Voice Pathology

Classification of Laryngeal Pathology:

• Structural Pathologies

• Inflammatory Conditions

• Trauma or injury

• Systemic conditions affecting voice

• Aerodigestive conditions affecting voice

• Psychiatric or psychological disorders affecting voice

• Neurological voice disorders

• “Other” disorders of voice

Structural Pathologies of the VFs:

• Any alteration in the histological structure of the VF

  • changes in the layered structure of the VF may affect the…

    • mass

    • size (mass lesion)

    • stiffness

    • flexibility

    • tension of the vibrating mechanism

  • These changes may alter vocal quality, pitch, & loudness

Malignant Lesion:

• Laryngeal Carcinoma (typically squamous cell type originating from the epithelium)

• As tumor progresses, it invades the deeper layers of the VF including the vocalis muscle

• Dysphonia severity varies according to location & extent of tumor invasion

What are risk factors for laryngeal carcinoma?

• smoking

• alcohol use

• laryngopharyngeal reflux

What are treatment options for a carcinoma?

• Radiation Therapy

• Chemotherapy

• Surgical excision (depends on size, extent, & type of malignancy)

  • partial or full laryngectomy

• Or a combo approach

Benign Epithelial & Lamina Propria Abnormalities of the VF:

• Traditional labels:

  • Polyps

  • Nodules

  • Cysts

• Newer labels:

  • Pseudocyst(s)

  • Fibrous mass(es)

  • Reactive lesion(s)

What are vocal fold nodules?

• BILATERAL, “relatively” symmetrical lesions occurring on the medial edge between anterior 1/3 & posterior 2/3’s of VFs (i.e., site of maximum collision & shearing forces)

• Inflammatory degeneration of SLLP w/ fibrosis & edema of VF cover (transition & body of the VF are not typically affected)

What are the 2 types of VF nodules?

• Acute (“immature,” gelatinous & floppy)

• Chronic (“mature," harder & more fixed to the underlying mucosa)

(VF Nodules) Age & Gender Trends:

• Children (boys > girls, 3:1 ratio)

• Adults (women > men, rare among post-pubescent & adult males

(VF Nodules) Possible Personality Factors (Women w/ Nodules):

• Extraverted (talkative)

• Socially Dominant

• Stress Reactive (tense)

• Aggressive

• Impulsive

(VF Nodules) Occupational factors:

• singers'; professions w/ extended (& loud) voice use (e.g., teachers)

VF Nodules Dysphonia:

• Mild to Moderate Dysphonia

  • roughness, breathiness related to gaps anterior & posterior to lesions, increased muscular tension

• Severity of dysphonia varies depending upon:

  • extent (size) of lesions

  • length of time since onset (type of nodules, chronic vs. acute)

  • degree of accompanying inflammation

How are VF Nodules treated?

• First line = voice therapy

• Surgical removal by “skilled” laryngologist & only…

  • If/when patient has been compliant w/ voice therapy, but did not respond completely/satifactorily

  • Surgery to be followed by post-surgical voice therapy

What are VF Polyps?

• fluid-filled, exophytic lesion composed of gelatinous material in SLLP w/ active blood supply (typically located on middle third of the VF)

  • Most often seen in adults

  • Often unilateral, but can be bilateral

What are the types of VF polyps?

• sessile (blister-like) → gelatinous, does NOT cause breathing problems or impact airway

• pedunculated (attached to a stalk)

What can cause VF polyps?

• acute vocal trauma (i.e., phonotrauma)

How do VF polyps affect voicing?

• Mild to severe dysphonia depending upon:

  • size, type, & location (& associated mass & stiffness effects)

  • Degree of interference w/ glottic closure & VF vibration

  • Presence of hemorrhagic blood vessel “feeding the lesion”

How do you treat VF Polyps?

1. Voice Conservation/Rehabilitation (primary)

2. Phonosurgery (& voice rehabiliation)

What are VF Cysts?

• Fluid-filled, typically unilateral, sessile lesions (sacs) on cephalic surface or medial edge of the VF that be:

  • Congenital or Acquired

  • Embedded in SLLP, but often extent into ILLP & DLLP (i.e., the vocal ligament)

• No clear etiology, but…

  • Mucous gland blockage &/or

  • Phonotrauma

What are VF Cysts often confused with?

• nodules bc a cyst can often be associated w/ “reactive” thickening of the contralateral VF (i.e., opposite to the cyst) suggesting bilateral lesions

• Unlike nodules, cysts create a stiff adynamic segment due to reduced vibratory freedom of the cover of the VF

How do you treat VF Cysts?

• Surgical excision/dissection of the cyst off of the vocal ligament (from a superior & lateral approach to avoid scarring of the vocal fold)

What is Reinke’s Edema?

• SLLP becomes filled w/ viscous, gelatinous fluid

• “Polypoid degeneration” is a severe form of edema wherein the entire membranous VF is filled w/ fluid

What are Etiologic Factors of Reinke’s Edema?

• Chronic Phonotrauma

• Smoking

What are vibratory effects of Reinke’s Edema?

• increased mass & stiffness

How can Reinke’s Edema affect voicing?

• signature low pitch & husky hoarseness described as a “whiskey” or “smoker’s” voice

How do you treat Reinke’s Edema?

• Surgery!

  • accompanied/preceded by smoking cessation program

  • Pre-operative and post-operative voice therapy

What is Vocal Fold Scarring?

• _____ is general term given to “permanent” tissue changes in the structure of lamina propria (LP) due to any # of etiologies

  • Lesion presence (cyst ruptured & caused a _____)

  • Chronic tissue irritation (related to phonotrauma or other causes)

  • Iatrogenic (postsurgical) changes

How can scarring impact the VFs & voicing?

• Increases stiffness of VFs (owing to loss of layered structure of VF)

• Reduces freedom of cover to oscillate = reduced mucosal wave during VF vibration

• Reduces glottic closure in severe cases (bc of non-vibrating scar & adynamic VF)

• Effects on voice vary depending upon severity, extent, & location of scar

• No accepted/effective behavioral or phonosurgical treatment

What is Sulcus/Sulcus Vocalis?

• special form of scarring that forms a “ridge” or “furrow” along the SLLP that produced bowing or spindle-shaped gap

  • Unilateral or Bilateral

  • Small pit or divot (sulcus vocalis) vs. entire length of medial surface (sulcus vergeture)

What is the etiology of Sulcus/Sulcus Vocalis?

• unknown, but possibly…

  • Congenital (abnormal embryological develop of VF cover)?

  • Acquired following rupture of intracordal VF cyst?

  • Secondary to lasers surgery?

  • Associated w/ age-related changes?

What is a granuloma?

• unilateral or bilateral, vascular & inflammatory exophytic lesions related to tissue irritation in the posterior larynx typically on medial surface of arytenoid cartilage(s)

What is a contact ulcer?

• ulcerated lesion on the same site often on opposite side of granuloma (cup/saucer relationship)

What are signs/symptoms of VF granuloma & contact ulcer?

• Pain, sore throat, w/ or w/o voice change (i.e., posterior site of lesion(s), may not affect VF vibration)

What are the 2 primary etiologies of VF granuloma & contact ulcer?

• “Mechanical” or “Chemical” tissue irritants of posterior larynx

  • Mechanical = endotracheal intubation

  • Chemical = laryngopharyngeal reflux

• Persistent Voice Misuse…

  • Pressed, low-pitched voice w/ excess tension

How do you treat VF granuloma & contact ulcer?

• Medical, Surgical, Behavioral, or a combo!

(VF Granuloma & Contact Ulcer Treatment) Medical:

• Pharmacologic

  • Antireflux Regimen (including medications)

  • Unilateral (intracordal) Botox injection to reduce medial compression forces (to allow healing) → reduce how tight closure is in back, no longer done as often bc it can cause swallowing problems.

    • Never used for unilateral VF, it's already paralyzed. Used for extra muscle tension to reduce movement

(VF Granuloma & Contact Ulcer Treatment) Behavioral:

• Voice Therapy

  • Reduce medial compression by reducing strain & pressed voice, pitch elevation, reduce “hard” glottal onsets

(VF Granuloma & Contact Ulcer Treatment) Surgical:

• Excision (if fail medical &/or behavioral management)

• Given their location & etiology, these lesions can be recalcitrant & recurrence can be common!

What are Keratosis, Leukoplakia, & Erythroplasia?

• Three (benign) VF pathologies often subsumed under “Epithelial Hyperplasia” = abnormal mucosal changes

• Although benign, may be precancerous, & direct microlaryngoscopy w/ biopsy is often recommended

*Leukoplakia =

• “white plaque” → precancerous & can look like carcinoma

• Thick substance on superior surface of VFs in diffuse white patches

*Hyperkeratosis =

• “excessive keratin”

• Buildup of keratinized tissue, rough, irregular VF margins

*Erythroplasia =

• “thickened & red”

• Due to combo of hyperfunctional voice use & chemical irritation especially alcohol & tobacco use

What is Recurrent Respiratory Papilloma (RRP)?

• Wart-like growths that develop in the epithelium & invade deeper in the LP & vocalis muscle

• Can grow rapidly & in large clusters

• Can proliferate & compromise the airway

What is the Etiology of RRP?

• Human Papilloma Virus (HPV) infection

• Types:

  • Juvenile

  • Adult

(RRP Types) Juvenile:

• in children, onset @ age 2-4 years, boys = girls, can resolve spontaneously, especially after puberty

(RRP Types) Adult:

• males > females, persistent & progressive

What are the Effects of RRP on Voice?

• Lesions can affect the cover, transition, & body of the VFs & produce significant stiffness, compromise vibratory fxn, & cause severe dysphonia

• Multiple surgical treatments lead to scarring w/ worsening dysphonia

How do you treat a Papilloma?

• Surgical (laser or cold-steel excision)

• Pharmacotherapy (as a primary or secondary approach)

(Treatment - Papilloma) Surgical (laser or cold-steel excision):

• but recurrence is common requiring multiple de-bulking surgeries (& increased likelihood of VF scarring)

(Treatment - Papilloma) Pharmacotherapy (as a primary or secondary approach):

• Interferon therapy (systemic, in select cases)

• Intra-lesional Cidofovir VF injections (repeated)

  • Cidofovir is an antiviral medication designed to inhibit the HPV virus @ the site of injection

• Sub-lesional Bevacizumab (Avastin) VF injections as an adjunct to surgical excision to limit disease recurrence

  • Avastin is an angiogenesis inhibitor, i.e., blocks the growth of blood vessels, designed to starve papilloma of necessary blood supply which may limit recurrence

Subglottic Stenosis, Glottic Stenosis, & Anterior Glottic Web:

• _____ → fibrous tissue overgrowth that narrows the airway (typically subglottic just below the true VFs)

• Glottic _____ or anterior _____ web-acquired scar across medial edges of the VFs beginning in the anterior commissure & extending posteriorly

What is the Etiology of Subglottic Stenosis?

• Congenital

• Post-intubation scarring

• Laryngopharyngeal reflux

What is the Etiology of Glottic Stenosis/Web?

• Congenital (synechia) or Acquired

• Acquired web secondary to surgery involving anterior membranous portion of the VFs

What does management of subglottic stenosis & web involve?

• Surgery!

Vascular Lesions - Hemorrhage, Hematoma, Varix, Ectasia:

• Vascular lesions caused by traumatic injury to small blood vessels of the VF; focal or diffuse discoloration of VF

• Often related to intense screaming, singing, coughing, crying

• Occur more often in premenstrual women using blood thinners/ anticoagulants e.g., aspirin or related products

What is a Hemorrhage?

• small capillary on superior surface of VF ruptures abruptly & bleeds into SLLP (i.e., Reinke’s space)

What is a Hematoma?

• accumulation of blood that has leaked from the ruptured vessel

What is a Varix?

• mass of blood capillaries that appears as small, longstanding blood blister that has hardened over time w/ an adynamic VF segment

What is an Ectasia?

• larger collection of varices

Vascular Lesions:

• _____ have potential to increase stiffness of the cover, w/ localized scarring in more severe cases

• Voice quality can vary from severe at time of bleed (acutely) to mild later

• Small varices or ectasis may have negligible effects on voice (except in singers &/or professional voice users where even small vascular lesions may have disastrous effects)

How do you treat Vascular Lesions?

• Aggressive Voice Conservation (i.e.. complete voice rest)

• Medical (Steroids)

• Laser Cauterization (to stop bleed)

• Surgery: Micro-excision of persistent varix

Maturational Changes Affecting Voice:

• Puberphonia (a.k.a. Mutational Falsetto)

  • Post-pubescent males who speak in falsetto or near top of their modal frequency range

  • Voice weak, often breathy or raspy, unable to increase intensity or shout

Etiology poorly understood, but proposed causes for puberphonia include…

• Resistance to puberty

• Feminine self-identification

• Desire to maintain a competent childhood soprano singing voice

• Embarrassment when voice lowers dramatically earlier than one’s peers

Etiology poorly understood, but proposed causes include…

• Resistance to puberty

• Feminine self-identification

• Desire to maintain a competent childhood soprano singing voice

• Embarrassment when voice lowers dramatically earlier than one’s peers

What is puberphonia associated with?

• associated w/ significant negative socioemotional consequences including rejection by peers in some cases

• Behavioral voice therapy is usually effective

What is Juvenile Voice?

• Post-adoloscent females w/ higher than normal pitch, breathy voice, “child-like” speech distortions & prosody, & high tongue carriage

• Etiology unknown, but hypothesized…

  • Women who resisted transition into adulthood

  • Habituated the altered laryngeal & vocal tract posture

Presbyphonia (Presbylaryngeus):

• Voice disorder presumably related to processes of laryngeal aging

• An “older” sounding voice…

  • Thin, muffled voice quality

  • Decreased loudness

  • Increased breathiness

  • Pitch instability

  • Lack of vocal endurance & flexibility

• Classic laryngeal appearance is a slightly bowed glottic configuration presumably related to “thinned or atrophic” VFs

• Voice rehabilitative therapy, especially Vocal Function Exercises (VFEs) can be effective

Inflammatory Conditions of the Larynx:

• Rheumatoid Arthritis

  • Cricoarytenoid & Cricothyroid Arthritis

• Acute Laryngitis

• Laryngopharyngeal Reflux

• Chemical Sensitivity/Irritable Larynx Syndrome

Trauma or Injury to the Larynx:

• Internal Laryngeal Trauma:

  • Thermal

  • Chemical

  • Intubation/Extubation Injury

• External Laryngeal Trauma:

  • Blunt Force or Penetrating Wounds

• Arytenoid Dislocation:

  • External Laryngeal Trauma &

  • Intubation or Extubation Injury

Systemic Conditions Affecting the Voice:

• Systemic or “Whole-body” Influences…

  • Endocrine Function

  • Allergies

  • Immunologic responses

• Adverse Effects of Medications on the Larynx…

  • Drying/muscle atrophy/inflammatory effects (Bronchodilators, e.g., asthma medications)

  • Drying effects via reduced fluid levels (diuretics, corticosteroids, decongestants)

  • Drying effects via reduced upper airway secretions (antihistamines, antitussives)

  • Altered vocal fold structure (via hormone therapies including estrogen & testosterone)

Nonlaryngeal Aerodigestive Disorders Affecting Voice:

• Asthma

• Chronic Obstructive Pulmonary Disease

• Croup (acute laryngotracheobronchitis)

  • All of the above associated w/ Acute or Chronic Symptoms of Dyspnea (& possible voice change)

• Gastroesophageal Reflux Disease (GERD)

• Infectious Diseases of the Aerodigestive Tract

• Mycotic (Fungal) Infections: Candida

Peripheral Nervous System Pathology:

• • Superior Laryngeal Nerve Paralysis (External Branch):

    • Unilateral ESLN paralysis = Unilateral Cricothyroid m. dysfunction

  • Laryngeal Findings:

    • Epiglottic petiole deviation to the side of weakness during high pitched voice as a possible diagnostic marker?

  • Phonatory Effects:

    • Mild dysphonia, loss of upper pitch range, voice characterized by weakness, increased physical effort expended to produce voice

Neurological Disorders Affecting Voice:

• Peripheral Nervous System Pathology

  • Recurrent Laryngeal Nerve (RLN) Paralysis: Unilateral

    • Laryngeal Findings

    • Phonatory Effects

  • Recurrent Laryngeal Nerve (RLN) Paralysis: Bilateral

    • Laryngeal Findings

    • Phonatory Effects