Vocal fold nodules are symmetrical free edge swelling typically located at the junction between anterior 1/3rd to posterior 2/3rd of the vocal fold. It is associated with phonotrauma caused by voice misuse, overuse, or abuse. Speech therapy is the preferred management for early/soft nodules with microlaryngeal surgery reserved for more mature/fibrous nodules. In some,early surgical intervention is justified.
Hourglass appearance of glottic aperture upon phonation in vocal fold nodules.
Watch video of vocal fold nodules @ YouTube
Before Surgery After Surgery
Image on the left also shows evidence of subcordal oedema which is one
of the finding strongly suggestive of laryngopharyngeal reflux disease.
Watch video on microlaryngeal surgery of vocal fold nodules @ YouTube
It is important to address on voice rest during acute laryngitis. Additional phonotrauma may end-up with the risk of scar formation and further worsens the voice quality. Strict voice rest is advocated initially and later to limited usage.
Watch video of vocal folds fibrin formation complicating voice overused @ YouTube
Arrow - anterior commissure scar, rounded rectangle - variceal lesion, LVF - left vocal fold, RVF right vocal fold. Flexometallic endotracheal tube is seen centrally.
Dotted circle -vascular lakes with ectasia, arrows - nodules
Subepithelial haemorrhage secondary to phonotrauma. Patient was advised for complete voice rest initially for 3-5 days followed by limited and gradual voice use to normal. No other significant vocal fold pathology.
Evidence of LPR noted over arytenoid mucosa and interarytenoid area.
Watch video of acute vocal fold haemorrhage @ YouTube
Abnormal capillaries predispose to vocal fold haemorrhage and may result in benign vocal fold lesions and scar formation. KTP and pulse-dye laser would
be ideal for the management of these lesions. However, bipolar diathermy at
low power setting is a good alternative if laser is not available.
Watch video on telangiectasia of true vocal folds @ YouTube
Vocal fold polyp is a unilateral mass lesion usually arising near its free edge. It can be sessile or pedunculated. There might be contralateral vocal fold reactions usually a thickened epithelium which resolves spontaneously upon microsurgical excision of the primary lesion.
Figure on the left shows a small vocal fold polyp with a thin pedicle
while on the right a multilobular type with a thick and broad pedicle.
Watch video on intraoperative vocal fold polyp assessment @ YouTube
Large right vocal fold polyp Anterior commissure polyp.
with a thin broad-based attachment.
Right vocal fold polyp with recent subepithelial hemorrhage
secondary to voice overuse.
The view of the same lesion as above during phonation.
Video clip showing a small sessile right vocal fold polyp.
Video clip showing a large right vocal fold polyp with a broad-based pedicle.
Video clip of right vocal fold polyp excision by using cold instruments.
Watch video on avulsion of vocal fold polyp @ YouTube
Prolonged and repetitive voice over-used or abuse have detrimental effect on vocal folds especially when voice projection is needed in a very noisy background. In this video, left vocal fold polyp has formed (white arrow) with opposite vocal fold thickening seen and evidence of recent bleeding into superficial vocal fold layer (green arrow with yellowish tinge underneath the vocal folds lining on both sides). The mucosa of arytenoids and posterior commissure appeared swollen, reddish and oedematous due to coexisting untreated reflux laryngitis (blue interrupted line).
In this video, a huge a obstucting vocal fold polyp is seen between the vocal folds. It was successfully excised by using carbon dioxide (CO2) laser and his laryngeal symtoms (hoarse voice, difficulty in breathing, and throat irritations) recovered to normal.
Reinke's oedema of polypoid corditis is a generalised oedema of the
subepithelial space with cumulation of gelatinous/myxomatous material.
It can occur unilaterally or bilaterally. Treament is by microsurgical
aspiration and alleviating the predisposing factor- usually smoking.
Still image on fiberoptic laryngoscopy.
Severe Reinke's oedema as seen during direct laryngoscopy.
Vascularity pattern in Reinke's oedema.
Watch video of Reinke's oedema intraoperative assessment @ YouTube
Gel-like substance (arrows) Lateral cordotomy
Suctioning of excess material View at completion of surgery
Video of Reinke's oedema on examination under general anaesthesia.
Watch video of Reinke's oedema microlaryngeal surgery @ YouTube.
Cyst is fluid filled swelling lined by mucosal lining.
It needs to be excised completely by using microsurgical technique.
Watch video of vocal fold cyst with 'Cup & Saucer' effect @ YouTube
This image shows a swollen left true vocal fold due to an intracordal cyst.
There is an abnormal capillary on the opposite vocal fold (blue arrow)
which needs to be treated as well. This vessels predispose to vocal fold haemorrhage with subsequent development of benign vocal lesions and scarring.
Close-up view of the same lesion showing an obviously abnormal subepithelial vessels of right true vocal fold. (R - right, L - left)
Intraoperative view of left vocal fold cyst.
Thick mucopus seen emanating from the cyst upon infiltration of adrenaline-mixed saling (the needle tip had gone into the cyst causing its content to leak)