Pathophysiology 1C

Definition: Vocal fold papilloma, also referred to as recurrent respiratory papillomatosis (RRP), is a viral disease affecting the larynx.
Cause: It is caused by the human papilloma virus (HPV).
- HPV is a virus known for its various strains, some of which are associated with warts and others with cancers, such as oropharyngeal cancer often linked to strain p16.

Visual Characteristics: The appearance of the vocal folds resembles irregular clusters akin to raspberries, featuring punctate features (tiny pink dots).
Transmission:
- Potential maternal-fetal transmission has been suggested, though not conclusively proven.
Demographics: Particularly affects infants and children with smaller airways.
Concern: Overgrowth can lead to airway compromise, necessitating careful monitoring in young patients.

Juvenile Patients: Associated risk factors include:
- Young maternal age.
- Being firstborn.
- Low socioeconomic status.
Adult Patients: The prevalence shows a male to female ratio of approximately 2:1.

Severity of vocal impairment correlates with the extent of vocal fold involvement:
- Ranges from mild dysphonia to complete aphonia if the entire vocal fold length is affected.
- Affected individuals may exhibit varying levels of dysphonia.

Antiviral Agents: Commonly used antiviral agent includes cidofovir.
Surgical Intervention: Surgical options are the primary treatment modality—methods include:
- Cold instrumentation.
- CO₂ laser surgery.
- Pulse dye laser surgery, which delivers lower dosage energy to lesions over multiple sessions for reduction.
Voice Therapy:
- Perioperative voice therapy is essential for optimizing vocal outcomes post-surgery.
- Education on recognizing airway compromise signs (shortness of breath, stridor) is critical.

Definition: Occurs with leakage of blood into the lamina propria, often appearing as a bruise or blood blister.
Visual Presentation:
- Can vary from red, yellow to brownish hues depending on healing progress.
Causes:
- Commonly due to phonotraumatic behaviors (e.g., yelling, prolonged vocal use).
- Laryngeal trauma, frequently from intubation/extubation.
- Risk is heightened for patients on anticoagulants (e.g., aspirin, Coumadin, Xarelto).
Vocal Impairment: Can be minimal to profound, potentially resulting in aphonia in cases of severe hemorrhage.
Treatment Protocol:
- Voice rest is critical to allow healing, typically spanning 14 days.
- Laser surgery may be indicated in recurrent hemorrhage instances.
- Voice therapy focusing on proper voice usage may help prevent future occurrences.

Definitions:
- Varix: Enlarged blood vessels observable on the vocal folds.
- Ectasia: A more severe form where blood vessels are significantly engorged.
Symptoms: Can lead to hemorrhage, presenting similarly to vocal fold hemorrhage.
Management:
- Education on vocal hygiene and potentially laser cauterization for blood vessels.

Definition: Characterized by a bridge of tissue connecting the vocal folds, typically at the anterior commissure.
Causes: Can be:
- Congenital development issues, where the web forms during fetal development, leading to neonatal respiratory distress or a weak cry.
- Acquired through surgical trauma, often from intubation that causes mucosal injury and subsequent scar tissue formation between the vocal folds during healing.
Vocational Implications:
- Often leads to high-frequency voice due to reduced vibratory area of vocal folds, affecting phonation, and can also cause breathing difficulties.
Treatment:
- Typically surgical division of the web, which involves cutting the fibrous tissue.
- Requires careful stenting of the glottis post-operative, using a keel or silicone stent to prevent the vocal folds from re-adhering during the healing process, due to significant risks of reformation.

Definition: Age-related thinning and weakening of vocal fold muscles.
Appearance and Symptoms:
- Visible bowing of vocal folds and may present hoarseness, breathiness, and vocal fatigue.
Prognosis:
- Voice therapy is usually very effective, and vocal fold musculature can be exercised to enhance function.
Surgical Interventions:
- Injectables (e.g., Prolarean, Radiesse) may be used to improve vocal fold mass and closure.

Definition: A rare condition where arytenoid motion is compromised due to joint injury, not stemming from neurogenic causes.
Causes: Most commonly occurs due to intubation or direct trauma to the larynx.
Vocal Impairment Symptoms: Similar to vocal fold paralysis, featuring breathiness and reduced vocal intensity.
Treatment: May require surgical manipulation or medialization to restore function.

Definition: An inflammatory condition resulting from the gastric content movement into the larynx, causing mucosal inflammation.
Symptoms: Includes globus sensation, throat clearing, cough, and variable vocal performance.
Diagnostic Procedures:
- pH and impedance probes are used to diagnose LPR by detecting acid and pressure changes in the esophagus/larynx.
Management Approaches:
- Proton pump inhibitors (e.g. Prevacid, Nexium) and H2 blockers (e.g. Zantac, Pepcid) are common prescriptions despite assessment variabilities.
Behavioral Changes: Emphasis on dietary modifications and vocal hygiene practices is critical for effective management.
Vocal Impairment: Highly variable, often exacerbated in the morning due to supine position.

The discussion covered various aspects of vocal fold pathologies, including diagnosis, treatment, and management of conditions that affect vocal health. The next section will focus on neurogenic disorders and other miscellaneous laryngeal pathologies.