Otolaryngology, ENT

1. Structural Disorders
Of The Vocal Cords
Dr.Khalil Nasr Elkahlout
R3 ENT , Alshifa hospital
Supervisor : Dr.Mohammad Khalil Murad
ENT & CI consultant

2. Introduction
The assessment of a patient with a voice disorder should be
done in a multidisciplinary clinic by a laryngologist and a speech
therapist.
Persistent or progressive dysphonia may suggest an organic
lesion in the larynx, while intermittent dysphonia may
suggest a functional disorder.

3. History
• Dysphonia/hoarseness : any impairment of voice or difficulty speaking
• Dysarthria : difficulty in articulating words
• Dysarthrophonia : dysphonia + dysarthria (e.g. CVA)
• Dysphasia : impairment of the comprehension of spoken or written
language
• Odynophonia : pain when talking
It is important to know the patient’s occupation and professional and
recreational voice usage

4. Examination
• Neck for previous surgery or masses
• Nasal cavity
• cranial nerve or neurological disease
Laryngoscopy with stroboscopy or digital acoustic voice analysis.
Videolaryngostroboscopy is the standard of care for a voice clinic.

6. Categories of voice disorders:
• Inflammatory
• Structural or neoplastic
• Neuromuscular
• Muscle tension

7. Treatment overview:
• Vocal hygiene, lifestyle and dietary
advice
• Voice therapy
• Specialist therapy e.g. singing therapy or
osteopathy
• Medical treatment
• Phonosurgery

8. Specific Voice Disorders
and their Management

9. Laryngitis erythema, oedema, epithelial change
include ulceration,leukoplakia orstiffness of themucosa withincreased
amount of thickmucus.
Acute laryngitis , URTIs usually.
Chronic laryngitis with smoking, alcohol, reflux, occupational
exposures, social activities, allergies and throat hygiene.
The voice is hoarse .
Treatment:
• self-limiting in acute .
• Chronic , voice hygiene with avoid abuse and rest.

10. This video shows the function of the larynx in a 24 yr old patient with
acute laryngitis. Talking was painful and she only talked in a faint whisper.

11. Arytenoid Granuloma
•Benign inflammatory lesions arise from the perichondrium
of the vocal processes .
•Trauma-related injury, intubation .
•Reflux is important factor, it slow healing .
Symptoms:
• Dysphonia , vocal fatigue
• Tickling sensation
• Discomfort

13. Management
•Reducing laryngeal irritants, stopping smoking, improving VH,
treating reflux.
•voice therapy (reducing hyper functional vocally abusive
behavior).
•Phonosurgery not cure in isolation as high rate of recurrence.
•Botulinum toxin into the thyroarytenoid muscle helpful to stop
impact, allow healing.

14. Vocal Fold Polyps
Benign swellings of > 3 mm arise from lamina propria of
vocal folds.
• MCC of structural dysphonia.
• solitary, occasionally bilateral.
• men > women.
• Smoking.
• age 30–50 years.
As a cause of polyp formation , contralateral vocal fold
examination is crucial as sulcus or intracordal cyst may
found.

15. Right-side hemorrhagic vocal fold polyp

16. Symptoms:
• Dysphonia
• Strain to speak
• seldom, dyspnoea and episodes of choking if large.
Management:
• VT, unlikely to resolve the polyp.
• concomitant inflammatory conditions.
• surgery , laser or cold steel.
• The goal, restore smooth edge of V.C to allow full closure and
normal vibration.

17. Vocal Fold Nodules
bilateral swellings < 3 mm develop on the free edge
of the vocal fold at the maximal contact area .
• Associated with teaching ,singing.
• In children, boys > girls.
• In adults, women < 30 years old.
Aetiology , voice abuse rather than overuse.

19. Symptoms:
• husky, breathy voice , worse with use.
• discomfort on phonation.
• deeper in pitch and with breaks .
Management:
• If not significant problems > left alone.
• Aggravating as infections and reflux should treated.
• Mainstay is VT with VH, voice and function improve, but may
nodules persist.
• Surgery reserved for those who fail voice therapy and remain
symptomatic.
Aim precise excision of the nodule alone, no exposure of the
underlying ligament.

20. A5yroldpatientwithtruevocalcordnodulescalledscreamer'snodesorsinger'snodes

21. Pseudocysts
the lesion has no cyst wall but filled with
serous fluid.
• due to phonotrauma.
• Initial management is VH.
• PS if symptoms are recalcitrant to therapy .

22. Reinke’s Oedema
oedema of the subepithelial space (Reinke’s space).
• Almost smokers.
• may be , Hypothyroidism.
• equal gender, but the pitch-lowering effects more on women.
• Age 40–60 years.
Symptoms:
• Deepening of pitch in women
• Gruffness
• Inability to raise the pitch of the voice
• Choking episodes
• Reflux symptoms

24. Management
Conservative , VH and smoking cessation .
underlying hypothyroidism, infections, or reflux.
VT help in a well-motivated patient.
Surgical if:
• Leukoplakia.
• choking episodes or airway compramize.
• inability to pitch elevation is problematic.
There is significant worsening by scarring after PS.
Reduction glottoplasty by cold steel or laser.
minimize epithelial excision due to the risk of permanent scar and
hoarseness.
“ myxematous material is aspirated or vaporized, epithelial edges apposed
after excision of redundant mucosa”
good results are obtained by treating one side.

25. Cysts
less frequently than polyps and nodules, and sulci and mucosal bridges even less so.
two types :
• A mucous retention cyst “ blocked minor salivary gland”
• Epidermoid cysts “ lined by squamous epithelium ,filled with keratin and cholesterol
debris”.
result of voice abuse .
For both types, a definitive diagnosis is only by microlaryngoscopy and cordotomy.

26. Mucous retention cyst Epidermoid cyst

28. Asulcusvocalis“alocalizedinvaginationofthemucosaofvaryingdepth”

29. A mucosal bridgethought to arise by the rupture through a
deep aspects of two sulci or cysts to form pedicle of mucosa.

30. Laryngealkeratosis
“inflammatorydiseaseofepitheliumof
thevocalcordsduetochronic
hyperplasiaandhyperkeratosisofthe
laryngealmucosa”
relatedtosmoking,alcoholandreflux.
Thepredominantsymptomis
hoarseness.
Thisconditionmaybeprecancerous ,
somanagementsurgicalexcisionfor
histology.

31. Ackermann’stumour
(verrucous carcinoma)
“ a slow-growingvariant of SCC
thatdoesnotmetastasize”
a completeendoscopic excisionis
recommendedto prevent
recurrence.
Thistumouris lessradiosensitive
thanothers.

32. Adult Laryngeal Papilloma
• Associated , HPV 6 and 11
• Bimodal incidence
• Juvenile: 2–4 years
• Adult: 20–40 years
• Small risk of malignant transformation in adult papilloma
Presentation:
• Progressive dysphonia
• Dyspnoea
• Stridor

33. Treatment:
Endoscopic excision : Cold steel, Microdebrider or Laser
Adjuvant treatments:
• Cidofovir— carcinogenic potential.
• Interferon-α—significant side effects and morbidity.
• Bevacizumab—antiangiogenic monoclonal antibody appears to work ,
undergoing RCTs.
• Photodynamic therapy—starting to emerge, need more evidence.
• HPV vaccineis now offered .
• Tracheostomy avoided if possible due to risk of seeding the stoma or
distal airways .

34. Vocal Cord Palsy/Paresis
• presents with breathy voice and symptoms of
aspiration.
• An obvious laryngeal paresis “ asymmetry of
movement on abduction and adduction” , affected side
‘lags behind’ the normal side.
• maybe subtle and apparent on prolonged endoscopic
observation while phonate and sniff .
• Bilateral palsies present with upper airway symptoms,
dyspnea, stridor, and respiratory compromise.

35. Causes include:
• Iatrogenic injury (surgery)
• Malignant disease
• Trauma
• Idiopathic
• Neurological disease
Rule out malignancy with CT skull base to
thorax.

37. Management:
1- VT for compensation and decrease aspiration.
2- Surgery.
• Injection medialization procedure—absorbable semi-
permanent materials (e.g. hydroxyapatite, collagen)
• Laryngeal framework surgery—insertion of an implant
• Laryngeal reinnervation
3- Bilateral palsies may need a tracheostomy acutely,
may use other procedures to improve the airway, such as
a cordectomy.

38. Muscle Tension dysphonia (MTd )
Muscle tension imbalance causing MTD is one of the biggest
causes or contributors to voice disorders.
• diagnosis of exclusion (i.e. the vocal folds look normal and move
normally), laryngeal muscles try to overcome a deficiency in voice
production due to inflammatory or structural lesions.
• Lead to trauma and structural changes in the vocal fold mucosa.
•Muscles are hyperfunctional or hypofunctional, giving patterns of clinical
presentation and laryngeal appearance.

39. The degree of dysphonia variable, intermittent related to a
particular voice task (e.g. teaching) to constant hoarseness.
Other symptoms include:
• Pitch: too high or low
• Reduced range
• Sensation of tightness or lump in the throat
• Discomfort on speaking or singing
• Vocal fatigue

40. Treatment
precipitating causes and as:
• Vocal hygiene and lifestyle advice
• Voice therapy targeted at specific muscle
groups
• Laryngeal manipulation
• Behavioral therapy
• Medical treatment (e.g. reflux
management)

41. Spasmodic dysphonia
• a voice disorder arising from a focal dystonia involving certain
laryngeal muscles but reflecting central motor processing
abnormalities.
•It is a task-specific dystonia: occurs only on phonation, can
overridden by laughing, chanting, or singing.
•There is a background of normal speech overlaid with vocal
spasms not under voluntary control, leads to strained and
strangled speech pattern of adductor dysphonia (more common)
and breathy pattern of abductor dysphonia.

43. Treatment
Controlled with injections of botulinum toxin
to the affected muscle groups, with VT to
eliminate hyperfunction .

44. Thanks