Traumatic Lesions of the Vocal Folds
Vocal cord lesions, also known as vocal fold lesions, are benign (noncancerous) growths that include nodules, polyps, and cysts. All can cause hoarseness and may be associated with vocal overuse or vocal cord trauma.
Types of vocal cord lesions
Vocal fold nodules are smooth, paired lesions that form at the junction of the anterior one-third and posterior twothirds of the vocal folds. They are a common cause of hoarseness resulting from vocal abuse. In adults, they are referred to as “singer’s nodules” and in children as “screamer’s nodules.”
Treatment requires modification of voice habits, and referral to a speech therapist is indicated. While nearly all true nodules will resolve with behavior modification, recalcitrant nodules may require surgical excision. Often, additional pathology, such as a polyp or cyst, may be encountered.
Vocal fold polyps are unilateral masses that form within the superficial lamina propria of the vocal fold. They are related to vocal trauma and seem to follow resolution of vocal fold hemorrhage. Small, sessile polyps may resolve with conservative measures, such as voice rest and corticosteroids, but larger polyps are often irreversible and require operative removal to restore normal voice.
Vocal fold cysts are also considered traumatic lesions of the vocal folds and are either true cysts with an epithelial lining or pseudocysts. They typically form from mucussecreting glands on the inferior aspect of the vocal folds. Cysts may fluctuate in size from week to week and cause a variable degree of hoarseness. They rarely, if ever, resolve completely and may leave behind a sulcus, or vocal fold scar, if they decompress or are marsupialized. Such scarring can be a frustrating cause of permanent dysphonia.
Polypoid corditis is different from vocal fold polyps and may form from loss of elastin fibers and loosening of the intracellular junctions within the lamina propria. This loss allows swelling of the gelatinous matrix of the superficial lamina propria (called Reinke edema). These changes in the vocal folds are strongly associated with smoking, but also with vocal abuse, chemical industrial irritants, and hypothyroidism. While this problem is common in both male and female smokers, women seem more troubled by the characteristic decline in modal pitch caused by the increased mass of the vocal folds. If the patient stops smoking or the lesions cause stridor and airway obstruction, surgical resection of the hyperplastic vocal fold mucosa may be indicated to improve the voice or airway, or both.
Vocal cord lesions can result in hoarseness, breathiness, multiple tones, loss of vocal range, vocal fatigue or loss of voice.
Patients with vocal cord nodules or polyps may describe their voice as harsh, raspy, or scratchy. There may be frequent voice breaks, easy vocal fatigue with use or there may be a decreased range of vocal sounds. Pain is another symptom that is felt as a shooting pain from ear to ear, general neck pain or as a lump in the throat. Patients may also experience frequent coughing, throat clearing, or general fatigue.
Detection and diagnosis
The exact cause of benign vocal cord lesions is unknown. Lesions are thought to arise following heavy or traumatic use of the voice, including voice misuse such as speaking in an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick.
Diagnosis begins with a complete history of your voice problem and an evaluation of your speaking method. Your doctor will carefully examine your vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through your mouth to allow your doctor to see your voice box. Images are often recorded on video. The stroboscopic light source allows your doctor to assess vocal fold vibration.
Sometimes a second exam will follow after a period of voice rest to allow your doctor an opportunity to assess changes in the lesion. Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication side effects, and hormonal imbalances. Evaluation of these conditions is important to diagnosis.
The correct diagnosis of vocal cord lesions is very important because therapy can range from conservative behavioral, medical, and dietary treatments to more invasive treatments like surgery.
Nodules are typically treated conservatively with voice therapy and behavioral modification under the guidance of a speech language pathologist. Surgery is reserved for refractory lesions or in situations where vocal needs are not being met with voice therapy alone. In contrast to nodules, polyps and cysts do not typically respond to voice therapy and are best managed with a surgical approach.
Treatment of underlying medical problems that affect the voice, such as reflux, allergies, and sinusitis, may help lessen the severity or occurrence of vocal lesions and enhance vocal hygiene in general. Behavioral intervention for smoking cessation, stress reduction, and improved vocal awareness may also ease voice problems. Voice therapy typically reinforces these behaviors and provides techniques and strategies to maximize vocal efficiency and function.
If you have a vocal cord disorder, you can:
- Stop smoking, and avoid being in smoke-filled rooms.
- If you have hypothyroidism, sinusitis, allergies, or reflux, get treatment.
- Avoid excess use of alcohol and limit caffeine intake.
- Drink plenty of water.
- Get a good night’s sleep.
- Avoid excessive talking or speaking loudly without adequate vocal rest.
- Use a microphone.
- Use a humidifier in your home.
- Warm up your voice before singing or prolonged speaking.
- Rest your voice in anticipation of future speaking obligations.
- Avoid singing or excessive talking if you have an upper respiratory infection.
- Wash your hands often.
- Use stress reduction techniques, cognitive therapy, or yoga to lessen muscle tension.