Учебники / Voice Disorders and Their Management Freeman 2000

Histological examination shows that the predominant changes are in the stratified squamous layer of the vocal fold cover, which is always thickened and which shows many epithelial pegs penetrating deeply into the superficial layer of the lamina propria (Reinke’s space). This latter usually presents as hyaline degeneration. There are other lesions that may resemble this typical nodule.

The serous pseudo-cyst is a well-circumscribed lesion whose macroscopic appearance is that of a translucent, thin-walled cyst containing serum that runs out as soon as the cyst is incised. Histological examination, however, shows that this lesion is not a true cyst as there is no cyst wall. These anomalies are predominantly situated within the superficial layer of the lamina propria and essentially consist of an area of gross oedema over which the epithelium of the vocal-fold cover is thinned and atrophic.

Fusiform thickening of the mucosa differs from a nodule in both its extent and its elongated shape, and in the degree of associated inflammatory changes. It is like the typical nodule in that the thickening is usually bilateral. Histological sections show that the epithelium of the cover is thickened and hyperplastic, while the superficial layer of lamina propria is diffusely oedematous.

Nodules are most commonly seen in adult females. They are unusual in adult males and children, particularly boys.

Indications for surgery. The principal factors in deciding whether surgery is appropriate or not are as follows:

•The size and, most importantly, the age of the lesion (whether the surface is keratinized or not).

•Alteration of stroboscopic vibration (the ‘hour-glass’ glottic chink is more clearly visible under stroboscopic light).

•The objective and subjective importance of the voice problem to the patient. With singers, for example, one may occasionally suggest operating on a very small nodule that produces significant problems in singing despite the speaking voice remaining virtually unaffected.

•Failure of medical treatment or speech therapy.

Preferably, one should always begin treatment with speech therapy prior to any surgical procedure.

The operation. Avulsion of tissue by tearing it off the fold with cupped or plain forceps is best avoided as it may remove unnecessarily large fragments of mucosa. A much better technique is to remove the lesion as precisely as possible by gripping it with fenestrated heart-shaped tissueholding forceps, and then using microscissors to divide the mucosa along-

side the edge of the forceps in order to conserve as much healthy tissue as possible. This method minimizes the risk of producing a secondary notch when the mucosa heals. Two nodules may be removed at the same time, even in older children over the age of eight, so long as a zone of intact mucous membrane is preserved around the anterior commissure. This prevents the formation of adhesions by subsequent scarring.

In 22% of cases of nodules, a congenital mucosal micro-web may be found at the anterior commissure. This may be divided with an arrowhead knife if the web is of significant size.

Finally, after excision of the nodule, if associated inflammatory changes are present, cortisone is injected into the fold and any remaining dilated capillaries on the upper surfaces of the folds are sealed with diathermy.

Postoperative follow-up and results. The immediate postoperative results are generally excellent. At the end of the eight-day period of complete voice rest, the folds have resumed their normal shape with a good, straight, free border. Stroboscopy shows that the mucosa is vibrating well, albeit with slightly diminished amplitude. At this stage it also shows a persistent small longitudinal notch. Initially the voice is usually slightly higher in pitch, with a clearer though still slightly veiled quality. Voicing is still somewhat unstable and weak.

Postoperative speech therapy produces rapid stabilization of the results and normal voicing generally returns within a few weeks. During this period there is marked improvement in the stroboscopic appearance of the vibration and glottal closure. Nonetheless, speech therapy should be continued over several months in order to stabilize modified vocal habits and prevent recurrence.

Long-term results are on the whole excellent, and very much depend on the quality of the speech therapy. Recurrence of a nodule is rare when speech therapy has been regularly attended (3% of revision procedures in our personal series).

Capillary telangiectases

These present as small, dilated vessels situated on the superior aspect of the vocal folds. These vessels normally travel in a direction parallel to the free border but frequently terminate in angiomatous clusters of variable size; this appearance is often referred to as ‘vascular corditis’. The term ‘varices of the vocal cords’ is sometimes used (incorrectly) and should be avoided.

Indications for surgery. The most important aspect of the diagnosis at indirect laryngoscopy is the elimination of intrafold lesions of which capillary telangiectases are simply the superficial manifestation. Stroboscopy may make one suspect the presence of cysts or a sulcus vocalis, both of which are associated with these vascular dilatations.

Capillary telangiectases are also frequently associated with nodular lesions. In this instance, vocal problems and indications for surgery are related more to the nodule than to the telangiectasis itself.

There are occasions, however, when a capillary telangiectasis alone may be solely responsible for all the laryngeal symptoms. Generally these lesions do not hamper stroboscopic vibration, nor do they produce much modification of vocal timbre. Patients mostly complain of vocal fatigue. Without doubt this is due to secondary vasomotor phenomena which appear after prolonged voice use. It is therefore the functional disability experienced by the patients (especially singers), rather than any visible change in vibration patterns, that suggests a surgical solution.

The operation. A series of point coagulations are made along the length of the vessel with a needle-point monopolar diathermy electrode. It is always wise to check that palpation of the fold does not show any localized areas of induration, which would make one suspect the presence of an underlying intrafold lesion. Where there is any uncertainty, one can perform an exploratory cordotomy.

As before, hydrocortisone suspension is injected into the fold at the end of the procedure.

Postoperative follow-up and results. Postoperative follow-up is straightforward. It is important to remember that cauterized vessels take many weeks to disappear completely. The final result is usually good from both the anatomical and vocal point of view, as long as the patient has preand postoperative speech therapy. Even so, from time to time there are patients who will relapse.

Polyps

The vocal fold polyp is an inflammatory laryngeal pseudotumour seen almost exclusively in males, and most common in the age group between 25 and 50 years. Vocal strain is a recognized factor in the production of polyps.

Histologically a polyp is composed of fibrinous exudates separated by proliferations of vascular clefts. They are described as being oedematous or haemangiomatous, depending on the predominant component.

Polyps nearly always arise anteriorly near the free border of the vocal fold. They may be sessible or pedunculated, and vary in size. Contralateral keratotic lesions with notching of the mucosal cover of the fold arise when the polyp has been present for a long time.

Indications for surgery. All polyps warrant microsurgical removal, as spontaneous regression is the exception rather than the rule. In addition, it is worth remembering that 15% of polyps represent a complication of an intrafold lesion – cyst or sulcus – which is often extremely difficult to demonstrate at preoperative assessment.

The operation. We are firmly of the opinion that polyps should not be removed at indirect laryngoscopy, regardless of the ability of the surgeon. Operating under direct vision using the microscope diminishes the likelihood of incomplete removal with subsequent recurrence, and more importantly, avoids production of a scarred notch where an over-enthusi- astic avulsion has ‘bitten’ into the vocal ligament.

Resection of a polyp is simple and is performed by excising it at its attachment to the vocal fold. Because polyps are most commonly sessile, the excision will tend to produce a large raw area which may be initially rather haemorrhagic and thus may require the application of swabs of vasoconstrictor. However, when secondary healing of the mucosa has taken place, this area fills out without leaving a depression.

Postoperative follow-up and results. After excision of a polyp, the anatomical and vocal recovery is normally extremely rapid. Where the base of the polyp has been particularly broad and deeply implanted within the superficial layer of the lamina propria (Reinke’s space), on stroboscopic examination at the first follow-up, one may periodically see a minimal depression at the site of excision. This always disappears rapidly and perfect anatomical resolution is the rule. The voice is usually changed in a spectacular manner by this simple surgical manoeuvre. Even so, we insist on preand postoperative speech therapy as standard clinical practice, and perhaps because of this we have only ever had a single recurrence.

Reinke oedema

This particular form of chronic laryngitis is principally associated with smoking and vocal abuse. These days females are almost as commonly affected as males. Typically this is a myxoid oedema that develops in the easily distended Reinke’s space, usually on the superior surface of the fold spreading over the free border, thus making it extremely bulky. This process can continue to the point where the oedematous mucosa may obstruct the whole glottic orifice.

The gelatinous quality of the vocal folds in Reinke oedema explains the low-pitched guttural vocal characteristics associated with the condition.

Indications for surgery. Indications for surgery are governed not so much by the anatomical appearance but more by the patient’s vocal requirements. Some moderate pseudomyxomas are well tolerated, particularly by males, and do not necessarily justify surgery.

The operation. The greatest possible care should be taken of the mucosa covering the free border of the vocal fold. Over-enthusiastic resection of mucosa that has been distended by pseudomyxomatous oedema produces perfect anatomical results which may nonetheless be vocally disastrous.

Beginning with a mucosal incision just medial to the ventricle, the pseudomyxoma is dissected off the vocal ligament and aspirated. The mucosa is then laid back on the superior surface of the vocal fold and any excess is removed with microscissors. After an intrafold injection of cortisone the mucosa is kept in place with a biological glue.

Usually both sides are operated on at the same time. An intact zone of mucosa is always left anteriorly. However, if it is difficult to expose the whole glottis properly (which is quite common with this type of lesion) or if the lesion is very bulky, it may be preferable to operate on one fold at a time, leaving four to six months between procedures in order to avoid producing adhesions.

Postoperative outcome and results.The postoperative outcome is excellent. As soon as the period of voice rest is finished the folds no longer appear thickened and are supple on stroboscopic examination. The voice is higher in pitch, clearer and distinctly less rough. This type of minimal surgery avoids too radical (and often inappropriate) modification of vocal characteristics and conserves the ‘vocal personality’ of the patient.

The results should remain stable if the patient has stopped smoking and cooperated fully with the speech therapy programme. If neither of these conditions is met, the Reinke oedema tends to recur.

Mucus retention cyst

These are true cysts found in the submucosa. They are of glandular origin, hence their mucinous contents. The origin of a retention cyst is due to an obstruction of the excretory canal and the resultant accumulation of mucoid secretions within the lumen of the mucus gland. The cyst wall consists of glandular epithelium made up of two layers of cells, an external layer of cuboidal cells, and an internal layer made up of cylindrical ciliated cells lying on a basement membrane. The lumen typically contains mucinous liquid. These cysts may be found in any age group including children. They are as common in adult females as they are in male subjects.

Indications for surgery. The prime indication for surgery is the diagnosis of a mucus cyst at indirect laryngoscopy. The diagnosis may be made because of a yellowish and occasionally very voluminous arching of the middle third of the vocal fold, which causes a bulging outwards of both the free border and the superior surface. Usually the fold distended by this cyst will not vibrate on stroboscopy.

More commonly the cyst presents as an elongated bulge slightly below the free border, and may quite easily be confused with a nodule, especially if a contact lesion has developed on the opposite fold, producing an appearance of kissing nodules. Stroboscopy leads one to suspect a cyst

when one finds a loss of stroboscopic vibration localized to the area of the bulge. Occasionally the presence of a cyst is only revealed at operation: when ablating a lesion that was thought to be a simple nodule produces a characteristic flow of mucous liquid.

The operation. Ablation with microcups or microscissors is not recommended because removal of too much overlying mucosa risks the production of a significant notch postoperatively. Moreover, an incomplete excision is liable to produce recurrence. We recommend another technique: incising the mucosa on the superior aspect of the fold where it overlies the bulge and meticulously dissecting out the cystic pocket with microdissectors. The dissection is extremely delicate because the cyst wall is particularly thin and fragile and one rarely performs a complete exenteration without rupturing the cyst. It is nonetheless possible to progressively separate the cyst wall from the mucosal cover, and even from the vocal ligament, and remove it intact. Cysts are routinely sent for histopathological examination. The nidus from which the cyst was removed is checked and cleaned with a very small cotton-wool ball soaked in vasoconstrictors. The mucosa then collapses down in a normal position on to the fold without any loss of substance. The contralateral contact lesion is always removed.

Postoperative follow-up and results. The immediate result is usually good. At the first postoperative visit the vocal fold remains slightly pink, the volume of Reinke’s space has returned to normal and it is unusual to find a notch in the mucosa. Stroboscopic vibrations, however, are usually diminished in amplitude with respect to the contralateral vocal fold. The voice is much improved although at this stage it remains a little veiled and unstable. Voice breaks still persist on quiet phonation.

The final result after speech therapy is excellent both anatomically and functionally. There is always a risk of recurrence, however, because of the difficulty of dissecting out the entire contents of the cystic pocket clearly.

Congenital lesions

Epidermoid cysts

Epidermoid cysts of the vocal fold are more or less rounded or flattened structures, limited by a wall, and are situated in the submucosal space. From time to time they may invaginate into the fibroelastic fibres of the vocal ligament, which are spread apart. The contents are generally liquid, and are white and opalescent due to accumulation of squamous debris in the cavity. Histologically, an epidermoid cyst is composed of a cavity bounded by stratified squamous epithelium of variable degrees of keratinization and thickness, which develops in a centripetal manner

from a rest on a basement membrane. The cavity contains cornified desquamated material together with crystals of cholesterol. There is sometimes an inflammatory reaction in the tissue of Reinke’s space around the cyst.

Some cysts may have an opening, most commonly slightly underneath the free border of the vocal fold, which allows intermittent spontaneous emptying of the cyst.

These cysts may be seen at any age, including childhood.

Indications for surgery. Diagnosis of this lesion is sometimes easy at indirect laryngoscopy. Some cysts, however, present as a whitish arching of the mucosa, which bulges out of the superior surface of the mid-third of the fold and produces stroboscopic absence of vibration over the whole fold.

In general the lesion is not clinically obvious and the indirect signs suggesting the probable diagnosis are as follows:

•localized swelling of the mid-third of the fold, where stroboscopic examination shows a reduced amplitude of the mucosal wave where it overruns the swelling;

•dilated capillaries converging on a precise point on the superior surface of the vocal fold in the mid-third; monocorditis;

•in children, a fusiform appearance of the vocal folds with loss of stroboscopic vibration;

•when the appearance is not absolutely pathognomonic, other factors suggest that surgery is still the appropriate management;

•the characteristic acoustic patterns: lesions that increase rigidity of the vocal fold produce rather irregular, weak laryngeal vibrations;

•the clinical history which often suggests a dysphonia beginning in childhood;

•failure of speech therapy.

The operation. An incision (cordotomy) a few millimetres in length, slightly longer than the diameter of the cyst and running parallel to the free border, is made in the mucosa of the superior aspect of the vocal fold. A blunt dissector is then used to modify the incision appropriately.

In general, mobilization is fairly easy underneath the cyst next to the vocal ligament and more delicate superficially in the plane between the epithelium of the vocal fold cover and the cyst. From time to time the inferior pole of the outer surface of the cyst wall may be embedded within a split in the elastic fibres of the vocal ligament. As with aural surgery for cholesteatoma, when the cyst is excised intact there is no risk of future recurrence.

Following the removal of a cyst, the pocket should always be meticulously checked to avoid missing a second, deeper cyst, which sometimes occurs concealed within the vocal ligament.

Commonly there are inflammatory changes associated with the lesion and so cortisone is injected into the body of the fold before replacing the mucosa. The mucosa is not trimmed, the incision edges are simply approximated edge to edge and are held in place with an application of fibrin glue.

Postoperative follow-up and results. There is generally a satisfactory appearance of the vocal fold at the first postoperative inspection; although modest inflammatory changes remain, the cordotomy incision is usually no longer visible. Sometimes there is a slight depression in the vocal fold cover over the area that previously contained the cyst. Stroboscopic vibration is usually weak at the outset but rapidly improves during the first examination. Initially, voice quality is often rather mediocre, being rather veiled and unstable and producing voice breaks on quiet phonation. Postoperative speech therapy is absolutely essential in order to produce a steady and entirely satisfactory improvement in voicing. It must be stressed that improvement is a progressive affair and that it will be necessary for the patient to undergo a protracted course of therapy.

Sulci. The term sulcus has been used since the turn of the century to define a lesion that at indirect laryngoscopy appears as a ‘whitish furrow running parallel to the free border of the vocal cord giving the glottis an oval appearance’. In reality the sulcus thus defined corresponds to two quite different anatomical entities.

The term sulcus glottidis, when correctly used, describes an invagination of the epithelial cover of the fold into Reinke’s space. This produces a pocket of variable depth that pushes downwards and inwards, often deeply enough to contact the vocal ligament to which it may be more or less adherent depending on the degree of inflammatory reaction in the surrounding tissue. Histological examination shows that the sulcus is a true blind-ended sac, bounded by walls of stratified squamous epithelium of variable thickness, keratinization being most marked around the base of the pocket. We think that these features show that a sulcus is actually an open epidermoid cyst.

A furrow-like appearance may also be produced by an entirely different type of lesion that we have entitled a ‘stretch mark’ (Bouchayer and Cornut, 1992). This lesion presents as an atrophic furrow of variable extent lying underneath the free border of the vocal fold, giving the border a bowed appearance. The inferior margin of the furrow often contains a tight, stiff, submucosal band whereas the superior margin is rather more supple. The mucosa lining the floor of the stretch mark is thin, atrophic,

and intimately bound to the fibres of the vocal ligament. This prevents any sliding between the layers.

Both sulcus and stretch marks may be seen from adolescence onwards, and they appear slightly more common in males than females. It would seem most likely that they are both congenital in origin.

Indications for surgery. In some cases the furrow may be obvious, lying at the level of the free border in one or both vocal folds, producing an oval appearance of the glottis highly suggestive of a sulcus or stretch mark. Occasionally the appearance is less obvious and the furrow may only be visible in stroboscopic light. There may only be evidence of an absent closed phase over the entire length of the free borders of the vocal folds, perhaps associated with monocorditis or some capillary telangiectases.

The acoustic voice patterns are highly characteristic and support the diagnosis: the voice is often loud, and particularly in males, dull. It is also rather veiled, with frequent voice breaks. Patients usually present with significant vocal fatigue, paralaryngeal aches, or the need for further treatment when speech therapy has not improved things sufficiently.

The operation. For a sulcus glottidis or open epidermoid cyst it is essential not to remove too much mucosa in order to avoid producing a secondary puckered scar. To achieve this the superior and inferior crests circumscribing the epidermal pocket are precisely incised with a very sharp arrowhead knife. The floor of the pocket is then dissected off the vocal ligament with blunt elevators. Following this the sulcus may be removed intact after section of the remaining anterior and posterior attachments with microscissors. The subglottic mucosa is mobilized over a few millimetres in order to achieve approximation of the superior and inferior mucosal margins without loss of tissue thickness.

Surgery is extremely difficult to perform. It requires excellent instruments and considerable competence of the surgeon, but it does give good primary and secondary anatomical and functional results. The phoniatrician in charge of the postoperative care will be well aware of this.

For a stretch mark the aim of the surgery is to elevate the atrophic adherent section of mucosa after distending the fold with an injection of hydrocortisone suspension. An incision is made on the superior surface of the fold and a plane between the mucosa and the ligament is created using a blunt elevator. This is always an extremely difficult dissection because the mucosa is closely adherent to the ligament and cannot always be preserved. It is frequently necessary to detach fibres of connective tissue from the mucosal cover, and when freed these fibres should be laid back in place on the vocal ligament. This is particularly important for the inferior bar where these fibres may act like a bow-string, pulling a flange of mucosa over the inferior margin of the stretch mark.

This operation generally produces a satisfactory sliding plane under the mucosa of both the free border and the subglottic margins. The period of scarring and shrinkage then pulls both parts into the closest possible approximation.

These lesions are generally bilateral and may be operated on at the same time. Nevertheless, when the dissection of the first side has been particularly difficult, or where the larynx is small, as for instance in children, then it is preferable to operate on one side only and to leave an interval of approximately six months before operating on the second side.

Postoperative follow-up and results. After removal of a sulcus, the area of resection often appears as a small discrete dent which rapidly fills out and becomes supple with postoperative speech therapy.

Eight days after operating on a stretch mark, the furrowed appearance is still evident and the stroboscopic vibration remains feeble. The voice is usually mediocre, and is sometimes actually rather worse than it was prior to the operation. Frequent voice breaks and very veiled voicing are the norm. It is only with protracted postoperative speech therapy that one begins to clearly see a steady improvement in the suppleness of the vocal folds. In particular, the stroboscopic appearance of the hitherto rigid inferior border demonstrates greatly improved mucosal waves, and one often ends up with a considerably improved closure of the folds, given that it is never possible to achieve a perfect result. The pitch of the voice is generally lower and the timbre improves although retaining a rather veiled quality. The majority of patients are well satisfied even though the objective result is not perfect, because the combination of surgery and speech therapy completely removes both the pronounced laryngeal ache and the vocal fatigue, thus producing a significant improvement in the patient’s vocal comfort.

Mucosal bridge

A mucosal bridge presents as a separate mucosal band running parallel to the free border, having anterior and posterior attachments to the fold. Structurally it is composed of everted stratified squamous epithelium and is always associated with one of the three lesions previously described. We think that the bridge arises from a cyst open sac with two (superior and inferior) ostia. Between these openings there remains a characteristic healthy band of mucosa of variable size and it is this that becomes the mucosal bridge.

The operation. Usually mucosal bridges are thin, and most of the time the appropriate technique is simply to excise the bridge using microscissors at its anterior and posterior attachments. From time to time, however, a mucosal bridge is large and thick, and simple resection would incur an excessive loss of mucosal bulk, resulting in the secondary production of a