Symptom Complexes Index > Benign Mucosal Disease

• Etiology
• Diagnosis
  • History
  • Vocal Capability Testing
  • Laryngeal exam
• Treatment
  • Medical
  • Behavioral
  • Surgical
• Patient information
• Example cases
  • Smokers polyps
  • polyp
  • ectasia

Etiology

This symptom complex results from an injury to the surface lining of the vocal fold. The surface lining of the vocal fold reacts to an injury by a change in the surface architecture (involving the epithelium, the lamina propria or the vasculature). Because the surface lining of the vocal fold is the sound generator, a change in the surface results in a change in the quality of the voice.

Mucosal injury is typically related to abuse of the voice. The abuse may be from a sudden overuse or from chronic behavior. A sudden onset injury may occur from yelling at a sporting event one night and would be evident from a immediate hoarseness afterwards. In other people a behavior pattern of prolific talkativeness leads to a chronic injury affecting the mucosa.

The injury goes through an evolution with time that depends on whether further injury is induced before resolution of the initial problem. The initial injury often begins as a swelling, most commonly in the mid portion of the membranous vocal fold. It results from accumulation of fluid in the interstitial space, either serous or blood or from thickening of the mucosa from collision, shearing and impact injury. With voice rest, either injury may resolve. With continued injury, a callous, cyst or capillary malformation may form.

A disordered voice may still be considered a normal voice by the patient. Mucosal injury alters the voice from its original firm, clear, warm quality and decreases the efficiency of phonation. While this represents a voice disorder, at least from the physicians perspective, many people are quite accepting of a disordered voice. Indeed, the person and the people who know them come to view their voice as their distinct vocal signature. It becomes familiar and normal. Many popular music singers could be used as examples of mucosal injury where their voice is so familiar that correcting the mucosal injury might significantly alter their public image.

While anyone may have an acute injury, chronic injuries are the provenance of the Vocal Overdoer. Thus, in the taking of the history, if the problem has been present for more than a few days, first determine if the patient is a Vocal Overdoer.

Diagnosis

History

Typical complaints

• daily variability of voice
• reduced endurance
• huskiness
• tired feeling
• increased effort
• Singers
  • less joy to sing
  • need more support
  • need more mental concentration

Character of an overdoer

• talk until they are hoarse
• vocal invincibility
• highly extroverted
• comfortable speaking to strangers
• histrionic
• their batteries are charged by talking
• think quiet people are missing something in life
• talkativeness scale: 6 or 7
• talkativeness may be as low as a 5 and still lead to problems if external demands such as occupation force the person to behave like a 7

The patient with a mucosal disorder will complain of daily variability in the use of their voice, huskiness or tiredness. Singers often attribute each symptom as it comes along to technique problems, thus delaying for some time their presentation to the laryngologist.

Mucosal injuries are almost certainly limited to overdoers. Exceptions would include cysts and ruptured cysts (sulci). Elements of the above characteristics should direct the next two portions of the exam. They will aid you in looking long and hard enough to find nearly hidden vocal cysts and sulci when the expected mucosal problem does not jump right out at you.

In generalizing about vocal overdoers, their characteristics do not carry the weight of judgement. It is not bad to be the life of the party. In fact, these people are the social engines that keep life interesting. They are very necessary in the overall makeup of society. Imagine a party of social introverts. So while these characteristics are not bad, they are vocally expensive.

Just the opposite of a vocal underdoer (see muscle deconditioning) a 6 or 7 talker will complain if they are placed in a job requiring silence. If they meet a 1 or 2 in a conversation they will feel that that person is cold, aloof and uncaring; not just untalkative!

Vocal capabilities

• Reading voice
  • Quite often this will sound clear and normal. The anchor pitch or average fundamental frequency of speaking is generally close to the bottom of the vocal range. At low pitches the vocal folds are shortened and mass lesions, while they would drop the pitch slightly (from the patients premorbid anchor pitch), they would not interfere with the mucosal wave until the vocal fold is stiffened at higher pitches.
• Pitch range
  • Abnormalities will be present at upper end of pitch range because mucosal disorders alter the stiffness of the fold and high pitch adds physiologic stiffness. As the vocal fold becomes stiffer it fails to vibrate.
  • pianissimo mucosal ceiling (loss of vocal fold entrainment @ pianissimo high pitch) lower than muscular ceiling.
  • staccato pianissimo difficult near ceiling because of onset delays.
  • short segment vibration due to mass effect of lesion effectively segmenting the fold into a short segment.
  • diplophonia - caused when two vocal folds or two segments of a vocal fold have a different length, mass or stiffness and thus vibrate at two or more different frequencies.
  • mucosal ceiling may be overcome with higher volume driving the vocal folds.
  • Listen to video example for examples of some of the above.
• The loss of high soft singing is the most characteristic feature of this disorder. Even huge voices should be able to make soft sounds.

Laryngeal Exam

• nodule
  • elevation in central portion of vocal fold.
  • Example photos
  • Discrete and a narrow base compared with it’s height
  • whitish and not translucent - think callus
  • It should move with the membranous edge of the vocal fold.
  • They are more common in women.
  • In men there is a significant chance that an apparent nodule is a cyst.
• polyp
  • Case history
  • video example of pitch changes
  • broad based swelling along the vibratory margin
  • may have a capillary within it
  • may have hemorrhage within it
  • may be clear and translucent
  • rapid inspiration will often draw in the polyp making its size more apparent.
• cyst
  • a white sphere may be visible beneath the surface
  • If the white area is oval shaped, consider an open cyst
  • cysts may move separately from the mucosal edge causing a covering and uncovering of the cyst during stroboscopy if it is inferior to the vibratory margin.
  • A nodule, will be on the vibratory edge
• sulcus
  • along the membranous vocal fold inspiratory phonation may open the lips of a sulcus making it more visible
• granuloma
  • located over the arytenoid
  • may be bilateral
  • associated with intubation trauma
  • seems to be associated with male, 50’s, business type, vocal fry type voice
  • immature granulomas tend to be broad based, pink
  • mature granulomas tend to be pale/white, pedunculated
  • granulomas also associated with surgical trauma in other locations of the larynx
  • granulomas may be associated with Teflon injection
• capillary ectasia
  • Case history
  • dilated capillaries
  • vascular lakes
  • capillaries are normally not visible along the vibratory margin so a vessel in a polyp is an ectasia
  • often run in a tortuous pattern or cross the vocal fold rather than running the length of the fold
• hemorrhage
  • acute-dark red
  • may fill entire membranous fold or be localized to a polyp
  • If within a polyp, a repeat examination of the polyp in two weeks may reveal a capillary ectasia.
  • chronic or more than a week old - yellow discoloration, diffuse
• smokers polyp
  • Case history
  • polyp associated with smoking
  • exam will be similar to polyps
  • will typically not resolve with discontinuation of smoking but will stabilize
  • both upper and lower end of pitch range are lower than expected
• leukoplakia
  • white lesion typically on the true vocal folds
  • causes stiffness
  • may be anywhere on the larynx

If the history and vocal capabilities point to a mucosal lesion, look for it. Even very small lesions can be significant, particularly if the patient is a singer and needs their high range for soft singing.

Treatment

Medical

Reflux may be a contributing factor and a two week trial of medication, dietary and life-style adjustments and perhaps bed positioning may be appropriate to determine reflux’s contribution.

Granulomas should be managed medically as they nearly always spontaneously decapitate in 4 to 6 months. They tend to recur. They seem to be most common in middle aged businessmen who speak at the very bottom of their vocal range.

Smokers polyps will stop enlarging if the patient stops smoking and behavioral management is initiated. Surgery is required for any reduction in size.

Behavioral

Behavioral modification is the primary treatment of mucosal lesions and is likely a lifelong treatment of the problem. It is seldom someone can change their personality but it is possible for someone to manage their behavior. If they are a singer, it is usually not the singing that is the problem. More often it is the amount of talking that goes on daily. People who rate themselves a 6 or a 7 on the talkativeness scale are busy people. They need to take a look at their life, perhaps in conjunction with a speech therapist, to decide where they can rest their voices.

Many times managing their talkativeness will reduce a vocal fold swelling to an acceptable size such that the voice becomes dependable and acceptable to the patient.

Hemorrhage can generally be managed behaviorally, particularly if it was from a one time indiscretion. If capillary lakes or ectasias seem to be a source of recurrent hemorrhage then surgical management can be considered.

Surgical

After behavioral management surgery would be indicated if the patient desires further improvement. Surgery is directed at removing only the mucosal lesion and preserving as much of the intermediate and deep layers of the vocal fold as possible.

With an appropriately delicate touch, nodules are removed most successfully. Patients experience a substantial improvement. In fact, in singers, who may have had the swellings for many years, they may feel the improvement is greater than 100%, suggesting that they had been dealing with vocal fold swellings even longer than they imagined.

As the lesion gets deeper into the layers of the vocal fold such as cysts and sulci, improvement is more limited. If deep lesions are present bilaterally, one needs to be extremely prudent before plunging any steel into the second fold. Waiting to see if stiffness develops from a deep dissection on one side may be the better part of valor.

Leukoplakia can be removed with the surface mucosa leaving the lamina propria intact.