Case Report

VOCAL FOLD POLYP

Presentator : dr. Riko Radityatama Susilo

Advisor : dr. Linda Irwani Adenin, Sp. T.H.T.K.L
Moderator : dr. Vive Kananda, Sp. T.H.T.K.L.
Assessor : 1. Dr. dr. H. R. Yusa Herwanto, M.Ked (ORL-HNS),
Sp. T.H.T.K.L.(K)
2. Prof. dr. Ramsi Lutan, Sp. T.H.T.K.L. (K)
Day / Date : Thursday, November 28th 2019
Time : 09.00 WIB
Place : ENT Meeting Room 4th Floor
H. Adam Malik General Hospital

OTORHYNOLARYNGOLOGY HEAD AND NECK SURGERY DEPARTMENT

MEDICAL FACULTY OF NORTH SUMATERA UNIVERSITY
H. ADAM MALIK GENERAL HOSPITAL
MEDAN
 Vocal Fold Polyp
Introduction
Vocal fold polyp are one of the most frequent benign laryngeal lesions,
impacting the quality of life of those affected by them, primarily by the vocal production.
Vocal fold polyps are benign lesions that are generally unilateral.1-2

Vocal fold polyps can be sessile or pedunculated, unilateral or bilateral. They

occur commonly at the free edge of the vocal fold characterized as edematous, hyaline
or mixed. Acute or chronic voice abuse results in micro-vascular trauma that leads to
sub-cellular changes. These polyps typically affect adults whose work involves
frequent voice stress, for example, teachers and they are also at higher risk of vocal
fold cyst and nodules. The typical histological in the lamina propria, such as
edematous changes, increased capillaries and inflammation are characteristic. The
same histological changes can often be seen in vocal fold nodules and Reinke’s
edema.1-2

The origin of the vocal polyp is phonotraumatic. Other irritating processes,

however, may contribute to the emergence of polyps, such as gastroesophageal
reflux, smoking, aspiration of aggressive chemical substances, or intense respiratory
activities.2,3

The main signs and symptomps in individuals with vocal fold polyps are
hoarseness or breathinness and vocal fatigue.4 However, some recent studies
demonstrated the importance of speech therapy as a primary treatment of polyps, with
total or partial regression, followed by surgery when the lesions are persistent or if the
patients are dissatisfied with their vocal quality.5-6

Vocal polyps were the second most prevalent laryngeal lesion (0.3-0.6%), after
vocal nodules (1.0-1.7%). Considering only the study population, several articles
reported a predominance of vocal polyps in women.2,7 The greater discomfort cause
in incidence between genders in patientd with poyps, acording to the literature, was
71.3% in men and 28.7% in women, aged between 17 and 59 years old (mean of 42.1
± 10.4 years old).7
The etiological relationship between smoking and vocal fold polyps has been
widely studied. Some authors consider smoking as the primary factor for the
development of vocal fold polyps, mainly when associated with vocal abuse. 1

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Unilateral or bilateral vocal fold paresis has been described as the etiological factor of
vocal fold polyps.8

Despite the priority of traditional laryngeal microsurgery and the scientific

advances in term of the surgical techniques used, other treatment alternatives for
vocal fold polyps have produced positive results, such as conservative medical
treatment,9 the use endoscopic laser, steroid injection,10 flexible laryngostroboscopic
surgery,10 acupunture, and vocal health orientation associated with anti reflux
medication.10.

Case reports

A 22-year-old woman came to the ENT Department General Hospital Adam Malik
complaining about hoarseness since four months ago. Patient did dental surgery four
months ago with general anesthesia and his voice became harsh after the surgery.
The hoarseness was getting worse ever since. There were no dyspnea, dysphagia,
history of trauma and upper respiratory tract infection found on the patient.

We did optic laryngoscope procedure on patient and found a pedunculated

mass on his front left part of vocal cord.

Pedunculated mass on
the wall of left anterior
vocal cord, with a smooth
surface and not easily
bleed.

Figure 1 : Optical Laryngoscope

Then the patient was planned for microlaryngeal surgery. The surgery was
prepared by ordering chest X-ray and blood test. Patients scheduled for surgery on
14/08/2019.

The patient lay on the operating table in supine position. The anesthesiologist
intubates the larynx directed to the left side of the mouth. Then the pads were placed

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under the shoulders so that the head and neck can be perfectly extended. The table
were set on the upside down / tredelenburg position to obtain a comfortable position
for viewing the larynx through a laryngoscope.

Figure 2 : Inserted the Laryngoscope

Laryngoscope was inserted as previously mentioned. When the larynx was

visualized adequately, the tip of the operator's laryngoscope was brought close to the
midline so that pathologic tissue were visible.

The laryngoscope was inserted, the epiglottis was raised, then the
laryngoscope was inserted to evaluate the entire anterior laryngeal structure. Then the
laryngoscope was fixed using a suspension apparatus and connected to the
laryngoscope and then connected to the Mayo stand or glued to the operating table.
Laryngoscope hanging from the table attached to the bed moved from the table without
disturbing the position of the laryngoscope. Then we inserted the optic laryngoscope,
brought it closer to the operative field and visualized the larynx.

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 A mass was visible on the left anterior vocal cords wall, with a smooth surface,
not easy to bleed.

Figure 3 : A mass was visible on the left anterior vocal cords wall

Then the mass is removed by using cutting forceps. The bleedinfg around the
area was controlled. The operation was completed then the mass was examined by
department of Pathological Anatomy.

Figure 4 : The mass is removed by using cutting forceps

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 Pathological anatomy results showed that polypoid specimen was lines with
squamous monotonous epithelium, fibrous tissue stroma with lymphocyte infiltration.
It was assumed that the mass was benign polyp.

Discussion.

Vocal fold polyp are one of the most frequent benign laryngeal lesions,
impacting the quality of life of those affected by them, primarily by the vocal production.
Vocal fold polyps are benign lesions that are generally unilateral.1-2
They are most often unilateral and located on the anterior third of the vocal
folds. Polyps are known to interfere with phonation more than nodules, depending on
their size and location and the patients’ ability to compensate Their colour varies from
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red to translucent, and the mucosal wave is normally present or increased.
Vocal fold polyps are common benign laryngeal lesions, which can result in
persistent hoarseness. They are red, white, or translucent elevated lesions located on
the free edge of the true vocal fold at the junction of the anterior and middle third. They
are thought to develop from vocal abuse, which causes rupture of the vessels in the
superficial layer of the lamina propria, resulting in hematoma. Edema and
inflammatory cell infiltration then result from this phonotrauma leading to the formation
of newmatrix. The presence of the lesion inhibits approximation of the vocal folds at
the closed phase of the glottal cycle resulting in increased vocal effort and hoarseness.

Vocal fold polyp is a common disorder of the larynx, typically observed as

unilateral masses of the free edge of the vocal fold. Most phonosurgeons consider
surgery to be the mainstay of treatment of these lesionsSurgery is preferred by many
for vocal fold polyps.1 However,some phonosurgeons have observed that a certain
proportion of polyps resolve without surgery.12

Phonosurgery (PS) using the operating microscope has replaced simple

resections of benign lesions on the vocal folds like polyps, cysts and nodules in order
to optimize the preservation or restoration of the voice. Video-laryngoscopy is used to
assess the quality of vocal fold vibration and the effect of treatment. Phono Surgery is
a quick and effective surgical procedure entailing only few complications. All but one
patient in this study benefitted from surgery and 85% had a normal voice post-
operatively.11

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Conclusion.

Vocal fold polyp are one of the most frequent benign laryngeal lesions,
impacting the quality of life of those affected by them Polyps are extensions from the
lamina propria and can be broad-based or have a narrow stem. They are most often
unilateral and located on the anterior third of the vocal folds.
Vocal fold polyps are common benign laryngeal lesions, which can result in
persistent hoarseness. After the extubation, the frustrate and overwhelming attempts
of the patient in emitting the voice of “more clean” form, unchains muscular efforts
adds and tension of the cervical musculature and the larynx. This inadequate standard
of speech can become habitual and the traumatic and constant impact of the vocal
folds during speaks will give to origin secondary injuries on the mucous covering of
the larynx as the vocal fold (VF) polyps.
Besides the repetitive trauma, the addition causes that may contribute to polyp
formation are airway infections, allergies, nicotine, gastro-esophageal reflux, aspirin
and other blood thinning medications12. Classically, surgery has been the mainstay of
management for vocal fold (VF) polyps.
Phonosurgery (PS) using the operating microscope has replaced simple
resections of benign lesions on the vocal folds like polyps, cysts and nodules in order
to optimize the preservation or restoration of the voice. Video-laryngoscopy is used to
assess the quality of vocal fold vibration and the effect of treatment. Phono Surgery is
a quick and effective surgical procedure entailing only few complications. All but one
patient in this study benefitted from surgery and 85% had a normal voice post-
operatively.11

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 DAFTAR PUSTAKA

1. Sushna M, Ramesh P, Puja N. Vocal Nodules and Polyps: Clinical and

Histological Diagnosis. Glob J Oto 2017; 8(5): 555744. DOI:
10.19080/GJO.2017.08.555744. 002.
2. Wallis L, Jackson-Menaldi C, Holland W, Giraldo A (2004) Vocal fold nodule vs.
vocal fold polyp: answer fromsurgical pathologist and voice pathologist point of
view. J Voice 18(1): 125-129.
3. Bohlender J. Diagnostic and therapeutic pitfalls in benign vocal fold diseases.
GMS Curr Top Otorhinolaryngol Head Neck Surg 2013;12:Doc01 Doi:
10.3205/cto000093
4. Toran KC, Vaidhya BK. Objective voice analysis for vocal polyps following
microlaryngeal phonosurgery. Kathmandu Univ Med J (KUMJ)
2010;8(30):185–189 Doi: 10.3126/kumj.v8i2.3555
5. Kusunoki T, Fujiwara R, Murata K, Ikeda K. A giant vocal fold polyp causing
dyspnea. Ear Nose Thoat J [serial online]. December 2009;88:1248–9.
Avaliable from: https://www.entjournal.com/ article/giant-vocal-fold-polyp-
causing-dyspnea. Accessed February 28, 2015.
6. Yiing WC, Abdullah B. Sudden airway obstruction secondary to bilateral vocal
cord polyps. Pak J Med Sci 2011;27(03):699–701. Avaliable from:
http://pjms.com.pk/index.php/pjms/article/view/ 741/212. Accessed March
2,2015.
7. GnjaticM, Stankovic P, Djukić V. [The effect of smoking and forced use of the
voice to development of the vocal polyps]. Acta ChirIugosl 2009;56(02):27–32
8. Effat KG, Milad M. A comparative histopathological study of vocal fold polyps
in smokers versus non-smokers. J Laryngol Otol 2015; 129(05):484–488 Doi:
10.1017/S002221511500064X
9. Srirompotong S, Saeseow P, Vatanasapt P. Small vocal cord polyps:
completely resolved with conservative treatment. Southeast Asian J Trop Med
Public Health 2004;35(01):169–171. Avaliable from:
http://www.tm.mahidol.ac.th/seameo/2004_35_1/27-3155.pdf. Accessed
March 01, 2015.

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10. Jeong WJ, Lee SJ, LeeWY, Chang H, Ahn SH. Conservative management for
vocal fold polyps. JAMA Otolaryngol Head Neck Surgery 2014;140(05):448–
452 Doi: 10.1001/jamaoto.2014.243
11. Nakagawa, H., Miyamoto, M., Kusuyama, T., Mori, Y., & Fukuda, H.
(2012). Resolution of Vocal Fold Polyps With Conservative Treatment. Journal
of Voice, 26(3), e107–e110. doi:10.1016/j.jvoice.2011.07.005
12. J, B, Jensen., Niels, Rasmussen., (2013) Phonosurgery of vocal fold polyps,
cysts and nodules is beneficial . Dan Med J 2013;60(2):A4577