Mohamed Farahat Ibrahim, MD, PhD

Transcription

1 Mohamed Farahat Ibrahim, MD, PhD Consultant, Assistant Professor Phoniatrics (Communication and Swallowing Disorders) Deputy chairman, Communication and Swallowing Disorders Unit (CSDU) King Abdulaziz University Hospital Supervisor, Swallowing disorders clinic King Khalid University Hospital King Saud University, Riyadh, Saudi Arabia.

2 Benign Vocal Fold Lesions II

3 The Scream, 1893 Edvard Munch Mohamed Farahat Ibrahim, MD, PhD

4 Introduction Mohamed Farahat Ibrahim, MD, PhD

5 Definition Benign, non-neoplastic, noninflammatory, traumatic lesions of the vocal folds. Kotby, M.N.; Ghali, A.F. and Barakah, M. (1980): Recategorization of non-malignant organic vocal fold changes in dysphonia. The proceedings of the 18 th congress of the International Association of Logopedics and Phoniatrics (IALP), Washington, I, 525.

6 Nature and Nomenclature 1- Chronic laryngitis (Jackson, 1941; Ellis, 1952 and Salmon, 1979). 2- Benign lesions of the vocal folds (Holinger and Johnston, 1951; Stewart, 1957 ; Dikkers, 1994). 3- Irritants induced lesions (Myerson, 1950; Fritzell and Hertegard, 1986). 4- Traumatic vocal lesions Arnold, 1962; (Damste and Lerman, 1975; Kleinsasser, 1968) 5- Minimal associated pathological lesions (Kotby et al, 1980, 1986, 1995; Mossallam et al, 1986).

7 The impact of benign lesions of the vocal folds on health 1- Threatening life! 2- Causing pain! 3- Loss of function: The main impact is affection of the optimal use of voice in communication Dysphonia! Mohamed Farahat Ibrahim, MD, PhD

8 Relative incidence of MAPLs (Benign vocal folds lesions) Kotby et al. (1980) N=41 Kotby et al. (1983) N=102 Mosallam et al. (1983) N=47 Mosallam et al. (1986) N=95 Kotby et al. (1988) N=30 Kotby and Orabi, 1995 N=26 Polyp Nodules Cyst Reinke s edema Contact granuloma 3 7 Mohamed Farahat Ibrahim, MD, PhD

9 The lesions Mohamed Farahat Ibrahim, MD, PhD

10 Reinke s edema of the vocal fold A- General profile:- 1- Relative incidence: % of benign lesions of the V.F. [MAPLs] 2- Type of patient: age: 4 th 6 th decade sex: male < female 3- Predisposing factors: smoking, voice misuse/abuse 4- Types/Degrees: partial, full length, cushion, extreme ballooning

11 Reinke s edema of the vocal fold Cont. 5- Laterality: bilateral 62-85% 6- Site: usually full length of the vocal fold 7- Shape: diffuse spindle-shaped translucent swelling of both V.F.s along their entire length with intact epithelium. 8- Presentation: Dysphonia, low pitch voice in 97% of cases

12 Reinke s edema of the vocal fold Cont. B- Pathophysiology Predisposing factors Ischemia Vascular endothelial growth factor Greater subepithelial vascularization and capillary permeability in Reinke's space

13 Reinke s edema of the vocal fold Cont. C- Grading: Grade I: contact - anterior third of vocal folds. Grade II: contact - anterior two thirds of vocal folds. Grade III: contact extended to the posterior third of vocal folds.

14 D- Gross Pathology 1- Whole organ section 2- Endoscopic picture 3- Histopathology Mohamed Farahat Ibrahim, MD, PhD

15 Hirano M. Phonosurgery-basic and clinical investigations. Official Report, 75th Annual Convention of the ORL Soc Japan. Otologica (Fukuoka) 1975;21 (suppl 1): (in Japanese)

16 Bilateral Reinke s Edema Stroboscopy? Respiration Phonation

17 Bilateral Reinke s Edema Mohamed Farahat Ibrahim, MD, PhD

18 Bilateral Reinke s Edema: Bilateral Reinke s Edema Respiration Phonation

19 Bilateral Reinke s Edema: Bilateral Reinke s Edema Respiration Phonation

20 Bilateral Reinke s Edema: Bilateral Reinke s Edema Respiration Phonation

21 Bilateral Reinke s Edema: Bilateral Reinke s Edema Respiration Phonation

22 Right-sided Reinke s Edema: Unilateral Reinke s Edema Respiration Phonation

23 Right-sided Reinke s Edema: Unilateral Reinke s Edema Respiration Phonation

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26 Management of Reinke s edema Phonosurgery (MLS): When? Why?!

27 Oscar Kleinsasser ( ) Oscar Kleinsasser ( )

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32 Polypoid degeneration of the vocal fold General profile:- Polypoid degeneration represents a long standing Reinke s edema with increased fibrous elements in the stroma (thicker septa) and decreased edema spaces.

33 Polypoid degeneration Mohamed Farahat Ibrahim, MD, PhD

34 Polypoid degeneration Respiration Respiration Phonation Phonation Mohamed Farahat Ibrahim, MD, PhD

35 Irregular mucosa Less edematous, more fibrous stroma with hyaline degeneration

36 Contact granuloma of the vocal fold A- General profile:- 1- Relative incidence: 6.2 % of benign lesions of the V.F 2- Type of patient: age: 4 th 6 th decade sex: male [energetic competitive hypertense] 3- Predisposing factors: voice abuse/misuse tension! 4- Types: hyperfunctional, hyperacidity, intubation Mohamed Farahat Ibrahim, MD, PhD

37 Contact granuloma of the vocal fold 5- Laterality: unilateral or bilateral 6- Site: over the vocal process (vocal process granuloma) 7- Shape: one lesion may cause a dimple in the contralateral one with no ulceration 8- Presentation: Phonasthenia, no dysphonia

38 Contact granuloma of the vocal fold B- Pathogenesis: Mechanical (hammer and anvil) Irritation (LPRD) Mohamed Farahat Ibrahim, MD, PhD

39 Left vocal process granuloma Left-sided Contact Granuloma: Stroboscopy? Respiration Phonation

40 Right vocal process granuloma Respiration Phonation

41 Bilateral vocal process granulomas Mohamed Farahat Ibrahim, MD, PhD

42 DENSE connective tissue core with abundant collagenous fibers and fibroblasts Mohamed Farahat Ibrahim, MD, PhD

43 Management Behavioral readjustment therapy (Accent Method up to 60 sessions ) Anti-LPR advices and management Combined

44 Svend Smith ( )

45 Contact granuloma Pre-voice therapy Post-voice therapy 22 sessions Post-voice therapy 60 sessions

46 Contact granuloma Initial assessment After 10 sessions of voice therapy

47 Contact Granuloma Pre-voice therapy Post-voice therapy

48 Summary Type of lesion Relative incidence Age Sex Laterality Dysphonia Phonaesthenia Polyp 43.88% 3-5 decade Both sexes Unilateral + + Nodules 16.56% 3-4 decade Females Bilateral ++ + Cyst 9.62% 3-5 decade Males and females Unilateral ++ + Reinke s edema Polypoid degeneration Contact granuloma 19.02% 4-5 decade Females (smoker) Bilateral ++! Females Bilateral % 4-5 decade Males Unilateral and bilateral ++

49 Why grouped together? Commonality: - Predisposing factors. - Size of lesion. - Nature: traumatic, non-neoplastic, noninflammatory, benign. - Presentation. - Management. - Prognosis. Mohamed Farahat Ibrahim, MD, PhD

50 Sulcus vocalis Definitions and terminologies: 1- Sulcus vocalis: furrowing Sato and Hirano (1998) 2- Sulcus vocalis: invagination, sulcus vergature: atrophic changes Bouchayer and Cornut (1992)

51 Sulcus vocalis Types: Sulcus vocalis Type I Type II Type III Other terms Pseudosulcus Sulcus vergeture Ruptured cyst Dysphonia Variable to normal Moderate Severe Videostroboscopy Variable to normal Focal stiffness Stiff, no wave Superficial lamina propria Intact Involved/lost Involved/lost Vocal ligament Normal Normal or attached Invaded/lost Vocalis muscle Possibly atrophic Normal Involved +/- Ford, C.N. (1999): Advances and refinements in phonosurgery. Laryngoscope, 109,

52 Etiology of Sulcus vocalis UNCERTAIN - Congenital: [Hirano (1975), Bouchayer et al. (1985), Pontes and Behlau, (1993)] * Faulty develpement of fourth and sixth branchial arches, ruptured epidermoid cyst * Others - Acquired: [Van Caneghem (1928, as cited from Ford et al., 1996), Bastian (1993), Nakayama et al., (1994), Ford et al., (1996)] * Aging, trauma, inflammatory, associated with cancer, voice abuse and misuse Mohamed Farahat Ibrahim, MD, PhD

53 Sulcus vocalis Epidemiology: - Age of onset of symptoms: Adulthood - Childhood - Gender: Males > Females

54 Sulcus vocalis Clinical picture: (presenting symptoms) 1- Dysphonia: Breahty 2- Phonasthenic symptoms 3- Quality of voice: High pitch, low intensity, poor vocal range, register breaks, and diplophonia Mohamed Farahat Ibrahim, MD, PhD

55 Bilateral Sulcus vocalis Respiration Phonation

56 Management Voice therapy!! - Elimination of poor compensatory movements - limited aid to vocal quality Surgery: 1- Slicing technique 2- Sulsectomy [cold, laser] 3- Injection: Teflon, fat, hyalouronic acid Mohamed Farahat Ibrahim, MD, PhD

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58 Thank You