Autoimmune-related dysphonia: vocal fold bamboo nodes.

Introduction: Bamboo node is a rare vocal cord pathology causing dysphonia among patients with autoimmune disorders. These “bamboo-joint-like” transverse deposits on the vocal cords interfere with the vibratory cycle during phonation leading to voice hoarseness. A review of Schwemmle from 1993-2009, showed seven cases of bamboo node among patients with mixed connective tissue disease (MCTD). With the patient’s consent, this case is presented to contribute to current knowledge about MCTD. Case Presentation: A 36-year-old Filipino female developed voice hoarseness one year after she was diagnosed with MCTD. Videostroboscopic findings revealed bilateral bamboo nodes, vibratory defects, and amplitude abnormalities. Treatment with prednisone, methotrexate, hydroxychloroquine, along with voice rest and speech therapy resulted in normalization of amplitude, mucosal wave and vibratory behavior during repeat videostroboscopy. Conclusion: To date, this is the first known case of bamboo nodes associated with MCTD in a Filipino patient. This case highlights the importance of properly investigating the symptom of hoarseness among patients with rheumatologic diseases. A multidisciplinary approach involving the rheumatologist, otorhinolaryngologist, and speech therapist play an important role in the complete care of this patient. Keywords: bamboo nodes, dysphonia, mixed connective tissue disorder, filipino, case report

Objectives: The present study aims to compare acoustic voice parameters in patients with vocal cord nodules, polyps, and normal subjects. Methods: In this cross-sectional case-control study, the participants were selected by convenience sampling, including 30 patients with vocal polyps for the first group, 38 patients with vocal nodules for the second group, and 42 participants without voice pathologies as the control group. For each group, participants were examined by a speech and language pathologist (SLP) using an Endo-vision laryngoscope. Acoustic voice parameters were measured by MDVP software in Visi-Pitch; then, these parameters were compared in groups in terms of sex. Results: Three groups showed significant differences in terms of fundamental frequency (P<0.001), jitter (P<0.001), shimmer (P<0.001), and noise-to-harmonic ratio (NHR) values (P<0.001). Women in three groups had the substantial differences in terms of fundamental frequency (P<0.001), jitter (P<0.001), shimmer (P<0.001), and NHR (P<0.001). For men, the three groups showed a significant difference for jitter (P<0.001) and shimmer (P=0.001), but for NHR (P=024), and fundamental frequency (P=0.93) no signification difference were observed. Discussion: It seems that the existence of benign mass lesions, such as vocal cord nodules and polyps affects the acoustic parameters of the voice. The measurement of acoustic voice parameters may help us to differentiate between the voices of normal people and patients with vocal cord nodules and polyps as a supplementary assessment in clinical procedures.

The Phonosurgery Committee of the European Laryngological Society (ELS) has examined the definition and technical description of phonosurgical procedures. Based on this review, the committee has proposed a working classification. The current presentation is restricted to vocal fold surgery (VFS) with phonosurgical intent. Both the pathology and the therapeutic aim define VFS: (1). vocal fold lesions that impair vibratory movements require excision (e.g., vocal fold nodule), incision and suction (e.g., Reinke's edema), dissection and/or augmentation (e.g., sulcus-vergeture), coagulation or vaporization (e.g., varicosity) and incision and stenting (e.g., glottal web); (2.vocal fold movement disorders require position and/or tension correction by augmentation (e.g., vocal fold paresis), injection (e.g., botulinum toxin for spasmodic dysphonia) and excision (e.g., dysphonia plicae ventricularis). This presentation excludes surgical instrumentation, implants or injectable materials. Being essentially surgeon-dependent, usage may vary over time and with experience.

Background: Vocal fold lesions are commonly found in the pediatric age group. The lesions of the vocal fold among children are variable. The laryngoscopic examination is needed for the identification of the vocal fold lesions. The objective of this study is to find out the different vocal fold lesions, clinical presentations, and diagnoses of the vocal fold lesions.Methods: The children aged from 5 to 18 years diagnosed with vocal fold lesions were included in this study. The study was conducted between June 2017 to July 2022. All the children with vocal fold lesions were subjected to video laryngoscopy for assessment of the larynx.Results: There were 156 children diagnosed with vocal fold lesions. The majority of this study's participants were male children (52.56%). The most common symptom was hoarseness. Most common vocal fold lesion was vocal fold nodule (43.58%). Voice abuse was the most common etiological factor behind the vocal fold lesions. Out of 156 children with vocal fold lesions, 72 children (46.15%) underwent microlaryngeal surgery under anesthesia. Voice therapy was given to all the children along with vocal hygiene care.Conclusions: Vocal fold lesions are often found among children. Dysphonia is the commonest clinical presentation of children with vocal fold lesions. Microlaryngeal surgery and voice therapy are two important options for the treatment of vocal fold lesions in pediatric patients.

Background Benign superficial lesions of vocal fold (nodule, polyp, cyst and Reinke's edema) arise from the epithelium and the lamina propria. Vocal abuse and misuse presumably lead to excessive mechanical stress and trauma in the membranous portion of vocal fold, resulting in wound formation. Wound healing leads to remodeling of the superficial layer of the lamina propria. This tissue remodeling leads to formation of benign vocal fold lesions. These lesions are classically treated by conventional microsurgery and recently by CO2 laser. The use of the CO2 laser for the surgical treatment of Minor Associated Pathological Lesions (MAPL's) is still controversial. Some preferred cold instruments, whereas others appreciate CO2 laser as a novel alternative to conventional microsurgery for benign vocal fold lesions. To summarize the reviewed literature the issue of CO2 laser versus cold instruments is still controversial and the stage is open for more studies. Aim The aim of this study is to investigate the effect of Co2 Laser versus cold instruments in the treatment of benign lesions of the vocal folds regarding voice outcome & vocal fold function. Methodology A meta-analysis study is done to assess the use of Co2 Laser versus conventional microlaryngeal surgery in treatment of vocal fold benign lesions. Results This study does not reveal any detectable differences in clinical outcomes in patients with nodules, polyps and cysts who underwent excision via CO2 laser or cold instruments. Conclusion There is no sufficient evidence to determine if conventional surgery or CO2 assisted surgery is better.

We present in-vivo 3D human vocal fold images with polarization sensitive optical coherence tomography (PS-OCT). Characterizing the extent and location of vocal fold lesions provides useful information in guiding surgeons during phonomicrosurgery. Previous studies showed that PS-OCT imaging can distinguish vocal fold lesions from normal tissue, but these studies were limited to 2D cross-sectional imaging and were susceptible to sampling error. In-vivo 3D endoscopic imaging was performed by using a recently developed 2-axis MEMS scanning catheter and a spectral domain OCT (SD-OCT), running at 18.5 frames/s. Imaging was performed in the operating room with patients under general anesthesia and 3D images were acquired either by 2D scanning of the scanner on the sites of interest or by combining 1D scanning and manual sliding to capture whole length of the vocal fold. Vocal fold scar, polyps, nodules, papilloma and malignant lesions were imaged and characteristics of individual lesions were analyzed in terms of spatial distribution and variation of tissue structure and birefringence. The 3D large sectional PS-OCT imaging showed that the spatial extent of vocal fold lesions can be found non-invasively with good contrast from normal tissue.

<bold>Objective</bold>To investigate the clinical efficacy of voice therapy in children with vocal nodules and to analyze the applicability of different assessment methods for evaluating the therapeutic outcomes.<bold>Methods</bold>A total of 37 patients with vocal cord nodules who visited the Voice Department of Zhongshan Hospital, Xiamen University between January 2023 and January 2025 were selected as the study participants. The patients received a two-month voice therapy program provided by a therapist in a one-on-one individual training format. The therapy included vocal hygiene education, relaxation training, and resonant voice therapy (RVT), conducted once weekly for 45 minutes per session. Patients were instructed to perform daily home exercises once a day, 30 minutes per session. Assessments were conducted before training, after one month of training, and after two months of training using the following tools: the Pediatric Voice Handicap Index (pVHI) to evaluate the impact of the voice disorder on the children's quality of life; the GRBAS scale for subjective auditory perceptual evaluation of voice quality; stroboscopic laryngoscopy to examine the morphology of the vocal cord nodules, glottal closure, symmetry of vocal fold movement, mucosal wave, and regularity of vocal cord vibration; and objective acoustic parameters (fundamental frequency, jitter, shimmer) to assess voice quality.<bold>Results</bold>Compared with pre-training, the total pVHI score, as well as the physical and emotional domain scores all decreased after 1 month of training (<italic>P</italic>&lt;0.05); after 2 months of training, the total pVHI and functional, physical, and emotional domain scores all decreased (<italic>P</italic>&lt;0.05); When comparing the results at 2 months after training with those at 1 month after training, the total pVHI score, as well as the functional and emotional domain scores all decreased (<italic>P</italic>&lt;0.05). Compared with pre-training, the G, R, and B scores in the GRBAS Scale all decreased after 1 month and 2 months of training (<italic>P</italic>&lt;0.05); compared with those after 1 month of training, the G, R, and B scores all decreased (<italic>P</italic>&lt;0.05) after 2 months of training. There was no statistically significant difference in the distribution of different grades of vocal nodules among the number of patients before and after one month of training (<italic>Z</italic>=-1.908, <italic>P</italic>=0.056); after 2 months of training the distribution proportion of the number of patients with different grades of vocal cord nodules showed statistically significant difference (<italic>Z</italic>=-5.024, <italic>P</italic>&lt;0.001). Compared with pre-training, the scores for glottal closure, vocal fold mucosal wave, and regularity of vocal fold vibration under stroboscopic laryngoscopy after 1 month of training all decreased (<italic>P</italic>&lt;0.05); after 2 months of training the scores for glottal closure, symmetry of vocal fold movement, vocal fold mucosal wave, and regularity of vocal fold vibration all decreased (<italic>P</italic>&lt;0.05); compared with that after 1 month of training, the score for symmetry of vocal fold movement decreased after 2 months of training (<italic>P</italic>&lt;0.05). Compared with pre-training, the values of jitter and shimmer after 1 month and after 2 months of training all decreased (<italic>P</italic>&lt;0.05); compared with that after 1 month of training, the value of shimmer after 2 months of training decreased (<italic>P</italic>&lt;0.05).<bold>Conclusion</bold>Voice therapy effectively improves vocal quality in pediatric vocal cord nodules, although morphological changes lag behind the subjective and objective acoustic assessment results. Auditory-perceptual assessments and acoustic analysis exhibit superior clinical applicability compared to laryngoscopic evaluation. As a noninvasive tool, acoustic analysis is particularly valuable for monitoring therapeutic efficacy during voice rehabilitation.

To compare the prevalence and severity of depression and anxiety among patients with vocal fold (VF) nodules, polyps and edema. At the same time the aim was to analyse association between severity of distress and the level of vocal handicap as well as to identify other factors related to severity of depression and anxiety in these patients. To all participants were given five questionnaires: (1) questionnaire on socio-demographic and some other characteristics of patient; (2) Beck's Depression Inventory (BDI); (3) State-Trait Anxiety Inventory (STAI) 1 (State Anxiety); (4) STAI 2 (Trait Anxiety); and (5) Voice Handicap Index (VHI)-10. A total of 205 patients were included in this study. Mild-to-severe depression, according to BDI was present in 79 (38.6%) patients. Mild-to-severe state anxiety and trait anxiety were present in 199 (97.1%) and 200 (97.6%) patients, respectively. Only 10 patients had VHI-10 score ≤ 11. Multivariate analyses showed that there were no significant differences in the level of depression and anxiety between patients with VF nodules, polyps and edema. The VHI-10 score was significantly higher in patients with VF edema in comparison with VF nodule patients (p = 0.001), as well as in comparison with VF polyp patients (p = 0.001). The present study identified a high prevalence of psychological and vocal distress among patients with vocal disorders. Severity of depression and anxiety did not differ between patients with VF nodules, polyps and edema, and it was not related to the level of vocal handicap.

Microvascular lesions, also called varices or capillary ectasias, in contrast to vocal fold polyps with telangiectatic vessels, are relatively small lesions arising from the microcirculation of the vocal fold. Varices are most commonly seen in female professional vocalists and may be secondary to repetitive trauma, hormonal variations, or repeated inflammation. Microvascular lesions may either be asymptomatic or cause frank dysphonia by interrupting the normal vibratory pattern, mass, or closure of the vocal folds. They may also lead to vocal fold hemorrhage, scarring, or polyp formation. Laryngovideostroboscopy is the key in determining the functional significance of vocal fold varices. Management of patients with a varix includes medical therapy, speech therapy, and occasionally surgical vaporization. Indications for surgery are recurrent hemorrhage, enlargement of the varix, development of a mass in conjunction with the varix or hemorrhage, and unacceptable dysphonia after maximal medical and speech therapy due to a functionally significant varix.

Effects of Repeated Intracordal Glucocorticoid Injection on the Histology and Gene Expression of Rat Vocal Folds

Vocal fold nodules are benign vocal cord lesions which develop in voice abusers, including children, though chronic cough, sinusitis, and reflux may also be the causative agents. Since low or no-evidence treatment strategies, like the boone technique, are in use in paediatrics, this study was conducted to determine the treatment strategies used by speech-language pathologists in paediatric vocal fold nodules using a cross-sectional survey at Riphah International University, Lahore, from October 2016 to May 2017. Sixty-five speech-language pathologists working with children in private clinics and multidisciplinary settings were recruited using purposive sampling. A self-structured questionnaire was used for data collection. Analysis using SPSS -18 revealed that a combination of voice therapy and vocal hygiene was the most favoured treatment used by 65 (100%) speech-language pathologists, followed by 58 (89.2%) who also favoured respiratory and relaxation exercises, and 56 (86.2%) who also included parental counselling. Hence, a combination of voice therapy and vocal hygiene is a good therapeutic technique being practiced by speech pathologists for the treatment of vocal nodules among paediatric population.

Bamboo nodes (BNs) is a rare disease detected in the Department of Otorhinolaryngology. Here, we reported two cases of BNs, highlighting a potential association of BNs with autoimmune diseases. Upon presentation, the primary concerns of both patients were hoarseness and foreign body sensation. In both cases a co-existence between BNs and an autoimmune disease was identified. In one case, BNs were initially diagnosed while undifferentiated connective tissue disease was later identified by serological testing. In contrast, the other patient did not show any BN-related symptom until two months of therapy for undifferentiated connective tissue disease. Both cases received oral administration of medicines for immunotherapy, with one taking voice training. Both recovered from the larynx symptoms after 10 to 12 months of therapy. This report reminded us of the potential association of BNs with autoimmune diseases. Voice training may be an effective adjuvant intervention for the treatment of BNs.

自身免疫性疾病常为多器官累及的全身性疾病，临床特征多种多样，咽喉部也可有所表现。但是一直以来，自身免疫性疾病合并咽喉部损害并未得到足够的重视。1959年Searpelli等首次报道了1例系统性红斑狼疮患者累及喉部受损，患者死于严重喉水肿。文献记载，自身免疫性疾病引起喉部损伤的患病率最高者可达1/3。近年来，自身免疫性疾病有关喉部的表现逐渐受到一些学者的关注，他们观察到自身免疫性疾病在咽喉部的损害可表现为广泛的炎性反应和弥漫性水肿，可累及黏膜或黏膜下层。其中，自身免疫性疾病引起声带黏膜下的病变较为特殊，声带呈结节状病变，这种改变和一般的声带小结有所不同，为了与之区别，有学者将这种形似竹节状的声带病变称之为“竹节样结节”。

Evolution of Vocal Fold Nodules from Childhood to Adolescence

Phonomicrosurgical treatment of premalignant vocal fold epithelium and microinvasive cancer combines principles of surgical oncology with advanced laryngoscopic microsurgical-techniques. This treatment is guided by mucosal-wave theory of voice production and strives not only to cure the disease but also to achieve optimal vocal function. Surgical techniques developed during the past two centuries have improved methods for vocal fold visualization, tissue retrieval, and tissue evaluation. Examination of the evolution of these surgical techniques reveals the incomplete convergence of laryngoscopic surgical theory with both the concept of premalignancy and the anatomical-physiological principles of voice production. This historical review, which helps to explain the lack of consensus about current treatment options, led to a series of four investigations. They were conducted with the aim of developing a laryngoscopic (phonomicrosurgical) management approach for improving the treatment of premalignant and microinvasive vocal fold epithelium. In the first of four investigations, 42 patients (each of whom had a significant smoking history) underwent microlaryngoscopic biopsy of 52 vocal fold lesions. These lesions, which were suspicious for atypia or malignancy and were confined to the musculomembranous vocal fold, were mapped according to surface involvement and depth of penetration. Review of the maps revealed that 27 of the 52 lesions involved only the superior/ventricular surface. For these patients, the entire layered vocal fold structure could potentially be preserved on the medial/vocalizing surface. Twenty-five of the 52 lesions involved both the superior/ventricular surface and the medial/vocalizing surface. No lesion involved only the medial surface. These data suggest that (in smokers) geographic localization of keratotic and erythroplastic lesions on the superior/ventricular surface of the musculomembranous vocal fold are likely to contain atypia. This characteristic facilitates the appropriate selection of patients for biopsy and may spare individuals, who have lesions resulting from hyperfunctional dysphonia and/or gastroesophageal reflux, from unnecessary biopsy. These two disorders typically result in pathology on the medial and/or posterior glottal surfaces. In order to determine whether a directed biopsy or an excisional biopsy approach is preferable for obtaining an accurate diagnosis, all specimens underwent whole-mount sectioning for three-dimensional histopathological analysis. Keratosis was noted: without atypia in 14; with atypia in 27; and with carcinoma in 11. The severity of the atypia usually varied throughout each specimen. The surface appearance of the lesion was not a reliable prognosticator of the severity of dysplasia either between patients or in different areas of the same lesion; therefore, excisional biopsy and whole-mount, multiple-section histopathological analysis were necessary for obtaining an accurate diagnosis.(ABSTRACT TRUNCATED AT 400 WORDS)