60 - Benign Vocal Fold Mucosal Disorders

60 Benign Vocal Fold Mucosal Disorders
Robert W. Bastian, Melissa L. Wingo
KEY POINTS
• The two most common risks for vocal fold mucosal and vibratory physiology to guide surgical precision; (2)
vibratory injury are a high intrinsic tendency to use the proven technical ability of the surgeon; (3) preoperative
voice (talkativeness, extroversion) and a high extrinsic and postoperative laryngeal videostroboscopy examination
opportunity or necessity to use the voice, driven by to diagnose clearly at the initial presentation and after
occupation, family needs, social activities, and avocations. surgery to assess results; and (4) access to voice-qualified
• Visible vocal fold lesions from overuse may not cause an behavioral (speech pathology) support.
audible change in the speaking voice. • Capillary ectasia can be an incidental finding that does not
• Visible vocal fold lesions that cause phonatory mismatch at necessarily require treatment. Surgical intervention may be
the free margin or mucosal stiffness are always detectable indicated, on the other hand, when the ectasia causes one
audibly in the singing voice provided that the examiner or more of the following: a tendency to decreased vocal
knows how to elicit upper-range vocal tasks. endurance (reduced voice use time before huskiness
results), intermittent bruising, or a hemorrhagic polyp.
• Singing-voice symptoms of mucosal injury are loss of the
ability to sing softly at high pitches, increased day-to-day • Contact ulcers and granulomas are best thought of as
variability of singing-voice capabilities, phonatory onset exuberant healing responses to injury, which can be from
delays, reduced vocal endurance, and a sense of increased aggressive chronic throat clearing, aggressive coughing, or
effort. endotracheal tube injury. Some believe that acid reflux is a
contributor. Treatment is generally supportive over many
• Small or subtle vocal fold lesions may escape visual months during the wait for maturation, pedunculation, and
detection unless the larynx is viewed with high spontaneous detachment; surgical removal is nearly always
magnification; vocalization in the upper range sometimes followed by recurrence.
requires topical anesthesia.
• Marsupialization of saccular cysts is sometimes followed by
• With few exceptions, brief initial speech pathology recurrence; therefore, when possible, complete removal of
evaluation and treatment are indicated when vocal fold saccular cysts appears to be preferred. Even large ones can
injury is clearly due to overuse, misuse, or abuse of the often be removed endoscopically.
voice. Speech therapy alone may suffice if the vocal
improvement that follows is adequate for the patient’s • Recurrent respiratory papillomatosis is caused by the
needs; otherwise speech therapy will serve as preparation human papillomavirus. Currently optimal management
for vocal fold microsurgery. includes careful serial laser laryngoscopic treatment with
consideration of various adjuvant medications.
• Key requirements for successful vocal fold microsurgery
are (1) detailed knowledge of vocal fold microarchitecture
Benign vocal fold mucosal disorders—vocal nodules, laryngeal Benign vocal fold mucosal disorders are common. More than
polyps, mucosal hemorrhage, intracordal cysts, glottic sulci, and 50% of patients who seek medical attention because of a voice
mucosal bridges—seem to be caused primarily by vibratory injury change have a benign mucosal disorder. Even before the laryngeal
from an excessive amount or aggressive manner of voice use. videostroboscopy era, when subtle and small lesions may have
Review of thousands of patients reveals that an expressive, talkative been missed, Brodnitz1 reported that 45% of 977 patients had a
personality correlates best with most of these disorders. Occupa- diagnosis of nodules, polyps, or polypoid thickening. From the
tional and lifestyle vocal demands appear to be additional but same era (1964–1975), Kleinsasser2 reported that slightly more
lesser risks unless these demands are extreme. Occasionally, injury than 50% of 2618 patients seen for a voice complaint had one of
can occur as a fluke based on one episode of vocal strain in an these benign entities.
otherwise moderate voice user. Cigarette smoking is a cofactor
for smoker’s polyps (Reinke edema). Infection, allergy, and acid
reflux may also potentiate vibratory injury.
ANATOMY AND PHYSIOLOGY
Nonsingers with benign vocal fold mucosal disorders come to The anatomy most relevant to the benign vocal fold mucosal
medical attention because of change in the sound or capabilities disorders is the microarchitecture of the vocal folds as seen on
of the speaking voice. By contrast, singers may have no issues with whole-organ coronal sections in a study of cancer growth patterns3,4
their speaking voices but may seek help because of singing voice and in the work of Hirano.5 Medially to laterally, the membranous
limitations, usually in the upper range. Benign vocal fold mucosal vocal fold is made up of squamous epithelium, Reinke’s potential
disorders are significant because spoken or sung communication space (superficial layer of the lamina propria), the vocal ligament
is important and a person’s voice is a part of his or her identity. (elastin and collagen fibers), and the thyroarytenoid muscle.
868
Downloaded for Karan Gandhi (gandhi95@icloud.com) at Canadian Medical Association from ClinicalKey.com by Elsevier on
August 22, 2021. For personal use only. No other uses without permission. Copyright ©2021. Elsevier Inc. All rights reserved.
CHAPTER 60 Benign Vocal Fold Mucosal Disorders 868.e1
Abstract Keywords
60
Most commonly, benign vocal fold mucosal disorders are caused Vibratory injury
by vibratory injury in “vocal overdoers.” Exceptions include mucous vocal capability battery
retention cyst, papillomas due to human papillomavirus (HPV) flexible chip-tip video-endoscope
infection, granulomas, uncommon benign tumors, and other lesions. videostroboscopy
Accurate diagnosis and management require a skillful history; a microlaryngoscopy
perceptual assessment of the patient’s vocal capabilities, limitations,
and aberrations (if present); and a high-quality laryngeal examina-
tion. A voice-qualified speech pathologist is often part of the
patient’s care to improve vocal hygiene and optimize voice produc-
tion. Lesions found to be otherwise irreversible may be addressed
with vocal fold microsurgery. This chapter discusses in detail the
diagnosis and management of various benign vocal fold mucosal
disorders, including vocal nodules, capillary ectasia, intracordal
cysts, glottic sulcus, bilateral diffuse polyposis, postoperative
dysphonia, contact ulcer/granuloma, intubation granuloma, saccular
disorders, benign mesenchymal neoplasms, recurrent respiratory
papillomatosis, vascular neoplasms, muscle neoplasms, neoplasms
of adipose origin, benign neoplasms of glandular origin, oncocytic
neoplasms of the larynx, cartilaginous neoplasms, and neoplasms
of neural origin.
CHAPTER 60 Benign Vocal Fold Mucosal Disorders 869
Perichondrium and thyroid cartilage provide the lateral boundary characteristics of these layers, they decouple mechanically from
of the vocal fold (Fig. 60.1). each other somewhat during phonation. Graphically illustrated 60
The vocal folds move as a whole between abducted and adducted in Fig. 60.2 (mucosa being stretched), decoupling allows the mucosa
positions for breathing and phonation, respectively. The mucosa— to oscillate with some freedom from the ligament and muscle.
that is, the epithelium and superficial layer of the lamina propria Imagine the vocal fold as a child’s paddleball toy: as the red rubber
(Reinke’s potential space), which covers the vocal folds—is the ball and elastic band move with relative freedom apart from the
chief oscillator during phonation (continuous adduction of the paddle, so the mucosa moves with a degree of freedom from the
folds during expiratory flow of pulmonary air). Thus it is correct ligament and muscle. During phonation, pulmonary air power
to speak of vocal fold mucosal vibration rather than vocal fold supplied to adducted vocal folds is transduced into acoustic power.
vibration. In a canine study supporting this idea, Saito and associ- To accomplish this, pulmonary air is passed between appropriately
ates6 placed metal pellets at varying depths within the vocal fold adducted vocal folds. At this point, the vocal fold mucosa vibrates
(e.g., epithelially, subepithelially, intramuscularly) and used passively according to the length, tension, and edge configuration
radiographic stroboscopy to trace their coronal plane trajectories determined by the intrinsic muscles and elastic recoil forces of
during vibration. Pellet trajectories of the mucosa were far wider the vocal fold tissues. Fig. 60.3 shows the maximum open and
than those of the ligament or the muscle; thus it is primarily the closed phases of one vibratory cycle, as seen during laryngeal
vocal fold mucosa that oscillates to produce sound. videostroboscopy. Further details concerning the mucosa’s vibratory
The work of Hirano7 provides an explanation for these observa- behavior can be found in the works of Baer8 and Hirano5 and in
tions. Hirano described the vocal fold muscle as the body of the Chapter 56.
fold, the epithelium and superficial layer of the lamina propria Other important microanatomy includes glands in the supraglot-
(Reinke’s potential space) as the cover, and the intermediate layers tic, saccular, and infraglottic areas, which produce secretions that
of collagenous and elastic tissue (vocal ligament) as the transitional bathe the vocal folds during vibration.
zone (see Fig. 60.1). Because of the different physiologic stiffness
Stratified Vocal
squamous ligament Respiratory
epithelium epithelium
Thyroarytenoid
muscle
Superficial (vocalis)
layer, lamina
propria
(Reinke’s
space)
Fig. 60.2 Gentle medial retraction shows the relative decoupling of

Fig. 60.1 Cross-section of the vocal fold. the mucosa from the underlying nondeformed vocal ligament.
A B
Fig. 60.3 The maximum open (A) and closed (B) phases of an apparent single vibratory cycle as seen during
videostroboscopy. The moving part is primarily mucosa; participation of ligament or muscle is slight.
870 PART V Laryngology and Bronchoesophagology
EVALUATION OF THE PATIENT: Common Symptom Complexes

GENERAL PRINCIPLES As in the case of many other types of voice disorders, a characteristic
The scientific method demands that hypotheses be tested using symptom complex usually accompanies benign mucosal disorders.
observation or measurement. In the clinical realm of voice Nonsingers, who often experience moderate to large mucosal
disorders, an unresolved issue is how important are observation disturbances before they seek medical attention, usually describe
and measurement, respectively, for diagnosis. In this author’s chronic hoarseness with exacerbations at times of increased voice
view, the necessary and sufficient elements for diagnosis and use. Singers may not note speaking-voice symptoms but rather
management of benign mucosal disorders are (1) a skillful history; often describe (1) exaggeration of day-to-day variability of singing
(2) a perceptual assessment of vocal capabilities, limitations, capabilities; (2) increased effort necessary for singing; (3) reduced
and aberrations (when present), particularly through elicitation vocal (mucosal) endurance; (4) deterioration of high, soft singing;
of vocal tasks designed to detect mucosal disturbances; and and (5) delayed phonatory onset and air wastage (breathiness).
(3) a high-quality laryngeal examination, which often includes
laryngeal videostroboscopy. Although not particularly useful
for diagnosis, certain measures of phonatory function (aerody-
Talkativeness Profile: Vocal Overdoer Syndrome
namic, acoustic) may be of interest for research and publication, The factor that correlates most strongly with the formation and
documentation of the disorder’s physiologic effects, and as maintenance of many benign vocal fold mucosal disorders appears
an adjunct to observational assessment of improvement after to be personality. A simple and even rudimentary but nevertheless
treatment. powerful way to assess this issue is to ask the patient to self-rate
talkativeness on a 7-point scale; a score of 1 is very untalkative,
a person with a score of 4 is average, and a person with a score
History of 7 is unusually talkative. (In asking this question, the clinician
Besides the usual items in the general medical history, the voice must stress that this scale deals with innate predisposition, not the
history should focus in particular on the following items, which demands of work or lifestyle.) Virtually all patients with nodules
may be best captured by using a questionnaire9,10: and polyps and even those with cysts and sulci rate themselves at
6 or 7, except for those less talkative individuals who work in
1. Onset and duration of vocal symptoms
vocally extreme occupations (e.g., financial trading).
2. Patient’s beliefs about causes or exacerbating influences
3. Common symptom complexes
4. Talkativeness profile (intrinsic, personality-based tendency to Vocal Commitments
use the voice)
To assess vocal commitments and activities, the clinician or
5. Vocal commitments or activities (extrinsic requirement, invitation,
questionnaire should inquire briefly about occupation, voice type
or opportunity to use the voice), including voice type and
and level of training, and the nature and extent of vocal activities
training if the patient is a performer
related to family life, child care, politics, religion, hobbies, athletics,
6. Other risk factors
and musical rehearsal and performance.
7. Patient’s perception of the severity of the disorder
8. Vocal aspirations and consequent motivation for rehabilitation
Other Risk Factors
Other risk factors are tobacco and alcohol use, acid reflux, insuf-
Onset ficient fluid intake, certain drying medications, systemic illnesses,
It is appropriate during history taking to test the hypothesis that and allergies. Even when the history is positive for one of these
a patient who complains of frequently recurring bouts of vocal factors, it is usually a secondary issue in comparison with
dysfunction may be experiencing exacerbations of a more chronic “sevenness.”
overuse disorder. Based on an assessment of vocal personality,
lifestyle, vocal commitments, and voice production, such a patient Patient Perception of Severity and Vocal Aspirations and
is often found to be “living on the edge” vocally and may have
been pushed over that edge by only a small increase in vocal Consequent Motivation for Rehabilitation
activity or by an upper respiratory infection. In this situation, It is important to explore how severe the patient perceives the
without sophisticated insight, both the patient and the clinician voice problem to be as well as his or her vocal aspirations and
may tend to focus on the recent or current upper respiratory motivations for rehabilitation. For example, the clinician may be
infection (e.g., providing supportive treatments or antibiotics) confronted by a patient who only wants to be reassured that the
rather than seeing past this acute issue to recognize the need for problem is not cancer. Even with a diagnosis of large smokers’
the more sophisticated behavioral therapy appropriate for a chronic polyps with severe range virilization and dysphonia, the manage-
“vocal overdoer.” ment of such a patient might appropriately be short term and
supportive, consisting primarily of counseling about smoking
cessation. Another patient, a professional singer, may have a normal
Patient’s Beliefs Regarding Causes speaking voice but have upper limitations to the singing voice
A clinician is prudent to remain open and curious about cause, caused by small nodules. To help this patient pursue a competitive
even when the patient is already convinced of a certain explanation. singing career, rehabilitation might be intense and might include
For example, a patient may insist that the voice disorder results significant behavioral therapy by a speech pathologist. It might
from allergies or acid reflux. After thorough consideration, the also eventually include surgery.
clinician may instead find that the patient’s vocal overdoer status
(see the following section) is primary and that allergy and acid
reflux in that patient actually happen to be inconsequential by
Vocal Capability Battery
comparison if they are present at all. Of course, in this instance, The vocal capability battery is an auditory-perceptual assessment
considerable time is required at the conclusion of the consultation of vocal capabilities, limitations, and aberrations (if present). It
for teaching to help the patient redirect his or her thinking, to macrophenomenologically assesses two crucial questions, the first
meet objections, and so on. relating to limitation (“What can’t this voice do that it should be
able to?”) and the second to aberration (“What does this voice the visual examination to help determine, along with the patient’s
do that it should not?”). This process involves elicitation of a variety needs and motivation, the intensity and direction of management. 60
of vocal tasks followed by an auditory-perceptual assessment of
the voice. The vocal capability battery is an often neglected part
of the diagnostic process, although it provides the best means of
Office Examination of the Larynx
understanding the nature and severity of the voice disorder. To The larynx can be examined in several ways (Fig. 60.4). The
be most efficient, this part of the diagnostic process is performed laryngeal mirror should provide three-dimensional viewing and
by the same clinician who takes the history and performs the good color resolution; however, in practice it offers poor visualiza-
laryngeal examination. Alternatively, a second clinician can perform tion in many cases. In other cases, visualization is good but only
this assessment, but for best results, the findings of vocal capability during phonation, because the view is obstructed by the epiglottis
elicitation are immediately correlated with the other two compo- during respiration. In addition, no permanent image of the larynx
nents of the diagnostic process. results from this examination technique. Because the physician
Vocal elicitation and interpretation require that the examiner must therefore remember the lesion or document it with a simple
have good pitch-matching abilities; a reasonably normal voice; sketch, precise critique of the effectiveness of the therapy chosen
extensive familiarity with his or her own vocal capabilities (and may not be possible. Rigid and also flexible laryngeal scopes often
limitations, if any); intimate familiarity with normal singing-voice allow a clearer view, particularly during respiration. When used
capabilities according to age, sex, and voice classification; and the with the naked eye, however, they have disadvantages similar to
willingness to model and elicit a response with his or her own those of the mirror. The fiberoptic nasolaryngoscope or a newer
voice. Also needed is a frequency reference, such as a small “chip-tip” videoendoscope is especially important in a patient who
electronic keyboard. These elements are straightforward and can is difficult to examine because of unusual anatomy or an exceptional
be acquired by motivated clinicians with reasonably “aware and gag reflex. Even with these technologies, however, it is possible
insightful” auditory perception. to overlook subtle to small mucosal changes unless the larynx is
In voice clinics where expert vocal capability elicitation and topically anesthetized to allow a close approach of the tip of the
assessment are not available or are not immediately correlated fiberscope to the vocal folds. With topical anesthesia, the vocal
with history and laryngeal examination, clinicians may overlook folds, subglottis, and trachea can be examined easily (Fig. 60.5).13,14
or reject the power and centrality of this part of the evaluation.
They may instead rely on various items of equipment that measure
components of vocal output (e.g., acoustic, aerodynamic). Although
useful for quantification, documentation, and some biofeedback
applications, this equipment is cumbersome and expensive, and
the data it collects are time consuming to interpret. Most impor-
tantly, instrumented measures of phonation are diagnostically weak
in comparison with the insights provided by the vocal capability
battery, which can answer far more quickly, powerfully, and syntheti-
cally the question, What’s wrong with this voice?
The basic vocal capabilities and phenomena to be tested are
(1) average or anchor speech frequency; (2) maximum frequency
range; (3) projected voice and yell; (4) very-high-frequency, very-
low-intensity tasks that detect mucosal disturbances11; (5) register
use and phenomena; (6) maximum phonation time; and (7)
instability and tremors.
The ability to perform high-frequency, low-intensity tasks (e.g.,
singing “Happy Birthday” at the extreme upper range and in a
tiny voice) is the single most important part of the vocal capability
battery in people with benign mucosal disturbances. If a patient’s Fig. 60.4 Three of the most commonly used tools for viewing the
voice loses its expected upper range under these performance larynx: a mirror, a 90-degree telescope, and a flexible distal-chip
constraints or if it suffers from onset delays, air escape, diplophonia, endoscope.
or lack of tonal clarity, the clinician may expect to find a mucosal
disorder. The clinician should also search for inconsistencies
between spoken and sung capabilities and should informally note
the patient’s sincerity of effort and skill. Basic vocal capability
testing requires only a few minutes to perform because the examiner
focuses primarily on the extremes of physical capability and
secondarily on vocal skill.
As stated, the vocal capability battery, combined with the
initial voice history and then subsequent laryngeal examination,
is crucial in diagnosing a voice disorder and in directing subsequent
management. For example, if, during history taking, the patient’s
speaking voice sounds normal, then—even if he or she actually
has (perhaps small) vocal nodules—the clinician might, due to
confirmation bias and selective perception “see” “normal” vocal folds
during visual examination; however, if the patient also performs
some high-frequency, low-intensity vocal tasks and the clinician
detects signs of a mucosal disturbance (e.g., escaping air, onset
delays, diplophonia, loss of clarity and range), the clinician will
be more prepared to find any nodules that may be present.12 The
vocal capability battery also provides insight into the severity of Fig. 60.5 Extreme closeup of the larynx with adequate resolution of
the patient’s vocal limitations, which can then be correlated with the vocal folds, subglottis, and even high trachea.
Strobe illumination added to any of these examining instruments their own merits; however, the clinician may need to help diminish
allows mucosal vibratory dynamics to be evaluated in apparent the patient’s perception of how much these problems contribute
slow motion (e.g., to understand mucosal scarring and to distinguish to a voice disorder in favor of more likely behavioral causes. When
cysts from nodules). Adding a video camera and recording device, optimal laryngeal function is of concern, as in a vocal performer,
typically a computer hard drive, to the rigid or flexible scopes nasal conditions should be managed locally (topically) when possible.
brings additional advantages; for example, showing a video of the The reason is that many systemic drugs (e.g., oral decongestants,
examination to a patient can help him or her to understand and antihistamine-decongestant combinations) dry not only nasal
be motivated. Also, such recordings enable other clinicians— secretions but also secretions in the larynx, where a continuous
otolaryngologists, speech pathologists, voice teachers—to participate secretional flow is important for proper vibratory function and
more easily in assessment and management, and these recordings mucosal endurance, particularly under demanding phonatory
serve as permanent records that document the result of voice conditions. Medications that affect the voice minimally are the
therapy or surgery and enhance the teaching of residents. topical nasal decongestants, which should be used for only a few
days before the nasal mucosa is allowed to rest so as to avoid
rhinitis medicamentosa. The profuse rhinorrhea that accompanies
Objective Measures of Vocal Output the common cold can also be managed with ipratropium bromide
Skillful “triangulation” on the voice problem through the use of inhalations,15,16 and corticosteroid inhalers are invaluable for the
the voice history, auditory-perceptual evaluation of vocal capabilities, management of nasal allergies. Activating pump-action nasal inhalers
limitations and aberrations, and a high-quality laryngeal examination without any inspiratory airflow avoids the alleged risk of the effects
is sufficient for a clear diagnosis and description of the problem. of nasally applied corticosteroid on the vocal folds.
Aerodynamic and acoustic information, although weak diagnostically
because of its nonspecificity, may be useful to quantify and document
severity and change in response to treatment, to deepen understand-
Management of Acid Reflux Laryngopharyngitis
ing in the research arena, and to assist in some helpful biofeedback In a person with an incompetent lower esophageal sphincter
applications. or hiatal hernia, acid reflux into the pharynx and larynx during
sleep can lead to chronic laryngopharyngitis. Such persons may
or may not experience one or more of the following symptoms:
Direct Laryngoscopy and Biopsy exaggerated “morning mouth,” excessive phlegm, scratchy or dry
When videostroboscopy with magnified viewing is available, lesions throat irritation that is usually worse in the morning, habitual
suspicious for cancer or papillomatosis can nearly always be throat clearing, and huskiness or lowered pitch of the voice in
distinguished easily from nodules, polyps, and cysts. Therefore the morning. The larynx may show characteristic erythema of the
removal of the latter entities is appropriate only within a com- arytenoid mucosa, interarytenoid pachyderma, or contact ulcers;
prehensive plan for treatment or voice restoration and rarely if however, laryngeal findings may be subtler than those in Fig. 60.6.
ever for preliminary tissue diagnosis. Careful attention to patient history, laryngeal examination, and
a commonsense empiric trial in a thoroughly educated patient is
sufficient for virtually everyone in whom this diagnosis is being
GENERAL MANAGEMENT OPTIONS considered. Ford17 suggests that the most reliable way to confirm
the diagnosis is using ambulatory multichannel intraluminal
Hydration impedance and pH-monitoring studies; this could be considered
Adequate hydration promotes the free flow of lubricating secretions, in the small number of patients for whom empiric trials com-
which helps the vocal fold mucosa withstand the rigors of vibratory bined with careful patient history and laryngeal examination do
collisions and shearing forces. A consistent, rather than episodic, not suffice.
supply of fluids seems to be particularly important. An expectorant, Basic management of this condition consists of avoiding caffeine,
such as guaifenesin, may also help when secretions are viscid. alcohol, and spicy foods; eating the last meal of the day, preferably
a light one, no fewer than 3 hours before retiring; using bed blocks
to place the bed on a mild head-to-foot slant; and taking an antacid
Sinonasal Management at bedtime, a histamine H2-receptor antagonist (H2 blocker) 2
Patients often incorrectly attribute chronic hoarseness to sinonasal or 3 hours before bed, or a proton pump inhibitor 30 to 60 minutes
conditions. Existing sinonasal problems should be managed on before dinner.
A B
Fig. 60.6 (A) Acid reflux–associated findings of interarytenoid pachyderma and swelling just below the margin
of the folds (blue arrows) and erythema of the mucosa that covers the anterior face of the arytenoid cartilages
(green arrows). (B) Different patient with the same disorder, during phonation. Accumulation of excess
inflammatory and viscous mucus is shown.
analysis, spirometric measures to test respiratory adequacy, fre-

Acute Mucosal Swelling of Overuse quency and loudness measures, translaryngeal airflow rates, and 60
Public speakers or singers may sometimes perform of necessity other measures under various conditions. Speech pathologists may
despite acute noninfectious mucosal swelling resulting from recent use this equipment for biofeedback (e.g., using a visual electronic
overuse of the voice. A careful strategy of relative vocal rest in frequency readout to modify average pitch for speech in a tone-deaf
context is needed (e.g., interspersing high-intensity songs with patient). For obligate false vocal fold phonation and intractable
low-intensity songs, avoiding conversation during intermission, psychogenic disorders of voice production with visible vocal fold
etc.) along with preperformance warm-up and solid vocal technique; posture abnormalities, therapy room videoendoscopy can also be
these may be sufficient for the patient to “get through.” A short- converted into an effective biofeedback tool.11,18
term, high-dose tapering regimen of corticosteroids can also be
useful in this context as part of a larger strategy to help the patient
through a performance.
SURGERY
Some lesions are known at diagnosis to be irreversible except via
surgery. Aside from these exceptions, vocal fold microsurgery
Laryngeal Instillations for Mucosal Inflammation should follow an appropriate trial of voice therapy. Individualization
In past years more so than currently, laryngologists have used is the rule, but patients are typically reexamined with the vocal
drugs such as mono-p-chlorophenol, topical anesthetics, mild capability battery and videostroboscopy at 16-week intervals after
vasoconstrictors, sulfur vapors, certain oils, and other substances diagnosis. When a compliant patient does not improve after two
for the reduction of swelling, a soothing effect, or promotion of or more successive examinations and remains unhappy with the
healing. Some physicians and patients believe in the efficacy of voice’s capabilities, surgery may be considered. Good surgical
such management, although it is supported only by anecdotal results are directly related to diagnostic accuracy, surgical judgment
reports. and precision, and the patient’s compliance with proper voice care.
Although specific techniques vary for each disorder, the basic
requirements for successful laryngeal microsurgery for all benign
Systemic Medicines That May Affect the Larynx vocal fold mucosal disorders are the same. An understanding of
Medicines that patients take for other reasons—such as antidepres- vocal fold microarchitecture and vibratory dynamics (see previous
sants, decongestants, antihypertensives, and diuretics—may dry discussion) is a prerequisite, and preoperative and postoperative
and thicken normal secretions, which thereby reduces their protec- videostroboscopic evaluation is necessary so that the patient and
tive lubricating effect on the vocal folds and conceivably makes surgeon can see the results together.
the vocal fold mucosa more vulnerable to the development of The first principle of surgery is that microlaryngoscopy, not
benign disorders. The clinician should inquire about these medicines direct laryngoscopy with the unaided eye, and extreme technical
during history taking. precision are required so as to disturb the mucosa as minimally
as possible. Because the disorder is benign and confined to the
mucosa, including Reinke’s potential space, the cancer concept of
VOICE THERAPY surgical margins does not apply. Every case should be approached
A course of therapy by a voice-qualified speech pathologist is with the awareness that overly aggressive or imprecise surgery of
frequently appropriate in patients with benign vocal fold mucosal the vocal fold mucosa can result in regenerated or surgically
disorders, given the common relationship of such disorders with manipulated mucosa that scars and thus adheres to the underlying
vocal overuse, abuse, or misuse. Vocal nodules in particular are vocal ligament, which will cause severe dysphonia.
expected to resolve, regress, or at least stabilize under a regimen A set of laryngoscopes, microlaryngeal forceps, scissors, dis-
of improved voice hygiene and optimized voice production. In sectors, and knives should be on hand. In the face of the plethora
some cases, however, success is defined as having achieved a more of instruments currently available, the comment by Kleinsasser2
consistent voice, without the exacerbations of hoarseness and even that a relatively simple set suffices the experienced surgeon remains
aphonia, even if that now-more-reliable voice remains somewhat true (Fig. 60.7).
husky. In other cases, the definition of success may mean resolution The carbon dioxide (CO2) laser has become an important part
of all upper singing voice limitations. If surgery becomes an of the surgeon’s armamentarium, and many have discussed its
option—because the mucosal disorder has not resolved completely, application to benign laryngeal disorders. Tissue effects of the
and the patient regards residual symptoms and vocal limitations laser depend on spot size and focus, wattage, duration of beam
as unacceptable—voice therapy will have optimized the patient’s activation, waveform mode (pulsed vs continuous), and perhaps
surgical candidacy by educating him or her additionally about the most important, surgical precision. Cold microdissection may be
surgical process, and it will have decreased the risk of postoperative safer than laser techniques, provided that the surgeon is equally
recurrence. proficient in both. In the days before diminished spot size per-
During evaluation, the speech pathologist gathers information mitted increased precision, Norris and Mullarky,19 comparing a
on behavior that may adversely affect the voice and establishes a continuous-mode CO2 laser with the cold scalpel for incising pig
program to eliminate injurious behavior. Voice-qualified speech skin, reported that a short-term advantage resulted after laser
pathologists also model and elicit a battery of spoken and sung incision with regard to the speed of reepithelialization; no long-term
vocal tasks to make plain to themselves and patients the type and difference in healing was noted. However, although the fact was
degree of impairment that has resulted from the lesion. They also not noted in their report, these investigators’ histologic sections
assess the skill and appropriateness of voice production for both clearly showed a wider zone of tissue destruction beneath the
speaking and singing. Depending on the results of this second epithelium with the laser than with the scalpel. Duncavage and
part of the evaluation, the speech pathologist may help the patient Toohill20 compared healing response in dogs after traditional fold
optimize the intensity, average pitch, registration, resonance stripping and after CO2 mucosal vaporization. They concluded that,
characteristics, overall quality, general and vocal tract posture, and until late in healing, more edema and giant-cell reactions to bits
respiratory support for voice production. For singers, the singing of charred debris and greater subepithelial fibrosis occurred with
teacher plays an invaluable role in this process, particularly with the laser technique than with the cup forceps alone. Manipula-
respect to the production of singing voice. tion of wattage, focus, and mode of laser irradiation of tissues
Finally, in this technologic era, voice clinicians increasingly may decrease thermal injury, charring, and other adverse effects
document various aspects of vocal tract output using acoustic of the laser.
A B C
Fig. 60.7 (A) The viewing ends (left to right) of the Jackson, Hollinger, Zeitels, and Bouchayer operative
laryngoscopes. (B) The distal ends of these laryngoscopes shown in reverse order: Bouchayer, Zeitels,
Hollinger, and Jackson. Each scope has its advantages, and this set meets virtually every challenge, from the
difficult airway to the excision of large tumors. (C) A simple set of microsurgical instruments is often sufficient
for the experienced laryngeal microsurgeon. From left, Dissection spatula (e.g., for cysts), scissors, alligator
forceps, microring (heart-shaped) forceps, and cup forceps.
The preceding studies date from the early era of the CO2 laser.
The microspot CO2 laser appears to diminish these disadvan-
Epidemiology
tages,21,22 and Geyer and colleagues23 reported a more recent series Vocal nodules occur most commonly in boys and women. Such
of 235 patients for whom the CO2 laser achieved good results. persons are almost always vocal overdoers (i.e., rating 6 or 7 on
However, a systematic comparison of functional results, including the 7-point talkativeness scale). Intrinsic talkativeness correlates
vocal capabilities and videostroboscopy, is not available to guide more consistently than occupation unless the occupation is
the surgeon in choosing between laser and microdissection methods. extraordinarily demanding vocally (e.g., rock singer, stock trader).
With a caseload of more than 1000 singers and at least triple that Comparatively, nodules frequently develop in children with cleft
number of nonsingers, for whom laser and nonlaser methods have palates, presumably from their use of glottal stops to compensate
been used on an individualized basis, it appears that surgical for velopharyngeal incompetence.
technique and skill are preeminent over the specific tools used.
After surgery, vocal quality and capabilities should show good
to excellent improvement; however, patients should be counseled
Pathophysiology and Pathology
preoperatively as to what the risk of worsening the voice is predicted Only the anterior two-thirds (membranous portion) of the vocal
to be. For nodules it may be appropriate to say, “This surgery folds participates in vibration because the arytenoid cartilages lie
typically restores the voice to ‘original equipment status,’ but there within the posterior third of the glottic aperture. Vibration that
is a small risk that you will experience a large improvement but is too forceful or prolonged causes localized vascular congestion
not to fully normal; and there is a remote, rare risk that your voice with edema at the midportion of the membranous (vibratory)
will be worse after surgery.” By contrast, you may say to the person portion of the vocal folds, where shearing and collisional forces
with bilateral sulci in whom the mucosa is thin, “I am expecting are greatest. Fluid accumulation in the submucosa from acute
at best a modest improvement of your voice, but it will take many abuse or overuse results in submucosal swelling, sometimes unwisely
months to achieve this improvement, and there is a quite significant called incipient or early nodules. Long-term voice abuse leads to
chance your voice will be no better, and it may possibly be worse.” some hyalinization of Reinke’s potential space of and, in a subset
For the experienced surgeon who uses dissection rather than of cases, to some thickening of the overlying epithelium. This
microavulsion techniques along with preoperative and postoperative pathophysiologic sequence explains the easily reversible nature
videostroboscopy as his or her “teacher,” the question in the general of most acute, nonhemorrhagic swellings in contrast to the slower,
case becomes not so much one of possibly making the voice worse incomplete, or failed resolution of chronic vocal nodules. Whether
but rather of “Can I make this patient’s speaking and singing acute edema or more chronic nodules are present, it is the change
capabilities normal, and if not, how close can I come?” Cornut in mucosal mass, lessened ability to thin the free margin, and
and Bouchayer’s24 experience of operating on 101 singers and incomplete glottic closure caused by the nodules that together
Bastian’s25 experience in the same population established a role account for a constellation of vocal symptoms and limitations
for laryngeal microsurgery in restoring vocal capabilities and in characteristic of mucosal swelling.11,25
abolishing or diminishing limitations. More recently, in a series
of 47 patients with various benign mucosal lesions, van Dinther
and colleagues26 concluded, “Voice quality and voice handicap
Diagnosis
improve significantly after vocal fold surgery.” History. A pediatric patient with vocal nodules is usually described
by the parent as “vocally exuberant.” An adult patient, virtually
SPECIFIC BENIGN VOCAL FOLD always a woman who rates herself as a 6 or 7 on the talkativeness
scale (discussed earlier), describes experiencing chronic hoarseness
MUCOSAL DISORDERS or repeated episodes of acute hoarseness. Sometimes the initial
onset is associated with an upper respiratory infection or acute
Vocal Nodules laryngitis, after which the hoarseness never clears completely,
The term nodules should be reserved for lesions of proven chronicity. leading the patient to incorrectly attribute the voice problem to
Recent or acute mucosal swellings, which disappear quickly in the infection and to neglect more relevant ongoing behavioral
response to simple voice rest and perhaps supportive medical causes. Singers with chronic nodules are usually relatively unaware
management, are thus excluded when one is referring to nodules. of speaking-voice limitations unless the nodules are at least
moderate in size. More sensitive symptoms of vocal nodules, present, the amount of recent voice use, and interindividual dif-
including very small ones, are as follows: ferences in mucosal response to voice abuse. Also, some variability 60
exists in the correlation between size of nodules and their effect
• Loss of the ability to sing high notes softly
on vocal capabilities. Nodules do not occur unilaterally, although
• Delayed phonatory onset, particularly with high, soft singing
one may be larger than the other. It is important to distinguish
• Increased breathiness (air escape), roughness, and harshness
between nodules and cysts, because management of these entities
• Reduced vocal endurance (“my voice gets husky easily”)
differs. The correlation between nodule appearance and reversibility
• A sensation of increased effort for singing
with voice therapy is imperfect. The larynx should be examined
• A need for longer warm-ups
at high frequency (500 to 1000 Hz) to visualize subtle to small
• Day-to-day variability of vocal capabilities that is greater than
swellings, which can be poorly appreciated at lower frequencies.
expected for the singer’s level of vocal training
Vocal Capability Battery. In patients with moderate to large vocal

Management
nodules, the speaking voice is usually lower than expected and Medical. Good laryngeal lubrication should be ensured through
may be husky, breathy, or harsh. Patients with subtle to moderate general hydration. Allergy and reflux, when present, should also
swellings often have speaking voices that sound normal, so the be treated.
speaking voice is an insensitive indicator of mucosal disorders in
comparison with the singing voice. In patients with subtle or small Behavioral. Vocal nodules arise from the vocal overdoer profile,
swellings (usually only singers come to medical attention with small so initially speech (voice) therapy plays a primary role. Typically,
mucosal disturbances), vocal limitations such as delayed phonatory the nodules and their more obvious symptoms regress, particularly
onset with preceding momentary air escape, diplophonia, and if the patient is not a singer. However, the most skilled behavioral
inability to sing softly at high frequencies may become evident (voice) therapy sometimes fails to achieve complete visual resolution
only when high-frequency, low-intensity vocal tasks for detect- of nodules that have been present for many months to years.
ing swelling are elicited.12 At high frequencies, short-segment Sensitive singing tasks that detect impairment, and not the size
vibration may occur; in other words, the nodules stop vibrating, of persistent swellings, are generally more helpful in the decision
and the short segments of mucosa anterior or posterior to them, as to whether to consider surgical removal of the nodules.11,25
or both, vibrate.
Many patients with nodules may have undergone indirect Surgical. Surgical removal becomes an option when nodules of
laryngoscopy and may have been told that their vocal folds were any size persist and when the voice remains unacceptably impaired
normal, or they have been given a nonspecific diagnosis such as from the patient’s perspective after an adequate trial of therapy,
“laryngeal irritation.” Use of vocal tasks that detect swellings and generally a minimum of 3 months. Some writers prefer precise
videostroboscopy when indicated (see Figs. 60.3–60.5) protect the removal using microexcision techniques (Fig. 60.8); regardless,
laryngologist from missing the most subtle vocal fold swellings. vocal fold stripping has no place in the surgery of nodules. The
The ability to diagnose tiny nodules is crucial, because failure to proper duration of voice rest is controversial, and some writers
make such a diagnosis can have serious consequences for the prefer a relatively short period. In the author’s practice, the patient
professional voice user. is asked not to speak for 4 days, although sighing sounds begin
1 day after surgery. Beginning on the fourth day, the patient
Laryngeal Examination. Nodules can vary in size, contour, gradually progresses over 4 weeks to full voice use under a speech
symmetry, and color, depending on how long they have been pathologist’s supervision. Early return to nonstressful voice use, as
A B C
Fig. 60.8 The operative sequence in a professional actress specializing in musical theater who, for more than
2 years, had been experiencing vocal symptoms and limitations compatible with fusiform vocal nodules.
(A) The operative view after many months of conservative management. Not all fusiform swellings are
reversible with conservative measures alone. (B) A polypoid nodule is grasped superficially and tented medially
with Bouchayer forceps. Scissors that curve away from the vocal fold are used for removal. The nodule is
thus removed in a very superficial plane, which minimizes the risk of scar between the remaining and
regenerated mucosa and the underlying vocal ligament. (C) Vocal fold appearance after excision. The patient
experienced dramatic normalization of her vocal capabilities, and no evidence of scarring was found on
postoperative stroboscopic examination. The dilated capillaries may predispose to recurrent nodule formation
and can be spot-coagulated with a microspot laser.
TABLE 60.1 General Guidelines for Initial Voice Use After Vocal Fold Microsurgery
Time After Surgerya Talking Scoreb Singing (for Singers)
Days 1–4 None Gentle attempts at yawn or sigh for approximately 30 s 6–8 times dailyc
Week 2 (begins day 5) 3 Singing-voice warmup exercises for 5 min twice daily (after first postoperative exam)
Week 3 4 Same exercises for 10 min twice dailyd
Week 4 5 Same exercises for 15 min twice dailyd (after second postoperative exam)
Week 5 4 or 5 Same exercises for 20 min twice dailyd
Weeks 6–8 4 or 5 Same exercises for up to 20 min three times dailye
a
After the fourth examination, return to performance should be considered.
b
Based on a 7-point talkativeness scale, in which 1 is very untalkative, 4 is average, and 7 is extremely talkative.
c
Accept what comes out, even if it is only air or is very hoarse.
d
With emphasis on ease, clarity, and agility, not voice building. The entire expected range should be practiced in each session with gentle insistence on
high notes, which are difficult to elicit. In general, practice mostly a mezzo piano dynamic and only occasionally mezzo forte.
e
Same as the preceding footnote, with the addition of gradually increasing the dynamic range and insistence.
A B C
Fig. 60.9 (A) The abducted breathing position with standard light. This is called a “capillary lake.”
(B) Prephonatory instant with standard light in the same patient shows a slight projection from the free
margin. (C) After surgical ablation, the condition resolved, the voice normalized, and mucosal oscillation was
preserved to the highest vocal range.
described in Table 60.1, seems to promote dynamic healing. The

results of precision surgery are typically remarkably good, even
in singers. In their study of approximately 160 singers treated
with surgery, Cornut and Bouchayer24 stated, “As long as certain
management principles are followed in a majority of cases, laryngeal
microsurgery enables the singing voice to regain the whole of
its functioning.”
Capillary Ectasia
Epidemiology
Capillary ectasia seems to happen most often in vocal overdoers
(Figs. 60.9 and 60.10). Because of the female preponderance of
this disorder, some writers have speculated about an estrogen
effect.
Pathophysiology and Pathology Fig. 60.10 Ectatic capillaries need not be ablated in their entirety.
Instead, flow is stopped with spot coagulations (arrows) along the
Repeated vibratory microtrauma can lead to capillary angiogenesis. course of the capillary. Within 3 weeks, capillary “segments”
In a circular fashion, abnormally dilated capillaries seem to increase disappeared.
the mucosa’s vulnerability to further vibratory trauma. When
present with capillary ectasia, mucosal swelling appears to be larger
on the side with greater ectasia. It seems that capillary ectasia
predisposes to one or more of the following: increased vulnerability short periods of singing (reduced vocal/mucosal endurance). When
to mucosal swelling (reduced vocal endurance), a small incidence this complaint is associated with mucosal swelling, additional
of vocal fold hemorrhage, and hemorrhagic polyp formation. symptoms reminiscent of nodules—delayed phonatory onset; loss
of high, soft singing; increased effort—may also be noted. The
occasional singer with capillary ectasia may have experienced one
Diagnosis or more episodes of acute vocal fold hemorrhage, which may have
History. Capillary ectasia is diagnosed most often in female singers precipitated the patient’s first visit; capillary ectasia may be discerned
who complain that they become a little hoarse after relatively only after the bruising has resolved.
Vocal Capability Battery. Without mucosal swelling, the voice

capabilities in a patient with capillary ectasia may be entirely 60
normal. With swelling, vocal limitations may be similar to
those detected in the patient with nodules. If mucosal hemorrhage
is recent, the speaking voice and the singing voice may be
very hoarse.
Laryngeal Examination. Capillary ectasia may manifest as

abnormal dilation of the long arcades of capillaries that proceed
mostly from anterior to posterior (see Figs. 60.9 and 60.10).
However, aberrant clusters of dilated capillaries may also be seen.
Occasionally, a vascular dot may appear when a loop comes from
within Reinke’s space to the surface and doubles back down into
the submucosa. Finally, some dilated capillaries are confluent or
become large enough to almost resemble a chronic hemorrhage;
this variant can be termed a capillary lake.
Management Fig. 60.11 Hemorrhagic polyp, right fold. Note the blood-blister
appearance. Recent further bleeding is evident from the yellowish
Medical. The use of drugs that have anticoagulant effects, such discoloration of the upper surface of the fold because of breakdown
as aspirin and other nonsteroidal antiinflammatory drugs (NSAIDs), products of a bruise, estimated to have occurred 2 weeks earlier.
should cease if medically appropriate. These drugs do not appear Hemorrhagic polyps sometimes rebruise intermittently.
to increase the incidence of hemorrhage but may increase the severity
of bruising when it does occur. In addition, acid reflux may have
an amplified effect on the mucosa when capillary ectasia is visible;
thus management of reflux is particularly important.
to focal accumulation of blood, similar to a blood blister. This
Behavioral. Many persons with capillary ectasia are vocal overdo- type of hemorrhage alters the margin contour and stiffens the
ers; therefore the behavioral changes appropriate for individuals mucosa, as seen stroboscopically. It causes significantly more and
with nodules are advocated. In particular, patients are warned longer-lasting hoarseness and may be the precursor of a hemor-
about sudden explosive use of the voice. The duration of voice rhagic polyp. In this case, microscopic examination would reveal
use per practice session should also be reduced (e.g., three a relatively rich vascular stroma and areas of hyalinization, although
20-minute sessions per day vs a single 1-hour session). a unilateral, nonhemorrhagic, often pedunculated polyp may also
be seen as the end stage of a hemorrhagic polyp.
Surgical. If the patient cannot accept residual vocal symptoms
and limitations (e.g., decreased vocal endurance) after medical
and behavioral management, laryngeal microsurgery is an excellent
Diagnosis
option.25,27 Dilated capillaries are spot-coagulated to interrupt History. The history of abrupt onset of hoarseness during extreme
blood flow every few millimeters (see Fig. 60.10), and capillaries vocal effort, such as at a party or sporting event or even after a
proximal to each interrupted segment may subsequently dilate. loud sneeze, is classic but not universal in patients with vocal fold
Even so, not all visible dilations should be ablated; those that hemorrhage and a unilateral hemorrhagic vocal fold polyp.
remain visible at the end of the procedure, and even at the first
postoperative visit, routinely involute within a few weeks. If the Vocal Capability Battery. Vocal capabilities vary according to
mucosal edema accompanying ectatic capillaries is minimal, the size, age, turgidity, and pedunculation of the polyp. Some
management of the capillaries alone often leads to resolution of patients have a normal-sounding speaking voice except for intermit-
the edema. tent and subtle aberrant sounds. Other patients have a normal
speaking voice but an impaired or nonexistent falsetto register.
Vocal Fold Hemorrhage and a Unilateral Some patients also manifest chronic vocal huskiness.
(Hemorrhagic) Vocal Fold Polyp Laryngeal Examination. Laryngeal examination demonstrates
a largely unilateral lesion in the node position, a contact reaction—
Epidemiology or a nodule, if the person is a vocal overdoer—on the fold opposite
The occurrence of vocal fold hemorrhage (Fig. 60.11) and unilateral the polyp. In the case of the chronic vocal overdoer, a hemorrhagic
hemorrhagic vocal fold polyp is more common in men, particularly polyp may represent an acute injury superimposed on chronic
those who engage in intermittent severe voice abuse or who work nodules. The hemorrhagic polyp is usually much larger than the
in noisy environments. Surprisingly few patients have a history typical nodule and may appear dark and filled with blood in the
of using aspirin or other anticoagulants. early stages. Depending on when the submucosal bleeding occurred,
discoloration may be in any stage of bruise evolution. Long-standing
hemorrhagic polyps may lose their vascular appearance and may
Pathophysiology and Pathology become pedunculated, moving in and out of the glottis with
Shearing forces that act on capillaries within the mucosa during inspiration and expiration, respectively. During phonation, this
extreme vocal exertion lead to capillary rupture. Capillary ectasia end-stage polyp may be displaced upward onto the fold’s superior
seems to predispose to this sort of injury. Breakage of superficial surface, interfering little with basic phonation.
capillaries may lead to a thin, widely suffused, superficial bruise
without vocal fold margin convexity. Within a few days, this type
of hemorrhage may often have little effect on mucosal oscillation.
Treatment
Resolution of the bruise may be complete within 2 weeks. By Medical. If possible, the intake of anticoagulant medications
contrast, extravasation of blood from a deeper capillary may lead (NSAIDs and warfarin) should be stopped. Because acid reflux
A B
C D
Fig. 60.12 (A) Hemorrhagic polyp, right vocal fold. (B) Polyp is grasped with right-turning heart-shaped
forceps to reveal pedunculation and flexibility of the mucosa. (C) At the moment of excision with a left-turning
scissors. (D) Tiny residual wound. This patient’s voice was entirely normalized, including the upper voice.
can increase hyperemia and dilate normal and abnormal capillaries, retention cysts (ductal cysts, see Figs. 60.15 and 60.17) arise when
this condition should be controlled. the duct of a mucous gland becomes plugged and retains glandular
secretions; epidermal cysts (see Figs. 60.14 and 60.16) contain
Behavioral. A short course of voice therapy is appropriate, mainly accumulated keratin.28–31 Two theories state that the epidermal
to instruct the patient in voice care. The occasional small, early cyst results from a nest of epithelial cells buried congenitally in
hemorrhagic polyp resorbs completely with many months of the subepithelial layer or from healing of mucosa injured by voice
conservative measures, but typically surgical removal is required abuse over buried epithelial cells. In time, cysts may rupture
to return the vocal fold to its normal appearance and vibratory spontaneously. If the resulting opening is small in relation to the
function and to return the voice to normal capabilities. overall size of the cyst, some epidermal debris may be retained
and may create an open cyst (see Fig. 60.16); if the opening is as
Surgical. Evacuation of blood through a tiny incision in a recent large as the cyst, the resulting empty pocket becomes a glottic
large hemorrhage that looks like a blood blister may be appropriate sulcus (Figs. 60.18 and 60.19).
because, in the best case, a long wait for resorption and (more
likely) progression to a chronic hemorrhagic polyp would be
expected. After microsurgical evacuation of the hematoma, care
Diagnosis
should be taken to detect the large capillaries within Reinke’s History. A patient with epidermal cysts has many of the same
space because these also should be interrupted, although a slightly symptoms and voice abuse factors as a patient with nodules.
deeper coagulation may be required to reach the level of the However, mucous retention cysts can arise seemingly spontaneously,
capillary. A long-standing polyp, whether hemorrhagic or at end without relation to the amount or manner of voice use.
stage and pale, should be trimmed away superficially at the
time the spot coagulations take place. Prognosis for full return of Vocal Capability Battery. The vocal capability battery uncovers
vocal functioning after precision surgery is excellent (Figs. 60.12 vocal limitations similar to those for a patient with vocal nodules.
and 60.13; Video 60.1). Patients with epidermal cysts are more likely to experience dip-
lophonia in the upper vocal range, and they may manifest an
abrupt and irreducible transition to severe impairment at a relatively
Intracordal Cysts specific frequency rather than a more gradual transition to greater
degrees of impairment, as is often noted in patients with nodules.
Epidemiology Mucous retention cysts often cause less vocal limitation than might
The most prominent epidemiologic finding is a history of vocal be anticipated from the laryngeal appearance; epidermal inclusion
overuse. This is routine for the epidermal cyst but less so for the cysts often cause more limitation than expected.
mucous retention variety.
Laryngeal Examination. Mucous retention cysts often originate
just below the free margin of the fold with significant medial
Pathophysiology and Pathology projection from the fold. For this reason, such cysts are sometimes
Histologically, intracordal cysts are classified as either mucous misdiagnosed as nodules or polyps. Epidermal cysts project less
retention or epidermal inclusion types (Figs. 60.14–60.17). Mucous from the fold and are harder to diagnose when small. An
60
A B
C D
Fig. 60.13 (A) Hemorrhagic polyp, left fold, with broad attachment and “shoulders” rather than a stalk-like
attachment. (B) Beginning of excision, starting with broad-based anterior and posterior shoulder elements.
(C) Laser dissection directed to the thrombosed contents of the polyp and sparing much of the stretched
overlying mucosa. (D) Resultant linear wound after removal. Because of the remaining layers of Reinke’s
space (superficial lamina propria), adherence to the vocal ligament does not occur and vibratory ability is
normalized, including at high pitch.
A B
Fig. 60.14 (A) Epidermal cyst, right vocal fold. Note the white submucosal mass predominantly on the upper
surface of the fold but with bilateral free margin elevation as well. (B) After submucosal dissection and removal
of cyst. In some similar cases, free margin swelling remains because the margin cannot be straightened (i.e.,
redundant mucosa that had been stretched over the cyst cannot be removed) at the same time as cyst
removal through an upper vocal fold surface incision. In this case, the margin was straight. Vocal fold
oscillatory ability improved markedly but was not normal at very high pitches. The voice was highly improved
overall.
inexperienced clinician may be more aware of what appear to be

nodules than the faint cyst outline on the superior surface of the
Treatment
fold. In an open cyst, the sphere may be less discrete and may Medical. General supportive measures, such as hydration and
have a more mottled appearance on the superior surface of the potential acid reflux management, may be helpful but will not
vocal fold (see Fig. 60.16). Under strobe illumination, as the resolve this problem.
fundamental frequency of phonation increases, the mucosa overlying
the cyst often stops vibrating before the mucosa anterior and Behavioral. Voice therapy is more appropriate for people with
posterior to the cyst. Even so, diagnosis can be confirmed in some epidermal cysts and, beyond teaching in preparation for surgery
patients only at the time of microlaryngoscopy. in those with cysts of the mucous retention variety, often is not
Fig. 60.16 Bilateral open cysts. Because the openings are small in
Fig. 60.15 Mucous retention cyst after laser excision of early vocal
relation to the size of the cysts, partial emptying of the keratin
fold cancer, left vocal fold. Note capillary reorientation, which is typical
contents causes a mottled appearance.
after full-thickness mucosal excision. The small projecting lesion could
be mistaken for a polyp. Instead, it is the result of plugging of a tiny
mucous gland just below the free margin of the vocal folds during
mucosal regeneration. A polyp is not consistent with this man’s very
quiet nature and minimal vocal commitments. Note that the lesion is
below the point of maximum contact and vibratory injury that would
produce a polyp. This man’s voice is excellent.
A B C
Fig. 60.17 (A) Mucous retention cyst of right vocal fold. Yellowish spherical mass shines through overlying
mucosa and was causing the patient severe hoarseness. Incision to enter the fold is made on the dotted line.
(B) Near completion of dissection of the cyst from its final attachments using curved scissors. (C) After cyst
removal. The patient’s voice sounded virtually normal in the recovery room, although the upper voice was still
abnormal.
A B
Fig. 60.18 (A) Glottic sulci, normal light; there is retained material and granulation emerging from within the
sulcus on the right. A partial ring of capillaries is seen around the sulcus on the right (arrows), but no
significant vessels are found within the sulcus. (B) Same patient after surgery on the right fold. Note the
microvasculature where it was not present before surgery, especially at the arrow. A continuous layer of
mucosa is now evident. The voice was much improved but was still not normal because of the unavoidable
disturbance required by the dissection and the residual stiffness.
60
A B C D
Fig. 60.19 Glottic sulcus. (A) At the beginning of surgery, the fold is infiltrated with lidocaine/epinephrine to
provide hydrodissection and expand the mucosa. The line of the sulcus is seen proceeding anteriorly from the
point of needle entry. (B) An elliptic incision has been made around the lips of the sulcus. (C) Right-curved
alligator clip tents the medial mucosal flap. Arrows indicate the fine line representing the opening into the
sulcus. Curved scissors dissect the anterior aspect of the sulcus pocket from the underlying vocal ligament.
(D) After the sulcus pocket has been removed, gossamer mucosa is tented medially to show remaining
flexibility. The voice is expected to be improved, but normal upper voice capabilities are only sometimes
achieved.
needed. The reason is that those with epidermal inclusion cysts

are by far the more likely of the two to be vocal overdoers. Of
Glottic Sulcus
course, speech (voice) therapy may also be warranted for those
who have mucous retention cysts if the person is a vocal overdoer—
Epidemiology
not to resolve the lesion, which requires surgery, but to avoid the Although some writers believe sulci to be congenital, glottic sulcus
risk of another, this time vibration-induced, lesion. appears to occur exclusively in vocal overdoers (see Figs. 60.18
and 60.19).
Surgery. Patients with large mucous retention cysts and no
history of voice abuse may be scheduled for surgery promptly.
If it is under the edge of the vocal fold and extremely superficial
and translucent, resembling a polyp, the cyst may be removed Bouchayer and colleagues30 reviewed acquired and congenital
in its entirety with a small slip of overlying mucosa, particularly theories for these conditions. They described the appearance of
when its wall is so thin as to make its dissection from the the sulcus as an epithelium-lined pocket whose lips parallel the
overlying mucosa virtually impossible. In this case, mucosal free edge of the folds and suggested that a sulcus may represent
oscillation will still be normal after healing is complete. More an epidermal cyst that has emptied spontaneously, leaving the
typical mucous retention cysts are removed, as described in the collapsed pocket behind to form a sulcus. In effect, a mucosal
following paragraph, via dissection that leaves the overlying bridge is the result of two parallel sulci that arise from a single
mucosa intact. cyst (Fig. 60.20). The chief problem caused by a sulcus is the same
A small, extremely shallow incision is made on the fold’s superior as that caused by scarring: stiffening of the mucosa, which inhibits
surface. Careful dissection reveals that the swelling is indeed caused oscillation and leads to dysphonia.32
by a cyst. Taking care to avoid any injury to the mucosa other
than that of the incision, the surgeon dissects the cyst free of the
mucosa and vocal ligament (see Fig. 60.17). The opposite fold
Diagnosis
should be examined carefully because of the possibility of a more History. The patient with a glottic sulcus often has a history of
subtle cyst or sulcus. Results are not as uniformly good as for voice overuse and complains of chronic hoarseness.
nodules and polyps. Considerable improvement is expected,
however, and some patients achieve excellent results (Videos 60.2 Vocal Capability Battery. Typically the voice is noticeably hoarse.
and 60.3). Patients should also know that maximal postoperative Upper voice limitations, particularly diplophonia, are obvious. As
recovery takes longer than for nodule or polyp surgery (many is the case for cysts, the transition between hoarse phonation and
months rather than a few weeks). Bouchayer and colleagues30 aphonia may occur abruptly, almost at a specific frequency, generally
reported a series of 148 patients managed for cysts, sulci, or mucosal in the middle of the singing range.
bridges—very difficult surgical problems compared with nodules
and polyps—of whom 10% had an overall excellent result, 42% Laryngeal Examination. Laryngeal examination may initially
had a good result, 41% had a fair result, and 5% had a poor result. reveal fewer findings than expected to account for the abnormal
Follow-up supportive voice therapy from the speech pathologist speaking voice or reduced singing voice capabilities. Because the
or singing teacher assists vocal rehabilitation. A return to active patient is likely a vocal overdoer, associated fusiform vocal fold
voice use or training should occur within a few days of surgery, margin swellings might also be seen. Stroboscopic evaluation shows
because the amount of mucosal disturbance required leads to a a segment of reduced vibration. The entire length of the mucosa
greater tendency to mucosal adherence and stiffness. may oscillate at lower frequencies; at higher frequencies, the
Needle to balloon
Reinke’s space (hydrodissection)
Mucosa
Vocal
ligament
A Muscle
B
Fig. 60.20 Mucosal bridge of the left mucosal fold. If an epidermal

cyst opens in two places and parallels the margin of the vocal fold,
the mucosa between the openings becomes a bridge. In this case,
the forceps enters the upper (lateral) opening and exits the lower
(medial) opening.
midportion of the mucosa stops oscillating and short-segment C D

vibration of anterior and posterior segments begins to occur.
Microlaryngoscopy is often required for definitive diagnosis because Fig. 60.21 Schematic of the removal of a glottic sulcus. (A) Vocal
the lips of the sulcus are not always visible with inspiratory phona- fold coronal section shows the sulcus. (B) Injection of 1% lidocaine
tion during the office or voice laboratory examination. with epinephrine into Reinke’s space spreads the lips of the sulcus.
(C) Incisions at the sulcus lips and dissection off the vocal ligament.
(D) After removal of the sulcus.
Management
Medical. Medical management for glottic sulcus is supportive
as appropriate, but it is not expected to resolve this structural
abnormality.
Behavioral. A short preoperative course of voice therapy is There seems to be an individual susceptibility to this condition,
indicated if the patient with a glottal sulcus is a confirmed vocal because it develops in only a small percentage of those at risk
overdoer because the behavioral goal for patients with cysts (e.g., smokers who use their voices a lot). As detailed by several
initially is selection and preparation for surgery. Restoration of writers, chronic smoking and voice abuse result in edema, vascular
the mucosa to normal cannot be achieved by medical or behavioral congestion, and venous stasis.33,34 These conditions cause diffuse
treatment. polypoid changes that become permanent, although the degree
of edema or turgidity and consequent voice disturbance may rise
Surgical. Sulcus removal is technically demanding, involving and fall with voice use.
considerable surgical disturbance of the vocal fold mucosa in
comparison with surgery for nodules. Bouchayer and colleagues30
described the steps for removal of a glottic sulcus (Fig. 60.21),
Diagnosis
including cordal injection to make the sulcus lips spread, make History. The combination of smoking and avid voice use is classic
the sulcus shallower, and accomplish some hydrodissection. This for this entity. A woman with smoker’s polyps may complain of
step is followed by circumcision of the lips of the sulcus and by being called “sir” on the phone, or she may have problems with
dissection of the invaginated mucosal pocket from the underlying increasing hoarseness during the day.
fold without injuring the vocal ligament. Results seem to depend
not only on excellent surgical skill but also on the thickness of Vocal Capability Battery. The voice examination demonstrates
the mucosa. A thick, almost polypoid mucosa may sometimes yield lower pitch than would be expected, often well into the masculine
a normal voice. In the patient in whom the mucosa is very thin range when the condition is seen in women. Upper voice is lost,
and more widely adherent to the ligament, the voice is typically and the female patient can often phonate through the range of
better than before surgery, but residual mucosal stiffness may a true bass singer! With large polyps, the voice may even be
occur even after optimal surgery. hypermasculine.
Laryngeal Examination. Laryngeal examination usually reveals

Bilateral Diffuse Polyposis pale, watery bags of fluid attached to the superior surface and
margins of the folds. Large smoker’s polyps may cause an invol-
Epidemiology untary laryngeal snore on sudden inhalation. A to-and-fro motion
Voice change caused by bilateral diffuse polyposis (chronic Reinke is often seen with respiration. In severe cases, clusters of polyps
edema or smoker’s polyps; Figs. 60.22 and 60.23) typically becomes on polyps may be seen. Small smoker’s polyps are easily overlooked
noticeable enough to prompt a laryngeal examination in middle- unless the patient is instructed to phonate on inspiration, when
aged talkative women who have been long-term smokers. the polypoid tissue is drawn from the superior surface of the folds
60
A B
Fig. 60.22 Bilateral diffuse polyposis. (A) Quiet breathing under standard light. (B) Elicited inspiratory
phonation (same patient) draws in and, hence, reveals the edematous mucosa, which is greater on the right
than on the left. Dashed lines indicate the location and contour of the free margin had these vocal folds been
normal.
A B
Fig. 60.23 Smoker’s polyp; operative

sequence. (A) Voice laboratory view of
smoker’s polyps; the right fold is much
more pronounced than the left. (B) During
the first thulium laser coagulation. Note C D
the attempt to pull the redundant tissue
medially from the underlying vocal ligament.
(C) Six weeks postsurgery, during the
second thulium laser treatment. (D) Twelve
weeks postsurgery. Early postlaser
inflammatory reaction is still evident, but the
voice is dramatically improved. (E) Strobe
light and chest phonation, closed phase.
(F) Open phase as the patient finishes
phonation and begins to separate the folds.
Note slight edema in Reinke’s space
(translucence) of the left (unoperated) fold.
The right fold oscillated well at low
frequency and less well at high frequency E F
in this early postoperative examination.
A B
Fig. 60.24 Iatrogenic mucosal scarring. This patient underwent bilateral vocal fold stripping elsewhere
for persistent dysphonia, which was subsequently diagnosed as spasmodic dysphonia. The patient was
reportedly aphonic for many weeks postoperatively. (A) This operative photograph was taken 4.5 months after
the original surgery. Granulomas are highly pedunculated and may have eventually detached or regressed
spontaneously. Note the medial-to-lateral reorientation of vocal fold capillaries, a common finding after vocal
fold stripping. (B) The same patient after granuloma removal. Attachment points of the granulomas are
marked at arrows. In this view, the vocal folds are rolled superiorly and considerable scarring is evident,
particularly on the right vocal fold.
into the glottic aperture and is thereby made more visible as a Line of adherence Incision and plane of Microadhesions
greater-than-normal convexity of the margin (see Fig. 60.22B). at site of prior mucosal flap creation of mucosa
The examiner knows to elicit inspiratory phonation and look for polypectomy down to
this type of lesion when the vocal capability battery reveals viriliza- vocal ligament
tion of the singing range.
Management
Medical. The patient with bilateral diffuse polyposis is encouraged
to give up smoking. Thyroid function tests can be performed if
hypothyroidism is suspected. The latter entity has often been
implicated as causal in this condition, although diffuse polyposis
is extremely rare in the absence of smoking and avid voice use.
Behavioral. Short-term voice therapy may be appropriate to

introduce optimal vocal behavior. These measures alone may reduce
the polyps’ turgidity, with a corresponding modest improvement A B
in vocal functioning. Fig. 60.25 Schematic of mucosal adhesion to underlying vocal
ligament and one surgical option. (A) The operative view shows a
Surgical. Microsurgery for polyp reduction is necessary when the longitudinal scar. (B) Cross-sectional view shows the surgical
voice remains objectionable to the patient. The older, common approach to release microadhesion of mucosa from the vocal
practice of stripping the polyps away often results in aphonia for ligament. Such a patient may have only a modest effect on vocal
many weeks postoperatively, and the final voice achieved may capability but a more noticeable relief from aberrations such as
sound unacceptably high and husky to the patient. Polyp reduction diplophonia.
with mucosal sparing (see Fig. 60.23) is recommended for an
earlier and optimal return of voice, usually beginning within 10
days. It is better to leave the patient with a voice that still sounds
rich, even with some residual polyposis and mild vocal virilization, on.35,36 The prior surgeon may have performed vocal fold stripping
than to strip the folds and leave the patient with a voice that or laser vaporization of the mucosa. The pathology report from
sounds thin, insubstantial, and effortful. that operation frequently describes a fairly large specimen that
may have contained fibrous tissue or even muscle, which suggests
that the removal went deeply into the vocal fold.
Postoperative Dysphonia
Epidemiology Pathophysiology and Pathology
Vocal fold surgery performed without extreme precision can lead Dysphonia can result from a scarred, stiff vocal fold cover, phonatory
to permanent postoperative dysphonia (Figs. 60.24 and 60.25) that mismatch of the vocal fold margins, or both. Scarring adheres
can be worse than the hoarseness from the lesion that was operated mucosa to the underlying vocal ligament, which abolishes the
ability of mucosa to oscillate with any freedom from the underlying difficult to procure. However, improvement does not seem to
vocal ligament. Mismatch may arise from a divot caused by arise only from spontaneous softening of scar tissue, because it 60
overzealous removal or from pseudobowing, such as that resulting can occur with the preceding voice-building strategy in patients
from the failure to spare enough mucosa during smoker’s polyp more than 1 year after surgery or another scarring event.
reduction. With few exceptions, postoperative dysphonia can be The rationale for this aggressive, voice-building strategy may
avoided by the use of an appropriately precise surgical technique require some explanation for patients whose voice abuse caused
and by early graduated resumption of voice use after surgery (see the problem for which they underwent surgery. A voice-qualified
Table 60.1). speech pathologist who is comfortable with teaching vigorous
voice production throughout the expected range should monitor
voice-building exercises initially. Some patients can work inde-
Diagnosis pendently because of the short duration of exercise sessions, and
History. A history of prior surgery is common to all cases, but because the overall idea of the voice-building approach is primarily
a clear understanding of the original lesion should be sought to enhance vocal skills, not to scream abusively. Rather, the goals
in addition to any history that indicates continuing vocal abuse, are to strengthen the laryngeal musculature to compensate for—to
which might have led to recurrent mucosal injury rather than overdrive—the damaged mucosa and to encourage the mucosa to
scarring. oscillate more freely because of this sort of “phonatory massage”
of the mucosa.
Vocal Capability Battery. The voice may vary from aphonia to
a harsh whisper to a relatively normal speaking voice, but it is Surgical. Reoperation is occasionally an option. Ample time (9
accompanied by disastrous limitation of the upper singing voice to 12 months) should pass before this idea is entertained, however,
with diplophonia and loss of the expected upper range. because the voice may improve, and iatrogenic lesions may diminish
slowly for many months after the first operation. A second pro-
Laryngeal Examination. Laryngeal videostroboscopy is essential cedure can be planned to correct the videostroboscopically identified
for patients with possible postoperative dysphonia. This technique defect in mucosal mass, mobility, or edge configuration. For
enables careful analysis of mass lesions, areas of asymmetry, and example, if an iatrogenic mass (granuloma) is causing poor phona-
the mucosa’s vibratory pattern, from which a clear diagnosis and tory closure, it should first be allowed to mature and possibly to
therapeutic plan can be generated. resolve spontaneously. If it remains after a minimum of 6 months,
it can be removed. Injection of collagen into an area of depression
has been advocated,37 but this approach does not yield more than
Management very modest results, and even these occur on an inconsistent basis.
Medical. General medical issues that relate to the voice should Incision and simple mucosal elevation across a limited line of
be optimized in the course of management. adherence with early postoperative phonation may cure diplophonia
or lessen dysphonia, occasionally to a surprising extent. It should
Behavioral. If stiffness, scarring, and tissue loss pose problems, be stressed, however, that in some instances little can be done
voice therapy is tried first, with a voice-building approach. A person beyond voice building, and avoidance of this problem altogether
who is resting his or her voice should instead resume talking per through precision surgery is the ideal. Some authorities have written
routine. In addition, the individual is coached to sing with mod- of fat injection or medialization thyroplasty, but these approaches
erately great vigor for 10 minutes two or three times a day at all remain to be systematically validated. They do make some sense
vocal frequencies of his or her range. Using the facilitating vowel theoretically, primarily if a significant gap is present between the
/oo/ is helpful in cases of severe dysphonia. When only a very folds and the problem is not simply mucosal stiffness.
narrow frequency range is available because of postoperative
scarring, the patient is asked to start phonating at a frequency
that works, which is often quite high in the expected vocal range,
Contact Ulcer or Granuloma
and to coax the voice lower and higher from this small area of
working frequencies. Some remarkable improvements may be seen
Epidemiology
with this approach. However, even with achievement of a serviceable Contact granuloma or ulceration is seen primarily in men (Figs.
speaking voice, the voice’s singing capabilities will remain limited 60.26 and 60.27). Chronic coughing or throat clearing and reflux
in comparison with a normal voice. Proof for this approach is of acid from the stomach into the posterior larynx during sleep
A B
Fig. 60.26 (A) Contact granuloma, right posterior vocal fold. Note bilobularity and surrounding inflammation
(erythema). (B) Same patient as the folds arrive at phonatory contact. The medial surface of the left arytenoid
cartilage will fit into the cleft between the two lobes of the contact granuloma.
A B C
Fig. 60.27 (A) Large, bilobed contact granuloma, left fold, with significant pedunculation. The patient’s voice
is surprisingly unaffected by the pedunculation and the deep cleft between the lobes. (B) This granuloma was
allowed to mature and detach spontaneously. Here, a few months later, the inferior lobule has detached, and
a single spherical and highly pedunculated granuloma remains. (C) Several months later in the same patient,
the remaining granuloma has detached, leaving a characteristic bruise at its base. This mark may remain
visible for many months.
A B
Fig. 60.28 Granulomas after long-term intubation. (A) Evidence of posterior commissure divots from
pressure necrosis of the endotracheal tube, along with reparative granulomas. (B) Same patient a few months
later. Without any intervention, granulomas have matured, pedunculated, and spontaneously detached,
leaving the divots more visible.
also seem to cause contact ulceration.38 Some have also suggested husky. The patient may be noted to be speaking habitually in
that patients with this entity are experiencing psychological stress an overly low frequency range, often with a held-back vocal
or conflict. quality but sometimes with a kind of constrained emphasis. In
particular, the voice characteristics of the held-back quality, habitual
coughing or throat clearing, and low and monotone voice use
Pathophysiology and Pathology are typical.
The thin mucosa and perichondrium overlying the cartilaginous
glottis become inflamed, perhaps as a result of overly forceful Laryngeal Examination. A depressed, ulcerated area with a whitish
apposition (slamming together) of the arytenoids at the onset of exudate clinging to it or a bilobed, heaped-up lesion on the vocal
voicing (glottal stroke) or during chronic coughing or throat process may be noted. At the instant of glottal closure, the vocal
clearing. Acid reflux may also increase inflammation of the vocal process of the uninvolved side can be seen to fit into the cleft of
process area; the traumatized area ulcerates or produces a heaped-up a bilobed granuloma (see Fig. 60.26B). Erythema is also usually
granuloma. apparent on the vocal process and coming upward on the medial
surface of the arytenoid cartilage. A mature, soon-to-detach
granuloma may be pedunculated and may flip above (see Fig.
Diagnosis 60.27A) and below the plane of the vocal fold margin with expiratory
History. Behavioral patterns should be elicited, including caffeine and inspiratory phonation, respectively.
and alcohol consumption and late-night eating, along with more
specific acid reflux symptoms (e.g., acid eructations; raw throat
in the morning with sour taste; unusually low-pitched, gravelly
Management
morning voice; heartburn). Frequent symptoms include unilateral An antireflux regimen should be started on an empiric basis even
discomfort over the midthyroid cartilage, occasionally with referred for patients with no symptoms of reflux. The necessity of routine
pain to the ipsilateral ear. When contact granulation tissue becomes barium or pH-monitoring studies remains controversial. Maturation
large, hoarseness can occur. and resolution of the granuloma can often occur spontaneously
over 3 to 6 months (Fig. 60.28B; see Fig. 60.27C). Thus the role
Vocal Capability Battery. The speaking voice of a patient with for voice therapy to abolish throat clearing, raise average pitch
a contact ulcer or granuloma may sound normal or only slightly for speech, and so forth is indeterminate.
Indirect injection of a depot corticosteroid directly into the commonness. For optimal results, diagnosis should include a skillful
lesion and the area around its base can be accomplished in a history, vocal capability elicitation, and laryngeal videostroboscopy. 60
videoendoscopy procedure room with the patient sitting in a chair.13 Whether medical management, voice therapy, surgery, or some
Visible lesions tend to diminish in size, and the symptoms disappear. combination is used to treat the patient, the intervention should
Inhaled triamcinolone or mometasone has also been used for match the diagnosis.
treatment and avoids systemic side effects. Patients are assessed
at 6- to 8-week intervals, and treatment is continued if there is a
reduction in size and improvement in symptoms.
SACCULAR DISORDERS
Surgery should be a last resort, not only because of the expecta- At its anterior end, the normal laryngeal ventricle has a small
tion of maturation and spontaneous detachment but also because outpouching called the saccule or laryngeal appendix. This structure
postoperative recurrence of the ulcer or granuloma is predictable. is a blind sac that extends upward between the false vocal fold
Furthermore, when the lesion has a classic appearance and can and thyroid cartilage, just posterolateral to the edge of the epiglottis
be visually monitored, there is little need for tissue diagnosis: at the level of the petiole. The saccule contains many mucous
visual criteria are sufficient. Microlaryngoscopy may be justified, glands and empties through an orifice in the anterior part of the
however, if after a several-month trial of management, an unin- ventricle. In a study of 100 random cadaver larynges, Broyles39
flamed, pedunculated lesion remains and is causing symptoms. found significant variation in the size of this normal structure,
Removal should be limited, and it should leave the base or pedicle with 75% measuring 6 to 8 mm in length, 25% measuring 10 mm
undisturbed. or greater, and 7% of the 25% measuring 15 mm or more. Although
these structures may represent vestigial air sacs, their function is
unknown in humans besides perhaps to supply lubrication to the
Intubation Granuloma true folds via the many glands that line a saccule. For review of
this anatomy, see Fig. 60.29A.
Epidemiology
Intubation granulomas may occur after brief or prolonged intuba- Etiology of Saccular Disorders: Laryngocele and
tion and are more common in females (see Fig. 60.28).
Saccular Cysts
In infants, saccular disorders appear to be congenital. Otherwise
Pathophysiology and Pathology the cause of an air-filled laryngocele may be uncertain for the
Granuloma after intubation occurs due to mucosal injury and individual patient. Some writers have cited an increase in transglottic
injury to the arytenoid perichondrium. The resulting reparative pressure, such as that seen in trumpet players, glass blowers, and
granuloma may be sessile, resulting in a large pedunculated lesion. people using the voice in unusually forceful ways. Others, such
Sclerosis of the arytenoid is frequently seen on computed tomog- as Stell and Maran,40 believe that the relationship of laryngocele
raphy (CT) scan. The granulomas are attached directly to the to these activities may have been overstated, because few reported
vocal process and are frequently bilateral. In cases of long-standing patients with such disorders described in the world literature had
intubation, there may be associated findings such as tissue loss hobbies or occupations that required high transglottic pressures.
with resulting posterior glottic incompetence. In even more severe A perhaps more clearly documented although uncommon cause
cases, partial or complete fixation of one or both arytenoid cartilages of saccular cysts is laryngeal carcinoma, which causes obstruction
may be evident. An interarytenoid synechia may also be noted on of the saccular orifice.41 One of the authors has also seen saccular
occasion. cysts months or years after successful excision of a large supraglottic
carcinoma with the laser that left remnants of the saccule buried.
Diagnosis
History. The history of a patient with intubation granuloma
Clinical Scenario
includes a fairly recent event during which the larynx was subjected Holinger and associates,42 in their review of 46 patients with
to direct instrumentation or intubation. laryngocele or saccular cyst, found that of the 41 cases that involved
a saccular cyst, 10 occurred in infants and children and 31 in
Vocal Capability Battery. The speaking voice of a patient with adults. Of the 31 adult cases, 22 were anterior and 9 were lateral
intubation granuloma may not sound abnormal, because the saccular cysts; in the infants and children, 4 cysts were anterior
membranous (vibratile) portion of the vocal folds may be unaffected and 6 were lateral. When a saccular cyst occurs in infancy, it
by the granuloma, which may sit above or below the vocal process usually appears early, even at birth, in the form of respiratory
during phonation. distress with inspiratory stridor. The infant’s cry is abnormal, and
cyanosis and dysphagia can occur. In adults, hoarseness seems to
be the most common complaint, although dyspnea, dysphagia,
Management pain, and a neck mass can occur with large or infected lateral
An intubation granuloma is best thought of as an exuberant healing saccular cysts (laryngopyoceles).42
response to injury. For recent injuries, assessment of vocal fold
motion is imperative. With normal vocal fold motion, a more
conservative approach with antireflux therapy and inhaled
Classification
corticosteroids is warranted. When impairment of vocal fold motion Saccular disorders can be classified in various ways (Figs.
is present, more aggressive management is indicated. In this situ- 60.30–60.33; see Fig. 60.29).42–45 It seems reasonable to think
ation, direct microlaryngoscopy with excision of granuloma and first of the contents of the dilated saccule, as in the following
steroid injection should be considered. Voice therapy may have a classification:
role on a highly individualized basis.
• Air filled = laryngocele with patent saccular orifice (see
Fig. 60.33)
Summary • Mucus filled = saccular cyst with blocked orifice (see Figs. 60.29
The benign vocal fold mucosal disorders are important because through 60.32)
of their impact on identity and communication and their • Purulence filled = laryngopyocele with blocked orifice
Saccule
A B
Combined
Internal
C D
Fig. 60.29 The classification scheme for a laryngocele or saccular cyst. (A) Normal anatomy. (B) Anterior
saccular cyst. (C) Lateral saccular cyst. (D) Laryngocele types.
A second classification might be by the size and direction of cyst ventricle in the case of an anterior saccular cyst or deep within
dissection within the larynx, as follows (see also Figs. 60.29–60.33): the false vocal fold and aryepiglottic fold to a degree commensurate
with the laryngocele’s size. If a component of the laryngocele
• Anterior saccular cyst: This cyst tends to protrude from the
extends through the thyrohyoid membrane, a mass will be palpable
anterior ventricle toward the laryngeal vestibule. When large,
in the lateral neck at the thyrohyoid membrane.
it may “push down” on the vocal fold and cause dysphonia.
• Lateral saccular cyst or laryngocele, internal only: This lesion tends
to dissect more superiorly and laterally up into the false and Treatment
aryepiglottic folds, sometimes bulging not only those structures
Management is surgical. In infants with congenital lateral saccular
(medially) but also the medial wall of the piriform sinus (later-
cysts who have a weak cry, stridor, and cyanosis, the airway should
ally), or it may even fill the vallecula.
first be secured. This is followed by aspiration of the cyst contents
• Lateral saccular cyst or laryngocele, internal/external: This variant
through a direct laryngoscope or by endoscopic marsupializa-
tends to dissect as described for the lateral cyst but also tends
tion with or without stripping of the cyst lining. Abramson and
to penetrate through the thyrohyoid membrane and to appear
Zielinski46 described application of the CO2 laser to incise the
as a palpable swelling in the neck.
cyst and to vaporize its lining. Reporting on laryngocele and
lateral saccular cyst in neonates, Booth and Birck47 described
using simple cup forceps to unroof both lesions, followed by a
Diagnosis 3-day intubation to act as a stent and to maintain the infant’s
The diagnosis and classification of disorders of the laryngeal saccule airway. A 5-year follow-up revealed no recurrences. Frederick48
are made through a combination of careful history, detailed describes endoscopic excision of internal laryngoceles. Holinger
examination of the larynx and neck, and CT to determine contents and coworkers,42 in their report of 10 infants with saccular cysts,
(air vs fluid) as well as the precise size and direction of expansion described direct laryngoscopy and aspiration of the cyst. They
or dissection of the process. Symptoms depend somewhat on whether noted that a mean of 7.5 aspirations were required for each infant,
the laryngocele is internal, external, or combined. The usual five of whom later needed endoscopic marsupialization. One child
symptoms are hoarseness, generally from downward pressure on had external excision of a persistent laryngeal cyst after 11 direct
the vocal fold or premature closure of the laryngeal vestibule at laryngoscopies. These investigators also described the necessity
the false-fold level during phonation, and—in decreasing order for tracheotomy in 6 of 10 children, with a mean tracheotomy
of frequency—stridor, dysphagia, sore throat, snoring, and cough. duration of 17 months. On the basis of this report, earlier complete
Examination of the head and neck in a person with laryngocele dissection of the entire cyst or aggressive marsupialization seems like
reveals submucosal swelling that protrudes from the anterior a better option.
60
A B
C D
Fig. 60.30 Lateral saccular cysts may not present as obviously into the laryngeal vestibule as this one does,
but its lateral extent has dissected over the top of the thyroid cartilage. (A) Note margin of false fold (line of
arrows). (B) Removal begins with excision of the false fold margin in order to dissect downward to the lining
of the saccule. (C) After removal. Note upper border of inner surface of thyroid cartilage (dotted line); the
distal end of the laryngoscope is aimed laterally toward the neck contents. (D) In-line view of vocal folds at
conclusion of surgery.
A B C
Fig. 60.31 Lateral saccular cyst. (A) Right of image is superior at the chin. Note dome of the cyst (arrow).
(B) Near completion of dissection, the cyst has ruptured and spilled its contents. (C) Completely collapsed
cyst.
DeSanto and colleagues43 reported on adult patients and their cases, another finding that points to the need to rule out a
described endoscopic cyst avulsion for 29 cases of anterior saccular small ventricular cancer in cases of saccular cysts or laryngoceles.
cysts. Only one patient had recurrence of the cyst, which was The experience of Holinger and coworkers42 concerning 22
later removed via laryngofissure. These researchers found anterior adults with anterior saccular cysts involved direct laryngoscopy
saccular cysts in association with laryngeal carcinoma in two of and endoscopic removal with cup forceps. With this method,
A B
C D
Fig. 60.32 Anterior saccular cyst. (A) This cyst presents only into the laryngeal vestibule and has not
dissected outside the larynx. (B) Forceps retracted to show true vocal fold below. (C) Laryngoscopic view just
after excision. (D) Intact anterior saccular cyst.
A B
C D
Fig. 60.33 Laryngocele (air-filled variant of saccular cyst) in preoperative and postoperative computed
tomography scans. (A) Preoperative view of a large air-filled sac that pushes the epiglottis (arrow) to the
patient’s left. (B) At the level of the ventricle, the opening to the dilated saccule is shown. (C) Postoperative
view. (D) Postoperative view.
no cyst recurred. I have found that anterior saccular cysts are retracting or releasing its wall progressively into view through
not infrequently incidental findings on examination performed the laryngoscope. 60
for another reason; they can be followed if they are not causing
symptoms.
For the larger lateral saccular cysts and laryngoceles, some
Summary
controversy exists in the literature on the merits of primary Saccular disorders, whether laryngoceles or saccular cysts, can
endoscopic marsupialization versus an external approach.40–50 Until be easily diagnosed through appropriate history taking, physical
more recently, most writers seem to have preferred the external examination, and radiologic evaluation. Initial evaluation in adults
approach for definitive removal in adults, particularly when an should exclude the presence of an occult laryngeal carcinoma
external component is present (see Fig. 60.31). This transcervical that involves the ventricle, the region of the saccular orifice, or
approach involves following the external portion (neck presentation) the saccule. Whether to use an endoscopic or external approach
of the laryngocele or cyst sac through the thyrohyoid membrane. depends on the classification of laryngocele or saccular cyst, its
Although not my experience, some writers believe that removal size, patient factors, and, perhaps most of all, surgeon experience
of the upper portion of one side of the thyroid cartilage may be and preference.
necessary to provide easier access to the endolarynx. The lesion
is then transected as close as possible to the orifice of the saccule.
Many writers have cited the need for careful endoscopic
BENIGN MESENCHYMAL NEOPLASMS
examination and multiple biopsies to rule out laryngeal carcinoma Compared with the benign vocal fold mucosal disorders—such
in the ventricle as the cause of the laryngocele before definitive as nodules, polyps, cysts, sulci, and contact ulcers—neurologic
surgery. Removal of small internal laryngoceles, which are relatively disorders, scarring or stenosis problems, malignant tumors of the
rare, through laryngofissure or microlaryngoscopic techniques has larynx, and benign tumors of the larynx are rare. The literature
been reported. Much of the literature seems to favor an external sometimes incorrectly includes nonneoplastic mucosal reactive
approach, but Hogikyan and Bastian50 described complete endo- disorders—that is, response to chronic injury, such as polyps and
scopic removal of large or recurrent saccular cysts (see Fig. 60.30). nodules—in the category of benign neoplasms.51,52 And if papillomas
Their report on seven large lateral saccular cysts is well documented are excluded, laryngologists can expect to see only a few non
with preoperative and postoperative CT scans and endoscopic malignant laryngeal neoplasms during their careers.
photos. These researchers affirm complete endoscopic excision, instead
of endoscopic marsupialization or transcervical removal, even for
large recurrent lateral saccular cysts. In this series, complete excision
Epithelial Tumors
was possible on an outpatient basis for four of seven patients; the
other three were admitted for a single night’s observation. None
Recurrent Respiratory Papillomatosis
of the patients required tracheotomy, and none of the lesions had For additional discussion regarding epidemiology, virology,
recurred several years later. The present author has also removed transmission, vaccine prevention, surgical and medical management,
two combined internal-external saccular cysts with palpable neck staging, and other considerations, also see Chapter 208.
components completely via endoscopic methods. This approach Squamous papillomas caused by HPV are the most common
requires following the cyst wall endoscopically over the top of the benign neoplasms seen by laryngologists (Figs. 60.34 and 60.35).
thyroid cartilage and into the neck (see Fig. 60.30C). Jones and colleagues,51 who found that 84% of the benign laryngeal
The surgeon who attempts complete removal of a saccular tumors they managed were papillomas, noted that this statistic
cyst via the endoscopic approach should note that even a large matches those of other large series. On the basis of physician
lateral cyst that bulges dramatically during awake endoscopy can questionnaires about patients with recurrent respiratory papil-
virtually disappear under conditions of direct laryngoscopy with lomatosis (RRP), it is estimated that this entity occurs at a rate
general anesthesia. When that happens, the surgeon can begin by of 4.3 per 100,000 children and 1.8 per 100,000 adults.53 HPV
excising the false fold, during which maneuver the wall of the cyst infection can be separated into many different serotypes by means
is invariably encountered. In small and moderate lesions, often of polymerase chain reaction methodology. The majority of infec-
the entire cyst can be delivered intact by careful dissection along tions are the result of subtypes 6 and 11. Type 11 appears to
its external wall. When the lesion is unusually large, the surgeon predispose to more aggressive disease, more frequent need for
may have to transect the presenting part of the cyst, decompress surgical intervention, and a higher risk of tracheopulmonary
its glue-like contents, and then deliver the rest of the cyst by involvement.54,55 Weiss and Kashima56 reviewed 39 cases and also
A B
Fig. 60.34 (A) Papillomas at the posterior vocal folds; the left side is much larger than the right. (B) Two
weeks after microsurgical removal and cidofovir injection, normal voice has returned.
A B
Fig. 60.35 Recurrent respiratory papillomatosis. (A) Under standard light, faint stippled vascularity is seen,
along with a general mild inflammatory response (pinkness). These patients are often misdiagnosed with acid
reflux. (B) Same patient with narrow-band light. The stippled human papillomavirus effect is apparent, showing
vascularity known as carpet variant papillomatosis.
reported that a history of tracheotomy, a high number of endoscopic The CO2 laser remains the most widely accepted management
procedures, and a long duration of the disease seem to correlate for papillomas in the larynx; more than 100 laryngoscopic removals
with an increased incidence of tracheal involvement. The present may be required to control these lesions during childhood, and
author has also seen types 16 and 18, which are known to pose a sometimes they must occur every few weeks. The laser is useful
higher risk of malignant transformation. because of its hemostatic properties (papillomas tend to be friable
An association between genital condylomas in the mother and and vascular). In addition, the precision of the microspot laser
RRP in the child is known; however, the fact that only approximately allows for vaporization of the lesion plane by plane to avoid harming
1 in 400 children at risk because of maternal infection actually the underlying vocal fold. Over the last two decades, as “shaver”
experience RRP, as reported by Shah and associates,57 suggests technology has evolved, the laryngeal microdebrider has gained
relatively low infectivity. Another study of 3033 births to mothers acceptance for the treatment of RRP. Use of the microdebrider
with genital condylomas yielded 57 cases of RRP, for a rate of 7 has been shown to reduce operating room time, reduce mucosal
per 1000 births to genitally infected mothers, a markedly greater injury, improve voice outcomes, and reduce cost. Risks associated
incidence than that seen in uninfected mothers. Nevertheless, with the laser are also obviated.
somewhat counterintuitively, cesarean delivery was not found to Many other management modalities have been tried. Systematic
be protective against respiratory papillomatosis.58 These kinds of reviews of the English literature suggest that the strongest current
findings make the question as to whether to perform cesarean interest might be in the antiviral agent cidofovir.60–62 Options such
section in the context of maternal infection controversial. A different as cryotherapy, irradiation, photodynamic therapy, and vaccines
question is whether children born to women with RRP (genital such as Gardasil are not yet validated or are even rejected by some
status unspecified) are likely to develop RRP themselves. Gerein for treatment of existing disease, although Freed and Derkay63
and colleagues55 found no cases of RRP among children and have advocated use of the vaccine to prevent not only genital HPV
grandchildren of a group of German mothers with RRP or among infection but also RRP.
those of a second group of Russian women with this disease. All Dramatic responses to interferon have been observed in some
the same, Mammas and associates59 found HPV DNA in the cases, but this agent’s long-term role in the management of laryngeal
specimens of 9 of 106 children (8.5%) after removal of hyperplastic papillomatosis appears to be limited at best. In 1983, McCabe
tonsils and adenoids; in these no clinical papillomas were found. and Clark64 reported a series of 19 patients with moderate to
RRP may commence in childhood or adulthood. The juvenile severe RRP that was managed with interferon. They found that
form, almost always a result of HPV type 6 or 11 and commonly six patients were disease free by visual criteria, seven had a small
designated papillomatosis because of diffuse involvement of the amount of visible disease but not enough to require surgery, and
larynx, usually manifests in infancy or childhood as hoarseness two showed no response to interferon. These investigators also
and stridor. This form of papillomatosis is often aggressive and noted that the papillomas tended to regrow upon cessation of
rapidly recurrent; it requires frequent laryngoscopic removal interferon therapy. Overall, they thought that during the time
for management. Rarely, papillomas may regress spontaneously, administered, interferon spared patients the need for multiple
especially at puberty. On laryngoscopic examination, exuberant operations. In a later study that used higher doses and longer
tissue that resembles miniature clusters of grapes may be seen, duration of interferon therapy, Leventhal and colleagues65 noted
especially on the anterior part of the true vocal folds, the false a significantly higher response rate; some responses appeared to
folds, or the epiglottis (see Fig. 60.34A). The bulk of papilloma be long term. Similar findings arose in an even larger study by
tissue can be so great as to obscure normal laryngeal landmarks. Gerein and coworkers,55 and Ogura and associates66 reported the
Adult-onset papillomas are occasionally solitary or at least more recurrence of papilloma after a 6-year interval in a patient who
localized than juvenile-onset lesions and more likely to be of the seemed to have achieved a durable response to interferon. The
so-called carpet variant (see Fig. 60.35). The latter morphology present author has used interferon according to the Leventhal
does not show the typical exophytic growth pattern but instead criteria in 12 adults. Three achieved long-term remission after 6
causes a velvety appearance with little projection from the surface; months of treatment, and most of the rest had notable reduction
however, the red dots on the surface that represent the fibrovascular of growth rate of the disease, sometimes on a durable basis, but
core of each papilloma are still visible. Behavior of adult-onset not remission. Better understanding of the role of interferon in
papillomatosis may also be less aggressive, and, rarely, a single RRP awaits further study.
removal leads to cure. However, adult-onset papillomatosis can Another newer medical management modality uses indole-
also behave like the more aggressive juvenile-onset form. 3-carbinol, a natural derivative of cruciferous vegetables such as
cabbage and broccoli.67 Anecdotal reports suggest that some patients previously been found by Tan and colleagues90 for cutaneous warts,
who take this medication benefit significantly. An estimated 30 of the hemoglobin in the microvasculature selectively absorbed the 60
110 patients in the author’s adult practice have used this nutritional laser energy. In the McMillan study, either the CO2 or pulsed dye
supplement but with somewhat disappointing results. A case report laser was used on different areas of papilloma growth. Papilloma
suggests good results can be achieved,68 but perhaps they are more response to both laser treatments appeared to be good, at least
common in patients with more rapid growth of RRP than is often to the limited time of follow-up reported. Early edema seemed
seen in adults. to be less on the side of the pulsed dye laser. This laser coagulates
Avidano and Singleton69 reported the use of methotrexate in the microvasculature owing to the red color of hemoglobin, but
three patients with severe RRP who did not respond to interferon it leaves the overlying epithelium relatively uncoagulated. The
or cis-retinoic acid. All three experienced a prolonged interval mechanism of action for regression of papillomas was said to be
before repeat surgery and reduced disease severity, but regression deprivation of oxygen and nutrients to the lesions. Franco and
was not complete. colleagues91 subsequently used the pulsed dye laser on lesions in
European investigators first wrote about the use of intralesional 41 patients. In about half of these, papillomas were treated with
cidofovir as a treatment for DNA viruses, including HPV.70–72 At the laser but not removed. This group also noted marked response
least one anecdotal report showed disappearance of a papillomatous without evident scarring. As a continuation of long-established
lesion of the esophagus injected serially with cidofovir.73 Subse- office-based surgery,13,14 the present author uses two office-based
quently, others have shown good results with this medicine, either lasers: the pulsed potassium-titanyl-phosphate laser with hemo-
for regression or remission of existing lesions or as an adjunct to globin as the chromophore for small to moderate disease and
surgery.73–83 In my experience with more than 30 patients, rapidly especially for carpet variant papillomas (Figs. 60.36 and 60.37)
growing and focal lesions seem to respond best. Some durable and the less selectively coagulating thulium laser with the water
remissions are indeed achievable, and pending further experience, molecule as the chromophore. The latter is more useful for larger
long-term remission appears feasible in approximately 25% of
adult patients when patients with slow-growing papillomas are
included. Neither the investigators mentioned nor I have seen
scarring believed to be due to the use of cidofovir except when
an overly aggressive bleb was raised that deprived the mucosa of
a blood supply. However, in a study that used a canine model,
Chhetri and colleagues81 found atrophy and scarring that appeared
to be worse with an increase in the number of injections and with
increasing concentration of cidofovir. In this model, use of con-
centrations of 20 mg/mL or higher seemed to have this effect.
The same group found no change in leukocyte count or renal
parameters up to the highest dose of 4.26 mg/kg body weight.
The carcinogenic potential has never to my knowledge been proven
for intralesional use of cidofovir, and it bears remembering that
HPV infection itself has a documented risk for cancer.55,84,85
The use of bevacizumab as an adjuvant treatment for RRP,
based on its potential as an antiangiogenesis agent, was first reported
by Zeitels and colleagues.86 In a 20-patient series follow-up,
bevacizumab was found to have a noteworthy effect.87 A study on
the safety of bevacizumab for laryngeal injection explored the use
of higher doses and reported no concerns.88 Fig. 60.36 Pulsed potassium-titanyl-phosphate laser treatment of
In a pilot study, McMillan and associates89 described use of chronic and recurrent keratosis with atypia. The same laser and
the 585-nm pulsed dye laser on three patients with RRP. As had technique are used for papillomas.
A B
Fig. 60.37 (A) Papillomas, primarily at the anterior commissure, before pulsed potassium-titanyl-phosphate
laser treatment. (B) Same larynx after treatment. Although this laser targets the hemoglobin molecule,
sufficient power density also creates superficial coagulation and haziness of the tissues, later to slough. Note
the delivery glass fiber (arrow).
A B
C D
Fig. 60.38 Recurrent respiratory papillomatosis operative sequence in a patient operated dozens of times
elsewhere. (A) Initial operative view. (B) Initial step of infiltration of left vocal fold papilloma for hydrodissection
and “heat sink” purposes. (C) Exceedingly superficial peeling with CO2 laser, taking great care to aim the laser
at the last layer of papilloma and not at normal tissue. Arrows mark dissection plane between papilloma and
normal tissue. (D) After final infiltration with cidofovir. The patient’s voice was much improved and no sign of
recurrence was seen after several years of follow-up. Arrow indicates former site of papilloma.
amounts of disease. The CO2 laser continues to be invaluable, such as stridor and pseudocroup, usually within the first 6 months
and precision removal provides excellent voice results even after of life. For additional detailed discussion regarding laryngeal
multiple surgical procedures (Fig. 60.38). hemangiomas and other vascular anomalies, also see Chapter 203.
During direct laryngoscopy, a mucosa-covered mass with or
without bluish coloration may be seen in the subglottis. Other
Vascular Neoplasms suggestive findings are compressibility with palpation and shrinkage
with administration of epinephrine.
Polypoid Granulation Tissue In his review of the management of subglottic hemangioma
Fechner and colleagues92 reviewed 639 vascular lesions of the in 1968, Calcaterra93 addressed the then-prevalent practice of
head and neck, 62 of which were found in the larynx or trachea, low-dose irradiation for subglottic hemangioma in infants. On
and reported that polypoid granulation tissue is the most common the basis of experience in an infant with a large cavernous hem-
vascular tumor in the larynx. They also noted that pyogenic angioma that did not respond to irradiation as well as general
granuloma does not occur in the larynx. Pyogenic granuloma, as knowledge of radiation’s effect on vascular tissues, Calcaterra93
seen most often on the tongue, consists of distinct lobules of indicated that this therapy was inadvisable. He suggested that
capillaries separated by fibromyxoid stroma, whereas polypoid tracheotomy be done when indicated for airway protection.
granulation tissue consists of radially arranged capillaries. These This step allows the tracheal lumen to enlarge with growth of
investigators attribute formation of polypoid granulation tissue the child, and, more importantly, it gives the hemangioma an
in the larynx to one of several forms of trauma (i.e., caused by opportunity to involute spontaneously, as most such lesions do
laryngeal biopsy, intubation, direct external trauma to the larynx, if left alone.
and an external penetrating wound). Granulation tissue in the Later reports by Healy and colleagues94 and Mizono and Dedo95
larynx should be handled primarily by conservative measures that explored the usefulness of the CO2 laser for the management of
include removal of the source of any ongoing irritation, such as this lesion. On the basis of 11 cases in the three centers reported
from inappropriate voice use or from acid reflux laryngitis, and by the authors, the researchers concluded that for the usual capillary
intralesional corticosteroids. For nonresponse and continuing hemangioma in the infant subglottis, the CO2 laser is clearly
symptoms, careful endoscopic removal may be considered after superior to radiotherapy or corticosteroid therapy. They described
the granulation tissue has been allowed to mature and to become the procedure as beginning with removal of tissue for histologic
less active and vascular. examination followed by simple vaporization of remaining abnormal
tissue. These researchers also believe that if tracheotomy was not
required before the procedure for airway maintenance, it is probably
Laryngeal Hemangiomas unnecessary provided that intense humidification is supplied
Infants with laryngeal hemangiomas often have associated cutaneous in the immediate postoperative period. None of the patients
hemangiomas. These infants typically have respiratory symptoms reported in this series had significant complications, although four
required a second laser treatment for a satisfactory final result.

All patients with previously placed tracheotomy tubes were suc-
Benign Neoplasms of Glandular Origin 60
cessfully decannulated.
Adult hemangiomas are usually found at or above the level of
Benign Mixed Neoplasm
the vocal folds. Because they are more often the cavernous form Benign mixed tumors (pleomorphic adenomas) are extremely
and are usually covered by thinner mucosa than the congenital uncommon in the larynx. Som and coworkers100 found only 27
hemangioma, adult hemangiomas appear more often as bluish cases of this tumor in the literature (up to 1979) that involved
discolored masses. the larynx, and they supplied one case report. Most of these tumors
Bridger and associates96 reviewed the literature on hemangioma involved the subglottic laryngeal region and only six involved the
in the adult patient and noted that, in contrast to the congenital supraglottis. These researchers described the typical appearance
form, symptoms of this lesion may have been present for many as that of a smooth, ovoid submucosal mass. As is the case of most
years. Hoarseness is the expected symptom, and respiratory distress other benign laryngeal tumors, the approach to surgical excision
never occurs. Although hemorrhage may occur spontaneously, it of a benign mixed neoplasm of the larynx depends on the tumor’s
is usually a surgical complication. These investigators advised that size and location.
adult laryngeal hemangiomas be left alone if at all possible. They
recommended that corticosteroid therapy or radiotherapy be used
when necessary and that surgery of adult laryngeal hemangioma
Oncocytic Neoplasms of the Larynx
be undertaken only when the hemangioma shows a tendency to According to the literature, oncocytic tumors are actually oncocytic
progressively involve additional parts of the larynx, as occurred metaplasia and hyperplasia of the ductal cell portion of glandular
in the case they presented. The CO2 laser is not generally advised tissue. Gallagher and Puzon101 found that 18 of 19 cases in their
for adult cavernous hemangioma because the diameter of the series were cystic and concluded that these lesions represented
vascular spaces exceeds this laser’s coagulating ability. duct metaplasia and hyperplasia rather than true neoplasia. One
solid tumor in their series was considered an oncocytic adenoma,
as seen in the parotid gland.
Muscle Neoplasms LeJeune and associates102 reported a case of a woman with
numerous cystic oncocytic lesions of the epiglottis, aryepiglottic
Rhabdomyoma folds, false vocal fold, and right true vocal fold, which supports
Most extracardiac rhabdomyomas are found in the head and neck the opinion of Gallagher and Puzon.101 Lundgren and colleagues103
region, especially in the pharynx and larynx. Winther97 found 53 presented a series of seven oncocytic cysts of the larynx and agreed
cases that involved the hypopharynx or larynx in the literature that these lesions represented glandular duct metaplasia and
up until 1976 and also supplied two case reports. He noted that hyperplasia rather than true neoplasia.
none of these tumors recurred after local excision and advised All of these writers seem to agree that simple excision, by
that the approach be as conservative as possible for complete whatever approach necessary according to lesion size and location,
removal. He also noted that rhabdomyoma can be confused is the management of choice.
with a granular cell tumor or a rhabdomyosarcoma. Modlin98
also stressed the need to differentiate between rhabdomyoma
and granular cell tumor and noted that complete local excision
Cartilaginous Neoplasms
is curative.
Chondroma
Although an attempt to differentiate histologically between
Neoplasms of Adipose Origin chondroma and low-grade chondrosarcoma has been made, Mills
and Fechner104 believe that the behaviors of the chondromas and
Lipoma the low-grade chondrosarcomas are so similar that histologic
In his review of the literature through 1965, Zakrzewski99 found distinction has little practical significance. Because neither grows
that only 70 of the many cases reported as laryngeal lipomas quickly or metastasizes, the clinical approach to these entities
actually involved the larynx and were sufficiently described to can be the same. In their experience with 33 patients, Neel and
allow for analysis of this entity. He noted, however, that 23 of the Unni105 noted that most had an “obvious smooth rounded mass
70 cases had some characteristics of other tumors, such as fibro- covered by mucous membrane in the subglottic region of the
lipoma, myxolipoma, nervous tissue, cyst fragments, and angioli- larynx,” and in most cases this mass was situated posteriorly and
poma. Although laryngeal lipomas were sometimes seen among laterally. They did not tabulate symptoms separately for benign
those with numerous lipomas in other body areas, most were and malignant cartilaginous tumors; symptoms consisted mainly
isolated occurrences. Of the 70 cases, 54 were designated extrinsic, of hoarseness, dyspnea, neck mass, and dysphagia. These writers
whereas only 16 were classified as true intrinsic laryngeal tumors. used laryngofissure most often for tumor removal, and they used
Because lipomas occurred more frequently in parts of the larynx total laryngectomy for high-grade malignant tumors.
in which fat was a normal part of the subepithelium, most tumors In a review of laryngeal tumors seen at four major hospitals
arose on the aryepiglottic fold and epiglottis (the periphery of the between 1960 and 1977, Singh and associates106 found only two
laryngeal vestibule). Of the intrinsic tumors, the most common cartilaginous tumors of the larynx, but they found 177 cases reported
site of origin was the false vocal fold. Only one case involved a in the English literature. Of cartilaginous tumors, 70% arose in
true vocal fold. the cricoid cartilage, primarily from the posterior plate. The growth
Because lipomas grow slowly, symptoms were often present of these tumors is mostly intraluminal, with a rare case that appeared
for many years before diagnosis. In general, respiratory symptoms externally into the neck. These writers believed that because
were most common, and hoarseness was relatively infrequent. chondrosarcomas are usually indolent and rarely metastasize, local
Surgical management was successful. Procedures such as resection, if technically feasible, is adequate management. They
endoscopic removal, subhyoid pharyngotomy, lateral pharyn- described laryngofissure with submucosal resection as the most
gotomy, and laryngofissure were used according to tumor size and common approach to these tumors, unless the cricoid would be
location. The guiding principle was conservative, with complete collapsed entirely by its subtotal removal.
removal or enucleation, because incompletely removed lipomas In a series of 31 cartilaginous tumors of the larynx, Hyams
regrow. and Rabuzzi107 found 15 chondromas and 16 chondrosarcomas.
The chondromas occurred in a slightly younger age group than and dysphagia. On physical examination, lobulated nodules that
the chondrosarcomas. However, the chondromas included nine ranged from less than 2 to 8 cm in diameter were noted, and the
“chondromas of the true vocal cord,” which probably represented most common site of origin was the arytenoid or aryepiglottic fold.
metaplasia of the elastic connective tissue of the vocal fold rather Because these lesions are benign, the surgical approach should
than true chondromas. balance conservatism with the need for complete excision. For
larger tumors, an external approach (e.g., lateral pharyngotomy,
laryngofissure, lateral thyrotomy) may be needed.114
Neoplasms of Neural Origin
Granular Cell Neoplasms Neurilemmoma
104
Mills and Fechner noted evidence indicating a Schwann cell Neurilemmomas are less common than neurofibromas and usually
origin in granular cell tumors; these had previously been called involve the aryepiglottic fold and false vocal fold. Symptoms
granular cell myoblastomas because they resemble muscle tissue with correspond with the slow growth of these lesions and can include
standard staining techniques. A notable characteristic of granular a sensation of fullness in the throat, voice change, and slow
cell tumors is their frequent association with overlying pseudo- development of respiratory distress. Management should consist
epitheliomatous hyperplasia of the mucosa. Insufficiently deep of conservative but complete removal by an approach consistent
biopsy of this lesion can lead to an incorrect diagnosis of epidermal with tumor size and location. Neurilemmomas are more encap-
carcinoma. sulated than neurofibromas; simple enucleation (e.g., by a lateral
Although granular cell neoplasms can involve any part of the thyrotomy) with removal of a portion of the thyroid cartilage is
larynx, the middle to posterior part of the true vocal fold is the believed to be adequate management.115,116
most common site, and hoarseness is thus the most common
complaint. Conservative but complete local excision is considered
definitive therapy.108–111
Summary
True benign neoplasms of the larynx do not include benign (reac-
tive) vocal fold mucosal disorders. If papillomas are excluded,
Neurofibroma the number of laryngeal neoplasms is small; busy laryngologists
Chang-Lo112 reviewed 19 previously reported cases of von Reck- rarely see these lesions. The basic management principles are
linghausen disease with laryngeal involvement and supplied one similar to these for tumors, regardless of the cell of origin. To
case. Supance and colleagues113 reported that solitary neurofibromas spare the voice, removal should be complete but should also be
of the larynx not associated with von Recklinghausen disease were conservative, with the approach determined primarily by tumor size
more common than those associated with the disease. The most and location.
common symptoms in patients with laryngeal involvement by von
Recklinghausen disease were hoarseness, dyspnea (most striking), For a complete list of references, visit ExpertConsult.com.
CHAPTER 60 Benign Vocal Fold Mucosal Disorders 896.e1
REFERENCES 33. Kambic V, Radsel Z, Zargi M, et al: Vocal cord polyps: incidence,
1. Brodnitz FS: Results and limitation of vocal rehabilitation, Arch histology and pathogenesis, J Laryngol Otol 95:609, 1981. 60
Otolaryngol Head Neck Surg 77:148, 1963. 34. Kleinsasser O: Pathogenesis of vocal cord polyps, Ann Otol Rhinol
2. Kleinsasser O: Microlaryngoscopy and endolaryngeal microsurgery: technique Laryngol 91:378, 1982.
and typical findings, ed 2, Baltimore, 1979, University Park Press. 35. Baker BM, Fox SM, Baker CD, et al: Persistent hoarseness after
3. Cummings CW, et al: Atlas of laryngeal surgery, St Louis, 1984, surgical removal of vocal cord lesions, Arch Otolaryngol Head Neck
Mosby. Surg 107:148, 1981.
4. Michaels L: Pathology of the larynx, New York, 1984, Springer-Verlag. 36. Wolfe VI, Ratusnik DL: Vocal symptomatology of postoperative
5. Hirano M: Clinical examination of voice, New York, 1981, Springer-Verlag. dysphonia, Laryngoscope 91:635, 1981.
6. Saito S, et al: X-ray stroboscopy. In Stevens KN, Hirano M, editors: 37. Ford CN, Bless DM: Use of collagen for scarring problems on the
Vocal fold physiology, Tokyo, 1981, University of Tokyo Press. vocal fold, J Voice 1:116, 1987.
7. Hirano M: Structure of the vocal fold in normal and disease states: 38. Goldberg M, Noyek AM, Pritzker KPH: Laryngeal granuloma
anatomical and physical studies. In Proceedings of the Conference secondary to gastro-esophageal reflux, J Otolaryngol 7:196, 1978.
on the Assessment of Vocal Pathology (ASHA Report II), Rockville, 39. Broyles EN: Anatomical observations concerning the laryngeal
MD, 1981, The American Speech-Language-Hearing Association. appendix, Ann Otol Rhinol Laryngol 68:461, 1959.
8. Baer T: Observations of vocal fold vibration: measurement of excised 40. Stell PM, Maran AGD: Laryngocele, J Laryngol Otol 89:915, 1975.
larynges. In Stevens KN, Hirano M, editors: Vocal fold physiology, 41. Micheau C, Luboinski B, Lanchi P, et al: Relationship between
Tokyo, 1981, University of Tokyo Press. laryngoceles and laryngeal carcinomas, Laryngoscope 88:6808, 1978.
9. Sataloff RT: Professional singers: the science and art of clinical care, 42. Holinger LD, Barnes DR, Smid LJ, et al: Laryngocele and saccular
Am J Otol 2:251, 1981. cysts, Ann Otol Rhinol Laryngol 87:675, 1978.
10. Sataloff RT: Efficient history taking in professional singers, Laryngoscope 43. DeSanto LW, Devine KD, Weiland LH: Cysts of the larynx: clas-
94:1111, 1984. sification, Laryngoscope 80:245, 1970.
11. Bastian RW, Keidar A, Verdolini-Marston K: Simple vocal tasks for 44. DeSanto LW: Laryngocele, laryngeal mucocele, large saccules, and
detecting vocal fold swelling, J Voice 4:172, 1990. laryngeal saccular cysts: a developmental spectrum, Laryngoscope 84:
12. Bastian RW, Nagorsky MJ: Laryngeal image biofeedback, Laryngoscope 1291, 1974.
97:1346, 1987. 45. de Vincentiis I, Biserni A: Surgery of the mixed laryngocele, Acta
13. Bastian RW, Collins SL, Kaniff T, et al: Indirect videolaryngoscopy Otolaryngol 87:142, 1979.
versus direct endoscopy for larynx and pharynx cancer staging: 46. Abramson AL, Zielinski B: Congenital laryngeal saccular cyst of the
toward elimination of preliminary direct laryngoscopy, Ann Otol newborn, Laryngoscope 94:1580, 1984.
Rhinol Laryngol 98:693, 1989. 47. Booth JB, Birck HG: Operative treatment and postoperative manage-
14. Bastian RW, Delsupehe KG: Indirect larynx and pharynx surgery: a ment of saccular cyst and laryngocele, Arch Otolaryngol Head Neck
replacement for direct laryngoscopy, Laryngoscope 106:1280, 1996. Surg 107:500, 1981.
15. Diamond L, Dockhorn RJ, Grossman J, et al: A dose-response study 48. Frederick FJ: Endoscopic microsurgical excision of internal laryngocele,
of the efficacy and safety of ipratropium bromide nasal spray in the J Otolaryngol 14:163, 1985.
treatment of the common cold, J Allergy Clin Immunol 95:1139, 1995. 49. Baker HL, Baker SR, McClatchey KD: Manifestations and manage-
16. Dockhorn R, Grossman J, Posner M, et al: A double-blind, placebo- ment of laryngoceles, Head Neck Surg 4:450, 1982.
controlled study of the safety and efficacy of ipratropium bromide 50. Hogikyan ND, Bastian RW: Endoscopic CO2 laser excision of large
nasal spray versus placebo in patients with the common cold, J Allergy or recurrent laryngeal saccular cysts in adults, Laryngoscope 107:260,
Clin Immunol 90:1076, 1992. 1997.
17. Ford CN: Evaluation and management of laryngopharyngeal reflux, 51. Jones SR, Myers EN, Barnes L: Benign neoplasms of the larynx,
JAMA 294:1534, 2005. Otolaryngol Clin North Am 17:151, 1984.
18. Bastian RW: Laryngeal image biofeedback for voice modification. 52. Holinger B, Johnston K: Benign tumors of the larynx, Ann Otol
In Transcripts of the Fourteenth Annual Symposium for the Care of the Rhinol Laryngol 60:496, 1951.
Professional Voice, Denver, 1985. 53. Derkay CS: Task force on recurrent respiratory papillomas, Arch
19. Norris CW, Mullarky BS: Experimental skin incision made with the Otolaryngol Head Neck Surg 121:1386, 1995.
carbon dioxide laser, Laryngoscope 92:416, 1982. 54. Wiatrak BJ, Wiatrak DW, Broker TR, et al: Recurrent respiratory
20. Duncavage JA, Toohill RJ: Wound healing of true vocal cord squamous papillomatosis: a longitudinal study comparing severity associated
epithelium following CO2 laser ablation and cup forceps stripping. with human papilloma viral types 6 and 11 and other risk factors in
Paper presented at: Laser Surgery Congress, Chicago, 1984. a large pediatric population, Laryngoscope 114(Suppl 104):1, 2004.
21. Shapshay SM, Rebeiz EE, Bohigian RK, et al: Benign lesions of the 55. Gerein V, Soldatski IL, Babkina N, et al: Children and partners of
larynx: should the laser be used?, Laryngoscope 100:953, 1990. patients with recurrent respiratory papillomatosis have no evidence of
22. Shapshay SM, Wallace RA, Kveton JF, et al: New microspot micro- the disease during long-term observation, Int J Pediatr Otorhinolaryngol
manipulator for carbon dioxide laser surgery in otolaryngology: early 70:2061, 2006.
clinical results, Arch Otolaryngol Head Neck Surg 114:1012, 1988. 56. Weiss MD, Kashima HK: Tracheal involvement in laryngeal papil-
23. Geyer M, Ledda GP, Tan N, et al: Carbon dioxide laser-assisted lomatosis, Laryngoscope 93:45, 1983.
phonosurgery for benign glottic lesions, Eur Arch Otorhinolaryngol 57. Shah K, Kashima H, Polk BF, et al: Rarity of cesarian delivery in cases
267:87, 2010. of juvenile-onset respiratory papillomatosis, Obstet Gynecol 68:795,
24. Cornut G, Bouchayer M: Phonosurgery for singers, J Voice 3:269, 1986.
1989. 58. Silverberg MJ, Thorsen P, Lindeberg H, et al: Condyloma in pregnancy
25. Bastian RW: Vocal fold microsurgery in singers, J Voice 10:389, 1996. is strongly predictive of juvenile-onset recurrent respiratory papil-
26. van Dinther JJS, De Bodt M, Wuyts FL, et al: Vocal fold surgery of lomatosis, Obstet Gynecol 101:645, 2003.
benign inflammatory lesions of Reinke’s space: an outcome study in 59. Mammas IN, Sourvinos G, Michael C, et al: Human papilloma virus
47 subjects, Eur Arch Otorhinolaryngol 266:1753, 2009. in hyperplastic tonsillar and adenoid tissues in children, Pediatr Infect
27. Zeitels SM: Ectasias and varices of the vocal fold: clearing the striking Dis J 25:1158, 2006.
zone, Ann Otol Rhinol Laryngol 108:10, 1999. 60. Chadha NK, James AL: Antiviral agents for the treatment of recurrent
28. Bouchayer M, Cornut G: Microsurgery for benign lesions of the respiratory papillomatosis: a systematic review of the English-language
vocal folds, Ear Nose Throat J 67:446, 1988. literature, Otolaryngol Head Neck Surg 136:863, 2007.
29. Monday LA, Cornut G, Bouchayer M, et al: Epidermoid cysts of 61. Derkay CS, Darrow DH: Recurrent respiratory papillomatosis, Ann
the vocal cords, Ann Otol Rhinol Laryngol 92:124, 1983. Otol Rhinol Laryngol 115:1, 2006.
30. Bouchayer M, Cornut G, Witzig E, et al: Epidermoid cysts, sulci, 62. Schraff S, Derkay CS, Burke B, et al: American Society of Pediatric
and mucosal bridges of the true vocal cord: a report of 157 cases, Otolaryngology members’ experience with recurrent respiratory
Laryngoscope 95:1087, 1985. papillomatosis and the use of adjuvant therapy, Arch Otolaryngol
31. Loire R, Bouchayer M, Cornut G, et al: Pathology of benign vocal Head Neck Surg 130:1039, 2004.
fold lesions, Ear Nose Throat J 67:357, 1988. 63. Freed GL, Derkay CS: Prevention of recurrent respiratory papil-
32. Dailey SH, Ford CN: Surgical management of sulcus vocalis and lomatosis: role of HPV vaccination, Int J Pediatr Otorhinolaryngol
vocal fold scarring, Otolaryngol Clin North Am 39:23, 2006. 70:1799, 2006.
896.e2 PART V Laryngology and Bronchoesophagology
64. McCabe BC, Clark KF: Interferon and laryngeal papillomatosis, Ann 87. Zeitels SM, Barbu AM, Landau-Zemer T, et al: Local injection of
Otol Rhinol Laryngol 92:2, 1983. bevacizumab (Avastin) and angiolytic KTP laser treatment of recurrent
65. Leventhal BG, Kashima HK, Mounts P, et al: A long-term study of respiratory papillomatosis of the vocal folds: a prospective study, Ann
lymphoblastoid interferon in recurrent respiratory papillomatosis, Otol Rhinol Laryngol 120:627, 2011.
N Engl J Med 325:613, 1991. 88. Best SR, Friedman AD, Landau-Zemer T, et al: Safety and dosing
66. Ogura H, Ozawa K, Ogura H, et al: Persistence of human papil- of bevacizumab (Avastin) for the treatment of recurrent respiratory
lomavirus type 6e in adult multiple laryngeal papilloma and the papillomatosis, Ann Otol Rhinol Laryngol 121:587, 2012.
counterpart false cord of an interferon-treated patient, Jpn J Clin 89. McMillan K, Shapshay SM, McGilligan JA, et al: A 585-nanometer
Oncol 23:130, 1993. pulsed dye laser treatment of laryngeal papillomas: preliminary report,
67. Rogan EG: The natural chemopreventive compound indole-3-carbinol: Laryngoscope 108:968, 1998.
state of the science, In Vivo 20:221, 2006. 90. Tan OT, Hurwitz RM, Stafford TJ: Pulsed dye laser treatment of
68. Rosen CA, Bryson PC: Indole-3-carbinol for recurrent respiratory recalcitrant verrucae: a preliminary report, Lasers Surg Med 13:127,
papillomatosis: long-term results, J Voice 18:248, 2004. 1993.
69. Avidano MA, Singleton GT: Adjuvant drug strategies in the treatment 91. Franco RA, Zeitels SM, Farinelli WA, et al: 585-nm pulsed dye laser
of recurrent respiratory papillomatosis, Head Neck Surg 112:197, treatment of glottal papillomatosis, Ann Otol Rhinol Laryngol 111:486,
1995. 2002.
70. Aduma P, Connelly MC, Srinivas RV, et al: Metabolic diversity and 92. Fechner RE, Cooper PH, Mills SE: Pyogenic granuloma of the larynx
antiviral activities of acyclic nucleoside phosphonates, Mol Pharmacol and trachea: a causal and pathologic misnomer for granulation tissue,
47:816, 1995. Arch Otolaryngol Head Neck Surg 107:30, 1981.
71. Neyts J, DeClercq E: Mechanism of action of acyclic nucleoside 93. Calcaterra TC: An evaluation of the treatment of subglottic hem-
phosphonates against herpes virus replication, Biochem Pharmacol angioma, Laryngoscope 78:1956, 1968.
47:39, 1994. 94. Healy G, Fearon B, French R, et al: Treatment of subglottic hem-
72. Snoeck R, Wellens W, Desloovere C, et al: Treatment of severe angioma with the carbon dioxide laser, Laryngoscope 90:809, 1980.
laryngeal papillomatosis with intralesional injections of cidofovir, J 95. Mizono G, Dedo HH: Subglottic hemangiomas in infants: treatment
Med Virol 54:219, 1998. with CO2 laser, Laryngoscope 94:638, 1984.
73. Van Cutsem E, Snoeck R, Van Ranst M, et al: Successful treatment 96. Bridger GP, Nassar VH, Skinner HB: Hemangioma in the adult
of a squamous papilloma of the hypopharynx-esophagus by local larynx, Arch Otolaryngol Head Neck Surg 92:493, 1970.
injections of (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl) cytosine, 97. Winther LK: Rhabdomyoma of the hypopharynx and larynx, J Laryngol
J Med Virol 45:230, 1995. Otol 90:1041, 1976.
74. Pransky SM, Brewster DF, Magit AE, et al: Clinical update on 10 98. Modlin B: Rhabdomyoma of the larynx, Laryngoscope 92:580, 1982.
children treated with intralesional cidofovir injections for severe 99. Zakrzewski A: Subglottic lipoma of the larynx: case report and literature
recurrent respiratory papillomatosis, Arch Otolaryngol Head Neck Surg review, J Laryngol Otol 79:1039, 1965.
126:1239, 2000. 100. Som PM, Nagel BD, Feuerstein SS, et al: Benign pleomorphic adenoma
75. Bielamowicz S, Villagomez V, Stager SV, et al: Intralesional cidofovir of the larynx: a case report, Ann Otol Rhinol Laryngol 88:112, 1979.
therapy for laryngeal papilloma in an adult cohort, Laryngoscope 101. Gallagher JC, Puzon BO: Oncocytic lesions of the larynx, Ann Otol
112:696, 2002. Rhinol Laryngol 78:307, 1969.
76. Naiman AN, Ceruse P, Coulombeau B, et al: Intralesional cidofovir and 102. LeJeune JE, Putman HC, Yamase HT: Multiple oncocytic papil-
surgical excision for laryngeal papillomatosis, Laryngoscope 113:2174, lary cystadenomas of the larynx: a case report, Laryngoscope 90:501,
2003. 1980.
77. Pransky SM, Albright JT, Magit AE: Long-term follow-up of pediatric 103. Lundgren J, Olofsson J, Hellquist H: Oncocytic lesions of the larynx,
recurrent respiratory papillomatosis managed with intralesional Acta Otolaryngol 94:335, 1982.
cidofovir, Laryngoscope 113:1583, 2003. 104. Mills SE, Fechner RE: Pathology of the Larynx (atlases of head and neck
78. Peyton SW, Wiatrak B: Is cidofovir a useful adjunctive therapy pathology), Chicago, 1985, American Society of Clinical Pathologists
for recurrent respiratory papillomatosis in children?, Int J Pediatr Press.
Otorhinolaryngol 68:413, 2004. 105. Neel HB, Unni KK: Cartilaginous tumors of the larynx: a series of
79. Chung BJ, Akst LM, Koltai PJ: 3.5 year follow-up of intralesional 33 patients, Otolaryngol Head Neck Surg 90:201, 1982.
cidofovir protocol for pediatric recurrent respiratory papillomatosis, 106. Singh J, Black MJ, Fried I: Cartilaginous tumors of the larynx: a
Int J Pediatr Otorhinolaryngol 70:1911, 2006. review of literature and two case experiences, Laryngoscope 90:1872,
80. Naiman AN, Abedipour D, Ayari S, et al: Natural history of adult-onset 1980.
laryngeal papillomatosis following multiple cidofovir injections, Ann 107. Hyams VJ, Rabuzzi DD: Cartilaginous tumors of the larynx, Laryn-
Otol Rhinol Laryngol 115:175, 2006. goscope 80:755, 1970.
81. Chhetri DK, Jahan-Parwar B, Hart SD, et al: Local and systemic 108. Agarwal RK, Blitzer A, Perzin KH: Granular cell tumors of the
effects of intralaryngeal injection of cidofovir in a canine model, larynx, Otolaryngol Head Neck Surg 87:807, 1979.
Laryngoscope 113:1922, 2003. 109. Booth JB, Osborn DA: Granular cell myoblastoma of the larynx,
82. Wierzbicka M, Jackowska J, Bartochowska A, et al: Effectiveness Acta Otolaryngol 70:279, 1970.
of cidofovir intralesional treatment in recurrent respiratory papil- 110. Frable MA, Fischer RA: Granular cell myoblastomas, Laryngoscope
lomatosis, Eur Arch Otorhinolaryngol 268:1305, 2011. 86:36, 1976.
83. Mikolajczak S, Quante G, Weissenborn S, et al: The impact of cidofovir 111. Thawley SE, May M, Ogura JH: Granular cell myoblastoma of the
treatment on viral loads in adult recurrent respiratory papillomatosis, larynx, Laryngoscope 84:1545, 1974.
Eur Arch Otorhinolaryngol 269:2543, 2012. 112. Chang-Lo M: Laryngeal involvement in von Recklinghausen’s disease:
84. Syrjanen S: Human papillomavirus (HPV) in head and neck cancer, a case report and review of the literature, Laryngoscope 87:435, 1977.
J Clin Virol 32(Suppl 1):S59, 2005. 113. Supance JS, Quenelle DJ, Crissman J: Endolaryngeal neurofibromas,
85. Reidy PM, Dedo HH, Rabah R, et al: Integration of human papil- Otolaryngol Head Neck Surg 88:74, 1980.
lomavirus type 11 in recurrent respiratory papilloma-associated cancer, 114. Cummings CW, Montgomery WW, Balogh K: Neurogenic tumors
Laryngoscope 114:1906, 2004. of the larynx, Ann Otol Rhinol Laryngol 38:76, 1969.
86. Zeitels SM, Lopez-Guerra G, Bums JA, et al: Microlaryngoscopic and 115. Gooder P, Farrington T: Extracranial neurilemmomata of the head
office-based injection of bevacizumab (Avastin) to enhance 532-nm and neck, J Laryngol Otol 94:243, 1980.
pulsed KTP laser treatment of glottal papillomatosis, Ann Otol Rhinol 116. Nanson EM: Neurilemmoma of the larynx: a case study, Head Neck
Laryngol Suppl 201:1–13, 2009. Surg 1:69, 1978.

60 - Benign Vocal Fold Mucosal Disorders

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

60 - Benign Vocal Fold Mucosal Disorders

Uploaded by

Copyright:

Available Formats

60 Benign Vocal Fold Mucosal Disorders

Robert W. Bastian, Melissa L. Wingo

Fig. 60.2 Gentle medial retraction shows the relative decoupling of

EVALUATION OF THE PATIENT: Common Symptom Complexes

analysis, spirometric measures to test respiratory adequacy, fre-

Vocal Capability Battery. In patients with moderate to large vocal

described in Table 60.1, seems to promote dynamic healing. The

Vocal Capability Battery. Without mucosal swelling, the voice

Laryngeal Examination. Capillary ectasia may manifest as

inexperienced clinician may be more aware of what appear to be

needed. The reason is that those with epidermal inclusion cysts

Fig. 60.20 Mucosal bridge of the left mucosal fold. If an epidermal

midportion of the mucosa stops oscillating and short-segment C D

Laryngeal Examination. Laryngeal examination usually reveals

Fig. 60.23 Smoker’s polyp; operative

Behavioral. Short-term voice therapy may be appropriate to

required a second laser treatment for a satisfactory final result.

You might also like