Vascular Lesions of the Vocal Fold Treatment & Management

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.

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. ^[7]

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.

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. ^{[2, 3]}  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. ^[8] Direct surgical excision of the vascular abnormalities is another treatment option. This technique uses cold steel phonomicrosurgical techniques and instruments.

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.

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 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.

A case study by Alighieri et al found that a female, aged 25 years, who underwent vaporization of a true vocal fold varix with a KTP laser was well healed after 6 weeks. Pretreatment, the patient had muscle tension dysphonia, reflux laryngitis, Reinke edema, left vocal fold hypomobility, left vocal fold scarring, bilateral striking zone fullness, bilateral vocal fold stiffness, and a left perpendicular vocal fold varix that, with phonation, became engorged. The individual was treated with bilateral injection of 5-fluorouracil along with KTP vaporization of the varix. Resolution of the varix was found on postoperative day 1, although the left true vocal fold showed mild edema and there was a “slight subepithelial blush anterosuperiorly around an area of laser use.” A blush found on postoperative day 8 indicated that blood was extravasating from the left true vocal fold, but at week 6, videostroboscopy revealed that the edema and erythema had completely resolved. ^[3]

In their study of 11 lesions, Postma et al reported no recurrences with follow-up periods as long as 4.5 years. ^[4] Patients who adhere to principles of healthy voice production and avoid vocal overuse and trauma have an excellent prognosis. However, no long-term studies of the recurrence rates of variceal lesions are available.

A retrospective study by Lennon et al indicated that in patients who have experienced vocal fold hemorrhage, the presence of varices is a risk factor for recurrence. The study included 47 patients with vocal fold hemorrhage who were found to have varices, mucosal lesions, and/or vocal fold paresis. Twelve patients (26%) suffered repeat hemorrhage, including 48% of patients with a varix. Multivariate logistic regression analysis indicated that varix was the only condition significantly associated with recurrence. ^[9]

The exact cause of vascular lesions of the vocal fold is still largely unknown; therefore, identifying patients at risk is difficult. The issue of hormonal therapy also remains unresolved. Some surgeons differ on the use of the laser as opposed to cold dissection in surgical treatment of these lesions.