Case histories: Vocal polyps

• History
• Vocal Capability Testing
• Laryngeal exam
• Treatment
  • Medical
  • Behavioral
  • Surgical

History

Complaints

• 6th Decade
• female
• Six years progressive onset of voice problems
• Initially affected only singing and now affects speaking voice
• vocal fatigue
• steroids help temporarily but taking more and more frequently
• Evaluation and treatment for inhalent allergies - no help

Character

• talkativeness scale: 7
• loudness: 6

Vocal capabilities

• Reading voice
  • coarse or gravelly sounding
• Pitch range
  • Anchor pitch (F0) - A3
  • Low pitch - F3
  • High pitch - C6
  • pianissimo mucosal ceiling (onset delays and breathiness) - G4
  • 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 - note high pitch photo - front and back of vocal fold are out of phase
  • mucosal ceiling may be overcome with higher volume driving the vocal folds.
• The loss of high soft singing is the most characteristic feature of this disorder. Even huge voices should be able to make soft sounds.

Stroboscopic Examination of the Polyps

• broad based swelling along the left vibratory margin
• has a capillary within it
• no hemorrhage within it
• clear and translucent
• slight elevation on the opposite side

Treatment

Medical

Behavioral

Physician treatment information
Patient treatment information

Behavioral modification is the initial treatment of these mucosal lesions and is likely a lifelong treatment for this patient. It is seldom someone can change their personality but it is possible for someone to manage their behavior. She is a severely impaired singer, yet it is usually not the singing that is the problem. More often it is the amount of talking that goes on daily. She rates herself a 7 and 6 on the talkativeness and loudness scales.

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, though the capillary ectasia on the vibratory margin makes this a difficult managment problem since that will likely swell with moderate usage or rupture intermittantly.

Speech therapy can be very helpful in controlling the amount and style of vocal use.

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, this polyp can be 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.

Laser, cautery or stripping of the vessel on the vocal fold margin may be successfully used to remove this ectasia.