eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vascular Lesions of the Vocal Fold: Treatment

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

Treatment

Medical Therapy

Use of medications with anticoagulant properties should cease if they are not medically necessary. Treat any conditions predisposing to trauma and irritation (eg, cough, reflux disease) with the appropriate therapy. Hormonal therapy has not been proven effective in either prevention or treatment of varices. Voice use should be modified, limiting the frequency, intensity, and duration of voice use and maximizing vocal rest. Hard glottal attacks should be avoided and easy-onset patterns used. Applicable speech therapy techniques include direct, indirect, and confidential voice therapy (see the eMedicine article Voice Therapy).

Surgical Therapy

Surgery is recommended for recurrent hemorrhage, enlargement of the lesion, development of an associated mass, or intolerable dysphonia. In addition, in some instances, an acute hemorrhage may require evacuation to prevent formation of a hemorrhagic polyp. Surgical candidates must be willing to postpone speaking and singing engagements for at least 3 months postoperatively. Intervention in an asymptomatic patient should be approached with caution, as the potential always exists for a worse voice postoperatively.

Office-based pulse dye laser is an alternative for patients with small microvascular lesions. Ivey noted a 70% improvement in 11 if 29 lesions after 1 or 2 treatments.3

Preoperative Details

Evaluate patients presenting with dysphonia by indirect laryngoscopy and videostroboscopy, with particular attention paid to vocal fold mobility, glottic closure, and presence, amplitude, and symmetry of the mucosal wave. Ensure that any concurrent medical conditions affecting the voice (eg, reflux laryngitis, allergic rhinitis) are evaluated and treated. In addition, the stage of the menstrual cycle in women can be important for accurate gauging of clinical severity and timing of intervention. Often the size and nature of the blood vessels of the vocal folds increase and become more fragile in the premenstrual period (approximately 5 days prior to menses).

Maximally reduce all known sources of mechanical trauma prior to considering surgical therapy to determine reversibility and to hopefully prevent a postoperative recurrence. This is accomplished in part by medical and speech therapy directed at reducing vocal trauma through improved technique and vocal hygiene. Surgery is reserved for lesions that show no reversibility with exhaustive medical and speech therapy.

Intraoperative Details

Surgical technique begins by identifying the feeding and emptying vessels, which are then photocoagulated sequentially with a carbon dioxide laser or specific photoangiolytic lasers such as the KTP (potassium titanyl phosphate) or 585 nm pulsed dye laser. The primary lesion may then be excised via a microflap approach or photocoagulated, depending upon its size. The goal of surgical excision is preservation of the mucosal cover with minimal disruption of the underlying tissue. Scar formation should not be a factor if the power is kept at 1-2 W, pulse width at 0.1 second, and spot size at 300-400 µm. Use of iced saline and/or topical 1:10,000 epinephrine solution can be beneficial in hemostatic control and possibly in limiting spread of the zone of thermal injury. Direct surgical excision of the vascular abnormalities is another treatment option. This technique uses cold steel phonomicrosurgical techniques and instruments.

Postoperative Details

Place patients on strict voice rest for 2 weeks after microflap surgery. Patients with more extensive dissections may be placed on a short course of corticosteroids. All patients receive antibiotics and a mild narcotic for pain relief. Patients with symptoms or findings of laryngopharyngeal reflux are treated medically. Encourage patients to avoid aspirin and nonsteroidal anti-inflammatory agents in the first 2 weeks postoperatively.

Follow-up

Reexamine patients at 2, 4, 8, and 12 weeks postoperatively. Perform videostroboscopy at the 2-week postoperative visit. The patient resumes therapy with a speech pathologist at this point. A gradual return to voice use occurs over the first few weeks. Singers may begin to work with a vocal pedagogue (ie, singing teacher) after 1 month. Most patients can expect 90% of their functional surgical result after approximately 3 months.

Complications

Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may cause tongue numbness, altered taste, and oropharyngeal, mucosal, and dental injuries. Deep plane dissection or exposure of the vocal ligament can result in scarring and fibrosis of the mucosa with loss of mucosal wave and glottal insufficiency. Injudicious use of the laser can result in a wide zone of thermal damage with mucosal scarring and fibrosis and in unintended burn injuries and endotracheal tube fires.

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
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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.

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Further Reading

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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

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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

 
 
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