Hoarseness & Vocal Cord Lesions

Hoarseness (dysphonia) is any change in the quality, pitch or loudness of voice and is the cardinal symptom of laryngeal disease. For NEET PG, the high-yield axis is: distinguishing benign mucosal lesions (nodules, polyp, Reinke oedema, papilloma) from laryngeal carcinoma, knowing the diagnostic ladder (indirect → flexible → direct laryngoscopy with stroboscopy), and mastering recurrent laryngeal nerve (RLN) palsy.

Definition & basic voice physiology

Phonation requires three things working together: a power source (lungs/expiratory air), a vibrator (vocal cords/folds), and a resonator (pharynx, oral & nasal cavities). The vocal folds adduct and the Bernoulli effect plus the mucosal wave (the loose superficial lamina propria = Reinke space) generates sound. Anything that adds mass to the cord, stiffens the mucosal wave, or prevents glottic closure produces hoarseness.

High-yield: Hoarseness of more than 3 weeks duration, especially in a smoker over 40, is laryngeal carcinoma until proven otherwise → mandates laryngoscopic visualisation. Never label it "laryngitis" without seeing the cords.

Key anatomical layers of the vocal fold (cover–body theory, Hirano):

• Epithelium (stratified squamous over the free edge)
• Superficial lamina propria = Reinke space (gelatinous, where oedema/polyp/nodule form)
• Intermediate + deep lamina propria = vocal ligament
• Vocalis muscle (body)

Classification of vocal cord lesions

Category	Examples	Typical patient
Benign mucosal (phonotrauma)	Vocal nodule, polyp, Reinke oedema, vocal cyst	Voice abusers, smokers
Benign neoplastic	Recurrent respiratory papillomatosis (HPV 6/11), haemangioma	Children & adults
Inflammatory	Acute/chronic laryngitis, TB larynx, contact ulcer/granuloma	Reflux, infection
Neurogenic	RLN palsy, superior laryngeal nerve palsy, spasmodic dysphonia	Post-thyroidectomy, malignancy
Premalignant	Leukoplakia, keratosis, dysplasia	Smokers
Malignant	Squamous cell carcinoma (glottic, supraglottic, subglottic)	Older male smoker + alcohol

Benign vocal cord lesions

Vocal nodules ("singer's / screamer's nodules")

• Bilateral, symmetrical, whitish swellings at the junction of anterior 1/3 and posterior 2/3 of the membranous cord — the point of maximum vibratory contact.
• Cause: chronic voice abuse/misuse (singers, teachers, hawkers, children who scream).
• Pathology: localised epithelial hyperplasia + Reinke space fibrosis.
• Treatment: voice rest + speech therapy is first line (early/soft nodules regress). Mature/fibrosed nodules → microlaryngeal surgical excision.

High-yield: Vocal nodules are BILATERAL and sit at the anterior-1/3–posterior-2/3 junction. A unilateral lesion at the same site is usually a polyp or cyst, not a nodule.

Vocal polyp

• Usually unilateral, pedunculated or sessile, soft, often haemorrhagic or gelatinous, on the free edge of the anterior third.
• Cause: a single episode of severe vocal strain or submucosal haemorrhage; smoking contributes.
• Treatment: surgical removal (microlaryngeal cold-instrument excision); does not respond well to voice rest alone. A large pedunculated polyp can produce intermittent hoarseness as it flips above/below the glottis.

Reinke oedema (polypoid corditis)

• Bilateral, diffuse, fusiform fluid-filled swelling of the entire membranous cord — oedema of the Reinke space.
• Classic triad of risk: smoking (almost universal), voice abuse, hypothyroidism (and GERD).
• Voice becomes low-pitched/gruff/masculine (added mass lowers fundamental frequency) — a woman developing a deep voice is a classic vignette.
• Treatment: stop smoking + microlaryngeal surgery (incise the superior surface, evacuate gelatinous fluid, redrape mucosa — do not strip both cords simultaneously to avoid anterior web).

Feature	Vocal nodule	Vocal polyp	Reinke oedema
Laterality	Bilateral	Usually unilateral	Bilateral diffuse
Site	Ant 1/3–post 2/3 junction	Free edge, anterior	Whole membranous cord
Cause	Chronic abuse	Acute strain	Smoking + hypothyroid + abuse
Voice change	Breathy/rough	Rough, intermittent	Low-pitched, gruff
First-line Rx	Voice rest + therapy	Excision	Stop smoking + surgery

Vocal cord cyst

• Sub-epithelial mucus-retention or epidermoid cyst within the lamina propria; unilateral, often refractory to therapy and frequently mistaken for a nodule. Stroboscopy shows reduced/absent mucosal wave over the cyst. Treated by careful microflap excision preserving the ligament.

Contact ulcer / granuloma

• On the vocal process of the arytenoid (posterior glottis) — cartilage-covered area. Causes: vocal abuse with hard glottal attack, GERD, and endotracheal intubation trauma (intubation granuloma). Treat the cause: anti-reflux therapy, voice therapy; surgery only if obstructive/persistent (recurrence common).

Recurrent respiratory papillomatosis (RRP)

• Most common benign laryngeal neoplasm; caused by HPV types 6 and 11 (low-risk types).
• Two peaks: juvenile-onset (acquired during vaginal delivery from maternal genital warts; multiple, aggressive, recur) and adult-onset (less aggressive).
• Lesions are wart-like, friable, often bunch-of-grapes appearance, commonest at the anterior commissure and along ciliated–squamous junctions.
• Symptoms: progressive hoarseness in a child + stridor; can spread to trachea/bronchi.
• Treatment: microdebrider / CO₂ laser excision preserving normal mucosa; recurrence is the rule. Adjuvants: intralesional cidofovir, bevacizumab; the quadrivalent/9-valent HPV vaccine reduces incidence.

High-yield: A child with hoarseness + stridor + recurring "warty" laryngeal masses = juvenile recurrent respiratory papillomatosis (HPV 6 & 11). Avoid tracheostomy (promotes distal seeding) when possible.

Laryngeal carcinoma

High-yield: Carcinoma larynx is squamous cell carcinoma (>95%) in an elderly male smoker + alcohol user. Glottic is the commonest site overall (in most Indian/Western data) and has the best prognosis because it presents earliest (hoarseness) and the glottis has sparse lymphatics.

Anatomical subtypes & behaviour

Site	Earliest symptom	Lymphatic spread	Prognosis
Glottic (true cords)	Early persistent hoarseness	Poor lymphatics → late nodes	Best (presents early)
Supraglottic (epiglottis, false cords)	Throat pain, dysphagia, referred otalgia, neck node	Rich bilateral lymphatics → early nodes	Worse
Subglottic (below cords)	Late; stridor, airway obstruction	To paratracheal/Delphian nodes	Worst (silent, late)

• T-staging of glottic cancer is functional: T1 cord with normal mobility → T2 supra/subglottic extension or impaired mobility → T3 = vocal cord fixation → T4 cartilage/extralaryngeal invasion. Cord fixation indicates deep vocalis/cricoarytenoid involvement.
• Referred otalgia is via the vagus → auricular (Arnold's) nerve.

Management overview

• Early (T1–T2): single modality — radiotherapy (good voice preservation) or transoral laser/endoscopic excision. Outcomes comparable; choice depends on lesion and voice needs.
• Advanced (T3–T4): combined therapy — chemoradiation (organ/voice preservation protocols, e.g. cisplatin + RT) or total laryngectomy with neck dissection ± adjuvant RT/CRT.
• Voice rehabilitation post-laryngectomy: tracheo-oesophageal puncture with Blom–Singer prosthesis (best quality), oesophageal speech, or electrolarynx.

Recurrent laryngeal nerve (RLN) palsy

The RLN supplies all intrinsic muscles of the larynx except the cricothyroid (the cricothyroid, a tensor, is supplied by the external branch of the superior laryngeal nerve). The sole abductor of the cord is the posterior cricoarytenoid (PCA) — paralysis abolishes abduction, so a paralysed cord tends to lie near the midline.

Mnemonic — "PACT to open": Posterior Cricoarytenoid is the only Abductor; Lateral cricoarytenoid + interarytenoid adduct. "Read PCA as Please Come Apart."

Causes (left RLN more commonly affected — longer course, loops under aortic arch)

Flow of left RLN: vagus → loops under the arch of aorta (ligamentum arteriosum) → ascends in tracheo-oesophageal groove → larynx.

• Surgical (commonest overall): thyroidectomy — the RLN lies in the tracheo-oesophageal groove near the inferior thyroid artery & ligament of Berry.
• Malignancy: carcinoma thyroid, apex of lung (Pancoast), oesophagus, bronchus.
• Cardiovascular: mitral stenosis with left atrial enlargement / aortic arch aneurysm (Ortner's cardiovocal syndrome — left RLN compression).
• Mediastinal nodes, idiopathic (viral neuritis), neck trauma.

Lesion	Cord position	Voice / airway
Unilateral RLN palsy	Paramedian	Hoarse/breathy, weak cough; airway usually adequate
Bilateral RLN (abductor) palsy	Both paramedian/median	Stridor & airway obstruction (voice may be near-normal) → often needs tracheostomy
Combined RLN + SLN (complete vagal)	Cadaveric (intermediate)	Hoarse + aspiration
Bilateral complete palsy	Cadaveric	Aspiration, weak voice

High-yield (Semon's law): In a progressive organic lesion, the abductor fibres are paralysed before adductors → cord first goes to the paramedian (adducted) position, then later to cadaveric. So a slowly compressing tumour gives a paramedian cord.

High-yield: Bilateral abductor palsy = good voice but stridor (cords near midline obstruct airway) — the dangerous one. Unilateral palsy = hoarse/breathy voice but safe airway.

Bowing vs paralysis (presbylarynx)

• Bowing = age-related vocal cord atrophy (presbyphonia): cords are mobile but thinned, leaving a spindle-shaped glottic gap on adduction → breathy voice. Mobility is preserved (differentiates from paralysis, where the cord is immobile). Managed with voice therapy ± injection/medialisation.

Diagnostic approach & investigation of choice

Stepwise evaluation: History (duration, smoking, occupation, surgery) → Indirect laryngoscopy (mirror) as the bedside screen → Flexible fibre-optic laryngoscopy (best office tool, assesses mobility) → Videostroboscopy (best for mucosal wave/early lesions) → Direct laryngoscopy + microlaryngoscopy under GA with biopsy (the definitive diagnostic/therapeutic step for suspicious or operable lesions).

• Microlaryngoscopy (suspension) indications: biopsy of suspicious lesion, excision of benign lesions (nodule, polyp, papilloma, cyst), assessment of anterior commissure/subglottis not seen on mirror, paediatric airway lesions.
• CT/MRI neck: for staging carcinoma (cartilage invasion, nodal disease, subglottic/paraglottic spread).
• Stroboscopy is the single best test to evaluate the mucosal wave and pick early/sulcus/cyst lesions invisible on standard light.

High-yield: Best office investigation for hoarseness = flexible laryngoscopy (sees cords + mobility). Best test for early mucosal lesions / mucosal wave = videostroboscopy. Definitive (tissue) diagnosis = direct microlaryngoscopy + biopsy.

Principles of management & "voice rest"

• Voice rest + speech therapy is first-line for phonotraumatic lesions (early nodules, contact granuloma) and an essential adjunct around any phonosurgery.
• Phonomicrosurgery uses cold steel micro-instruments with a microflap technique to preserve the vocal ligament and superficial lamina propria (the mucosal wave). Laser (CO₂) is used for papillomas and early cancers but carries thermal-injury risk to the wave.
• Treat the underlying cause: stop smoking (Reinke, leukoplakia), anti-reflux (granuloma), thyroxine (hypothyroid Reinke), HPV vaccination (RRP).

Complications

• Untreated phonotrauma → permanent dysphonia, fibrosis, scar/sulcus vocalis.
• Anterior glottic web after bilateral anterior-commissure surgery (e.g. stripping both cords) → airway/voice compromise.
• Laryngeal carcinoma → airway obstruction, aspiration, nodal/distant metastasis.
• RRP → airway obstruction, rare malignant transformation (HPV 11), tracheobronchial spread.
• Bilateral RLN palsy → acute airway obstruction needing tracheostomy/cordotomy.
• Aspiration pneumonia in combined vagal palsy.

Key differentials of chronic hoarseness

Clue in vignette	Most likely diagnosis
Singer/teacher, bilateral midcord swellings	Vocal nodules
Smoker woman with deep/gruff voice, diffuse cord swelling	Reinke oedema
Single haemorrhagic unilateral swelling after one shout	Vocal polyp
Child, recurring warty masses + stridor	Recurrent respiratory papillomatosis
Elderly male smoker, >3 wk hoarseness, neck node	Carcinoma larynx
Post-thyroidectomy breathy voice	Unilateral RLN palsy
Mitral stenosis with hoarseness	Ortner's syndrome (left RLN)
Elderly, breathy voice, spindle glottic gap, mobile cords	Presbylarynx (bowing)
Reflux symptoms + posterior cord granuloma	Contact granuloma/LPR

Recently asked / exam angle

• "Singer's nodule site" → junction of anterior 1/3 and posterior 2/3, bilateral.
• Only abductor of vocal cord → posterior cricoarytenoid; only muscle NOT supplied by RLN → cricothyroid (external SLN).
• Semon's law sequence (abductor before adductor) and the resulting paramedian cord.
• Left RLN palsy causes mnemonic and Ortner's cardiovocal syndrome (mitral stenosis / aortic aneurysm).
• HPV 6 & 11 → respiratory papillomatosis; 16 & 18 → malignancy elsewhere (don't confuse).
• Best prognosis laryngeal cancer = glottic (early hoarseness, poor lymphatics); worst = subglottic.
• T3 glottic carcinoma = vocal cord fixation.
• Bilateral abductor palsy → good voice but stridor; the airway emergency.
• Investigation of choice for mucosal wave → stroboscopy; for tissue diagnosis → direct microlaryngoscopy + biopsy.
• Voice rehab after total laryngectomy → tracheo-oesophageal puncture / Blom–Singer prosthesis (best).

Rapid revision

1. Hoarseness > 3 weeks in a smoker = rule out carcinoma larynx by laryngoscopy.
2. Vocal nodules: bilateral, anterior 1/3–posterior 2/3 junction; Rx = voice rest + speech therapy first.
3. Vocal polyp: unilateral, anterior free edge; Rx = excision.
4. Reinke oedema: bilateral diffuse, smoking + hypothyroid + abuse, gruff low-pitched voice.
5. PCA = only abductor; cricothyroid = only muscle not by RLN (external SLN, a tensor).
6. Semon's law: abductors paralyse before adductors → cord first paramedian.
7. Left RLN more affected (loops under aortic arch); thyroidectomy is the commonest cause.
8. Ortner's syndrome = hoarseness from cardiovascular (mitral stenosis/aortic aneurysm) left RLN compression.
9. Bilateral abductor palsy → near-normal voice but stridor (airway emergency).
10. RRP = HPV 6 & 11; child with stridor + warty cords; treat with debrider/laser, avoid tracheostomy.
11. Laryngeal SCC: glottic best prognosis, subglottic worst; T3 = cord fixation.
12. Best office test = flexible laryngoscopy; mucosal wave = stroboscopy; diagnosis = microlaryngoscopy + biopsy.