Benign Lesions of Vocal cords

Benign vocal lesions are non-malignant growths of abnormal tissue on the vocal cords. Several factors can be responsible for the development of benign vocal lesions such as vocal abuse, overuse or misuse of the voice, chronic infections of the upper airway, allergy, smoking and gastroesophageal reflux. Frequent coughing and throat-clearing also contribute to mucosal irritation which worsens the voice.

Excessive mechanical trauma and stress in the mid-membranous area of the vocal cord lead on to wound formation. Subsequently, remodelling of the superficial layer of the lamina propria and, to a lesser extent, epithelium results in the formation of vocal cord nodules, polyps, and cysts.

The common benign lesions of the vocal cord are the singer’s nodule, polyps, papilloma, polypoidal degeneration and cysts. While others are sulcus vocalis, mucosal bridge, intracordal cysts, vocal cord varices and anterior webs. Benign vocal lesions are predominantly seen in males (70%) over females (30%).

Voice disorders cause communication handicaps which leads to psychosocial problems and impaired quality of life.

The patient-based, voice-specific outcome measures can potentially provide more information than the biological and physiological variables that are associated with voice production, functional abilities and quality of life.

The significance of benign lesions of the larynx lies in the importance of its function in speech and the contribution of the voice to one’s identity. Since these lesions are not malignant, they are usually not life-threatening.

What are the symptoms?

Patients present with complaints of hoarseness of voice, of variable duration. Other associated symptoms include throat pain, vocal fatigue, throat irritation and respiratory difficulty.

How is it diagnosed?

IDL:

A routine IDL(Indirect Laryngoscopic examination) at OPD can be performed to visualise the vocal lesions.

Clinical neck examination: To look for Metastatic lymph nodes.

Video-laryngoscopy:

Endoscopic visualisation of Vocal cords using a 90o endoscope can be done at the Out-patient department (OPD)

VLS :

Video-laryngo-stroboscopy (VLS) currently is considered as the most important, popular and clinically feasible imaging method for vocal fold visualization and evaluation of patients with voice disorders.

DL Scopy:

Direct laryngoscopy (DL) & Biopsy is performed under General anaesthesia, the biopsy specimen is sent for Histopathological examination (HPE).

CECT neck :

Patient will be subjected to Contrast Enhanced Computed Tomography from skull base to mediastinum to exclude malignancy and to see the extent of the lesion.

HPE :

A clinical diagnosis of nodules, polyps or cysts does not rule out a malignancy unless the lesion resolves with treatment or is reported benign on histopathological examination.

Medical management :

Treatment options vary according to the patient’s degree of voice constraint and vocal needs. In many cases, voice therapy and better vocal hygiene are helpful in patients with benign lesions. However, voice therapy and vocal hygiene may benefit the symptoms but may not completely reverse the irreversible changes that might have occurred in the vocal cords. Such cases usually require phono-microsurgery to remove the pathology.

Surgical management :

Microlaryngeal surgery(MLS):

MLS is used to manage most cases of benign lesions of the vocal fold for the restoration of voice quality or diagnosis of the disease. MLS aims to improve the vibratory characteristics of the layered microvascular structure of the vocal fold. Microlaryngeal surgery is an effective way to provide speech improvement in patients with benign lesions of the vocal cord.

Surgery is done, to excise the lesion on the vocal fold, it is performed under general anaesthesia using a suspension video laryngoscope. The general surgical sequence is general anaesthesia is given, and then the patient is placed in a direct laryngoscopy position (Boyce position). The laryngoscope will be placed and stabilised so that the glottis clearly visualised. The camera is fixed on a video laryngoscope. The lesion is excised with cold steel conventional dissection i.e., truncation surgery.

CO2 laser excision :

CO2 Laser is a relatively recent addition to laryngeal surgery. Since its invention, Laser use and applications have expanded rapidly. CO2 Laser is used for excision of the vocal cord lesions. It has minimal complications & better voice outcomes have been reported in the treatment of vocal fold lesions with lasers citing the accuracy, minimal tissue manipulation needs and better field of view.

In cases with stridor, Tracheostomy is required to secure the airway. Speech therapy following micro-laryngeal surgery forms an essential part of treatment, to avoid recurrence.

Speech therapy :

Speech assessment is done following 6 weeks of surgery and speech therapy is required in a few cases.

Outcome:

The outcome of surgery & prognosis of the disease is good since it is a benign condition, and the chances of recurrence are less.