Mohamed Farahat Ibrahim, MD, PhD · Mohamed Farahat Ibrahim, MD, PhD. Consultant, Assistant...

Mohamed Farahat Ibrahim, MD, PhDConsultant, Assistant Professor

Phoniatrics (Communication and Swallowing Disorders)

Deputy chairman, Communication and Swallowing Disorders Unit (CSDU)

King Abdulaziz University Hospital

Supervisor, Swallowing disorders clinic

King Khalid University Hospital

King Saud University, Riyadh, Saudi Arabia.

http://faculty.ksu.edu.sa/mfarahat/default.aspx

Mohamed Farahat Ibrahim, MD, PhD

Benign Vocal Fold Lesions II

Mohamed Farahat Ibrahim, MD, PhD

‘The Scream, 1893’Edvard Munch

Mohamed Farahat Ibrahim, MD, PhD

Introduction

Mohamed Farahat Ibrahim, MD, PhD

Definition

Benign, non-neoplastic, non-inflammatory, traumatic lesionsof the vocal folds.

Kotby, M.N.; Ghali, A.F. and Barakah, M. (1980): Recategorization of non-malignantorganic vocal fold changes in dysphonia. The proceedings of the 18th congress of theInternational Association of Logopedics and Phoniatrics (IALP), Washington, I, 525.

Mohamed Farahat Ibrahim, MD, PhD

Nature and Nomenclature

1- Chronic laryngitis (Jackson, 1941; Ellis, 1952 and Salmon, 1979).

2- Benign lesions of the vocal folds (Holinger and Johnston, 1951; Stewart, 1957 ; Dikkers, 1994).

3- Irritants induced lesions (Myerson, 1950; Fritzell and Hertegard, 1986).

4- Traumatic vocal lesions Arnold, 1962; (Damste and Lerman, 1975; Kleinsasser, 1968)

5- Minimal associated pathological lesions (Kotby et al, 1980, 1986, 1995; Mossallam et al, 1986).

Mohamed Farahat Ibrahim, MD, PhD

1- Threatening life !

2- Causing pain !

3- Loss of function:

The main impact is affection of the optimal use of voice in communication

Dysphonia !

The impact of benign lesions of the vocal folds on health

Mohamed Farahat Ibrahim, MD, PhD

Kotby et al. (1980) N=41

Kotby et al. (1983) N=102

Mosallam et al. (1983) N=47

Mosallam et al. (1986) N=95

Kotby et al. (1988) N=30

Kotby and Orabi, 1995

N=26

Polyp 12 39 44 19 11

Nodules 4 8 10 11 7

Cyst 12 19 19 5

Reinke’s edema

10 15 3

Contact granuloma

3 7

Relative incidence of MAPLs (Benign vocal folds lesions)

Mohamed Farahat Ibrahim, MD, PhD

The lesions

Mohamed Farahat Ibrahim, MD, PhD

Reinke’s edema of the vocal fold

A- General profile:-1- Relative incidence: 17.4 – 20 % of benign lesions of the

V.F. [MAPLs]2- Type of patient: age: 4th – 6th decade

sex: male < female3- Predisposing factors: smoking, voice misuse/abuse4- Types/Degrees: partial, full length, cushion, extreme

ballooning

Mohamed Farahat Ibrahim, MD, PhD

Reinke’s edema of the vocal fold Cont.

5- Laterality: bilateral 62-85%6- Site: usually full length of the vocal fold7- Shape: diffuse spindle-shaped translucent

swelling of both V.F.s along their entire length with intact epithelium.

8- Presentation: Dysphonia, low pitch voice in 97% of cases

Mohamed Farahat Ibrahim, MD, PhD

Reinke’s edema of the vocal fold Cont.

B- PathophysiologyPredisposing factors

Ischemia

Vascular endothelial growth factor

Greater subepithelialvascularization and capillary

permeability in Reinke's space

Mohamed Farahat Ibrahim, MD, PhD

Reinke’s edema of the vocal fold Cont.

C- Grading:

Grade I: contact - anterior third of vocal folds.

Grade II: contact - anterior two thirds of vocal folds.

Grade III: contact extended to the posterior third of

vocal folds.

Mohamed Farahat Ibrahim, MD, PhD

D- Gross Pathology

1- Whole organ section

2- Endoscopic picture

3- Histopathology

Mohamed Farahat Ibrahim, MD, PhD

Hirano M. Phonosurgery-basic and clinical investigations.Official Report, 75th Annual Convention of the ORL SocJapan. Otologica (Fukuoka) 1975;21 (suppl 1):239-442 (inJapanese)

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema

Respiration Phonation

Stroboscopy?

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema:Bilateral Reinke’s Edema

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema:Bilateral Reinke’s Edema

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema:Bilateral Reinke’s Edema

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Bilateral Reinke’s Edema:Bilateral Reinke’s Edema

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Respiration Phonation

Right-sided Reinke’s Edema:Unilateral Reinke’s Edema

Mohamed Farahat Ibrahim, MD, PhD

Right-sided Reinke’s Edema:Unilateral Reinke’s Edema

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Management of Reinke’s edema

• Phonosurgery (MLS):

When?

Why?!

Mohamed Farahat Ibrahim, MD, PhD

Oscar Kleinsasser

(1929-2001)

Oscar Kleinsasser (1929-2001)

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Polypoid degeneration of the vocal fold

General profile:-

Polypoid degeneration representsa long standing Reinke’s edemawith increased fibrous elements inthe stroma (thicker septa) anddecreased edema spaces.

Mohamed Farahat Ibrahim, MD, PhD

Polypoid degeneration

Mohamed Farahat Ibrahim, MD, PhD

Polypoid degeneration

Respiration Phonation

Respiration Phonation

Mohamed Farahat Ibrahim, MD, PhD

Irregular mucosa

Less edematous, more fibrous stroma with hyaline degeneration

Mohamed Farahat Ibrahim, MD, PhD

Contact granuloma of the vocal fold

A- General profile:-

1- Relative incidence: 6.2 % of benign lesions of the V.F

2- Type of patient: age: 4th – 6th decade

sex: male [energetic – competitive – hypertense]

3- Predisposing factors: voice abuse/misuse – tension!

4- Types: hyperfunctional, hyperacidity, intubation

Mohamed Farahat Ibrahim, MD, PhD

5- Laterality: unilateral or bilateral

6- Site: over the vocal process (vocal process granuloma)

7- Shape: one lesion may cause a dimple in the

contralateral one with no ulceration

8- Presentation: Phonasthenia, no dysphonia

Contact granuloma of the vocal fold

Mohamed Farahat Ibrahim, MD, PhD

Contact granuloma of the vocal fold

B- Pathogenesis:

Mechanical (hammer and anvil)

Irritation (LPRD)

Mohamed Farahat Ibrahim, MD, PhD

Left-sided Contact Granuloma:

Respiration Phonation

Stroboscopy?

Left vocal process granuloma

Mohamed Farahat Ibrahim, MD, PhD

Respiration Phonation

Right vocal process granuloma

Mohamed Farahat Ibrahim, MD, PhD

Bilateral vocal process granulomas

Mohamed Farahat Ibrahim, MD, PhD

DENSE connective tissue core with abundant collagenous fibers and fibroblasts

Mohamed Farahat Ibrahim, MD, PhD

Management

• Behavioral readjustment therapy (Accent Method

“up to 60 sessions”)

• Anti-LPR advices and management

• Combined

Mohamed Farahat Ibrahim, MD, PhD

Svend Smith

(1907 - 1985)

Mohamed Farahat Ibrahim, MD, PhD

Pre-voice therapy Post-voice therapy22 sessions

Post-voice therapy60 sessions

Contact granuloma

Mohamed Farahat Ibrahim, MD, PhD

Initial assessment After 10 sessions of voice therapy

Contact granuloma

Mohamed Farahat Ibrahim, MD, PhD

Contact Granuloma

Pre-voice therapy Post-voice therapy

Mohamed Farahat Ibrahim, MD, PhD

Summary Type of lesion Relative

incidenceAge Sex Laterality Dysphonia Phonaesthenia

Polyp 43.88% 3-5 decade Both sexes

Unilateral + +

Nodules 16.56% 3-4 decade Females Bilateral ++ +

Cyst 9.62% 3-5 decade Males and females

Unilateral ++ +

Reinke’s edema

19.02% 4-5 decade Females (smoker)

Bilateral ++

Polypoid degeneration

! Females Bilateral ++

Contact granuloma

6.2% 4-5 decade Males Unilateral and bilateral

++

Mohamed Farahat Ibrahim, MD, PhD

Why grouped together?

Commonality:

- Predisposing factors.

- Size of lesion.

- Nature: traumatic, non-neoplastic, non-inflammatory, benign.

- Presentation.

- Management.

- Prognosis.

Mohamed Farahat Ibrahim, MD, PhD

Sulcus vocalis

• Definitions and terminologies:

1- Sulcus vocalis: furrowing Sato and Hirano (1998)

2- Sulcus vocalis: invagination, sulcus vergature:

atrophic changes Bouchayer and Cornut (1992)

Mohamed Farahat Ibrahim, MD, PhD

Sulcus vocalis

• Types:Sulcus vocalis Type I Type II Type III

Other terms

Dysphonia

Videostroboscopy

Superficial lamina propria

Vocal ligament

Vocalis muscle

Pseudosulcus

Variable to normal

Variable to normal

Intact

Normal

Possibly atrophic

Sulcus vergeture

Moderate

Focal stiffness

Involved/lost

Normal or attached

Normal

Ruptured cyst

Severe

Stiff, no wave

Involved/lost

Invaded/lost

Involved +/-

Ford, C.N. (1999): Advances and refinements in phonosurgery.Laryngoscope, 109, 1895-1900.

Mohamed Farahat Ibrahim, MD, PhD

Etiology of Sulcus vocalis

• UNCERTAIN

- Congenital: [Hirano (1975), Bouchayer et al. (1985), Pontes and Behlau, (1993)]

* Faulty develpement of fourth and sixth branchial arches,ruptured epidermoid cyst

* Others

- Acquired: [Van Caneghem (1928, as cited from Ford et al., 1996), Bastian (1993), Nakayama

et al., (1994), Ford et al., (1996)]

* Aging, trauma, inflammatory, associated with cancer, voice abuse and misuse

Mohamed Farahat Ibrahim, MD, PhD

Sulcus vocalis

• Epidemiology:

- Age of onset of symptoms:

Adulthood - Childhood

- Gender:

Males > Females

Mohamed Farahat Ibrahim, MD, PhD

Sulcus vocalis

• Clinical picture: (presenting symptoms)

1- Dysphonia:

Breahty

2- Phonasthenic symptoms

3- Quality of voice:

High pitch, low intensity, poor vocal range,register breaks, and diplophonia

Mohamed Farahat Ibrahim, MD, PhD

Respiration Phonation

Bilateral Sulcus vocalis

Mohamed Farahat Ibrahim, MD, PhD

Management

• Voice therapy !!

- Elimination of poor compensatory movements

- limited aid to vocal quality

• Surgery:

1- Slicing technique

2- Sulsectomy [cold, laser]

3- Injection: Teflon, fat, hyalouronic acid

Mohamed Farahat Ibrahim, MD, PhD

Mohamed Farahat Ibrahim, MD, PhD

Thank You