Vocal Polyps and Nodules Workup

  • Author: Robert A Buckmire, MD; Chief Editor: Arlen D Meyers, MD, MBA   more...
 
Updated: Nov 21, 2011
 

Other Tests

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.

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Diagnostic Procedures

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.

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Histologic Findings

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."[13]

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.[6]

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Contributor Information and Disclosures
Author

Robert A Buckmire, MD  Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina; Chief, Division of Voice and Swallowing Disorders, Director, University of North Carolina Voice Center

Robert A Buckmire, MD is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, and National Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

John Schweinfurth, MD  Professor, Department of Otolaryngology, University of Mississippi Medical Center

John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, American Laryngological Association, American Medical Association, and Triological Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Robert M Kellman, MD  Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University

Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, American Neurotology Society, American Rhinologic Society, American Society for Head and Neck Surgery, Medical Society of the State of New York, and Triological Society

Disclosure: GE Healthcare Honoraria Review panel membership; Revent Medical Honoraria Review panel membership

Christopher L Slack, MD  Private Practice in Otolaryngology and Facial Plastic Surgery, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders

Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA  Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society

Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation Unrestricted gift Unknown; Axis Three Corporation Ownership interest Consulting; Omni Biosciences Ownership interest Consulting; Sentegra Ownership interest Board membership; Syndicom Ownership interest Consulting; Oxlo Consulting; Medvoy Ownership interest Management position; Cerescan Imaging Honoraria Consulting; GYRUS ACMI Honoraria Consulting

Additional Contributors

Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.

References

  1. 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. Nov 14 2011;[Medline].

  2. 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. Oct 2011;19(5):583-7. [Medline].

  3. 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. Nov 2011;25(6):743-50. [Medline].

  4. Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol. Sep 1995;104(9 Pt 1):698-703. [Medline].

  5. 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. Mar 1999;13(1):128-42. [Medline].

  6. Gray SD, Titze I, Lusk RP. Electron microscopy of hyperphonated canine vocal cords. J Voice. 1987;1(1):109-115.

  7. 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. Jun 2000;14(2):240-6. [Medline].

  8. Shah RK, Woodnorth GH, Glynn A, et al. Pediatric vocal nodules: correlation with perceptual voice analysis. Int J Pediatr Otorhinolaryngol. Jul 2005;69(7):903-9. [Medline].

  9. Roy N, Holt KI, Redmond S, et al. Behavioral characteristics of children with vocal fold nodules. J Voice. Mar 2007;21(2):157-68. [Medline].

  10. Kuhn J, Toohill RJ, Ulualp SO, et al. Pharyngeal acid reflux events in patients with vocal cord nodules. Laryngoscope. Aug 1998;108(8 Pt 1):1146-9. [Medline].

  11. Czerwonka L, Jiang JJ, Tao C. Vocal nodules and edema may be due to vibration-induced rises in capillary pressure. Laryngoscope. Apr 2008;118(4):748-52. [Medline].

  12. 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. Sep 2011;268(9):1321-7. [Medline].

  13. Gray SD, Hammond E, Hanson DF. Benign pathologic responses of the larynx. Ann Otol Rhinol Laryngol. Jan 1995;104(1):13-8. [Medline].

  14. Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of Vocal Fold Polyps With Conservative Treatment. J Voice. Nov 12 2011;[Medline].

  15. Benninger MS. Microdissection or microspot CO2 laser for limited vocal fold benign lesions: a prospective randomized trial. Laryngoscope. Feb 2000;110(2 Pt 2 Suppl 92):1-17. [Medline].

  16. 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. Feb 1999;108(2):156-64. [Medline].

  17. Ragab SM, Elsheikh MN, Saafan ME, et al. Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol. Dec 2005;119(12):961-6. [Medline].

  18. Bastian RW. Vocal fold microsurgery in singers. J Voice. Dec 1996;10(4):389-404. [Medline].

  19. Courey MS, Gardner GM, Stone RE, et al. Endoscopic vocal fold microflap: a three-year experience. Ann Otol Rhinol Laryngol. Apr 1995;104(4 Pt 1):267-73. [Medline].

  20. Courey MS, Shohet JA, Scott MA, et al. Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol. Jul 1996;105(7):525-31. [Medline].

  21. Dikkers FG, Nikkels PG. Lamina propria of the mucosa of benign lesions of the vocal folds. Laryngoscope. Oct 1999;109(10):1684-9. [Medline].

  22. Hochman II, Zeitels SM. Phonomicrosurgical management of vocal fold polyps: the subepithelial microflap resection technique. J Voice. Mar 2000;14(1):112-8. [Medline].

  23. Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol Rhinol Laryngol. Jul-Aug 1982;91(4 Pt 1):378-81. [Medline].

  24. Kotby MN, Nassar AM, Seif EI, et al. Ultrastructural features of vocal fold nodules and polyps. Acta Otolaryngol. May-Jun 1988;105(5-6):477-82. [Medline].

 
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Vocal fold polyp (VFP) found during office videostroboscopy.
This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.
This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).
Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from office examination of the same patient as in Image 3, 6 days following VFP removal. Note the straight edge of the vocal fold (right side of image).
Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen. Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.
In this patient with hoarseness, opposing nodules are clearly seen at the anterior one third of the true vocal cords. These responded nicely to outpatient nonsurgical treatment (voice therapy). Video courtesy of Vijay R Ramakrishnan, MD.
 
 
 
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