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Which histologic layers of the true vocal fold comprise the "cover" and which comprise the "body"?
Cover: stratified squamous epithelium and superficial lamina propria. The cover is pliable, elastic, and nonmuscular.
Body: Intermediate and deep lamina propria and thyroarytenoid muscle. Confers tensile strength.
A woman with h/o smoking and GERD complains of low-pitched, raspy voice. On exam, she has watery edema of the TVCs B/L. What treatment should you offer?
Reinke's edema is swelling of the superfical lamina propria. Treatment should address the underlying cause (GERD, smoking, vocal abuse). Surgical management includes decordication of TVCs, one at a time.
Where and what is the saccule?
This is the appendix of the laryngeal ventricle, a blind pouch (diverticulum) or membranous sac, originating at the anterior roof of the laryngeal ventricle situated between the ventricular fold and inner surface of thyroid cartilage. They are tubular extensions of the each ventricle anteriosuperiorly. Histology includes pseudostratified columnar epithelium and mixed mucous and serous glands found in submucosa.
What are the treatment options for saccular cysts and laryngoceles?
Endoscopic vs open: for smaller anterior saccular cysts, it appears that endoscopic approach with removal or avulsion of the cyst was adequate with low recurrence. However, for larger lateral saccular cysts and laryngocele with an external component, some prefer a transcervical approach for the external portion with possible removal of part of the thyroid cartilage.
Describe the classification of various types of laryngoceles.
- Saccular disorders can be classified by its content:
- air = laryngocele, patent saccular orifice
- mucus = saccular cyst, blocked orfice
- pus = laryngopyocele, blocked orifice
- Or can be classified anatomically:
- anterior saccular cyst - protrudes from anterior ventricle toward vestibule
- lateral saccular cyst or laryngocyele (internal only) - tends to dissect superiorly and laterally up into false cord and AE
- lateral saccule cyst or laryngocele (internal/external) - like internal
- only but penetrates through thyrohyoid membrane
Describe the two types of vocal fold cysts
- Mucus retention cysts occur when a glandular duct becomes blocked and is unable to secrete. This can occur after an upper respiratory infection or with vocal overuse.
- Epidermoid cysts are unilateral submucosal swelling of the superior mid-third surface of the vocal fold. They are lined with stratified keratinizing squamous epithelium and contain keratin debris. Can derive from trapped epithelium or phonotrauma.
What is a sulcus vocalis?
A longitudinal furrow parallel to the edge of the vocal fold and an oval glottic chink. Either the superficial layer of the lamina propria is absent altogether (usually causing severe dysphonia and requiring considerable vocal effort), or a portion of the epithelium invaginates through the superficial layer of the lamina propria and adheres to the vocal ligament.
Patient has bilateral nodules at the posterior third of the VF. What is the most likely etiology?
Contact granulomas are benign lesions usually located on the posterior third of the vocal fold, which corresponds to the vocal process of the arytenoid cartilage. Contact granulomas may occur unilaterally or bilaterally. Classic contact ulcers are thought to be the result of vocal misuse and abuse. These lesions often are similar in appearance to those found in patients after intubation (intubation granulomas) and in patients with gastroesophageal reflux. Treatment is typically conservative (PPI, voice therapy).
What are the most common types of human papilloma virus in respiratory papillomatosis? Which types are associated with squamous cell carcinoma?
- RRP: 6 and 11 (11 more aggressive disease)
- SCC: 16 and 18
What are the medical options for treatment of recurrent respiratory papillomatosis?
Interferon use is much less common today, though it’s effective. The decrease in use is due to the side effects associated with the drug and the success of intralesional cidofovir. The acute side effects are fever and generalized flu-like symptoms as well as nausea and vomiting. They tend to subside with prolonged therapy. Chronically, interferon can cause growth rate decreases in children, elevated liver enzymes, alteration in the central nervous system (leukopenia spastic diplegia) and febrile seizures, as well as thrombocytopenia. There is a statistically significant difference in responses based upon HPV subtype, with 68% of patients with HPV 6 remaining in remission at the end of the follow-up in contrast to only 18% of patients with HPV 18.
You are referred a patient with worsened dysphonia after removal of vocal fold polyps. What is the pathophysiology of postoperative dysphonia?
Scarring is the single greatest cause of poor voice after surgery. This often leads to glottic insufficiency due to increased effort. To decrease risk of post-surgical scarring it is important to preserve the superficial and deep layers of the lamina propria and its mucosal pliability. Medical treatment post-surgery may include anti-reflux medications, diet modifications, steroids, antibiotics and/or voice rest.