eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vascular Lesions of the Vocal Fold

Author: John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
Coauthor(s): Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Contributor Information and Disclosures

Updated: Sep 3, 2008

Introduction

Prominent or enlarged blood vessels that exist on the vibratory surface of the vocal fold may eventually cause problems from hemorrhage or mass effect within the lamina propria and may cause dysphonia by disrupting the vibratory pattern and closure of the true vocal folds.

Vascular lesions found within the true vocal fold may threaten the career of a professional vocalist because of recurrent inopportune hemorrhage or scar formation. In the asymptomatic patient, they may create a management dilemma due to the risk of future hemorrhage versus the immediate risks of intervention.

Problem

No widely accepted system of nomenclature is available for vascular lesions. Microvascular lesions of the true vocal folds are known as varices, capillary ectasias, papillary ectasias, capillary and venous lakes, and spider telangiectasias. The anatomic variations based on these terms are subtle, and treatment approaches are similar regardless of the type. A varix is a prominent, dilated, and commonly tortuous vein found on the surface of the vocal fold. Ectasias are distinguished by a coalescent hemangiomatous appearance.

Frequency

Vocal fold varices occur most commonly in female professional vocalists, although they are not rare in males. Postma et al found a prevalence of 3.5% among their patient population, with 14.5% of those cases occurring in female professional voice users.1 Prevalence in the general population is unknown.

Etiology

Formation of varices is related to vocal use, abuse, and trauma. Most patients presenting with symptoms stemming from these lesions are professional voice users. Repeated trauma may lead to new blood vessel formation and weakening of the vessel walls.

Pathophysiology

The immediate cause of vocal fold varices is unknown, although they may originate from shearing stress along the lateral fold near the termination and reversal point of the mucosal wave. A hormonal cause has been postulated because of the prevalence in female singers, but this has not been proven. In addition, physiologic and histologic changes associated with menses may increase the risk of variceal hemorrhage. However, hormonally directed therapy has not been successful in treatment of these lesions. The predilection may be attributable to the unique anatomy and associated mechanics of voice production in female vocalists.

Presentation

The clinical presentation of vocal vascular lesions is highly variable. Vocal fold varices may be entirely asymptomatic, or they may result in dysphonia through hemorrhage and edema, scarring, or mass effect with resultant disruption of mucosal wave. Dysphonia may be severe with an acute, dramatic onset. This presentation typically appears after episodic vocal abuse or straining. Other presentations can be subtle, with patients having an apparently normal voice while being easily fatigued or incurring loss of normal vocal range. Patients with recurrent hemorrhage may relate a history of episodes of hoarseness followed by resolution.

Patients may have completely normal sounding voices with a pronounced varix on the surface of the true vocal fold. Patients presenting immediately after an acute bleed may have extensive ecchymosis and hemosiderosis of the involved true vocal fold. Acute hemorrhage may resolve without event, or it may transform into a hemorrhagic polyp, cyst, or scar, which then causes dysphonia through a mass effect or vibratory margin effects.

In women, the appearance of the lesion may depend on the stage of the menstrual cycle; therefore, periodic examinations may be required to accurately establish severity.

Indications

Indications for surgical intervention in a patient with a vascular lesion of the vocal fold include enlargement of the lesion, recurrent hemorrhage, development of a mass in conjunction with the varix, unacceptable dysphonia, and uncertainty as to the diagnosis.

Relevant Anatomy

Vascular lesions appear on the superior surface of the vocal fold or, less commonly, along the vibratory margin. Because of the large numbers of vascular arcades found in the vocal fold, they are not critical to the blood supply of the tissue. Varices may manifest as abnormally dilated capillary arcades running in the anterior-to-posterior direction or as clusters of capillaries. Another formation is a dot, which represents the tip of a vascular loop rising superficially from the underlying mucosa. Finally, venous lakes may form that are so large as to appear as a chronic area of hemorrhage. Hochman et al postulated that vascular lesions are more likely to form on the superior lateral surface of the vocal fold because of the shearing forces generated by the termination of the mucosal wave at that point.2

Contraindications

Please see the Preoperative details section.

More on Vascular Lesions of the Vocal Fold

Overview: Vascular Lesions of the Vocal Fold
Workup: Vascular Lesions of the Vocal Fold
Treatment: Vascular Lesions of the Vocal Fold
Follow-up: Vascular Lesions of the Vocal Fold
Multimedia: Vascular Lesions of the Vocal Fold
References
[ CLOSE WINDOW ]

References

  1. Postma GN, Courey MS, Ossoff RH. Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol. Jun 1998;107(6):472-6. [Medline].

  2. Hochman I, Sataloff RT, Hillman RE, et al. Ectasias and varices of the vocal fold: clearing the striking zone. Ann Otol Rhinol Laryngol. Jan 1999;108(1):10-6. [Medline].

  3. Ivey CM, Woo P, Altman KW, et al. Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study. Ann Otol Rhinol Laryngol. May 2008;117(5):353-8. [Medline].

  4. Franz P, Aharinejad S. The microvasculature of the larynx: a scanning electron microscopic study. Scanning Microsc. Mar 1994;8(1):125-30; discussion 131. [Medline].

  5. Frenzel H, Kleinsasser O. Ultrastructural study on the small blood vessels of human vocal cords. Arch Otorhinolaryngol. 1982;236(2):147-60. [Medline].

  6. Hsiung MW, Kang BH, Su WF, et al. Clearing microvascular lesions of the true vocal fold with the KTP/532 laser. Ann Otol Rhinol Laryngol. Jun 2003;112(6):534-9. [Medline].

  7. Lin P, Stern JC, Gould WJ. Risk factors and management of vocal fold hemorrhages. J Voice. 1991;5:74-7.

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

vascular lesions of the vocal fold, telangiectasias, capillary ectasias, venous lakes, vascular lesions, vascular malformations, varices, papillary ectasias, capillary lakes, spider telangiectasias, varix, dysphonia, vocal cords, lesions, vocal folds, disphonia, true vocal folds, professional vocalist, professional singer

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

John Schweinfurth, MD, Associate 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, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Robert Ossoff, DMD, MD, MS 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 Bronchoesophagological Association, American College of Chest Physicians, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, Sigma Xi, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine
Clark A Rosen, 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, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

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 Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, 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 unstricted gift unknown

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.