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Disorder of local abuse impact in public
- 1. Disorders of voice abuse Disorders of voice abuse Dr. Abhinav Srivastava Professor and Head Dept. of ENT
- 2. Vocal nodules Vocal nodules Syn: Singers nodules, teachers nodules, screamers nodules, jugglers nodules, etc. Defined as disorder of voice abuse commonly seen in professional voice users, characterized by hoarseness, vocal fatigue and presence of pin head sized raised lesions on both the vocal cords at the junction of its anterior I/3 and posterior 2/3.
- 3. Etiopathology Etiopathology Hyperkinetic voice Voice abuse- professional voice users Increased intensity Altered pitch Long duration Chronic cough Reflux laryngitis (GERD)
- 4. Hyperkinetic voice Maximum vibration at the junction of anterior 1/3 and posterior 2/3 Trauma leading to odema and submucosal microhaemorrhage Epithelial hyperplasia and subepithelial hyalinization and fibrosis Bilateral vocal nodules in the free edge of the cords
- 5. Symptoms Symptoms Professional voice users Hoarseness Improves initially with voice rest Voice fatigue (Phonesthenia) Strained speech- pain in the neck/ throat
- 6. Signs Signs Indirect laryngoscopy Pin-head sized pearly white projections on the free edge of the vocal cords at the junction of anterior 1/3 and posterior 2/3 Vocal cord movements are normal Congestion of the cords +/-
- 8. Investigations Investigations Diagnosis usually made clinically If ILS is difficult Flexible laryngoscopy Rigid angled laryngeal endoscopy (70属/ 90属) Stroboscopy
- 10. Treatment- Conservative Treatment- Conservative Voice rest- Absolute Treatment of local sepsis, cough, reflux, etc. Speech therapy Vocal hygiene Relaxing exercises Early lesions may disappear
- 11. Surgical treatment Surgical treatment MICROLARYNGOSCOPY (MLS) AND PRECISE EXCISION under GA Advantage of microscope Hands free Illumination Magnification Speech therapy and vocal hygiene should be continued following excision- prevents recurrence
- 14. Vocal polyp Vocal polyp Defined as a disorder of voice abuse commonly seen in professional voice users, characterized by hoarseness and presence of a sessile or pedunculated mass usually arising from one of the vocal cords
- 15. Etiology Etiology Hyperkinetic voice Professional voice users Sudden shouting Allergy Smoking/ other irritants Reflux laryngitis Chronic cough
- 16. Pathogenesis Pathogenesis Hyperkinetic voice Submucosal hemorrhage Bernoulli's phenomenon Hemorrhagic polyp Mucosal edema and polyp formation Organized, hyperplasia, hyalinization- Vocal polyp
- 17. Pathological types Pathological types Hemorrhagic polyp Hyperplastic polyp Hyaline polyp Sessile Pedunculated
- 18. Sites Sites Usually unilateral Common site: Junction of anterior 1/3 and posterior 2/3 Can be seen in other areas like anterior commisure Free edge or under surface
- 19. Symptoms Symptoms Common in females and between 30- 50 years Professional voice users Hoarseness Phonesthenia Diplophonia (double voice) Very rarely, a large polyp may give rise to choking spells/ stridor
- 20. Signs Signs Indirect laryngoscopy Sessile/ pedunculated mass Smooth reddish/ whitish mass Unilateral Junction of anterior 1/3 and posterior 2/3 Polyp may move up and down during respiration or may pop up during phonation Vocal cord movements- normal
- 25. Investigations Investigations Diagnosis usually made clinically Flexible laryngoscopy Rigid angled laryngeal endoscopy Stroboscopy
- 27. Treatment Treatment Small/ sessile polyp- try Voice rest Speech therapy Steroid inhalers Large polyp MICROLARYNGOSCOPY AND PRECISE EXCISION under GA Continue speech therapy and observe vocal hygiene
- 28. Reinkes odema Reinkes odema Syn: Bilateral diffuse polyposis Polypoid degeneration of vocal cords Defined as benign condition of the vocal cords, commonly seen in professional voice users and is characterized by diffuse odema of the entire length of both vocal cords in the Reinkes space Reinkes space: Subepithelial space in the vocal cords
- 29. Etiopathology Etiopathology Same as chronic laryngitis
- 30. Clinical features Clinical features Symptoms Same as chronic laryngitis Signs Diffuse odema of both vocal cords Spindle shaped swelling on the cords Vocal cords are mobile
- 32. Treatment Treatment Conservative Voice rest Speech therapy Treat etiological factors, if any Steroid inhalers Surgical Microlaryngoscopy Vocal cord stripping One cord at a time to prevent adhesions Avoid injury to vocal ligament
- 33. Contact ulcer/ granuloma Contact ulcer/ granuloma Defined as disorder of voice abuse characterized by hoarseness and pain in the throat on speaking and presence of of an ulcer on the vocal process of one arytenoid and granuloma on the vocal process of other arytenoid
- 34. Etiology Etiology Hyperkinetic voice Same as chronic laryngitis
- 35. Pathology Pathology Chronic trauma at the vocal process of arytenoidsulceration on one side and granuloma on the other
- 36. Symptoms Symptoms Hoarseness Pain on speaking- throat/ neck Phonesthenia Sticky/ FB sensation in the throat
- 37. Signs Signs Indirect laryngoscopy Characteristic granuloma on the vocal process of one arytenoid and ulcer on the other Granuloma fits into the ulcer on phonation DD: Malignancy of larynx
- 38. Treatment Treatment Microlaryngoscopy and excision biopsy of the granuloma Voice rest Vocal hygiene Speech therapy Treat etiological factors, if any
- 39. Classification Classification Benign PAPILLOMA Hemangioma Glomus Chondroma Fibroma Lymphangioma Adenoma Malignant SQUAMOUS CELL CARCINOMA Adenocarcinoma Carcinosarcoma Small cell carcinoma Chondrosarcoma
- 40. PAPILLOMA OF THE PAPILLOMA OF THE LARYNX LARYNX Types Juvenile laryngeal papillomatosis (Children) Solitary laryngeal papilloma (Adults)
- 41. Juvenile laryngeal papillomatosis Juvenile laryngeal papillomatosis Syn: Recurrent respiratory papillomatosis Benign neoplasm of the larynx, commonly seen in children and is characterized by presence of multiple warty lesions on the larynx which may give rise to fatal respiratory obstruction
- 42. Incidence Incidence Most common benign tumor of the larynx in childhood Approximately 1500 new cases reported annually
- 43. Etiology Etiology Human papilloma virus 6 and 11- tissue specific- targets stratified squamous epithelium of the oropharynx, larynx, and anogenital region but not epidermis ? Genetic predisposition 80-90% of cases present before 3 years of age May get infected during birth if mother has genital condylomata (Genital warts)- 50% of cases have mothers with this! But delivery by caesarian section does not prevent it- ? Transplacental spread/ postnatal infection
- 44. Pathology Pathology Gross: Multiple pinkish white warty lesions on the supraglottis and vocal cords- may obstruct the airwary Can occur anywhere in the respiratory tract- but common glottis and supraglottis Microscopy: Finger like projections of epithelial tumor cells with central fibrovascular core
- 45. Symptoms Symptoms Hoarseness Any child with hoarseness of more than 1 month duration should be diagnosed as JLP until otherwise proved Asthma-like features Stridor
- 46. Signs Signs Hoarse voice/ harsh weak cry ILS: Multiple pinkish warty lesions, airway may be obscured Inspiratory/ biphasic stridor +/-
- 47. Investigations Investigations X-ray lateral/ AP view of the neck Chest X-ray Flexible/ rigid laryngoscopy Microlaryngoscopy and excision- Biopsy Bronchoscopy to r/o tracheobronchial lesions
- 48. Treatment Treatment Various methods of treatment described Microlaryngoscopy and excision with microcautery- common method of treatment Avoid trauma to adjacent areas- seeding into raw areas can result in recurrence? Recurrence rates very high May need repeated such procedures to clear the airway Spontaneous regression may occur after puberty
- 49. Other methods of treatment: Other methods of treatment: Inconsistent success reported Inconsistent success reported Cryosurgery Ultrasonic destruction Laser vaporization MLS and application of podophyllum Interferon therapy Autogenous vaccines Long term antibiotics have been tried Antiviral treatment
- 50. If stridor + If stridor + Tracheostomy if intubation is not possible Tracheostomy should be avoided because recurrence in the tracheastoma site can occur- more difficult to treat
- 51. Prognosis Prognosis High recurrence rates Death due to respiratory obstruction If survives till puberty- prognosis is good NOT PREMALIGNANT
- 52. SOLITARY PAPILLOMA SOLITARY PAPILLOMA Occurs in adults Clinical presentation is similar to vocal polyp- commonly occurs on membranous vocal cord Etiology: Human papilloma virus Treatment: Microlaryngoscopy and excision PREMALIGNANT CONDITION Prognosis is good if completely excised- recurrence rates very low compared to Juvenile papillomatosis
- 53. Thank you