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Clinical Challenge
Endoscopy
June 25, 2020

Lateral Vocal Fold Fullness in a Patient With Heavy Voice Use

Author Affiliations
  • 1Keck School of Medicine, Tina and Rick Caruso Department of Otolaryngology–Head and Neck Surgery, University of Southern California, Los Angeles
  • 2Keck School of Medicine, Department of Clinical Pathology, University of Southern California, Los Angeles
JAMA Otolaryngol Head Neck Surg. Published online June 25, 2020. doi:10.1001/jamaoto.2020.0941

A 45-year-old male professional voice user with a history of asthma being treated with inhaled steroids presented with a 1-year history of dysphonia. He reported throat tightness after significant voice use and consistent voice roughness that worsened over several weeks. On examination, he had moderate to severe dysphonia with predominant roughness and strain. Videostroboscopy findings were consistent with fungal laryngitis; a 2-week course of fluconazole was administered. Follow-up videostroboscopy findings demonstrated resolution of the fungal laryngitis but revealed residual fullness of the left false vocal fold and appearance of prolapsed ventricular mucosa obstructing the lateral extent of the left true vocal fold. There was a reduction of lateral excursion of the mucosal wave on the left. The patient continued to report dysphonia and increased vocal effort. A computed tomography scan with contrast showed no specific abnormalities. A direct laryngoscopy for evaluation and treatment was planned. Intraoperatively, there was a firm lesion in the left paraglottic space extending to the lateral aspect of the true vocal fold (Figure, A). A subtle but similar finding was seen on the right true vocal fold, not causing any mass effect (Figure, B). An incision was made in the mucosa of the ventricle overlying the lesion at its lateral extent, and a mucosal flap was elevated over the lesion. This revealed a cartilaginous lesion, which was removed using an AcuBlade CO2 laser (Lumenis) and cup forceps until the cartilaginous edge was smooth within the paraglottic space (Figure, C and D). The histologic specimen showed fragments of cartilage with no nuclear atypia or mitosis (Figure, E and F). At 3-months’ follow-up, the patient reported improvement in his voice with decreased effort and strain, which correlated with improvement in the Voice Handicap Index score and objective assessment by the clinicians.

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