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 and vibratory physiology to guide surgical precision; (2) vibratory injury are a...

60 Benign Vocal Fold Mucosal Disorders Robert W. Bastian, Melissa L. Wingo KEY POINTS The two most common risks for vocal fold mucosal and vibratory physiology to guide surgical precision; (2) vibratory injury are a high intrinsic tendency to use the proven technical ability of the surgeon; (3) preoperative voice (talkativeness, extroversion) and a high extrinsic and postoperative laryngeal videostroboscopy examination opportunity or necessity to use the voice, driven by to diagnose clearly at the initial presentation and after occupation, family needs, social activities, and avocations. surgery to assess results; and (4) access to voice-qualified Visible vocal fold lesions from overuse may not cause an behavioral (speech pathology) support. audible change in the speaking voice. Capillary ectasia can be an incidental finding that does not Visible vocal fold lesions that cause phonatory mismatch at necessarily require treatment. Surgical intervention may be the free margin or mucosal stiffness are always detectable indicated, on the other hand, when the ectasia causes one audibly in the singing voice provided that the examiner or more of the following: a tendency to decreased vocal knows how to elicit upper-range vocal tasks. endurance (reduced voice use time before huskiness results), intermittent bruising, or a hemorrhagic polyp. Singing-voice symptoms of mucosal injury are loss of the ability to sing softly at high pitches, increased day-to-day Contact ulcers and granulomas are best thought of as variability of singing-voice capabilities, phonatory onset exuberant healing responses to injury, which can be from delays, reduced vocal endurance, and a sense of increased aggressive chronic throat clearing, aggressive coughing, or effort. endotracheal tube injury. Some believe that acid reflux is a contributor. Treatment is generally supportive over many Small or subtle vocal fold lesions may escape visual months during the wait for maturation, pedunculation, and detection unless the larynx is viewed with high spontaneous detachment; surgical removal is nearly always magnification; vocalization in the upper range sometimes followed by recurrence. requires topical anesthesia. Marsupialization of saccular cysts is sometimes followed by With few exceptions, brief initial speech pathology recurrence; therefore, when possible, complete removal of evaluation and treatment are indicated when vocal fold saccular cysts appears to be preferred. Even large ones can injury is clearly due to overuse, misuse, or abuse of the often be removed endoscopically. voice. Speech therapy alone may suffice if the vocal improvement that follows is adequate for the patient’s Recurrent respiratory papillomatosis is caused by the needs; otherwise speech therapy will serve as preparation human papillomavirus. Currently optimal management for vocal fold microsurgery. includes careful serial laser laryngoscopic treatment with consideration of various adjuvant medications. Key requirements for successful vocal fold microsurgery are (1) detailed knowledge of vocal fold microarchitecture Benign vocal fold mucosal disorders—vocal nodules, laryngeal Benign vocal fold mucosal disorders are common. More than polyps, mucosal hemorrhage, intracordal cysts, glottic sulci, and 50% of patients who seek medical attention because of a voice mucosal bridges—seem to be caused primarily by vibratory injury change have a benign mucosal disorder. Even before the laryngeal from an excessive amount or aggressive manner of voice use. videostroboscopy era, when subtle and small lesions may have Review of thousands of patients reveals that an expressive, talkative been missed, Brodnitz1 reported that 45% of 977 patients had a personality correlates best with most of these disorders. Occupa- diagnosis of nodules, polyps, or polypoid thickening. From the tional and lifestyle vocal demands appear to be additional but same era (1964–1975), Kleinsasser2 reported that slightly more lesser risks unless these demands are extreme. Occasionally, injury than 50% of 2618 patients seen for a voice complaint had one of can occur as a fluke based on one episode of vocal strain in an these benign entities. 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. ANATOMY AND PHYSIOLOGY Nonsingers with benign vocal fold mucosal disorders come to The anatomy most relevant to the benign vocal fold mucosal medical attention because of change in the sound or capabilities disorders is the microarchitecture of the vocal folds as seen on of the speaking voice. By contrast, singers may have no issues with whole-organ coronal sections in a study of cancer growth patterns3,4 their speaking voices but may seek help because of singing voice and in the work of Hirano.5 Medially to laterally, the membranous limitations, usually in the upper range. Benign vocal fold mucosal vocal fold is made up of squamous epithelium, Reinke’s potential disorders are significant because spoken or sung communication space (superficial layer of the lamina propria), the vocal ligament is important and a person’s voice is a part of his or her identity. (elastin and collagen fibers), and the thyroarytenoid muscle. 868 Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  CHAPTER 60 Benign Vocal Fold Mucosal Disorders 868.e1 Abstract Keywords 60 Most commonly, benign vocal fold mucosal disorders are caused Vibratory injury by vibratory injury in “vocal overdoers.” Exceptions include mucous vocal capability battery retention cyst, papillomas due to human papillomavirus (HPV) flexible chip-tip video-endoscope infection, granulomas, uncommon benign tumors, and other lesions. videostroboscopy Accurate diagnosis and management require a skillful history; a microlaryngoscopy perceptual assessment of the patient’s vocal capabilities, limitations, and aberrations (if present); and a high-quality laryngeal examina- tion. A voice-qualified speech pathologist is often part of the patient’s care to improve vocal hygiene and optimize voice produc- tion. 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. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  CHAPTER 60 Benign Vocal Fold Mucosal Disorders 869 Perichondrium and thyroid cartilage provide the lateral boundary characteristics of these layers, they decouple mechanically from of the vocal fold (Fig. 60.1). each other somewhat during phonation. Graphically illustrated 60 The vocal folds move as a whole between abducted and adducted in Fig. 60.2 (mucosa being stretched), decoupling allows the mucosa positions for breathing and phonation, respectively. The mucosa— to oscillate with some freedom from the ligament and muscle. that is, the epithelium and superficial layer of the lamina propria Imagine the vocal fold as a child’s paddleball toy: as the red rubber (Reinke’s potential space), which covers the vocal folds—is the ball and elastic band move with relative freedom apart from the chief oscillator during phonation (continuous adduction of the paddle, so the mucosa moves with a degree of freedom from the folds during expiratory flow of pulmonary air). Thus it is correct ligament and muscle. During phonation, pulmonary air power to speak of vocal fold mucosal vibration rather than vocal fold supplied to adducted vocal folds is transduced into acoustic power. vibration. In a canine study supporting this idea, Saito and associ- To accomplish this, pulmonary air is passed between appropriately ates6 placed metal pellets at varying depths within the vocal fold adducted vocal folds. At this point, the vocal fold mucosa vibrates (e.g., epithelially, subepithelially, intramuscularly) and used passively according to the length, tension, and edge configuration radiographic stroboscopy to trace their coronal plane trajectories determined by the intrinsic muscles and elastic recoil forces of during vibration. Pellet trajectories of the mucosa were far wider the vocal fold tissues. Fig. 60.3 shows the maximum open and than those of the ligament or the muscle; thus it is primarily the closed phases of one vibratory cycle, as seen during laryngeal vocal fold mucosa that oscillates to produce sound. videostroboscopy. Further details concerning the mucosa’s vibratory The work of Hirano7 provides an explanation for these observa- behavior can be found in the works of Baer8 and Hirano5 and in tions. Hirano described the vocal fold muscle as the body of the Chapter 56. fold, the epithelium and superficial layer of the lamina propria Other important microanatomy includes glands in the supraglot- (Reinke’s potential space) as the cover, and the intermediate layers tic, saccular, and infraglottic areas, which produce secretions that of collagenous and elastic tissue (vocal ligament) as the transitional bathe the vocal folds during vibration. zone (see Fig. 60.1). Because of the different physiologic stiffness Stratified Vocal squamous ligament Respiratory epithelium epithelium Thyroarytenoid muscle Superficial (vocalis) layer, lamina propria (Reinke’s space) Fig. 60.2 Gentle medial retraction shows the relative decoupling of Fig. 60.1 Cross-section of the vocal fold. the mucosa from the underlying nondeformed vocal ligament. A 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. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 870 PART V Laryngology and Bronchoesophagology EVALUATION OF THE PATIENT: Common Symptom Complexes GENERAL PRINCIPLES As in the case of many other types of voice disorders, a characteristic The scientific method demands that hypotheses be tested using symptom complex usually accompanies benign mucosal disorders. observation or measurement. In the clinical realm of voice Nonsingers, who often experience moderate to large mucosal disorders, an unresolved issue is how important are observation disturbances before they seek medical attention, usually describe and measurement, respectively, for diagnosis. In this author’s chronic hoarseness with exacerbations at times of increased voice view, the necessary and sufficient elements for diagnosis and use. Singers may not note speaking-voice symptoms but rather management of benign mucosal disorders are (1) a skillful history; often describe (1) exaggeration of day-to-day variability of singing (2) a perceptual assessment of vocal capabilities, limitations, capabilities; (2) increased effort necessary for singing; (3) reduced and aberrations (when present), particularly through elicitation vocal (mucosal) endurance; (4) deterioration of high, soft singing; of vocal tasks designed to detect mucosal disturbances; and and (5) delayed phonatory onset and air wastage (breathiness). (3) a high-quality laryngeal examination, which often includes laryngeal videostroboscopy. Although not particularly useful for diagnosis, certain measures of phonatory function (aerody- Talkativeness Profile: Vocal Overdoer Syndrome namic, acoustic) may be of interest for research and publication, The factor that correlates most strongly with the formation and documentation of the disorder’s physiologic effects, and as maintenance of many benign vocal fold mucosal disorders appears an adjunct to observational assessment of improvement after to be personality. A simple and even rudimentary but nevertheless treatment. 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 History of 7 is unusually talkative. (In asking this question, the clinician Besides the usual items in the general medical history, the voice must stress that this scale deals with innate predisposition, not the history should focus in particular on the following items, which demands of work or lifestyle.) Virtually all patients with nodules may be best captured by using a questionnaire9,10: and polyps and even those with cysts and sulci rate themselves at 6 or 7, except for those less talkative individuals who work in 1. Onset and duration of vocal symptoms vocally extreme occupations (e.g., financial trading). 2. Patient’s beliefs about causes or exacerbating influences 3. Common symptom complexes 4. Talkativeness profile (intrinsic, personality-based tendency to Vocal Commitments use the voice) To assess vocal commitments and activities, the clinician or 5. Vocal commitments or activities (extrinsic requirement, invitation, questionnaire should inquire briefly about occupation, voice type or opportunity to use the voice), including voice type and and level of training, and the nature and extent of vocal activities training if the patient is a performer related to family life, child care, politics, religion, hobbies, athletics, 6. Other risk factors and musical rehearsal and performance. 7. Patient’s perception of the severity of the disorder 8. Vocal aspirations and consequent motivation for rehabilitation Other Risk Factors Other risk factors are tobacco and alcohol use, acid reflux, insuf- Onset ficient fluid intake, certain drying medications, systemic illnesses, It is appropriate during history taking to test the hypothesis that and allergies. Even when the history is positive for one of these a patient who complains of frequently recurring bouts of vocal factors, it is usually a secondary issue in comparison with dysfunction may be experiencing exacerbations of a more chronic “sevenness.” overuse disorder. Based on an assessment of vocal personality, lifestyle, vocal commitments, and voice production, such a patient Patient Perception of Severity and Vocal Aspirations and 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 Consequent Motivation for Rehabilitation activity or by an upper respiratory infection. In this situation, It is important to explore how severe the patient perceives the without sophisticated insight, both the patient and the clinician voice problem to be as well as his or her vocal aspirations and may tend to focus on the recent or current upper respiratory motivations for rehabilitation. For example, the clinician may be infection (e.g., providing supportive treatments or antibiotics) confronted by a patient who only wants to be reassured that the rather than seeing past this acute issue to recognize the need for problem is not cancer. Even with a diagnosis of large smokers’ the more sophisticated behavioral therapy appropriate for a chronic polyps with severe range virilization and dysphonia, the manage- “vocal overdoer.” ment 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 Patient’s Beliefs Regarding Causes speaking voice but have upper limitations to the singing voice A clinician is prudent to remain open and curious about cause, caused by small nodules. To help this patient pursue a competitive even when the patient is already convinced of a certain explanation. singing career, rehabilitation might be intense and might include For example, a patient may insist that the voice disorder results significant behavioral therapy by a speech pathologist. It might from allergies or acid reflux. After thorough consideration, the also eventually include surgery. 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 Vocal Capability Battery comparison if they are present at all. Of course, in this instance, The vocal capability battery is an auditory-perceptual assessment considerable time is required at the conclusion of the consultation of vocal capabilities, limitations, and aberrations (if present). It for teaching to help the patient redirect his or her thinking, to macrophenomenologically assesses two crucial questions, the first meet objections, and so on. relating to limitation (“What can’t this voice do that it should be Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  CHAPTER 60 Benign Vocal Fold Mucosal Disorders 871 able to?”) and the second to aberration (“What does this voice the visual examination to help determine, along with the patient’s do that it should not?”). This process involves elicitation of a variety needs and motivation, the intensity and direction of management. 60 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 Office Examination of the Larynx understanding the nature and severity of the voice disorder. To The larynx can be examined in several ways (Fig. 60.4). The be most efficient, this part of the diagnostic process is performed laryngeal mirror should provide three-dimensional viewing and by the same clinician who takes the history and performs the good color resolution; however, in practice it offers poor visualiza- laryngeal examination. Alternatively, a second clinician can perform tion in many cases. In other cases, visualization is good but only this assessment, but for best results, the findings of vocal capability during phonation, because the view is obstructed by the epiglottis elicitation are immediately correlated with the other two compo- during respiration. In addition, no permanent image of the larynx nents of the diagnostic process. results from this examination technique. Because the physician Vocal elicitation and interpretation require that the examiner must therefore remember the lesion or document it with a simple have good pitch-matching abilities; a reasonably normal voice; sketch, precise critique of the effectiveness of the therapy chosen extensive familiarity with his or her own vocal capabilities (and may not be possible. Rigid and also flexible laryngeal scopes often limitations, if any); intimate familiarity with normal singing-voice allow a clearer view, particularly during respiration. When used capabilities according to age, sex, and voice classification; and the with the naked eye, however, they have disadvantages similar to willingness to model and elicit a response with his or her own those of the mirror. The fiberoptic nasolaryngoscope or a newer voice. Also needed is a frequency reference, such as a small “chip-tip” videoendoscope is especially important in a patient who electronic keyboard. These elements are straightforward and can is difficult to examine because of unusual anatomy or an exceptional be acquired by motivated clinicians with reasonably “aware and gag reflex. Even with these technologies, however, it is possible insightful” auditory perception. to overlook subtle to small mucosal changes unless the larynx is In voice clinics where expert vocal capability elicitation and topically anesthetized to allow a close approach of the tip of the assessment are not available or are not immediately correlated fiberscope to the vocal folds. With topical anesthesia, the vocal with history and laryngeal examination, clinicians may overlook folds, subglottis, and trachea can be examined easily (Fig. 60.5).13,14 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 impor- tantly, 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 syntheti- cally 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, very- low-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 Fig. 60.4 Three of the most commonly used tools for viewing the voice loses its expected upper range under these performance larynx: a mirror, a 90-degree telescope, and a flexible distal-chip constraints or if it suffers from onset delays, air escape, diplophonia, endoscope. 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 Fig. 60.5 Extreme closeup of the larynx with adequate resolution of the patient’s vocal limitations, which can then be correlated with the vocal folds, subglottis, and even high trachea. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 872 PART V Laryngology and Bronchoesophagology Strobe illumination added to any of these examining instruments their own merits; however, the clinician may need to help diminish allows mucosal vibratory dynamics to be evaluated in apparent the patient’s perception of how much these problems contribute slow motion (e.g., to understand mucosal scarring and to distinguish to a voice disorder in favor of more likely behavioral causes. When cysts from nodules). Adding a video camera and recording device, optimal laryngeal function is of concern, as in a vocal performer, typically a computer hard drive, to the rigid or flexible scopes nasal conditions should be managed locally (topically) when possible. brings additional advantages; for example, showing a video of the The reason is that many systemic drugs (e.g., oral decongestants, examination to a patient can help him or her to understand and antihistamine-decongestant combinations) dry not only nasal be motivated. Also, such recordings enable other clinicians— secretions but also secretions in the larynx, where a continuous otolaryngologists, speech pathologists, voice teachers—to participate secretional flow is important for proper vibratory function and more easily in assessment and management, and these recordings mucosal endurance, particularly under demanding phonatory serve as permanent records that document the result of voice conditions. Medications that affect the voice minimally are the therapy or surgery and enhance the teaching of residents. 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 Objective Measures of Vocal Output the common cold can also be managed with ipratropium bromide Skillful “triangulation” on the voice problem through the use of inhalations,15,16 and corticosteroid inhalers are invaluable for the the voice history, auditory-perceptual evaluation of vocal capabilities, management of nasal allergies. Activating pump-action nasal inhalers limitations and aberrations, and a high-quality laryngeal examination without any inspiratory airflow avoids the alleged risk of the effects is sufficient for a clear diagnosis and description of the problem. of nasally applied corticosteroid on the vocal folds. 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 understand- Management of Acid Reflux Laryngopharyngitis ing in the research arena, and to assist in some helpful biofeedback In a person with an incompetent lower esophageal sphincter applications. 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: Direct Laryngoscopy and Biopsy exaggerated “morning mouth,” excessive phlegm, scratchy or dry When videostroboscopy with magnified viewing is available, lesions throat irritation that is usually worse in the morning, habitual suspicious for cancer or papillomatosis can nearly always be throat clearing, and huskiness or lowered pitch of the voice in distinguished easily from nodules, polyps, and cysts. Therefore the morning. The larynx may show characteristic erythema of the removal of the latter entities is appropriate only within a com- arytenoid mucosa, interarytenoid pachyderma, or contact ulcers; prehensive plan for treatment or voice restoration and rarely if however, laryngeal findings may be subtler than those in Fig. 60.6. ever for preliminary tissue diagnosis. 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 GENERAL MANAGEMENT OPTIONS considered. Ford17 suggests that the most reliable way to confirm the diagnosis is using ambulatory multichannel intraluminal Hydration impedance and pH-monitoring studies; this could be considered Adequate hydration promotes the free flow of lubricating secretions, in the small number of patients for whom empiric trials com- which helps the vocal fold mucosa withstand the rigors of vibratory bined with careful patient history and laryngeal examination do collisions and shearing forces. A consistent, rather than episodic, not suffice. supply of fluids seems to be particularly important. An expectorant, Basic management of this condition consists of avoiding caffeine, such as guaifenesin, may also help when secretions are viscid. 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 Sinonasal Management at bedtime, a histamine H2-receptor antagonist (H2 blocker) 2 Patients often incorrectly attribute chronic hoarseness to sinonasal or 3 hours before bed, or a proton pump inhibitor 30 to 60 minutes conditions. Existing sinonasal problems should be managed on before dinner. A 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. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  CHAPTER 60 Benign Vocal Fold Mucosal Disorders 873 analysis, spirometric measures to test respiratory adequacy, fre- Acute Mucosal Swelling of Overuse quency and loudness measures, translaryngeal airflow rates, and 60 Public speakers or singers may sometimes perform of necessity other measures under various conditions. Speech pathologists may despite acute noninfectious mucosal swelling resulting from recent use this equipment for biofeedback (e.g., using a visual electronic overuse of the voice. A careful strategy of relative vocal rest in frequency readout to modify average pitch for speech in a tone-deaf context is needed (e.g., interspersing high-intensity songs with patient). For obligate false vocal fold phonation and intractable low-intensity songs, avoiding conversation during intermission, psychogenic disorders of voice production with visible vocal fold etc.) along with preperformance warm-up and solid vocal technique; posture abnormalities, therapy room videoendoscopy can also be these may be sufficient for the patient to “get through.” A short- converted into an effective biofeedback tool.11,18 term, 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. SURGERY Some lesions are known at diagnosis to be irreversible except via surgery. Aside from these exceptions, vocal fold microsurgery Laryngeal Instillations for Mucosal Inflammation should follow an appropriate trial of voice therapy. Individualization In past years more so than currently, laryngologists have used is the rule, but patients are typically reexamined with the vocal drugs such as mono-p-chlorophenol, topical anesthetics, mild capability battery and videostroboscopy at 16-week intervals after vasoconstrictors, sulfur vapors, certain oils, and other substances diagnosis. When a compliant patient does not improve after two for the reduction of swelling, a soothing effect, or promotion of or more successive examinations and remains unhappy with the healing. Some physicians and patients believe in the efficacy of voice’s capabilities, surgery may be considered. Good surgical such management, although it is supported only by anecdotal results are directly related to diagnostic accuracy, surgical judgment reports. 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 Systemic Medicines That May Affect the Larynx vocal fold mucosal disorders are the same. An understanding of Medicines that patients take for other reasons—such as antidepres- vocal fold microarchitecture and vibratory dynamics (see previous sants, decongestants, antihypertensives, and diuretics—may dry discussion) is a prerequisite, and preoperative and postoperative and thicken normal secretions, which thereby reduces their protec- videostroboscopic evaluation is necessary so that the patient and tive lubricating effect on the vocal folds and conceivably makes surgeon can see the results together. the vocal fold mucosa more vulnerable to the development of The first principle of surgery is that microlaryngoscopy, not benign disorders. The clinician should inquire about these medicines direct laryngoscopy with the unaided eye, and extreme technical during history taking. 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 VOICE THERAPY surgical margins does not apply. Every case should be approached A course of therapy by a voice-qualified speech pathologist is with the awareness that overly aggressive or imprecise surgery of frequently appropriate in patients with benign vocal fold mucosal the vocal fold mucosa can result in regenerated or surgically disorders, given the common relationship of such disorders with manipulated mucosa that scars and thus adheres to the underlying vocal overuse, abuse, or misuse. Vocal nodules in particular are vocal ligament, which will cause severe dysphonia. expected to resolve, regress, or at least stabilize under a regimen A set of laryngoscopes, microlaryngeal forceps, scissors, dis- of improved voice hygiene and optimized voice production. In sectors, and knives should be on hand. In the face of the plethora some cases, however, success is defined as having achieved a more of instruments currently available, the comment by Kleinsasser2 consistent voice, without the exacerbations of hoarseness and even that a relatively simple set suffices the experienced surgeon remains aphonia, even if that now-more-reliable voice remains somewhat true (Fig. 60.7). husky. In other cases, the definition of success may mean resolution The carbon dioxide (CO2) laser has become an important part of all upper singing voice limitations. If surgery becomes an of the surgeon’s armamentarium, and many have discussed its option—because the mucosal disorder has not resolved completely, application to benign laryngeal disorders. Tissue effects of the and the patient regards residual symptoms and vocal limitations laser depend on spot size and focus, wattage, duration of beam as unacceptable—voice therapy will have optimized the patient’s activation, waveform mode (pulsed vs continuous), and perhaps surgical candidacy by educating him or her additionally about the most important, surgical precision. Cold microdissection may be surgical process, and it will have decreased the risk of postoperative safer than laser techniques, provided that the surgeon is equally recurrence. proficient in both. In the days before diminished spot size per- During evaluation, the speech pathologist gathers information mitted increased precision, Norris and Mullarky,19 comparing a on behavior that may adversely affect the voice and establishes a continuous-mode CO2 laser with the cold scalpel for incising pig program to eliminate injurious behavior. Voice-qualified speech skin, reported that a short-term advantage resulted after laser pathologists also model and elicit a battery of spoken and sung incision with regard to the speed of reepithelialization; no long-term vocal tasks to make plain to themselves and patients the type and difference in healing was noted. However, although the fact was degree of impairment that has resulted from the lesion. They also not noted in their report, these investigators’ histologic sections assess the skill and appropriateness of voice production for both clearly showed a wider zone of tissue destruction beneath the speaking and singing. Depending on the results of this second epithelium with the laser than with the scalpel. Duncavage and part of the evaluation, the speech pathologist may help the patient Toohill20 compared healing response in dogs after traditional fold optimize the intensity, average pitch, registration, resonance stripping and after CO2 mucosal vaporization. They concluded that, characteristics, overall quality, general and vocal tract posture, and until late in healing, more edema and giant-cell reactions to bits respiratory support for voice production. For singers, the singing of charred debris and greater subepithelial fibrosis occurred with teacher plays an invaluable role in this process, particularly with the laser technique than with the cup forceps alone. Manipula- respect to the production of singing voice. tion of wattage, focus, and mode of laser irradiation of tissues Finally, in this technologic era, voice clinicians increasingly may decrease thermal injury, charring, and other adverse effects document various aspects of vocal tract output using acoustic of the laser. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 874 PART V Laryngology and Bronchoesophagology A B C 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 disadvan- Epidemiology tages,21,22 and Geyer and colleagues23 reported a more recent series Vocal nodules occur most commonly in boys and women. Such of 235 patients for whom the CO2 laser achieved good results. persons are almost always vocal overdoers (i.e., rating 6 or 7 on However, a systematic comparison of functional results, including the 7-point talkativeness scale). Intrinsic talkativeness correlates vocal capabilities and videostroboscopy, is not available to guide more consistently than occupation unless the occupation is the surgeon in choosing between laser and microdissection methods. extraordinarily demanding vocally (e.g., rock singer, stock trader). With a caseload of more than 1000 singers and at least triple that Comparatively, nodules frequently develop in children with cleft number of nonsingers, for whom laser and nonlaser methods have palates, presumably from their use of glottal stops to compensate been used on an individualized basis, it appears that surgical for velopharyngeal incompetence. 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 Pathophysiology and Pathology preoperatively as to what the risk of worsening the voice is predicted Only the anterior two-thirds (membranous portion) of the vocal to be. For nodules it may be appropriate to say, “This surgery folds participates in vibration because the arytenoid cartilages lie typically restores the voice to ‘original equipment status,’ but there within the posterior third of the glottic aperture. Vibration that is a small risk that you will experience a large improvement but is too forceful or prolonged causes localized vascular congestion not to fully normal; and there is a remote, rare risk that your voice with edema at the midportion of the membranous (vibratory) will be worse after surgery.” By contrast, you may say to the person portion of the vocal folds, where shearing and collisional forces with bilateral sulci in whom the mucosa is thin, “I am expecting are greatest. Fluid accumulation in the submucosa from acute at best a modest improvement of your voice, but it will take many abuse or overuse results in submucosal swelling, sometimes unwisely months to achieve this improvement, and there is a quite significant called incipient or early nodules. Long-term voice abuse leads to chance your voice will be no better, and it may possibly be worse.” some hyalinization of Reinke’s potential space of and, in a subset For the experienced surgeon who uses dissection rather than of cases, to some thickening of the overlying epithelium. This microavulsion techniques along with preoperative and postoperative pathophysiologic sequence explains the easily reversible nature videostroboscopy as his or her “teacher,” the question in the general of most acute, nonhemorrhagic swellings in contrast to the slower, case becomes not so much one of possibly making the voice worse incomplete, or failed resolution of chronic vocal nodules. Whether but rather of “Can I make this patient’s speaking and singing acute edema or more chronic nodules are present, it is the change capabilities normal, and if not, how close can I come?” Cornut in mucosal mass, lessened ability to thin the free margin, and and Bouchayer’s24 experience of operating on 101 singers and incomplete glottic closure caused by the nodules that together Bastian’s25 experience in the same population established a role account for a constellation of vocal symptoms and limitations for laryngeal microsurgery in restoring vocal capabilities and in characteristic of mucosal swelling.11,25 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 Diagnosis improve significantly after vocal fold surgery.” History. A pediatric patient with vocal nodules is usually described by the parent as “vocally exuberant.” An adult patient, virtually SPECIFIC BENIGN VOCAL FOLD always a woman who rates herself as a 6 or 7 on the talkativeness scale (discussed earlier), describes experiencing chronic hoarseness MUCOSAL DISORDERS or repeated episodes of acute hoarseness. Sometimes the initial onset is associated with an upper respiratory infection or acute Vocal Nodules laryngitis, after which the hoarseness never clears completely, The term nodules should be reserved for lesions of proven chronicity. leading the patient to incorrectly attribute the voice problem to Recent or acute mucosal swellings, which disappear quickly in the infection and to neglect more relevant ongoing behavioral response to simple voice rest and perhaps supportive medical causes. Singers with chronic nodules are usually relatively unaware management, are thus excluded when one is referring to nodules. of speaking-voice limitations unless the nodules are at least Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  CHAPTER 60 Benign Vocal Fold Mucosal Disorders 875 moderate in size. More sensitive symptoms of vocal nodules, present, the amount of recent voice use, and interindividual dif- including very small ones, are as follows: ferences in mucosal response to voice abuse. Also, some variability 60 exists in the correlation between size of nodules and their effect Loss of the ability to sing high notes softly on vocal capabilities. Nodules do not occur unilaterally, although Delayed phonatory onset, particularly with high, soft singing one may be larger than the other. It is important to distinguish Increased breathiness (air escape), roughness, and harshness between nodules and cysts, because management of these entities Reduced vocal endurance (“my voice gets husky easily”) differs. The correlation between nodule appearance and reversibility A sensation of increased effort for singing with voice therapy is imperfect. The larynx should be examined A need for longer warm-ups at high frequency (500 to 1000 Hz) to visualize subtle to small Day-to-day variability of vocal capabilities that is greater than swellings, which can be poorly appreciated at lower frequencies. expected for the singer’s level of vocal training Vocal Capability Battery. In patients with moderate to large vocal Management nodules, the speaking voice is usually lower than expected and Medical. Good laryngeal lubrication should be ensured through may be husky, breathy, or harsh. Patients with subtle to moderate general hydration. Allergy and reflux, when present, should also swellings often have speaking voices that sound normal, so the be treated. speaking voice is an insensitive indicator of mucosal disorders in comparison with the singing voice. In patients with subtle or small Behavioral. Vocal nodules arise from the vocal overdoer profile, swellings (usually only singers come to medical attention with small so initially speech (voice) therapy plays a primary role. Typically, mucosal disturbances), vocal limitations such as delayed phonatory the nodules and their more obvious symptoms regress, particularly onset with preceding momentary air escape, diplophonia, and if the patient is not a singer. However, the most skilled behavioral inability to sing softly at high frequencies may become evident (voice) therapy sometimes fails to achieve complete visual resolution only when high-frequency, low-intensity vocal tasks for detect- of nodules that have been present for many months to years. ing swelling are elicited.12 At high frequencies, short-segment Sensitive singing tasks that detect impairment, and not the size vibration may occur; in other words, the nodules stop vibrating, of persistent swellings, are generally more helpful in the decision and the short segments of mucosa anterior or posterior to them, as to whether to consider surgical removal of the nodules.11,25 or both, vibrate. Many patients with nodules may have undergone indirect Surgical. Surgical removal becomes an option when nodules of laryngoscopy and may have been told that their vocal folds were any size persist and when the voice remains unacceptably impaired normal, or they have been given a nonspecific diagnosis such as from the patient’s perspective after an adequate trial of therapy, “laryngeal irritation.” Use of vocal tasks that detect swellings and generally a minimum of 3 months. Some writers prefer precise videostroboscopy when indicated (see Figs. 60.3–60.5) protect the removal using microexcision techniques (Fig. 60.8); regardless, laryngologist from missing the most subtle vocal fold swellings. vocal fold stripping has no place in the surgery of nodules. The The ability to diagnose tiny nodules is crucial, because failure to proper duration of voice rest is controversial, and some writers make such a diagnosis can have serious consequences for the prefer a relatively short period. In the author’s practice, the patient professional voice user. is asked not to speak for 4 days, although sighing sounds begin 1 day after surgery. Beginning on the fourth day, the patient Laryngeal Examination. Nodules can vary in size, contour, gradually progresses over 4 weeks to full voice use under a speech symmetry, and color, depending on how long they have been pathologist’s supervision. Early return to nonstressful voice use, as A B 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. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 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 None Gentle attempts at yawn or sigh for approximately 30 s 6–8 times dailyc Week 2 (begins day 5) 3 Singing-voice warmup exercises for 5 min twice daily (after first postoperative exam) Week 3 4 Same exercises for 10 min twice dailyd Week 4 5 Same exercises for 15 min twice dailyd (after second postoperative exam) Week 5 4 or 5 Same exercises for 20 min twice dailyd Weeks 6–8 4 or 5 Same exercises for up to 20 min three times dailye a After the fourth examination, return to performance should be considered. b 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. 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 Fig. 60.10 Ectatic capillaries need not be ablated in their entirety. Instead, flow is stopped with spot coagulations (arrows) along the Repeated vibratory microtrauma can lead to capillary angiogenesis. course of the capillary. Within 3 weeks, capillary “segments” In a circular fashion, abnormally dilated capillaries seem to increase disappeared. 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 short periods of singing (reduced vocal/mucosal endurance). When to mucosal swelling (reduced vocal endurance), a small incidence this complaint is associated with mucosal swelling, additional of vocal fold hemorrhage, and hemorrhagic polyp formation. 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 Diagnosis or more episodes of acute vocal fold hemorrhage, which may have History. Capillary ectasia is diagnosed most often in female singers precipitated the patient’s first visit; capillary ectasia may be discerned who complain that they become a little hoarse after relatively only after the bruising has resolved. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  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 60 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. 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 Fig. 60.11 Hemorrhagic polyp, right fold. Note the blood-blister appearance. Recent further bleeding is evident from the yellowish Medical. The use of drugs that have anticoagulant effects, such discoloration of the upper surface of the fold because of breakdown as aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs), products of a bruise, estimated to have occurred 2 weeks earlier. should cease if medically appropriate. These drugs do not appear Hemorrhagic polyps sometimes rebruise intermittently. 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. to focal accumulation of blood, similar to a blood blister. This Behavioral. Many persons with capillary ectasia are vocal overdo- type of hemorrhage alters the margin contour and stiffens the ers; therefore the behavioral changes appropriate for individuals mucosa, as seen stroboscopically. It causes significantly more and with nodules are advocated. In particular, patients are warned longer-lasting hoarseness and may be the precursor of a hemor- about sudden explosive use of the voice. The duration of voice rhagic polyp. In this case, microscopic examination would reveal use per practice session should also be reduced (e.g., three a relatively rich vascular stroma and areas of hyalinization, although 20-minute sessions per day vs a single 1-hour session). a unilateral, nonhemorrhagic, often pedunculated polyp may also be seen as the end stage of a hemorrhagic polyp. 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 Diagnosis option.25,27 Dilated capillaries are spot-coagulated to interrupt History. The history of abrupt onset of hoarseness during extreme blood flow every few millimeters (see Fig. 60.10), and capillaries vocal effort, such as at a party or sporting event or even after a proximal to each interrupted segment may subsequently dilate. loud sneeze, is classic but not universal in patients with vocal fold Even so, not all visible dilations should be ablated; those that hemorrhage and a unilateral hemorrhagic vocal fold polyp. remain visible at the end of the procedure, and even at the first postoperative visit, routinely involute within a few weeks. If the Vocal Capability Battery. Vocal capabilities vary according to mucosal edema accompanying ectatic capillaries is minimal, the size, age, turgidity, and pedunculation of the polyp. Some management of the capillaries alone often leads to resolution of patients have a normal-sounding speaking voice except for intermit- the edema. tent and subtle aberrant sounds. Other patients have a normal speaking voice but an impaired or nonexistent falsetto register. Vocal Fold Hemorrhage and a Unilateral Some patients also manifest chronic vocal huskiness. (Hemorrhagic) Vocal Fold Polyp Laryngeal Examination. Laryngeal examination demonstrates a largely unilateral lesion in the node position, a contact reaction— Epidemiology or a nodule, if the person is a vocal overdoer—on the fold opposite The occurrence of vocal fold hemorrhage (Fig. 60.11) and unilateral the polyp. In the case of the chronic vocal overdoer, a hemorrhagic hemorrhagic vocal fold polyp is more common in men, particularly polyp may represent an acute injury superimposed on chronic those who engage in intermittent severe voice abuse or who work nodules. The hemorrhagic polyp is usually much larger than the in noisy environments. Surprisingly few patients have a history typical nodule and may appear dark and filled with blood in the of using aspirin or other anticoagulants. 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 Pathophysiology and Pathology become pedunculated, moving in and out of the glottis with Shearing forces that act on capillaries within the mucosa during inspiration and expiration, respectively. During phonation, this extreme vocal exertion lead to capillary rupture. Capillary ectasia end-stage polyp may be displaced upward onto the fold’s superior seems to predispose to this sort of injury. Breakage of superficial surface, interfering little with basic phonation. 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. Treatment Resolution of the bruise may be complete within 2 weeks. By Medical. If possible, the intake of anticoagulant medications contrast, extravasation of blood from a deeper capillary may lead (NSAIDs and warfarin) should be stopped. Because acid reflux Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 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, retention cysts (ductal cysts, see Figs. 60.15 and 60.17) arise when this condition should be controlled. the duct of a mucous gland becomes plugged and retains glandular secretions; epidermal cysts (see Figs. 60.14 and 60.16) contain Behavioral. A short course of voice therapy is appropriate, mainly accumulated keratin.28–31 Two theories state that the epidermal to instruct the patient in voice care. The occasional small, early cyst results from a nest of epithelial cells buried congenitally in hemorrhagic polyp resorbs completely with many months of the subepithelial layer or from healing of mucosa injured by voice conservative measures, but typically surgical removal is required abuse over buried epithelial cells. In time, cysts may rupture to return the vocal fold to its normal appearance and vibratory spontaneously. If the resulting opening is small in relation to the function and to return the voice to normal capabilities. 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 Surgical. Evacuation of blood through a tiny incision in a recent large as the cyst, the resulting empty pocket becomes a glottic large hemorrhage that looks like a blood blister may be appropriate sulcus (Figs. 60.18 and 60.19). 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 Diagnosis should be taken to detect the large capillaries within Reinke’s History. A patient with epidermal cysts has many of the same space because these also should be interrupted, although a slightly symptoms and voice abuse factors as a patient with nodules. deeper coagulation may be required to reach the level of the However, mucous retention cysts can arise seemingly spontaneously, capillary. A long-standing polyp, whether hemorrhagic or at end without relation to the amount or manner of voice use. stage and pale, should be trimmed away superficially at the time the spot coagulations take place. Prognosis for full return of Vocal Capability Battery. The vocal capability battery uncovers vocal functioning after precision surgery is excellent (Figs. 60.12 vocal limitations similar to those for a patient with vocal nodules. and 60.13; Video 60.1). Patients with epidermal cysts are more likely to experience dip- lophonia in the upper vocal range, and they may manifest an abrupt and irreducible transition to severe impairment at a relatively Intracordal Cysts specific frequency rather than a more gradual transition to greater degrees of impairment, as is often noted in patients with nodules. Epidemiology Mucous retention cysts often cause less vocal limitation than might The most prominent epidemiologic finding is a history of vocal be anticipated from the laryngeal appearance; epidermal inclusion overuse. This is routine for the epidermal cyst but less so for the cysts often cause more limitation than expected. mucous retention variety. Laryngeal Examination. Mucous retention cysts often originate just below the free margin of the fold with significant medial Pathophysiology and Pathology projection from the fold. For this reason, such cysts are sometimes Histologically, intracordal cysts are classified as either mucous misdiagnosed as nodules or polyps. Epidermal cysts project less retention or epidermal inclusion types (Figs. 60.14–60.17). Mucous from the fold and are harder to diagnose when small. An Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  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 Treatment fold. In an open cyst, the sphere may be less discrete and may Medical. General supportive measures, such as hydration and have a more mottled appearance on the superior surface of the potential acid reflux management, may be helpful but will not vocal fold (see Fig. 60.16). Under strobe illumination, as the resolve this problem. fundamental frequency of phonation increases, the mucosa overlying the cyst often stops vibrating before the mucosa anterior and Behavioral. Voice therapy is more appropriate for people with posterior to the cyst. Even so, diagnosis can be confirmed in some epidermal cysts and, beyond teaching in preparation for surgery patients only at the time of microlaryngoscopy. in those with cysts of the mucous retention variety, often is not Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 880 PART V Laryngology and Bronchoesophagology Fig. 60.16 Bilateral open cysts. Because the openings are small in Fig. 60.15 Mucous retention cyst after laser excision of early vocal relation to the size of the cysts, partial emptying of the keratin fold cancer, left vocal fold. Note capillary reorientation, which is typical contents causes a mottled appearance. 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. A B C 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. Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados.  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 Glottic Sulcus course, speech (voice) therapy may also be warranted for those who have mucous retention cysts if the person is a vocal overdoer— Epidemiology not to resolve the lesion, which requires surgery, but to avoid the Although some writers believe sulci to be congenital, glottic sulcus risk of another, this time vibration-induced, lesion. appears to occur exclusively in vocal overdoers (see Figs. 60.18 and 60.19). 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 Pathophysiology and Pathology and translucent, resembling a polyp, the cyst may be removed Bouchayer and colleagues30 reviewed acquired and congenital in its entirety with a small slip of overlying mucosa, particularly theories for these conditions. They described the appearance of when its wall is so thin as to make its dissection from the the sulcus as an epithelium-lined pocket whose lips parallel the overlying mucosa virtually impossible. In this case, mucosal free edge of the folds and suggested that a sulcus may represent oscillation will still be normal after healing is complete. More an epidermal cyst that has emptied spontaneously, leaving the typical mucous retention cysts are removed, as described in the collapsed pocket behind to form a sulcus. In effect, a mucosal following paragraph, via dissection that leaves the overlying bridge is the result of two parallel sulci that arise from a single mucosa intact. cyst (Fig. 60.20). The chief problem caused by a sulcus is the same A small, extremely shallow incision is made on the fold’s superior as that caused by scarring: stiffening of the mucosa, which inhibits surface. Careful dissection reveals that the swelling is indeed caused oscillation and leads to dysphonia.32 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 Diagnosis should be examined carefully because of the possibility of a more History. The patient with a glottic sulcus often has a history of subtle cyst or sulcus. Results are not as uniformly good as for voice overuse and complains of chronic hoarseness. nodules and polyps. Considerable improvement is expected, however, and some patients achieve excellent results (Videos 60.2 Vocal Capability Battery. Typically the voice is noticeably hoarse. and 60.3). Patients should also know that maximal postoperative Upper voice limitations, particularly diplophonia, are obvious. As recovery takes longer than for nodule or polyp surgery (many is the case for cysts, the transition between hoarse phonation and months rather than a few weeks). Bouchayer and colleagues30 aphonia may occur abruptly, almost at a specific frequency, generally reported a series of 148 patients managed for cysts, sulci, or mucosal in the middle of the singing range. bridges—very difficult surgical problems compared with nodules and polyps—of whom 10% had an overall excellent result, 42% Laryngeal Examination. Laryngeal examination may initially had a good result, 41% had a fair result, and 5% had a poor result. reveal fewer findings than expected to account for the abnormal Follow-up supportive voice therapy from the speech pathologist speaking voice or reduced singing voice capabilities. Because the or singing teacher assists vocal rehabilitation. A return to active patient is likely a vocal overdoer, associated fusiform vocal fold voice use or training should occur within a few days of surgery, margin swellings might also be seen. Stroboscopic evaluation shows because the amount of mucosal disturbance required leads to a a segment of reduced vibration. The entire length of the mucosa greater tendency to mucosal adherence and stiffness. may oscillate at lower frequencies; at higher frequencies, the Descargado para Anonymous User (n/a) en National Autonomous University of Mexico de ClinicalKey.es por Elsevier en junio 25, 2020. Para uso personal exclusivamente. No se permiten otros usos sin autorización. Copyright ©2020. Elsevier Inc. Todos los derechos reservados. 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 C D vibration of anterior and posterior segments begins to occur. Microlaryngoscopy is often required for definitive diagnosis because Fig. 60.21 Schematic of the removal of a glottic sulcus. (A) Vocal the lips of the sulcus are not always visible with inspiratory phona- fold coronal section shows the sulcus. (B) Injection of