Vocal Cord Lesions

Vocal cord lesions, nodules and growths
The term vocal cord lesion (physicians call them vocal “fold” lesions) refers to a group of noncancerous (benign), abnormal growths (lesions) within or along the covering of the vocal cord. Vocal cord lesions are one of the most common causes of voice problems and are generally seen in three forms; nodules, polyps, and cysts. Vocal cord lesions often arise following “heavy” or traumatic use of the voice, including voice misuse such as speaking in an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick.

What Are The Symptoms Of Benign Vocal Cord Lesions?
A change in voice quality and persistent hoarseness are often the first warning signs of a vocal cord lesion. Other symptoms can include:

  • Vocal fatigue
  • Unreliable voice
  • Delayed voice initiation
  • Low, gravelly voice
  • Low pitch
  • Voice breaks in first passages of sentences
  • Airy or breathy voice
  • Inability to sing in high, soft voice
  • Increased effort to speak or sing
  • Hoarse and rough voice quality
  • Frequent throat clearing
  • Extra force needed for voice
  • Voice “hard to find”

When a vocal cord lesion is present, symptoms may increase or decrease in degree, but will persist and do not go away on their own.

How Is The Diagnosis Of A Benign Vocal Cord Lesion Made?
Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient’s mouth that allows the examiner to view the voice box (images are often recorded on video). The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion. Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication’s side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor.

Types of Lesions and their Treatment

Vocal Cord Nodules (also called Singer’s Nodes, Screamer’s Nodes)
Vocal cord nodules are also known as “calluses of the vocal fold.” Just like calluses, these nodules arise from harsh and abrasive speech. Voice overuse or abuse occurs in a variety of situations; Talking for long periods of time as commonly seen with teachers, stage performers and business men and women, singing without appropriate breathing techniques or coaching as may occur with professional musicians. In all the above situations, as the vocal cords vibrate to emit sound, over-vibrating the lining of the vocal cord can cause injury. Vocal cord nodules form as a protective mechanism, protecting  the structures underneath from exposure to further friction and injury.

How is the diagnosis made?
A visit to the otolaryngology (Ear Nose and Throat specialist) is necessary in order to assess voice abnormalities. The ENT physician will usually have a special camera device that allows visualization of the vocal cords that is called an endoscope. The procedure involves spraying the nose with a numbing decongestant which takes effect within several seconds. The endoscope is gently inserted through the nose or mouth allowing for visualization of the voice box.

On examination of a normal voice box, the vocal cords appear like an upside down V, the nodules usually appear on both sides of the vocal cords directly facing each other.

How are vocal cord nodules treated?
Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped. Therefore, voice rest is recommended in all cases.  We normally advise against whispering which is actually more harmful than normal speech and causes more vocal strain.

Inflammation of the vocal cords or the voice box from stomach acid reflux may be present and requires a change in diet and treatment with acid reducing medications in order to improve the voice further.

We usually offer Professional singers, teachers, stage performers and other voice professionals voice and speech therapy which will allow the healthy return to vocal activity without strain.

Vocal Cord Polyp
A vocal cord polyp typically occurs only on one side of the vocal cord and can occur in a variety of shapes and sizes. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances similar to vocal cord nodules. Vocal cord polyps may appear for a variety of reasons ranging from acid reflux to smoking.

Treatment
Initial treatment for a vocal cord polyp will involve a change in diet and lifestyle and medications that reduce acid production in the stomach to prevent the effects of acid reflux on the vocal cords. If the polyp still persists despite acid reflux treatment, the polyp may require removal to rule out a cancerous growth.

Removal of the vocal cord polyp is usually performed in the operating room under general anesthesia to allow proper and safe visualization of the vocal cords. This procedure is called a micro-suspension direct laryngoscopy. During the procedure and after general anesthesia is obtained, a special metallic tube called a laryngoscope is gently inserted through the mouth bringing the vocal cords into view. An operating microscope is used to magnify the vocal cords. Specialized microscopic instruments are used to remove the polyp with or without the use of a laser depending on the nature of the lesion. Great care is taken to only deal with the polyp and return the vocal cord to its original condition.

The polyp is costumarily sent for examination in the lab to rule out a cancerous growth.

During the first few days after the procedure, you may experience some discomfort in the throat when swallowing which is mild and temporary. We usually recommend voice rest for several days to a week, continuation of a reflux diet regimen and acid reflux reducing medication. The downtime from direct laryngoscopy is usually no more than one to two days.

Vocal Cord Cyst
A vocal cord cyst is a firm mass of tissue contained within a membrane (sac). The cyst can be located near the surface of the vocal cord or deeper, near the ligament of the vocal cord.  As with vocal cord polyps and nodules, the size and location of vocal cord cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem.

Surgery followed by voice therapy is the most commonly recommended treatment for vocal cord cysts that significantly alter and/or limit voice. The surgical procedure for the removal of vocal cord cysts is similar to that used with the removal of vocal cord polyps (direct laryngoscopy). Since cysts are ball like masses hidden behind the mucosal cover of the vocal cord, during direct laryngoscopy procedures, the mucosa is incised and the “ball” is gently peeled out of its cover leaving the lining of the vocal cord undamaged and the voice soon returns to normal.