Evidence-Based Laryngology

© Springer Nature Switzerland AG 2021

D. E. Rosow, C. M. Ivey (eds.)Evidence-Based Laryngologyhttps://doi.org/10.1007/978-3-030-58494-8_1

1. Vocal Fold Nodules

Patrick O. McGareyJr¹   and C. Blake Simpson²

(1)

Department of Otolaryngology, Head and Neck Surgery, University of Virginia Health System, Charlottesville, VA, USA

(2)

UAB Voice Center, Department of Otolaryngology, University of Alabama-Birmingham, Birmingham, AL, USA

Patrick O. McGareyJr

Email: pmcgarey@virginia.edu

Email: POM4FB@hscmail.mcc.virginia.edu

Keywords

Vocal fold nodulesPhonotraumaVoice therapyVocal hygienePhonosurgeryNon-surgical treatments

Introduction

While there is no universally accepted nomenclature system for benign vocal fold lesions, vocal fold nodules (VFNs) are defined as bilateral, mid-membranous vocal fold lesions that respond to voice therapy (Fig. 1.1) [1]. They are the most common organic laryngeal pathology seen in professional voice users and voice patients overall, identified in 15% of patients presenting with dysphonia [2]. A national South Korean health survey reported a 1.3% prevalence of VFN in men and women >19 years old [3].

Fig. 1.1

Vocal fold nodules viewed by laryngeal videostroboscopy

VFNs are characterized histopathologically by epithelial hyperplasia, basement membrane thickening, and fibrosis. These lesions are contained within the basement membrane zone and superficial lamina propria [4]. VFNs contain dense organizations of fibronectin [5], a molecule that plays an important role in wound healing and tissue remodeling [6], and is thought to be a precursor for collagen formation [7].

Etiology and Diagnosis

VFNs develop in the setting of phonotrauma. Jiang and Titze demonstrated that the mid-membranous portion of the vocal fold receives the maximum impact stress during phonation , helping to establish the relationship between most mid-membranous lesions and phonotrauma [8]. In one study of 221 patients with benign vocal fold lesions, 80% occurred at the mid-membranous location [9]. Not surprisingly, occupation is a risk factor for development of voice disorders, including VFNs . Heavy vocal use professions are at highest risk, including not only singers, actors, and other performing artists, but also teachers and other educators, social workers, counselors, clergy, and lawyers [10, 11]. The majority of VFNs occur in young females. Zhukhovitskaya et al. revealed that roughly 90% of VFNs identified in a voice clinic were in female patients, and roughly 85% in patients 18–39 years of age [12]. Extroverted personality has been associated with VFNs [13]. Bouchayer et al. reported on over 500 patients with nodules who underwent surgery and found a small congenital anterior glottic web in 22% of cases , the significance of which is unknown [14]. While laryngopharyngeal reflux (LPR) has been shown to occur more often in patients with VFNs compared to controls [15], pepsin is generally not present in VFNs excision specimens [16]. It is conceivable that in some patients, the chronic cough and throat clearing associated with gastroesophageal reflux disease (GERD) and LPR could contribute to vocal fold trauma leading to development of VFNs, although this is more commonly associated with posterior laryngeal pathology such as granuloma [17].

Vocal fold nodules are typically identified on laryngeal videostroboscopy as bilateral lesions , which are most often symmetric. VFNs have normal or minimally impaired mucosal wave. They are also defined by their response to non-operative treatment, specifically vocal hygiene, management of comorbid conditions contributing to laryngeal inflammation, and voice therapy [1].

Treatment

Conservative Treatment

Behavioral therapy including behavioral education , laryngeal hygiene, and voice therapy has been shown to be effective in improving vocal function in patients with VFNs, with treatment success rates ranging from 88% to 100% [18–21]. It is important to note that the definition of treatment success varies greatly, and many studies did not assess patients with laryngeal videostroboscopy after treatment. It has been shown that while vocal function and voice quality often improve with behavioral treatment and voice therapy, complete regression of vocal fold lesions after treatment was low in several reports [22–25]. In addition, one study found no difference in short- and long-term VHI-10, perceptual voice evaluation scores, and acoustic parameters between patients with remnant nodules and those with a complete lesion response after treatment with voice therapy [25]. A meta-analysis of studies assessing acoustic voice parameters before and after voice therapy for treatment of VFNs showed a statistically significant improvement in fundamental frequency and jitter after treatment [26].

Given the lack of availability of voice therapists in some medical settings, a Japanese study sought to evaluate the effectiveness of a vocal hygiene education program consisting of an individualized private short lecture (by a physician or voice therapist) followed by standardized videotaped lessons. This study randomized participants with VFNs and vocal fold polyps (VFPs) to receive this education program or the standard basic laryngeal hygiene education. Although the results reported VFNs and VFPs together, there was a combined 61.3% lesion resolution rate in the treatment group compared to 26.3% (p < 0.001) in the standard education group. In addition, the rate of lesion resolution for VFNs was higher (OR 4.8, P < 0.001) compared to VFP, although the individual data was not reported for each lesion type [27].

Voice therapy via telepractice is gaining popularity, especially in the wake of the COVID-19 pandemic, and there is evidence for its use in VFNs and other voice disorders. A randomized trial demonstrated similar efficacy of voice therapy via telepractice compared to in-person voice therapy in the treatment of muscle tension dysphonia [28]. Fu et al. demonstrated the efficacy of this practice in the treatment of 10 women with VFNs using video conferencing technology. After an initial vocal hygiene education session face-to-face in the clinic, patients underwent eight sessions of voice therapy via telepractice. Perceptual, stroboscopic, acoustic, and physiologic assessments were made by a blinded speech language pathologist and an otolaryngologist. Results were similar when compared to results from a separate group of patients treated with conventional face-to-face intensive voice therapy by the same group of clinicians [29].

Surgical Treatment

While non-surgical interventions are the mainstay of treatment of VFNs, surgical therapy can be entertained in selected patients who fail initial therapy. A Cochrane review first performed in 2001 and last updated in 2012 sought to compare the effectiveness of surgical vs. non-surgical therapy for VFNs. No suitable trials were identified [30]. Béquignon et al. (2013) retrospectively analyzed a group of 62 patients who had undergone surgical therapy for VFNs, with or without postoperative voice therapy. The rate of recurrent dysphonia without postoperative voice therapy was 56%, compared to 22% for those receiving postoperative voice therapy. Recurrent dysphonia, when it occurred, was noted at a mean interval of 5.2 years after surgery, and new vocal fold pathology (VFNs or polypoid corditis) was seen in 18% of patients [31]. This study highlights that while surgery can remove VFNs successfully, addressing the underlying behavioral etiology of this condition is critical to treatment success.

There are other non-surgical modalities for the treatment of VFNs. Woo et al. demonstrated a 42% complete resolution rate among 33 patients with VFNs who underwent percutaneous subepithelial steroid injection after refusing voice therapy and surgery. Their recurrence rate was low (3%), but long-term follow-up was lacking [32]. Wang et al. performed a retrospective review of adults with VFNs and vocal fold polyp (VFP), comparing vocal hygiene education to in-office vocal fold steroid injection. Comparing 33 patients with VFNs treated with vocal fold steroid injection, lesion size improved to a greater extent with steroid injection at 1 month, but both steroid injection and vocal hygiene groups had comparable lesion size reduction at 2 months (37% reduction for steroid group, 26% reduction for vocal hygiene group) [33]. Long-term follow-up of 72 patients with VFNs treated by this same laryngology group with in-office vocal fold steroid injection demonstrated only a 31% failure rate (symptom recurrence or need for additional intervention) at 2 years [34]. Additional research is needed to characterize the role of steroid injection in the management of VFNs.

Transcutaneous electrical nerve stimulation (TENS) is a well-established technique in the physical therapy field, and it has been studied as an adjunct to voice therapy for the treatment of voice disorders. Although there remains some controversy regarding its effectiveness [35], studies have demonstrated beneficial effects on pain pathways [36], local blood flow [37], and muscle relaxation [38]. Several studies combining this technique with standard voice therapy maneuvers have shown promising effects on glottic function in patients with VFNs [39, 40].

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© Springer Nature Switzerland AG 2021

D. E. Rosow, C. M. Ivey (eds.)Evidence-Based Laryngologyhttps://doi.org/10.1007/978-3-030-58494-8_2

2. Recurrent Respiratory Papillomatosis

David E. Rosow¹   and Chandra M. Ivey²

(1)

Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, USA

(2)

Department of Otolaryngology, Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA

David E. Rosow

Email: DRosow@med.miami.edu

Keywords

PapillomatosisHuman papillomavirusNarrow band imagingLaser microsurgeryBevacizumabVaccination

Introduction

Recurrent respiratory papillomatosis (RRP) is an acquired condition resulting in the growth of exophytic, wart-like lesions anywhere in the upper aerodigestive tract. This chapter will solely focus on papillomatosis affecting the larynx, the most affected site. While RRP is a benign condition, its recurrent nature makes it a source of morbidity due to the frequent need for surgical debulking and rare potential for airway obstruction or malignant transformation. Management has evolved significantly over the last 50 years, and understanding the evidence basis for diagnostic and treatment approaches is critically important.

Etiology and Pathogenesis

RRP is caused primarily by two strains of human papillomavirus (HPV), HPV-6 and HPV-11. HPV-11 is generally associated with more aggressive disease and higher potential for malignant transformation [1]. The disease has a bimodal distribution, with onset occurring both in children (approximately 4 per 100,000) and in adults (approximately 2 per 100,000) [2]. In spite of the relatively rare incidence, its recurrent nature leads to numerous surgical procedures, with an annual estimated cost to the US health care system of $200 million [3]. The average child requires nearly 20 procedures in their lifetime and an average of 4.4 per year, with over 15% of adults and children requiring over 40 lifetime procedures.

The exact mode of transmission is unknown. It is postulated that juvenile-onset RRP is transmitted vertically, from mother to child. Greater than 60% of women test positive for HPV antibodies, and anywhere from 1.5% to 5% of pregnant women in the USA are clinically infected, with a transmission risk in uncomplicated vaginal deliveries of approximately 1:400 for women with active cervical HPV [4]. Virus transmitted in this fashion may remain dormant and then activate during a period of immune decline or suppression.

Transmission may also occur horizontally, through sexual contact that may be orogenital or oral-anal in nature. Ruiz