Benign lesions Flashcards
What are the causes of nodules?
hyperfunction primarily,
but also associated with:
reflux, allergy, chronic cough, URI, throat clearing, infection, dehydration, endocrine problems and VPI (velo pharyngeal incompetence-more vocal effort b/c trying to get closure- have hyperfunction.)
• Most time caused by phonotrauma. Reaction to the reflux causes nodules., not actual reflux. More sensitive mucosal lining. Can vary in size (pinhead to pea).
Where are nodules usually located?
epithelium at juncture anterior and middle thirds of vocal folds (bc medial compression where they cme together first).
-midpoint of the glottis.
How do nodules begin?
- Start as localized swelling; matures into white, fibrotic hard nodule (may need surgery)
- Generally bilateral
- Generally due to long term irritation of tissue
What are symptoms of nodules?
o Range minimal/mild to severe
o Features include hoarseness (just means dysphonia), breathiness (cant adduct the cords), possibly lowered pitch (perceived lower but in reg. range), strain (more effort to close), vocal fatigue, poor pitch control
o No 1:1 correspondence between size of nodule and degree of symptoms
o Vocal tract tension, pain, sense of something in throat
-less vibration in mucosal wave.
o * Acoustic features: can be normal or see jitter/shimmer outside normal range, reduced dynamic range; fundamental frequency unchanged
What tx should be used for nodules?
o voice tx first - patient education, awareness of muscle tension and use of easier phonation patterns
- reduce tension
- improve breath support
- use easy onset
- holistic approaches (ex. accent method) to take tension away from larynx.
o Need to manage associated factors, e.g., GERD, allergy and psychological problems
o Surgery may be required; approach typically microdissection or removal with CO2 laser
What are the causes of polyps?
due to hyperfunction, often one severe event, but also related to variety of other causes, especially smoking and allergy
Polyps characteristics?
• Tend to be unilateral
-usually filled with fluid.
• Can be pedunculated (connected by a little stem) or sessile (broad lesion)
• Can be located anywhere on cord (supraglottal and glottal) or subglottic
• Can be pervasive leading to condition called Reinke’s edema (chronic smokers, and vocal abusers too.. Terrible voice quality. Have to strip the cords and surgical intervention gets them working again) or polypoid degeneration; occurs more often in older women with smoking history
• Start as a nodule, tumor, blood. . Hard to tell if its in the anterior portion of cords because cant tell if nodule or polyp . Polyp can flop around under cords or above and does not affect.
Polyps symptoms?
worse dysphonia than nodules
o Hoarse, breathy quality
o Low pitch
o Can have airway obstruction if large, pervasive with stridor and dyspnea on exhalation
o If large, sense of globus, need to clear throat
o Coughing to clear throat ( functional behavior). Feel likes something is there.
tension.
• Acoustic features: similar to nodules
o Increased levels of jitter/shimmer
o Increased spectral noise
o Reduced pitch and dynamic range
Tx for polyps?
o Voice therapy alone: vocal hygiene and (direct approaches) easy phonation patterns, especially in patients with recent onset of acute polyp of medium size
- decrease tension
- improve breath support
- regulating pitch
o Surgical management: Often required, especially with RE and large, longer term lesions. No longer use vocal fold stripping where epithelial layer of fold removed, resulting in scarring
o Combination: often treat with voice therapy trial before surgery, especially to work on identifying and reducing vocal fold irritants; also tx after surgery/voice rest to prevent recurrence
o Ideal is to have tx before surgery, to avoid recurrence.
What is Leukoplakia/hyperkeratosis?
- An abnormal build up (dysplasia) of keratin on epithelial surface. Since vocal fold epithelium in normal state is non keratinizing, this development is always abnormal
- Some benign, some pre-cancerous: seems associated with degree
Vocal features associated with Leukoplakia?
hoarseness and reduced pitch
Tx for Leukoplakia?
o biopsy first to r/o Cancer
o Surgery is problematic- leads to scarring
o Alternatives: antireflux tx meds
o photodynamic tx: drug administered that is retained by abnormal cells, killing them
o Vocal hygiene, especially to eliminate the irritants causing the tissue change: dust, fumes, smoke, infected sinuses or pharynx, XRT
o If caused by irritation, to environmental things (dust, etc). Need to be counseled on how to portect themselves. Need to get careful history about env aspects that can contribute.
What are Contact ulcers and Granuloma?
• mucosa covering vocal processes collide repeatedly with hard surface
- usually includes inflammation
- results from inflammation, increased blood collection and connective tissue covered by squamous epithelium- may be end result of healing process associated with chronic irritation
- In hyperfunction, tips of aryt processes strike each other and abrade tissues, leads to devel of granulation
Characteristics of contact ulcers and granulomas?
- Occur posterior on VF, where folds attach to vocal processes of arytenoid cartilages
- Can be unilateral but often bilateral
- Granulomas may be pedunculated or sessile
Causes of contact ulcers?
o phonotrauma from low pitch and excess effort, explosive speech pattern (HGAs)
o high association with reflux
o endotracheal intubation
o smoking, allergies, infections, postnasal drip and chronic abusive throat clearing
o Also associated with air pollution, alcohol abuse
o Associated with stress
o Very often a combination of above!
o
Symptoms of contact ulcers and granulomas?
o throat clearing, o hoarseness, o low pitch and reduced pitch range, o vocal fatigue o sore throat o globus sensation o cough/throat clearing o dyspnea o May also experience pain, especially burning sensation with radiation to other areas, like ear; also ache and dryness
Treatment of contact ulcers and granulomas?
o Once correct diagnosis made, recommend voice therapy to focus on cause of problem and/or medical management of underlying conditions: reflux, allergies, etc.
o If nonsurgical means unsuccessful, might consider surgical management. Surgery alone often leads to recurrence
What are Vascular Lesions?
• Typical path of blood vessels in superficial Lamina Propria is longitudinal, but with phonotrauma, may see alteration in path of vessels due to dilation or ruptures:
What are the 3 types of vascular lesions?
o Hemorrhage(vessel bleeds out, happen to short term severe event)
o Varix: prominent, dilated vessel on surface (looks enlarged)
o Ectasia: proliferation of vessels in an area (little swollen vessels on cord, can cause voice change or not)
o Later two more likely to rupture than normal vessel; hemorrhage and edema can lead to stiffness of cord or formation of polyp or cyst
What are the causes of vascular lesions?
• Causes: trauma to cords, especially related to occupation use, such as with singers, teachers
- phonotrauma
- strain
What are the symptoms of vascular lesions?
o variable ranging from little to no voice change to severe disruption of phonation; may be sudden onset and may have history of repeated episodes
What Tx for vascular lesions?
often strict short term voice rest and then vocal hygiene program, managing hydration, underlying associated factors; sometimes requires surgical management
o Vascularizatio: Parallel to the edge of the cord. can be unilateral or bilateral. Professional NT. Most ppl don’t. if due to vocal abuse need tx after voice rest. Hem def need tx.
Characteristics of vocal fatigue?
bowing of cords or posterior chink, so cords not fully adducting
• May occur over course of day, worsening with use or may progressively worsen over time with no periods of recovery
• If it occurs without a hyperfunctional stage, may be psychogenic in etiology, not related to muscle fatigue
What are the symptoms of vocal fatigue?
o subjective perception of increasing effort to phonate;
o inconsistent voice quality and endurance;
o sometimes hoarseness,
o pain,
o dryness,
o reduced respiratory support,
o reduced dynamic range
what is needed for recovery of vocal fatigue?
o quick in muscles; more time needed for damage to epithelium and lamina propria
o Well hydrated tissues heal faster
o Dangerous case to work with: most itme try to get more force to close it but that’s what made them get it in the first place. Does it vary with occupational voice use. When teaching worst. Teach them to do everything you would do with hyperfucntioning client. Good breath support, least minimal effort, exaggerate easy onset speaking.
-usually 72 hours.
dx for vascular lesions?
videostroboscopy shows lesion, vf stiffness, loss of mucosal wave and amplitude.
