Vocal Pathology: Reflux Login

‎Vocal Pathology: Reflux on the App Store

4 hours ago ‎The Vocal Pathology: Reflux app helps students and patients learn and professionals teach vocal pathologies. The app features contact ulcer, granulomas, leukoplakia and LPRD videos. Each disorder case includes a key highlight view of abducted and adducted …

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Vocal Issues #1: Polyps, Hemorrhages, Nodules, and Acid

9 hours ago Jan 23, 2014 . Add reflux to the mix– often caused by the stress itself– and things can start to feel pretty overwhelming. Fortunately, true vocal pathology isn’t as common as people think. Whatever vocal troubles you may be having– whether nodules, reflux, a cold, or something as yet diagnosed– keep things in perspective. Stay calm, stay confident.

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Pathology of Nonneoplastic Lesions of the Vocal Folds

6 hours ago

• 1. Introduction 1. IntroductionThe vocal folds, also known as vocal cords, extend through the laryngeal cavity bilaterally and are primarily responsible for voice production. The thyroarytenoid muscle, deep lamina propria, intermediate lamina propria, superficial lamina propria, and squamous epithelium comprise the vocal folds [, , ]. The superficial lamina propria, which is also called Reinke’s space, consists of loose fibrous or elastic components and provides a gelatinous surface for vocal folds to vibrate upon. The deep and superficial lamina propria forms the vocal ligament. Madruga et al. demonstrated that type I collagen is abundant in the superficial lamina propria which forms a narrow band. The intermediate lamina propria essentially contains type III collagen, and the deep lamina propria is rich from both type I and type III collagen [].In a study of Chandramouli et al., nonneoplastic lesions of the larynx comprise 80% of the benign lesions diagnosed []. The etiology of the nonneoplastic vocal fold lesions is usually multifactorial, including phonotrauma (excessive loudness and cough, excess tension while speaking or singing, etc.), laryngeal trauma (endotracheal intubation), hypothyroidism, cigarette smoking, alcohol abuse, and gastroesophageal reflux (GERD) [, , , , ].
• 2. Exudative lesions of Reinke’s space 2. Exudative lesions of Reinke’s spaceVocal fold nodules and polyps and Reinke’s edema are exudative vascular-stromal lesions involving Reinke’s space. The similarities and distinct features of these lesions have long been studied []. Although some discriminating features have been emphasized, most of the literature concludes that these lesions share the same histopathologic features which prevent a definitive diagnosis [, ].2.1 Reinke’s edemaReinke’s edema is one of the most common causes of hoarseness and approximately comprises 10% of the laryngeal pathologies [, ]. It is the result of fluid accumulation in Reinke’s space that lies beneath the surface epithelium of the true vocal cords []. Smoking, vocal abuse, upper respiratory tract infection, and gastroesophageal reflux (GERD) have been associated with Reinke’s edema [, , , ]. Marcotullio revealed that the occurrence and recurrence of Reinke’s edema depend on the number of cigarettes daily used []. Zeitels et al. showed that increased subglottic aerodynamic driving pressure is the underlying mechanism of edema []. It has been hypothesized that vocal hyperfunction along with the underlying conditions such as reflux, smoking, etc. is more prone to Reinke’s edema []. Vecerina et al. classified Reinke’s edema into transparent and livid type []. Hypothyroidism is stated not to be related with Reinke’s edema [, , , ]. Majority of the patients are adults (aged between 20 and 60 years). Most of the patients experience Reinke’s edema unilaterally (74%). Only a small group of the patients has bilateral edema (26%) [].Most of the time, serous fluid is observed upon incision in macroscopic evaluation. However, if the condition persists longer, a jellylike fluid can be seen []. Patients are treated with vocal rehabilitation and surgery after eliminating the underlying conditions. Cessation of cigarette smoking is an important factor in long-term treatment [, ]. Histopathologic features include subepithelial edema and expansion of the intercellular space, especially the basal membrane. Few blood vessels can be observed []. The overlying epithelium is normal most of the time []. Duflo et al. showed that antioxidant gene expression is increased in Reinke’s edema compared to the vocal fold polyps []. In addition, Branski et al. demonstrated that heme oxygenase is increased in vocal fold fibroblasts []. Collagen and elastin fiber configuration alterations are demonstrated in Reinke’s edema [, ]. Dikker et al.’s stated that increased fibrin, hemorrhage, and thickening of the basement membrane are related with Reinke’s edema [].2.2 Vocal fold nodule and polypVocal fold nodules and polyps are polypoid lesions of the vocal folds sharing the same histopathologic features. They are usually differentiated by clinical findings. A polypoid lesion larger than 3 mm is often regarded as a polyp, whereas smaller lesions are classified as a nodule []. Vocal fold nodules are usually bilateral lesions involving anterior or middle vocal fold and located superficially to the free edge of the vocal fold []. They are slightly more common in women and in young age [, ]. Vocal polyps occur more commonly at the anterior portion of the vocal fold, and in more than 90% of the patients, they are unilateral []. There is no age and gender predilection for vocal polyps. Vocal abuse is the leading etiologic factor for vocal fold nodules and polyps; singers, lecturers, and coaches are more prone to developing these lesions due to excessive and loud voice use [, ]. Infection, hypothyroidism, GERD, cigarette smoking, and allergy are the other frequent causes [, , , ]. Patients present with hoarseness and change in voice quality.Grossly, vocal cord polyps and nodules present as sessile or polypoid lesions with nodules presenting as few millimeters and polyps up to few centimeters in size []. They can be white or bright red, and their consistency varies from firm to soft with a mucoid or glistening cut surface [].Although previous studies have attempted to identify histopathologic features which may aid in the differential diagnosis, it is now widely accepted that vocal fold nodules/polyps cannot be differentiated on the histopathologic basis [, , , ]. Epithelial hyperplasia, basement membrane thickening, edema, and vascular proliferation can be seen both in nodules/polyps and Reinke’s edema [, , ]. Ancillary studies such as Verhoeff-van Gieson, Masson trichrome, and Alcian blue did not reveal any difference among these entities [].Histopathology represents primarily the extent of the vascular damage and the temporal stage of the lesion []. Vocal abuse causes vascular injury and increased vascular permeability. If the damage is minimal, then increased permeability causes only edema, and the microscopic evaluation reveals hypocellular myxoid stroma which is defined as edematous myxoid-type vocal fold nodule/polyp according to some authors (). When this lesion is not removed or resolved, it undergoes fibrosis, and fibrous-type polyp/nodule evolves. Oval and spindle cells are observed embedded in a fibrous stroma (). Rarely atypical cells can be detected in this type which is not related with an aggressive behavior [, , ]. However, if the vascular injury is severe enough for fibrin escape to the subepithelium and interstitium at the beginning of the injury, then hyaline-type polyp/nodule occurs which is characterized by a hypocellular/acellular eosinophilic stroma. By the time capillary proliferation occurs, it progresses to a vascular-type nodule/polyp. This subtype shows ectatic vascular channels in a hypocellular stroma (). Although, these classification and staging are helpful in understanding the histopathologic spectrum, it is clinically insignificant. In addition, mixed features are seen in a single lesion most of the time. The overlying squamous epithelium may be normal, atrophic, or hypertrophic, and keratosis can be seen.Figure 1.Polyp with hypocellular myxoid stroma (H&E, ×100).Figure 2.Polyp stroma appears fibrotic, and spindle cells can be observed embedded within the stroma (H&E, ×200).Figure 3.Polyp stroma shows ectatic vasculature with a hypocellular stroma (H&E, ×200).Differential diagnosis includes amyloidosis, myxoma, and contact ulcer. Differentiation of hyaline-type vocal fold nodule/polyp from amyloidosis can be made by observing the distribution of eosinophilic material carefully. In hyaline-type nodule/polyp, it is more homogenous, whereas in amyloidosis there is perivascular and periglandular accentuation of the deposit. Histochemical stains like Congo red and crystal violet can be helpful in identifying the nature of the amorphous material. Myxoma has been rarely reported in the larynx, and it has characteristic stellate spindle cells embedded in an avascular, basophilic, gelatinous-like matrix [, ]. Contact ulcer has an ulcerated and fibrin-coated surface and usually involves the posterior portion of the vocal folds.Surgery has a limited value for these lesions as they are reactive changes to an underlying injurious condition which must be managed. Not surprisingly, voice therapy may result in resolution in most of the patients [, ]. Also, treatment of the exact underlying condition such as hypothyroidism can be helpful in the treatment of vocal fold polyps/nodules.
• 3. Contact ulcer 3. Contact ulcerContact ulcer is an ulcerated granulation tissue due to vocal abuse, endotracheal intubation, and GERD. Men are more commonly affected than women except that postintubation-related ulcers are more common in female patients. Clinically patients present with hoarseness, cough, dysphonia, habitual coughing, and throat cleaning [].Contact ulcers are generally bilateral (“kissing ulcer”) and involve the posterior part of the vocal fold. Grossly they present as an ulcerated, tan-white to erythematous polypoid lesion up to 3 cm in diameter. Microscopic evaluation reveals ulceration underlying a fibrin and/or fibrinoid necrosis and capillary proliferation that is oriented perpendicularly to the mucosal surface (). Central and base part of the lesion contains hemosiderin-laden macrophages. Usually a dense inflammatory infiltration accompanies. Re-epithelization, mucosal hyperplasia, and fibroblastic proliferation can be observed in chronic phase of the lesion [].Figure 4.Ulceration, necrosis, and granulation tissue formation. Capillaries oriented perpendicular to surface (H&E, ×200).Clinicopathologic correlation is important in the correct diagnosis as histopathologic features are somewhat nonspecific. Differential diagnosis includes vascular-type vocal cord polyp/nodule, Kaposi sarcoma, Wegener granulomatosis, and infectious agents. Wegener granulomatosis can be differentiated from contact ulcer with features of vasculitis and necrotizing granulomas. Also, laboratory findings, such as cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA) positivity, support a diagnosis of Wegener granulomatosis over contact ulcer. Kaposi sarcoma may rarely involve the larynx, and histopathologic evaluation reveals spindle cells with intracellular spheroid hyaline globules forming slit-like spaces and anastomosing vascular channels. Immunohistochemical staining with human herpes virus 8 (HHV8) reliably confirms the diagnosis as Kaposi sarcoma.Like vocal polyps/nodules, contact ulcer is treated with voice therapy, anti-GERD medication, and behavioral modifications in order to decrease habitual coughing and throat clearing [].
• 4. Amyloidosis 4. AmyloidosisAmyloidosis is the deposition of an extracellular, acellular, fibrillar, and amorphous material in various sites of the body. It can be primary (associated with plasma cell neoplasms) or secondary (associated with chronic systemic diseases such as familial Mediterranean fever, rheumatoid arthritis, etc.). Primary amyloidosis can be classified as systemic or localized. The larynx is the most common site for localized amyloidosis [, ]. It may also be associated with “mucosa-associated lymphoid tissue” (MALT) lymphoma or a neuroendocrine tumor. Laryngeal amyloidosis generally affects adults at the sixth decade. Patients present with hoarseness and voice changes because of mass effect []. Grossly it presents as a firm polypoid lesion up to 4 cm covered by normal-appearing mucosa. Cut surface may be firm and starch-like and gray or yellow-orange in color. Localized laryngeal amyloidosis can involve the larynx diffusely or present as a nodule. Microscopic examination reveals diffuse subepithelial or discrete nodular lesion consisting of amorphous, fibrillary, and hyaline-like eosinophilic substance deposition. Usually the distribution of the deposition is more pronounced in perivascular and periglandular areas. Lymphoplasmacytic infiltration and foreign body giant cells can be seen but usually sparse.Differential diagnosis includes hyalinized-type vocal fold polyps/nodules and lipoid proteinosis which are negative with Congo red and crystal violet. Most importantly as amyloid can be associated with multiple myeloma, laryngeal neuroendocrine tumors, and medullary thyroid carcinoma, a systemic evaluation of the patient is necessary.If amyloidosis is limited to the larynx, patients are treated with surgical removal of the lesion. However, other treatment options will be applied if the patient has an underlying neoplastic condition or chronic inflammatory disease.
• 5. Cysts of the larynx 5. Cysts of the larynxNonneoplastic cysts of the larynx consist of laryngocele, saccular, and ductal cysts [, , ].5.1 LaryngoceleLaryngeal ventricles are the spaces between the true and false vocal cords which extend upward and form the laryngeal saccule bilaterally. Laryngocele can be defined as a symptomatic dilation of the laryngeal saccule with air entrapment []. An important feature of laryngocele is that the lumen of the cyst communicates with the laryngeal cavity. Radiography reveals an air-filled cystic enlargement. They are usually unilateral, may occur over a wide age range, and are more frequent in males. Occupations such as glassblower or wind instrumentalists are at increased risk of developing laryngocele due to repetitive increase in intralaryngeal pressure. Patients present with hoarseness and foreign body or globus sensation.Clinically it can be divided as internal, external, or combined. Internal laryngocele is confined to the endolarynx and presents as a supraglottic submucosal lesion. In contrast external laryngocele extends through the thyrohyoid membrane. However, in combined laryngocele, the cyst herniates through the thyrohyoid membrane and presents as an anterior neck mass [, , ]. Patients present with hoarseness, dyspnea, and chronic cough. In histopathologic examination, the respiratory epithelium is identified as the lining of the cyst wall.Differential diagnosis includes other laryngeal cysts. However, laryngocele is the only air-filled cyst of this region and communicates with the laryngeal cavity—an important finding in differentiation.Symptoms may resolve with the expulsion of trapped air from the cyst lumen. Treatment of laryngocele is simple excision or marsupialization of the cyst wall.5.2 Saccular cystSaccular cyst is a mucin-filled cyst due to obstruction of the laryngeal saccule. It can be acquired or congenital [, ]. If it extends medially, it may obscure the anterior vocal fold. Lateral saccular cysts are similar to the external laryngoceles, herniated through the thyrohyoid membrane, and may present as a neck mass [].Saccular cysts are usually lined by respiratory-type epithelium. Squamous or oncocytic lining can be observed in some cases. Cyst lumen is filled with mucin or acute inflammatory exudate.Differential diagnosis includes laryngocele and thyroglossal ductus cyst. It is differentiated from laryngocele by mucin content, and it does not communicate with the laryngeal cavity. It is difficult to discriminate a thyroglossal cyst from a saccular cyst when it invades through the pre-epiglottic space and histopathologically lacks the thyroid tissue. When this is the situation, investigation of the anatomic localization of the cyst is a reliable finding in the differentiation of these cysts. Thyroglossal ductus cysts are related with the hyoid bone and located in the midline of the neck.5.3 Ductal cysts (squamous, tonsillar, oncocytic)Ductal cysts are the most common type of laryngeal cysts. Cyst lining epithelium can be squamous or oncocytic [, ] ( and ). When a squamous lined cyst is surrounded by lymphoid tissue, it is called a tonsillar cyst. Tonsilar cysts are more common in the vallecula which contains tonsillar remnants.Figure 5.The right side of the figure represents a squamous cell lined cyst. On the left cyst lining cells appear oncocytic (H&E, ×400).Figure 6.Ductal cyst with lining oncocytic cells (H&E, ×400).5.4 Other cystsRarely epidermal, dermoid, and branchial cleft cysts may occur in the endolarynx.
• 6. Hyperplastic lesions of the larynx 6. Hyperplastic lesions of the larynxHyperplastic lesions of the larynx are a result of a reparative process. Clinical terms such as leukoplakia (white plaque), erythroplakia (red plaque), erythroleukoplakia (red and white changes), or pachydermia (extensive thickening of the mucosa) are used to describe the lesion macroscopically, and they are not histologic entities [].Keratosis of the larynx is synonymously used with simple hyperplasia and squamous hyperplasia []. Singers and other occupations that lead to an individual to use his/her voice excessively and cigarette smokers are at risk of keratosis. Hoarseness is the leading complaint. Laryngoscopy identifies leukoplakia. Microscopic evaluation reveals a thickened squamous epithelium without cellular or architectural atypia []. Generally, a hyperkeratotic layer overlies the epithelium. Lesions with warty configuration are referred as verrucous keratosis [, ].Pseudoepitheliomatous hyperplasia (PEH) is a reactive proliferation of the squamous epithelium which develops in response to infections, trauma, or neoplasia. Histologically these lesions are downward thickening of the epithelium (). Due to a less well-defined epithelial stromal interface and the tendency of anastomosing epithelial tongues entrapping the submucosa, the lesion may mimic squamous cell carcinoma []. However, in PEH, the hyperplastic epithelium forms large bulbous projections, and basement membrane is always preserved.Figure 7.Downward proliferation of benign appearing surface epithelium (H&E, ×200).Verrucous hyperplasia is a verrucous and keratotic form of squamous hyperplasia which may show varying degrees of cytological atypia (). The presence of cellular atypia and a relatively regular epithelial-stromal border supports a diagnosis of verrucous hyperplasia over verrucous squamous cell cancer (SCC) [].Figure 8.Parakeratosis and verrucous hyperplasia of the surface epithelium (H&E, ×100).
• 7. Conclusions 7. ConclusionsVoice change or hoarseness of voice and nonneoplastic vocal fold lesions lead to a high percentage of vocal fold biopsies. Both clinical and histopathologic features should be considered in order to differentiate lesions involving Reinke’s space and also hyperplastic epithelial lesions from squamous cell carcinoma.Sections1.2.3.4.5.6.7.

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Reflux - Apps on Google Play

9 hours ago The Reflux app helps students and patients learn and professionals teach vocal pathology. The app features contact ulcer, granulomas, leukoplakia and LPRD videos. Each disorder case includes a key highlight view of abducted and adducted vocal folds. All disorders and normal video include an audio clip of the patient reading the rainbow passage.

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Association between gastroesophageal reflux disease and

3 hours ago Gastroesophageal reflux disease (GERD) is one of the most common chronic disorders of the digestive system. Acid reflux can not only damage the esophageal mucosa, but also reach the pharynx, larynx, nasal cavity, middle ear, and upper respiratory tract and cause damage. [1,2] GERD is classified as reflux esophagitis if esophageal mucosal injury ...

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Laryngeal polyp associated with reflux disease: a case

12 hours ago Among the most common benign laryngeal lesions are vocal nodules and polyps. Their etiology is related to vocal abuse. Gastroesophageal reflux disease is a common condition presenting with a broad spectrum of symptoms, among which are extraesophageal manifestations such as laryngeal polyps. A 24-year-old Middle Eastern woman presented to the author’s institution with dysphonia and …

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Voice Disorders - ASHA

9 hours ago

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Voice Disorders - GBMC HealthCare in Baltimore, MD

12 hours ago The Johns Hopkins Voice Center at GBMC specializes in state-of-the-art diagnostic and therapeutic services to individuals of all ages who present with a variety of voice disorders. Our patients include professional and non-professional singers, speakers, teachers, clergy, attorneys, salespeople, actors, elected officials, cheerleaders, coaches, or any individual experiencing a vocal pathology.

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www.hanoverent.com - Voice & Swallowing

2 hours ago Most common causes of hoarseness reflux disease, post nasal drip and vocal cord damage from prolonged vocal abuse. Other causes are benign lesions like nodule and warts on the vocal cords. Most common causes for chronic cough are allergies, asthma and Reflux disease. Many times more than one factor can be identified.

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Laryngology & Larynx Disorders: Overview, Conditions

12 hours ago

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The Radiology Assistant : Swallowing disorders update

2 hours ago Aug 13, 2018 . Publicationdate 2018-08-13. Swallowing is a complex movement. It requires the coordination of nerves and muscles in the buccolabial area, the tongue, the palate, the pharynx, the larynx and finally the esophagus. Radiographic studies of patients with swallowing disorders can help to analyse the problem.

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Symptoms & Disorders UNC Voice Center

8 hours ago The condition may develop as a maladaptive compensation for some other vocal pathology, or irritant such as gastroesophageal reflux. Occasionally, muscle tension dysphonia may develop in an attempt to use a hoarse, weak voice during or following an upper respiratory infection.

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Unilateral Laryngeal Paralysis or Vocal Cord Paralysis

6 hours ago Unilateral vocal cord paralysis may cause 'glottic incompetence' if the paralyzed vocal cord is laterally positioned and lacks sufficient tone to provide a buttress against which the normal mobile vocal cord can oppose. A breathy dysphonia will usually occur with glottic incompetence.

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Medical Articles PatCom Medical FEES Stroboscopy

9 hours ago Free to download and use commercially. Find a collection of original articles with topics related to dysphagia, voice disorders, reflux and more. A great resource for any Speech Language Pathologists (SLP) or Otolarynoglogists (ENT) that are interested in FEES, video stroboscopy and pH monitoring.

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Acute Laryngitis - StatPearls - NCBI Bookshelf

4 hours ago Acute non-infectious laryngitis can be due to vocal trauma/abuse/misuse, allergy, gastroesophageal reflux disease, asthma, environmental pollution, smoking, inhalational injuries, or functional/conversion disorders. Vocal misuse or abuse can be acute in onset, as seen after a day or days of shouting/yelling.

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Polyps - Apps on Google Play

5 hours ago The Vocal Pathology: Polyps app helps students and patients learn and professionals teach vocal pathology. The app features small, medium, large and hemorrhagic videos. Each disorder case includes a key highlight view of abducted and adducted vocal folds. All disorders and normal video include an audio clip of the patient reading the rainbow ...

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Frequency Response of the Fourcin Electroglottograph and

8 hours ago The purpose of this investigation was to study the frequency response of a modified Fourcin EGG at frequencies associated with the slow varying laryngeal movement of swallowing and to compare those findings with the response characteristics of the EGG at frequencies associated with phonation.

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Reinke's Edema

1 hours ago Reinke's edema (RE) is the polypoid degeneration of one or both vocal folds within Reinke's space. The viscoelastic properties of the mucosal folds are characteristically altered by the expansion of the subepithelial space. Most frequently, patients present with dysphonia, with women being more affe …

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The Advanced Voice Function Assessment Databases (AVFAD

1 hours ago Sep 13, 2017 . A new open access resource called Advanced Voice Function Assessment Databases (AVFAD) was developed, based on a sample of 709 individuals (346 clinically diagnosed with vocal pathology and 363 with no vocal alterations) recruited in Portugal. All clinical conditions were registered according to the Classification Manual of Voice Disorders-I. Participants were audio-recorded, …

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