Voice Pathology

Classification of Laryngeal Pathology:

• Structural Pathologies

• 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, pitchMalign & 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 ration)

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

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

• Extraverted (talkative)

• Socially dominant

• Stress reactive (tense)

• agressive

• impulsive

(VF Nodules) Occupational factors:

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

Vocal Fold Nodules:

• 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?

• Voice Conservation/Rehabilitation (primary)

• 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” vpice

How do you treat Reinke’s Edema?

• Surgery!

  • accompanied/preceded by smoking cessation program

  • Pre-operative and post-operative voice therapy

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 vocalist) 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?

Vocal Fold Granuloma & Contact Ulcer:

• Granulomas → unilateral or bilateral, v

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 combination 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

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