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Vascular Lesions of the Vocal Fold

  • Author: John Schweinfurth, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
 
Updated: Mar 25, 2016
 

Background

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.

In a retrospective study of 499 vocal performers, Tang et al found that the hemorrhage rate in those with vocal fold varices was 2.68% at 12 months, versus 0.8% in performers without varices. Based on a Cox proportional hazard regression analysis, performers with varices were reported to have a hazard ratio of 10.1 for hemorrhage development compared with the other performers.[1]

An image depicting vascular lesions of the vocal fold can be seen below.

Vocal cords in a performing artist with minor diff Vocal cords in a performing artist with minor difficulty singing. Videostroboscopy revealed fullness of the entire fold as well as slightly decreased mucosal wave.
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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.

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Epidemiology

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.[2] Prevalence in the general population is unknown.

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Etiology

Formation of varices is related to vocal use, abuse, and trauma.[3] 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.

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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.

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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.

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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.

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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.[4]

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Contraindications

Please see the Preoperative details section.

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Contributor Information and Disclosures
Author

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 Laryngological Association, Triological Society, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Robert H Ossoff, DMD, MD Maness Professor of Laryngology and Voice, Department of Otolaryngology, Executive Medical Director, Vanderbilt Voice Center, Vanderbilt Medical Center

Robert H Ossoff, DMD, MD is a member of the following medical societies: American Head and Neck Society, 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, The Triological Society, American Medical Association, American Rhinologic Society, American Society for Laser Medicine and Surgery, Sigma Xi, Southeastern Surgical Congress

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

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 Head and Neck Society, American Rhinologic Society, Triological Society, American Neurotology Society, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Medical Society of the State of New York

Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, 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, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;SymbiaAllergySolutions<br/>Received income in an amount equal to or greater than $250 from: Symbia<br/>Received from Allergy Solutions, Inc for board membership; Received honoraria from RxRevu for chief medical editor; Received salary from Medvoy for founder and president; Received consulting fee from Corvectra for senior medical advisor; Received ownership interest from Cerescan for consulting; Received consulting fee from Essiahealth for advisor; Received consulting fee from Carespan for advisor; Received consulting fee from Covidien for consulting.

Additional Contributors

Clark A Rosen, MD Director, University of Pittsburgh Voice Center; 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, Pennsylvania Medical Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Merz North America Inc<br/>Received consulting fee from Merz North America Inc for consulting; Received consulting fee from Merz North America Inc for speaking and teaching.

References
  1. Tang CG, Askin G, Christos PJ, Sulica L. Vocal fold varices and risk of hemorrhage. Laryngoscope. 2015 Oct 20. [Medline].

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

  3. 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].

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

  5. 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. 2008 May. 117(5):353-8. [Medline].

  6. Burns JA, Friedman AD, Lutch MJ, Zeitels SM. Subepithelial vocal fold infusion: a useful diagnostic and therapeutic technique. Ann Otol Rhinol Laryngol. 2012 Apr. 121(4):224-30. [Medline].

  7. Lennon CJ, Murry T, Sulica L. Vocal fold hemorrhage: factors predicting recurrence. Laryngoscope. 2014 Jan. 124(1):227-32. [Medline].

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

  9. 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. 2003 Jun. 112(6):534-9. [Medline].

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

 
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Vocal cords in a performing artist with minor difficulty singing. Videostroboscopy revealed fullness of the entire fold as well as slightly decreased mucosal wave.
Hemorrhagic polyp on the surface of the true vocal fold in a professional singer. Note the fullness along the medial edge of the true vocal fold in the area of the lesion.
Untreated or recurrent hemorrhage can evolve into a large hemorrhagic polyp. Conservative therapy has little chance of success at this point, and these lesions can lead to scarring if untreated.
 
 
 
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