Keywords
Polyps - Vocal Cords - Microsurgery
Introduction
Dysphonia is the main symptom of lesions that affect the vocal tract. More than 50%
of individuals with voice disorders have benign alterations of the vocal fold mucosa.
Polyps are one of the most frequent vocal cord lesions and are the most prevalent
indication for laryngeal microsurgery. Like nodules, polyps are caused by overuse
and abuse of the voice[1], although they may also occur as a result of a single traumatic incident[2]
[3]. Trauma can affect the superficial vases of the lamina propria causing the liquids
within to overflow, displacing the epithelial layer and inducing scarring due to the
deposition of fibrin and vascular proliferation. Depending on the type of vascularization,
polyps are classified as angiomatous or hemorrhagic if accompanied by vascularity
or as hyaline or gelatinous in the absence of vascularization.
The clinical picture is characterized by dysphonia related to intense vocal use, and
is generally well-defined and recognized by the patient. The dysphonia is constant,
and may progressively worsen. The voice presents as hoarse and breathy; sometimes
it can be rough and, infrequently, diplophonic. A diagnosis is made by assessing the
clinical history, and by perceptive analysis and observation of the phonatory system,
which includes assessments of the phonatory posture adopted, articulation, and attitude.
Laryngoscopy with or without stroboscopy can confirm the diagnosis. Treatment of vocal
polyps is essentially surgical[4].
Vocal polyps can have many presentations and characteristics, and the aim of our study
was to identify the characteristics of the polyps found in our population.
The objective of this study was to analyze and compare the features of polyps (intrinsic
characteristics, associated lesions, and treatment outcomes) from patients undergoing
laryngeal surgery at our hospital.
Methods
This prospective study was conducted from February 2010 to February 2011 using an
electronic computerized protocol once the approval of the ethics committee had been
obtained (CAEE :0286.0208.000-11). We used the SINPE © electronic protocol with the
SINPE© Analyzer for data analysis[5]
[6]
[7]. The protocol-based software program is capable of storing and manipulating data
on a theoretical basis. The SINPE© Analyzer module is used to create reports, graphs,
and statistics summarizing the main findings. A specific protocol for laryngeal disorders
among the master ENT protocol available in SINPE was used for the analysis; only patients
diagnosed with vocal fold polyps were analyzed.
In total, 245 microsurgeries of the larynx were performed in our Hospital during the
study period. The inclusion criteria were as follows: a diagnosis of polyps, clinical
laryngoscopy, and intraoperative confirmation of the diagnosis by anatomopathology.
Exclusion criteria were as follows: a diagnosis of infiltrative processes or storage
disease (vocal polyps not identified upon anatomopathologic examination).
Of the 245 patients who underwent surgery during the study period, 93 (36.61% of lesions)
with vocal polyps and an indication for microsurgery were evaluated. These 93 patients
were classified into 2 groups according to the physical and histological characteristics
of the lesions: (a) those with angiomatous polyps (n = 63, 67.75%) and (b) those with
gelatinous polyps (n = 30, 32.25%). Comparisons between the 2 groups were made according
to 12 anatomic and surgical parameters based on the polyp characteristics. Parameters
1–8 refer to the intrinsic characteristics of the polyps ([Table 1]), parameters 9 and 10 refer to polyp-associated lesions ([Table 2]), and parameters 11 and 12 refer to the treatment strategy ([Table 3]).
Table 1.
Polyp Intrinsic Characteristics.
|
Parameter
|
Description
|
|
1. Sex
|
male or female
|
|
2. Age
|
|
3. Size
|
a) small: the polyp takes up one-third of the vocal fold
|
|
b) medium: the polyp occupies two-thirds of the vocal fold
|
|
c) large: the polyp fills more than two-thirds of the vocal fold
|
|
4. Implantation
|
a) sessile: the lesion is considered sessile if it has a wide base
|
|
b) pedunculated: the polyp presenting small implantation with elevation of its base
(with a stalk or peduncle)
|
|
5. Lobulation
|
a) unilobulated: only one lobulation
|
|
b) bilobulated: two lobulations
|
|
c) multilobulated: many lobulations
|
|
6. Position
|
a) anterior third: the polyp is within the anterior third of the vocal fold
|
|
b) middle third: the polyp is within the middle third of the vocal fold
|
|
c) posterior third: the polyp is within the posterior third of the vocal fold
|
|
7. Location
|
a) free edge: the polyp is located at the free edge of the vocal fold
|
|
b) upper edge: the polyp is located at the top edge of the vocal fold
|
|
c) lower edge: the polyp is located on the bottom edge of the vocal fold
|
|
d) more than one location: the polyp covers various sites (e.g., transglottic polyp)
|
|
8. Location of polyp
|
a) right vocal fold
|
|
on vocal fold
|
b) left vocal cord
|
|
c) bilateral: polyp on both the right and left folds
|
Table 2.
Associated lesions.
|
Parameter
|
Description
|
|
|
|
9. Presence of associated lesions and their type
|
a) nodular reaction
|
d) groove bag
|
g) mucous cyst
|
|
b) varicosity
|
e) stria minor
|
h) mucosa bridge
|
|
c) stria major
|
f) intracordal cyst
|
i) microdiaphragm
|
|
10. Associated lesions in relation to the vocal fold
|
a) ipsilateral - on the same vocal fold polyp
|
|
|
|
|
b) contralateral - on opposite vocal fold polyp
|
|
|
Table 3.
Treatment.
|
Parameter
|
Description
|
|
11. Surgical technique
|
a) polyp grip + microscissors (holding the polyp and performing resection with microscissors)
|
|
b) medial microflap + microscissors (microbisturi incision, creation of a medial microflap,
and resection with microscissors)
|
|
12. Evolution of
|
a)optimal: satisfactory treatment
|
|
Speech therapy
|
b) poor: unsatisfactory treatment
|
The protocols were performed on the day before surgery after the pre-anesthetic consultation,
and supplemented during the postoperative follow-up. Endolaryngeal microsurgeries
were performed in the operating room of the same institution using suspension laryngoscopy
(SL) by 3 doctors from the Laryngology and Voice Service department.
During SL, the vocal folds were subject to visual inspection and palpation with delicate
microforceps. The microsurgical technique used depended on the preoperative evaluation
and its confirmation during surgery.
Statistical analyses were performed using the Chi-square test to compare the variables
discussed above, and the significance level was set at p < 0.05.
Results
All 93 patients underwent laryngeal surgery due to a diagnosis of polyps of the vocal
folds during the period February 2010 to February 2011. Of these, 63 (64.74%) had
angiomatous and 30 (32.26%) had gelatinous polyps. Regarding sex, 51 were male and
42 female. Their age ranged from 20 to 80 years. The distribution according to the
12 parameters for each type of polyp is shown in [Tables 4], [5], and [6].
Table 4.
Comparative analysis of internal characteristics of angiomatous and gelatinous polyps.
|
Parameter
|
Angiomatous n = 63 (64.74%)
|
Gelatinous n = 30 (32.26%)
|
p < 0.05
|
|
1. Sex
|
|
|
|
|
Male
|
41 (65.08%)
|
10 (33.33%)
|
|
|
Female
|
22 (34.92%)
|
20 (66.67%)
|
p = 0.008
|
|
2. Age
|
41–60 years (49.21%)
|
20–40 years (46.67%)
|
|
|
3. Size
|
Medium
|
Small
|
|
|
43 (68.25%)
|
17 (56.67%)
|
p = 0.001
|
|
4. Implantation
|
Pedunculated
|
Sessile
|
|
|
35 (55.56%)
|
19 (63.33%)
|
|
|
5. Lobulation
|
Unilobulated
|
Unilobulated
|
|
|
53 (84.13%)
|
26 (86.67%)
|
|
|
6. Position
|
|
|
|
|
anterior third
|
25 (35.71%)
|
8 (26.67%)
|
|
|
middle third
|
36 (51.43%)
|
11 (36.67%)
|
p = 0.02
|
|
posterior third
|
9 (12.86%)
|
11 (36.67%)
|
|
|
*Number of positions:
|
34 (53.96%)
|
24 (80%)
|
p = 0.03
|
|
One
|
29 (46,04%)
|
6 (20%)
|
|
|
More than one
|
|
|
|
|
7. Location
|
Free edge
|
Free edge
|
|
|
42 (66.67%)
|
20 (66.67%)
|
|
|
8. Location of polyp on
|
|
|
|
|
vocal fold:
|
|
|
|
|
right
|
39 (61.9%)
|
14 (46.67%)
|
|
|
left
|
22 (34.92%)
|
9 (30%)
|
p = 0.009
|
|
bilateral
|
2 (3.17%)
|
7 (23.33%)
|
|
Table 5.
Comparative analysis of parameters relating to lesions associated with angiomatous
and gelatinous polyps.
|
Parameter
|
Angiomatous n = 63 (64.74%)
|
Gelatinous n = 30 (32.26%)
|
p < 0.05
|
|
9. Associated lesions
|
|
|
p = 0.02
|
|
a) nodular reaction
|
26 (44.83%)
|
13 (65%)
|
|
|
b) varicosity
|
8 (13.79%)
|
4 (20%)
|
|
|
c) stria major
|
8 (13.79%)
|
1 (5%)
|
|
|
d) groove bag
|
4 (6.9%)
|
0
|
|
|
e) stria minor
|
3 (5.17%)
|
0
|
|
|
f) intracordal cyst
|
4 (6.9%)
|
1 (5%)
|
|
|
g) mucous cyst
|
2 (3.45%)
|
1 (5%)
|
|
|
h) mucosa bridge
|
2 (3,45%)
|
0
|
|
|
i) microdiaphragm
|
1 (1.72%)
|
0
|
|
|
* Presence of MSA
|
|
|
|
|
Present
|
30 (47,61%)
|
6 (20%)
|
|
|
Absent
|
33 (52.39%)
|
24 (80%)
|
|
|
10. Association of lesions with the vocal fold:
|
|
|
|
|
Ipsilateral
|
44 (69.84%)
|
27 (76.67%)
|
|
|
Contralateral
|
19 (30.16%)
|
7 (23.33%)
|
|
Table 6.
Comparative analysis of parameters for treatment of angiomatous and gelatinous polyps.
|
Parameter
|
Angiomatous n = 63 (64.74%)
|
Gelatinous n = 30 (32.26%)
|
p < 0.05
|
|
11. Surgical technique
|
|
|
|
|
Grip+ microscissors
|
36 (57.14%)
|
12 (40%)
|
|
|
Medial microflap+ microscissors
|
27 (42.6%)
|
18 (60%)
|
|
|
12. Evolution of speech therapy
|
Optimal
|
Optimal
|
|
|
56 (88.89%)
|
28 (93.33%)
|
|
Discussion
Benign lesions of the vocal folds represent a significant problem for otolaryngologists
because they are very common and require a multidisciplinary treatment approach. When
such lesions do not respond to drug therapy and/or speech therapy, surgery is required
with the aim of increasing phonatory function or establishing a histological diagnosis
by biopsy[8]
[9].
In our study, we found 93 (36.61%) polyps among 245 patients with vocal fold lesions
who underwent laryngeal surgery during the period from February 2010 to February 2011
in our Hospital. This was the most frequent diagnosis observed in this study, which
supports the reports by Haas & Doderlein, Mossallam, and Lehmann and Kleinsasser,
who noted that polyps were the main indication for laryngeal microsurgery[10]
[11]
[12]
[13].
Angiomatous polyps were more common (63 patients, 64.74%) than gelatinous polyps (30
patients, 32.26%). In addition, we noticed a male predominance among patients with
angiomatous polyps and a female predominance among those with gelatinous polyps. The
Chi-square test (significance level, p = 0.008) showed that the type of polyp was dependent on sex. The male predominance
of angiomatous polyps (65.08%) is consistent with the findings reported in the literature[3]
[14]
[15], but there was no male predominance of gelatinous polyps. Instead, these were more
common in women (66.67%), which is a similar finding to that obtained by Dailey, who
reported a female incidence of 62% among patients with gelatinous polyps[16]. This may be because women are more likely to seek medical advice than men. In addition,
female patients with increased vocal fold mass have a lower pitch, which has a greater
impact on the social life of these patients than is the case with male patients.
Regarding size, the statistical analysis demonstrated that the polyp size was dependent
on type. Most angiomatous polyps were of medium size (68.25%) whereas most gelatinous
polyps were small (56.67%) (p = 0.001). Angiomatous polyps were also found most frequently in the middle third
of the vocal fold (51.43%), whereas the gelatinous polyps tended to be found in the
middle and posterior thirds of the fold (36.67% each) (p = 0.02). Thus, the position of the polyp in the vocal fold was also dependent on
type.
In our study, both angiomatous and gelatinous polyps were predominantly found on the
right vocal fold (p = 0.009), and so there is also a relationship between polyp type and its location
on the vocal fold. Eckley et al. reported similar findings[14], whereas Sakae et al.[17] reported that polyps were found in the left vocal fold in 53% of cases.
The presence of MSA occurred in 47.61% of patients with angiomatous polyps, in comparison
with 20% of patients with gelatinous polyps (p = 0.02). There was thus also a correlation between polyp type and the presence of
MSA (greater in angiomatous polyps). In Sakae et al.'s study[16], polyps were associated with MSA in 23.5% of patients.
Reaction nodular lesions were found in 41.26% of the patients with angiomatous polyps
and 43.33% of the patients with gelatinous polyps. There was no statistical difference
between the two groups (p = 0.97). In Eckley et al.'s study[14], 37% of patients had reaction lesions, confirming the suspicion that the impact
of the polyp on the healthy vocal fold can cause long-term alterations in the epithelial
layer of the contralateral vocal fold[14]
[18].
Regarding the MSA, stria were the most frequently encountered lesions (49.9%) in angiomatous
polyps, whereas varicosity was predominant in gelatinous polyps (66.66%). In Eckley
et al.'s study[14], stria were the most frequently encountered MSA (70%).
In our study, the patients underwent larynx surgery with SL, which led to considerable
improvement in voice quality and the remission of other symptoms. The surgical technique
most commonly used for angiomatous polyps is to grab the polyp and resect it with
a microscissors (57.14%). For gelatinous polyps, the main surgical technique is to
create a medial microflap and then resect it with a microscissors (60%). There was
no difference in outcome when these techniques were compared.
After surgery, all of the patients underwent speech therapy with optimal developments
in most cases (88.89 and 93.33% for those with angiomatous and gelatinous polyps,
respectively). There is a consensus regarding the use of postoperative speech therapy
and appropriate follow-up and successful outcome[9]. We plan to undertake further analysis of the therapy outcomes in subsequent research
projects.
Conclusion
In this study, angiomatous polyps were more frequently encountered than gelatinous
polyps. There was a male predominance among patients with angiomatous polyps, and
a female predominance among those with gelatinous polyps. Angiomatous polyps were
more frequently associated with MSA. There was also a correlation between the size
of the polyp, and its position and location in the vocal fold and the presence of
MSA. Different surgical techniques were used, but the postoperative results were similar
and satisfactory once the therapy was complete.
