Right posthemorrhagic polyp with vocal fold varices. (Laryngoscopic Clinic).

A 40-year-old professional guitarist and rock and folk singer came to us with a 6-month history of hoarseness and cracking of both his speaking and singing voice. His hoarseness had developed gradually and had not changed significantly during the 6-month period. He had had previous episodes of sudden hoarseness after singing, but his voice had always returned to normal within a few days. He had never had formal singing lessons or voice therapy. He had been treated previously for gastroesophageal reflux disease with a proton-pump inhibitor for 6 weeks, but when he did not notice any improvement in his voice, he discontinued therapy. The patient had the most difficulty in his midrange voice, especially when he was singing softly. He also noticed breaks in his speaking voice. He had a 15 pack-year history of cigarette smoking, although he had quit smoking 6 years earlier.

Strobovideolaryngoscopy detected aposthemorrhagic polyp on the right vocal fold. The vocal fold was very stiff at the base of the mass (figure). Ectatic and varicose vessels were present at the base of the mass as well as on the superior surface of the vocal fold. The patient also exhibited substantial muscle-tension dysphonia, erythema and edema of the arytenoids, and posterior mucosal cobblestoning.

Initially, we prescribed aggressive antireflux treatment combined with intensive voice and singing therapy. Although this conservative strategy did result in a slight improvement in the patient's voice, the polyp did not shrink. Therefore, we performed microlaryngoscopy to excise the mass. We used a mini-microflap technique to carefully separate the polyp from the lamina propria. (1) In light of the large number and irregular course of the varicose vessels and their lateral positions, they were not removed with a vascular knife; instead they were gently retracted even farther away from the vocal ligament and coagulated superficially with a C[O.sup.2] laser. The patient was kept on voice rest for 1 week postoperatively, followed by a slow increase in singing activity over the next 6 months. With aggressive voice therapy, he regained his previous speaking voice and began performing again.

Reference

(1.) Sataloff RT, Spiegel JR, Heuer RJ. Laryngeal mini-microflap: A new technique and reassessment of the microflap saga. J Voice 1994;9:198-204.

From the Department of Otolaryngology, Graduate Hospital, Philadelphia, and the Department of Otolaryngology, Thomas Jefferson University, Philadelphia (Dr. Anderson and Dr. Sataloff), and the American Institute for Voice and Ear Research, Philadelphia (Ms. Hawkshaw).