Structural

CONTACT ULCERS

Overview:

Contact ulcers are raw sores, pale or red in color, located on the posterior third of the vocal fold. Contact ulcers can exist on one vocal fold (unilaterally) or both (bilaterally). They develop on the posterior third of the vocal fold because this is where your arytenoid cartilages--the elastic cartilages the vocal folds attach to--are located. (Note: the area of the vocal fold at which the aretynoid cartilages are located are known as the vocal processes.) The sores are located on the mucous membrane covering covering these cartilages. Specifically, there are two subtypes of contact ulcers: specific granulomas and nonspecific granulomas. Specific granulomas are more rare and are caused by tuberculosis and syphilis. Nonspecific granulomas, which are benign, are more common.

Cause:

Vocal Abuse:

People who use their voices excessively, such as teachers, singers, lawyers, preachers, and sales representatives may develop contact ulcers as a result of vocal abuse. Vocal abuse occurs when increased pressure is placed on the vocal folds for sustained periods of time. It also includes voice production patterns such as glottal fry or having hard glottal attacks. When you speak, your two vocal folds abduct and adduct many times. When you are abusing your voice, the thin layer of mucous covering the arytenoid cartilage of the one vocal fold crashes against the opposite vocal fold and the mucosa breaks down. This causes the raw sore known as a contact ulcer.

For information of the treatment of contact ulcers caused by vocal abuse, see the Treatment section.

Gastroesophageal Reflux Disease:

Stomach acid flowing back up into the larynx can also cause contact ulcers as the acid breaks down the mucous membrane covering the arytenoid cartilages of the vocal folds. If your doctor suspects that gastroesophageal reflux disease may be causing your contact ulcers, there are two tests which he/she may utilized to test for the presence of stomach acid: a double-pH probe and pharyngeal pH probe.

For information of the treatment of contact ulcers caused by gastroesophageal reflux disease, see the Treatment section.

Trauma:

Objects such as an endotracheal tube may cause an injury which, in turn, can lead to the development of a contact ulcer.

For information of the treatment of contact ulcers caused by trauma, see the Treatment section.

Other Factors:

Contributing Factors:

• Smoking
• Allergy
• Infections
• Postnasal drop
• Chronic throat clearing

Psychosocial Traits:

• Aggressive personality
• Introversion
• Depression
• Emotional tension
• Cancerophobia 

Dietary Factors:

Some dietary factors can affect the mucous membrane and lead to contact ulcers.

• Caffeine
• Coffee
• Alcohol
• Peppermint
• Spicy foods
• Tomato products
• High-fat diets
• Poor water intake
• Use of tobacco products

Idiopathic:

Occasionally, a contact ulcer develops in a patient for whom none of these factors are apparent or present.

It should be noted that these factors are meant to be informative, and a direct causal relationship in the formation of contact ulcers has not been established.

Symptoms:

• Chronic or acute hoarseness of the voice which can very in degree/severity
• Vocal fatigue
• Mild throat pain when swallowing, coughing, or speaking, especially during pressed phonation
• Cough
• Throat clearing
• Airway obstruction due to the ulcer blocking the space which is normally present between open vocal folds
• Bleeding (usually minor)
• Vocal fold fixation

Diagnosis:

Flexible Nasopharyngoscopy:

A flexible nasopharyngoscopy is a flexible scope allows for a visual of your vocal folds to look for evidence of laryngeal hyperfunction, muscular tension, reflux disease, and the presence of the contact ulcers on the vocal folds. This procedure allows the dynamic activity of the larynx to be evaluated without any distortions that come from opening the mouth and moving the tongue anteriorly, as is done in traditional mirror or rigid telescopic examinations. 

There are two types of flexible scopes. The traditional process does has some disadvantages:

• Reduced detail compared to the mirror or rigid telescopic examinations
• A red bias, or tendency to see the tissue as more red than it really is due to the scope's color scale
• There is a fish-eye distortion of structures 

The newer, chip-end flexible scopes do not have these issues. However they are more expensive and require additional equipment. Therefore, they may not be used by your physician.

Videostrobolaryngoscopy:

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view. 

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

Objective Voice Measurements:

Using objective measurements of the voice is a non-invasive way to measure progress, assess treatment results, and confirm perceived changes by analyzing data regarding pitch, volume, voice quality, and other factors. This could be used as a supplemental procedure to help the treating specialists to adapt a whole-picture view of the patient's current status and any changes that have occurred throughout treatment.

Speech Therapy Evaluation:

An evaluation by a speech language pathologist provides a thorough assessment of the behaviors of the patient that are contributing to their vocal miss-use and the formation and development of the contact ulcer. These evaluations typically examine whether the following are present: poor breath support, hard glottal attack, improper pitch placement, etc. Recommendations for treatment and strategies to correct this behaviors are given. 

Treatment:

Medical:

Cough Prevention and Treatment:

If the cough is due to a recent illness or instrumentation, a cough suppressant such as a narcotic may prescribed. If the cough is chronic, or the patient experiences chronic throat clearing, the following may be used to manage problem: improved hydration, reflux treatment, topical anesthetics, asthma or allergy treatments, and others. 

Antireflux Treatment:

The following treatments may be prescribed to treat reflux diseases: proton pump inhibitors, lansoprazole. rabeprazole, or ranitidine if proton pump inhibitors are not an option.

Lifestyle Modifications:

Lifestyle modifications are crucial and are necessary for every patient, even those who have been prescribed remedies. The following instructions are typically given to patients with contact ulcers:

• Avoid acidic foods that can cause reflux (see Dietary Factors for more information)
• Do not wear tight clothing
• Avoid eating 2-3 hours prior to sleeping
• Sleep with your head elevated

Speech Therapy:

Speech therapy is essential for patients who have developed their contact ulcer from vocal miss-use, trauma, or reflux. In speech therapy, patients will work with a skilled professional to improve their breath support, reduce their hard glottal attack, and eliminate other habits such as excessive throat clearing or vocal straining which cam cause and contribute to contact ulcers. 

Botulinum Toxin Type A:

Botulinum toxin type A is a toxin that is injected into the thyroidarytenoid muscle on the side of the larynx of the contact ulcer. This toxin acts by chemically paralyzing the muscle for a period of 3 months, which reduces the force of the glottal attack and the amount of impact between the two vocal folds while speaking or coughing. It is used for contact ulcers which are non-responsive to other forms of treatment, however speech therapy is conducted during the same time period as when this treatment is being administered so that this new soft glottal attack can be carried over after the injection wears off. 

Surgical:

Surgical treatment to remove the contact ulcer is usually held as a last-resort for cases in which other treatments fail to work, when cancer is suspected, when the lesion is a fibroepithelial polyp, or when the airway and breathing is compromised. It is reserved for these cases as these surgeries have a high recurrence rate of 37-50% and can cause the ulcer to migrate in some cases. Two types of surgical procedures are currently used for the treatment of contact ulcers: 1.) excision to remove the ulcer, and 2.) the use of a laser to stop the feeding vessels from reaching the ulcer, therefore stunting its growth. The use of the flash lamp pulse dye laser is still investigational and the long-term efficacy is unknown at this time. 

Pre-Operation:

Prior to surgery, the patient should follow the following advice accordingly to increase the chances of healing and decrease the risk of recurrence:

• Attend speech therapy to reduce and eliminate vocally-abusive behaviors
• Modify diet and behavior to reduce reflux
• Utilize medical treatments for the management of reflux
• Follow the vocal rest guidelines after surgery

Intra-Operation:

The approach that your surgeon will take during your procedure may include the following: removing part of the ulcer in order to shrink the base, removing the entire ulcer with a cold-knife excision, or a low-watt laser. It is best to discuss the procedure with your physician and surgeon.

Post-Operation:

After surgery, the following guidelines must be followed to ensure proper healing:

• Vocal rest for two weeks (no audible sounds, whispers, or throat clearing)
• Continue anti-reflux treatment
• Continue dietary and behavioral modifications
• Perform a video laryngeal stroboscopy at 2-, 4-, and 8-weeks post-operation to monitor the healing process and adjust the treatment plan as necessary

Follow-Up:

The patient must receive follow-up care on a regular basis to monitor recurrence and the development of secondary lesions on the vocal folds.

Complications:

• Recurrence
• Migration following surgery
• Airway obstruction
• Minor bleeding
• Vocal fold fixation
• Formation of a scar bridge, leading to vocal fold immobility

Outcome/Prognosis:

• 80-100% of patients with contact ulcers respond to medical and/or surgical management
• 80-90% of patients whose major risk factor for contact ulcers is vocal abuse respond to speech therapy and medical management
• 70-80% of patients whose major risk factor for contact ulcers is reflux respond to medical management
• 100% success rate for the use of botulinum toxin type A (note: the numbers in these studies have been small)

References:

Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. Aug 2009;13(8):1422-9. 

Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52.

Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas. Laryngoscope. Feb 1999;109(2 Pt 1):301-6.

Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3.

http://www.merckmanuals.com/home/ear_nose_and_throat_disorders/throat_disorders/vocal_cord_contact_ulcers.html

http://emedicine.medscape.com/article/865924-overview

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VOCAL FOLD CYSTS:

Overview:

A vocal fold cyst is a benign, collection of fluid that is located within the membrane of the vocal fold. The vocal folds are lined with many small glands that secrete mucous to help the vocal folds move easily, but when they do not drain properly the fluid build up into a sac-like structure, or a cyst. 

There are two types of vocal fold cysts: mucus retention cysts and epidermoid cysts. Mucus retention cysts are often translucent and lines with cuboidal or columnar epithelium cells. Epidermoid cysts contain epithelium cells or keratin.

Vocal fold cycts often occur only on one vocal fold, but can occur bilaterally as well. The presence of a cyst on one vocal fold can irritate the opposite fold and cause it to swell. They can occur anywhere along the length of the vocal fold, however it is most common for them to occur in the middle. Vocal fold cysts are usually spherical in shape, white or translucent in color, and look like a mound within the fold itself.  

As vocal fold cysts occur just below the surface of the vocal fold, they interrupt sound production by causing voice changes or hoarseness.

Cause:

Epidermoid Cysts:

Epidermoid cysts may be caused by vocal misuse, from an injury to the mucuos membrane, or from developmental problems before birth.

Mucus Retention Cysts:

Mucus retention cysts may occur spontaneously in some people. They may also be the result of poor vocal hygeine: when mucus-producing glands become obstructed and unable to secrete, i.e., after an upper respiratory infection.

Symptoms:

Vocal fold cysts affect the mucosal wave, which is essential for sound production. A wide variety of symptoms can exist with vocal fold cysts and can include the following:

• Hoarseness
• Increased effort to speak
• Easily fatigued when speaking
• Pain or soreness with vocal use
• Singers report abrupt loss of voice, breaks at certain pitches, or diplophonia (the production of two tones simultaneously)
• Dysphonia (an unaturally deep or rough quality of voice) that becomes increasingly severe with vocal use when the lesions are between the vocal folds
• Periods of aphonia following vocal overuse
• Sometimes one's singing voice remains unaffected while his/her speaking voice is compromised

Vocal fold cycts rarely affect the following:

• Stridor
• Aspiration
• Globus sensation
• Dysphagia

Diagnosis:

Videostroboscopy is essential in making the diagnosis of a cyst. Vocal fold cysts will create asymmetric-looking vocal folds which will be be visible during a videostroboscopy. In addition, the mucousal wave will be significantly decreased unlike vocal fold polyps.

Steroid treatments, which reduce the overlying (and sometimes camouflaging) inflammation while leaving the cyst unchanged, making its diagnosis easier.

Treatment:

Medical:

The key to identifying intracordal cysts is minimizing surrounding edema and inflammation. This can be accomplished through the following: 

• Modified voice use
• Improved vocal hygiene
• Medication aids in accomplishing reduced edema and inflammation
• A 2-week period of vocal rest

In addition, any co-occuring medical conditions which may affect the voice (e.g., reflux, laryngitis, allergies) should be evaluated anr treated.

Speech therapy is essential for all patients in order to address vocal misuse and one's vocal hygeine. In addition, patients with vocal fold cysts often have other compounding functional issues that need to be addressed through speech therapy.

Surgical:

Surgery is an option for patients whose lesions show no improvment following exhaustive medical and speech therapy. Although nodules and polyps may respond to conservative management, vocal cysts typically do not, making surgery a more common treatment for this type of voice issue. Delaying insurgical treatment can potentially lead to the progression of the cyst formation and scarring between the vocal folds. 

The goal of surgery is to remove the cyst, preserve the mucosal cover, and only minimally disrupt the underlying tissue if necessary. In addition, the deep layers of the lamina propria, which hold fibroblasts that produce extracellular proteins, should be avoided in order to prevent scarring along the vocal ligament and damaging of the mucosal cover. 

Pre-Operation:

Surgery is reserved for patients with unresolving lesions that cause troublesome dysphonia.  Medical and speech therapy directed at reducing vocal trauma through improved technique and vocal hygiene are involved in reducing mechanical trauma. It should be noted that patients must endure a three-month period of vocal rest for at least 3 months post-surgery.

Intra-Operation:

The lateral microflap is a surgical technique that is used when the cyst is deep within the vocal fold next to the vocal ligament and the overlying mucosa is normal. The advantage of the lateral microflap is that the incision and the subsequent scar are lateral to the medial surface of the vocal fold. In addition, the unaffected portion of the vocal ligament is often used to orient the flap. 

The medial microflap is a surgical technique used for lesions that involve a discrete portion of the vocal fold and appear to separate easily from the underlying vocal ligament. This approach allows for a shorter flap and can be used to treat mucosa that is overlying a lesion. 

At the end of the procedure, triamcinolone acetate may be injected into the flap in order to further minimize scar formation. With both techniques, most patients experience return of mucosal wave and are satisfied with voice quality.

Post-Operation:

For two weeks after microflap surgery, a patient must follow strict vocal rest. For those whose surgery was more extensive, corticosteroids may be prescribed. All patients will be given antibiotics for one week, and a mild narcotic pain medication. Symptoms of reflux will be treated with a proton-pump inhibitor. 

Follow-Up:

Patients will be examined 2-, 4-, 8-, and 12-weeks following surgery. At the 2-week postoperative visit, a videostroboscopy will be given and the patient will resume their speech therapy. A gradual return to voice use occurs over the first few weeks, increasing by 5-minute intervals twice daily. Singers may begin to work after 1 month, but are cautioned to decrease vocal work if they feel any discomfort or strain. 

Most patients can expect 90% of their functional surgical result after approximately 3 months.

Complications:

Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may result in the following:

• Tongue numbness
• Altered taste
• Oropharyngeal, mucosal, or dental injuries

Deep-plane dissection or exposure of the vocal ligament can result in the following:

• Scarring of the mucosa
• Fibrosis of the mucosa with 
• Loss of mucosal wave
• Glottal insufficiency

Outcome/Prognosis:

Following surgery in the most extreme cases, patients are found to have improved contouring of their vocal folds, better glottal closure, and improved mucosal wave propagation. 

References:

Beham AW, Puellmann K, Laird R, Fuchs T, Streich R, Breysach C, et al. A TNF-regulated recombinatorial macrophage immune receptor implicated in granuloma formation in tuberculosis. PLoS Pathog. Nov 2011;7(11):e1002375. 


Jackson C. Contact ulcer of the larynx. Ann Otol Rhinol Laryngol. 1928;37:227-30.


Jackson C, Jackson CL. Contact ulcer of the larynx. Arch Otolaryngol. 1935;22:1-15.

Ayazi S, Lipham JC, Hagen JA, Tang AL, Zehetner J, Leers JM, et al. A new technique for measurement of pharyngeal pH: normal values and discriminating pH threshold. J Gastrointest Surg. Aug 2009;13(8):1422-9.

Bloch CS, Gould WJ, Hirano M. Effect of voice therapy on contact granuloma of the vocal fold. Ann Otol Rhinol Laryngol. Jan-Feb 1981;90(1 Pt 1):48-52.


de Lima Pontes PA, De Biase NG, Gadelha EC. Clinical evolution of laryngeal granulomas: treatment and prognosis. Laryngoscope. Feb 1999;109(2 Pt 1):289-94.


Gould WJ, Rubin JS, Yanagisawa E. Benign vocal fold pathology through the eyes of the laryngologist. In: Rubin JS, ed. Diagnosis and Treatment of Voice Disorders. New York, NY:. Igaku-Shoin;1995:146-9.


Havas TE, Priestley J, Lowinger DS. A management strategy for vocal process granulomas.Laryngoscope. Feb 1999;109(2 Pt 1):301-6. 


Nasri S, Sercarz JA, McAlpin T, Berke GS. Treatment of vocal fold granuloma using botulinum toxin type A. Laryngoscope. Jun 1995;105(6):585-8. 


Orloff LA, Goldman SN. Vocal fold granuloma: successful treatment with botulinum toxin. Otolaryngol Head Neck Surg. Oct 1999;121(4):410-3.


Wenig BM, Heffner DK. Contact ulcers of the larynx. A reacquaintance with the pathology of an often underdiagnosed entity. Arch Pathol Lab Med. Aug 1990;114(8):825-8.

www.entnet.org/HealthInformation/nodPolypCysts.cfm

ent.about.com/od/entdisordersvx/a/VocalCysts.htm

www.voicemedicine.com/cyst.htm

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VOCAL FOLD NODULES:

Overview:

Vocal fold nodules are benign, growths on the surface of the true vocal folds. It is commonly believed that they are result of vocal trauma. Nodules are located bilaterally, or on each of the two vocal folds, commonly at the junction of the anterior and middle third of the vocal fold, or the midpoint of the membranous vocal fold. A unilateral mass is not a nodule. 

Vocal fold nodules are most often observed in women aged 20-50 years, but they are also found commonly in children, both male and female. It has been suggested that laryngeal size may be a factor that predisposes women and pre-adolescent boys and girls (who have smaller larynxes than adult men) to nodule formation. As vocal fold nodules are rare in men, bilateral vocal fold lesions should be examined carefully. An adult male who is diagnosed with vocal fold nodules should be careful in accepting a diagnosis of nodules without a thorough diagnostic examination. See "Diagnosis" for more information on the diagnostic process for vocal fold nodules.

Vocal fold nodules are a well-known problem in singers, both amateur and professional, possible due to the singing style of the singers or simple their increased amount of vocal use in general.

Nodules are symmetric or nearly symmetric and can vary in size. (Note: bilateral masses that are not symmetric should be examined very carefully, as they most likely are cysts or polyps that have damaged the opposite vocal fold, causing swelling. This swelling may resemble a second mass and therefor may be mistaken for a pair of nodules.) They resemble a mound of tissue and will stand out from the edge of the vocal folds. Unlike polyps, vocal fold nodules are the same color as the rest of the vocal fold. They will not significantly grow in size, however with time they may swell due to repeated trauma from vocal use. 

Cause:

Vocal Abuse:

Vocal fold nodules are thought to be caused by vocal trauma, or more specifically, phonotrauma. Vocal trauma can be caused by vocal abuse, vocal misuse, and  vocal overuse. Vocal abuse refers to vocal behaviors that are done under circumstances that lead to trauma of the mucosa of the larynx. Vocally abusive behaviors include the following:

• Excessive talking
• Prolonged and excessive loudness
• Use of inappropriate pitch
• Excessive cough
• Throat clearing

Vocal misuse involves abnormal vocal behaviors that cause stress or trauma to the larynx. Vocal misuse includes the following behaviors:

• The use of excessive tension and effort while phoning
• Hard glottal attacks
• Ventricular phonation

It is important that your physician take a complete history to identify any potential contributing factors including:

• Thyroid disease
• Smoking history
• Caffeine use
• Use of prescription or over-the-counter (OTC) medications
• Patterns of vocal behavior (including occupational use and recreational and social behaviors)
• This may provide clues to contributing vocal overuse, vocal misuse, and vocal abuse

Symptoms:

Symptoms of vocal fold nodules include the following:

• Hoarse sounding speech
• Hoarseness worsens with vocal use and during a cold or sore throat
• Hoarseness improves with vocal rest
• Painful speech production
• Frequent vocal breaks
• Reduced vocal range
• Breathiness
• Vocal fatigue
• Inability to produce voice with soft volume

Diagnosis:

Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared with other indirect laryngoscopy techniques because of it can detect subtle differences in the appearance, pliability, and mucosal wave characteristics of the true vocal fold.

Treatment:

Vocal Rest

Vocal rest is often prescribes for cases of hoarseness. It is a temporary fix as it improves the condition somewhat, but is not likely to make the nodules go away. Vocal rest may improve the hoarse quality of the voice, decrease the size of the nodules, and reduce the swelling due to phonotrauma. However, these improvements will reoccur the next time the voice is strenuously used. 

Medication

Steroids, which are anti-inflammatory medications, are often prescribed to reduce swelling caused by the phonotrauma and vocal fold nodules. However, steroids will not address the main issue: the nodules themselves.

Voice Therapy

Voice therapy from a speech and language pathologist is the most prominently used treatment for vocal fold nodules. The goal of therapy is to make the person aware of the habits that have led to their problem and teach them strategies to use their voice more efficiently so as to not lead to these problems again. The poor vocal habits to be addressed and mediated in therapy include:

• Excessive talking
• Prolonged and excessive loudness
• Use of inappropriate pitch
• Excessive cough
• Throat clearing
• The use of excessive tension and effort while phoning
• Hard glottal attacks
• Ventricular phonation

Voice therapy will make vocal fold nodules more soft and flexible, therefore improving the quality of the patient's voice. It is important to note, however, that voice therapy usually does not make vocal fold nodules disappear as other factors such as the anatomy play a role in their formation and existence.

Surgery

Due to the fact that vocal fold nodules are the result of poor vocal habits, surgery is usually not recommended, as these vocal habits will most likely return after surgery, causing those nodules to reform. However, for vocal fold nodules that are a result of long-standing and repeated damage and are so well-formed that no amount of voice therapy can improve the voice, microlaryngoscopic surgery is considered. During this procedure, an endoscope and special microlaryngeal instruments are used to remove the nodules. 

Following surgery, your physician will follow-up with the patient to use videostroboscopic technology to examine the vocal folds for the presence of mucosal waves, which should be present once again.

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes, which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view.

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

Scarring should be monitored, as it can interfere with the movement of the vocal folds and present symptoms similar to the vocal fold nodules themselves.

Complications:

Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may result in the following:

• Numbness of the tongue
• Altered taste
• Oro-pharyngeal, mucosal, or dental injuries

Deep-plane dissection or exposure of the vocal ligament can result in the following:

• Scarring of the mucosa
• Fibrosis of the mucosa
• Loss of mucosal wave
• Glottal insufficiency

References:

Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The Clinicopathologic Spectrum of Benign Mass Lesions of the Vocal Fold due to Vocal Abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.[Medline].

Dikkers FG, Nikkels PG. Benign lesions of the vocal folds: histopathology and phonotrauma. Ann Otol Rhinol Laryngol. Sep 1995;104(9 Pt 1):698-703. [Medline].

Hogikyan ND, Appel S, Guinn LW, et al. Vocal fold nodules in adult singers: regional opinions about etiologic factors, career impact, and treatment. A survey of otolaryngologists, speech pathologists, and teachers of singing. J Voice. Mar 1999;13(1):128-42. [Medline].

Gray SD, Titze I, Lusk RP. Electron microscopy of hyperphonated canine vocal cords. J Voice. 1987;1(1):109-115.

Kuhn J, Toohill RJ, Ulualp SO, et al. Pharyngeal acid reflux events in patients with vocal cord nodules.Laryngoscope. Aug 1998;108(8 Pt 1):1146-9. [Medline].

Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of Vocal Fold Polyps With Conservative Treatment. J Voice. Nov 12 2011;[Medline].

Ragab SM, Elsheikh MN, Saafan ME, et al. Radiophonosurgery of benign superficial vocal fold lesions. J Laryngol Otol. Dec 2005;119(12):961-6. [Medline].

http://www.otolaryngology.com/vocalnodule.html

http://www.bbivar.com/vp_vocal_nodules.php

http://www.voiceproblem.org/disorders/vflesions/understanding.php

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VOCAL FOLD HEMORRHAGE:

Overview:

The vocal folds are composed of many layers of thick tissue which contain blood vessels within them. A vocal fold hemorrhage is when the superficial lamina propria, or the layer of the vocal fold under the mucosa that makes the vocal folds pliable and able to vibrate well, suffers a bleed. When the voice if used forcefully, blood vessels in the superficial lamina propria may burst open and cause blood to leak into the vocal fold. As the superficial lamina propris is made of a network of fibers that are arranged loosely, blood spreads throughout this layer quickly and affects it greatly. This causes swelling. The result of a vocal fold hemorrhage is that the vocal fold will not vibrate as well as before the bleed. 

A vocal fold hemorrhage is not life-threatening, as it does not require a large amount of blood to cause it. The leakage of blood will stop after a short period of time, but the blood will remain the the vocal fold longer due to the fact that the bleeding has taken place under the mucosa and therefore has no way out of the vocal fold.

Normally, the vocal fold should be a white color. With a vocal fold hemorrhage, however, the blood can turn patches of the vocal fold red. Additionally, the red color may extend throughout the whole fold. Over time, as the blood resorbs, it undergoes the vocal fold will experience the same changes as a bruise, turning darker red to brown. Eventually it will fade and return to the white color. However, repeated hemorrhages often leave a yellowish tint to the vocal folds due to the by-products of blood resorption.

Cause:

A vocal fold hemorrhage is caused from phonotrauma, or the physical stresses caused by using the voice, often inappropriately. Phonotrauma can result from the following behaviors:

• Singing aggressive styles of music, e.g., gospel & rock
• Singing incorrectly, e.g., with poor technique or when one is sick
• Singing in poor environments, e.g., with poor amplification or in a loud environment that may cause the singer to use an excessively loud volume
• Throat clearing
• Excessive coughing
• Shouting

The small blood vessels of the vocal fold endure this stress and may rupture after loud voicing or sustained voicing. This may also occur when the blood vessels are more fragile than normal, as when they are swollen during laryngitis. Small irregularities, like tiny polyps or weak areas in the blood vessel wall called varices, may also predispose someone to vocal fold hemorrhages.

Hemorrhage may be a one-time event, or it may recur. In situations of repeated bleeding, the vocal folds should be examined very carefully for other abnormalities.

Symptoms:

Hemorrhage causes hoarseness which usually develops over a very short period of time, typically as a result of a specific event that required strenuous voice use, e.g.,  a musical performance, speaking over the noise at a party, or cheering at a baseball game. The hoarseness may range in severity: it may be obvious in the speaking voice, or it may be more subtle, and only be evident in the person's singing voice. Additionally, one may experience vocal fatigue.

People who use their voice for a living, such as a singer or actor may experience the following symptoms:

• Diplophonia, or producing two pitches at the same time
• Hearing a flutter in the voice
• Significantly decreased range of pitch
• Inability to speak or sing quietly
• Inability to hold a steady pitch, or frequent pitch breaks
• Neck pain

The following symptoms are not associated with a vocal fold hemorrhage:

• Pain
• Difficulty swallowing
• Difficulty breathing 
• Blood in your saliva
• Coughing up blood

If you have been diagnosed with a vocal fold hemorrhage and experience any of these symptoms, speak with your doctor, as you may need to be re-evaluated to examine other possibilities. 

Diagnosis:

If you are experiencing symptoms that suggest a vocal fold hemorrhage, your vocal folds must be examined using videostroboscopy by a laryngologist.

During a videostrobolaryngoscopy, a camera captures a video of your vocal folds, which vibrate at an extremely fast rate. During this procedure, a stroboscopic light (from a rigid or flexible scope) flashes which allows the examiner to view the vocal folds vibrating at a seemingly much slower rate. This process therefore allows for a visual of the larynx in action. A recording of this examination is reviewed, and subtle abnormalities that tend to be missed under ordinary light come into view. 

This process is also used to monitor treatment success or progression of the ulcers, as videostrobolaryngeoscopies can be conducted at various times and compared to one another.

The laryngologist will look for the following signs of a vocal fold hemorrhage:

• Patches of red on the vocal fold
• Entire vocal fold that is red in color
• Yellow-ish tint of the vocal folds due to the by-products of blood resorption 
• Reduced or no vocal fold vibration

It should be noted that a general Ear, Nose, and Throat doctor (ENT) cannot determine the cause of your symptoms, as their traditional scope is not sophisticated enough to get a close-up view of the vocal folds and their vibrations.

Treatment:

Medical:

Anticoagulant medications may be prescribed in instances where the bleeding has not yet stopped, as the bleeding itself should be a short-term problem. Any conditions which may have predisposed a patient to vocal fold hemorrhage, such as excessive cough or reflux disease, should be treated with the appropriate medications.

Vocal Rest:

Vocal rest is a basic behavior change which gives the vocal folds some time off from phonation in order to allow for healing of a temporary condition like vocal fold hemorrhage to occur. It should be noted, however, that vocal rest does not address the underlying problems that may be causing the vocal fold hemorrhage.

Vocal rest can range in terms of the amount of voice use that is allowed. Total vocal rest refers to no voice use at all, including whispering. Relative vocal rest refers to voice use that may be limited in terms of amount, volume, or under what conditions one may speak (e.g., not in noisy environments where increased volume is often necessitated).

Vocal rest is beneficial when it is used for a period of 1-2 weeks. Longer periods of vocal rest do not provide any additional benefit and may in fact only mask the problem and delay the start of potentially-beneficial treatment.

Voice Therapy:

Because vocal fold hemorrhages are often caused by phonotrauma, voice therapy with a speech and language pathologist is important to modify the vocal behaviors that caused that phonotrauma in the first place. Voice therapy may target the following vocal behaviors:

• Avoid hard glottal attacks
• Use easy-onset vocal patterns
• This includes using a reduced rate of speech, coordinated breathing and phonation, light articulatory contacts, and easy & relaxed phonation 

Surgery:

Surgery is only recommended for the following reasons:

• Hemorrhages that are recurrent
• Enlargement of the lesion
• Development of an associated mass
• Intolerable dysphonia
• Acute hemorrhages that may result in the formation of a hemorrhagic polyp

Preoperative:

Patients should be evaluated by indirect laryngoscopy and videostroboscopy. During this examination, the following will be examined:

• Vocal fold mobility
• Glottic closure
• The presence, amplitude, and symmetry of the mucosal wave. 

Any concurrent medical conditions that may affect the voice such as reflux disease, laryngitis, and allergic rhinitis should be evaluated and treated prior to surgical intervention. In addition, the stage of the menstrual cycle in women is important in order to gauge the severity and timing of intervention. This is because the size of the blood vessels in the vocal folds often increase and become more fragile in the premenstrual period: approximately 5 days prior to menstruation.

All known sources of mechanical trauma should be reduced prior to considering surgical therapy to determine reversibility of the vocal fold hemorrhage and to hopefully prevent recurrence post-surgery. This is accomplished in part by medical and speech therapy. See the Medical and Voice Therapy sections for more information. Surgery is reserved for vocal fold hemorrhages that show no reversibility with exhaustive medical and speech therapy.

Intraoperative:

Surgical technique begins by identifying the feeding and emptying vessels, which are then photocoagulated sequentially with a laser. Some lasers that are typically used are: 

• Carbon dioxide lasers
• Specific photoangiolytic lasers
• A KTP (potassium titanyl phosphate)
• A 585 nm pulsed dye laser 

At this point, depending on the size of the primary lesion, it is either removed using a microflap approach or photocoagulated to stop the bleeding. If it is removed, the goal is to preserve the mucosal layer of the vocal fold with minimal disruption to the underlying tissue. Scar formation should not be a factor in many instances. The use of iced saline and/or a topical epinephrine solution can be beneficial in controlling the hemorrhage limiting the spread of thermal injury beyond the immediate area being treated surgically.

Another surgical option is the direct excision of the hemorrhage by using cold steel phonomicrosurgical techniques and instruments.

Postoperative:

Patients will be placed on strict vocal rest for 2 weeks after microflap surgery. Patients with more extensive excisions may be placed on a short course of corticosteroids to reduce swelling. All patients receive antibiotics and a mild narcotic for pain relief. 

Patients with symptoms or findings of laryngopharyngeal reflux are treated medically. 

Aspirin and nonsteroidal anti-inflammatory agents should be avoided during the first 2 weeks following surgery.

Follow-Up:

Reexamine patients at 2, 4, 8, and 12 weeks following surgery. At the 2-week postoperative visit, videostroboscopy will be performed to examine the vocal folds and evaluate the patient's progress. At the two-week mark, the patient resumes therapy with a speech pathologist. The physician will discuss a plan to gradually return to vocal use with the patient, and this typically occurs over the first few weeks following surgery. Singers may begin to work with a singing coach after 1 month. 

Most patients can expect 90% of their functional surgical result after approximately 3 months.

Complications:

Complications of vocal fold hemorrhages typically arise when a diagnosis is made too late, and can include the following:

• Permanent hoarseness
• Scarring
• Pain during phonation
• Loss of vocal range

To ensure that these complications are avoided, early diagnosis is imminent, especially if you use your voice for your occupation, e.g., singers. Often times, singers assume that hoarseness is to be expected following intense vocal usage, however this is not normal and is an indication that something is wrong. Further more, hoarseness usually resolves following vocal rest, making it seem insignificant. However, it is important that a singer see their doctor at this time, as temporary hoarseness is an indication that the vocal problem is reversible. Once one realizes that their hoarseness is not going away, it may mean that an irreversible vocal problem is present which may require surgical intervention. 


Some complications can arise from surgical intervention. These may include the following:

• Tongue numbness
• Altered taste
• Oropharyngeal, mucosal, and dental injuries
• Loss of mucosal wave 
• Glottal insufficiency. 

References:

Postma GN, Courey MS, Ossoff RH. Microvascular lesions of the true vocal fold. Ann Otol Rhinol Laryngol. Jun 1998;107(6):472-6. 


Cipriani NA, Martin DE, Corey JP, Portugal L, Caballero N, Lester R, et al. The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse. Int J Surg Pathol. Oct 2011;19(5):583-7.

Hochman I, Sataloff RT, Hillman RE, et al. Ectasias and varices of the vocal fold: clearing the striking zone.Ann Otol Rhinol Laryngol. Jan 1999;108(1):10-6. 


Ivey CM, Woo P, Altman KW, et al. Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study. Ann Otol Rhinol Laryngol. May 2008;117(5):353-8. 


Burns JA, Friedman AD, Lutch MJ, Zeitels SM. Subepithelial vocal fold infusion: a useful diagnostic and therapeutic technique. Ann Otol Rhinol Laryngol. Apr 2012;121(4):224-30. 


Franz P, Aharinejad S. The microvasculature of the larynx: a scanning electron microscopic study.Scanning Microsc. Mar 1994;8(1):125-30; discussion 131. 


Frenzel H, Kleinsasser O. Ultrastructural study on the small blood vessels of human vocal cords. Arch Otorhinolaryngol. 1982;236(2):147-60. 


Hsiung MW, Kang BH, Su WF, et al. Clearing microvascular lesions of the true vocal fold with the KTP/532 laser. Ann Otol Rhinol Laryngol. Jun 2003;112(6):534-9. 


Lin P, Stern JC, Gould WJ. Risk factors and management of vocal fold hemorrhages. J Voice. 1991;5:74-7.

http://www.rightdiagnosis.com/v/vocal_cord_hemorrhage/intro.htm

http://www.voicemedicine.com/hemorrhage.htm

http://www.gbmc.org/home_voicecenter.cfm?id=1564