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DrtBalu's Otolaryngology Online

 

Benign Vocal fold disorders

 

These disorders involve the mucosa lining the vocal cord. The free border of the vocal cord is responsible for voice production. At any
given period of time about 50% of patients are affected by this disorder. These disorders are caused by vibratory trauma to the mucosa
lining the free border of the vocal cord. Certain predisposing factors like Gastro esophageal re ux disorder, Smoking, Infections, Allergy
may predispose this condition. This problem is most common among expressive and talkative personalities.

The following conditions are included under Benign vocal fold mucosal disorders:

1. Vocal nodules

2. Laryngeal polyps

3. Mucosal haemorrhage

4. Intracordal cysts

5. Mucosal bridges

6. Glottic sulci

If the affected pateint happens to be a singer, they may seek professional help because of voice limitation during singing, usually in the
upper range. If the patient is a non singer then the patient may seek help with a little advanced lesion with a change in sound
capabilities of the speaking voice.
Anatomy of the vocal fold:

Medial to lateral the membranous vocal fold is made up of squamous epithelium, Reinke's space (super cial layer of lamina propria)
which is a potential space, vocal ligament (consisting of elastin & collagen bres), thyroarytenoid muscle. Perichondrium & thyroid
cartilage provide the lateral boundary.

Image showing vocal fold polyp

Image showing cut section of vocal fold

These vocal folds move as a whole between the extremes of abduction & adduction for breathing and phonation respcetively. The vocal
fold mucosa (consisting of epithelium & super cial layer of lamina propria also known as Reinke's space) which covers the vocal folds
is the chief oscillator during phonation causing continuous adduction. So it is the vocal fold mucosa which vibrates and not the vocal
cord perse.

Hirano gave an excellent description of the ultra structure of the vocal cord. Acccording to him the body of the vocal fold is formed by
muscle, which is covered by epithelium and super cial layer of lamina propria as the cover. The intermediate layers are formed by
Collagenous and elastic bres. These layers differ in their stiffness characteristics leading to different rates of vibrations during
phonation. This whole process is known as decoupling. This decoupling allows the mucosa to oscillate with a degree of freedom from
the ligament and muscle.

For phonation to occur pulmonary air is passed between adducted vocal folds. During this phase the vocal fold mucosa vibrates
passively according to the length, tension and edge con guration determined by the intrinsic muscles, elastic recoil forces of the vocal
fold mucosa.

How to evaluate these patients?

a. A good history taking is a must.

b. Assessment of vocal capabilities and limitations should be done.

c. Laryngeal examination.
History taking: should concentrate on the onset and duration of the vocal symptoms, exacerbating factors if any should be taken note
of, symptom complexes must be studied, talkativeness of the patient must be ascertained, vocal commitments, other risk factors,
severity of the disorder and vocal aspirations must be clearly noted.

Onset of symptoms: If the patient has complaints of frequently recurring bouts of vocal dysfunction, it could be safely assumed that it
may be an exacerbation of a more chronic voice overuse disorder. These patients will bene t from voice training.

Exacerbating causes: Common symptoms are

1. Exaggeration of day to day variations of singing capabilitis.

2. Increased effort necessary for singing

3. There is clear reduction in vocal endurance

4. There is deterioration of ability for high frequency singing

5. There is delayed phonatory onset and air wastage

Risk factors:

1. Tobacco

2. Alcohol

3. GERD

4. Certain drying medications prescribed for allergy

The following are the management options available:

1. Hydration

2. Management of sinusitis

3. Management of acid re ex laryngitis : These patients have bad taste in the morning, scratching throat irritation, habitual throat
clearing, erythema of arytenoid mucosa, and interarytenoid pachydermia / contact ulcers.

4. Voice rest.

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