A Comprehensive Analysis of Benign Vocal Fold Lesions Causing Hoarseness of Voice and Our Experience with Cold Knife Endolaryngeal Surgery in a Tertiary Healthcare Centre

Abstract

Benign vocal fold lesions (BVFL) frequently affect the general population and cause significant hoarseness by interfering with daily communication. Healthcare for low income groups in India is all about affordability and availability without giving up on quality and providing maximum satisfaction. (1) To analyse over a period of 4 years, the demographics, clinical profile, diagnostics and management options of BVFL. (2) To assess the diagnostic potential of rigid laryngoscopy in diagnosing these lesions. (3) Cold knife endolaryngeal surgery as a cost effective, satisfactory and efficient treatment modality to tackle majority of these BVFL. A prospective cross sectional study over a period of 4 years from 2013 to 2017. 114 patients presenting with hoarseness of voice were evaluated by indirect laryngoscopy followed by video laryngoscopy and stroboscopy in the department of ENT, MYH Hospital Indore (M.P.). Male:female ratio of 1.59:1 with male predominance (61.4%) and maximum incidence in the third decade (32%). All cases presented with hoarseness (100%) while vocal fatigue (63%) was the most common associated complaint followed by foreign body sensation (60%). Housewives (32%) were most commonly involved non professional group while teachers (13%) constituted the most common group of professionals. Laryngitis (26%) involving bilateral vocal folds diffusely was the most common finding followed by vocal fold sulcus (18%) and vocal fold cysts (14%). The duration of symptom was 6 months to 1 year in 52% patients. The positive predictive value for rigid laryngoscopy was 100% for vocal nodules, arytenoid granulomas and anterior glottis web. Out of 114 patients, 66 patients improved on conservative management while 48 patients underwent cold knife endolaryngeal surgery. As per the GRBAS scale to assess the post therapeutic prognosis, all had good outcome of voice with only two recurrences due to patient non compliance. In this rapidly evolving era of sophisticated lasers which is a costly affair that requires skilled personnel and safety precautions, the prime goal in a government run setup has always been to provide affordable and quality healthcare to the common man. Cold knife endolaryngeal surgery is a simple, cost effective and efficient way to tackle most of these lesions and hence helps in achieving this goal.

Introduction

Just like our fingerprints and DNA, our voice shapes our identity and provides individuality. We have been listening for voices not only since birth, but much before that. Research has shown that a child in the womb shows discernible preference for a mother’s voice. Hence the voice became the primary mode of communication for humans both socially and in work place.

Hoarseness is defined as an altered vocal quality, pitch, loudness, or vocal effort that impairs communication or reduces voice-related quality of life [1]. Brodnitz [2] reported 45% of 977 patients had a diagnosis of nodules, polyps or polypoidal thickening. Bernoulli’s principle i.e. “An increase in the speed of fluid flow results in a decrease in the pressure” explains the development of a vibratory pattern at the vocal cords when air passes and the resultant sound produced appreciated as voice. When the regularity of vibratory pattern is lost, the resulting vocal sound is hoarse [3]. Vocal abuse, cigarette smoking, infections, allergy and acid reflux increases the mucosa’s vulnerability to vibratory trauma leading to injury [4].

An evaluation of the hoarse patient always starts with a careful history and physical examination. Indirect laryngoscopy as a routine outpatient procedure is useful but often yields insufficient information in some cases and hence further evaluation. Rigid laryngoscopy using a 90° laryngoscope is a simple, non-invasive, and fairly accurate diagnostic tool for patients with vocal fold pathology [4]. Video laryngoscopy combined with Stroboscopy is yet another diagnostic tool to appreciate the viscoelastic properties of the phonatory mucosa.

The management includes initial conservative treatment and phonosurgery in cases refractory to medical treatment. Over the years there have been technological advancements in the field of phonosurgery. Microlaryngoscopy with the help of direct laryngoscope and operating microscope using 400 mm lens was developed by Kleinsasser [5]. This led to a new era of precession with stable and magnified field but had its own limitations of being a bulky system and an expensive procedure. Next came the use of a rigid telescope equipped with a high definition endoscopic video system as an alternative to operating microscope in endolaryngeal surgery. This system is economical, provides high resolution television image, improved surgeon comfort and ease. This method was recommended over standard microscope aided laryngeal surgery for greater depth of field, unimpeded instrumental access, instant documentation and superior teaching value.

Materials and methods

The study was undertaken in the Department of ENT, M.G.M. Medical College and M.Y. Group of Hospitals, Indore, Madhya Pradesh, India.

A total of 114 patients over a period of 4 years from 2013 to 2017 presenting with hoarseness of voice aged 18–60 years comprised the study group.

They were subjected to careful history and examination which included indirect laryngoscopy, perceptual assessment of voice using GRBAS scale, vocal fold imaging by video laryngoscopic examination using rigid 90° laryngoscope along with stroboscopy to appreciate the mucosal waves. Preliminary conservative treatment in the form of short course steroids, voice rest, quitting exacerbators, lifestyle modifications and speech therapy were provided. Patients requiring surgery and refractory to conservative treatment underwent video assisted cold knife endolaryngeal surgery. The samples were sent for histopathological evaluation to confirm the clinical diagnosis. This study used an assembly of Kantor Berci model laryngoscope which employs a centrally located 15° rigid telescope to visualise the endolarynx (Fig. 1). The laryngoscope-telescope assembly was fixed to the chest piece placed over a table mounted mayo stand forming a Fulcrum suspension device.

Fig. 1.

15° video-endoscope with Kantor Berci model laryngoscope and chest piece holder

Observations

Chart 1 Age-sex distribution

Chart 2 Positive past history and distribution of occupation

Chart 3 Comparison between rigid laryngoscopy and direct endolaryngoscopy and histopathological evaluation

Discussion

The study findings were compared to previous studies done by Muniraju and Vidya [6], Siddapur et al. [7], Saha et al. [8] and Buche et al. [9] (Tables 1, 2, 3, 4).

Table 1.

Associated presenting complaints

Symptom	No. of cases (n = 114)	Percentage
Hoarseness	114	100
Cough	56	49
Heart burn	64	56
Foreign body sensation in throat	68	60
Frequent throat clearing	52	46
Vocal fatigue	72	63
Difficulty in swallowing	58	51
Low grade pain in throat	66	58

Table 2.

Showing rigid laryngoscopic evaluation

Lesions	No. of cases		Total	Percentage
	Male	Female
Laryngitis	18	12	30	26
Vocal nodules	8	7	15	13
Vocal polyps	7	4	11	10
Vocal fold cysts	10	6	16	14
Reactive lesions	6	4	10	9
Arytenoid granulomas	1	0	1	1
Vocal sulcus	13	8	21	18
Vocal fold papilloma	4	1	5	4
Anterior glottis web	3	2	5	4

Table 3.

Post therapeutic prognosis

Type of lesions	Symptom free		Recurrence
	Complete GRBAS grade 3–0 or grade 2–0	Partial GRBAS grade 3–1
Laryngitis	22	0	0
Vocal nodules	14	0	0
Vocal polyps	10	1	0
Vocal fold cysts	13	2	1
Reactive lesions	9	1	0
Arytenoid granulomas	1	0	0
Vocal fold papilloma	3	1	1
Anterior glottis web	5	0	0

Table 4.

Comparative analysis between our study and other 4 studies

	Muniraju and Vidya [6] (n = 50)	Saha et al. [8] (n = 60)	Buche et al. [9] (n = 40)	Siddapur et al. [7] (n = 57)	Our study (n = 114)
Age distribution	31–40 years (46%)	41–50 years	20–50 years	30–40 years (61.4%)	31–40 years (32%)
Sex distribution	Male predominance (54%)	Male predominance (53%)	Male predominance (62%)	Male predominance (66.7%)	Male predominance (61.4%)
Predominant symptom	Hoarseness (100%)	Hoarseness (100%)	Hoarseness (100%)	Hoarseness (82.5%)	Hoarseness (100%)
Predominant complaint	Vocal fatigue (100%)	Vocal fatigue (80%)	Vocal fatigue (48.5%)	Vocal fatigue	Vocal fatigue (81%)
Associated risk factor	Vocal abuse (100%)	Smoking (50%)	Vocal abuse (62.5%)	Vocal abuse (80%)	Vocal abuse (67%)
Occupation	Females—housewives (24%) Males—businessman (34%)	Housewives (30%)	Housewives (25%)	–	Housewives (32%)

Total 114 patients were included in this study presenting with hoarseness of voice (100%) followed by vocal fatigue as the predominant complain (81%). Majority of patients (32%) presented in the third decade age group. 70 (61.4%) were males and 44 (38.6%) were females. Male predominance was observed with male: female ratio of 1.59:1. It was interesting to observe that, the number of females reporting with complains of hoarseness of voice as compared to previous studies has increased significantly over the years. This can be attributed to the increased awareness regarding the various etiological factors causing hoarseness of voice and availability of affordable healthcare in a government run tertiary care centre.

In this study non vocal professionals were the most affected and the incidence was maximum in housewives (32%) followed by labourers (15%). In case of vocal professionals, teachers were the group commonly affected (13%) followed by vendors (11%). This was in accordance to the previous studies (Table 4). Benign lesions of larynx constitute an interesting array of lesions, etiological factors for lesions such as vocal nodules, vocal polyps, mucosal hemorrhage, intracordal cyst seems to be vibratory trauma. Secondary influences such as smoking, infection, allergy, acid reflux may also increase the mucosa’s vulnerability to the kind of injuries that may occur during mucosal oscillation [4]. Vocal abuse or overuse was the most common offending factor present in 67% of cases as was observed in similar studies by Muniraju and Vidya [6], Siddapur et al. [7], Buche et al. [9], Singhal et al. [10], Kapoor and Chopra [11] followed by laryngopharyngeal reflux (59%) as was seen by Harding and Richter [12] and Koufman [13]. Chronic mucosal irritation by heavy smoking, excessive intake of alcohol and tobacco chewing in Asian countries play significant role in etiology of hoarseness. It was observed that in India and other developing countries the prevailing lower socio economic status, poor nutrition, poorer general health, different food habits, vocal habits, smoking and drinking habits, unhealthy environment, and different social customs influence the incidence of hoarseness as per Parikh [14]. In terms of smoking, tobacco chewing, alcohol intake, findings in our study was comparable to studies done by Buche et al. [9], Banjara et al. [15] and Wani et al. [16].

Among specific laryngitis tuberculosis of larynx is the commonest presentation in 4 cases, (3.5% of cases) all were secondary to pulmonary tuberculosis. This is in accordance with Kapoor and Chopra [11] who had 3 cases of tuberculosis of larynx, of which 2 were secondary to pulmonary tuberculosis.

In this study the duration of symptom was less than 1 year in 75.4% patients this was in accordance with Batra et al. [17] (86%). Saudi [18] (73%) and Kapoor and Chopra [11] (68%). This can be attributed to Increased awareness by word of mouth, availability of care and affordability which has improved the time between appearance of a symptom and reporting to the hospital.

On rigid telescopic examination, our study showed laryngitis as the most common finding (26%) followed by vocal fold sulcus (18%), vocal fold cysts (14%). Laryngitis, both specific and reflux cases as the most common finding was also seen in studies conducted by Soni et al. [19] 24% of cases, Baitha et al. [20] 50% and Parikh [14] 48%. It is currently estimated that 4–10% of patients evaluated by otolaryngologist have reflux related disease and that patients who have oesophagitis are twice as likely to have laryngitis as those who do not have. Harding and Richter [21] estimated the prevalence of GERD associated cough and found it in the range of 10–40% [12].

The symptomatology has showed a change in trend. This can be attributed to lifestyle changes, increased level of mental stress, long gaps between meals, no physical exercise and odd working hours. The most important predisposing factor after vocal abuse was laryngopharyngeal reflux. Vocal sulcus was observed in 18% cases. This is in accordance with the study by Buche et al. [9]. Vocal cysts were seen in 14% cases similar to Satheesh et al. [22] (17%) and Siddapur et al. [7] (16%). These cysts are sub epidermal epithelial lined sacs located within laminar propria and may be mucus retention or epidermoid in origin.

In our study, Bilateral vocal folds were involved in the form of vocal nodules, chronic laryngitis, anterior glottis web and vocal sulcus (54%), with right sided vocal fold affected more commonly (25%) as compared to left vocal fold (19%) in unilateral lesions like polyps and cysts. Sharma et al. [23] reported Bilateral lesion predominated overall (40%). Epstein et al. [24] showed majority of bilateral lesions with right sided preponderance as per our study results. Similar findings were observed in study by Sharma et al. [23] and Wani et al. [16].

In our study the positive predictive value was 100% in cases of vocal nodules, arytenoid granuloma, anterior glottic web but the accuracy was 90% in reactive lesions, 76% in sulcus, 72% in case of vocal polyp and 75% in vocal cyst. After direct suspension laryngoscopy the lesion was found to be a papilloma which on rigid laryngoscopy appeared like a polyp. Histopathology confirmed these findings. In a similar study by Nupur and Garg [25] it was found that the clinical diagnosis was 100% accurate in vocal fold cyst, vocal nodules, laryngeal papilloma and ulcer and had a reliability of 30% for vocal polyps.

The discrepancy in diagnosis between rigid telescopic laryngoscopy and suspension microlaryngoscopy highlights certain key points:

1. During office endoscopy, tangential views of the medial surface of the glottis limit the diagnostic sensitivity.

2. Sulci and mucosal bridges are most subject to this limitation.

Out of the total 114 patients, 66 patients got relieved by conservative management while 48 patients (42%) underwent phonosurgery using cold steel instruments (Fig. 2). Surgical treatment of the benign lesions of larynx is necessary not only for the histological confirmation of the clinical diagnosis but also to re-establish the mechanism of normal phonation which is altered by the changes in the mass, flexibility, elasticity, resistance or morbidity of the true vocal cord as per Doloi et al. [26].

Fig. 2.

An overview of the different benign vocal fold lesions and their surgical management. a Showing cystic swelling over right vocal fold; b typical sessile unilateral post hemorrhagic polyp of right vocal fold with histopathologic evidence (HPE); c a polypoidal mass on superior border of right vocal fold with HPE

As per study conducted by Phaniendra Kumar et al. [27] 70% of patient showed improvement on GRBAS scale from grade 3 to 0 and rest from grade 3 to 1 post operatively. In our study, out of these 48 patients operated, all had good outcome of voice. As per GRBAS scale 43 patients (89.5%) improved from grade 3 to grade 0 and 5 patients (10%) from grade 3 to grade 1. A case each of vocal fold papilloma and vocal fold polyp and 2 cases of vocal fold cyst were partially free of symptoms but were satisfied with the improvement in voice. Recurrence of lesion was noted in 2 cases; one case each of vocal fold papilloma and vocal fold cyst because of noncompliance of patients. The present study showed encouraging results with video assisted cold knife endolaryngeal surgery as 98% of patients were satisfied with their voice quality and only 2 cases showed recurrence after single operation.

Conclusion

In this dazzlingly fast moving era of sophisticated lasers for vocal surgery and dearth of basic necessary healthcare and resources in a government run set up, access to such advanced privileges are still far-fetched dreams for the common man. Health care for low-income groups in India is all about affordability and availability of care, without giving up on the quality and providing maximum satisfaction. Phonosurgery using cold steel instruments emerged as a simple, cost effective yet efficient way in treating these benign vocal fold lesions compared to laser surgery which required a greater number of skilled personnel in order to ensure effectiveness and safety, thereby increasing the overall cost of the procedure.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Human and Animal Rights

This article does not contain any studies with animals performed by any of the authors.

Informed Consent

Informed consent was obtained from all individual participants included in the study.