History
A thorough history of all patients presenting with a voice symptom is essential. A complete medical history must include a chief problem and history of present illness, which requires the patient to articulate the exact quality, timing, frequency, and task-specific nature as well as exacerbating or ameliorating factors, of their voice problems. A review of past medical and social history and present medications is necessary to identify potential contributing factors, such as thyroid disease, smoking history, caffeine use, and/or use of prescription or over-the-counter (OTC) medications. A unique portion of the vocal history is the careful attention paid to patterns of vocal behavior (including occupational use and recreational and social behaviors) that may provide clues to contributory vocal overuse, vocal misuse, and vocal abuse (ie, phonotrauma) as well as the state of vocal hygiene.
Careful attention to voice-use history in immediate proximity to the onset of the symptom can offer clues to the nature of the problem. In the case of singers, understanding the patient's singing history and level of vocal training (as well as performance style and setting) is essential in formulating an accurate differential diagnosis.
A characteristic history of present illness referable to either vocal fold polyps (VFPs) or vocal fold nodules (VFNs) may include subjective symptoms of breathy, weak, raspy, or hoarse voice quality. The patient may also report a change in the baseline vocal pitch with limited vocal range. Patients may report increased effort and fatigue associated with voice production. Singers commonly note decreased voice quality and singing endurance, loss of upper registers, and difficulty with precise vocal control.
Physical Examination
The clinical presentation of benign vocal fold lesions is most commonly associated with voice change. [9] Typical presenting symptoms include generalized and persistent hoarseness, change in voice quality, and increased effort in producing the voice. The laryngeal examination may show either unilateral or bilateral lesions of the TVF.
Because it has the ability to demonstrate subtle differences in the appearance, pliability, and mucosal wave characteristics (ie, symmetry, periodicity, amplitude, vertical phase difference) of the TVF cover, videostroboscopy is far more sensitive for detecting and differentiating laryngeal lesions when compared with other indirect laryngoscopy techniques.
Diagnostically, nodules do not tend to significantly disturb propagation of the mucosal wave on stroboscopy, but they may contribute to incomplete closure during the glottic cycle, depending upon their size.
Polyps have various appearances but generally are unilateral and much more likely to interfere with proper closure of the glottis during phonation; they also have a tendency to cause a more noticeable change in the quality of the speaking/singing voice. The potential location of polyps on the superior and infraglottic (as well as the medial) surface of the cord makes the ability to separately visualize both upper and lower vertical lips of the cord on videostroboscopic examination all the more important to their detection.
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Vocal fold polyp (VFP) found during office videostroboscopy.
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This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.
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This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).
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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).
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Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen. Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.
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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.
