Vocal cord polyps and nodules: how to treat them?
Vocal cord injuries are more common than you might expect. It seems obvious to be able to speak, but alternating phonation, i.e. voice modulation and breathing, in the right way is not at all
The vocal cords can lose tension and ‘fall out of tune’ just like an out-of-tune musical instrument, or develop lesions that limit effective sound performance.
Vocal cords: the main injuries
The vocal cords are two membranous bands located in the centre of the larynx.
They are about 2 cm long and generate harmonic vibrations as air passes through them, which, together with the action of the pharyngeal muscles, the tongue and finally the lips, produce the sound we identify with the voice.
If used incorrectly – inability to alternate phonation with breathing -, overexcited – shouting in a loud manner -, or exposed to unhealthy hygienic habits (think of the fact that cigarette smoke generates 400 toxic and 40 carcinogenic substances), the impairment of their effectiveness is expressed by a symptom: dysphonia.
Nodules and polyps of the vocal cords are frequent non-cancerous lesions of the larynx
The altered profile of the vocal cord, its increased rigidity and the inability of the vocal cords to fully face each other during the passage of air from the trachea result in a distorted sound – hoarseness – or a whispered voice.
The same symptomatology appears in the case of granulomas on the vocal cords, lesions arising in the posterior portion of the cords, and associated with gastroesophageal reflux.
Finally, it should not be overlooked that, in smokers, an altered voice must be immediately brought to the attention of the ENT specialist because dysphonia may be the cause of a malignant lesion of the vocal cord.
Early diagnosis is essential because it guarantees conservative treatment with a greater chance of a full recovery.
Vocal cord nodules usually affect both cords, arising in the middle third of the cord and preventing proper closure and vibration.
They are usually chronic lesions secondary to inappropriate use of the voice.
They can to some extent be considered an ‘occupational disease’ in those who, like teachers, see the voice used for explanations, not always in tune with correct breathing, but also to regulate classroom disturbances.
A word of warning to the child who, using the voice also to assert his personality and claim his rights against perhaps older and ‘overbearing’ siblings, may raise it incorrectly.
Early intervention by the speech therapist – the voice physiotherapist – promotes the correct approach and leads to a resolution of the problem.
The polyp usually affects only one vocal cord, is related to an altered ‘high-pitched’ use of the voice, i.e. the shout for a goal scored, but can also be secondary to exposure to chronic irritants.
Reflux has to be taken into account, but certainly with its many toxic and carcinogenic substances, so does cigarette smoking.
Vocal nodules and polyps: the risk factors
In addition to incorrect or excessive use of the voice, there are a number of factors that can play an important role in increasing the risk of vocal cord injury.
A cigarette releases around 400 irritants and 40 carcinogens such as carbon monoxide, formaldehyde, cadmium, ammonia, tar and arsenic, which alter DNA and cause numerous adverse events in the cardiovascular system, liver, pancreas, lungs, oesophagus and, of course, the larynx.
At the same time, the heat of combustion can also damage the vocal cords.
Statistically, 20 cigarettes a day shortens life by one day a week.
Irritation and thus chronic inflammation result in the collection of exudate in the Reinke’s space between the mucous surface layer of the vocal cord and the underlying vocal ligament, the tension element of the cord. Reinke’s oedema gives the voice a deep, hoarse tone.
Listen to Louis Armstrong’s voice to get an idea.
Metaplasia, the change in the normal characteristics of the epithelium lining the vocal cords, results in increased stiffness of the vocal cord and changes in the voice.
Modern video laryngoscopes have great image magnification capacity and the use of light filters highlights the vascular structure of the structures explored, anticipating inauspicious diagnoses or opening up the possibility of ultra-conservative surgical treatment.
Of course, prevention and early diagnosis must be more deeply rooted in the territory, starting with general practitioners and paying particular attention to the patients most exposed to risk factors.
Local nodules and polyps: how to intervene
Not all vocal cord lesions require surgery.
In fact, speech therapy plays a strategic role in correcting inappropriate voice patterns.
It is very useful in treating vocal cord nodules, especially at school age. It is more difficult in adults to correct a mode of vocal expression that also represents a nuance of the individual’s personality.
Speech therapy may also be indicated in the post-surgical rehabilitation pathway both in subjects who need to recover the correct tension of the vocal cords after prolonged periods of deficient use, and in subjects who, having undergone major surgery, need to rehabilitate phonation and swallowing.
As in the case of diagnosis, technological evolution has refined procedures and results in surgery.
The laser has progressively dominated the laryngeal surgery scene since the last decades of the last century.
Initially combined with the microscope, then with the microscope and endoscope, and today with the exoscope, which, coupled with modern full HD 4K monitors, gives the operator a sharp and extremely detailed image of the surgical field, increasing cutting precision.
If, in the oncological field, it is essential to guarantee surgical radicality, thus ensuring patient safety, it is no less important to preserve the organ, especially in this particular district, since the larynx not only has a phonatory function, but also the function of guaranteeing correct swallowing and protection of the lower airways.
With prevention and early diagnosis, organ function is often guaranteed and the overall management of the patient is very similar to that of patients with benign vocal cord disease.
The operations, all under general anaesthesia, can be scheduled as day hospital operations.
Resumption of normal nutrition, phonation – possibly optimised by the complementary work of the speech therapist – and routine work and social activities is rapid and without sequelae.
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