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Consistency of the preoperative and intraoperative diagnosis of benign vocal fold lesions
Consistency of the Preoperative and Intraoperative Diagnosis of Benign Vocal Fold Lesions *Patrick J.P. Poels, *,†Felix I.C.R.S. de Jong, and ‡Harm K. Schutte Veghel, Nijmegen, and Groningen, The Netherlands
Summary: The purpose of this retrospective study was to compare the preoperative and intraoperative diagnosis of benign vocal fold lesions for consistency. The diagnosis was made in 221 consecutive patients with benign vocal fold lesions for which a microlaryngoscopy was carried out in a general ENT-clinic. The preoperative diagnosis was obtained by both white halogen and stroboscopic light. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients, the preoperative diagnosis was changed intraoperatively. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion was diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Specially intracordal lesions constituted a diagnostic pitfall. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery. Key Words: Vocal folds—Diagnosis—Classification—Microlaryngoscopy— Voice.
INTRODUCTION The formation of the primary sound of the voice is a result of the delicate interaction between the expiratory airstream and the vocal fold mucosa. The histo-architecture of the vocal folds allows the development of a mucosal wave. Especially Reinke’s space makes a movement of the epithelial layer in relation to the vocal ligament possible.1 Even small abnormalities of the vocal fold mucosal wave may lead to dysphonia. The abnormalities may be acquired, due to phonotrauma, the abuse of drugs, alcohol and nicotine, inflammation, benign or malignant neoplasm’s, or may be congenital.2 Phonotrauma can be caused by an excessive demand of the voice in social circumstances, recreational activities, or in a voice demanding profession. With laryngostroboscopy the vocal fold mucosal wave and
Accepted for publication October 28, 2002. From the *Bernhoven Hospital, Veghel, The Netherlands, †Department of ENT/Voice and Speech Pathology, University Medical Center, St. Radboud, Nijmegen, The Netherlands, and the ‡Groningen Voice Research Laboratory, Department of Biomedical Engineering, University of Groningen, Groningen, The Netherlands. Address correspondence and reprint requests to Felix I.C.R.S. de Jong, MD, PhD, Department of ENT/Voice and Speech Pathology, University Medical Center St. Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail: f.dejong@ kno.umcn.nl Journal of Voice, Vol. 17, No. 3, pp. 425–433 쑕 2003 The Voice Foundation 0892-1997/2003 $30.00⫹0 doi:10.1067/S0892-1997(03)00010-9
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glottal closure can be observed, and the impact of a lesion on the mucosal wave pattern, on the glottal closure, and consequently its distribution to the development of dysphonia can be determined.3 In our experience, the diagnosis of benign vocal fold lesions cannot be established exactly, or it cannot be established at all, with the use of white halogen and stroboscopic light in a substantial number of cases. A correct clinical diagnosis is important because this determines the next step in the treatment: conservative therapy or microlaryngeal surgery. A correct diagnosis is also important to inform the patient adequately about further therapy and possible sequelae. In the assessment of a clinical diagnosis of benign vocal fold lesions, intraindividual and interindividual differences have been demonstrated.4 In literature, detailed studies on the consistency of a preoperative and intraoperative diagnosis after careful examination of the larynx are scarce,5 whereas it is common in daily practice that phonosurgery professionals experience this inconsistency.
PURPOSE The purpose of this study was to assess the consistency of the clinical diagnosis of benign vocal fold lesions established at the preoperative examination and at the intraoperative examination. The number and diagnosis of the missed lesions in the clinical examination was established. Consequences for the diagnostic and surgical procedure will be formulated.
PATIENTS AND METHODS The medical records of 221 consecutive patients who had undergone a microlaryngoscopy for benign lesions of the vocal folds in the department of ENT of the Bernhoven Hospital in Veghel, The Netherlands, over a 5-year period, were examined retrospectively. The preoperative examination and microlaryngoscopy were carried out by one laryngologist (FdJ, also engaged in the University Medical Centre St Radboud, Nijmegen, The Netherlands). The preoperative examination was carried out with both white halogen and stroboscopic light. The Journal of Voice, Vol. 17, No. 3, 2003
Atmos endo-stroboscope (Atmos Medizin technik GmbH&Co, Germany) and a piezo-electric microphone were used. A rigid Hopkins 90⬚ endoscope was used. A flexible endoscope (Pentax FNL 10 S) was used for the white light and the laryngostroboscopic examination in a few cases, in which the patient could not tolerate the rigid endoscope, even with topical anesthesia. The judgment was made without the use of a camera. During suspension microlaryngoscopy, both vocal folds were carefully examined. Depending on the need for changing the depth of field, various magnifications were used. In addition to visual inspection, palpation of the vocal folds with microinstruments was carried out. If an intraoperative lesion was suspected, an exploratory cordotomy was carried out. At this time, there is no definite common terminology for vocal fold lesions. Our definitions of polyp, Reinke’s edema, vocal fold nodules, and cyst essentially were the same as those given by Dikkers et al.6 Polyp: a lesion of the vocal fold, often on the free edge and usually unilateral. The lesion can be either sessile or pedunculated. If pedunculated, it abundantly moves with the mucosal wave. Reinke’s edema: a unilateral or bilateral bleach sessile swelling of the vocal fold, apparently filled with fluid. The edema abundantly moves with the mucosal wave. Vocal fold nodules: bilateral, symmetric lesions at the junction of the anterior and middle third of the vocal folds, and variably interfering with the mucosal wave. As in this study, each lesion was examined on each vocal fold, the presence of nodules on both vocal folds at the same time in one patient was counted as two separate lesions. Cysts: a flat unilateral swelling with a smooth translucent surface, immobile during phonation, usually on the middle third of the vocal fold. Our definitions of sulcus vocalis and vergeture essentially were the same as those given by Bouchayer et al.2 Sulcus vocalis: a more or less visible furrow running parallel to the free edge of the fold, with or without an oval-shaped glottis, usually associated with a diminished vibration pattern. The lesion may vary in length and depth and may be unilateral or bilateral. Vergeture: a deep and long furrow contacting the vocal ligament, usually with a severely disturbed vibration pattern. Chronic laryngitis: a variable clinical condition. Symptoms of diffuse inflammation
BENIGN VOCAL FOLD LESIONS
427
FIGURE 1. Distribution of age among the male and female patients.
may be present in a variable degree. The mucosa of the vocal folds is more or less irregular thickened, and frequently, a frosted glass appearance is observed. The vibration pattern is disturbed. The diagnostic category labeled as “other lesions” included a.o. hemangioma, blood vessel ectasias, hyperplasia, and hyperkeratosis. Because there were relatively few patients with these diagnoses, the diagnosis was assembled in a group of diagnoses labeled as “other lesions.” Both the preoperative and intraoperative diagnoses were made on clinical grounds. The lesions were registered separately for each vocal fold and delineated directly in the medical record. The intraoperative diagnosis was considered as the final correct diagnosis and determined subsequent to the surgical strategy. Age, sex, and professional voice use were registered. A subject is considered to be a professional voice user if he/she is dependent on vocal endurance and quality for his/her livelihood and profession.7,8 The delineated preoperative diagnoses were compared with the delineated intraoperative diagnoses.
RESULTS Age, sex distribution, and professional voice use The medical files from 221 patients were evaluated. Fifty-three patients were males. The median age of these 53 males was 40.0 years (interquartile range: 29.0–50.0). The median age of the 168 females was 24.0 years (interquartile range: 20.0– 35.8). There was a remarkable large number (108) of females aged 15–29 years of age (Figure 1). In contrast to the distribution of age among the females, the distribution of age among the males is more homogeneous, with a slight biphasic pattern. The first phase is at 25–34 years, and the second phase is at 40–54 years. In this study, 111 of the 221 patients had a voice-demanding profession or were in training for a voice-demanding profession. Preoperative and intraoperative findings At the preoperative examination, the vocal folds could be examined adequately in 213 out of 221 Journal of Voice, Vol. 17, No. 3, 2003
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FIGURE 2. Distribution of the lesions during microlaryngoscopy according to diagnosis in 221 patients.
(96%) patients. In eight patients (3 males and 5 females), a sufficient view on the vocal folds could not be obtained preoperatively, due to young age or intense gag reflexes. Unilateral lesions were found in 94 patients (43%), and bilateral lesions were found in 119 patients (53%). More specifically, unilateral lesions were found in 37 of the 50 (74%) males and 57 of the 163 (35%) females. The vocal folds of all patients could be examined adequately during microlaryngoscopy. The results of the eight patients who could not have been examined properly preoperatively consisted of six bilateral lesions and two unilateral lesions. During microlaryngoscopy, lesions that were not observed preoperatively were now detected, which increased the number of patients with bilateral lesions in this study from 53% to 82%. During microlaryngoscopy, unilateral lesions were found in 16 of the 53 (30%) males and 23 of the 168 (13%) females. In the group of bilateral lesions, sulci vocalis, polyps, and cysts were observed remarkably frequently. In 16% (9/57) of the unilateral diagnosed polyps, a sulcus vocalis was found on the other vocal fold. A Journal of Voice, Vol. 17, No. 3, 2003
total of 403 lesions were found during microlaryngoscopy (Figure 2). These lesions were equally distributed over the left (204) and right (199) vocal folds. Nodules (30%), polyps (23%), sulci vocalis (14%), and Reinke’s edema (11%) were the lesions found most frequently. In the present study, the diagnoses of sulci vocalis, vergetures, and cysts constituted 22% of all observed intraoperative lesions. The location of the diagnosed lesions on the vocal folds during microlaryngoscopy was delineated in the medical record. Most lesions were located in the mid-portion of the vocal folds (80%) (Figure 3). In 7%, the lesions were found on the anterior third and in 3%, on the posterior third of the vocal folds. In 10%, the lesion was more diffuse like Reinke’s edema. Consistency of diagnosis In 79 out of the 221 patients, the preoperative diagnosis of 111 lesions (ie, 28% of the total of 403 lesions) was not consistent with the intraoperative diagnosis. In 69 out of the 221 patients, 74 lesions
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FIGURE 3. Distribution of the lesions on the vocal folds.
(ie, 18% of the total of 403 lesions) were not recognized at the preoperative examination. These lesions were only diagnosed during microlaryngoscopy (Table 1). In these 69 patients, a group of 30 lesions that were found only intraoperatively consisted of sulci vocalis, vergetures, and cysts. In 4 out of 221 patients, the preoperative diagnosis of four lesions (2%) could not be established anymore during microlaryngoscopy as these lesions had disappeared.
DISCUSSION The consistency of the preoperative diagnosis was the main objective of this study. The preoperative diagnosis was obtained by both white light and stroboscopic illumination with the use of the rigid endoscope in most patients and the flexible endoscope in some patients. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients,
the preoperative diagnosis was changed. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion had been diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Age, sex distribution, and professional voice use The female to male ratio in the present study is 3.2 : 1. The data suggest that females are more susceptible to develop benign vocal folds lesions with an indication for microlaryngoscopy than males, but we have to take into account that more females than males visit the ENT-clinic for voice problems. At the Department of ENT/Voice and Speech Pathology of the University Medical Centre St. Radboud over a 6-year period, 1301 consecutive patients visited this clinic for the first time (de Jong, personal communication, 2001). The female to male ratio was 1.8 : 1. Kooijman et al (Kooijman et al, unpublished observations, 2001) found in a study of 97 teachers, Journal of Voice, Vol. 17, No. 3, 2003
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TABLE 1. Inconsistency of 185 Preoperative Diagnoses Preoperative
Intraoperative
Diagnosis
No.
Polyp Nodule Reinke’s edema Sulcus vocalis Cyst Chronic laryngitis Other lesions Missed lesions
27 29 6
Polyp Nodule Reinke’s edema Sulcus vocalis Cyst 7 9 1
13 16 6
2 5
14 74
2 10
6 4
2
2 13 1
5 9
8 1 1 8
2 22
Chronic laryngitis
Other lesions 4 1
1
1 2 1
1 1 1
4
5 2 2
2 6
1 10
7
1 2
Vergeture
1 2
7
The left part of the crosstable shows the number of preoperative diagnoses (111 ⫹ 74) that changed intraoperatively. The right part of the crosstable shows the intraoperative diagnoses.
which had absence of work due to voice problems, a female to male ratio of 2.6 : 1. Proven explanations of increased susceptibility to develop benign vocal fold lesions in females are not available in literature. Half of the operated patients in the present study were professional voice users. Remarkably, many females had been operated on at a young age, ie, 15– 29 years of age. The present study has a retrospective design to make an inventory of the clinicians perception of inconsistency in the diagnosis of benign vocal fold lesions. A patient was selected for microlaryngoscopy, if the lesion was considered to interfere with laryngeal function, and was expected or had proven not to resolve with conservative therapy. These selected patients being operated for benign vocal fold lesions were a selection of the total population that visited the ENT-surgeon in the study period. Only in this selected group of patients, inconsistency of the diagnosis could be assessed because a final diagnosis could be established during microlaryngoscopy. The results of this study cannot be generalized to the entire population of patients that visited the ENT department. Intraoperative findings During microlaryngoscopy, 403 lesions were found. In this study, nodules and polyps were the lesions most frequently found. This is in accordance to Colton et al (9) who found in their study the largest number of patients with nodules (38%, Journal of Voice, Vol. 17, No. 3, 2003
only in females) and polyps (30%). However, they found a sulcus vocalis in a minority of patients, not reported on separately. In our study, 14% of all intraoperative lesions were sulci vocalis. In relation to the appearance of nodules, polyps, Reinke’s edema, sulci, cysts, and vergetures, no preference could be found for the left or right vocal fold. In literature (6), the preference for localization of lesions at the vocal folds is found at the crossing of the first third and middle third, and the middle third itself. Our data confirm this observation. At the middle third of the vocal fold, the amplitude of mucosal vibration and probably the mechanical strain are at the greatest. In the current study, 80% of the lesions were found at this localization. Consistency of diagnosis In this study, the diagnosis of a lesion changed either from (1) a lesion preoperatively to (2) another lesion intraoperatively, or from (3) no lesion preoperatively to (4) a lesion intraoperatively. In 36% of the patients, the diagnosis of 111 lesions changed (1 → 2) during microlaryngoscopy (Table 1). When assessing for a systematic change in the diagnoses of the 111 lesions, 13 out of 29 lesions diagnosed as nodules at the preoperative examination were diagnosed as a sulcus vocalis during microlaryngoscopy. In 8 of the 16 lesions diagnosed as cysts, the lesions were diagnosed as sulci vocalis intraoperatively. In conclusion, there was no specific tendency of change discovered in the diagnosis of these 111
BENIGN VOCAL FOLD LESIONS lesions. In this study, the number of false-positive diagnoses was 2%. During microlaryngoscopy, bilateral lesions were found in 82% of all the patients. In 69 patients, 74 lesions were missed preoperatively and the lesions were only observed during microlaryngoscopy (3 → 4). Sulci vocalis, cysts, and vergetures constituted 30 of these 74 lesions (Table 1). There may be several explanations why the preoperative diagnosis was not consistent with the intraoperative diagnosis (ie, change from 1 → 2 or 3 → 4): Reactive lesions A lesion contralateral to a sulcus vocalis, polyp or cyst may be secondary, and it is also called “contact swelling.”2 Cornut et al10 considered the sulcus vocalis, vergeture, and cyst as “intracordal lesions,” a group of lesions that constitutes a diagnostic pitfall. Our findings corroborate this vision. It may be possible that a reactive swelling has developed during the surgery delay. A reactive swelling is superficial and immediately contralateral to the causative lesion. If a reactive lesion exists for a short time, it will be rather mobile, but it may be indurated after a longer period of time. Furthermore, this process will depend on laryngeal load. Remarkably, a unilateral lesion was found in only 18% of the patients. Diagnostic difficulty Another explanation for the discovery of lesions for the first time during surgery can be the fact that contralateral lesions such as polyps or edema overshadowed the mucosal vibration pattern of the other vocal fold. Laryngostroboscopy in the ENTclinic allows for better assessment of the mucosal wave and glottic closure than can be obtained with the use of continuous light. However, a quasi-regular mucosal vibration pattern is necessary for a good interpretation of the stroboscopic image. A lesion cannot be detected properly when the stroboscope does not trigger properly, in case of significant perturbation of frequency and intensity. Colton et al9 systematically rated the stroboscopic signs for nodules, cysts, polyps, and edema in 80 patients to be helpful to classify patients in a correct diagnostic or treatment group. They found several distinctive
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signs. However, their study did not provide evidence that the stroboscopic signs were indeed the typical signs of these four categories of benign lesions; eg, the authors did not report on observations during microlaryngoscopy in the same patients to check for the initial clinical diagnosis. Surgical procedure The vocal folds are tensioned due to the suspension procedure. This results in a change of the aspect of the lesions. At the time of surgery, a three-dimensional view is obtained, and the entire rim of the vocal fold can be observed gently touching the vocal fold by a microscopic instrument. As it is impossible to investigate the patients preoperatively in this way, we were only able to assess a final diagnosis during microlaryngoscopy. Waiting list It was also likely that the surgery delay influenced the natural development of the lesion. The surgery waiting time varied between a few weeks and several months. Intraobserver variation Intraobserver variation could also be a cause of this inconsistency of diagnoses. A great intraobserver variation and interobserver variation was described by Dikkers et al.4 In the present study, diagnoses were assessed by a single ENT-surgeon. As our study reflects normal daily practice in an ENT-clinic, the ENT-surgeon must be aware of the existence of intraobserver variation. Terminology The lack of a common terminology that takes into account the functional aspects of the vocal folds generally plays an important role in the occurrence of intraobserver and interobserver variation. The “nodules” constitutes a clear example: There is a continuity stretched out from a local mucosal edema at the crossing of the first one third and the second third part of the vocal folds, via small and larger flexible, edematous swellings to the more obdurate and fibrotic nodules. The polyps show a similarity with the nodules in a variation from local edema, via small to broad based, to more obdurate swellings. Only few polyps could be described as Journal of Voice, Vol. 17, No. 3, 2003
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pedunculated. Bouchayer et al2 described another continuity in relation to “congenital lesions”: from a vergeture via a sulcus to a so-called “cyst ouvert” to a cyst. In the present study, an overlap might be seen between miscellaneous lesions such as nodules, edema, polyps, and Reinke’s edema. A relatively small appearance of the lesions, traditionally described as “typical,” was established in this study. In the European Laryngological Society, the terminology of benign vocal fold lesions is a topic of discussion.11 Several reasons for inconsistency of a diagnosis were mentioned above. Probably, a video playback system would allow for a better diagnosis preoperatively. In addition, laryngostroboscopy can be completed with recently obtainable videokymography, because perturbation of frequency and intensity does not disturb this method of examination.12 Consequences The results of this study provide consequences for diagnostic evaluation and surgical procedure for benign vocal fold lesions. Despite examination with both white halogen and stroboscopic light, some lesions were still difficult to diagnose. Meticulous examination of both vocal folds for lesions during microlaryngoscopy may be necessary for an adequate diagnosis in cases of unclear dysphonia or discrepancy between the clinical examination and the quality and performance of the voice. It is recommended to carry out a diagnostic microlaryngoscopy in this situation as the preoperative diagnosis of a lesion changed intraoperatively and lesions were missed at the preoperative examination. During microlaryngoscopy, four out of five patients had bilateral lesions. As “congenital” lesions constituted 41% of all missed lesions at the preoperative examination, an ENT-surgeon should discuss with the patient that a planned surgical procedure might alter during surgery. In the present study, half of the operated patients were professional voice users. Especially in this category of patients, the type of microlaryngoscopy for an expected diagnosis of a benign vocal fold lesion has also an impact on the patients’ personal lives and the economic costs. The recovery time after surgery may vary from weeks to several months in different circumstances. The recovery Journal of Voice, Vol. 17, No. 3, 2003
time after being operated for a sulcus vocalis is much longer than for a polyp. CONCLUSIONS Inconsistency was observed between the preoperative diagnosis and the intraoperative diagnosis despite the use of both white halogen and stroboscopic light. In 36% of the patients, the preoperative diagnosis was not consistent with the intraoperative diagnosis. In 31% of the patients, the lesion was not recognized at the preoperative examination. Thus, these lesions were only diagnosed during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively and in 82% of the patients intraoperatively. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery. The authors recommend carrying out a diagnostic microlaryngoscopy in cases of unclear dysphonia or discrepancy between the examination and the quality and performance of the voice as the preoperative diagnosis of a lesion changed intraoperatively and lesions were missed at the preoperative examination. More research is needed about the consistency of diagnosis in benign vocal fold lesions to optimize the preoperative examination for surgical intervention in dysphonic patients. REFERENCES 1. Hirano M, Bless DM. Videostroboscopic Examination of the Larynx. San Diego, CA: Singular Publishing Group; 1993:119–190. 2. Bouchayer M, Cornut G. Microsurgical treatment of benign vocal fold lesions: indications, technique, results. Folia Phoniatr. 1992;44:155–184. 3. Kitzing P. Stroboscopy: A pertinent laryngeal examination. J Otolaryngol. 1985;14:151–157. 4. Dikkers FG, Schutte HK. Benign lesions of the vocal folds: Uniformity in assessment of clinical diagnosis. Clin Otolaryngol. 1991;16:8–11. 5. Rosen CA, Lombard LE, Murry T. Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions. Ann-Otol-Rhinol-Laryngol. 2000;109:823–828. 6. Dikkers FG, Nikkels PGJ. Benign lesions of the vocal folds: Histopathology and phonotrauma. Ann-Otol-RhinolLaryngol. 1995;104:698–703.
BENIGN VOCAL FOLD LESIONS 7. Sataloff RT. Care of the professional voice. In: Sataloff RT, ed. Performing Arts Medicine. 2nd ed. San Diego and London: Singular Publishing Group; 1998:137–187. 8. Wellens WAR, van Opstal MJMC. Performance stress in professional voice users. In: Dejonckere PH, ed. Occupational voice: care and cure. The Haguem: Kugler Publications; 2001:81–100. 9. Colton RH, Woo P, Brewer DW, Griffin B, Casper J. Stroboscopic signs associated with benign lesions of the vocal folds. J Voice. 1995;9:312–325.
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10. Cornut G, Bouchayer M. Du fonctionnel a` l’organique en phoniatrie. Rev-Laryngol-Otol-Rhinol-Bord. 1987;108:417–419. 11. Dejonckere PH, Bradley P, Clemente P, et al. A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2001;258:77–82. 12. Schutte HK, Svec JG, Sram F. Videokymography: Research and clinical issues. Log Phon Vocol. 1997;22:152–156.
Journal of Voice, Vol. 17, No. 3, 2003
Summary: The purpose of this retrospective study was to compare the preoperative and intraoperative diagnosis of benign vocal fold lesions for consistency. The diagnosis was made in 221 consecutive patients with benign vocal fold lesions for which a microlaryngoscopy was carried out in a general ENT-clinic. The preoperative diagnosis was obtained by both white halogen and stroboscopic light. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients, the preoperative diagnosis was changed intraoperatively. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion was diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Specially intracordal lesions constituted a diagnostic pitfall. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery. Key Words: Vocal folds—Diagnosis—Classification—Microlaryngoscopy— Voice.
INTRODUCTION The formation of the primary sound of the voice is a result of the delicate interaction between the expiratory airstream and the vocal fold mucosa. The histo-architecture of the vocal folds allows the development of a mucosal wave. Especially Reinke’s space makes a movement of the epithelial layer in relation to the vocal ligament possible.1 Even small abnormalities of the vocal fold mucosal wave may lead to dysphonia. The abnormalities may be acquired, due to phonotrauma, the abuse of drugs, alcohol and nicotine, inflammation, benign or malignant neoplasm’s, or may be congenital.2 Phonotrauma can be caused by an excessive demand of the voice in social circumstances, recreational activities, or in a voice demanding profession. With laryngostroboscopy the vocal fold mucosal wave and
Accepted for publication October 28, 2002. From the *Bernhoven Hospital, Veghel, The Netherlands, †Department of ENT/Voice and Speech Pathology, University Medical Center, St. Radboud, Nijmegen, The Netherlands, and the ‡Groningen Voice Research Laboratory, Department of Biomedical Engineering, University of Groningen, Groningen, The Netherlands. Address correspondence and reprint requests to Felix I.C.R.S. de Jong, MD, PhD, Department of ENT/Voice and Speech Pathology, University Medical Center St. Radboud, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. E-mail: f.dejong@ kno.umcn.nl Journal of Voice, Vol. 17, No. 3, pp. 425–433 쑕 2003 The Voice Foundation 0892-1997/2003 $30.00⫹0 doi:10.1067/S0892-1997(03)00010-9
425
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glottal closure can be observed, and the impact of a lesion on the mucosal wave pattern, on the glottal closure, and consequently its distribution to the development of dysphonia can be determined.3 In our experience, the diagnosis of benign vocal fold lesions cannot be established exactly, or it cannot be established at all, with the use of white halogen and stroboscopic light in a substantial number of cases. A correct clinical diagnosis is important because this determines the next step in the treatment: conservative therapy or microlaryngeal surgery. A correct diagnosis is also important to inform the patient adequately about further therapy and possible sequelae. In the assessment of a clinical diagnosis of benign vocal fold lesions, intraindividual and interindividual differences have been demonstrated.4 In literature, detailed studies on the consistency of a preoperative and intraoperative diagnosis after careful examination of the larynx are scarce,5 whereas it is common in daily practice that phonosurgery professionals experience this inconsistency.
PURPOSE The purpose of this study was to assess the consistency of the clinical diagnosis of benign vocal fold lesions established at the preoperative examination and at the intraoperative examination. The number and diagnosis of the missed lesions in the clinical examination was established. Consequences for the diagnostic and surgical procedure will be formulated.
PATIENTS AND METHODS The medical records of 221 consecutive patients who had undergone a microlaryngoscopy for benign lesions of the vocal folds in the department of ENT of the Bernhoven Hospital in Veghel, The Netherlands, over a 5-year period, were examined retrospectively. The preoperative examination and microlaryngoscopy were carried out by one laryngologist (FdJ, also engaged in the University Medical Centre St Radboud, Nijmegen, The Netherlands). The preoperative examination was carried out with both white halogen and stroboscopic light. The Journal of Voice, Vol. 17, No. 3, 2003
Atmos endo-stroboscope (Atmos Medizin technik GmbH&Co, Germany) and a piezo-electric microphone were used. A rigid Hopkins 90⬚ endoscope was used. A flexible endoscope (Pentax FNL 10 S) was used for the white light and the laryngostroboscopic examination in a few cases, in which the patient could not tolerate the rigid endoscope, even with topical anesthesia. The judgment was made without the use of a camera. During suspension microlaryngoscopy, both vocal folds were carefully examined. Depending on the need for changing the depth of field, various magnifications were used. In addition to visual inspection, palpation of the vocal folds with microinstruments was carried out. If an intraoperative lesion was suspected, an exploratory cordotomy was carried out. At this time, there is no definite common terminology for vocal fold lesions. Our definitions of polyp, Reinke’s edema, vocal fold nodules, and cyst essentially were the same as those given by Dikkers et al.6 Polyp: a lesion of the vocal fold, often on the free edge and usually unilateral. The lesion can be either sessile or pedunculated. If pedunculated, it abundantly moves with the mucosal wave. Reinke’s edema: a unilateral or bilateral bleach sessile swelling of the vocal fold, apparently filled with fluid. The edema abundantly moves with the mucosal wave. Vocal fold nodules: bilateral, symmetric lesions at the junction of the anterior and middle third of the vocal folds, and variably interfering with the mucosal wave. As in this study, each lesion was examined on each vocal fold, the presence of nodules on both vocal folds at the same time in one patient was counted as two separate lesions. Cysts: a flat unilateral swelling with a smooth translucent surface, immobile during phonation, usually on the middle third of the vocal fold. Our definitions of sulcus vocalis and vergeture essentially were the same as those given by Bouchayer et al.2 Sulcus vocalis: a more or less visible furrow running parallel to the free edge of the fold, with or without an oval-shaped glottis, usually associated with a diminished vibration pattern. The lesion may vary in length and depth and may be unilateral or bilateral. Vergeture: a deep and long furrow contacting the vocal ligament, usually with a severely disturbed vibration pattern. Chronic laryngitis: a variable clinical condition. Symptoms of diffuse inflammation
BENIGN VOCAL FOLD LESIONS
427
FIGURE 1. Distribution of age among the male and female patients.
may be present in a variable degree. The mucosa of the vocal folds is more or less irregular thickened, and frequently, a frosted glass appearance is observed. The vibration pattern is disturbed. The diagnostic category labeled as “other lesions” included a.o. hemangioma, blood vessel ectasias, hyperplasia, and hyperkeratosis. Because there were relatively few patients with these diagnoses, the diagnosis was assembled in a group of diagnoses labeled as “other lesions.” Both the preoperative and intraoperative diagnoses were made on clinical grounds. The lesions were registered separately for each vocal fold and delineated directly in the medical record. The intraoperative diagnosis was considered as the final correct diagnosis and determined subsequent to the surgical strategy. Age, sex, and professional voice use were registered. A subject is considered to be a professional voice user if he/she is dependent on vocal endurance and quality for his/her livelihood and profession.7,8 The delineated preoperative diagnoses were compared with the delineated intraoperative diagnoses.
RESULTS Age, sex distribution, and professional voice use The medical files from 221 patients were evaluated. Fifty-three patients were males. The median age of these 53 males was 40.0 years (interquartile range: 29.0–50.0). The median age of the 168 females was 24.0 years (interquartile range: 20.0– 35.8). There was a remarkable large number (108) of females aged 15–29 years of age (Figure 1). In contrast to the distribution of age among the females, the distribution of age among the males is more homogeneous, with a slight biphasic pattern. The first phase is at 25–34 years, and the second phase is at 40–54 years. In this study, 111 of the 221 patients had a voice-demanding profession or were in training for a voice-demanding profession. Preoperative and intraoperative findings At the preoperative examination, the vocal folds could be examined adequately in 213 out of 221 Journal of Voice, Vol. 17, No. 3, 2003
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FIGURE 2. Distribution of the lesions during microlaryngoscopy according to diagnosis in 221 patients.
(96%) patients. In eight patients (3 males and 5 females), a sufficient view on the vocal folds could not be obtained preoperatively, due to young age or intense gag reflexes. Unilateral lesions were found in 94 patients (43%), and bilateral lesions were found in 119 patients (53%). More specifically, unilateral lesions were found in 37 of the 50 (74%) males and 57 of the 163 (35%) females. The vocal folds of all patients could be examined adequately during microlaryngoscopy. The results of the eight patients who could not have been examined properly preoperatively consisted of six bilateral lesions and two unilateral lesions. During microlaryngoscopy, lesions that were not observed preoperatively were now detected, which increased the number of patients with bilateral lesions in this study from 53% to 82%. During microlaryngoscopy, unilateral lesions were found in 16 of the 53 (30%) males and 23 of the 168 (13%) females. In the group of bilateral lesions, sulci vocalis, polyps, and cysts were observed remarkably frequently. In 16% (9/57) of the unilateral diagnosed polyps, a sulcus vocalis was found on the other vocal fold. A Journal of Voice, Vol. 17, No. 3, 2003
total of 403 lesions were found during microlaryngoscopy (Figure 2). These lesions were equally distributed over the left (204) and right (199) vocal folds. Nodules (30%), polyps (23%), sulci vocalis (14%), and Reinke’s edema (11%) were the lesions found most frequently. In the present study, the diagnoses of sulci vocalis, vergetures, and cysts constituted 22% of all observed intraoperative lesions. The location of the diagnosed lesions on the vocal folds during microlaryngoscopy was delineated in the medical record. Most lesions were located in the mid-portion of the vocal folds (80%) (Figure 3). In 7%, the lesions were found on the anterior third and in 3%, on the posterior third of the vocal folds. In 10%, the lesion was more diffuse like Reinke’s edema. Consistency of diagnosis In 79 out of the 221 patients, the preoperative diagnosis of 111 lesions (ie, 28% of the total of 403 lesions) was not consistent with the intraoperative diagnosis. In 69 out of the 221 patients, 74 lesions
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FIGURE 3. Distribution of the lesions on the vocal folds.
(ie, 18% of the total of 403 lesions) were not recognized at the preoperative examination. These lesions were only diagnosed during microlaryngoscopy (Table 1). In these 69 patients, a group of 30 lesions that were found only intraoperatively consisted of sulci vocalis, vergetures, and cysts. In 4 out of 221 patients, the preoperative diagnosis of four lesions (2%) could not be established anymore during microlaryngoscopy as these lesions had disappeared.
DISCUSSION The consistency of the preoperative diagnosis was the main objective of this study. The preoperative diagnosis was obtained by both white light and stroboscopic illumination with the use of the rigid endoscope in most patients and the flexible endoscope in some patients. The intraoperative diagnosis was obtained by direct microscopic visualization and palpation of the vocal folds. In 36% of the patients,
the preoperative diagnosis was changed. In 31% of the patients, a lesion was missed at the preoperative examination and a lesion had been diagnosed only during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively, and in 82% of the patients intraoperatively. Age, sex distribution, and professional voice use The female to male ratio in the present study is 3.2 : 1. The data suggest that females are more susceptible to develop benign vocal folds lesions with an indication for microlaryngoscopy than males, but we have to take into account that more females than males visit the ENT-clinic for voice problems. At the Department of ENT/Voice and Speech Pathology of the University Medical Centre St. Radboud over a 6-year period, 1301 consecutive patients visited this clinic for the first time (de Jong, personal communication, 2001). The female to male ratio was 1.8 : 1. Kooijman et al (Kooijman et al, unpublished observations, 2001) found in a study of 97 teachers, Journal of Voice, Vol. 17, No. 3, 2003
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TABLE 1. Inconsistency of 185 Preoperative Diagnoses Preoperative
Intraoperative
Diagnosis
No.
Polyp Nodule Reinke’s edema Sulcus vocalis Cyst Chronic laryngitis Other lesions Missed lesions
27 29 6
Polyp Nodule Reinke’s edema Sulcus vocalis Cyst 7 9 1
13 16 6
2 5
14 74
2 10
6 4
2
2 13 1
5 9
8 1 1 8
2 22
Chronic laryngitis
Other lesions 4 1
1
1 2 1
1 1 1
4
5 2 2
2 6
1 10
7
1 2
Vergeture
1 2
7
The left part of the crosstable shows the number of preoperative diagnoses (111 ⫹ 74) that changed intraoperatively. The right part of the crosstable shows the intraoperative diagnoses.
which had absence of work due to voice problems, a female to male ratio of 2.6 : 1. Proven explanations of increased susceptibility to develop benign vocal fold lesions in females are not available in literature. Half of the operated patients in the present study were professional voice users. Remarkably, many females had been operated on at a young age, ie, 15– 29 years of age. The present study has a retrospective design to make an inventory of the clinicians perception of inconsistency in the diagnosis of benign vocal fold lesions. A patient was selected for microlaryngoscopy, if the lesion was considered to interfere with laryngeal function, and was expected or had proven not to resolve with conservative therapy. These selected patients being operated for benign vocal fold lesions were a selection of the total population that visited the ENT-surgeon in the study period. Only in this selected group of patients, inconsistency of the diagnosis could be assessed because a final diagnosis could be established during microlaryngoscopy. The results of this study cannot be generalized to the entire population of patients that visited the ENT department. Intraoperative findings During microlaryngoscopy, 403 lesions were found. In this study, nodules and polyps were the lesions most frequently found. This is in accordance to Colton et al (9) who found in their study the largest number of patients with nodules (38%, Journal of Voice, Vol. 17, No. 3, 2003
only in females) and polyps (30%). However, they found a sulcus vocalis in a minority of patients, not reported on separately. In our study, 14% of all intraoperative lesions were sulci vocalis. In relation to the appearance of nodules, polyps, Reinke’s edema, sulci, cysts, and vergetures, no preference could be found for the left or right vocal fold. In literature (6), the preference for localization of lesions at the vocal folds is found at the crossing of the first third and middle third, and the middle third itself. Our data confirm this observation. At the middle third of the vocal fold, the amplitude of mucosal vibration and probably the mechanical strain are at the greatest. In the current study, 80% of the lesions were found at this localization. Consistency of diagnosis In this study, the diagnosis of a lesion changed either from (1) a lesion preoperatively to (2) another lesion intraoperatively, or from (3) no lesion preoperatively to (4) a lesion intraoperatively. In 36% of the patients, the diagnosis of 111 lesions changed (1 → 2) during microlaryngoscopy (Table 1). When assessing for a systematic change in the diagnoses of the 111 lesions, 13 out of 29 lesions diagnosed as nodules at the preoperative examination were diagnosed as a sulcus vocalis during microlaryngoscopy. In 8 of the 16 lesions diagnosed as cysts, the lesions were diagnosed as sulci vocalis intraoperatively. In conclusion, there was no specific tendency of change discovered in the diagnosis of these 111
BENIGN VOCAL FOLD LESIONS lesions. In this study, the number of false-positive diagnoses was 2%. During microlaryngoscopy, bilateral lesions were found in 82% of all the patients. In 69 patients, 74 lesions were missed preoperatively and the lesions were only observed during microlaryngoscopy (3 → 4). Sulci vocalis, cysts, and vergetures constituted 30 of these 74 lesions (Table 1). There may be several explanations why the preoperative diagnosis was not consistent with the intraoperative diagnosis (ie, change from 1 → 2 or 3 → 4): Reactive lesions A lesion contralateral to a sulcus vocalis, polyp or cyst may be secondary, and it is also called “contact swelling.”2 Cornut et al10 considered the sulcus vocalis, vergeture, and cyst as “intracordal lesions,” a group of lesions that constitutes a diagnostic pitfall. Our findings corroborate this vision. It may be possible that a reactive swelling has developed during the surgery delay. A reactive swelling is superficial and immediately contralateral to the causative lesion. If a reactive lesion exists for a short time, it will be rather mobile, but it may be indurated after a longer period of time. Furthermore, this process will depend on laryngeal load. Remarkably, a unilateral lesion was found in only 18% of the patients. Diagnostic difficulty Another explanation for the discovery of lesions for the first time during surgery can be the fact that contralateral lesions such as polyps or edema overshadowed the mucosal vibration pattern of the other vocal fold. Laryngostroboscopy in the ENTclinic allows for better assessment of the mucosal wave and glottic closure than can be obtained with the use of continuous light. However, a quasi-regular mucosal vibration pattern is necessary for a good interpretation of the stroboscopic image. A lesion cannot be detected properly when the stroboscope does not trigger properly, in case of significant perturbation of frequency and intensity. Colton et al9 systematically rated the stroboscopic signs for nodules, cysts, polyps, and edema in 80 patients to be helpful to classify patients in a correct diagnostic or treatment group. They found several distinctive
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signs. However, their study did not provide evidence that the stroboscopic signs were indeed the typical signs of these four categories of benign lesions; eg, the authors did not report on observations during microlaryngoscopy in the same patients to check for the initial clinical diagnosis. Surgical procedure The vocal folds are tensioned due to the suspension procedure. This results in a change of the aspect of the lesions. At the time of surgery, a three-dimensional view is obtained, and the entire rim of the vocal fold can be observed gently touching the vocal fold by a microscopic instrument. As it is impossible to investigate the patients preoperatively in this way, we were only able to assess a final diagnosis during microlaryngoscopy. Waiting list It was also likely that the surgery delay influenced the natural development of the lesion. The surgery waiting time varied between a few weeks and several months. Intraobserver variation Intraobserver variation could also be a cause of this inconsistency of diagnoses. A great intraobserver variation and interobserver variation was described by Dikkers et al.4 In the present study, diagnoses were assessed by a single ENT-surgeon. As our study reflects normal daily practice in an ENT-clinic, the ENT-surgeon must be aware of the existence of intraobserver variation. Terminology The lack of a common terminology that takes into account the functional aspects of the vocal folds generally plays an important role in the occurrence of intraobserver and interobserver variation. The “nodules” constitutes a clear example: There is a continuity stretched out from a local mucosal edema at the crossing of the first one third and the second third part of the vocal folds, via small and larger flexible, edematous swellings to the more obdurate and fibrotic nodules. The polyps show a similarity with the nodules in a variation from local edema, via small to broad based, to more obdurate swellings. Only few polyps could be described as Journal of Voice, Vol. 17, No. 3, 2003
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pedunculated. Bouchayer et al2 described another continuity in relation to “congenital lesions”: from a vergeture via a sulcus to a so-called “cyst ouvert” to a cyst. In the present study, an overlap might be seen between miscellaneous lesions such as nodules, edema, polyps, and Reinke’s edema. A relatively small appearance of the lesions, traditionally described as “typical,” was established in this study. In the European Laryngological Society, the terminology of benign vocal fold lesions is a topic of discussion.11 Several reasons for inconsistency of a diagnosis were mentioned above. Probably, a video playback system would allow for a better diagnosis preoperatively. In addition, laryngostroboscopy can be completed with recently obtainable videokymography, because perturbation of frequency and intensity does not disturb this method of examination.12 Consequences The results of this study provide consequences for diagnostic evaluation and surgical procedure for benign vocal fold lesions. Despite examination with both white halogen and stroboscopic light, some lesions were still difficult to diagnose. Meticulous examination of both vocal folds for lesions during microlaryngoscopy may be necessary for an adequate diagnosis in cases of unclear dysphonia or discrepancy between the clinical examination and the quality and performance of the voice. It is recommended to carry out a diagnostic microlaryngoscopy in this situation as the preoperative diagnosis of a lesion changed intraoperatively and lesions were missed at the preoperative examination. During microlaryngoscopy, four out of five patients had bilateral lesions. As “congenital” lesions constituted 41% of all missed lesions at the preoperative examination, an ENT-surgeon should discuss with the patient that a planned surgical procedure might alter during surgery. In the present study, half of the operated patients were professional voice users. Especially in this category of patients, the type of microlaryngoscopy for an expected diagnosis of a benign vocal fold lesion has also an impact on the patients’ personal lives and the economic costs. The recovery time after surgery may vary from weeks to several months in different circumstances. The recovery Journal of Voice, Vol. 17, No. 3, 2003
time after being operated for a sulcus vocalis is much longer than for a polyp. CONCLUSIONS Inconsistency was observed between the preoperative diagnosis and the intraoperative diagnosis despite the use of both white halogen and stroboscopic light. In 36% of the patients, the preoperative diagnosis was not consistent with the intraoperative diagnosis. In 31% of the patients, the lesion was not recognized at the preoperative examination. Thus, these lesions were only diagnosed during microlaryngoscopy. Bilateral lesions were found in 53% of the patients preoperatively and in 82% of the patients intraoperatively. Because the preoperative and intraoperative diagnosis often differed, both the patients and the ENT-surgeon must keep an open mind about what may need to be done at surgery. The authors recommend carrying out a diagnostic microlaryngoscopy in cases of unclear dysphonia or discrepancy between the examination and the quality and performance of the voice as the preoperative diagnosis of a lesion changed intraoperatively and lesions were missed at the preoperative examination. More research is needed about the consistency of diagnosis in benign vocal fold lesions to optimize the preoperative examination for surgical intervention in dysphonic patients. REFERENCES 1. Hirano M, Bless DM. Videostroboscopic Examination of the Larynx. San Diego, CA: Singular Publishing Group; 1993:119–190. 2. Bouchayer M, Cornut G. Microsurgical treatment of benign vocal fold lesions: indications, technique, results. Folia Phoniatr. 1992;44:155–184. 3. Kitzing P. Stroboscopy: A pertinent laryngeal examination. J Otolaryngol. 1985;14:151–157. 4. Dikkers FG, Schutte HK. Benign lesions of the vocal folds: Uniformity in assessment of clinical diagnosis. Clin Otolaryngol. 1991;16:8–11. 5. Rosen CA, Lombard LE, Murry T. Acoustic, aerodynamic, and videostroboscopic features of bilateral vocal fold lesions. Ann-Otol-Rhinol-Laryngol. 2000;109:823–828. 6. Dikkers FG, Nikkels PGJ. Benign lesions of the vocal folds: Histopathology and phonotrauma. Ann-Otol-RhinolLaryngol. 1995;104:698–703.
BENIGN VOCAL FOLD LESIONS 7. Sataloff RT. Care of the professional voice. In: Sataloff RT, ed. Performing Arts Medicine. 2nd ed. San Diego and London: Singular Publishing Group; 1998:137–187. 8. Wellens WAR, van Opstal MJMC. Performance stress in professional voice users. In: Dejonckere PH, ed. Occupational voice: care and cure. The Haguem: Kugler Publications; 2001:81–100. 9. Colton RH, Woo P, Brewer DW, Griffin B, Casper J. Stroboscopic signs associated with benign lesions of the vocal folds. J Voice. 1995;9:312–325.
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10. Cornut G, Bouchayer M. Du fonctionnel a` l’organique en phoniatrie. Rev-Laryngol-Otol-Rhinol-Bord. 1987;108:417–419. 11. Dejonckere PH, Bradley P, Clemente P, et al. A basic protocol for functional assessment of voice pathology, especially for investigating the efficacy of (phonosurgical) treatments and evaluating new assessment techniques. Guideline elaborated by the Committee on Phoniatrics of the European Laryngological Society (ELS). Eur Arch Otorhinolaryngol. 2001;258:77–82. 12. Schutte HK, Svec JG, Sram F. Videokymography: Research and clinical issues. Log Phon Vocol. 1997;22:152–156.
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