Учебники / Operative Techniques in Laryngology Rosen 2008

Key Points

■A successful surgical outcome is dependent upon proper clinical evaluation of the patient’s voice disorder. It therefore behooves the serious practitioner of laryngology to focus not only on his or her surgical skills, but also on evaluative and perceptual skills. This will ensure proper patient selection and make for improved surgical outcomes.

■Careful history taking and clinical evaluation are important tools in the diagnostic evaluation of the voice patient.

■When caring for patients with voice disorders, the clinician should pay particular attention to the level of voice use, the importance of the voice to the patient, and the impact of the voice disorder on their quality of life.

■Clinical outcome instruments such as the Reflux Symptom Index (RSI) and the Voice Handicap Index 10 (VHI-10) are extremely useful tools for the evaluation of vocal complaints.

Selected Bibliography

1Sataloff RT (1997) Professional voice—the science and art of clinical care, 2nd edn. Singular, San Diego

2Koufman JA, Amin MR, Panetti M, Prevalence of reflux in 113 consecutive patients with laryngeal and voice disorders (2000) Otolaryngol Head Neck Surg 123:385–8. Erratum in: Otolaryngol Head Neck Surg 124:104

3Koufman JA (1991) The otolaryngologic manifestations of gastroesophageal reflux disease. Laryngoscope 101(Suppl.)53:1–78

4Belafsky PC, Postma GN, Koufman JA (2002) Validity and reliability of the reflux symptom index (RSI). J Voice 16:274–277

5Ritter FN (1973) Endocrinology. In: Paparella M, Shumrick D (eds) Otolaryngology. Saunders, Philadelphia, pp 727–734

6Silverman EM, Zimmer CH (1978) Effect of the menstrual cycle on voice quality. Arch Otolaryngol Head Neck Surg 104:7–10

7Courey MS, Postma GN (1996) Microvascular lesions of the true vocal folds. Curr Opin Otolaryngol Head Neck Surg 4:134

8Sataloff RT (1995) Vocal fold hemorrhage: diagnosis and treatment. NATS J May/June:45

9Smith ME, Ramig LO (1995) Neurological disorders and the voice. In: Rubin JS, Sataloff RT, Korovin GS et al (eds) Diagnosis and treatment of voice disorders. Igaku-Shoin, New York, pp 203–219

10Koufman JA, Isaacson G (1991) The spectrum of vocal dysfunction. Otolaryngol Clin North Am 24:985–988

11Cooper M (1973) Modern trends in voice rehabilitation. Charles C. Thomas Springfield, Ill.

12Bassich CJ, Ludlow DL (1986) The use of perceptual methods by new clinicians for assessing voice quality. J Speech Hear Dis 51:125

13Dejonckere PH et al (1993) Perceptual evaluation of dysphonia: reliability and relevance, Folia Phoniatr (Base1) 45:76

14Kreiman J et al (1993) Perceptual evaluation of voice quality: review, tutorial, and a framework for future research, J Speech Hear Res 36:21

15Hirano M (1981) Clinical examination of the voice. Springer, Berlin, Heidelberg, New York

16Voice disorders: Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V). American Speech-Language-Hearing Association Special Interest Division 3: Voice and Voice Disorders. 2003. Available at: http://www.asha.org

17Benninger MS, Ahuja AS, Gardner G, Grywalski C (1998) Assessing outcomes for dysphonic patients. J Voice 12:540–550

18Jacobson GH, Johnson A, Grywalski C et al (1997) The Voice handicap index (VHI): development and validation. Am J Speech Lang Pathol 6:66–70

19Hogikyan ND, Sethuraman G (1999) Validation of an instrument to measure voice-related quality of life (V-RQOL). J Voice 13:557–569

20Ma EP-M, Yiu EM-L (2001) Voice activity and participation profile: assessing the impact of voice disorders on daily living. J Speech Lang Hear Res 44:511–524

21Carding PN, Horsley IA, Docherty GD (1999) Measuring the effectiveness of voice therapy in a group of forty-five patients with non-organic dysphonia. J Voice 13:76–113

22Deary IJ, Wilson JA, Carding PN et al (2003) VoiSS, a patientderived voice symptom scale. J Psychosometr Res 54:483–489

23Hogikyan ND, Rosen CA (2002) A review of outcome measurements for voice disorders. Otol Head Neck Surg 126:562–572

24Jacobson BH, Johnson A, Grywalsky C et al (1997) The Voice Handicap Index (VHI): development and validation. Am J Speech Lang Pathol 6:66–70

25Rosen CA, Lee AS, Osborne J, Zullo T, Murray T (2004) Development and validation of the Voice Handicap Index-10. Laryngoscope 114:1549–1556

3.1Fundamental and Related Chapters

Please see Chaps. 1, 2, 4, and 5 for further information.

3.2Introduction

Visualization of the larynx and specifically the vocal folds is paramount for the evaluation and care of patients with voice disorders. There are a variety of methods used for this visualization, ranging from indirect mirror laryngoscopy to high-speed photography. The most common and relevant clinical tools for modern-day voice evaluation and care include stroboscopic visualization of vocal fold vibration and dynamic voice evaluation with flexible laryngoscopy. These two techniques when used in a complimentary fashion can provide the clinician with detailed information on intricate vocal fold vibratory activity and phonatory and functional use of the entire vocal tract. This chapter focuses on these two main clinical methods.

3.3Surgical Indications and Contraindications

Stroboscopy utilizes a method of “shuttering,” or synchronized illumination of the vocal folds during vocal fold vibration (Fig. 3.1). This provides “pseudo” slow motion visualization of vocal fold vibration. Real-time vocal fold vibration is too rapid to visualize with the unaided eye. The stroboscopic light source illumination provides representative images from the entire vibratory cycle. A periodic or nearly periodic vocal fold vibratory activity is required for stroboscopy to be successful. It is important to note that stroboscopy can be done through any type of visualization instrument including flexible laryngoscopy and rigid perioral laryngoscopy. Stroboscopy is strictly the light source and not the actual equipment used for visualization of the vocal folds. (i. e., flexible laryngoscopy or rigid telescope).

The most common vocal fold vibratory characteristics that stroboscopy allows one to view are:

■Vocal fold closure (pattern and duration)

■Mucosal wave movement (propagation)

■Symmetry of vibration

■Amplitude of vocal fold vibration

■Periodicity

Stroboscopy helps elucidate specific lesions of the vocal folds, especially as they relate to closure pattern for exophytic lesions and defects of the lamina propria such as seen in adynamic segments of the vocal fold, vocal fold scar, and sulcus vocalis. Vocal fold closure pattern is typically described as the global overall pattern of vocal fold closure, as seen during the majority of the examination specifically at modal pitch and intensity of vowel prolongation. The most commonly cited and utilized closure patterns include complete, incomplete, hourglass, anterior glottic gap, and excessive posterior glottic gap (Fig. 3.2).

Mucosal wave as seen during stroboscopy refers to a rippling motion traveling over the vocal fold and within the vocal fold mucosa. The wave is propagated from the subglottic area and travels from underneath the vocal fold along the free edge, then over the superior surface of the vocal fold and is dampened in the area of the ventricle. This mucosal wave activity is crucial for assessing the pliability and functional characteristics of the lamina propria of the vocal folds. Areas of diminished mucosal wave represent loss of pliability or viscoelasticity of the vocal fold lamina propria and are an important aspect of voice evaluation. Mucosal wave activity should be assessed at a variety of phonatory tasks, specifically at low, medium, and high pitch and different levels of intensity.

The duration of vocal fold closure is also an important clinical assessment parameter. At modal pitch and intensity, vocal fold vibratory closure should occur approximately half of the vibratory cycle. This can be measured in a detailed fashion us-

Fig. 3.1  “Representative” set of images from stroboscopy depicting “one” vibratory cycle

ing electroglottography but can also be estimated using frame- by-frame review of the recorded stroboscopic images.

Vocal fold vibration symmetry during stroboscopy is judged by comparing the vocal folds’ vibratory activity to one another.

3 The vibration of one vocal fold should be a mirror image of the contralateral fold.

The degree of vocal fold amplitude (horizontal excursion from midline) during vocal fold vibration as seen during stroboscopy is an important assessment tool and involves both the comparative as well as overall subjective assessment of the amount of amplitude of each vocal fold during vocal fold vibration (Fig. 3.3). Of course, amplitude and closure are two stroboscopy parameters that are directly affected by the voice intensity and pitch during the stroboscopic examination and these factors must be constantly monitored and taken into consideration when assessing these parameters. For example, at high pitches both the amplitude and mucosal wave decrease as compared to lower pitches.

Periodicity describes the regularity of vocal fold vibration. Periodicity is based on the regularity of successive cycles of vibration. Even though symmetry and periodicity may be thought to assess similar behavior, in fact, vocal folds can have distinctly different amplitude and symmetrical activity and still be quite periodic. The converse is also true where vocal folds can demonstrate aperiodic activity with normal and symmetric amplitude (as often seen with vocal fold paresis).

Stroboscopy of the vocal folds is helpful for visualization of a variety of vocal fold lesions, which are discussed in detail in Chap. 4, “Pathological Conditions of the Vocal Cords.” Stroboscopy is also extremely important for visualization of seg-

ments of the vocal fold with poor vibratory characteristics due to scar, subtle lesions, loss of lamina propria tissue or sulcus vocalis (see Chap. 23, “Sulcus Vocalis and Vocal Fold Scar”).

Stroboscopy to assess vocal fold vibratory activity should be done using a fairly consistent assessment protocol. First, it is essential to identify that the patient has a periodic or nearly periodic signal. A typical stroboscopy examination protocol includes:

■Modal voice (most comfortable pitch and intensity)

■Low pitch (soft and loud to assess maximum pliability)

■High pitch, soft intensity phonatory task

The latter is extremely helpful for identifying subtle lesions of the vocal fold as well as assessing abnormalities associated with vocal fold pliability and vocal fold vibratory activities. The low pitch-loud task is helpful not only for assessing overall pliability, but also for patients with the most aperiodic voice. When performing stroboscopy, the vocal fold vibratory activity and characteristics should be first compared internally (to each other), and then compared to the examiners experiential database and most importantly correlated with the amount and nature of dysphonia of the patient. There should be a good correlation from an auditory and visual perceptual basis. If this is not the case, then a repeat examination or careful examination of other factors should be undertaken.

3.4Dynamic Voice Assessment with Flexible Laryngoscopy

Flexible laryngoscopy is an essential evaluation technique for voice disorders-related “functional” problems such as muscle tension dysphonia, paradoxical vocal fold motion disorder and

functional aphonia, neurologic voice disorders (spasmodic dysphonia, essential tremor, etc.), and vocal fold paresis. Dynamic voice assessment with flexible laryngoscopy evaluates multiple parameters associated with phonation done in a dynamic and “most natural” setting. Equipment required includes nasal speculum, decongestant and anesthetic for the nasal cavity, flexible laryngoscopy, and illumination light source(s) (continuous halogen and preferably stroboscopy). This examination is done in a stepwise fashion, examining each section of the vocal tract which is outlined below from an anatomic and a physiologic perspective (at rest and then in activation). The specific areas of activation include vegetative functions and phonation. The subregions of the dynamic voice assessment include nasopharynx, base of tongue, larynx (global), and the vocal folds. At each one of these specific subportions of the dynamic voice assessment, specific tasks are elicited from the patient to look for different pathologies in the area and confirm or rule out a variety of disorders (Table 3.1).

3.4.1Nasopharynx

1.Patient task: rest, sustained phonation (/ee/) and speech (/koka kola/) and prolonged fricative /s/

2.Parameters of evaluation: nasal disease, masses of the nasopharynx, tremor of the soft palate (rest and activation) and velopharyngeal incompetence (VPI)

3.Pathology: velopharyngeal incompetence, vocal tremor, sinonasal disease, (infectious or allergic) nasopharyngeal neoplasms

3.4.2Base of Tongue

1.Patient task: rest and tongue protrusion

2.Parameters of evaluation: tremor, fasciculations (ALS), tumors, infections

3.Pathology: essential tremor of the vocal tract, amyotrophic lateral sclerosis (ALS), neoplasm (benign and malignant) and infection

3.4.3Larynx (Global)

1.Patient task: quiet respiration, alternating sustained phona- tionandrespiration(hee-hee-hee,withabreathbetweeneach “hee”) and connected speech (“We were away a year ago.”)

2.Parameters of evaluation: vocal fold mobility and synchrony of mobility Paradoxical vocal fold motion, supraglottic constriction associated with phonation, and global laryngeal tremor

3.Pathology: paradoxical vocal fold motion disorder, primary muscle tension dysphonia, secondary muscle tension dysphonia, vocal tremor, vocal fold paralysis, vocal fold paresis, as well as pyriform/vallecular lesions, LPR

Table 3.1  DVA tasks, findings, and correlated diagnoses: examination protocol—tasks

Velum Sustained /ee/ /koka kola/

Base of tongue

Evaluation of symmetry and mucosa

Larynx

Quiet respiration

Sustained /ee/—comfortable pitch Sustained /ee/—low and high pitch

/ee/ /ee/ /ee/ (with a breath between each “hee”) “We were away a year ago.”

“We were away a year ago.”—comfortable pitch Example of connected speech (Ask,

“What did you do yesterday?”) Sing “Happy Birthday”

Cough

Laugh

3.4.4Vocal Fold (Focal)

1.Patient task: respiration, sustained phonation and alternating speech and respiration (see Table 3.1)

2.Parameters of evaluation: vocal fold lesions, glottal insufficiency and tremor

3.Pathology: focal vocal fold lesions (polyp, nodules, etc.) cancer, vocal fold atrophy, vocal field paralysis and vocal fold paresis

3.5Recording of Laryngeal Examination

It is highly recommended but not absolutely necessary that the stroboscopy and/or dynamic voice evaluation be recorded. The two most common methods of recording portions or all of these examinations are with either still photography or video recording. The advantages of recording all or portions of the laryngeal examinations include:

■Longitudinal comparison

■Preoperative planning

■Patient education

■Medical/legal uses

Further justification and use of a video recording include the ability to record an audio track in conjunction with the video examination. Both audio and video examination can be extremely helpful for all of the above-mentioned reasons; especially in a court of law. It is essential to have a baseline or preoperative audio and/or voice recording prior to and after

elective surgical procedures. This is analogous to the documentation procedures for cosmetic surgical procedures. Video recordings of the vibratory parameters of the vocal fold are also very helpful to refer to when surgically resecting a lesion.

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Key Points

■Stroboscopy and dynamic voice assessment (DVA) with flexible laryngoscopy are essential aspects of a voice evaluation and care.

■Strobe and DVA are complementary and should not be viewed in isolation.

■The dynamic voice assessment and evaluation allows for a natural in vivo evaluation of the entire vocal tract during rest, vegetative activities, and phonation (connected and sustained), and stroboscopy allows the examiner insight into key vocal fold vibratory activity, specifically the physiologic and pathophysiologic activities related to the patient’s dysphonia.

■The combination of stroboscopy and dynamic voice assessment with flexible laryngoscopy allows the clinician to correlate the patient’s voice symptoms, related physical exam abnormal findings, craft an accurate diagnosis and form a successful treatment plan.

Selected Bibliography

1Hirano M, Bless DM (1993) Videostroboscopic examination of the larynx. Singular, San Diego

2Stasney CR (1996) Atlas of dynamic laryngeal pathology. Singular, San Diego

3Cornut G, Bouchayer M. Assessing dysphonia: the role of videostroboscopy. Five videocassettes, 254 min

4Rosen CA (2005) Stroboscopy as a research instrument: development of a perceptual evaluation tool. Laryngoscope 115:423–428

5Roehm PC, Rosen C (2004) Dynamic voice assessment using flexible laryngoscopy—how I do it: a targeted problem and its solution. Am J Otolaryngol 25:138–141

4.1Fundamental and Related Chapters

Please see Chaps. 2 and 3 for further information.

4.2Introduction

The variety of pathologic conditions that occur within the vocal fold can be separated into categories based on their anatomical location. The chapter is divided among epithelial pathology of the vocal folds, benign midmembranous lesions, and miscellaneous vocal fold pathology. A brief overview and discussion of the key points of each of these vocal fold lesions, especially as they relate to the surgical treatment is included. It should be stressed that with the exclusion of carcinoma and recurrent respiratory papilloma of the vocal folds, most of the vocal fold lesions are benign and in general should be managed with a conservative approach that involves maximizing all nonsurgical treatment methods first, and then only proceeding with surgical treatment if key functional issues (i. e., voice quality and vocal function) are still persistent.

4.3Epithelial Pathology of the Vocal Folds

4.3.1Recurrent Respiratory Papillomatosis of the Larynx

Recurrent respiratory papillomatosis of the larynx is an epithelial growth of the larynx most commonly seen at the level of the vocal folds (Fig. 4.1). These growths are a direct response to a human papilloma virus infection and tend to be recurrent in nature. The most common human papilloma virus types involved with RRP of the larynx are HPV types 6 and 11. These recurrent benign lesions grow most significantly at epithelial transition sites, such as where pseudostratified columnar and stratified squamous are juxtaposed.

Any time a new epithelial transition site is created in a patient who is infected with the human papilloma virus, there is a high risk of a new papillomatous disease growth at that site. This is frequently demonstrated when a tracheotomy is performed on a patient with recurrent respiratory papillomatosis. Malignant transformation of these types of HPV infection are extremely rare, and historical experience has demonstrated that external beam radiation therapy, tobacco exposure, pul-

monary involvement, and alcohol exposure increase the risk of RRP malignant transformation. It cannot be overemphasized that the chance of curing patients with RRP using surgical excision alone is low; likewise, there is no evidence that a more aggressive operation will increase the patient’s long-term control of his or her disease. The surgical philosophical approach for RRP should be to: (1) maintain a patent airway without using a tracheotomy, (2) optimize functional results with respect to voice and swallowing, and (3) minimize chance of operative complications and sequelae such as glottic webbing and vocal fold scar formation.

4.3.2Leukoplakia of the Vocal Fold

Abnormal epithelial hypertrophy or dysplasia of the vocal folds can be manifested as redundancy of the epithelial or keratotic layers of the vocal folds resulting in hyperkeratosis, parakeratosis, and is clinically referred to as leukoplakia (Fig. 4.2). An important differentiation of this pathology relates to the anatomic structure of the cells involved in the abnormal epithelium. Often these cells can become dysplastic and are thought to be a precursor for malignancy. However, many patients who suffer from keratosis of the vocal fold show no dysplasia of these lesions and are strictly burdened by the repetitive regrowth of a hyperkeratotic epithelial covering at various locations of the

Fig. 4.1  Recurrent respiratory papillomatosis, bilateral

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Fig. 4.2  Keratosis of the left vocal fold

vocal folds. These lesions can be singular in nature or they can be multiple and diffuse throughout the vocal folds and arytenoid cartilages. Given that the risk of transformation of this leukoplakic biologic activity into a malignancy is present (statistically < 10%), these patients require careful monitoring and a complete surgical excision of any suspicious leukoplakic lesion. Suspected risk factors for keratosis include viral infection, LPR, and vocal fold phonotrauma (primary or secondary to glottal insufficiency). It is equally important to remember that the majority of patients with keratosis of the vocal folds will not develop a malignancy and most likely will have recurrent lesions in the future; thus, principles of conservative excision and patient observation with longitudinal photo documentation are essential to the care of this patient group. There is no role for external beam radiation for these patients.

4.3.3Dysplasia–Carcinoma in Situ of the Vocal Folds

4.4Benign Diseases of the Vocal Fold Lamina Propria

4.4.1Overview of Midmembranous Vocal Fold Lesions

Midmembranous lesions of the vocal fold are abnormalities of lamina propria of the vocal fold, with minimal or no changes of the overlying epithelium. These lesions are extremely common causes of voice disorders and often require surgical therapy. Significant confusion and debate exists regarding the nomenclature and classification of these lesions. Unfortunately, visualization alone of these lesions does not properly stratify and classify these lesions, and thus a multidimensional system has been developed and is required to classify properly the midmembranous vocal fold lesions. It is important for this classification to be exact, given that clinical outcomes and patient prognosis, and surgical treatment with different midmembranous vocal fold lesions differ significantly. This book uses a classification system utilizing four commonly used clinical modalities to differentiate seven distinct benign midmembranous vocal fold lesions. These classification methods include

(1) morphology (midmembranous vocal fold lesion), (2) characteristics of the mucosa wave of the lesion and surrounding areas as seen on stroboscopy (minimal–normal versus significant impairment), (3) response of the lesion in the form of resolution or reduction in size to voice rest/voice therapy, and

(4) intraoperative findings. The latter includes location of the pathology (subepithelial or near the vocal ligament) and the physical characteristics of the lesion, presence or absence of a capsule wall, physical features, and nature of the pathology.

4.4.2Approach to Midmembranous Vocal Fold Lesions

In most instances, patients with midmembranous vocal fold lesions have relatively normal epithelium overlying their pathologic process, and thus, the concern for cancer is extremely low. Often these lesions respond extremely well to nonsurgical treatment methods such as voice therapy and treatment of comorbid medical problems. This approach should be taken for most patients with midmembranous vocal fold lesions causing significant dysphonia (see Chap. 7, “Medical Treatment of Voice Disorders”). After the implementation and adequate treatment time of these nonsurgical treatment methods, the patient should have a repeat comprehensive voice evaluation to determine the amount of improvement and to determine if there are any residual functional limitations to their voice use and demands. If these functional limitations are significant to the patient and can be reasonably projected to improve with surgical excision of the vocal fold lesion(s), then phonomicrosurgery is indicated. The decision making on initial treatment(s), duration and timing of surgery is complex and does not lend to formulaic approaches. In general, patients should be treated with nonsurgical therapy before surgery. Exceptions include distinct lesions that are hightly unlikely to

improve without surgery (i. e., a large, pedunculated polyp). In these instances, a short period of both reduced voice use and voice therapy is implemented (2–3 weeks), followed by a reevaluation of the lesion(s) and patient’s vocal functional abilities (see Chap. 8, “Timing, Planning, and Decision Making for Laryngeal Surgery”).

4.4.3Vocal Fold Nodules

Vocal fold nodules are benign, midmembranous vocal fold lesions involving most likely the most superficial aspect of the lamina propria as well as the basement membrane zone of the vocal fold epithelium (Fig. 4.5). They are thought to be “calluses” of the vocal folds and are always bilateral and fairly symmetric. Vocal fold nodules are seen almost exclusively in females in adults, and both genders in children. These lesions by definition respond to a combination of voice rest and voice therapy, when the patient is compliant and the voice therapy is done in an appropriate fashion. Stroboscopic behavior of vocal fold nodules typically demonstrates an hourglass closure pattern and normal or minimally reduced mucosal wave vibratory activity (see Chap. 16, “Vocal Cord Nodules”).

4.4.4Vocal Fold Cyst (Subepithelial)

A subepithelial vocal fold cyst represents an encapsulated lesion within the superficial aspect of the lamina propria, typically found in the midmembranous vocal fold (Fig. 4.6). The stroboscopic pattern of a subepithelial vocal fold cyst is an hourglass closure pattern, with normal to minimal disruption of the mucosal wave vibratory activity (depending on

Fig. 4.5  Vocal fold nodules (bilateral)

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Fig. 4.6  Cyst (subepithelial) of left vocal fold

Fig. 4.7  Cyst (ligament) of left vocal fold

size). Subepithelial vocal fold cysts typically do not respond or change in any appreciable fashion to voice rest or voice therapy. Surgical excision when indicated of a vocal fold subepithelial cyst is done through a microflap approach to the vocal fold (see Chaps. 10, “Principles of Phonomicrosurgery” and 17, “Vocal Fold Cyst and Fibrous Mass”).

4.4.5Vocal Fold Cyst (Ligament)

A vocal fold cyst found in the area near the vocal ligament is an encapsulated, benign pathologic process that typically involves significant reduction of mucosal wave vibratory wave activity as seen on stroboscopy as well as an hourglass closure pattern (Fig. 4.7). It is located in the deep aspect of the lamina propria and often better visualized within the vocal fold in abduction compared to adduction. This lesion does not respond to voice

rest or voice therapy, and the prognosis for prompt recovery of the voice after surgical excision is less when compared with a vocal fold polyp or subepithelial cyst. The surgical approach to this lesion involves a microflap (see Chaps. 10 and 17).

4.4.6Vocal Fold Polyp

A vocal fold polyp is a pathologic process of the lamina propria that involves typically an exophytic or pedunculated lesion of the midmembranous vocal fold that can be unilateral or bilateral (Fig. 4.8). The stroboscopic pattern of a vocal fold polyp shows an hourglass closure pattern with normal or minimal reduction of the vibratory activity of the mucosa. A vocal fold polyp does not respond to voice therapy and rest (by definition), and intraoperative exploration reveals a focal accumulation of a gelatinous material, often under a severely thin and atrophic epithelium. Surgical excision of the vocal fold lesion can be done through a microflap approach or truncation of the vocal fold lesion (see Chap. 10, “Principles of Phonomicrosurgery” and 15, “Vocal Fold Polyp”).

4.4.7Fibrous Mass (Subepithelial)

A subepithelial fibrous mass represents an accumulation of fibrous tissue within the subepithelial aspect of the midmembranous vocal fold (Fig. 4.9). This material is typically amorphous in nature and often has thin extensions anteriorly and posteriorly within the vocal fold, giving it a fusiform shape. Stroboscopic pattern of fibrous mass in the subepithelium demonstrates an hourglass closure pattern, with significant reduction of the mucosal wave vibratory activity as seen on stroboscopy. This pathology does not respond to nonsurgical treatment methods, and the surgical approach for this lesion is through a microflap. The surgical approach to these lesions is similar to a subepithelial vocal fold cyst, but the vocal recovery is more delayed and overall prognosis reduced comparatively (see Chaps. 10, “Principles of Phonomicrosurgery” and 17, “Vocal Fold Cyst and Fibrous Mass”).

4.4.8Fibrous Mass (Ligament)

A ligamentous fibrous mass represents fibrous tissue accumulation in the midmembranous vocal fold near the vocal ligament (Fig. 4.10). Often this tissue is amorphous and has extensions anteriorly and posteriorly in the vocal fold. This lesion does not respond to nonsurgical treatment methods. The stroboscopic pattern of fibrous mass and ligament reveals hourglass closure pattern and significant reduction of the mucosal wave vibratory activity. The surgical approach is similar to a ligamentous vocal fold cyst, via a microflap. The speed of vocal recovery is reduced compared with a vocal fold cyst, and the overall vocal function prognosis is worse than other midmembranous vocal fold lesions (see Chaps. 10, “Principles of Phonomicrosurgery” and 17, “Vocal Fold Cyst and Fibrous Mass”).