Pathophysiology 1B

Definition: Vocal fold polyps are benign lesions characterized by vascularity; they appear as small lesions with tiny blood vessels.
Characteristics:
- Typically unilateral (affecting one side) but can be bilateral. They often appear as translucent, reddish, or grayish masses. Unlike nodules, polyps do not have a specific location but are found within the superficial lamina propria, interfering with the vocal fold's ability to vibrate symmetrically and efficiently.
- Lesions are found within the lamina propria.
Potential Risks: Though benign, polyps have a minimal chance of converting into malignancy, leading some surgeons to recommend their removal.

Sessile Polyps:
- Description: Have a broad base and extensive attachment to the vocal fold mucosa, making their removal potentially more complex due to the wider area of tissue involvement.
Pedunculated Polyps:
- Description: Characterized by a rounded mass (the body of the polyp) connected to the vocal fold by a narrow, stem-like stalk, allowing for greater mobility of the polyp during vibration.

Phonotraumatic Behaviors: Behaviors leading to strain on the vocal folds such as:
- Prolonged speaking (sales, coaching, preaching, teaching).
- Loud vocalization (e.g., screaming).
Vocal Fold Hemorrhage: Known to accompany the formation of polyps where internal blood vessels rupture, leading to polyp formation.
Reflux: Laryngeal irritation due to acid reflux.
Smoking: Considered a potential risk factor.
Dehydration: Can lead to vocal fold vulnerability.

Degree of dysphonia is dictated by:
- Size of lesion
- Location on vocal fold
Characteristics:
- Impaired vocal fold closure leads to gaps while phonating.
- Increased airflow due to closure obstruction.
- Changes in acoustics may result in reduced fundamental frequency and intensity; potential for pitch breaks due to interference from the polyp during phonation.

Voice Therapy:
- Essential pre-and post-surgical therapy.
- May result in resolution for small polyps; larger polyps typically require surgical intervention.
Post-Surgical Care:
- Voice rest
- Gentle phonation techniques to promote healing.

Definition: Benign lesions that are encapsulated round masses occurring submucosally, primarily at the mid-region of the true vocal folds.
Characteristics: Smooth, whitish appearance; typically unilateral, but can lead to reactive lesions on the opposing fold due to constant irritation during phonation.
Cause: Often attributed to blocked mucous glands (retention cysts) within the vocal folds, leading to an accumulation of fluid or keratin. They can also be congenital (epidermoid cysts) due to embryonic cell rests.

Severity: Voice effects depend on lesion size and location; they do not resolve with voice therapy alone.
Voice Therapy: Can aid in technique improvement, reducing strain, but does not eliminate the cyst.

Removal Method: Involves a precise microflap technique where a small incision is made along the superior surface of the vocal fold, a flap is lifted, and the encapsulated cyst is carefully excised without rupturing it, minimizing disruption to the delicate superficial lamina propria.

Definition: Also known as polypoid degeneration of the vocal folds.
Characteristics: Presence of increased and thickened, gelatinous material (myxoid fluid) in the superficial lamina propria (Reinke's space), causing a significant increase in the mass and size of the vocal folds. This typically affects both vocal folds, making them appear swollen and 'floppy,' which severely alters their vibratory patterns.
Etiology: Chronic inflammation primarily from smoking; laryngopharyngeal reflux and phonotraumatic behaviors may contribute.

Physical Changes: The increased mass of the vocal fold cover leads to a significantly lowered fundamental frequency, resulting in a deeper, 'whiskey' or 'smoker's voice,' often with considerable hoarseness and a rough, raspy quality due to irregular vibration.
Treatment:
- Voice therapy supports healthy voicing habits and smoking cessation.
- Surgical intervention necessary for excising gelatinous material.

Definition: A permanent alteration in the microarchitecture of the lamina propria.
Characteristics: Requires high-magnification video stroboscopy to detect the subtle changes. The scarring represents a permanent alteration of the collagen and elastic fibers in the lamina propria, leading to a significant loss of viscoelastic properties (pliability and elasticity). This results in a stiff segment of the vocal fold, causing a reduced or absent mucosal wave amplitude and impaired vibratory capabilities.
Causes: Can arise from:
- Extended phonotraumatic behaviors
- Surgical procedures
- Radiation therapy
- Vocal hemorrhages and prolonged reflux.

Impact: Dysphonia severity can vary, often resulting in a weak voice that becomes harsher under increased effort.
Treatment Options: Voice therapy focuses on achieving optimal vocal resonance and hygiene, often exploring compensatory strategies. Surgical intervention may involve injecting materials such as hyaluronic acid, calcium hydroxylapatite, or autologous fat into the scarred vocal fold. These fillers aim to restore vocal fold volume, improve mucosal wave symmetry, and facilitate better glottal closure, thereby enhancing voice quality.

Definition: A groove along the medial edge of the vocal fold, potentially bilateral.
Characteristics: Loss of viscoelastic properties; may be congenital or result from prior cyst excision.
Types:

Observation: Difficulty discerning complete fold closure leading to perceived voice issues despite mechanical closure.
Treatment Options:
- Voice therapy including vocal function exercises to strengthen closure.
- Surgical intervention with injectables to fill the sulcus.

Definition: An inflammatory lesion usually occurring at the vocal process of the arytenoids.
Characteristics: May appear as a large mass, sometimes exhibiting a 'cup and saucer' effect whereby one granuloma fits into an indentation on the opposing vocal process during adduction. They frequently occur due to repetitive microtrauma from excessive vocal fold adduction (contact granuloma), intubation injury, or chronic irritation from laryngopharyngeal reflux (LPR) or persistent coughing/throat clearing.

Voice Change: Minimal voice effect despite lesion presence; may show raspy quality.
Pain: Often presents with throat pain associated with hoarseness.

Voice Therapy: Important to reduce recurrence post-surgery; modifies voice behavior to promote healing.
Surgical Options: Generally a last resort as recurrence rates are high, especially if underlying causes like LPR or phonotrauma are not addressed. For recurrent or particularly stubborn lesions, Botox (botulinum toxin) injections into the thyroarytenoid muscle can be used to temporarily weaken the vocal fold adduction, reducing the impact stress on the vocal processes and promoting healing.