Pathology Descriptions

Vocal Pathologies
Complied by Alice Townsend
June 2013
Document includes description, pictures, and treatment options.
Vocal Fold Nodules
Contact Ulcers & Granulomas
Vocal Fold Hemorrhage, Sulcus Vocalis, &Vocal Fold Scarring
Papillomas & Carcinomas
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Vocal Fold Nodules
What are they?
Vocal fold nodules are bilateral whitish bumps located on the medial edge of the
vocal folds at the midpoint. They are caused by vocal exuberance which means speaking
in a loud voice, a high pitch, or speaking for long periods of time. When the vocal folds
come together too hard, the delicate tissue can be damaged and callous-like bumps form
where the vocal folds come together the hardest.
If nodules are large enough, they can prevent the vocal folds from coming
together and vibrating properly for phonation. Think of an hourglass shape with the vocal
folds meeting in the center at the nodules, but not closing fully on either end. The voice
may become hoarse, breathy, or aphonic and your pitch range may decrease, especially
the high notes.
What do they look like?
What can I do?
There are a number of options to help vocal nodules. Learning how to care for
your voice and use it in a safe way is the first step. This may mean learning about vocal
hygiene and using a clear, resonant voice to prevent further damage. Once you learn how
to use your voice safely and keep your vocal folds healthy, nodules usually start to
shrink. If, after a few weeks, vocal hygiene and resonant voice has not helped improve
the voice, there are surgical options which can be discussed.
Contact Ulcers & Granulomas
What are they?
When the delicate tissue covering the cartilaginous glottis becomes inflamed, the
area may ulcerate or produce heaped tissue which forms a granuloma. The damage may
be from vocal misuse (e.g. speaking with a hard glottal attack, coughing, or throat
clearing), intubation, laryngeal surgery, surgery after radiotherapy, or GERD (acid reflux
inflames the tissue of the vocal process). Ulcers are usually accompanied by pinpoint
pain. Granulomas, unless they are very large, may not cause problems. Both may give the
sensation of something in the throat which may increase the harmful habit of coughing or
throat clearing.
What do they look like?
What can I do?
Learning about the detrimental voice habits which may have contributed to the
formation of ulcers or granulomas is the first step is stopping them and allowing the
larynx to heal. Proper vocal hygiene and using a resonant voice can also help prevent
further damage and assist healing. Steriods may decrease healing time. Anti-acid
regimens can help treat GERD and prevent further damage from acid. Surgery is not
usually recommended for contact ulcers or granulomas because if the proper steps aren’t
taken to prevent further damage, the change of recurrence is high and surgery results in
vocal fold scarring. Usually, healthy vocal habits will begin to reverse the effects.
What are they?
Vocal fold polyps usually develop on the medial edge of the vocal fold near the
midpoint. They may be unilateral or bilateral, white or red, and vary in size and shape.
They are usually caused by voice misuse or heavy voice use. Generally painless, polyps
may result in incomplete closure of the vocal folds which can lead to hoarseness or
breathiness. If a polyp is large, it may result in voice breaks due to interrupting the
vibration of the vocal folds. It may also cause the sensation of something being in the
throat which can lead to further damage from coughing and throat clearing.
Reinke’s edema is a large, floppy polyp caused by the combination of smoking
and excessive voice which results in weakened capillary walls, capillary leakage and
swelling of the tissue. This can result in a hoarse or breathy sounding voice with a loss of
high pitches.
What do they look like?
Reinke’s edema
What can I do?
Good vocal hygiene and use of resonant voice can help reduce the size of the
polyp and minimize symptoms. Short periods of vocal rest, vocal naps, may help reduce
vocal fold inflammation but long periods of vocal rest have not been shown to decrease
the size of polyps. If voice therapy and healthy voice habits do not minimize the polyp
enough to restore proper vocal quality, there are surgical options but these can result in
vocal fold scarring and should be considered carefully.
What are they?
Cysts are masses on the vocal folds caused by a build up of mucous from a
blocked gland or a build up of keratin after vocal misuse. Cysts may be unilateral or
bilateral and vary in size and shape. If the cyst is large enough, it may result in
incomplete closure which can cause a hoarse or breathy voice. If the mass and stiffness of
the vocal folds are increased due to a cyst, loss of high notes or breaks in phonation may
be a consequence.
What do they look like?
What can I do?
Cysts may clear up on their own if the built up fluid drains and voice therapy may
reduce the size of cysts caused by vocal misuse and prevent further damage and future
cysts. Usually, cysts which are very problematic are removed using surgical options but
cysts must be removed completely to prevent recurrence and scarring is a concern. A
ruptured cyst may result in a sulcus vocalis which will be discussed later.
Vocal Fold Hemorrhage, Sulcus Vocalis, &Vocal Fold Scarring
What are they?
Hemorrhage – A vocal fold hemorrhage is bleeding underneath the outermost layer of
mucosa on the vocal folds. Usually caused by a single traumatic event (e.g. screaming
“fire”), hemorrhages are the result of sudden vocal fold damage. Anticoagulants may
increase the chance of vocal fold hemorrhage, especially when coupled with extreme
voice use.
Sulcus Vocalis – An indentation or furrow which runs along the length of a vocal fold
is a sulcus vocalis. It may be the result of a ruptured cyst and may cause vocal fold
bowing due to the decrease in tissue. Since people may need to exert more pressure to
achieve closure, this may cause a pressed, harsh voice.
Vocal Fold Scar – A scar on the vocal folds may be caused by trauma, surgery, burns,
or inflammation. It increases the stiffness of the vocal fold which impacts vibration.
What do they look like?
Sulcus Vocalis
Vocal Fold Scarring
What can I do?
Hemorrhage – Immediate vocal rest following the incident is recommended.
Sulcus Vocalis – Injections to bulk up the gap or push the vocal fold out to assist
closure are the most common treatment options. Vocal therapy is usually not as
Vocal Fold Scar – The best treatment is preventing the scar in the first place. Once
formed, vocal therapy may increase vocal function and reduce the impact of the scar.
Surgical options should be carefully considered since they may make scarring worse
or create additional scarring.
Papillomas & Carcinomas
What are they?
Papilloma – A papilloma is a benign tumor caused by the human papilloma virus
(HPV). Papillomas may be unilateral or bilateral and affect the mucus membranes
and the muscle of the vocal folds. They usually continue growing and vary in size and
shape. Since they impact the closer and vibration of the vocal folds, they may result
in a hoarse, breathy, or aphonic voice.
Carcinoma – A carcinoma is a cancerous tumor which starts out unilateral and may
spread around and beyond the larynx. It affects mass, stiffness, closure, and vibration
of the vocal folds depending on size, shape, and location. Smoking and drinking
increase the chances of developing a carcinoma.
What do they look like?
What can I do?
Papilloma – Surgery may be used to remove tumors temporarily but often, papillomas
grow back. Since recurrence is common, voice quality is usually taken into
consideration in the operating room. People with papillomas should speak with a
doctor about treatment options.
Carcinoma – As with other cancers, radiation, surgery, chemotherapy, or a
combination may be options for treating carcinomas. People with carcinomas should
speak with a doctor about treatment options.
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