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Vocal Cord Polyps, Nodules, and Granulomas

by Clarence T. Sasaki, MD

Acute trauma or chronic irritation causes changes in the vocal cords that can lead to polyps, nodules, or granulomas. All cause hoarseness and a breathy voice. Persistence of these symptoms for > 3 wk dictates visualization of the vocal cords. Diagnosis is based on laryngoscopy and on biopsy to rule out cancer. Judicious surgical removal restores the voice, and removal of the irritating source prevents recurrence.

Etiology

Polyps and nodules result from injury to the lamina propria of the true vocal cords. Granulomas result from injury to the perichondrium overlying the vocal processes of the arytenoid cartilages.

Polyps may occur at the mid third of the membranous cords and are more often unilateral. They frequently result from an initiating acute phonatory injury. Polyps may have several other causes, including gastroesophageal reflux, untreated hypothyroid states, chronic laryngeal allergic reactions, or chronic inhalation of irritants, such as industrial fumes or cigarette smoke. Polyps tend to be larger and more protuberant than nodules and often have a dominant surface blood vessel.

Nodules usually occur bilaterally at the junction of the anterior and middle third of the cords. Their main cause is chronic voice abuse—yelling, shouting, singing loudly, or using an unnaturally low frequency.

Granulomas occur in the posterior glottis against the vocal processes. They can be bilateral or unilateral. They usually result from intubation trauma but may be aggravated by reflux disease.

Symptoms and Signs

All result in slowly developing hoarseness and a breathy voice.

Diagnosis

  • Laryngoscopy

  • Sometimes biopsy

Diagnosis is based on direct or indirect visualization of the larynx with a mirror or laryngoscope. Biopsy of discrete lesions to exclude carcinoma is done by microlaryngoscopy.

Differentiating Vocal Polyps, Nodules, and Granulomas

Type

Causes

Features

Treatment

Polyps

Acute trauma, gastroesophageal reflux, untreated hypothyroid states, chronic laryngeal allergic reactions, chronic inhalation of irritants (eg, industrial fumes, cigarette smoke)

Unilateral

Occur at the membranous cord

Larger than nodules

Surface blood vessel

Surgical removal

Nodules

Chronic trauma (eg, voice abuse, yelling, shouting, singing loudly, using an unnaturally low frequency)

Bilateral

Occur at the membranous cord

Behavior modification (eg, decreasing musculoskeletal laryngeal tension when speaking), voice therapy, antireflux therapy

Granulomas

Repeated vocal abuse, reflux disease, endotracheal intubation

Often bilateral but can be unilateral

Occur at both vocal processes (posterior cords)

Larger than nodules

Voice therapy, antireflux therapy

For granulomas that do not regress, surgical removal

Treatment

  • Avoidance of cause

  • For polyps, usually surgical removal

Correction of the underlying voice abuse cures most nodules and granulomas and prevents recurrence. Removal of the offending irritants (including treatment of any gastroesophageal reflux) allows healing, and voice therapy with a speech therapist reduces the trauma to the vocal cords caused by improper singing or protracted loud speaking. Nodules usually regress with voice therapy alone. Granulomas that do not regress can be removed surgically but tend to recur.

Most polyps must be surgically removed to restore a normal voice. Cold-knife microsurgical excision during direct microlaryngoscopy is preferable to laser excision, which is more likely to cause collateral thermal injury if improperly applied.

In microlaryngoscopy, an operating microscope is used to examine, biopsy, and operate on the larynx. Images can be recorded on video as well. The patient is anesthetized, and the airway is secured by high-pressure jet ventilation through the laryngoscope, endotracheal intubation, or, for an inadequate upper airway, tracheotomy. Because the microscope allows observation with magnification, tissue can be removed precisely and accurately, minimizing damage (possibly permanent) to the vocal mechanism. Laser surgery can be done through the optical system of the microscope to allow for precise cuts. Microlaryngoscopy is preferred for almost all laryngeal biopsies, for procedures involving benign tumors, and for many forms of phonosurgery.

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