CHAPTER 62 Benign Vocal Fold Mucosal Disorders

• The two most common risks for vocal fold mucosal vibratory injury are high intrinsic tendency to use the voice (talkativeness, extroversion) and a high extrinsic “opportunity or necessity” to use the voice (driven by occupation, family needs, social activities, and avocations).

• Visible vocal fold lesions from overuse may not cause an audible change in the speaking voice.

• Visible vocal fold lesions causing phonatory mismatch at the free margin or mucosal stiffness are “always” detectable audibly, in the singing voice, provided that the examiner knows how to elicit upper-range vocal tasks.

• Small or subtle vocal fold lesions may escape visual detection until the larynx is viewed with high magnification, sometimes requiring topical anesthesia, with vocalization in the upper range.

• With few exceptions, brief initial speech pathology evaluation and treatment are indicated when vocal fold injury is clearly due to overuse, misuse, or abuse of the voice. Speech therapy alone may suffice if vocal improvement is adequate to patient needs, otherwise it serves as preparation for vocal fold microsurgery.

• Key requirements for successful vocal fold microsurgery are (1) detailed knowledge of vocal fold microarchitecture and vibratory physiology to guide surgical precision, (2) proven technical ability of the surgeon, (3) preoperative and postoperative laryngeal videostroboscopy examination to diagnose clearly at patient presentation, and to assess results, with the patient as a participant, after surgery, and (4) access to voice-qualified behavioral (speech pathology) support.

• Singing voice symptoms of mucosal injury are loss of high soft singing, increased day-to-day variability of singing voice capabilities, phonatory onset delays, reduced vocal endurance, and a sense of increased effort.

• Capillary ectasia can be an incidental finding not requiring treatment. Surgical intervention may be indicated, on the other hand, when the ectasia causes one or more of the following: a tendency to decreased vocal endurance (reduced voice use time to huskiness), intermittent bruising, and a hemorrhagic polyp.

• Contact ulcer and granuloma are best thought of as an exuberant healing response to injury. Injury may be from aggressive chronic throat clearing, aggressive coughing, or endotracheal tube injury. Some believe that acid reflux is a major contributor. Treatment is generally supportive over many months during the wait for maturation, pedunculation, and spontaneous detachment; surgical removal is nearly always followed by recurrence.

• Marsupialization of saccular cysts is sometimes followed by recurrence. Therefore, when possible, complete removal of saccular cysts appears to be preferred.

• Recurrent respiratory papillomatosis is caused by the human papillomavirus.

Benign vocal fold mucosal disorders (e.g., vocal nodules, laryngeal polyps, mucosal hemorrhage, intracordal cysts, mucosal bridges, glottic sulci) seem to be caused primarily by vibratory injury (excessive amount and/or manner of voice use). Review of thousands of patients reveals that an expressive, talkative personality correlates best with most of these disorders. Occupational and lifestyle vocal demands appear to be additional but lesser risks, unless these demands are extreme. Occasionally, injury can occur as a “fluke” based on one episode of vocal strain in an otherwise moderate voice user. Cigarette smoking is a cofactor for smoker’s polyps (Reinke’s edema). Infection, allergy, and acid reflux may also potentiate vibratory injury.

Nonsingers with benign vocal fold mucosal disorders present because of change in the sound or capabilities of the speaking voice. By contrast, singers may have no issues with their speaking voices but may seek help because of singing voice limitations, usually in the upper range. Benign vocal fold mucosal disorders are significant because of the importance of spoken or sung communication and the voice’s contribution to identity.

Benign vocal fold mucosal disorders are common. More than 50% of patients seeking medical attention because of voice change have a benign mucosal disorder. Even before the laryngeal videostroboscopy era, when subtle and small lesions may have been missed, Brodnitz ¹ reported that 45% of 977 patients had a diagnosis of nodules, polyps, or polypoid thickening. From the same era (1964-1975), Kleinsasser² reported that slightly more than 50% of 2618 patients seen for a voice complaint had one of these benign entities.

Anatomy and Physiology

The anatomy most relevant to the benign vocal fold mucosal disorders is the microarchitecture of the vocal folds, as seen on whole-organ coronal sections in a study of cancer growth patterns ^3,⁴ and in the work of Hirano.⁵ Medially to laterally, the membranous vocal fold is made up of squamous epithelium, Reinke’s potential space (superficial layer of the lamina propria), the vocal ligament (elastin and collagen fibers), and the thyroarytenoid muscle. Perichondrium and thyroid cartilage provide the lateral boundary of the vocal fold (Fig. 62-1).

Figure 62-1. Cross section of the vocal fold.

The vocal folds move as a whole between abducted and adducted positions for breathing and phonation, respectively. The mucosa (epithelium and superficial layer of the lamina propria [Reinke’s potential space]), which covers the vocal folds, is the chief oscillator during phonation (continuous adduction during expiratory flow of pulmonary air); thus, one might speak of vocal fold mucosal vibration rather than vocal fold vibration. In a canine study that supports this idea, Saito and associates ⁶ placed metal pellets at varying depths into the vocal fold (e.g., epithelially, subepithelially, intramuscularly) and used radiographic stroboscopy to trace their coronal plane trajectories during vibration. Pellet trajectories of the mucosa were far wider than those of the ligament or the muscle. Thus, primarily the vocal fold mucosa oscillates to produce sound.

’The work of Hirano ⁷ provides an explanation for these observations. Hirano described the vocal fold muscle as the body of the fold, the epithelium and superficial layer of the lamina propria (Reinke’s potential space) as the cover, and the intermediate layers of collagenous and elastic tissue (vocal ligament) as the transitional zone (see Fig. 62-1). Because of the different physiologic stiffness characteristics of these layers, they are somewhat decoupled mechanically from each other during phonation. Decoupling is graphically illustrated in Figure 62-2 (mucosa being stretched). This decoupling allows the mucosa to oscillate with some freedom from the ligament and muscle. An analogy can be made to the relative freedom from the paddle experienced by the red rubber ball and elastic band in a child’s paddleball toy. During phonation, pulmonary air power supplied to adducted vocal folds is transduced into acoustic power. To accomplish this, pulmonary air is passed between appropriately adducted vocal folds. At this point, the vocal fold mucosa vibrates passively according to the length, tension, and edge configuration determined by the intrinsic muscles and elastic recoil forces of the vocal fold tissues. Figure 62-3 shows the maximum open and closed phases of one vibratory cycle, as seen during laryngeal videostroboscopy. Further details concerning the mucosa’s vibratory behavior can be found in the works of Baer⁸ and Hirano⁵ and in Chapter 57.

Figure 62-2. Gentle medial retraction shows the relative decoupling of the mucosa from the underlying, nondeformed vocal ligament.

Figure 62-3. The maximum open (A) and closed (B) phases of an apparent single vibratory cycle as seen during videostroboscopy. The moving part is primarily mucosa, with little participation of ligament or muscle.

Other important microanatomy includes glands in the supraglottic, saccular, and infraglottic areas, which produce secretions that bathe the vocal folds during vibration.

Evaluation of the Patient: General Principles

The necessary and sufficient elements for diagnosis and management of benign mucosal disorders are (1) a skillful history, (2) a perceptual assessment of vocal capabilities and limitations, particularly through elicitation of vocal tasks designed to detect mucosal disturbances, and (3) a high-quality laryngeal examination (often including laryngeal videostroboscopy). In addition, certain measures of phonatory function (aerodynamic, acoustic), although not crucial for diagnosis, may be of interest for study, documentation of the disorder’s physiologic effects, and assessment of improvement after treatment.

History

Besides the usual items in the general medical history, the voice history should focus in particular on the following list of items, which may be best captured via use of a questionnaire ^9,¹⁰:

1. Onset and duration of vocal symptoms.

2. Patient beliefs about causes or exacerbating influences.

3. Common symptom complexes.

4. Talkativeness profile (intrinsic, personality-based tendency to use voice).

5. Vocal commitments or activities (extrinsic requirement, invitation, or opportunity to use voice), including voice type and training, if patient is a performer.

6. Other risk factors.

7. Patient perception of the severity of the disorder.

8. Vocal aspirations and consequent motivation for rehabilitation.

Patient Perception of Severity and Vocal Aspirations and Consequent Motivation for Rehabilitation

Exploration of the patient’s perception of the severity of the voice problem, vocal aspirations, and motivation also is important. For example, the clinician may be confronted by a patient who only wants to be reassured that the problem is not cancer. Even with a diagnosis of large smoker’s polyps with severe range virilization and dysphonia, management for such a patient might appropriately be short-term and supportive, consisting primarily of counseling about smoking cessation education. Another patient may have a normal speaking voice but have upper singing voice limitations caused by small nodules. In this patient, therapy might be intense and eventually include surgery for the patient with a normal speaking voice who, to pursue a competitive singing career, must be relieved of extreme upper singing voice limitations due to small nodules.

Vocal Capability Battery

The vocal capability battery is an auditory-perceptual assessment of vocal capabilities and limitations. It assesses, macrophenomenologically, the two crucial questions “What can’t this voice do that it should be able to?” and “What does this voice do that it shouldn’t?” This process involves elicitation of a variety of vocal tasks, followed by auditory-perceptual assessment of the voice production that results. The vocal capability battery is an often-neglected part of the diagnostic process that provides the best means of understanding the nature and severity of the voice disorder. To be most efficient, this part of the diagnostic process is performed by the same clinician who takes the history and performs the laryngeal examination. Alternatively, a second clinician can perform this assessment, but for best results, the findings of vocal capability elicitation are immediately correlated with the other two components of the diagnostic process.

Vocal capability elicitation and interpretation require that the examiner have good pitch-matching abilities, a reasonably normal voice, extensive familiarity with his or her own vocal capabilities (and limitations, if any), intimate familiarity with normal singing voice capabilities according to age, sex, and voice classification, and the willingness to model and elicit with his or her own voice. Also needed is a frequency reference, such as a small electronic keyboard.

In voice clinics where expert vocal capability elicitation and assessment are not available or are not immediately correlated with history and laryngeal examination, clinicians may overlook or reject the power and centrality of this part of the evaluation. They may instead rely on various items of equipment that measure components of vocal output (e.g., acoustic, aerodynamic). Although useful for quantification, documentation, and some biofeedback applications, this equipment is cumbersome and expensive, and the data it collects are time-consuming to interpret and, most importantly, diagnostically weak in comparison with those of the vocal capability battery, which can answer far more quickly, powerfully, and synthetically the question “What’s wrong with this voice?”

The basic vocal capabilities and phenomena to be tested are (1) average or anchor speech frequency, (2) maximum frequency range, (3) projected voice and yell, (4) very-high-frequency, very-low-intensity tasks that detect mucosal disturbances,¹¹ (5) register use and phenomena, (6) maximum phonation time, and (7) instability and tremors.

The ability to perform high-frequency, low-intensity tasks is the single most important part of the vocal capability battery in persons with benign mucosal disturbances. Upon elicitation of these sorts of tasks, mucosal disorders are suggested by a loss of expected range under these performance constraints, as well as onset delays, air escape, and lack of tonal clarity. The clinician should also search for inconsistencies between spoken and sung capabilities and should informally note the patient’s sincerity of effort and skill. Basic vocal capability testing requires only a few minutes to perform because the examiner focuses primarily on the extremes of physical capability and secondarily on vocal skill.

As stated, the vocal capability battery—coupled with the initial voice history and then subsequent laryngeal examination—is crucial in diagnosing a voice disorder and in directing subsequent management. For example, signs of a mucosal disturbance (e.g., detection of air escape, onset delays, loss of clarity and range) during assessment of the ability to perform high-frequency, low-intensity tasks minimize the possibility that a singer’s normal-sounding speaking voice during history-taking will subconsciously bias the clinician to selectively perceive normal vocal folds when, in fact, small vocal nodules are present.^11a The vocal capability battery also provides insight into the severity of the patient’s vocal limitations, which can then be correlated with the visual examination to help determine, along with the patient’s needs and motivation, the intensity and direction of management.

Office Examination of the Larynx

The laryngeal mirror should provide three-dimensional viewing and good color resolution but, in practice, offers poor visualization in many cases. In other cases, visualization is good, but only during phonation, because the view is obstructed by the epiglottis during respiration. In addition, no permanent image of the larynx results from this examination technique. Because the physician must therefore remember the lesion or document it with a simple sketch, precise critique of the effectiveness of the therapy chosen may not be possible. Rigid and also flexible laryngeal scopes often allow a clearer view, particularly during respiration. When used with the naked eye, however, they have similar disadvantages to those of the mirror. The fiberoptic nasolaryngoscope or a newer “chip-tip” video-endoscope is especially important in a patient who is difficult to examine because of unusual anatomy or an exceptional gag reflex. Even with these technologies, however, it is possible to overlook subtle-to-small mucosal changes unless the larynx is topically anesthetized to allow a close approach of the tip of the fiberscope to the vocal folds. With topical anesthesia, the vocal folds, subglottis, and trachea can be examined easily (Fig. 62-4).^12,¹³

Figure 62-4. Three of the most commonly used tools for viewing the larynx: a mirror, a 90-degree telescope, and a flexible fiberoptic nasolaryngoscope. A later addition, the distal chip endoscope, which looks nearly identical but has an internal video chip rather than optics, is supplanting the fiberoptic scope.

Strobe illumination added to any of these examining instruments allows mucosal vibratory dynamics to be evaluated in apparent slow motion (e.g., to understand mucosal scarring, to distinguish cysts from nodules). Adding a video camera and recording device (computer hard drive or tape) to the rigid or flexible scopes brings additional advantages; for example, a patient’s understanding and motivation are facilitated if he or she views the video documented examination. Also, such recordings enable other clinicians (otolaryngologists, speech pathologists, voice teachers) to participate more easily in assessment and management, serve as permanent records that document the result of voice therapy or surgery, and enhance teaching of residents.

Objective Measures of Vocal Output

Skillful “triangulation” on the voice problem through the use of the voice history, auditory-perceptual evaluation of vocal capabilities and limitations, and high-quality laryngeal examination is sufficient for a clear diagnosis and description of the problem. Although weak diagnostically due to nonspecificity, aerodynamic and acoustic information may be useful to quantify and document severity and change in response to treatment, to deepen understanding in the research arena, and to assist in some helpful biofeedback applications.

Direct Laryngoscopy and Biopsy

When videostroboscopy with magnified viewing is available, lesions that are suspicious for cancer or papillomatosis can nearly always be distinguished easily from nodules, polyps, and cysts. Therefore, removal of these latter entities is appropriate only within a comprehensive plan for treatment or voice restoration and rarely, if ever, for preliminary tissue diagnosis.

General Management Options

Hydration

Adequate hydration promotes free flow of lubricating secretions, which help the vocal fold mucosa withstand the rigors of vibratory collisions and shearing forces. Consistent supply of fluids seems to be particularly important. An expectorant, such as guaifenesin, may also help when secretions are viscid.

Sinonasal Management

Patients often incorrectly attribute chronic hoarseness to sinonasal conditions. Existing sinonasal problems should be managed on their own merits; however, the clinician may need to help diminish the patient’s perception of the contribution of these problems to a voice disorder in favor of more likely behavioral causes. When optimal laryngeal function is of concern, as in a vocal performer, nasal conditions should be managed locally (topically) when possible. The reason is that many systemic drugs (e.g., oral decongestants, antihistamine-decongestant combinations) dry not only nasal secretions but also secretions in the larynx, where a continuous secretional flow is important for proper vibratory function and mucosal endurance, particularly under demanding phonatory conditions. Medications that affect voice minimally are the topical nasal decongestants, which should be used for only a few days before the nasal mucosa is allowed to rest, so as to avoid rhinitis medicamentosa. Profuse rhinorrhea that accompanies the common cold can also be managed with ipratropium bromide inhalations.^14,¹⁵ Corticosteroid inhalers are invaluable for the management of nasal allergies. Activating pump-action nasal inhalers without any inspiratory airflow avoids the alleged risk of the effects of nasally applied corticosteroid on the vocal folds.

Management of Acid Reflux Laryngopharyngitis

In a person with an incompetent lower esophageal sphincter or hiatal hernia, acid reflux into the pharynx and larynx during sleep can lead to chronic laryngopharyngitis. Such persons may or may not experience one or more of the following symptoms: exaggerated “morning mouth,” excessive phlegm, scratchy or dry throat irritation that is usually worse in the morning, habitual throat clearing, and huskiness or lowered pitch of the voice in the morning. The larynx may show characteristic erythema of the arytenoid mucosa, interarytenoid pachyderma, or contact ulcers; laryngeal findings may, however, be subtle (Fig. 62-5).

Figure 62-5. Chronic laryngitis in a patient with severe acid reflux, a history of smoking, and excessive voice use. A, Note the interarytenoid pachyderma (arrows) and loss of normal color differential between the true folds and supraglottic mucosa. Broad-based convexity of the true vocal fold margins suggests diffuse submucosal edema. B, Appearance 3 weeks after institution of antireflux measures. Note the resolution of the interarytenoid pachyderma.

Basic management of this condition consists of avoiding caffeine, alcohol, and spicy foods; eating the last meal of the day (preferably a light one) no fewer than 3 hours before retiring; using bed blocks to place the bed on a mild head-to-foot slant; and taking an antacid at bedtime, an H₂ blocker 2 or 3 hours before bed, or a proton pump inhibitor 30 to 60 minutes before dinner.

Acute Mucosal Swelling of Overuse

Public speakers or singers may sometimes perform of necessity despite acute, noninfectious mucosal swelling resulting from recent overuse of the voice. A careful strategy of relative vocal rest in context is needed, and pre-performance warm-up, along with solid vocal technique, may be sufficient for the patient to “get through.” A short-term, high-dose, tapering regimen of corticosteroids can also be useful in this context, as part of a larger strategy to help the patient through the performance.

Laryngeal Instillations for Mucosal Inflammation

In past years more so than currently, laryngologists have used drugs such as mono-p-chlorophenol, topical anesthetics, mild vasoconstrictors, sulfur vapors, certain oils, and other substances for reduction of swelling, soothing effect, or promotion of healing. Some physicians and patients believe in the efficacy of such management, though it is supported only by anecdotal reports.

Systemic Medicines that May Affect the Larynx

Medicines that patients take for other reasons (e.g., antidepressants, decongestants, antihypertensives, diuretics) may dry and thicken normal secretions, thereby reducing their protective lubricating effect on the vocal folds and conceivably making the vocal fold mucosa more vulnerable to the development of benign disorders. History-taking should include inquiry about these medicines.

Voice Therapy

A course of therapy by a voice-qualified speech pathologist is frequently appropriate in patients with benign vocal fold mucosal disorders, given the common relationship of such disorders with vocal overuse, abuse, or misuse. Vocal nodules in particular are expected to resolve, regress, or at least stabilize under a regimen of improved voice hygiene and optimized voice production. In some cases, however, success is defined as having achieved a more consistent voice, without the exacerbations of hoarseness and even aphonia, even if that now-more-reliable voice remains somewhat husky. In other cases, success may require resolution of all upper voice limitations. If surgery becomes an option because the mucosal disorder has not resolved completely and the patient regards residual symptoms and vocal limitations as unacceptable, voice therapy will have optimized the patient’s surgical candidacy, by educating him or her additionally about the surgical process, and decreased the risk of postoperative recurrence.

During evaluation, the speech pathologist gathers information on behavior that may adversely affect the voice and establishes a program to eliminate injurious behavior. Voice-qualified speech pathologists also model and elicit a battery of spoken and sung vocal tasks to make plain to themselves and patient the type and degree of impairment from the lesion. They also assess the skill and appropriateness of voice production for both speaking and singing. Depending on the results of this second part of the evaluation, the speech pathologist may help the patient optimize the intensity, average pitch, registration, resonance characteristics, overall quality, general and vocal tract posture, and respiratory support for voice production. For singers, the singing teacher plays an invaluable role in this process, particularly with respect to singing voice production.

Finally, in this technologic era, voice clinicians increasingly document various aspects of vocal tract output, using acoustic analysis, spirometric measures to test respiratory adequacy, frequency and loudness measures, translaryngeal airflow rates, and other measures under various conditions. Speech pathologists may use this equipment for biofeedback (e.g., using a visual electronic frequency readout to modify average pitch for speech in a tone-deaf patient). For obligate false vocal fold phonation and intractable psychogenic disorders of voice production with visible vocal fold posture abnormalities, therapy room videoendoscopy can also be converted into an effective biofeedback tool (Fig. 62-6).^11,¹⁶

Figure 62-6. A patient learning to modify laryngeal posture by use of laryngeal image biofeedback. With a telescope rather than a fiberscope, pure vocal fold behavior is retrained initially (without speech gestures). Clearer optics and less mobility of the epiglottis permit a clearer and more stable view.

Surgery

Some lesions are known at diagnosis to be irreversible other than via surgery. Aside from these exceptions, vocal fold microsurgery should follow an appropriate trial of voice therapy. Patients are typically reexamined (vocal capability battery and videostroboscopy) at 16-week intervals after diagnosis. When a compliant patient does not improve after two or more successive examinations and remains unhappy with the voice’s capabilities, surgery may be considered. Good surgical results are directly related to diagnostic accuracy, surgical judgment and precision, and the patient’s compliance with proper voice care.

Although specific techniques vary for each disorder, the basic requirements for successful laryngeal microsurgery for all benign vocal fold mucosal disorders are the same. An understanding of vocal fold microarchitecture and vibratory dynamics (see earlier discussion) is a prerequisite, and preoperative and postoperative videostroboscopic evaluation is necessary so that the patient and surgeon can see the results together.

The first principle of surgery is that microlaryngoscopy (not direct laryngoscopy with the unaided eye) and extreme technical precision are required to minimally disturb mucosa. Because the disorder is benign and confined to the mucosa, including Reinke’s potential space, the cancer concept of surgical margins does not apply. Every case should be approached with the awareness that overly aggressive or imprecise surgery of the vocal fold mucosa can have disastrous results caused by scarring of regenerated or surgically manipulated mucosa to the underlying vocal ligament.

A set of laryngoscopes, microlaryngeal forceps, scissors, dissectors, and knives should be on hand. In the face of the plethora of instruments currently available, the comment by Kleinsasser ² that a relatively simple set suffices the experienced surgeon remains true (Fig. 62-7)!

Figure 62-7. A, The viewing ends (left to right) of the Holinger hourglass, Jako-Cherry, Bouchayer, and Dedo laryngoscopes. B, The distal ends of these laryngoscopes (same order). The Bouchayer scope (arrow) is most useful for microsurgery. C, From left, The up-cup forceps, smaller biting forceps, Bouchayer microring forceps, curved scissors, and curved alligator forceps.

The carbon dioxide laser has become an important part of the surgeon’s armamentarium, and many have discussed its application to benign laryngeal disorders. Tissue effects of the laser depend on spot size and focus, wattage, duration of beam activation, waveform mode (pulsed vs. continuous), and, perhaps most important, surgical precision. Cold microdissection may be safer than laser techniques, provided that the surgeon is equally proficient in both. Norris and Mullarky,¹⁷ comparing continuous-mode carbon dioxide laser with the cold scalpel for incising pig skin, reported that a short-term advantage resulted after laser incision with regard to the speed of reepithelialization; no long-term difference in healing was noted. However, although the fact was not noted in their report, these investigators’ histologic sections clearly showed a wider zone of tissue destruction beneath the epithelium with laser than with scalpel. Duncavage and Toohill¹⁸ compared healing response in dogs after traditional fold stripping and after carbon dioxide mucosal vaporization. They concluded that, until late in healing, more edema and giant-cell reactions to bits of charred debris, and greater subepithelial fibrosis occurred with the laser technique than with the cup forceps alone. Manipulation of wattage, focus, and mode of laser irradiation of tissues may decrease thermal injury, charring, and other adverse effects of the laser.

The preceding studies date from the early era of the carbon dioxide laser. The microspot carbon dioxide laser appears to diminish these disadvantages,^19,²⁰ although a systematic comparison of functional results (including vocal capabilities and videostroboscopy) is not available to guide the surgeon in choosing between laser and microdissection methods. With a caseload approaching 1000 singers and double or triple that number of non-singers—for whom laser and non-laser methods have been used on an individualized basis—I believe that surgical technique and skill are preeminent over the specific tools used.

After surgery, vocal quality and capabilities should show good to excellent improvement; however, patients should be counseled preoperatively what the risk of worsening the voice is predicted to be: For nodules it may be appropriate to say, “This surgery typically restores the voice to ‘original equipment status,’ but there is a small risk that you will experience a large improvement but not to fully normal; and there is a remote, rare risk that your voice will be worse after surgery.” By contrast, one may say to the person with bilateral sulci in whom mucosa is thin, “I am expecting a modest improvement of your voice, but it will take many months to experience this improvement, and there is a quite significant chance your voice will be no better, and even possibly worse.” For the experienced surgeon who uses dissection, rather than microavulsion techniques, along with preoperative and postoperative videostroboscopy as his or her “teacher,” the question in the general case becomes not so much one of possibly making the voice worse, but rather, “Can I make this patient’s speaking and singing capabilities normal, and if not, how close can I come?” Cornut and Bouchayer’s ²¹ experience operating on 101 singers and Bastian’s²² experience in the same population established a role for laryngeal microsurgery in restoring vocal capabilities and in abolishing or diminishing limitations.

Specific Benign Vocal Fold Mucosal Disorders

Vocal Nodules

The term nodules should be reserved for lesions of proven chronicity. Recent or acute mucosal swellings, which disappear quickly in response to simple voice rest and perhaps supportive medical management, are thus excluded when one is referring to nodules.

Epidemiology

Vocal nodules occur most commonly in boys and women. Such persons are almost always vocal overdoers (i.e., rating 6 or 7 on the 7-point talkativeness scale). Intrinsic talkativeness correlates more consistently than occupation, unless the occupation is extraordinarily demanding vocally (e.g., rock singer, stock trader). Comparatively, nodules develop frequently in children with cleft palates, presumably from their use of glottal stops to compensate for velopharyngeal incompetence.

Pathophysiology and Pathology

Only the anterior two thirds (membranous portion) of the vocal folds participates in vibration because the arytenoid cartilages lie within the posterior third of the glottic aperture. Vibration that is too forceful or prolonged causes localized vascular congestion with edema at the midportion of the membranous (vibratory) portion of the vocal folds, where shearing and collisional forces are greatest. Fluid accumulation in the submucosa from acute abuse or overuse results in submucosal swelling (sometimes unwisely called incipient or early nodules). Long-term voice abuse leads to some hyalinization of Reinke’s potential space and, in a subset of cases, some thickening of the overlying epithelium. This pathophysiologic sequence explains the easily reversible nature of most acute nonhemorrhagic swellings, in contrast to the slower, incomplete, or failed resolution of chronic vocal nodules. Whether acute edema or more chronic nodules, the change in mucosal mass, lessened ability to thin the free margin, and incomplete glottic closure caused by the nodules account for a constellation of vocal symptoms and limitations that is characteristic of mucosal swelling.^11,²²

Diagnosis

History

A pediatric patient with vocal nodules is usually described by the parent as vocally exuberant. An adult patient, virtually always a woman who rates herself as a 6 or 7 on the talkativeness scale (discussed earlier), describes experiencing chronic hoarseness or repeated episodes of acute hoarseness. Sometimes the initial onset is associated with an upper respiratory infection or acute laryngitis, after which the hoarseness never clears completely, leading the patient to incorrectly attribute the voice problem to the infection and to neglect more relevant ongoing behavioral causes. Singers with chronic nodules are usually relatively unaware of speaking voice limitations unless the nodules are at least moderate in size. More sensitive symptoms of vocal nodules, including very small ones, are as follows:

• Loss of the ability to sing high notes softly

• Delayed phonatory onset, particularly with high, soft singing

• Increased breathiness (air escape), roughness, and harshness

• Reduced vocal endurance (“I get husky more easily than others.”)

• A sensation of increased effort for singing

• A need for longer warm-ups

• Day-to-day variability of vocal capabilities that is greater than expected for the singer’s level of vocal training

Vocal Capability Battery

In patients with moderate to large vocal nodules, the speaking voice is usually lower than expected, husky, breathy, or harsh. Patients with subtle to moderate swellings often have speaking voices that sound normal; the speaking voice is an insensitive indicator of mucosal disorders in comparison with the singing voice. In patients with subtle or small swellings (usually only singers present with small mucosal disturbances), vocal limitations (e.g., delayed phonatory onset with preceding momentary air escape, diplophonia, inability to sing softly at high frequencies) may become evident only when high-frequency, low-intensity vocal tasks for detecting swelling are elicited.^11a At high frequency, short-segment vibration may occur; in other words, the nodules stop vibrating and the short segments of mucosa anterior or posterior to them, or both, vibrate.

Many patients with nodules may have undergone indirect laryngoscopy and have been told that their vocal folds were normal or have been given a nonspecific diagnosis such as “laryngeal irritation.” Use of vocal tasks that detect swellings and videostroboscopy, when indicated (see Figs. 62-3 and 62-4), protect the laryngologist from missing the most subtle vocal fold swellings. The ability to diagnose tiny nodules is crucial, because failure to make such a diagnosis can have serious consequences for the professional voice user.

Laryngeal Examination

Nodules can vary in size, contour, symmetry, and color, depending on how long they have been present, the amount of recent voice use, and interindividual differences in mucosal response to voice abuse. Also, some variability exists in the correlation between size of nodules and their effect on vocal capabilities. Nodules do not occur unilaterally, although one may be larger than the other. It is important to distinguish between nodules and cysts, because management of these conditions differs. The correlation between nodule appearance and reversibility with voice therapy is imperfect. The larynx should be examined at high frequency (500-1000 Hz) to visualize subtle to small swellings, which can be poorly appreciated at lower frequencies.

Vocal nodules arise from the vocal overdoer profile, so speech (voice) therapy plays a primary role initially. Typically, the nodules and their more obvious symptoms regress, particularly if the patient is not a singer. However, the most skilled behavioral (voice) therapy sometimes fails to achieve complete visual resolution of nodules that have been present for many months to years. Sensitive singing tasks that detect impairment (not the size of persistent swellings) are generally more helpful in the decision whether to consider their surgical removal.^11,²²

Surgical

Surgical removal becomes an option when nodules of whatever size persist and the voice remains unacceptably impaired (from the patient’s perspective) after an adequate trial of therapy (generally a minimum of 3 months). Some writers prefer precise removal using microdissection techniques (Fig. 62-8). Vocal fold stripping has no place in the surgery of nodules. The proper duration of voice rest is controversial; some writers prefer a relatively short period. Typically, the patient is asked not to speak for 4 days, although sighing sounds begin 1 day after surgery. Beginning on the fourth day, the patient gradually progresses over 4 weeks to full voice use under a speech pathologist’s supervision. Early return to nonstressful voice use, as described in Table 62-1, seems to promote dynamic healing. The results of precision surgery are typically remarkably good, even in singers. Cornut and Bouchayer²¹ stated, in their study of approximately 160 singers treated with surgery, “As long as certain management principles are followed in a majority of cases, laryngeal microsurgery enables the singing voice to regain the whole of its functioning.”

Figure 62-8. The operative sequence in a professional musical theater actress who had been experiencing vocal symptoms and limitations compatible with fusiform vocal nodules for more than 2 years. A, The operative view after many months of conservative management. Not all fusiform swellings are reversible with conservative measures alone. B and C, A polypoid nodule is grasped superficially and tented medially with Bouchayer forceps. Scissors, which curve away from the vocal fold, are used for removal. The nodule is thus removed in a very superficial plane, thereby minimizing the risk of engendering scar between the remaining and regenerated mucosa and the underlying vocal ligament. D, The vocal fold appearance after excision. The patient experienced dramatic normalization of vocal capabilities, and there was no evidence of scarring on postoperative stroboscopic examination. The dilated capillaries may predispose to recurrent nodule formation and can be spot-coagulated with a micro-spot laser.

Table 62-1 General Guidelines for Initial Voice Use after Vocal Fold Microsurgery

Time After Surgery*	Talking^†	Singing (for Singers)
Days 1 to 4	None	Gentle attempts at yawn or sigh for approximately 30 sec, 6-8 times per day^‡
Week 2 (begins day 5)	3	Same exercise 5 min twice per day (after first postoperative exam)
Week 3	4	Same exercise 10 min twice per day^§
Week 4	5	Same exercise 15 min twice per day^§ (after second postoperative exam)
Week 5	4 or 5	Same exercise 20 min twice per day^§
Weeks 6-8	4 or 5	Same exercise, up to 20 min three times per day^\|