see related sections: Case Example Vocal Fold Nodule Surgery 

Management of Specific Voice Disorders; Polyps Nodules Cysts; Vocal Fold Cysts (intracordal)

For more information about voice in general: National Center for Voice and Speech

DEFINITIONS

1. "Benign masses located in the lamina propria typically at the midpoint of the membranous vocal folds" (Verdolini 2006)
2. "Fair-colored bilateral epithelial thickening" in the middle third of the vocal fold resulting from constant collision caused by overcontraction of the laryngeal intrinsic muscles (Garcia Martins 2009).

ETIOLOGY

1. Epithelial response to stress
   1. Inflammation of the laryngeal mucosa - requires higher infraglottic pressure causing vocal overload (Garcia Martins 2009)
   2. Proposed factors: vocal abuse, nasal obstruction, recurrent nasosinusitis, velopharyngeal insufficiency, hypacusia, gastroesophageal reflux
2.   Maximal impact stress occurs at the mid-membranous fold during vocal fold vibration
   1. Results in acute disruption of epithelial attachments and changes in Reinke's space (Jiang 1998)
   2. Remodeling of Superficial Layer of the Lamina Propria (SLLP) with intense fibronectin deposition (Gray 1995)

EPIDEMIOLOGY 

1. Prevalence in pediatric population 6 - 23% (Carding 2006)
2. High number of nodules in teachers
3. Females and children are affected; males very rarely

HISTOPATHOLOGY

1. Benign lesions: nodules vs polyps  CONTROVERSY
   1. "No pathological anatomy finding is pathognomoic of a specific lesion" (Remacle 1996)
   2. "The histology of nodules is distinct from polyps and other vocal lesions" (Altman 2007).
   3. Nodules are generally acellular, with thickening of epithelium over a matrix with abundant fibrin and organized collagen. There is a more dense fibrous stroma than polyps.
      1. Immunohistochemical characterization of nodules reveals a thickened basement membrane
      2. Polyps have a more pronounced epithelial reaction
2. The varied histological descriptions available for polyps, nodules, and Reinkes space depend on the stage of histological degeneration present (Marcotullio 2003)
   1. Polyps and nodules have the same histopathological alterations in the 5 progressive stages of degeneration:
   2. Histologic Stages (From "early" to "advanced" stage)
      1. Edematous--edema of the chorion (All Reinke's edema is this stage; 2/3 of nodules are this stage)
      2. Angiomatous--vascular proliferation in the edematous chorion
      3. Hyaline--evolution of stage 2; high eosinophil proteic discharge that gives hyaline appearance
      4. Edematous-Angiomatous--mixed (about 50% of polyps are this stage)
      5. Angiomatous-Hyaline--Mixed
   3. Marcotullio et al. concluded "A polyp may be defined as an abnormal unilateral growth of vocal folds, a nodule as a bilateral growth situated between the anterior and medium third of the vocal fold, and Reinke's edema as a bilateral wound that extends to the whole of the true vocal fold."
   4. In studying 203 patients, no dysplasia was observed for polyps or nodules
   5. Dysplasia was present in 10/136 cases of Reinke's edema (7 laryngeal intraepithelial neoplasia 1 and 3 laryngeal intraepithelial neoplasia II).
3. Nodules (Gale 2000)
   1.  Constant findings: thickening of basement membrane, keratosis, and epithelial hyperplasia - not specific to nodules, rather a response to constant and chronic trauma
   2.  Less constant findings: edema, congestion and fibrosis
4. Pathologic analysis of 15 cases of vocal nodules (Garcia Martins 2009)
   1. Light microscopy of nodules: predominance of epithelial hyperplasia, basement membrane thickening, fibrosis, and lamina propria edema
   2. Ultrastructural analysis (SEM): basement membrane break points, thickening of the lamina reticularis, alterations in desmosome structure, enlargement in the cell junctions
   3. Immunohistochemical analyses: marked immunoexpression of fibronectinon the basement and the lamina propria
5. Pathology: see Laryngeal Lesions Pathology Teaching Module: Singer's Nodule

CLINICAL PRESENTATION

1. Symptoms
   1. Hoarseness, breathiness, vocal fatigue, inability to produce voice with soft volume and decreased vocal range.
2. Signs

MANAGEMENT

1. Review of Recent Literature
   1. General concept: nodules generally (especially if they are 'young nodules') resolve with behavioral management; polyps require surgery (McWhorter 2009)
   2. Survey identifying preferred initial treatment with voice therapy among members of the AAOHSN (Sulica 2003)
      1. Vocal fold nodules  91% prefer voice therapy as initial treatment
      2. Vocal fold polyps 30% prefer voice therapy as initial treatment
      3. Vocal fold cysts 22% prefer voice therapy as initial treatment
   3. A retrospective review of 57 patients with vocal fold cysts and polyps concluded that voice therapy is an effective treatment modality for these processes (Cohen and Garrett 2007)
      1. The endpoint evaluated was symptom resolution without the need for surgical intervention
      2. Among fifty-seven patients, 49.1% achieved symptom resolution with voice therapy alone. 
      3. Patients with translucent polyps more commonly responded to voice therapy than fibrotic, hyaline, or hemorrhagic polyps.
   4. Intralesional steroid injections are advocated by some Otolaryngologists as a safe intermediary that may be performed in-office via transnasal flexible endoscope (Wang et al 2013).
2. U of Iowa Approach
   1. Patients with dysphonia and clinical findings of benign vocal fold lesions are evaluated through the multidisciplinary VOICE CLINIC
      1. Includes Speech Pathologist and Otolaryngologist with videostroboscopy and vocal function analysis
      2. Selected cases (singers) may warrant inclusion of a vocologist as well as visitors: the patient's singing teacher
   2. Vocal fold nodules (classic presentation)
      1. Voice therapy as initial treatment (2 sessions per week for six weeks - modify according to response)
      2. Handouts: Handout: Voice Conservation, Handout: Esophageal Reflux Precautions, Handout: Homeopathic Throat Soothers
      3. Consider surgery
         1. Persistence of symptoms associated with identifiable lesions after adequate course of voice therapy
         2. In general: ensure the vocal behavior associated with nodule formation has been successfully modified before offering surgery
         3. In general: know the patient for a year (with sequence of evaluations) before offering surgery for vocal nodules
         4. Operative intervention for nodules : see video
   3. Vocal fold polyps and cysts (classic presentations)
      1. Voice therapy may offered as an alternative to surgery if appropriately analyzed patients
      2. Observation without intervention is an option if malignancy and airway compromise are considered unlikely; followup evaluation usually suggested
      3. Voice therapy is suggested treatment for patients with evidence for voice disorders that are identified in addition to the presence of the lesion
      4. Voice therapy before surgery is considered to diminish risk of recurrence after surgery
      5. Indications for surgery
         1. Counsel about options; offer of surgery contingent upon desires of well-informed patient
         2. Concern about malignancy (biopsy)
         3. Concern about airway compromise (large polyps, Reinke's space edema - see examples)

OPERATIVE PROCEDURE see: Suspension Microlaryngoscopy

REFERENCES

Garcia Martins RH, Defaaeri J, Custodio Domingues MA, de Albuquerque E, R Silva, and Fabro A: Vocal Fold Nodules: Morphological and Immunohistochemical Investigations. J Voice Oct 2009 (Epub)

Carding PN, Roulstone S, Northstone K. The prevalence of childhood dysphonia: a cross-sectional study J Voice.2006;20:623-630

Remacle M, Degols JC, Delos M.Exudative lesions of REinke's space. An anatomopathological correlation. Acta Otorhinolaryngol Belg. 1996;50:253-264

Marcotullio D, Magliulo G, Pietrunti S, Suriano M. Exudative laryngeal diseases of REinke's space: a clinicohistophathological framing J Otolaryngol 2002;31:376-380

Gale N, Zidar N, Fischinger J, Kambic V. Clinical applicability of the Ljubjana classificaiton of epithelial hyperplastic laryngeal lesions. Clin Otolaryngol Allied Sci. 2000;25:227-232

McWhorter AJ and Kunduk M: True Vocal Fold Nodules: the role of differential diagnosis. Current Opinion in Otolaryngology & Head and Neck Surgery 2009,17:449-452

Verdolini K, Rosen CA, Branaski RC. Classification manula for voice disorders I. Special interest division 3, Voice and voice disorders American Speech - Language-Hearing Association. Mahwah, NJ: Lawrence Erbaum Associates, Inc.; 2006

Jiang JJ, Diaz CE, Hanson DG: Finite element modeling of vocal fold vibrationin normal phonation and hypefunctional dysphoia: implications for the pathogenesis of vocal nodules. Ann Otol Rhinol Layrngol 1998:107-603-610

Gray SD, Hammond E, Hanson DF. Benign pathologic resonses of the larynx. Ann Otol Rhinol Laryngol 1995;104:13-18

Sulica C, Behman A. Management of benign vocallesions: a survey of current opinion and practice. Ann Otol Rhinol Laryngol 2003;112:827-833

Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Head Neck Surgy 2007;136:742-746

Wang CT, Liao LJ, Cheng PW, Lo WC, Lai MS. Intralesional steroid injection for benign vocal fold disorders: a systematic review and meta-analysis. Laryngoscope 2013 Jan;123(1):197-203

Altman KW: Vocal Fold Masses in Otolaryngol Clin N Am 40 (2007) 1091-1108