Vocal Polyps and Nodules Workup
- Author: Robert A Buckmire, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
Gomaa et al studied the value of high-resolution ultrasonography in the diagnosis of laryngeal lesions that had already been detected with rigid endoscopy. They concluded that it is an alternative technique for diagnosing some lesions, particularly small subglottic lesions.
No specific laboratory studies are singularly diagnostic of these conditions. Measurements within a voice laboratory, including aerodynamic, acoustic, and videostroboscopic baselines (as well as a high-quality audio recording of the patient's voice) are all helpful for appropriate pretreatment and posttreatment documentation. Lastly, clinician and patient perceptual measures are commonly performed to more subjectively gauge the impact of the vocal disability and improvement.
Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared with other indirect laryngoscopy techniques because of its ability to demonstrate subtle differences in the appearance, pliability, and mucosal wave characteristics (ie, symmetry, periodicity, amplitude, vertical phase difference) of the TVF cover.
On a structural level, a significant body of work has been performed to identify pathologic structural characteristics of benign vocal cord lesions and from this to infer pathogenesis. Immunohistochemical characterization of the extracellular matrix of excised, clinically diagnosed, benign laryngeal lesions revealed nodules to more commonly have a thickened basement membrane zone (BMZ) and dense fibronectin arrangement within the superficial lamina propria (LP), as compared with those diagnosed as polyps. These polypoid lesions tended to exhibit an unaltered BMZ thickness and to have fibronectin depositions clustered around neovasculature.
These patterns of structural deviation from the normal layered microanatomy of the TVF have been reported previously. In 1995, Gray et al formulated a theory of causation and pathologic response, hypothesizing as follows: "The vocal folds sustain enough injury to lead to BMZ disruption and injury to the superficial layer of the lamina propria. The injury, if repetitive, leads to aberrant healing and a fibroblastic response involving increased fibronectin deposition."
On an ultrastructural level, nodules tend to demonstrate epithelial changes in the form of increased thickness, gaping of the intracellular junctions, and absence of the basal lamina. These changes were much less prominent in the polyps examined. Conversely, polyps tended to show variable pathologic patterns; some demonstrated marked vascularity, and others had hyaline stromal changes. The authors interpreted differences as perhaps indicative of a more long-standing exposure to injurious agents in the case of VFNs; they interpreted "microstromal hemorrhages" as potentially playing a role in the formation of VFPs. Gray et al speculated that the heterogeneous findings might be due to the stage in the life cycle of the polyp examined.
A prospective, histopathologic study by Effat and Milad indicated that in comparison with vocal polyps in nonsmokers, those in people who do smoke tend to be larger and to display increased keratinization, dysplasia, basement membrane thinning, and hyaline degeneration. The study examined polyps from 29 patients, including smokers and nonsmokers.
El Uali Abeida M, Fernández Liesa R, Vallés Varela H, García Campayo J, Rueda Gormedino P, Ortiz García A. Study of the Influence of Psychological Factors in the Etiology of Vocal Nodules in Women. J Voice. 2011 Nov 14. [Medline].
Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The Clinicopathologic Spectrum of Benign Mass Lesions of the Vocal Fold due to Vocal Abuse. Int J Surg Pathol. 2011 Oct. 19(5):583-7. [Medline].
Yamasaki R, Behlau M, Brasil Ode O, Yamashita H. MRI anatomical and morphological differences in the vocal tract between dysphonic and normal adult women. J Voice. 2011 Nov. 25(6):743-50. [Medline].
Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol. 1995 Sep. 104(9 Pt 1):698-703. [Medline].
Hogikyan ND, Appel S, Guinn LW, et al. Vocal fold nodules in adult singers: regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing. J Voice. 1999 Mar. 13(1):128-42. [Medline].
Gray SD, Titze I, Lusk RP. Electron microscopy of hyperphonated canine vocal cords. J Voice. 1987. 1(1):109-115.
Andrade DF, Heuer R, Hockstein NE, et al. The frequency of hard glottal attacks in patients with muscle tension dysphonia, unilateral benign masses and bilateral benign masses. J Voice. 2000 Jun. 14(2):240-6. [Medline].
Shah RK, Woodnorth GH, Glynn A, et al. Pediatric vocal nodules: correlation with perceptual voice analysis. Int J Pediatr Otorhinolaryngol. 2005 Jul. 69(7):903-9. [Medline].
Roy N, Holt KI, Redmond S, et al. Behavioral characteristics of children with vocal fold nodules. J Voice. 2007 Mar. 21(2):157-68. [Medline].
Kuhn J, Toohill RJ, Ulualp SO, et al. Pharyngeal acid reflux events in patients with vocal cord nodules. Laryngoscope. 1998 Aug. 108(8 Pt 1):1146-9. [Medline].
Czerwonka L, Jiang JJ, Tao C. Vocal nodules and edema may be due to vibration-induced rises in capillary pressure. Laryngoscope. 2008 Apr. 118(4):748-52. [Medline].
Cho KJ, Nam IC, Hwang YS, Shim MR, Park JO, Cho JH, et al. Analysis of factors influencing voice quality and therapeutic approaches in vocal polyp patients. Eur Arch Otorhinolaryngol. 2011 Sep. 268(9):1321-7. [Medline].
Gomaa MA, Hammad MS, Mamdoh H, Osman N, Eissawy MG. Value of high resolution ultrasonography in assessment of laryngeal lesions. Otolaryngol Pol. 2013 Sep-Oct. 67(5):252-6. [Medline].
Gray SD, Hammond E, Hanson DF. Benign pathologic responses of the larynx. Ann Otol Rhinol Laryngol. 1995 Jan. 104(1):13-8. [Medline].
Effat KG, Milad M. A comparative histopathological study of vocal fold polyps in smokers versus non-smokers. J Laryngol Otol. 2015 May. 129 (5):484-8. [Medline].
Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of Vocal Fold Polyps With Conservative Treatment. J Voice. 2011 Nov 12. [Medline].
Wang CT, Liao LJ, Lai MS, Cheng PW. Comparison of benign lesion regression following vocal fold steroid injection and vocal hygiene education. Laryngoscope. 2013 Jul 30. [Medline].
Jensen JB, Rasmussen N. Phonosurgery of vocal fold polyps, cysts and nodules is beneficial. Dan Med J. 2013 Feb. 60(2):A4577. [Medline].
Benninger MS. Microdissection or microspot CO2 laser for limited vocal fold benign lesions: a prospective randomized trial. Laryngoscope. 2000 Feb. 110(2 Pt 2 Suppl 92):1-17. [Medline].
Remacle M, Lawson G, Watelet JB. Carbon dioxide laser microsurgery of benign vocal fold lesions: indications, techniques, and results in 251 patients. Ann Otol Rhinol Laryngol. 1999 Feb. 108(2):156-64. [Medline].
Mizuta M, Hiwatashi N, Kobayashi T, Kaneko M, Tateya I, Hirano S. Comparison of vocal outcomes after angiolytic laser surgery and microflap surgery for vocal polyps. Auris Nasus Larynx. 2015 Dec. 42 (6):453-7. [Medline].
Ragab SM, Elsheikh MN, Saafan ME, et al. Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol. 2005 Dec. 119(12):961-6. [Medline].
Bastian RW. Vocal fold microsurgery in singers. J Voice. 1996 Dec. 10(4):389-404. [Medline].
Courey MS, Gardner GM, Stone RE, et al. Endoscopic vocal fold microflap: a three-year experience. Ann Otol Rhinol Laryngol. 1995 Apr. 104(4 Pt 1):267-73. [Medline].
Courey MS, Shohet JA, Scott MA, et al. Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol. 1996 Jul. 105(7):525-31. [Medline].
Dikkers FG, Nikkels PG. Lamina propria of the mucosa of benign lesions of the vocal folds. Laryngoscope. 1999 Oct. 109(10):1684-9. [Medline].
Hochman II, Zeitels SM. Phonomicrosurgical management of vocal fold polyps: the subepithelial microflap resection technique. J Voice. 2000 Mar. 14(1):112-8. [Medline].
Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol Rhinol Laryngol. 1982 Jul-Aug. 91(4 Pt 1):378-81. [Medline].
Kotby MN, Nassar AM, Seif EI, et al. Ultrastructural features of vocal fold nodules and polyps. Acta Otolaryngol. 1988 May-Jun. 105(5-6):477-82. [Medline].