Nodules and Polyps By Lindsey Richter Presented to

Nodules and Polyps By Lindsey Richter Presented to Rebecca L. Gould, MSC, CCC-SLP

Definition • Benign abnormal growths within or along the covering of the vocal cords including: 1. Vocal Fold Nodules (VFNs) 2. Vocal Fold Polyps (VFPs) 3. Vocal Fold Cysts (VFCs) 4. Laryngeal Papilloma, Granuloma, and Leukoplakia (American Academy of Otolaryngology−Head and Neck Surgery, 2005)

Anatomy of the Larynx • The cartilages of the larynx consist of the thyroid cartilage, the epiglottis, the cricoid cartilage, and the arytenoid cartilages. • Functionally, there are three groups of intrinsic laryngeal muscles – the abductors, adductors, and tensors. • Understanding the anatomy of the vagus nerve is important because branches of the vagus nerve are responsible for innervation of the larynx. (Stemple, Glaze, & Klaben, 2000)

Normal Larynx (The Voice Problem Website, 2004)

The vocal cords are apart for breathing in. The rings of the trachea (wind pipe) can be seen. They are at their widest apart during a sniff. The vocal cords blur once At a high pitch, at they are vibrating, but at onset of phonation, the instant before they vocal cords are stretched. vibrate, the vocal cords can be seen in this shortened position, slightly bowed. The arytenoids have come together. (Voice and Swallowing Center, 2005)

Histology of the Vocal Folds • The true vocal folds have an epithelial lining that is composed of respiratory epithelium (pseudostratified squamous) on the superior and inferior aspects of the fold and nonkeratinizing squamous epithelium on the medial contact surface. • The subepithelial tissues are composed of a three-layered lamina propria based on the amount of elastin and collagen fibers. • Deep to the lamina propria is the thyroarytenoid (or vocalis) muscle. (Stemple, Glaze, & Klaben, 2000)

(Le. Maistre, 1994)

Mechanism of Injury • Vocal fold lesions disrupt closure and vibration. • Regardless of type, benign vocal fold lesions – nodules, polyps, or cysts – cause hoarseness by disrupting the vocal fold closure and vibration pattern. (American Academy of Otolaryngology−Head and Neck Surgery, 2005)

Nodules • VFNs are localized, benign, superficial growths on the medial surface of the true vocal folds that are commonly believed the result of phonotrauma. • Nodules are bilateral with a classic location at the junction of the anterior one third and posterior two thirds of the true vocal fold. • Nodules are most often observed in women aged 2050 years, but they are also found commonly in children (more frequently in boys than in girls) who are prone to excessive shouting or screaming. (Buckmire, 2003)

VFN (The Voice Problem Website, 2004)

Teacher’s Nodules Singer’s Nodules (Ghorayeb, 2005)

Polyps • VFPs generally are unilateral and have a broad spectrum of appearances, from hemorrhagic to edematous, pedunculated to sessile, and gelatinous to hyalinized. • VFPs are believed to result from phonotrauma; however, they are also recognized to potentially arise from a single episode of hemorrhage. • VFPs typically involve the free edge of the vocal fold mucosa, although they may also be found along the superior or inferior borders. (Buckmire, 2003)

Left Vocal Fold Polyps (Buckmire, 2003)

Vocal Fold Polyp (Medtronic ENT, 2005)

Nodules vs Polyps • A nodule differs from a polyp in that it is a growth of the epithelium that covers the mucous membrane, not of the mucous membrane itself. • Nodules are most frequently caused by vocal abuse or misuse. • Polyps are lesions that develop from voice abuse, chronic laryngeal allergic reactions and chronic inhalation of irritants, such as industrial fumes and cigarette smoke. It may also be seen in hypothyroidism. • Nodules in children frequently regress in puberty. (Baylor College of Medicine, 1996)

Vocal Fold Cyst • VFCs have a defined morphology and typically impair mucosal wave motion by occupying space in the lamina propria. • The pathogenesis of these cysts can be explained by the proliferation of the basement membrane zone in the mucosa of the sulcus in response to injury. • There are two types of VFCs: glandular (mucous retention cyst) and epithelial (an inclusion cyst filled with squamous debris). (Vocal Fold Cysts, n. d. )

VFC with Reactive Lesion (The Voice Problem Website, 2004)

Polyp vs Cyst? (The Voice Problem Website, 2004)

Differential Diagnosis Leukoplakia is a white patch on the vocal fold. It may be from an irritation such as reflux or smoking. It is considered precancerous. Leukoplakia is diagnosed and treated by phonosurgery, which can remove the surface mucosa, leaving the lamina propria intact. (Stemple, Glaze, & Klaben, 2000)

Differential Diagnosis Granulomas are typically located over the vocal process of the arytenoid cartilage. Granulomas are caused by trauma. They may also be caused from intubations during anesthesia or from vocal trauma (typically speaking at too low a pitch). (Stemple, Glaze, & Klaben, 2000)

Differential Diagnosis Laryngeal papilloma are wart-like growths on the larynx thought to be caused by a viral infection. Medical treatments are aggressive, including interferon therapy and laser excision. (Stemple, Glaze, & Klaben, 2000)

Differential Diagnosis • Bamboo Node – rare white transverse submucosal lesion in the vocal fold found during clinical examination. • This lesion is reported only in autoimmune disease. • Two patients were shown to have undiagnosed autoimmune disease, Sjogren's syndrome and systemic lupus erythematous. (Murano et al. , 2001)

Symptoms of Benign Lesions • Vocal fatigue • Unreliable voice • Delayed voice initiation • Low, gravelly voice • Low pitch • Voice breaks in first passages of sentences • Airy or breathy voice • Inability to sing in high, soft voice • Increased effort to speak or sing • Hoarse and rough voice quality • Frequent throat clearing • Extra force needed for voice (Emory Healthcare, 2003)

Physical Exam • The indirect mirror exam is the initial procedure used to view the larynx. It is quick, inexpensive, and only requires a mirror and external light source. • Gross abnormalities may be detected quickly, but subtle abnormalities may be missed. • Disadvantages include the larynx not being in physiologic phonation position (the tongue is extended and the larynx is elevated), some anatomic features limit the exam, and a hyperreflexive gag is present in 5 -10% of patients. (Hauptman, 2005)

Rigid Laryngoscope • Rigid laryngeal endoscopy is performed in the office using 70 or 90 degree telescopes passed through the mouth to obtain images of the larynx and pharynx. These are the highest quality images obtainable and offer excellent magnification. • The patients are viewed in a nonphysiologic phonation position similar to the indirect examination. Anatomic factors and hyperreflexive gags can again limit the results. (Columbia Presbyterian Medical Center, 2002)

Flexible Laryngoscope • The flexible laryngoscope is probably the tool that most otolaryngologists rely upon in the evaluation of the dysphonic patient. It is the sole method that allows examination of the nasopharynx, palate, larynx, and pharynx in a near physiologic position. It can be performed relatively easily even in patients with hyper-responsive gags and pediatric patients. (Columbia Presbyterian Medical Center, 2002)

Video Stroboscopy • A specialized diagnostic procedure in which a stroboscopic light is used in conjunction with a laryngoscope to electronically slow down the motion of the vocal folds in order to identify subtle changes in vibratory patterns that are diagnostically significant. • Video stroboscopy is used to differentiate vocal fold nodules from vocal fold polyps and cysts. (Voice and Swallowing Center, 2005)

Videostroboscopy provides a highly detailed view of the vocal folds. It can be performed via a nasal or oral pathway. Stroboscopic examination of the vocal fold lesion is essential for accurate diagnosis and successful treatment. (The Voice Problem Website, 2004)

Stroboscopy of Left Vocal Fold Cyst (Voice and Swallowing Center, 2005)

Microlaryngoscopy • A procedure conducted under general anesthesia which allows the physician to examine the vocal folds of the larynx with magnification tools. Microsurgical and laser removal of lesions is done at this time. (The Voice Problem Website, 2004)

Behavioral Treatment • Behavioral modification is the primary treatment of mucosal lesions and is likely a lifelong treatment of the problem. For example, if the patient is a singer, it is usually not the singing that is the problem. More often it is the amount of talking that goes on daily. They need to take a look at their life, perhaps in conjunction with a speech therapist, to decide where they can rest their voices. • Many times managing their talkativeness will reduce a vocal fold swelling to an acceptable size such that the voice becomes dependable and acceptable to the patient. • Hemorrhage can generally be managed behaviorally, particularly if it was from a one time indiscretion. (The Voice Problem Website, 2004)

Behavioral Voice Therapy • Traditional voice therapy consists of two primary avenues. • Vocal hygiene is a daily regimen to achieve and maintain a healthy voice. It includes maintaining adequate hydration (6 -8 glasses of water per day), minimizing exposure to noxious chemicals, no smoking of cigarettes, and the avoiding of excessive shouting, screaming or other loud voice use. • Voice therapy is a behavioral intervention technique that makes use of vocal exercises, speaker awareness and proper postures and alignment when using the voice. (Voice and Swallowing Center, 2005)

Medical Treatment • Reflux may be a contributing factor and a two week trial of medication, dietary and life-style adjustments and perhaps bed positioning may be appropriate to determine reflux’s contribution. • Granulomas should be managed medically as they nearly always spontaneously decapitate in 4 to 6 months. They tend to recur because they are located in an area of constant movement. The first line of treatment should be an antireflux regimen. (Baylor College of Medicine, 1996)

Medical Treatment • Steroid treatment reduces the overlying and sometimes camouflaging inflammation and swelling while leaving the cyst unchanged, thus making its diagnosis easier. • Patients may be placed on a 2 -week period of vocal rest, perhaps accompanied by a high-dose corticosteroid taper. (Schweinfurth and Ossoff, 2005)

Surgical Treatment • Surgery is directed at removing only the mucosal lesion and preserving as much of the intermediate and deep layers of the vocal fold as possible. • Surgery is performed when the nodules or polyps are very large or have existed for a long time and if the lesion extends deeper into the layers of the vocal fold. • Surgery is rarely used with children. • Patients experience a substantial improvement. If deep lesions are present bilaterally, the physician needs to be extremely prudent. Waiting to see if stiffness develops from a deep dissection on one side may be the better part of valor. (Baylor College of Medicine, 1996)

Surgical Complications • Complications are related either to laryngoscopy or to vocal fold mucosal injury. • Pressure effects from suspension laryngoscopy may result in tongue numbness, altered taste, and oropharyngeal, mucosal, and dental injuries. • Deep-plane dissection or exposure of the vocal ligament can result in scarring and fibrosis of the mucosa with loss of mucosal wave and glottal insufficiency. • Injudicious use of the laser can result in a wide zone of thermal damage with mucosal scarring and fibrosis, unintended burn injuries, and endotracheal tube fires. (Schweinfurth and Ossoff, 2005)

Microflap Techniques • The use of microflap techniques avoids a raw mucosal surface that heals by secondary intention. Avoidance of the deeper layers of the lamina propria and vocal ligament minimizes the fibroblastic response. • Using the microflap technique, Courey et al found that 85% of patients with an absent wave preoperatively regained their mucosal wave, while 97% percent of patients with an intact preoperative wave retained this important parameter. • Blinded comparison of preoperative and postoperative voice samples from this series showed that the postoperative voice was rated as better in 100% (48 of 48) of patients. (Schweinfurth & Ossoff, 2005)

"Vocal Cord/Vocal Fold Stripping" • According to current best practices, there is no role for a type of surgery called "vocal cord/vocal fold stripping" for the treatment of benign vocal fold lesions. (The Voice Problem Website, 2004)

References American Academy of Otolaryngology−Head and Neck Surgery. (2005). Fact Sheet: Understanding Vocal Fold (Cord) Lesions. Retrieved July 6, 2005, from http: //www. entnet. org/healthinfo/throat/Vocal-Cord. Lesions. cfm Baylor College of Medicine. (1996). Disorders of Speech and Swallowing. Retrieved July 6, 2005, from http: //www. bcm. edu/oto/studs/speech. html Buckmire, R. (2003). Vocal Polyps and Nodules. Retrieved July 6, 2005, from http: //www. emedicine. com/ent/topic 352. htm Columbia Presbyterian Medical Center. (2002). Retrieved July 6, 2005, from http: //www. entcolumbia. org/tfl. htm Emory Healthcare. (2003). Vocal Fold Nodules, Polyps and Cysts. Retrieved July 6, 2005, from http: //www. emoryhealthcare. org/print/department_Content_print_layout_1_20340. html Ghorayeb, B. (2005). Otolaryngology Houston. Retrieved July 6, 2005, from http: //www. ghorayeb. com/Pictures. html Hauptman. (2005). Hoarseness. Retrieved July 6, 2005, from http: //www. utmb. edu/otoref/Grnds/Hoarseness 050413/Hoarseness-050413. doc Le. Maistre, A. (1994). Respiratory System. Retrieved July 6, 2005, from http: //medic. med. uth. tmc. edu/Lecture/Main/tool 4. html Medtronic ENT. (2005). Retrieved July 6, 2005, from http: //www. xomed. com/xomed_iil_headandneck 1. html Murano E, Hosako-Naito Y, Tayama N, Oka T, Miyaji M, Kumada M, Niimi S. (2001). Bamboo node: primary vocal fold lesion as evidence of autoimmune disease. Journal of Voice, 15, 3, 441 -50. Schweinfurth & Ossoff. (2005). Vocal Fold Cysts. Retrieved July 6, 2005, from http: //www. emedicine. com/ent/topic 604. htm Stemple, Glaze, & Klaben. (2000). Clinical Voice Pathology. (3 rd ed. ) Singular: San Diego. The Voice Problem Website. (2004). Retrieved July 6, 2005, from http: //www. voiceproblem. org/disorders/vflesions/index. asp Vocal Fold Cysts. (n. d. ). Retrieved July 6, 2005, from http: //sprojects. mmi. mcgill. ca/Larynx/clinic/case 2/ccvcysts%20(dd). htm Voice and Swallowing Center. (2005). Retrieved July 6, 2005, from http: //www. voiceandswallowing. com/Voicediag_strob. html