Minutha R^1*, Sathish Kumar², Harsha P³

¹Associate Professor, ²Professor, ³Assistant Professor, Department of ENT, Vydehi Medical College and Research Centre, Banglore, Karnataka, INDIA.

Email: drminutha@gmail.com

Figures 1 and 2: Showing the vocal Cord polyp and removal

DISCUSSION

Innovative otolaryngologists, speech language pathologists, and voice scientists have continued to advance our understanding of the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. An article by Johns MM reviewed the recent publications over the past years with respect to these advances.

The article stated that support for the notion that benign vocal fold lesions arise from phonatory trauma and vocal misuse continues to become evident. Changes in the molecular characteristics of the lamina propria in these lesions are beginning to be understood. For diagnostic purposes, the use of innovative technology such as Ultrasonography and virtual laryngoscope is being explored. Continued support for behaviour modification as a primary treatment modality for benign vocal fold lesions has been published, and refinements in technical aspects of laryngeal microsurgery persist. Finally, outcomes studies have demonstrated improvements in vocal disability with both behavioural and surgical interventions. Our study also revealed an association with vocal abuse since more than 80 percent of the patients gave a history of vocal abuse of one form or the other. The quantification and study of the type and extent of vocal abuse has to be studied and analysed further.¹ Martins et al.. conducted a study to study the clinical, morphological, and immunohistochemical characteristics of vocal polyps. In the study, 76 medical charts from patients with polyps were reviewed. Histology study: in 42 slides from surgical specimens, the following were analyzed: epithelium, basal membrane, and lamina propria. In the transmission and scanning electron microscopy (TEM and SEM) studies, eight new cases of polyps were included. An immunohistochemical study was carried out in the 42 specimens, using antibody antifibronectin, antilaminin, and anticollagen IV.

They had the following results

Genders--43% males and 57% females; age range--between 21 and 40 years (36.85%); and between 41 and 60 years of age (51.31%); smoking and drinking-reported by 39 and 15 patients, respectively; associated symptoms-vocal abuse (61%), gastroesophageal (47%), and nasosinusal symptoms (32%); occupation--teachers (24.0%) and maids (18.0%). Histology--epithelial hyperplasia (31.71%), hyperkeratosis, (14.28%), edema (100%), vessel proliferation (92.86%), and congestion (83.33%). SEM--reduction in mucous lacing and increase in desquamating cells. TEM--hyperplastic epithelium, enlargement of the intercellular junctions, dense subepithelial network of collagen and basal membrane with adhesion loss. Immunohistochemistry--greater immunoexpression of fibronectin, laminin, and collagen IV around the vessels. They concluded that in vocal polyps, the morphological analyses show lamina propria with edema, vessel proliferation and inflammation, basement membrane with adhesion loss in some areas and dense network of subepithelial collagen. Immunohistochemistry techniques identify pigmentation of the antibodies anti-fibronectin, anti-laminin, and anti-collagen IV in the endothelium of blood vessels. Our study had a gender majority of males and associated vocal abuse in more than 80 percent of cases. Majority of age group was in the 30 to 45 range which was similar to the above study indicating younger and vocally active generation or working professionals or housewives. The Histopathological report was of polyp in almost all the cases and one case of Nodule.² According to Toran K C et al.., vocal polyps are the products of voice overuse, misuse and abuse. Treatment generally advised for them are voice therapy and Microlaryngeal Phonosurgery (MLPS). The improved or changed quality of voice is generally assessed perceptually and can cause intra rater variability. In a study they compared and analysed the acoustic characteristics before and after MLPS. The purpose of the study was to acoustically determine the changes in voice quality of a group of patients before and after the surgery. The following patients group were studied prior to and in between 3 and 4 weeks of surgery. Altogether there were 23 patients with either unilateral or bilateral vocal polyps. Voice recording and analysis were performed with Dr. Speech acoustic software (Tiger electronics, USA). The parameters analyzed were in terms of perturbation (Jitter and shimmer), harmonic-to-noise ratio (HNR) and fundamental frequency (F0). The results showed that shimmer, HNR and F0 decreased significantly (p<0.05) following MLPS, but jitter though reduced, was not statistically significant (p = 0.694). The acoustic output generally improved after MLPS as evidenced by decreased values of all the four acoustic parameters. The study also stress that voice quality can be improved through the phonosurgical procedures. This multidimensional voice analysis can be very helpful in our ability to provide objective clinical analysis of voices with vocal polyps, and following their surgical treatment. Our study also demonstrated an association with vocal abuse in more than 80 percent of patients. We also advised Microlaryngeal Surgery for all the patients with persistent symptoms. A definitive voice improvement was demonstrated by all the patients though a voice analysis was not carried out in our study. A patient questionnaire was used to ask the patient subjectively how he or she feels about his or her voice after surgery and all the patients had improvement in voice after surgery till at least the period of follow up.³ Empirical data are often not available to guide clinical practices in the treatment of benign mucosal lesions of the vocal folds. The purpose of a report by Sulica L, was to describe opinions and practices in order to identify areas of consensus and discrepancy and thus guide future inquiry. A 16-item survey mailed to all active US members of the American Academy of Otolaryngology-Head and Neck Surgery (n = 7,321) included questions on the use of voice therapy; diagnostic testing; perioperative use of steroids, antibiotics, and antireflux medications; and use of lasers. Responses used a Likert 5-point scale with end anchors of 1 equaling "never" and 5 equaling "always" and were stratified according to lesion (nodules, polyps, cysts). A 16.5% response rate (n = 1,208) was obtained. A lack of consensus was most evident in the use of voice therapy for lesions other than nodules; antireflux medication; and intravenous steroids. Disagreement was also noted regarding the use of lasers, oral steroids, and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication. Prospective clinical trials addressing voice therapy, antireflux medications, steroids, and antibiotics are needed to inform clinical practice. Furthermore, treatment practices appear to be largely independent of lesion type. Therefore, traditional diagnostic categories do not seem to be useful guides to treatment, and may need to be reevaluated in light of improvements in diagnostic technology and surgical technique.

For now the chief treatment is surgical excision since it has an excellent cure rate. The same has been demonstrated in our study.⁴ Vocal fold polyp is generally thought to require surgical removal. However, a certain proportion of polyps resolve with conservative treatment. A study was performed to clarify the frequency of spontaneous resolution of vocal fold polyp and identify features associated with polyps that are likely to resolve without surgery. A review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008 was done in this study. Of 644 patients with the diagnosis of vocal fold polyp, 132 received conservative treatment, 433 were treated surgically, and 79 dropped out without attending for further consultation after the initial visit. Of those treated conservatively, 55 experienced complete resolution after a mean of 5.1 months of follow-up from the outset, and 29 showed lesion shrinkage after a mean of 4.1 months of follow-up. Polyps that resolved with conservative therapy were more likely than those that remained unchanged or enlarged to occur in women, be smaller, and have a shorter duration of symptoms. They could not determine the superiority of voice therapy. The authors concluded that at least 9.7% of vocal fold polyps might resolve without surgery. Conservative treatment should be considered as an option for selected patients with smaller and more recent-onset polyps. In our experience and as demonstrated in our study, since surgery had a cent percent cure rate, it is the treatment of choice provided the lesion is identified properly and removed in toto. Conservative treatment is however even otherwise offered initially and to patients with contraindication to surgery due to any cause. Vocal cord and voice hygiene is anyway the corner stone of treatment both before and after the surgery.⁵  The aim of a study by Gökcan KM et al.. was to present symptoms, laryngological findings, clinical course, management modalities, and consequences of vascular lesions of vocal fold. This study examined 162 patients, the majority professional voice users, with vascular lesions regarding their presenting symptoms, laryngological findings, clinical courses and treatment results. The most common complaint was sudden hoarseness with hemorrhagic polyp. Microlaryngoscopic surgery was performed in 108 cases and the main indication of surgery was the presence of vocal fold mass or development of vocal polyp during clinical course. Cold microsurgery was utilized for removal of vocal fold masses and feeding vessels cauterized using low power, pulsed CO(2) laser. Acoustic analysis of patients revealed a significant improvement of jitter, shimmer and harmonics/noise ratio values after treatment. Depending on our clinical findings, the authors proposed treatment algorithm where voice rest and vocal therapy is the integral part and indications of surgery are individualized for each patient.^{6, 8}

According to Schindler A et al.., benign vocal fold lesions are common in the general population, and have important public health implications and impact on patient quality of life. Nowadays, phonomicrosurgery is the most common treatment of these lesions. Voice therapy is generally associated in order to minimize detrimental vocal behaviours that increase the stress at the mid-membranous vocal folds. Nonetheless, the most appropriate standard of care for treating benign vocal fold lesion has not been established. The aim of their study was to analyze voice changes in a group of dysphonic patients affected by benign vocal fold lesions, evaluated with a multidimensional protocol before and after voice therapy. Sixteen consecutive patients, 12 females and 4 males, with a mean age of 49.7 years were enrolled. Each subject had 10 voice therapy sessions with an experienced speech/language pathologist for a period of 1-2 months, and was evaluated before and at the end of voice therapy with a multidimensional protocol that included self-assessment measures and videostroboscopic, perceptual, aerodynamic and acoustic ratings. Videostroboscopic examination did not reveal resolution of the initial pathology in any case. No improvement was observed in aerodynamic and perceptual ratings. A clear and significant improvement was visible on Wilcoxon signed-rank test for the mean values of Jitt%, Noise to Harmonic Ratio (NHR) and Voice Handicap Index (VHI) scores. Even if it is possible that, for benign vocal fold lesions, only a minor improvement of voice quality can be achieved after voice therapy, rehabilitation treatment still seems useful as demonstrated by improvement in self-assessment measures. If voice therapy is provided as an initial treatment to the patients with benign vocal fold lesions, this may lead to an improvement in the perceived voice quality, making surgical intervention unnecessary. They concluded that this was one of the first reports on the efficacy of voice therapy in the management of benign vocal fold lesions; further studies were needed to confirm these preliminary data.^{7, 8} We have also opined that vocal cord hygiene is paramount for the treatment and prevention of vocal cord lesions.

CONCLUSION

Vocal cord lesions are common causes of voice change or Hoarseness of voice. Vocal abuse is a chief cause of vocal cord lesion. Benign lesions are commoner than malignant especially in the younger age groups. MLS or Microlaryngeal surgery is the treatment of choice. If properly done under good visualisation using either a Microscope or Endoscope, the recurrence or residual rates are low. Vocal and voice hygiene before and after the surgery is the cornerstone of management.

REFERENCES

1. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck Surg. 2003 Dec;11(6):456-61.
2. Martins RH1, Defaveri J, Domingues MA, de Albuquerque e Silva R. Vocal polyps: clinical, morphological, and immunohistochemical aspects. J Voice. 2011 Jan;25(1):98-106.
3. Toran KC, Vaidhya BK. Objective voice analysis for vocal polyps following microlaryngeal phonosurgery. Kathmandu Univ Med J (KUMJ). 2010 Apr-Jun;8(30):185-9.
4. Sulica L, Behrman A Management of benign vocal fold lesions: a survey of current opinion and practice. Ann Otol Rhinol Laryngol. 2003 Oct;112(10):827-33.
5. Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H. Resolution of vocal fold polyps with conservative treatment. J Voice. 2012 May;26(3):e107-10.
6. Gökcan KM, Dursun G. Vascular lesions of the vocal fold. Eur Arch Otorhinolaryngol. 2009 Apr;266(4):527-33. doi: 10.1007/s00405-008-0792-8. Epub 2008 Aug 13.
7. Schindler A, Mozzanica F, Ginocchio D, Maruzzi P, Atac M, Ottaviani F. Vocal improvement after voice therapy in the treatment of benign vocal fold lesions. Acta Otorhinolaryngol Ital. 2012 Oct;32(5):304-8.
8. Daniela de Vasconcelos, Adriana de Oliveira Camargo Gomes, and Cláudia Marina Tavares de Araújo. Vocal Fold Polyps: Literature Review. Int Arch Otorhinolaryngol. 2019 Jan; 23(1): 116–124.