CHAPTER II

LITERATURE VIEW

1. Anatomy and physiology of larynx

a. Anatomy of larynx

Larynx is located at anterior of cervical vertebrae, opposite from the 3rd

to 6th cervical vertebrae. The size of it is 44 mm long, 43 mm wide, 36 mm

deep. There are some cartilage that compose the larynx. It is consist of cricoid

cartilage, thyroid cartilage, epiglottis,arytenoid cartilage, cornicuate cartilage

and cuneiform cartilage (figure 1). Thyroid cartilage is the largest cartilage that

compose the larynx, while Epiglottis is an essential leaf shaped cartilage that

act as a gate of trachea which has a protective fuction to prevent chokced

(Pensky B, Gest TR.2001).

Figure 1. Computed tomography in trasnverse view of the head and neck

cartilage (Pensky B, Gest TR.2001)

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 The interior of larynx consist of some part. From the enterance to the

lower border of cricoid cartilage, It is consist of vestibule, ventricle and true

vocal fold. True vocal fold is Formed by mucous membrane lining conus

elasticus, with thyroarytenoideus muscle lying laterally. It also divide the

larynx into supraglottic an infraglottic portion, with separate the sensory

supply. Vocal cord is a structure which made from the thickened process of the

upper edge of conus elasticus. It is attaching specifically to vocal process of

arytentoid cartilage and junction of thyroid laminae anteriorly; also known as

vocal ligament, that is pearly white with covering of fine blood vessels when

seen via laryngoscope. The terms “vocal folds” and “vocal cords” are often

used interchangeably, because movement of 1 means movement of the other;

however, cord is the part of the fold which is most involved in vibrating to

create sound waves (figures 2) (Pensky B, Gest TR.2001)

Figure 2. anatomy of vocal fold

(https://upload.wikimedia.org/wikipedia/commons/5/50/Gray956.png

5
 Innervation of the larynx is served by some region of nerve, which is

localized in each region. By its function, it could be divided into 2 groups of

nerve, sensoric (to mucous membranes) and motoric (to instrinsik muscle).

Sensoric group of nerve which innervates the supraglottic portion of larynx is

served by internal branch of superior laryngeal nerve (from vagus Cranial

Nerve X), while the infraglottic portion is served by recurrent laryngeal nerves.

The motoric innervation of larynx is served by two nerves, that are External

branch of superior laryngeal nerve (from vagus Cranial Nerve X) which

innervates cricothyroid muscle and Recurrent laryngeal nerve (from vagus

Cranial Nerve X) which supplies all other laryngeal muscles via its inferior

laryngeal nerve (continuation within larynx) (Pensky B, Gest TR.2001).

Vascularization of larynx is served by to artery, that are superior

laryngeal artery and inferior laryngeal artery. Superior laryngeal artery rises

from superior thyroid artery, while inferior laryngeal artery rises from inferior

thyroid artery. Superior laryngeal artery supplies the blood to the upper half of

larynx, while the opposite supplies blood to inferior half of it. The vein of the

larynx follow the pattern of artery (Pensky B, Gest TR.2001).

Lympatic drainage of the larynx divided into supraglottic and

infraglotic protion. Supraglottic portion is drainage into infrahyoid nodes and

upper deep cervical nodes, while the infraglotic portion is draige into

prelaryngeal, pretracheal, and paratracheal nodes. There was a controversy

about the lymph drainage of the vocal fold, some experts believe that lymph

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drainage of the vocal fold is same like supraglottic portion of larynx, but other

believe that vocal cord has no lymphatic vessels. Either way, edematous,

swollen folds take time to return to normal, and tumors in this area can be long

confined before metastasizing (Pensky B, Gest TR.2001).

b. Physiology of larynx

The special function of the larynx is phonation. The ability to couple

phonation with articulation and Resonance allows for human speech.

Phonation and precisely how it relates to laryngeal vibration has undergone

many evolving theories over the years. Sound production requires that several

mechanical properties be met. There must be adequate breath support to

produce sufficient subglottic pressure. There also must be adequate control of

the laryngeal musculature to produce not only glottic closure, but also the

proper length and tension of the vocal folds. Finally, there must be favorable

pliability and vibratory capacity of the tissues of the vocal folds. Once these

conditions are met, sound is generated from vocal fold vibration. If there is any

physyilogical or structural abnormality that could make abnormal vibration

such like vocal node, it could produce abnormality of phonation (Rosen CA,

Simpson B.2008).

How the sound and its typical has been studied for several years. Actual

phonation is a complex and specialized process that involves not only

brainstem reflexes and the muscular actions described above, but high-level

cortical control as well. Accessory effects Such as Lung capacity, chest wall

7
compliance,pharyngeal, nasal and oral anatomy and subsequent mental status

also play a role (Rosen CA, Simpson B.2008).

Figure 3. mechanism of vocal cord during phonation (figure A) and respiration

(figure B) (Reiter R, Hoffmann TK, Pickhard A et al.2015)

The process begins with inhalation and subsequent glottal closure. An

increase In subglottic pressure follows until the pressure overcomes the glottal

closure force and air is allowed to escape between the vocal folds. Once air

passes between the vocal folds, the body-cover concept of phonation takes

effect. The body-cover theory describes the wave-like motion of the loose

mucosa of the vocal folds over the stiffer, more densely organized vocal

8
 ligament and vocalis muscle. This motion is known as the mucosal wave. The

wave begins infraglottically and is propagated upward to the free edge of the

vocal fold and then laterally over the superior surface. Eventually, the inferior

edges become reapproximated due both to a drop in pressure at the open

glottis, and to the elastic recoil of the tissues themselves. The closure phase is

also propagated rostrally. With the vocal folds fully approximated, subglottic

pressure may again build and the cycle is repeated. This mechanism is

contradictively with inspiration process (figure 3) (Rosen CA, Simpson

B.2008)

2. Vocal node disease

a. Definition

Vocal node is a tissue proliferations on the free margin of the vocal

cord and thus hamper phonation. This soft tissue proliferation is believed due

to adaptive process that stimulated by many factor, specially due to trauma.

The main symptom of it is hoarness together with the reduced of volume and

fatigue of the voice. Diagnostic evaluation by laryngoscopic visualization and

histological examination after exicision are needed to determine and confirm

the diagnosis (figure 4) (Reiter R, Hoffmann TK, Pickhard A et al. 2015)

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 Figure 4. lary/ngoscopic view of vocal cord nodules (Bohleneder J.2015)

b. Etiology

Voice overuse and poor technique (misuse) – especially in professional

voice users – are pivotal in the formationof vocal nodes. Vibration during

phonation leads to increased forces and maximum impact stress and trauma at

the midmembranous part of the vocal fold, resulting in wound formation

followed by healing, remodeling, scarring, and nodule development (Karkos

PD, McCormick M.2009)

There is some cause of the vocal node development. It believes that

vocal node is a adaptive mechanism of vocal cord after simultaneous trauma.

Vocal fold nodules (eg. singer’s nodes), are traditionally seen as the

consequence of functional voice disorders, often caused by vocal abuse or

10
misuse, and are amongst the most common vocal fold pathologies (Bohleneder

J.2013).

Other etiologies of vocal cord nodule is traumatic lesion caused by

smoking and chronic laryngitis. Smoking contribute to 51% to 90 % chance to

become vocal cord nodule. Chronic laryngitis is other cause of vocal cord

nodule. Chonic traumatic lesion produced by chronic laryngitis could stimulate

the proliferation of soft tissue in vocal fold the generate the nodule (Reiter R,

Hoffmann TK, Pickhard A et al. 2015).

c. Prevalence

Vocal cord nodule contribute to 30% of all cause of hoarness. This

means that vocal is prevalence disease of the vocal cord (Reiter R, Hoffmann

TK, Pickhard A et al. 2015). Despite of it, the nationwide study about the

global prevalence is rare. Vocal nodules are common among the general

population; with a lifetime prevalence reported at 2.29% to 16.9% of the

population are currently experiencing voice problems In the South Korean

study about the epidemiology of vocal node which had been conducted from

2008 to 2011, the prevalence of vocal cord nodul is varying. The prevalence of

vocal cord nodul 0.99% in 2008, 1.72% in 2009, 1.71% in 2010, and 1.21% in

2011 from total 19.636 sample represent the nation population (Won SJ, Kim

RB, Kim JP et al. 2016).

There are some risk factor contributing to development of vocal node.

Age, education level, and vocal disorder were significantly correlated with the

11
presence of vocal nodules. From that study, younger age and higer education

level (specially for those who completed education at college) has a significant

risk to develop vocal node. Althougt smoking was claimed as a substantial risk

factor for development of vocal node,this study doesn’t proof that smoking has

a relation to vocal node development (Won SJ, Kim RB, Kim JP et al. 2016 )

d. Pathogenesis

The pathogenesis of vocal cord nodule is believed due to cecchronic

trauma on vocal cord. Voice abuse cause the disproportionately high

mechanical shear on the free edge of the vocal fold which damages the

superficial layer of the lamina propria and results in micro-vascular changes in

the middle third of the fold. In time, this results in remodelling of the tissue

with increasing hyalinization and epithelial hyperplasia, leading to typically

circumscribed lesion in the vocal folds. Histologically, thickening of the

basement membrane and an edematous swelling of the lamina propria are

characteristic (Bohleneder J.2013).

Histologically, long term of voice abuse could trigger some of

histological changes in the vocal cord, and it is a cornerstone of differentiation

diagnosis of the vocal cord nodule with other benign vocal cord disease such

like vocal cord polyps and Reinke’s Oedema. In vocal cord nodule, histological

changes typically produce hyperplasia in the epitheliala layer and also

parakeratosis keratinization. Moreover, the typical lesion of lamina propia

layer in vocal cord disease is dominates by fibrosis of its layer. This

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histological founding is different with other bening lesion of vocal cord, which

is in vocal cord polyps, it is dominated with athrophy of the epithelial layer. By

its fact, it is necessary to includes the role of histological examination to

determine the diagnosis of vocal cord benign lesion (Nunes RB, Behlau M,

Nunes MB et al.2013).

Although the mechanism of formation of a particular type of lesion

(nodule, polyp, or cyst) remains incompletely understood, a recent study has

attempted to correlate the clinical diagnosis of vocal fold polyps, nodules, and

Reinke’s edema with histologic findings following excision, because it give

any different typical lesion which could help to determine the real diagnosis

(John MM.2003).

By its histopathological progression, lamina propria tend to play a

significant role in the pathogenesis of vocal nodes. By the lamina propia

progression, vocal nodes could be differentiated into 5 stages, edematous (least

mature), edematous-angiomatous, angiomatous, angiomatous-hyaline, and

hyaline (most mature). Stroboscopic examination is important to diffenetiated

the stage of vocal nodes. This stage of progression also important to start the

theraphy, wheter the voice therapy which preferably in earlier stage and

surgical stage which preferably in later stage (John MM.2003).

Lamina propia of the vocald fold is an important substances which

determine the elasticity of the vocald fold, which inturn also affect the quality

of voice. In the vocal nodes, the lamina propia which normaly contain of

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hyaluronic acid, were substitute with scars tissue. this mechanism then produce

the hoarness and fatigue of voices (Karkos PD, McCormick M.2009).

Despite it important function, hyaluronic acid are pottentialy to become

a treatment option of vocal node. In a recent animal study, crosslinked

hyaluronic acid (hylan B gel) was evaluated as a scaffold for tissue

regeneration and mucosal wave restoration in canine vocal folds. Five beagles

underwent stroboscopy before ablation of the vocal fold with a laser. Four

weeks later, stroboscopy was repeated before and after submucosal injection of

hylan B gel into the left vocal fold of four animals and of isotonic saline

solution in one animal. Stroboscopy was repeated 12 weeks later, and

histologic analysis was performed. Submucosal hylan B gel injection in laser-

ablated canine vocal folds restored tissue volume and mucosal waves and

facilitated functional tissue regeneration over 12 weeks. The authors concluded

that hyaluronic acidmayhaveutilityasasofttissuescaffoldforrehabilitation of

phonatory function in vocal folds with lamina propria defect, such as vocal

nodes (Li L. Kiick KL .2014)

e. Diagnosis

Diagnosis of vocal cord nodule is based on clinical appearance which

hoarness as the main symptom. Physical and supportive examination could

help to determine the diagnosis of vocal cord nodule. The differential diagnosis

of vocal cord nodule are other benign lesion of the vocal cord (vocal cord

14
polyps, reinke’s oedem) and malignan lesion (Maharhan S, Parajuli R,

Neopane P.2017).

From the physical examination using laryngoscope, Typically vocal cord

nodules are bilaterally symmetrical in the middle third of the vocal fold and

located superficially on the vibrating free edge of the fold. The anatomical

diagnosis can be difficult because of the heterogeneity of lesions ranging from

discrete, poorly circumscribed edematous lesions to hard, horny nodules.

Stroboscopic examination reveals the incomplete glottis closure (classically an

hour-glass closure pattern) that can help making the diagnosis. Patients often

present with a poor vocal endurance and a quickly tiring voice (Maharhan S,

Parajuli R, Neopane P.2017).

Histological examination of the tissue play a main role to

differentiating the diagnosis of vocal cord lesion. There are some keys point to

differentiating the diagnosis of vocal cord benign lesion by histological

finding. Vocal cord nodule represent with predominance of epithelial changes,

hyperplasia and parakeratosis keratinization . As for the polyps, there was a

predominance of atrophy. Moreover By analyzing the lamina propria,

predominance of edema is more prominence in polyps and fibrosis in the

nodules. In the basement Membrane examination, thickening of basement

membrane is more prominence in nodules and it was thin/intact in polyps. This

feature is very important in the differentiation of the lesions, being significant

15
in the pathological examination and could be a key point to determine the

diagnosis (figure 5) (Nunes RB, Behlau M, Nunes MB et al.2013).

Figure 5. histological pattern of vocal cord polyps (left) and vocal cord nodule
(right). Note that epithelial thickening is prominence in vocal cord nodule and
there is atrophy in lamina propia of vocal cord polyps (Nunes RB, Behlau M,
Nunes MB et al.2013)

Altough neccesery, it is often difficult to tell the different lesions of the

lamina propria apart (eg. nodules, polyps and Reinke’s edema). The correct

diagnosis cannot therefore be made purely histologically, but requires a

complete assessment including history, voice assessment and

laryngoscopic/stroboscopic findings (Bohleneder J.2013)

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3. Treatment option of vocal node disease

a. Overview of vocal node management

Conservative voice hygiene and voice therapy are viable therapeutic

measures for nodules. The patient’s motivation, vocal requirements in social

and professional life together with the correct diagnosis allows an appropriate

conservative treatment plan to be formulated. It is worth noting that a

specifically tailored program, including targeted voice therapy, achieves better

results than a generic program. Whilst there is often a subjective and objective

improvement of the voice, this is not always matched by improvements in the

laryngoscopic/stroboscopic findings (Bohleneder J.2013).

When conservative measures fail to achieve the desired results,

phonosurgery may be indicated. It is therefore the patient who dictates the need

for surgery rather than the size of the nodules alone. Furthermore, it should

also be borne in mind that surgery does not necessarily correct the underlying

causal process at hand Voice therapy is therefore key to gain a long lasting

improvement after surgery and reduce the likelihood of recurrence (Bohleneder

J.2013).

Surgical intervention is also not without risks. Despite careful micro-

dissection, damage to the lamina propria can lead to further voice problems.

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The deeper the resection, the more likely changes in stiffness of the vibrating

free edge will lead to a poor voice. Lesions which are only identifiable on

stroboscopic examination can be particularly difficult to operate on under

general anesthesia. For all intents and purposes, the surgeon is carrying out a

“blind” dissection which increases therefore the post-operative risks

(Bohleneder J.2013).

Radiophonosurgery was known to be potential as the treatment

approach for vocal cord nodule. A study which was comparing effectiveness of

radiophonosurgery and cold steel knife surgery in group of patient with vocal

cord nodule which fail with conservative theraphy, give no significant different

in both of theraphy. Although mean surgery time is less in phonosurgery

therapy, that was not significant. There was also no significant diiferent in

efficacy, effectiveness and side effect from both therapy

Whether surgery should be performed with cold steel dissection or laser

is still a matter of controversy as both afford much the same results in

experienced hands. We would argue however that the use of the laser for

superficial lesions should only be performed if good tissue protection can be

afforded. Until further evidence of its safety, overall we would recommend

against the use of lasers (Bohleneder J.2013).

b. Non surgical treatment of vocal node

Voice therapy is a based therapy for vocal node disease. Although

could be as preparation before surgery procedure or after surgery, voice

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therapy play a big role in the restoration of normal phonation. The rationale for

a non-surgical approach lies in the fact that voice therapy minimizes

detrimental vocal behaviours that increase the stress at the mid-membranous

vocal folds, and may lead to better voice quality and voice performance that is

sufficient to cope with everyday vocal load (Schindler A, Mozzanica F,

Ginnocchio P et al.2012)

Principles therapy of voice therapy in vocal nodes are restoring the

normal function of vocal fold. This can be achieved, for example, by reducing

vocal intensity or by minimizing behaviors that produce abrupt and forceful

contact between the vocal folds, such as hard glottal attacks at the onset of

voicing, coughing, throat clearing, etc. Patients may be advised to use

amplification in order to speak at a normal, conversational level, even when

speaking to a group or in a classroom. Other devices currently available permit

documentation of voice use, at what intensities and frequencies, over a given

time (Leonard R.2009).

Voice therapy consists of five basic behaviourally-based approaches:

vocal hygiene, direct facilitation of vocal production, respiratory support,

muscle relaxation and carryover. Nonetheless, the most appropriate standard

of care for treating benign vocal fold lesions has not been established, and no

consensus exists with respect to recommending voice therapy, because only

limited objective data exist regarding its efficacy (Schindler A, Mozzanica F,

Ginnocchio P et al.2012).

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 Despite its function to promote the rehabilitation of hoarness due to

vocal cord nodule, several study has conclude the benefit of voice therapy.

From the study that involved 16 person with mean age 49 years with vocal

cord lession who was follow 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, they found that voice therapy only give a

small benefit as only treatment of vocal cord lesion. the study found that 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. It could be concluded that voice therapy only give a minor chages

in vocal cord lesion, although it has to be considered in all of case of vocal

cord lesion to do voice theraphy as a first line theraphy (Schindler A,

Mozzanica F, Ginnocchio P et al.2012).

Other study about the benefit of voice therapy that conduct the sample

from pediatric patient with vocal cord nodule give a contradictive report. A

study that involved 46 children (ages 4–14, mean 10 years) with vocal cord

nodule who underwent a combination of pharmacologic treatment, physical

therapy, psychotherapy, occupation therapy, relaxation therapy, and speech

therapy. These children were compared to a control group of children without

voice disorders. After therapy, they noted a flattening of the nodules on

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stroboscopy. The group also noted that, on acoustic parameters, jitter

approached that of the control children, and that shimmer and noise to

harmonic ratio (NHR) also improved significantly (Ongkasuwan J, Friedman

EM.2013).

Other study also conclude that voice therapy has a significant

improvement for treating vocal cord nodule in children. A study invoved 39

children (ages 7–14, mean 10 years) with vocal fold nodules with therapy that

began with vocal hygiene and progressed to laryngeal massage, yawn/sigh,

chewing method, and resonant voice, depending on patient cooperation.

Therapy last for 45 minutes per week for 8 weeks. They also found statistically

significant improvements in jitter, shimmer, and NHR. Perceptually, there also

were statistically significant changes in overall grade, roughness, breathiness,

and strain. Even there are some contradictive result after voice therapy in case

for treatingvocal cord nodule, it is quiet usefull to do voice theraphy in patient

with vocal cord nodule, because of some evidence has proof the effictaion and

benefit of it (Ongkasuwan J, Friedman EM.2013).

There was a srudy comparing the effectiveness in each voice therapy.

Voice production therapy and vocal hygiene education is the leading type of

voice theraphy in patient with vocal node, but there is no study which

comparing which is more effective rom both. By detecting the Voice Handicap

Index (VHI) as the primary outcome of the study, voice production therapy is

significantly more effective compared to voice hygiene education in the

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resolution of the hoarness caused by vocal node (Behrmann A, Rutledge J,

Hambree A et al.2008).

c. Surgical treatment of vocal node

It has described above that vocal node mostly appear as hoarness.

Sometimes conservative therapy doesn’t give a significant progression, so

clinician then consider to do more advance therapeutic approach, such as

phonosurgery. Phonosurgery is a surgical procedure to restore the function of

phonation. Today, the procedure of phonosurgery comprise of

phonomicrosurgery with a direct or indirect acces to the larynx. The aim this

procedure include repairing the important tructyure of vocal fold that

contribute to normal phonation and also removing pathologic tissue, such as

vocal cord nodule, polyps, cyst, scars, carcinomatous tissue or defect (Nawka

T, Hosemann W. 2005).

Surgery of small epithelial and subepithelial changes of the vocal folds

(up to 5 mm), can be carried out on an awake patient with local anaesthesia.

Premedication (10 mg morphine and 0,5 mg atropin s.c.) is given 10 minutes

prior to the intervention. The throat and the larynx are anaesthetised

superficially with Tetracain, by spraying, and subsequently directly, by

applying a soaked cotton swab. This procedure allows for a safe removal of

nodules, polyps, oedema, small papilloma and diagnostic biopsies with the

advantage of stroboscopic and auditive voice control. These procedures are

performed on an outpatient basis. The operating field is visualised via a

22
laryngeal mirror and an operating microscope, or a rigid 90° (70°) telescope.

The larynx can be observed directly or on a video monitor. The correct

indication and skill facilitate the precise removal of pathologic changes. This

technique will remain important because of the need for cost effective

outpatient procedures. It should belong to the repertoire of any phonosurgeon

(Nawka T, Hosemann W. 2005).

Laser microsurgery has marked a big step ahead in the treatment of the

larynx. However, since its introduction, objections were made against it. The

main arguments were thermal damage, carbonisation, delayed wound healing

and subsequent scar formation. These observations were made based on lasers

with a large focus and a spot of more than 1 mm diameter. Meanwhile, lasers

have improved significantly, namely by a striking reduction of the focus

(microspot laser) to a spot size of 0,25 mm or less. Because of its small

penetration into tissue, due to the high absorption of infrared light with a

wavelength of 10,6 µm, the CO2 laser is especially suitable for cutting tissue.

Today, laser tissue interaction can be controlled in a way that the thermal

damage does not go deeper than 50µm. This is achieved by very short exposure

(up to 0,01 seconds). If a deeper cut is needed, the power has to be increased.

The quick repetition of laser pulses with high energy peaks, is termed

"ultrapulse" or "superpulse". With the Q-switched mode, the CO2 laser

produces very high levels of energy for very short periods of time (104-

105watts per picosecond) reducing, thereby, carbonisation and thermal

necrosis. A recent system of laser beam guidance is the acublade-system. It

23
 moves the laser beam very fast along a defined path, which minimises contact

time and, hence, thermal damage. The laser cut is similar to a cut with cold

instruments (Nawka T, Hosemann W. 2005).

As a result of technical improvements, the laser has become more

accepted in phonosurgery. Prospective randomised studies compared the

results of laser surgery with cold instruments, but did not yield significant

differences in voice quality and speed of recovery (Benninger MS.2000).

For lesions in the epithelium and the lamina propria such like vocal

cord nodule, a power of 2 to 3 watts may be sufficient when exposure time is

short. Resection of musculature needs a power up to 15 watts. Bleeding plays a

minor role in phonosurgery, being that the haemostatic cutting properties of the

laser utilising the mentioned parameters are sufficient for these procedures.

The technical execution of the surgery confining the laser resection to the

epithelium, has to be practised in order to avoid thermal damage of the lamina

propria. A surgeon who chooses the laser for phonosurgery has to be familiar

with the danger of destruction to obviate scarring of a big area or at a

functionally important localisation (Nawka T, Hosemann W. 2005).

4. Mycrolaryngocopic procedure to treat vocal node disease

a. Advantage of microlayngoscopic procedure for vocal node

The advantages of direct microlaryngoscopy are a binocular

stereoscopic technique is high magnification, a sharp image with excellent

illumination, medical relaxation of the patient, and a support for both hands of

24
the surgeon in a fixed position. This access is the most common one in

phonosurgery (Nawka T, Hosemann W. 2005).

b. Planning for phonosurgery in vocal cord nodule

It is necessary to plan when patient should undergo surgery for vocal

cord nodule. The majority of patients require a significant amount of time to

recover after phonomicrosurgery. Thus, it is important that the surgeon and

patient discuss the need for an adequate amount of time for voice recovery

after these procedures. Often a short period of complete voice rest immediately

after phonomicrosurgery is indicated. This can range from 2 to 14 days and

typically averages 7 days (Rosen CA, Simpson B.2008).

The time of voice limitation before allowing the phonomicrosurgery

patient to use full speaking voice activities ranges from 7 to 30 days. Similarly,

the vocal recovery time before full singing is allowed is individualized to the

patient situation, but typically ranges from 30 to 90 days. Thus, the patient

must cancel pending voice demands when scheduling phonomicrosurgery or

delay the surgery date until there is a more appropriate time after the surgery to

accommodate reduced voice demands. This is especially important for vocal

performers, given that they have many demands on themfrom management and

staff (Rosen CA, Simpson B.2008).

Any conditions that will create temporary vocal fold edema prior to

phonomicrosurgery should be avoided or treated prior to proceeding. Thus,

heavy vocal demands such as singing, screaming, yelling, or lecturing should

25
be avoided approximately 1–2 weeks before phonomicrosurgery. Similarly,

comorbid medical conditions such laryngopharyngeal reflux disease and

sinonasal allergic disease, and upper respiratory infection should be treated and

may be reason to reschedule the surgery. In some instances, a short dose of oral

steroids can be used to alleviate the temporary vocal fold edema associated

with these conditions prior to phonomicrosurgery (Rosen CA, Simpson

B.2008).

The reason for avoiding temporary vocal fold edema immediately prior

to phonomicrosurgery is to minimize the removal of vocal fold tissue

(epithelium and/or lamina propria) that appears permanently pathological but,

in fact, may represent temporary edema. If this occurs, excessive excision may

result and may affect voice restoration (Rosen CA, Simpson B.2008).

Normally, phonosurgery is an elective surgical procedure, but in any

cicumtances, there are some point to consider surgical procedure immedietly.

This circumstance include dysphagia associated with aspiration, impending

airway embrasement, and risk of malignancy (Rosen CA, Simpson B.2008).

c. Anesthesia and airway management for laryngeal surgery

Airway management in laryngeal surgery is a fundamental aspect.

Sharing the airway with our anesthesia colleagues is one of the most important

(and often neglected) aspects of successful laryngeal surgery. Lack of

collaboration and preoperative planning with the anesthesiology team can turn

26
an otherwisesimple microlaryngoscopy case into a chaotic, life-threatening

airway crisis(Rosen CA, Simpson B.2008).

There are some consideration to be prepared for airway management

before undergo laryngeal surgery and it should be discussed with

anesthesiologist. The patient should be placed in the “sniffing positioning,”

with the head extended (at the atlanto-occipital joint), and the neck flexed

(along the cervicothoracic vertebrae) for optimal laryngoscopic exposure

(Rosen CA, Simpson B.2008).

In general, lesions located on the anterior two thirds of the larynx

(membranous vocal folds) can be adequately exposed/treated with a 5.5 or

smaller ETT. Lesions of the posterior third of the larynx (vocal processes and

posterior commissure/arytenoids region) require one of the following ; jet

ventilation, Apneic technique or ETT placement anteriorly resting on top of the

laryngoscope. Microlaryngoscopic surgery generally employs one of the

following methods for maintaining the airway (Rosen CA, Simpson B.2008) :

o Oral intubation using a small diameter endotracheal tube of adequate

length: 5.0 or 5.5 MLT (microlaryngoscopy tube) (figure 6). MLT

(microlaryngoscopy) endotracheal tube is a small-diameter ETT with an

extended length. Most “regular” ETT (size 5.0 and smaller) are not long

enough to adequately span the distance between the oral commissure and

the subglottic/tracheal airway.

27
 Figure 6. Microlaryngoscopy tube (MLT) 5.0 & 5.5 (Rosen CA, Simpson
B. 2008)

o Jet Venturi ventilation using one of the following methods:

 Subglottic Mon-Jet/Hunsaker jet ventilation tube (figure 7)

 Supraglottic jet Venturi needle (via port within laryngoscope or

attached to laryngoscope) (figure 8)

Figure 7. subglottic Mon-Jet / Hunsaker jet ventilation tube (Rosen CA,

Simpson B.2008)

28
 Figure 8. jet venture needle and jet ventilation tubing / pressure gauge
(Rosen CA, Simpson B.2008)

d. Step by step of mycrolangiscopic procedure for vocal node

Surgery for vocal fold nodules is reserved for persistent and significant

dysphonia (with functional limitations) after all nonsurgical treatment options

are exhausted. Surgery for vocal fold nodules without a thorough and properly

implemented nonsurgical therapy course is not appropriate. A relative

contraindication to surgery for vocal fold nodules is a patient that has not been

compliant with voice therapy nor changed the habitual phonotraumatic

behavior that most likely led the formation of the lesions (Rosen CA, Simpson

B.2008).

There are two methode of surgical theraphy for treating vocal cord

nodule; phonomicrosurgery and CO2 laser microsurgery. Cold-steel excision is

29
the preferred method for vocal fold nodules removal; however, in rare

instances, and with great experience and the optimal laser technical abilities,

the CO laser can be used to remove vocal fold nodules as well. Despite of it, a

Cochrane study conclude that there is no significant difference in the outcome

of cold steel and laser method (Pedersen M, McGlashan J.2001).

The procedure of microlaryngeal surgery are following ((Rosen CA,

Simpson B.2008):

1. Complete exposure of the membranous vocal folds with suspension

laryngoscopy

2. The vocal fold lesions should be palpated gently under

highpowermagnification. During this, the vocal fold lesions should

be assessed for their degree of submucosal pathology and

examinined for associated pathologic lesions such as vascular

lesions, evidence of scar, sulcus vocalis, and other vocal fold

pathologies. Special attention should be given to the anterior

commissure to evaluate if there is a presence of an anterior

commissure microweb.

3. The surgical removal of vocal fold nodules starts with a very

careful grasping of one of the lesions with a small triangular or

curved alligator instrument. The approach to the grasping of the

lesion should be as close to perpendicular to the longitudinal axis

of the vocal fold as possible and as superficially as possible. After

30
 the lesion is grasped, the lesion is drawn to the midline gently and

very careful observation of the demarcation between vocal fold

pathology and the normal vocal fold free edge should be identified.

4. Microscissors, either straight-up or curved (aimed in a direction

Away from the vocal fold) should be used for a submucosal

excision of the vocal fold lesion (figure 9). As the excision is

performed from posterior to anterior,care should be taken to ensure

that the tips of the vocal fold scissors do not extend deep into the

vocal fold nor past the anterior border of the vocal fold lesion

(figure 10). Without special attention to this area, excessive

anterior vocal fold mucosa can be removed with the vocal fold

lesion excision.

5. If there are any residual mucosal irregularities at the excisionsite,

then these should be removed in a careful, conservative fashion by

either removal of the irregular abnormal mucosa with microcup

forceps or by microsurgical scissors excision (figure 11).

6. After removal of the benign vocal fold lesions, careful examination

Visually as well as on palpation (using The outside curve of curved

elevator or curved alligators) should be performed at the operative

site(s). There may be some additional fibrous or gelatinous material

at this location, which should be carefully removed to prevent a

rapid recurrence of the vocal fold pathology.

31
 7. This material can be removed with a microelevator or microcup

forceps. Extreme Care is required at this juncture of the surgery,

because too-aggressive removal of this material can result in

significant scar formation as well as a permanent deformity of the

free edge of the vocal fold.

8. At the completion of the vocal fold lesion(s) excision the free edge

of each vocal fold should be completely straight without exophytic

mucosal tags and without a divot or concavity of the free edge of

the surgical sites

Figure 9. submucosal exicision of vocal node (start) (Rosen CA, Simpson

B.2008)

32
Figure 10. submucosal exicision of vocal node (finish) (Rosen CA, Simpson
B.2008)

Figure 11. removal of abnormal mucosa from operative site (Rosen CA, Simpson
B.2008)

33
e. Postoperative care and complication

Voice rest is used for a variable length of time, depending not only on

the size and nature of the lesion, but also on compliance issues of the patient.

In general, compared with other phonomicrosurgical procedures, a shortened

amount of voice rest can be used after vocal fold nodules removal if the patient

will be compliant with light voice use instead of total voice rest. As an

example, for an extremely compliant patient, voice rest may be needed only 1

or 2 days, proceeding to light voice use if the patient is continuing to be

compliant, and the stroboscopy results are favourable (Rosen CA, Simpson

B.2008).

Some of complication after surgery include excessive scarring,

submucosal hemorrhage, residual vocal fold pathology, and excessive removal

of vocal fold tissue, resulting “cookie bite” defect. Cookie bite defect could be

prevented with very careful submucosal excision of the vocal fold lesion and

utilizing great precision and control to prevent the surgical excision from

entering into the deeper aspects of the lamina propria or vocal ligament (Rosen

CA, Simpson B.2008).

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f. Long term evaluation of procedure

As mentioned above, there are contradictively result about voice

therapy, so surgical therapy is one of potential methode to choose, but there

only limited data about the long term evaluation of voice restoration after

surgical therapy. In a ten year prospective study with aim to evaluate the

prognosis after 5 year undergo surgical therapy in vocal cord nodule patient,

there’s some report about recurency and tretamnet complication (Bequignon E,

Bach C, Fugain C et al.2013).

In the evaluation after surgery in 62 pasien who was undergo srurgical

therapy for vocal cord nodule, The immediate objective success rate was 95%

at the postoperative visit (59 normal vocal folds and 2 cases of incomplete

surgery). Fifty-nine patients were ‘‘satisfied’’ or ‘‘very satisfied’’ immediately

after surgery and the immediate satisfaction rate was 95%. Two cases of

postoperative subcutaneous emphysema and pneumomediastinum were

observed; pneumomediastinum resolved spontaneously in both cases

(Bequignon E, Bach C, Fugain C et al.2013).

Moreover, Recurrent dysphonia was observed in 19 patients (30%)

after a mean interval of 5.2 years after surgery and new benign vocal fold

lesions (nodules or Reinke’s edema) were observed in 11 patients (18%). In the

evaluation about voice handicap index (VHI), The mean long-term VHI score

was 11.5 (range: 0–67). The mean score of the physical handicap subscale,

which accounts for 49% of the overall VHI score, was 8.5. The mean score of

35
the functional handicap subscale, which accounts for 23%, was 4, and the mean

score of emotional handicap subscale, which accounts for 28%, was 5.

Subjective evaluation of dysphonia was significantly correlated with the VHI

score. Recurrences were associated with a significantly higher VHI score

(Bequignon E, Bach C, Fugain C et al.2013).

36
 CHAPTER III

CONCLUSION

Vocal cord nodule is a prevalence disease which mostly affect the person

who usualy got vocal abuse, such like singer. Hoarness is a the main complain of

the disease, and patient could also complain about reduced of voice volume and

fatigue when speaking.

Diagnostic approach for vocal cord nodule include examination of voice

abuse history, physical and supportive examination. By direct / indirect

laryngoscop, vocal cord nodule could appear as bilateral nodule at the vocal fold.

Histological examination is important as it could determin wheter the lesion is

vocal cord nodule, polyps or oedema.

Treatment approach of vocal cord nodule include surgical or non surgical.

Non surgical treatment by voice therapy is mandatory for the first line therapy. If

there is no significat of nonsurgical treatment, or there is any difficulty in breate

and also reflux, surgical treatment is the option. It could be done with cold steel or

CO2 procedure. There is some complication to be considered, as it could affect

the voice restoration.

37
 Flowchart of diagnostic and therapy of vocal cord nodule

history taking :
hoarness, vocal
abused

direct / indirect
laryngoscope

vocal cord vocal cord Reinke's

polyps nodule Oedema

Histological True diagnosis

of vocal cord Early stage Voice therapy
examination &
determining the nodule
stage

Late stage No adequate

responses
Airway
consideration

Post op therapy & Surgical therapy Long term evaluatin

Complication 38