Benign Laryngeal Lesions (Nodules, Polyps, and Granulomas): Etiology, Symptoms, Diagnosis, and Treatment

Benign laryngeal lesions are localized reactive morphologic changes of the vocal folds, that do not undergo malignant transformation or metastasize. These lesions are among the most common causes of dysphonia in adults and children. They are especially prevalent among voice professionals.

Typical symptoms include cough, hoarseness, changes in voice quality, throat discomfort, and occasionally dyspnea.

Epidemiology

They can also lead to persistent dysphonia.

The main types of lesions include:

• Vocal fold polyps (54 %);
• Nodules (11 %);
• Granulomas.

A gender difference is observed: nodules are more often diagnosed in women, whereas polyps and granulomas are more common in men.

Vocal fold nodules are more common in younger patients, polyps in middle-aged adults, and granulomas in older patients.

Because vocal fold nodules occur predominantly in voice professionals (singers, teachers, broadcasters), they are often called singer’s nodes or teacher’s nodes.

Vocal Fold Polyps

A vocal cord polyp is a localized swelling of the vocal fold mucosa arising in response to chronic phonotrauma. It can regress with appropriate vocal load, as it represents a reactive change in the mucosa.

Etiology

The fundamental cause of this pathology is prolonged elevated vocal load or abrupt excessive voice use (shouting, hysteria, high-pitched speech). Smoking often contributes to the development of the disease. Other risk factors include laryngopharyngeal reflux, allergies, and chronic upper respiratory tract infections.

Anatomy of Vocal Cord Polyps

Polyps form in Reinke’s space but, unlike nodules, are unilateral. Due to constant phonotrauma, there is hemorrhage and edema in the subepithelial space of the vocal fold. Altered tissues reorganize into a polyp, often a vascularized one. A polyp is a round soft tissue lesion located on the free edge of one of the vocal folds, significantly protruding into the glottis. The lesion most often forms in the area of maximal vibration, namely in the anterior third of the vocal folds.

Clinical presentation

The main symptom is dysphonia (hoarseness). The voice becomes rough, hoarse, and may disappear or become husky by the end of the day. The patient may start to complain of a foreign body sensation in the throat, tickling, and cough. With larger polyps, wheezing on breathing or dyspnea may occur.

Diagnosis of Vocal Fold Polyps

Diagnosis begins with a patient interview to clarify complaints and medical history. Then, an ENT examination is performed, assessing the larynx using indirect laryngoscopy or endolaryngoscopy. During the examination, a round elastic lesion of white, yellow, or pink color is visualized on one of the vocal folds, protruding into the glottis. Videostroboscopy shows aberrant vibration in the affected cord; the vocal folds do not close completely.

Treatment

Treatment is based on phonotherapy combined with voice rest. Phonopedists correct breathing and articulation. If necessary, therapy for laryngopharyngeal reflux, allergies, and upper airway infections is provided. During treatment, it is important to eliminate smoking and other risk factors. Conservative treatment can be effective in cases of small soft tissue polyps.

Surgical intervention is indicated for fibrous or large chronic polyps. Micro-surgical excision of altered tissues is performed while preserving the lamina propria of the vocal fold. Excised tissues are sent for mandatory histopathological examination. In the early postoperative period, vocal rest is necessary, followed by voice rehabilitation.

Vocal Fold Nodules

Nodules are benign symmetrical thickenings at the junction of the anterior and middle thirds of the vocal cords. They can completely resolve with vocal rest, being a mucosal reaction to increased vocal load. Therefore, they are also classified as pseudotumors.

Etiology and risk factors

The main cause is phonotrauma. It involves prolonged vocal load on the vocal folds, improper voice usage, frequent whispering or shouting, and persistent coughing. In children, nodules form as a result of prolonged loud shouting, screaming, tantrums, extended conversations, and whispering.

Risk factors

In adults, the condition may be triggered by:

• Smoking;
• Gastro-esophageal reflux disease (GERD).

Children are most commonly affected in cases of:

• Passive smoking;
• Voice problems in the mother;
• Male sex;
• Large family.

Anatomic Pathology of Nodules

Laryngeal nodules form in Reinke’s space between the mucosa and the true vocal fold. The pathology is caused by disruption of mucosal vibration due to increased load on the vocal folds. Maximum vibration and friction of the vocal folds are observed at the border of the anterior and middle thirds, where pathological changes are noted. In the initial period, microtraumas to the mucosa lead to edema — accumulation of exudate in Reinke’s space. Nodules are symmetrical, translucent, and soft. Then, exudate is replaced by fibrous tissue, making nodules denser and whitish.

Clinical manifestations

The main complaint is voice disorders. Hoarseness, roughness, change in range and volume are noted. There is also rapid vocal fatigue, especially after prolonged exertion, often by the end of the day. Cough and sensation of a lump or foreign body in the throat are less frequently observed. Pain is not typical for nodules.

Diagnostic Methods

For diagnosis, medical history is collected, and complaints, lifestyle, vocal habits, and presence of chronic diseases are assessed. Acoustic analysis using questionnaires (voice handicap index) is recommended to track treatment progress.

A routine ENT examination with assessment of the larynx (fibrolaryngoscopy) is performed. Laryngoscopy reveals symmetrical transparent or whitish nodules at the border of the anterior and middle thirds of the vocal folds.

If the necessary equipment is available, videostroboscopy is indicated. Stroboscopy evaluates vocal fold vibration and closure, with nodules disrupting closure at their site of formation.

Treatment of Vocal Fold Nodules

The main component of treatment is voice therapy. A phonopedists helps adjust the function of the vocal apparatus, using correct breathing and articulation. At the start of treatment, maintaining vocal rest is mandatory.

Surgical removal is indicated for dense fibrous nodules that do not respond to conservative therapy. Altered tissues are sequentially removed using micro-surgical instruments or a CO2 laser. If nodules are symmetrically located and there is intraoperative damage to the anterior commissure area, excision of the nodule from the opposite side is recommended. After healing of the contralateral side, the second nodule is excised. Subsequent voice rehabilitation is recommended.

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Laryngeal Granulomas

Laryngeal granulomas are benign formations located in the posterior sections of the larynx.

Etiology of Granulomas

The most common cause is trauma during intubation of the larynx or a history of prolonged endotracheal intubation. Factors contributing to the disease include excessive vocal strain (especially in men with forced voices), aggressive laryngopharyngeal reflux.

Anatomy

Granulomas typically occur in the area of one of the vocal processes of the arytenoid cartilage. An ulcer or erosion may be present on the opposite vocal fold due to constant friction from the granuloma against healthy tissues. At the site of intubation tube placement, pathological exposure to hydrochloric acid fumes, or intense rough closure of the vocal processes, chronic trauma to the mucosa occurs. Due to constant trauma and inflammation, granulation tissue starts to proliferate and significantly increases in size. Larger granulomas protrude into the lumen of the glottis and descend into the subglottic space. Post-intubation granuloma occurs 2–6 months post-intubation.

Clinical Manifestations

Complaints are varied. In most cases, patients report changes in voice, hoarseness, cough, and the sensation of a lump in the throat. Pain and discomfort in the throat are also characteristic, which worsen during swallowing or phonation.

Diagnosis

Diagnosis is based on medical history, previous intubation and chronic diseases, especially GERD, should be considered. An ENT examination, indirect laryngoscopy or endolaryngoscopy is performed. Laryngeal changes are assessed: a white-pink or red nodular formation on a wide base in the area of the vocal process of the arytenoid cartilage is visualized. Ulcerations may be present on the surface of the granuloma.

Treatment of Laryngeal Granulomas

Conservative therapy is the first-line approach. Antireflux medications, local corticosteroid injections, and in some cases, systemic corticosteroids are prescribed. Voice therapy is strongly recommended.

If conservative treatment proves ineffective, microsurgical removal of the granuloma followed by histological examination is performed. Subsequent voice rehabilitation is also recommended.