mucosa during extreme vocal exertion lead to capillary rupture. Capillary ectasia seems to predispose to this sort of injury. Breakage of superficial capillaries may lead to a thin, widely suffused, superficial bruise without vocal fold margin convexity. Within a few days, this type of hemorrhage may often have little effect on mucosal oscillation. Resolution of the bruise may be complete within 2 weeks. By contrast, extravasation of blood from a deeper capillary may lead Fig. 60.11 Hemorrhagic polyp, right fold. Note the blood-blister appearance. Recent further bleeding is evident from the yellowish discoloration of the upper surface of the fold because of breakdown products of a bruise, estimated to have occurred 2 weeks earlier. Hemorrhagic polyps sometimes rebruise intermittently. to focal accumulation of blood, similar to a blood blister. This type of hemorrhage alters the margin contour and stiffens the mucosa, as seen stroboscopically. It causes significantly more and longer-lasting hoarseness and may be the precursor of a hemorrhagic polyp. In this case, microscopic examination would reveal a relatively rich vascular stroma and areas of hyalinization, although a unilateral, nonhemorrhagic, often pedunculated polyp may also be seen as the end stage of a hemorrhagic polyp. Diagnosis History. The history of abrupt onset of hoarseness during extreme vocal effort, such as at a party or sporting event or even after a loud sneeze, is classic but not universal in patients with vocal fold hemorrhage and a unilateral hemorrhagic vocal fold polyp. Vocal Capability Battery. Vocal capabilities vary according to the size, age, turgidity, and pedunculation of the polyp. Some patients have a normal-sounding speaking voice except for intermittent and subtle aberrant sounds. Other patients have a normal speaking voice but an impaired or nonexistent falsetto register. Some patients also manifest chronic vocal huskiness. Laryngeal Examination. Laryngeal examination demonstrates a largely unilateral lesion in the node position, a contact reaction— or a nodule, if the person is a vocal overdoer—on the fold opposite the polyp. In the case of the chronic vocal overdoer, a hemorrhagic polyp may represent an acute injury superimposed on chronic nodules. The hemorrhagic polyp is usually much larger than the typical nodule and may appear dark and filled with blood in the early stages. Depending on when the submucosal bleeding occurred, discoloration may be in any stage of bruise evolution. Long-standing hemorrhagic polyps may lose their vascular appearance and may become pedunculated, moving in and out of the glottis with inspiration and expiration, respectively. During phonation, this end-stage polyp may be displaced upward onto the fold’s superior surface, interfering little with basic phonation. Treatment Medical. If possible, the intake of anticoagulant medications (NSAIDs and warfarin) should be stopped. Because acid reflux Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 878 PART V Laryngology and Bronchoesophagology A B C D Fig. 60.12 (A) Hemorrhagic polyp, right vocal fold. (B) Polyp is grasped with right-turning heart-shaped forceps to reveal pedunculation and flexibility of the mucosa. (C) At the moment of excision with a left-turning scissors. (D) Tiny residual wound. This patient’s voice was entirely normalized, including the upper voice. can increase hyperemia and dilate normal and abnormal capillaries, this condition should be controlled. Behavioral. A short course of voice therapy is appropriate, mainly to instruct the patient in voice care. The occasional small, early hemorrhagic polyp resorbs completely with many months of conservative measures, but typically surgical removal is required to return the vocal fold to its normal appearance and vibratory function and to return the voice to normal capabilities. Surgical. Evacuation of blood through a tiny incision in a recent large hemorrhage that looks like a blood blister may be appropriate because, in the best case, a long wait for resorption and (more likely) progression to a chronic hemorrhagic polyp would be expected. After microsurgical evacuation of the hematoma, care should be taken to detect the large capillaries within Reinke’s space because these also should be interrupted, although a slightly deeper coagulation may be required to reach the level of the capillary. A long-standing polyp, whether hemorrhagic or at end stage and pale, should be trimmed away superficially at the time the spot coagulations take place. Prognosis for full return of vocal functioning after precision surgery is excellent (Figs. 60.12 and 60.13; Video 60.1). Intracordal Cysts Epidemiology The most prominent epidemiologic finding is a history of vocal overuse. This is routine for the epidermal cyst but less so for the mucous retention variety. Pathophysiology and Pathology Histologically, intracordal cysts are classified as either mucous retention or epidermal inclusion types (Figs. 60.14–60.17). Mucous retention cysts (ductal cysts, see Figs. 60.15 and 60.17) arise when the duct of a mucous gland becomes plugged and retains glandular secretions; epidermal cysts (see Figs. 60.14 and 60.16) contain accumulated keratin.28–31 Two theories state that the epidermal cyst results from a nest of epithelial cells buried congenitally in the subepithelial layer or from healing of mucosa injured by voice abuse over buried epithelial cells. In time, cysts may rupture spontaneously. If the resulting opening is small in relation to the overall size of the cyst, some epidermal debris may be retained and may create an open cyst (see Fig. 60.16); if the opening is as large as the cyst, the resulting empty pocket becomes a glottic sulcus (Figs. 60.18 and 60.19). Diagnosis History. A patient with epidermal cysts has many of the same symptoms and voice abuse factors as a patient with nodules. However, mucous retention cysts can arise seemingly spontaneously, without relation to the amount or manner of voice use. Vocal Capability Battery. The vocal capability battery uncovers vocal limitations similar to those for a patient with vocal nodules. Patients with epidermal cysts are more likely to experience diplophonia in the upper vocal range, and they may manifest an abrupt and irreducible transition to severe impairment at a relatively specific frequency rather than a more gradual transition to greater degrees of impairment, as is often noted in patients with nodules. Mucous retention cysts often cause less vocal limitation than might be anticipated from the laryngeal appearance; epidermal inclusion cysts often cause more limitation than expected. Laryngeal Examination. Mucous retention cysts often originate just below the free margin of the fold with significant medial projection from the fold. For this reason, such cysts are sometimes misdiagnosed as nodules or polyps. Epidermal cysts project less from the fold and are harder to diagnose when small. An Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders 879 60 A B C D Fig. 60.13 (A) Hemorrhagic polyp, left fold, with broad attachment and “shoulders” rather than a stalk-like attachment. (B) Beginning of excision, starting with broad-based anterior and posterior shoulder elements. (C) Laser dissection directed to the thrombosed contents of the polyp and sparing much of the stretched overlying mucosa. (D) Resultant linear wound after removal. Because of the remaining layers of Reinke’s space (superficial lamina propria), adherence to the vocal ligament does not occur and vibratory ability is normalized, including at high pitch. A B Fig. 60.14 (A) Epidermal cyst, right vocal fold. Note the white submucosal mass predominantly on the upper surface of the fold but with bilateral free margin elevation as well. (B) After submucosal dissection and removal of cyst. In some similar cases, free margin swelling remains because the margin cannot be straightened (i.e., redundant mucosa that had been stretched over the cyst cannot be removed) at the same time as cyst removal through an upper vocal fold surface incision. In this case, the margin was straight. Vocal fold oscillatory ability improved markedly but was not normal at very high pitches. The voice was highly improved overall. inexperienced clinician may be more aware of what appear to be nodules than the faint cyst outline on the superior surface of the fold. In an open cyst, the sphere may be less discrete and may have a more mottled appearance on the superior surface of the vocal fold (see Fig. 60.16). Under strobe illumination, as the fundamental frequency of phonation increases, the mucosa overlying the cyst often stops vibrating before the mucosa anterior and posterior to the cyst. Even so, diagnosis can be confirmed in some patients only at the time of microlaryngoscopy. Treatment Medical. General supportive measures, such as hydration and potential acid reflux management, may be helpful but will not resolve this problem. Behavioral. Voice therapy is more appropriate for people with epidermal cysts and, beyond teaching in preparation for surgery in those with cysts of the mucous retention variety, often is not Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 880 PART V Laryngology and Bronchoesophagology Fig. 60.15 Mucous retention cyst after laser excision of early vocal fold cancer, left vocal fold. Note capillary reorientation, which is typical after full-thickness mucosal excision. The small projecting lesion could be mistaken for a polyp. Instead, it is the result of plugging of a tiny mucous gland just below the free margin of the vocal folds during mucosal regeneration. A polyp is not consistent with this man’s very quiet nature and minimal vocal commitments. Note that the lesion is below the point of maximum contact and vibratory injury that would produce a polyp. This man’s voice is excellent. Fig. 60.16 Bilateral open cysts. Because the openings are small in relation to the size of the cysts, partial emptying of the keratin contents causes a mottled appearance. C B A Fig. 60.17 (A) Mucous retention cyst of right vocal fold. Yellowish spherical mass shines through overlying mucosa and was causing the patient severe hoarseness. Incision to enter the fold is made on the dotted line. (B) Near completion of dissection of the cyst from its final attachments using curved scissors. (C) After cyst removal. The patient’s voice sounded virtually normal in the recovery room, although the upper voice was still abnormal. A B Fig. 60.18 (A) Glottic sulci, normal light; there is retained material and granulation emerging from within the sulcus on the right. A partial ring of capillaries is seen around the sulcus on the right (arrows), but no significant vessels are found within the sulcus. (B) Same patient after surgery on the right fold. Note the microvasculature where it was not present before surgery, especially at the arrow. A continuous layer of mucosa is now evident. The voice was much improved but was still not normal because of the unavoidable disturbance required by the dissection and the residual stiffness. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders 881 60 A B C D Fig. 60.19 Glottic sulcus. (A) At the beginning of surgery, the fold is infiltrated with lidocaine/epinephrine to provide hydrodissection and expand the mucosa. The line of the sulcus is seen proceeding anteriorly from the point of needle entry. (B) An elliptic incision has been made around the lips of the sulcus. (C) Right-curved alligator clip tents the medial mucosal flap. Arrows indicate the fine line representing the opening into the sulcus. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament. (D) After the sulcus pocket has been removed, gossamer mucosa is tented medially to show remaining flexibility. The voice is expected to be improved, but normal upper voice capabilities are only sometimes achieved. needed. The reason is that those with epidermal inclusion cysts are by far the more likely of the two to be vocal overdoers. Of course, speech (voice) therapy may also be warranted for those who have mucous retention cysts if the person is a vocal overdoer— not to resolve the lesion, which requires surgery, but to avoid the risk of another, this time vibration-induced, lesion. Surgery. Patients with large mucous retention cysts and no history of voice abuse may be scheduled for surgery promptly. If it is under the edge of the vocal fold and extremely superficial and translucent, resembling a polyp, the cyst may be removed in its entirety with a small slip of overlying mucosa, particularly when its wall is so thin as to make its dissection from the overlying mucosa virtually impossible. In this case, mucosal oscillation will still be normal after healing is complete. More typical mucous retention cysts are removed, as described in the following paragraph, via dissection that leaves the overlying mucosa intact. A small, extremely shallow incision is made on the fold’s superior surface. Careful dissection reveals that the swelling is indeed caused by a cyst. Taking care to avoid any injury to the mucosa other than that of the incision, the surgeon dissects the cyst free of the mucosa and vocal ligament (see Fig. 60.17). The opposite fold should be examined carefully because of the possibility of a more subtle cyst or sulcus. Results are not as uniformly good as for nodules and polyps. Considerable improvement is expected, however, and some patients achieve excellent results (Videos 60.2 and 60.3). Patients should also know that maximal postoperative recovery takes longer than for nodule or polyp surgery (many months rather than a few weeks). Bouchayer and colleagues30 reported a series of 148 patients managed for cysts, sulci, or mucosal bridges—very difficult surgical problems compared with nodules and polyps—of whom 10% had an overall excellent result, 42% had a good result, 41% had a fair result, and 5% had a poor result. Follow-up supportive voice therapy from the speech pathologist or singing teacher assists vocal rehabilitation. A return to active voice use or training should occur within a few days of surgery, because the amount of mucosal disturbance required leads to a greater tendency to mucosal adherence and stiffness. Glottic Sulcus Epidemiology Although some writers believe sulci to be congenital, glottic sulcus appears to occur exclusively in vocal overdoers (see Figs. 60.18 and 60.19). Pathophysiology and Pathology Bouchayer and colleagues30 reviewed acquired and congenital theories for these conditions. They described the appearance of the sulcus as an epithelium-lined pocket whose lips parallel the free edge of the folds and suggested that a sulcus may represent an epidermal cyst that has emptied spontaneously, leaving the collapsed pocket behind to form a sulcus. In effect, a mucosal bridge is the result of two parallel sulci that arise from a single cyst (Fig. 60.20). The chief problem caused by a sulcus is the same as that caused by scarring: stiffening of the mucosa, which inhibits oscillation and leads to dysphonia.32 Diagnosis History. The patient with a glottic sulcus often has a history of voice overuse and complains of chronic hoarseness. Vocal Capability Battery. Typically the voice is noticeably hoarse. Upper voice limitations, particularly diplophonia, are obvious. As is the case for cysts, the transition between hoarse phonation and aphonia may occur abruptly, almost at a specific frequency, generally in the middle of the singing range. Laryngeal Examination. Laryngeal examination may initially reveal fewer findings than expected to account for the abnormal speaking voice or reduced singing voice capabilities. Because the patient is likely a vocal overdoer, associated fusiform vocal fold margin swellings might also be seen. Stroboscopic evaluation shows a segment of reduced vibration. The entire length of the mucosa may oscillate at lower frequencies; at higher frequencies, the Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 882 PART V Laryngology and Bronchoesophagology Needle to balloon Reinke’s space (hydrodissection) Mucosa Vocal ligament A Muscle B Fig. 60.20 Mucosal bridge of the left mucosal fold. If an epidermal cyst opens in two places and parallels the margin of the vocal fold, the mucosa between the openings becomes a bridge. In this case, the forceps enters the upper (lateral) opening and exits the lower (medial) opening. midportion of the mucosa stops oscillating and short-segment vibration of anterior and posterior segments begins to occur. Microlaryngoscopy is often required for definitive diagnosis because the lips of the sulcus are not always visible with inspiratory phonation during the office or voice laboratory examination. Management Medical. Medical management for glottic sulcus is supportive as appropriate, but it is not expected to resolve this structural abnormality. Behavioral. A short preoperative course of voice therapy is indicated if the patient with a glottal sulcus is a confirmed vocal overdoer because the behavioral goal for patients with cysts initially is selection and preparation for surgery. Restoration of the mucosa to normal cannot be achieved by medical or behavioral treatment. Surgical. Sulcus removal is technically demanding, involving considerable surgical disturbance of the vocal fold mucosa in comparison with surgery for nodules. Bouchayer and colleagues30 described the steps for removal of a glottic sulcus (Fig. 60.21), including cordal injection to make the sulcus lips spread, make the sulcus shallower, and accomplish some hydrodissection. This step is followed by circumcision of the lips of the sulcus and by dissection of the invaginated mucosal pocket from the underlying fold without injuring the vocal ligament. Results seem to depend not only on excellent surgical skill but also on the thickness of the mucosa. A thick, almost polypoid mucosa may sometimes yield a normal voice. In the patient in whom the mucosa is very thin and more widely adherent to the ligament, the voice is typically better than before surgery, but residual mucosal stiffness may occur even after optimal surgery. Bilateral Diffuse Polyposis Epidemiology Voice change caused by bilateral diffuse polyposis (chronic Reinke edema or smoker’s polyps; Figs. 60.22 and 60.23) typically becomes noticeable enough to prompt a laryngeal examination in middleaged talkative women who have been long-term smokers. C D Fig. 60.21 Schematic of the removal of a glottic sulcus. (A) Vocal fold coronal section shows the sulcus. (B) Injection of 1% lidocaine with epinephrine into Reinke’s space spreads the lips of the sulcus. (C) Incisions at the sulcus lips and dissection off the vocal ligament. (D) After removal of the sulcus. Pathophysiology and Pathology There seems to be an individual susceptibility to this condition, because it develops in only a small percentage of those at risk (e.g., smokers who use their voices a lot). As detailed by several writers, chronic smoking and voice abuse result in edema, vascular congestion, and venous stasis.33,34 These conditions cause diffuse polypoid changes that become permanent, although the degree of edema or turgidity and consequent voice disturbance may rise and fall with voice use. Diagnosis History. The combination of smoking and avid voice use is classic for this entity. A woman with smoker’s polyps may complain of being called “sir” on the phone, or she may have problems with increasing hoarseness during the day. Vocal Capability Battery. The voice examination demonstrates lower pitch than would be expected, often well into the masculine range when the condition is seen in women. Upper voice is lost, and the female patient can often phonate through the range of a true bass singer! With large polyps, the voice may even be hypermasculine. Laryngeal Examination. Laryngeal examination usually reveals pale, watery bags of fluid attached to the superior surface and margins of the folds. Large smoker’s polyps may cause an involuntary laryngeal snore on sudden inhalation. A to-and-fro motion is often seen with respiration. In severe cases, clusters of polyps on polyps may be seen. Small smoker’s polyps are easily overlooked unless the patient is instructed to phonate on inspiration, when the polypoid tissue is drawn from the superior surface of the folds Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders 883 60 A B Fig. 60.22 Bilateral diffuse polyposis. (A) Quiet breathing under standard light. (B) Elicited inspiratory phonation (same patient) draws in and, hence, reveals the edematous mucosa, which is greater on the right than on the left. Dashed lines indicate the location and contour of the free margin had these vocal folds been normal. A Fig. 60.23 Smoker’s polyp; operative sequence. (A) Voice laboratory view of smoker’s polyps; the right fold is much more pronounced than the left. (B) During the first thulium laser coagulation. Note the attempt to pull the redundant tissue medially from the underlying vocal ligament. (C) Six weeks postsurgery, during the second thulium laser treatment. (D) Twelve weeks postsurgery. Early postlaser inflammatory reaction is still evident, but the voice is dramatically improved. (E) Strobe light and chest phonation, closed phase. (F) Open phase as the patient finishes phonation and begins to separate the folds. Note slight edema in Reinke’s space (translucence) of the left (unoperated) fold. The right fold oscillated well at low frequency and less well at high frequency in this early postoperative examination. C E B D F Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 884 PART V Laryngology and Bronchoesophagology A B Fig. 60.24 Iatrogenic mucosal scarring. This patient underwent bilateral vocal fold stripping elsewhere for persistent dysphonia, which was subsequently diagnosed as spasmodic dysphonia. The patient was reportedly aphonic for many weeks postoperatively. (A) This operative photograph was taken 4.5 months after the original surgery. Granulomas are highly pedunculated and may have eventually detached or regressed spontaneously. Note the medial-to-lateral reorientation of vocal fold capillaries, a common finding after vocal fold stripping. (B) The same patient after granuloma removal. Attachment points of the granulomas are marked at arrows. In this view, the vocal folds are rolled superiorly and considerable scarring is evident, particularly on the right vocal fold. into the glottic aperture and is thereby made more visible as a greater-than-normal convexity of the margin (see Fig. 60.22B). The examiner knows to elicit inspiratory phonation and look for this type of lesion when the vocal capability battery reveals virilization of the singing range. Line of adherence at site of prior polypectomy Incision and plane of mucosal flap creation Microadhesions of mucosa down to vocal ligament Management Medical. The patient with bilateral diffuse polyposis is encouraged to give up smoking. Thyroid function tests can be performed if hypothyroidism is suspected. The latter entity has often been implicated as causal in this condition, although diffuse polyposis is extremely rare in the absence of smoking and avid voice use. Behavioral. Short-term voice therapy may be appropriate to introduce optimal vocal behavior. These measures alone may reduce the polyps’ turgidity, with a corresponding modest improvement in vocal functioning. Surgical. Microsurgery for polyp reduction is necessary when the voice remains objectionable to the patient. The older, common practice of stripping the polyps away often results in aphonia for many weeks postoperatively, and the final voice achieved may sound unacceptably high and husky to the patient. Polyp reduction with mucosal sparing (see Fig. 60.23) is recommended for an earlier and optimal return of voice, usually beginning within 10 days. It is better to leave the patient with a voice that still sounds rich, even with some residual polyposis and mild vocal virilization, than to strip the folds and leave the patient with a voice that sounds thin, insubstantial, and effortful. Postoperative Dysphonia A B Fig. 60.25 Schematic of mucosal adhesion to underlying vocal ligament and one surgical option. (A) The operative view shows a longitudinal scar. (B) Cross-sectional view shows the surgical approach to release microadhesion of mucosa from the vocal ligament. Such a patient may have only a modest effect on vocal capability but a more noticeable relief from aberrations such as diplophonia. on.35,36 The prior surgeon may have performed vocal fold stripping or laser vaporization of the mucosa. The pathology report from that operation frequently describes a fairly large specimen that may have contained fibrous tissue or even muscle, which suggests that the removal went deeply into the vocal fold. Epidemiology Pathophysiology and Pathology Vocal fold surgery performed without extreme precision can lead to permanent postoperative dysphonia (Figs. 60.24 and 60.25) that can be worse than the hoarseness from the lesion that was operated Dysphonia can result from a scarred, stiff vocal fold cover, phonatory mismatch of the vocal fold margins, or both. Scarring adheres mucosa to the underlying vocal ligament, which abolishes the Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders ability of mucosa to oscillate with any freedom from the underlying vocal ligament. Mismatch may arise from a divot caused by overzealous removal or from pseudobowing, such as that resulting from the failure to spare enough mucosa during smoker’s polyp reduction. With few exceptions, postoperative dysphonia can be avoided by the use of an appropriately precise surgical technique and by early graduated resumption of voice use after surgery (see Table 60.1). Diagnosis History. A history of prior surgery is common to all cases, but a clear understanding of the original lesion should be sought in addition to any history that indicates continuing vocal abuse, which might have led to recurrent mucosal injury rather than scarring. Vocal Capability Battery. The voice may vary from aphonia to a harsh whisper to a relatively normal speaking voice, but it is accompanied by disastrous limitation of the upper singing voice with diplophonia and loss of the expected upper range. Laryngeal Examination. Laryngeal videostroboscopy is essential for patients with possible postoperative dysphonia. This technique enables careful analysis of mass lesions, areas of asymmetry, and the mucosa’s vibratory pattern, from which a clear diagnosis and therapeutic plan can be generated. Management Medical. General medical issues that relate to the voice should be optimized in the course of management. Behavioral. If stiffness, scarring, and tissue loss pose problems, voice therapy is tried first, with a voice-building approach. A person who is resting his or her voice should instead resume talking per routine. In addition, the individual is coached to sing with moderately great vigor for 10 minutes two or three times a day at all vocal frequencies of his or her range. Using the facilitating vowel /oo/ is helpful in cases of severe dysphonia. When only a very narrow frequency range is available because of postoperative scarring, the patient is asked to start phonating at a frequency that works, which is often quite high in the expected vocal range, and to coax the voice lower and higher from this small area of working frequencies. Some remarkable improvements may be seen with this approach. However, even with achievement of a serviceable speaking voice, the voice’s singing capabilities will remain limited in comparison with a normal voice. Proof for this approach is A 885 difficult to procure. However, improvement does not seem to arise only from spontaneous softening of scar tissue, because it can occur with the preceding voice-building strategy in patients more than 1 year after surgery or another scarring event. The rationale for this aggressive, voice-building strategy may require some explanation for patients whose voice abuse caused the problem for which they underwent surgery. A voice-qualified speech pathologist who is comfortable with teaching vigorous voice production throughout the expected range should monitor voice-building exercises initially. Some patients can work independently because of the short duration of exercise sessions, and because the overall idea of the voice-building approach is primarily to enhance vocal skills, not to scream abusively. Rather, the goals are to strengthen the laryngeal musculature to compensate for—to overdrive—the damaged mucosa and to encourage the mucosa to oscillate more freely because of this sort of “phonatory massage” of the mucosa. Surgical. Reoperation is occasionally an option. Ample time (9 to 12 months) should pass before this idea is entertained, however, because the voice may improve, and iatrogenic lesions may diminish slowly for many months after the first operation. A second procedure can be planned to correct the videostroboscopically identified defect in mucosal mass, mobility, or edge configuration. For example, if an iatrogenic mass (granuloma) is causing poor phonatory closure, it should first be allowed to mature and possibly to resolve spontaneously. If it remains after a minimum of 6 months, it can be removed. Injection of collagen into an area of depression has been advocated,37 but this approach does not yield more than very modest results, and even these occur on an inconsistent basis. Incision and simple mucosal elevation across a limited line of adherence with early postoperative phonation may cure diplophonia or lessen dysphonia, occasionally to a surprising extent. It should be stressed, however, that in some instances little can be done beyond voice building, and avoidance of this problem altogether through precision surgery is the ideal. Some authorities have written of fat injection or medialization thyroplasty, but these approaches remain to be systematically validated. They do make some sense theoretically, primarily if a significant gap is present between the folds and the problem is not simply mucosal stiffness. Contact Ulcer or Granuloma Epidemiology Contact granuloma or ulceration is seen primarily in men (Figs. 60.26 and 60.27). Chronic coughing or throat clearing and reflux of acid from the stomach into the posterior larynx during sleep B Fig. 60.26 (A) Contact granuloma, right posterior vocal fold. Note bilobularity and surrounding inflammation (erythema). (B) Same patient as the folds arrive at phonatory contact. The medial surface of the left arytenoid cartilage will fit into the cleft between the two lobes of the contact granuloma. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. 60 886 PART V Laryngology and Bronchoesophagology C B A Fig. 60.27 (A) Large, bilobed contact granuloma, left fold, with significant pedunculation. The patient’s voice is surprisingly unaffected by the pedunculation and the deep cleft between the lobes. (B) This granuloma was allowed to mature and detach spontaneously. Here, a few months later, the inferior lobule has detached, and a single spherical and highly pedunculated granuloma remains. (C) Several months later in the same patient, the remaining granuloma has detached, leaving a characteristic bruise at its base. This mark may remain visible for many months. A B Fig. 60.28 Granulomas after long-term intubation. (A) Evidence of posterior commissure divots from pressure necrosis of the endotracheal tube, along with reparative granulomas. (B) Same patient a few months later. Without any intervention, granulomas have matured, pedunculated, and spontaneously detached, leaving the divots more visible. also seem to cause contact ulceration.38 Some have also suggested that patients with this entity are experiencing psychological stress or conflict. Pathophysiology and Pathology The thin mucosa and perichondrium overlying the cartilaginous glottis become inflamed, perhaps as a result of overly forceful apposition (slamming together) of the arytenoids at the onset of voicing (glottal stroke) or during chronic coughing or throat clearing. Acid reflux may also increase inflammation of the vocal process area; the traumatized area ulcerates or produces a heaped-up granuloma. Diagnosis History. Behavioral patterns should be elicited, including caffeine and alcohol consumption and late-night eating, along with more specific acid reflux symptoms (e.g., acid eructations; raw throat in the morning with sour taste; unusually low-pitched, gravelly morning voice; heartburn). Frequent symptoms include unilateral discomfort over the midthyroid cartilage, occasionally with referred pain to the ipsilateral ear. When contact granulation tissue becomes large, hoarseness can occur. Vocal Capability Battery. The speaking voice of a patient with a contact ulcer or granuloma may sound normal or only slightly husky. The patient may be noted to be speaking habitually in an overly low frequency range, often with a held-back vocal quality but sometimes with a kind of constrained emphasis. In particular, the voice characteristics of the held-back quality, habitual coughing or throat clearing, and low and monotone voice use are typical. Laryngeal Examination. A depressed, ulcerated area with a whitish exudate clinging to it or a bilobed, heaped-up lesion on the vocal process may be noted. At the instant of glottal closure, the vocal process of the uninvolved side can be seen to fit into the cleft of a bilobed granuloma (see Fig. 60.26B). Erythema is also usually apparent on the vocal process and coming upward on the medial surface of the arytenoid cartilage. A mature, soon-to-detach granuloma may be pedunculated and may flip above (see Fig. 60.27A) and below the plane of the vocal fold margin with expiratory and inspiratory phonation, respectively. Management An antireflux regimen should be started on an empiric basis even for patients with no symptoms of reflux. The necessity of routine barium or pH-monitoring studies remains controversial. Maturation and resolution of the granuloma can often occur spontaneously over 3 to 6 months (Fig. 60.28B; see Fig. 60.27C). Thus the role for voice therapy to abolish throat clearing, raise average pitch for speech, and so forth is indeterminate. Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from ClinicalKey.com by Elsevier on July 10, 2020. For personal use only. No other uses without permission. Copyright ©2020. Elsevier Inc. All rights reserved. CHAPTER 60 Benign Vocal Fold Mucosal Disorders Indirect injection of a depot corticosteroid directly into the lesion and the area around its base can be accomplished in a videoendoscopy procedure room with the patient sitting in a chair.13 Visible lesions tend to diminish in size, and the symptoms disappear. Inhaled triamcinolone or mometasone has also been used for treatment and avoids systemic side effects. Patients are assessed at 6- to 8-week intervals, and treatment is continued if there is a reduction in size and improvement in symptoms. Surgery should be a last resort, not only because of the expectation of maturation and spontaneous detachment but also because postoperative recurrence of the ulcer or granuloma is predictable. Furthermore, when the lesion has a classic appearance and can be visually monitored, there is little need for tissue diagnosis: visual criteria are sufficient. Microlaryngoscopy may be justified, however, if after a several-month trial of management, an uninflamed, pedunculated lesion remains and is causing symptoms. Removal should be limited, and it should leave the base or pedicle undisturbed. Intubation Granuloma Epidemiology 887 commonness. For optimal results, diagnosis should include a skillful history, vocal capability elicitation, and laryngeal videostroboscopy. Whether medical management, voice therapy, surgery, or some combination is used to treat the patient, the intervention should match the diagnosis. SACCULAR DISORDERS At its anterior end, the normal laryngeal ventricle has a small outpouching called the saccule or laryngeal appendix. This structure is a blind sac that extends upward between the false vocal fold and thyroid cartilage, just posterolateral to the edge of the epiglottis at the level of the petiole. The saccule contains many mucous glands and empties through an orifice in the anterior part of the ventricle. In a study of 100 random cadaver larynges, Broyles39 found significant variation in the size of this normal structure, with 75% measuring 6 to 8 mm in length, 25% measuring 10 mm or greater, and 7% of the 25% measuring 15 mm or more. Although these structures may represent vestigial air sacs, their function is unknown in humans besides perhaps to supply lubrication to the true folds via the many glands that line a saccule. For review of this anatomy, see Fig. 60.29A. Intubation granulomas may occur after brief or prolonged intubation and are more common in females (see Fig. 60.28). Etiology of Saccular Disorders: Laryngocele and Saccular Cysts Pathophysiology and Pathology In infants, saccular disorders appear to be congenital. Otherwise the cause of an air-filled laryngocele may be uncertain for the individual patient. Some writers have cited an increase in transglottic pressure, such as that seen in trumpet players, glass blowers, and people using the voice in unusually forceful ways. Others, such as Stell and Maran,40 believe that the relationship of laryngocele to these activities may have been overstated, because few reported patients with such disorders described in the world literature had hobbies or occupations that required high transglottic pressures. A perhaps more clearly documented although uncommon cause of saccular cysts is laryngeal carcinoma, which causes obstruction of the saccular orifice.41 One of the authors has also seen saccular cysts months or years after successful excision of a large supraglottic carcinoma with the laser that left remnants of the saccule buried. Granuloma after intubation occurs due to mucosal injury and injury to the arytenoid perichondrium. The resulting reparative granuloma may be sessile, resulting in a large pedunculated lesion. Sclerosis of the arytenoid is frequently seen on computed tomography (CT) scan. The granulomas are attached directly to the vocal process and are frequently bilateral. In cases of long-standing intubation, there may be associated findings such as tissue loss with resulting posterior glottic incompetence. In even more severe cases, partial or complete fixation of one or both arytenoid cartilages may be evident. An interarytenoid synechia may also be noted on occasion. Diagnosis History. The history of a patient with intubation granuloma includes a fairly recent event during which the larynx was subjected to direct instrumentation or intubation. Vocal Capability Battery. The speaking voice of a patient with intubation granuloma may not sound abnormal, because the membranous (vibratile) portion of the vocal folds may be unaffected by the granuloma, which may sit above or below the vocal process during phonation. Management An intubation granuloma is best thought of as an exuberant healing response to injury. For recent injuries, assessment of vocal fold motion is imperative. With normal vocal fold motion, a more conservative approach with antireflux therapy and inhaled corticosteroids is warranted. When impairment of vocal fold motion is present, more aggressive management is indicated. In this situation, direct microlaryngoscopy with excision of granuloma and steroid injection should be considered. Voice therapy may have a role on a highly individualized basis. Summary The benign vocal fold mucosal disorders are important because of their impact on identity and communication and their Clinical Scenario Holinger and associates,42 in their review of 46 patients with laryngocele or saccular cyst, found that of the 41 cases that involved a saccular cyst, 10 occurred in infants and children and 31 in adults. Of the 31 adult cases, 22 were anterior and 9 were lateral saccular cysts; in the infants and children, 4 cysts were anterior and 6 were lateral. When a saccular cyst occurs in infancy, it usually appears early, even at birth, in the form of respiratory distress with inspiratory stridor. The infant’s cry is abnormal, and cyanosis and dysphagia can occur. In adults, hoarseness seems to be the most common complaint, although dyspnea, dysphagia, pain, and a neck mass can occur with large or infected lateral saccular cysts (laryngopyoceles).42 Classification Saccular disorders can be classified in various ways (Figs. 60.30–60.33; see Fig. 60.29).42–45 It seems reasonable to think first of the contents of the dilated saccule, as in the following classification: Air filled = laryngocele with patent saccular orifice (see Fig. 60.33) Mucus filled = saccular cyst with blocked orifice (see Figs. 60.29 through 60.32) Purulence filled = laryngopyocele with blocked orifice Downloaded for thanapa quannuy ([email protected]) at Prince of Songkla University from Clinica

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