Benign vocal fold mucosal disorders
Balasubramanian M.S. D.L.O.
These disorders involve the mucosa lining the
vocal cord. The free border of the vocal cord is responsible for
voice production. At any given period of time about 50% of patients
are affected by this disorder. These disorders are caused by
vibratory trauma to the mucosa lining the free border of the vocal
cord. Certain predisposing factors like Gastro esophageal reflux
disorder, Smoking, Infections, Allergy may predispose this
condition. This problem is most common among expressive and
The following conditions are included under Benign vocal fold
1. Vocal nodules
2. Laryngeal polyps
3. Mucosal haemorrhage
4. Intracordal cysts
5. Mucosal bridges
6. Glottic sulci
If the affected pateint happens to be a singer, they may seek
professional help because of voice limitation during singing,
usually in the upper range. If the patient is a non singer then the
patient may seek help with a little advanced lesion with a change in
sound capabilities of the speaking voice.
Anatomy of the vocal fold:
Medial to lateral the membranous vocal fold is made up of
squamous epithelium, Reinke's space (superficial layer of lamina
propria) which is a potential space, vocal ligament (consisting of
elastin & collagen fibres), thyroarytenoid muscle. Perichondrium
& thyroid cartilage provide the lateral boundary.
showing cut section of vocal fold
These vocal folds move as a whole between the extremes of
abduction & adduction for breathing and phonation respcetively.
The vocal fold mucosa (consisting of epithelium & superficial
layer of lamina propria also known as Reinke's space) which covers
the vocal folds is the chief oscillator during phonation causing
continuous adduction. So it is the vocal fold mucosa which vibrates
and not the vocal cord perse.
Hirano gave an excellent description of the ultra structure of
the vocal cord. Acccording to him the body of the vocal fold is
formed by muscle, which is covered by epithelium and superficial
layer of lamina propria as the cover. The intermediate layers are
formed by Collagenous and elastic fibres. These layers differ in
their stiffness characteristics leading to different rates of
vibrations during phonation. This whole process is known as
decoupling. This decoupling allows the mucosa to oscillate with a
degree of freedom from the ligament and muscle.
For phonation to occur pulmonary air is passed between adducted
vocal folds. During this phase the vocal fold mucosa vibrates
passively according to the length, tension and edge configuration
determined by the intrinsic muscles, elastic recoil forces of the
vocal fold mucosa.
How to evaluate these patients?
a. A good history taking is a must.
b. Assessment of vocal capabilities and limitations should be
c. Laryngeal examination.
History taking: should concentrate on the onset and duration of
the vocal symptoms, exacerbating factors if any should be taken note
of, symptom complexes must be studied, talkativeness of the patient
must be ascertained, vocal commitments, other risk factors, severity
of the disorder and vocal aspirations must be clearly noted.
Onset of symptoms: If the patient has complaints of frequently
recurring bouts of vocal dysfunction, it could be safely assumed
that it may be an exacerbation of a more chronic voice overuse
disorder. These patients will benefit from voice training.
Exacerbating causes: Common symptoms are
1. Exaggeration of day to day variations of singing
2. Increased effort necessary for singing
3. There is clear reduction in vocal endurance
4. There is deterioration of ability for high frequency
5. There is delayed phonatory onset and air wastage
4. Certain drying medications prescribed for allergy
The following are the management options available:
2. Management of sinusitis
3. Management of acid reflex laryngitis : These patients have bad
taste in the morning, scratching throat irritation, habitual throat
clearing, erythema of arytenoid mucosa, and interarytenoid
pachydermia / contact ulcers.
4. Voice rest.
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