Voice Disorders: Polyps, Edema, and Paralysis

Vocal Polyps

• Benign, fluid-filled lesions typically on the superficial layer of the lamina propria (Riemann Key space).
• Often result of phonotrauma (usually a single event).
• Key difference from vocal nodules: polyps are usually unilateral (on one side).
• Can disrupt normal vocal fold vibration, leading to hoarseness.
• Key Features:
  • Typically unilateral.
  • Blister-like lesions with an inflamed look.
• Voice Symptoms:
  • Hoarseness.
  • Rough, breathy, raspy voice.
  • Vocal fatigue.
  • Reduced vocal range.
• Diagnosis:
  • Case history is important to understand the onset of symptoms (usually from a single phonotraumatic episode).
  • Patients may complain of globus sensation (feeling something in the throat).
  • Endoscopy and stroboscopy are used to view the vocal folds and the polyp's movement.

Reineke's Edema

• Swelling of the vocal folds due to viscous fluid in the superficial layer of the lamina propria.
• Often caused by smoking.
• Key Features:
  • Swelling of vocal folds (can be unilateral or bilateral).
  • Hoarseness or rough voice.
  • Low pitch (smoker's voice).
  • More prevalent in females (possibly due to noticing lower pitch more).
  • Common in smokers.
  • Can be caused by acid reflux or voice overuse/misuse.
  • Gradual onset.
• Differentiation:
  • In-depth case history is crucial (smoking habits, irritant exposure, vocal strain).
  • Diagnostic laryngoscopy is essential for visual analysis.
  • Swelling appears as tiny grapes or water balloons.
  • Video stroboscopy visualizes vocal cord vibration and edema severity.
  • Classification systems help separate the severity of edema.

Questions to Differentiate Voice Disorders

• How often do you use your voice for work or hobbies?
• How would you describe your voice (coarse, rough, breathy, low pitched)?
• Do you experience voice fatigue or effort during speaking?
• When did you first notice the changes in your voice (sudden or gradual)?
• Do you smoke or have a history of smoking?
• Do you drink alcohol regularly (affects vocal folds)?
• Do you have acid reflux, allergies, or frequent throat clearing (throat clearing has a huge effect on the vocal folds)?
• Have you ever been diagnosed with vocal fold lesions before?
• Has your pitch changed? Do you have difficulty reaching high notes or projecting your voice?

Signs and Symptoms

Vocal Polyps

• Hoarseness, breathiness, voice fatigue.
• Pitch breaks or instability.
• Decreased vocal range.
• Throat discomfort or lump sensation.
• Sudden onset after voice strain.
• Typically unilateral.

Reineke's Edema

• Deep, husky voice (especially in women).
• Chronic hoarseness.
• Reduced vocal projection.
• Frequent throat clearing.
• Sensation of fullness in the throat.
• Gradual onset.
• Often bilateral and swollen vocal folds.
• Common in long-term smokers.

Benign Lesions

• Polyps and Reineke's edema are benign.
• Important to inform patients that while these conditions are not cancerous, continued smoking or abuse can lead to cancerous or precancerous lesions.
• Chronic abuse can break down the lamina propria, causing swelling and changes to vocal cord flexibility.
• Polyps are more focused bulges or blisters within the rank space.

Vocal Cord Paralysis

• Voice disorder where one or both vocal cords can't move properly due to nerve damage or dysfunction.
• Vagus nerve (from brainstem to larynx) controls vocal cord movement.
• Damage disrupts nerve impulses to muscles responsible for opening and closing vocal cords.
• Damage can result from surgical trauma, neurological conditions, tumors, infections, or strokes.
• Key Characteristics:
  • Impaired vocal cord movement.
  • Voice changes.
  • Difficulty speaking/swallowing.
  • Vocal fatigue.
• Types:
  • Unilateral (one vocal cord affected) - most common.
  • Bilateral (both vocal cords affected) - potentially life-threatening.

Case History Questions

• Any head/neck injuries, tumors, diseases, or surgeries in the neck/chest?
• Any breathing/swallowing issues (shortness of breath, breathy voice)?
• Recent viral infections (autoimmune diseases can cause transient or permanent paralysis)?
• Needed help breathing with a tube or ventilator (can cause injury to the recurrent laryngeal nerve)?
• History of tumors in the skull base, neck, or chest?
• Radiation treatments or chemotherapy (can compromise nerve supply)?
• Arthritis (severe cases can fix the cricoarytenoid joint and imitate paralysis)?

Important Note

• Vocal folds move passively via muscle contraction.
• Motor innervation from the vagus nerve goes to the intrinsic laryngeal muscles.
• The nerve innervates the muscles that contract to passively move the vocal folds.

Signs and Symptoms

• Hoarseness and breathy voice (weak, airy, rough).
• Inability to speak loudly.
• Limited pitch and loudness.
• Short durations of voice production (voice tires easily).
• Severe cases: aspiration pneumonia from choking/coughing while eating.

Auditory Perceptual Evaluation

• Use tools like CAPE to assess breathiness, roughness, pitch, and loudness.

Acoustic and Aerodynamic Tests

• Acoustic:
  • Jitter and shimmer (variations in pitch and loudness) may increase due to irregular movement.
  • Spectral analysis (e.g., cepstrum) assesses glottal sound source and vocal tract interaction.
  • Cepstral peak prominence is lower in vocal fold paralysis due to increased noise.
• Aerodynamic:
  • Average flow rate (high airflow, 400-600 mL/s due to incomplete closure).
  • Phonation threshold pressure (increased pressure needed to initiate vibration).
  • Patients may complain of physical fatigue due to increased effort.
• Acoustic and aerodynamic measures are typically done in a voice lab, but portable devices for septal peak information are emerging.

Laryngeal Visualization Procedures

• Use light source and scope (constant or strobic) to view laryngeal structures and functions.
• Includes indirect laryngoscopy, rigid fiber optic oral endoscopy and flexible fiber optic nasal nasoscopy.
• SLPs can perform the procedure, but medical diagnosis is made by a physician (otolaryngologist, ENT).
  *Children prefer flexible option.
  *Video version of the two options

Different Procedures

*Rigid Fiber Optic
*Flexible Fiber Optic
*Video Laryngo-Endoscopy

Limitations and Disadvantages

• Need to use other evaluation tasks as well to make that diagnosis.

Electromyography (EMG)

• Electrodes placed on muscles around the larynx to check muscle firing.
• Assesses difficulty in Swallowing

General points

• Treatment aims to reduce hyperfunction.
• Voice therapy can help with nerve repair.
• Bilateral paralysis requires focus on protecting swallow.