Most vocal cord nodules, polyps, and the condition known as Reinke edema arise as a result of repetitive trauma to the vocal cords, which is known as phonotrauma, and is associated with a local inflammatory response. Shear forces occur during phonation at the area of maximal wave amplitude, which is the border of the anterior and middle third of the vocal fold. Hence, vocal pathology secondary to phonotrauma tends to occur at this site.
Dikkers FG, Nikkels PG. Lamina propria of the mucosa of benign lesions of the vocal cords. Laryngoscope
. (Study demonstrating correlation between duration and pattern of phonotrauma and the histopathology of benign vocal cord lesions.)
Verdolini K, Rosen CA, Branski RC, Hebda PA. Shifts in biochemical markers associated with wound healing in laryngeal secretions following phonotrauma: a preliminary study. Ann Otol Rhinol Laryngol
. (Study demonstrating elevation of markers of acute inflammation in the vocal folds following prolonged voice use.)
- Usually affects children or individuals who use their voices professionally.
- History of voice abuse common, such as frequent shouting in a young child.
- Bilateral, pale lesions at the junction of the anterior one third and posterior two thirds of the vocal cords.
Vocal cord nodules are the most common cause of persistent dysphonia in children. They are also a frequent cause of deterioration in the voice quality of individuals who use their voices professionally, particularly singers; these nodules are commonly referred to as “singers' nodules.” Treatment strategies should be conservative; speech therapy is the primary treatment. The patient is taught how to use the voice appropriately, which often promotes regression of the vocal cord nodules.
Laryngoscopy clearly shows the presence of small, well-defined vocal cord lesions. These lesions are distinguishable from the normal vocal fold by their whitish hue and are most commonly found at the junction of the anterior third and posterior two thirds of the vocal fold. They are bilateral, though often asymmetric.
Speech therapy should be used as a first-line treatment. It is the mainstay of treatment in both children and adults. Photodocumentation of the nodules in voice clinic indicates the treatment progress and aids patient compliance during speech therapy.
Microlaryngoscopy should be performed under the following circumstances: (1) vocal cord nodules are suspected in a child, but the age or noncompliance of the patient prevents examination; and (2) in adults, either when microsurgical excision of the nodules is considered or when the diagnosis is not clear. Nodules may be excised using appropriate microsurgical instruments, or vaporized using a pulsed CO2 laser.
Benninger MS. Microdissection or microspot CO2
laser for limited vocal fold benign lesions: a prospective randomized trial. Laryngoscope
. (Study establishing the efficacy of the CO2
laser in the treatment of superficial benign vocal fold lesions.)
Kunduk M, Mcwhorter AJ. True vocal fold nodules: the role of differential diagnosis. Curr Opin Otolaryngol Head Neck Surg 2009;17:449–452. (A current update of diagnosis and treatment of nodules.)
- Usually unilateral, pedunculated lesions.
- Associated with smoking and voice abuse.
- Located throughout the glottis, particularly between the anterior and middle thirds of the vocal folds.
Vocal cord polyps are most commonly found in men with a history of voice abuse and heavy smoking. The treatment is most often surgical to confirm the diagnosis, exclude any coexisting malignant neoplasms, and provide resolution. Conservative voice therapy is often not successful.
Polyps are pedunculated, unilateral lesions that are morphologically similar to the laryngeal epithelium. They often occur on the true vocal folds and may have noticeable vascular markings. They generally occur at the point of maximal vibration, the middle of the true junction of the anterior and middle thirds of the vocal fold, in contrast to vocal process granulomas.
The treatment involves a microlaryngoscopic examination of the larynx plus excision of the polyp both to confirm the diagnosis and to exclude any other coexistent pathology. A large polyp may conceal an occult, early laryngeal squamous cell carcinoma. Excision is performed using appropriate microsurgical instruments, or laser. Smoking and vocal abuse should also be addressed.
Vocal Process Granulomas (Intubation Granuloma)
- Arise posteriorly, adjacent to the vocal process.
- Frequent history of intubation trauma.
Vocal process granulomas are often associated with endotracheal intubation. There is an association with gastroesophageal reflux.
Patients present with dysphonia and a combination of other symptoms, including odynophagia, cough, and globus symptoms. Vocal process granulomas are usually unilateral and are related to the vocal processes of arytenoid cartilage with an underlying perichondritis. Forceful glottic closure further traumatizes the lesion and is likely to be a factor in its failure to resolve.
The initial focus of treatment should be on conservative voice therapy, combined with aggressive antireflux therapy. Antibiotics and systemic steroids may be of use. Microlaryngoscopy is rarely required to exclude malignancy. Recurrence after surgical excision is common; the incidence may be reduced by the concomitant use of botulinum toxin to paralyze the affected hemilarynx and hence prevent further vocal process trauma.
- Strong association with cigarette smoking and heavy voice use.
- Diffuse edematous changes of the vocal cords.
- Usually bilateral.
Although a definite mechanism of injury has not been identified, there is a very strong association of cigarette smoking with the development of Reinke edema. The distinguishing feature of this condition is the diffuse nature of the swelling, which is an accumulation of fluid in the superficial layer of the lamina propria of the vocal fold.
Patients present with diffuse swelling of the vocal cords, which is usually bilateral. The cords feel boggy when manipulated during microlaryngoscopy, and the swelling can be rolled beneath the instruments.
Smoking cessation is the key to resolving Reinke edema. In mild cases, speech therapy may also prevent the need for surgical treatment. However, severe Reinke edema, which is intractable to speech therapy, may have to be treated surgically. Surgical measures involve making a lateral incision on the superior aspect of the vocal fold and extravasating the fluid before carefully replacing the mucosa. Trimming the excess mucosa may be required, but care must be taken not to injure the underlying vocal ligament.
Mucous glands are found throughout the larynx, with the exception of the medial edge of the vocal cord, and associated cysts may therefore occur also throughout the larynx. Their presentation and treatment are dictated primarily by their site; therefore, they are dealt with here on this basis.
- Often found within the middle third of the vocal cords.
- Unilateral, associated small area of hyperkeratosis on opposite cord.
- Do not respond to speech therapy.
Intracordal cysts may be simple mucous retention cysts or epidermoid cysts containing keratin.
Laryngoscopy reveals a unilateral cyst, usually of the middle third of the vocal cord with a corresponding area of hyperkeratosis on the opposite cord. Stroboscopy reveals loss of the mucosal wave at the site of the lesion.
Intracordal cysts do not respond to voice therapy and should be excised with phonosurgical instruments, using a local flap technique.
- May be congenital or acquired.
- Adults generally present with voice change.
- Children commonly present with airway compromise.
- Unilateral supraglottic mass, overlying mucosa unremarkable.
The laryngeal saccule arises as a diverticulum from the anterior end of the laryngeal ventricle. It extends upward between the false vocal fold and the inner surface of the thyroid cartilage and contains mucus-secreting glands. A saccular cyst occurs as a result of obstruction of these glands, which may be secondary to a congenital anomaly or acquired.
Examination reveals expansion of the aryepiglottic fold by the cyst within it, which may extend into the neck through the thyrohyoid membrane. Computed tomography (CT) imaging demonstrates a cyst expanding the supraglottis; the absence of air within the lesion distinguishes it from a laryngocele. Mesodermal tissue may be apparent in the wall of congenital saccular cysts and may influence the surgical approach.
Most saccular cysts may be managed endoscopically, either by marsupialization or excision, generally with the aid of a CO2 laser. Lesions extending beyond the larynx and congenital cysts containing mesodermal elements are optimally managed by a transcervical approach. The excised cyst should undergo histologic examination. Cysts displaying oncocytic metaplasia (oncocytic cysts) are more often multiple and more prone to recurrence.
- Patient age at onset is usually 2–4 years.
- Rare after age 40.
- Multiple warty lesions of “true” and “false” vocal cords.
Recurrent respiratory papillomatosis (RRP) is characterized by the development of exophytic warty lesions, primarily within the larynx, but which may be found in the nose, pharynx, and trachea. The condition is benign but associated with significant morbidity and mortality.
There is a bimodal distribution; juvenile-onset RRP is generally diagnosed between the ages of 2 and 4 years and is more aggressive than adult-onset disease, which peaks in the third decade.
RRP is caused by human papilloma virus (HPV), subtypes 6 and 11, and rarely by subtype 16. HPV 6 and 11 are also the most common causes of genital papillomatosis, and transmission from the genital tract is believed to be the primary cause of RRP.
Vertical transmission of the virus from mother to child occurs either as ascending uterine infection or through direct contact in the birth canal. However, the risk of a child developing RRP after vaginal delivery in the presence of a condyloma acuminatum is estimated at only 1 in 400. The factors dictating susceptibility remain under investigation.
Papillomas typically appear as multiple, friable, irregular warty growths in the larynx. These lesions particularly affect the “true” and “false” vocal cords, but are often found at areas of constriction in the upper aerodigestive tract where there is increased air turbulence, drying, and cooling of mucosa, and at the change from ciliary to squamous epithelium.
Presentation depends on the site of the lesion. Patients with glottic lesions present with dysphonia; those with supraglottic lesions may present with stridor.
HPV cannot be eradicated from the larynx. Even after spontaneous remission, HPV DNA can be detected in otherwise normal mucosa. The aim of treatment is therefore to remove symptomatic lesions with minimal morbidity. Suitable techniques include CO2 laser resection, cold steel dissection, or use of the laryngeal microdebrider. Tracheostomy should be avoided and is associated with distal airway involvement. Adjuvant treatments include intralaryngeal injection of cidofovir (Vistide), which is an off-label use with no conclusive evidence of efficacy, although an excellent response has been noted in some patients.
A recent licensing of prophylactic HPV vaccines may well have a role in prevention of RRP.
Spontaneous remission does occur, but recurrence can arise many years later. There is a small risk of malignant change.
Derkay CS, Darrow DH. Recurrent respiratory papillomatosis. Ann Otol Rhinol Laryngol
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