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One of the common complaints that people visit an Otolaryngologist for, is voice change or hoarseness of voice. When we normally speak, the air from the lungs is transmitted to the mouth via the vocal cords which vibrate to produce the voice. Any disparity in the vocal cords can hence cause change in voice. There are a variety of causes for the same, from simple inflammatory conditions like laryngitis (infection of the larynx or the voice box) to benign and malignant conditions of the vocal cord.
Vocal polyp is one such benign condition, which arises from the free end of the vocal cord, usually unilateral but can sometimes affect both cords. They are more commonly seen in smokers, and between the ages of 30 and 50 years.
ETIOLOGY
Phonotrauma, i.e., people who misuse their voice, whether by talking too much or too loudly, are more likely to experience structural abnormalities in their vocal folds due to mechanical trauma.1 Some are heralded by a sudden onset of hoarseness due to yelling or shouting. Other causative and risk factors include cigarette smoking, pharyngo-laryngeal reflux, recurrent laryngitis and allergy.
CLINICAL PRESENTATION
Alteration in voice, varying in duration, is the chief presenting symptom, associated with any reflux complaints or with history of cigarette smoking.
DIAGNOSIS
Videolaryngoscopy is used to visualise the laryx, using a 70 or 90 degree endoscope. Vocal polyps are usually unilateral, with or without hemorrhagic appearance. Benign vocal polyps can be exophytic, sessile or pedunculated. Sometimes, a sulcus (gap between the cords) maybe found on the opposite side. Videolaryngostroboscopy is an investigation that helps reveal the mucosal wave pattern of the vocal cords. Due to the effect of vocal polyp mass, there would be decrease in amplitude and mucosal wave pattern, as well as phase delay2.
A histopathological examination is the only way to confirm its benign character and rule out any malignancy.
TREATMENT
Polyps can shrink spontaneously or sometimes even be coughed out. Conservative treatment is typically administered in conjunction with speech therapy for coping mechanisms to lessen the symptoms and preventive advice, although it is unlikely to result in the resolution of the polyp3. It vitally includes cessation of risk factors (smoking), and anti-reflux medication.
Most polyps require surgical removal under general anaesthesia, and various techniques have been described for the same. The goal of the surgery is to excise the polyp producing a smooth edged vocal cord that closes completely and vibrates normally producing normal voice.
Few of the many techniques done for the same include:
Microlaryngeal surgery (MLS)- The excision of the polyp can be done either using cold steel instruments or carbon-di-oxide laser.
Endoscopic laser excision - the effectiveness of this technique in angiomatous polyps is due to their photocoagulative property, primarily in small lesions4.
Voice therapy and rehabilitation is adviced both pre- and post- operatively. It basically involves tips and techniques to prevent vocal abuse; breathing exercises; exercises for neck and shoulder muscles. With appropriate surgical excision and vocal therapy, vocal polyps generally have a good outcome given its benign nature.
REFERENCES:
Bastian R W, Thomas J P. Do talkativeness and vocal loudness correlate with laryngeal pathology? A study of the vocal overdoer/underdoer continuum J Voice 20163005557–562.Doi: 10.1016/j.jvoice.2015.06.012
Yamauchi A, Yokonishi H, Imagawa Het al. Quantification of vocal fold vibration in various laryngeal disorders using high-speed digital imaging J Voice 20163002205–214.Doi: 10.1016/j.jvoice.2015.04.016
Jeong WJ, Lee SJ, Lee WY, et al. Conservative management for vocal fold polyps. JAMA Otolaryngol Head Neck Surg 2014; 140(5): 448-52
Ivey C M, Woo P, Altman K W, Shapshay S M.Office pulsed dye laser treatment for benign laryngeal vascular polyps: a preliminary study Ann Otol Rhinol Laryngol 200811705353–358.Doi: 10.1177/000348940811700505