Vocal fold nodules, vocal cord nodules, singer's nodes
Monday, April 10, 2017

See also:

Definitions

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

Etiology

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

Epidemiology

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

Histopathology

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

Clinical Presentation

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

Management

  • Review of Recent Literature
    • General concept: nodules generally (especially if they are 'young nodules') resolve with behavioral management; polyps require surgery (McWhorter 2009)
    • Survey identifying preferred initial treatment with voice therapy among members of the AAOHSN (Sulica 2003)
      • Vocal fold nodules  91% prefer voice therapy as initial treatment
      • Vocal fold polyps 30% prefer voice therapy as initial treatment
      • Vocal fold cysts 22% prefer voice therapy as initial treatment
    • A retrospective review of 57 patients with vocal fold cysts and polyps concluded that voice therapy is an effective treatment modality for these processes (Cohen and Garrett 2007)
      • The endpoint evaluated was symptom resolution without the need for surgical intervention
      • Among fifty-seven patients, 49.1% achieved symptom resolution with voice therapy alone.
      • Patients with translucent polyps more commonly responded to voice therapy than fibrotic, hyaline, or hemorrhagic polyps.
    • Intralesional steroid injections are advocated by some Otolaryngologists as a safe intermediary that may be performed in-office via transnasal flexible endoscope (Wang et al 2013).

University of Iowa Approach

  • Patients with dysphonia and clinical findings of benign vocal fold lesions are evaluated through the multidisciplinary VOICE CLINIC
    • Includes Speech Pathologist and Otolaryngologist with videostroboscopy and vocal function analysis
    • Selected cases (singers) may warrant inclusion of a vocologist as well as visitors: the patient's singing teacher
  • Vocal fold nodules (classic presentation)
    • Voice therapy as initial treatment (2 sessions per week for six weeks - modify according to response)
    • Handouts: Handout: Voice Conservation, Handout: Esophageal Reflux Precautions, Handout: Homeopathic Throat Soothers
    • Consider surgery
      • Persistence of symptoms associated with identifiable lesions after adequate course of voice therapy
      • In general: ensure the vocal behavior associated with nodule formation has been successfully modified before offering surgery
      • In general: know the patient for a year (with sequence of evaluations) before offering surgery for vocal nodules
      • Operative intervention for nodules : see video
  • Vocal fold polyps and cysts (classic presentations)
    • Voice therapy may offered as an alternative to surgery if appropriately analyzed patients
    • Observation without intervention is an option if malignancy and airway compromise are considered unlikely; followup evaluation usually suggested
    • Voice therapy is suggested treatment for patients with evidence for voice disorders that are identified in addition to the presence of the lesion
    • Voice therapy before surgery is considered to diminish risk of recurrence after surgery
    • Indications for surgery
      • Counsel about options; offer of surgery contingent upon desires of well-informed patient
      • Concern about malignancy (biopsy)
      • Concern about airway compromise (large polyps, Reinke's space edema - see examples)

Operative Procedure

see: Suspension Microlaryngoscopy

References

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

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

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

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

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

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

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

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

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

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

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

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

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