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Clinical Challenge
Endoscopy
August 18, 2016

Chalky Vocal Fold Lesions

Author Affiliations
  • 1Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
  • 2Harvard Medical School, Boston, Massachusetts
  • 3Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts
JAMA Otolaryngol Head Neck Surg. Published online August 18, 2016. doi:10.1001/jamaoto.2016.1819

A man in his 60s was admitted to the hospital for a myocardial infarction. Several days into his stay, he complained of having a hoarse voice for the past year. He denied dyspnea, dysphagia, and reported no weight loss. His medical history was notable for congestive heart failure, coronary artery disease, and gout. He noted a 10-pack-year smoking history and Agent Orange exposure. On examination, he had no palpable neck masses. The cranial nerves were grossly intact. His voice was rough. He underwent a flexible laryngoscopy, which showed an exophytic yellow-white mid-membranous subepithelial lesion on the bilateral true vocal folds (Figure, A). On stroboscopy, there was decreased vibratory amplitude bilaterally and moderate phase asymmetry. Several weeks later, he underwent an indirect laryngoscopy and vocal fold biopsy in the office. Grossly, pathologic findings showed a chalky white lesion. Histopathologic review showed submucosal amorphous eosinophilic material (Figure, B). The amorphous material was negative for Congo red (Figure, C). Examination of an unstained slide showed needle-shaped birefringent crystals (Figure, D). With this nonspecific but benign diagnosis, and an inability for the patient to go to the operating room secondary to his comorbidities, he agreed to undergo office potassium titanyl phosphate laser photoangiolysis of the lesions to improve vocal fold contour and vibration. More of the chalky material was expressed as the overlying mucosa ablated with very little energy delivered. On follow-up, the lesions persisted but were less bulky.

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