Mohamed Farahat Ibrahim, MD, PhD · Mohamed Farahat Ibrahim, MD, PhD. Consultant, Assistant Professor. Phoniatrics (Communication and Swallowing Disorders) Deputy chairman, Communication

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

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

Benign Vocal Fold Lesions II


‘The Scream, 1893’Edvard Munch


Introduction


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.


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).


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


Kotby et al. (1980) N=41


Mosallam et al. (1983) N=47

Mosallam et al. (1986) N=95


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)


The lesions


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


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



B- PathophysiologyPredisposing factors

Ischemia

Vascular endothelial growth factor

Greater subepithelialvascularization and capillary

permeability in Reinke's space



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.


D- Gross Pathology

1- Whole organ section

2- Endoscopic picture

3- Histopathology


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)


Bilateral Reinke’s Edema

Respiration Phonation

Stroboscopy?


Bilateral Reinke’s Edema


Bilateral Reinke’s Edema:Bilateral Reinke’s Edema













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


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





Management of Reinke’s edema

• Phonosurgery (MLS):

When?

Why?!


Oscar Kleinsasser

(1929-2001)

Oscar Kleinsasser (1929-2001)






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.


Polypoid degeneration






Irregular mucosa

Less edematous, more fibrous stroma with hyaline degeneration


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


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




B- Pathogenesis:

Mechanical (hammer and anvil)

Irritation (LPRD)


Left-sided Contact Granuloma:


Stroboscopy?

Left vocal process granuloma



Right vocal process granuloma


Bilateral vocal process granulomas


DENSE connective tissue core with abundant collagenous fibers and fibroblasts


Management

• Behavioral readjustment therapy (Accent Method

“up to 60 sessions”)

• Anti-LPR advices and management

• Combined


Svend Smith

(1907 - 1985)


Pre-voice therapy Post-voice therapy22 sessions

Post-voice therapy60 sessions

Contact granuloma


Initial assessment After 10 sessions of voice therapy

Contact granuloma


Contact Granuloma

Pre-voice therapy Post-voice therapy


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 ++


! Females Bilateral ++

Contact granuloma

6.2% 4-5 decade Males Unilateral and bilateral

++


Why grouped together?

Commonality:

- Predisposing factors.

- Size of lesion.

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

- Presentation.

- Management.

- Prognosis.


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)


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.


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


Sulcus vocalis

• Epidemiology:

- Age of onset of symptoms:

Adulthood - Childhood

- Gender:

Males > Females


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



Bilateral Sulcus vocalis


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



Thank You

Documents

Mohamed Farahat Ibrahim, MD, PhD · Mohamed Farahat Ibrahim, MD, PhD. Consultant, Assistant Professor. Phoniatrics (Communication and Swallowing Disorders) Deputy chairman, Communication