M E D iC A L
JO URNAL
C A S E
R E P O J ~ T
E d m ir A m e ric a L o u re n r;o , L U Is H e n riq u e C h e c h in a to C o s ta
A n g y o m a t o u s v o c a l p o l y p u s ·
A c o m p l e t e s p o n t a n e o u s
r e g r e s s i o n
Otorhinolaryngology Course, Jundiai College of Medicine - Sao Paulo, Brazil
T h e a u th o rs d e s c rib e a m a le p a tie n t w h o h a d m a lig n a n t ly m p h o m a s e v e n y e a rs a g o w h ic h re m itte d w ith c h e m o th e ra p y . T w o y e a rs a g o h e d e v e lo p e d d y s p h o n ia . A n u n ila te ra l, p e d ic u la te s m o o th re d le s io n o n th e rig h t v o c a l fo ld w a s la te r d is c o v e re d . E v e n w ith o u t b e n e fit o f m e d ic a m e n to s u s tre a tm e n t, th e p a tie n t re fu s e d s u rg e ry . In a re e v a lu a tio n u s in g rig id te le s c o p y o f th e la ry n x tw o y e a rs la te r, th e le s io n h a d d is a p p e a re d , c o m p le te ly a n d s p o n ta n e o u s ly . A s th e re a re n o e x is tin g p u b lic a tio n s o n th is to p ic , th is c a s e re p o rt is a n a le rt th a t s u rg e ry s h o u ld b e re c o m m e n d e d w ith e x tre m e c a u tio n in th is ty p e o f v o c a l d is e a s e .
U N IT E R M S : L a ry n x . P o lip u s .
IN T R O D U C T IO N
V
o c a ll a r y n xc o r d sa l t e r a t i o n sp o l y p s a r ew h i c ht h e a f f e c tm o s t f r e q u e n tp h o n a t i o n ,b e n i g na n d r a r e l y o c c u r i n c h i l d r e n . U p t o 7 5 t o 8 0 p e r c e n t o f a l l p a t i e n t s w i t h v o c a l c o r d s p o l y p s a r e m a l e s , a n d t h e p o l y p s a r e 9 0 p e r c e n t s i n g l e a n d 1 0 p e r c e n t b i l a t e r a l o r m u l t i p l e u n i l a t e r a l . T h e y o c c u r c h i e f l y o n t h e v o c a l c o r d f r e e e d g e , a t t h e j u n c t i o n o f t h e a n t e r i o r t h i r d w i t h t h e p o s t e r i o r t w o - t h i r d s . T h e p a t h o g e n e s i s o f t h e v o c a l p o l y p u s i s n o t w e l l - k n o w n . S i n c e i t i s n o t a t r u e t u m o r , t h e t e r m s v o c a l f i b r o m a a n d m i x o m a a r e i n a d e q u a t e . I t s i n f l a m m a t o r y o r i g i n i s a l s o v e r y m u c h d i s c u s s e d . R a r e l y a r e t h e r e s i g n s o f r e c e n t o r o l d i n f l a m m a t i o n , e v e n o n a h i s t o l o g i c a l e x a m . M a n y o f t h e s e p a t i e n t s o v e r u s e t h e i r v o i c e s r o u t i n e l y d u e t o p r o f e s s i o n a l n e c e s s i t y . S o m e v o c a lA d d re s s fo r c o rre s p o n d e n c e : E d m ir A m e ric o L o u re n r;o
R u a d o R e tiro , 4 2 4 - 5Qa n d a r, c o n j. 5 3 / 5 4 -A n h a n g a b a u
J u n d ia f /S P - B ra s il- C E P 1 3 2 0 9 -0 0 0
p o l y p s a r i s e f r o m p o w e r f u l , i n t e n s e a n d u n u s u a l p h y s i c a l a c t i v i t y , w h i c h c a u s e s u b g l o t i c i n c r e a s e d p r e s s u r e f o l l o w e d b y a s u d d e n d e c r e a s e . I
V o c a l p o l y p s a r e s o m e t i m e s a c c o m p a n i e d b y v a r i c o s i t i e s ; m a i n l y i n t h o s e c a s e s c a u s e d b y v o c a l a b u s e i n v o i c e p r o f e s s i o n a l s w i t h n o v o c a l t r a i n i n g , m o r e c o m m o n l y i n t e a c h e r s .
T h e s i z e , o r i g i n , c o l o r a n d c o n s i s t e n c e o f p o l y p s a r e e x t r e m e l y v a r i a b l e . T h e l e s i o n i s u s u a l l y a r o u n d m a s s , m o n o - o r m u l t i l o b u l a t e d , a n d r a r e l y u l c e r a t e d . S m a l l p o l y p s h a v e a l a r g e b a s e ; a n d t h e b i g g e r t h e y a r e , t h e n a r r o w e r i s t h e i r b a s e , c a u s i n g c o n f u s i o n w i t h R e i n k e 's e d e m a . ' T h e m a j o r s y m p t o m s o f v o c a l p o l y p s a r e h o a r s e n e s s a n d d i p l o p h o n i a ( b i t o n a l v o i c e ) ; d y s p n e a r a r e l y o c c u r s . T h e p o l y p u s a r e c l a s s i f i e d h i s t o l o g i c a l l y a s :
1 . G e l a t i n o u s o r G a l l e r t 's p o l y p u s - w h e n i t h a s l i t t l e c o n n e c t i v e t i s s u e , t h i n f i b e r s , s o m e c a p i l l a r y v e s s e l s , t h i n p a v i m e n t o u s e p i t h e l i u m a n d m a n y m u c o u s g e l a t i n o u s m a s s e s . I t i s a n o n - p e d i c u l a t e d p o l y p , w i t h a t r a n s l u c e n t a s p e c t . R a r e l y i s t h e r e t h i c k , f i b r o u s c o n n e c t i v e t i s s u e ; a s i g n o f a n a g i n g p o l y p n u c l e u s . O n l y 5 p e r c e n t o f t h e p o l y p s h a v e a m a c r o s c o p i c
S a o P a u lo M e d ic a l J o u rn a l/R P M 1 1 4 (3 ): 1 1 6 2 -1 1 6 5 , 1 9 9 6 L O U R E N Q O , E A & C O S T A , L .H .C . - A n g y o m a to u s v o c a l p o ly p u s
keratinized cover. There are no nuclear atypias or other intense epithelium dysplasias. The polyp epithelium rarely show s discrete hyperplasia or acanthosis.
2. Fibrous - w ith a connective-tissue core rich in cells and fibers. It m ay be richly vascularized and hyalinized.
3. Telangiectasic - its core is com posed of cavernous, coiled blood vessels, w ith variable diam eters and thin w alls. Som e of these caverns m ay becom e trom bosed and hyalinized. A round the polypus there are often older m icroscopic hem orrhages at the level of the subm ucosa, w hich look like yellow -red belts. This kind of polypus has a red-gray or dark red appearance, som etim es w ith a hem angiom atous aspect.
A m ong these three histological types there are som e transitional form s, according to the age of the lesion. If aging results in a corneal cover, the polypus is alw ays covered by a sm ooth and non-ulcerated m ucosa. The treatm ent is surgical, w ith easy rem oval after finding its insertion. I
C A S E R E P O R T
Tw o years ago, a 54-year-old m ale banker cam e to us w ith dysphonic com plaints that had begun one w eek before. O ne m onth prior to this, he had had dry coughing spells. There w as no vocal abuse, acute vocal traum a, or intense physical effort. H e did not sm oke, and drank occasionally.
Seven years earlier, at age 47, he had had diffuse, non-clived, large-cell m alignant lym phom a. A t the onset there w as high respiratory obstruction, due to a hard, volum inous, pediculated m ass on the left side of the hypopharynx. Its im plantation extended from the left tonsilar base to the hom olateral valecula. The tonsil and the m ass w ere subm itted to extirpation under general anesthesia, follow ed by chem otherapy for four m onths. There w as a com plete regression of the disease, and up until this present com plaint, the patient had been under oncological control.
U nder a direct larynx exam w ith a flexible optical fibroscopy, there w as a unilateral, pediculated sm ooth red lesion of the right vocal fold, m acroscopically typical of an angyom atous polyp (Fig. 1). The patient w as told that it w as a benign pathology, and w as treated w ith topical corticosteroid therapy w ith beclom etasone for seven days, in addition to an antihistam inic drug w ith anticough agent and decongestant. Since this w as not successful, surgical rem oval by m icrosurgery w as recom m ended. The patient refused surgery, explaining that he had already gone
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F ig u r e 1 - L a r y n x fib r o s c o p ic im a g e s h o w in g u n ila te r a l p e d ic u la te d le s io n o f th e r ig h t fo ld .
through a serious health problem , and preferred to live w ith this vocal polypus, as he did not use his voice professionally. H e w as reexam ined recently, tw o years after the vocal angyom a diagnosis, because of dry coughing com plaints. H e underw ent indirect laryngoscopy follow ed by larynx telescopy, using a rigid telescope 10 m illim eters in diam eter, M achida, m odel LY -C 30. There w as no lesion at vocal fold (Figs. 2 and 3). The patient reported a progressive decrease of dysphonia, during the follow ing year, and received phoniatric treatm ent and/or additional m edications during this period.
H IS T O L O G IC A L F IN D IN G S
M icroscopically, the vocal nodules have varying p~lttcrns depending on their evolutionary stage. but the
F ig u r e 2 - L a r y n x r ig id te le s c o p y u n d e r p h o n a tio n s h o w s n o le s io n s .
L O U R E N y O , E .A . & C O S T A , L .H .C . - A n g y o m a to u s v o c a l p o ly p u s
-A c o m p le te s p o n ta n e o u s r e g r e s s io n
1164
F ig u r e 3 - L a r y n x r ig id te le s c o p y u n d e r in s p ir a tio n s h o w s n o le s io n s .
m a in h isto lo g ic a l c h a n g e s o c c u r in th e c o riu m . T h e se a re
m u ltip le c h a n g e s, a n d th e p re d o m in a n c e o f sp e c ific
c h a n g e , p lu s th e a g e o f th e le sio n , e x p la in s e n d o sc o p ic
p o ly m o rp h ism . In th e e a rly sta g e s, th e y sh o w e d e m a a n d
p ro life ra tio n o f y o u n g fib ro b la sts.2
T h e c o n sta n t e d e m a m a y b e a c c o m p a n ie d b y fib rin
e x u d a tio n o r h e m o rrh a g e . In fla m m a to ry in filtra tio n m a y
so m e tim e s o c c u r, b u t re m a in s d isc re te .3
L a te r, d ila te d b lo o d v e sse ls a n d h y a lin iz a tio n o f th e
stro m a2 a n d m o re o r le ss m a rk e d fib ro sis a p p e a r.3 T h e
le sio n s th a t sh o w a n e x u b e ra n t v a sc u la r c o m p o n e n t a re
fre q u e n tly m ista k e n fo r h e m a n g io m a .2 S in c e th e se
a n o m a lie s a re la c u n a e ,'th e y m a y g iv e rise to th ro m b o sis.3
T h e h y a lin e sta g e w a s th e p re v io u sly d e sig n a te d " a m y lo id
tu m o r," a m isn o m e r, b e c a u se th e m a te ria l is h y a lin iz e d
c o lla g e n ra th e r th a n a m y lo id , a n d so m e tim e s a c c o m p a n ie d
b y a m y lo id d e p o sits.2
T h e e p ith e liu m is g e n e ra lly n o rm a l, o r so m e tim e s
th in n e d o r u lc e ra te d . In th e c o u rse o f d e v e lo p m e n t, th e
e p ith e liu m so m e tim e s b e c o m e s h y p e rp la stic , a n d m a y
sh o w a v a ria b le d e g re e o f a c a n th o sis a n d k e ra to sis. T h is
is w h y p a th o lo g ists o fte n c o n fu se p o ly p s a n d n o d u le s.3
A le sio n k n o w n a s p o ste rio r c o m m isu re u lc e r, o r
c o n ta c t (g ra n u lo m a to u s) u lc e r, is so m e tim e s e rro n e o u sly
th o u g h t to b e la ry n g e a l n o d u le , b u t a c tu a lly h a s a d iffe re n t
p re se n ta tio n , h isto lo g y a n d b e h a v io r. A s th e first n a m e
im p lie s, th e le sio n is a lm o st a lw a y s fo u n d a t th e le v e l o f
th e p o ste rio r c o m m issu re , in th e a re a o f th e v o c a l p ro c e ss
o f th e a ry te n o id c a rtila g e , a t a site w h e re th e a m o u n t o f
su b e p ith e lia l stro m a is le sse r. M ic ro sc o p ic a lly , it h a s th e
a p p e a ra n c e o f e x u b e ra n t g ra n u la tio n tissu e , a n d it is o fte n
c o n fu se d w ith p y o g e n ic g ra n u lo m a , b u t la c k s th e
c h a ra c te ristic lo b u la r p a tte rn o f th e la tte r. It stu b b o rn ly
re c u rs fo llo w in g lo c a l e x c isio n , b u t e v e n tu a lly su b sid e s.
C o n se rv a tiv e m a n a g e m e n t is re c o m m e n d e d .2
D IS C U S S IO N
T h e a n g y o m a to u s v o c a l p o ly p u s is a re la tiv e ly
c o m m o n le sio n in la ry n g o lo g ic a l p ra c tic e . Its d ia g n o sis
w a s m a d e e a sie r b y th e d e v e lo p m e n t o f fle x ib le a n d rig id
o p tic a l a p p a ra tu s, w h ic h h a v e n o t re p la c e d th e in d ire c t
la ry n g o sc o p y , b a sic , p a n o ra m ic a n d ro u tin e se m io lo g ic a l
e x a m . A fte r d ia g n o sis b y a n y m e th o d , th e u su a l
m a n a g e m e n t is m ic ro su rg e ry , a n d so m e a u th o rs h a v e
re c e n tly d e v e lo p e d n e w te c h n iq u e s fo r a m b u la to ria l
le sio n e x tirp a tio n w ith to p ic a l a n e sth e sia . T h e
b ib lio g ra p h y m a k e s re fe re n c e to a IS -y e a r-o ld p re g n a n t
p a tie n t w ith m u ltip le v a g in a l p o ly p s. T h e se le sio n s h a d
sp o n ta n e o u sly re g re sse d six w e e k s a fte r th e b irth , a n d
a lth o u g h b e n ig n , w e re m ic ro sc o p ic a lly m ista k e n fo r
b o try o id e s sa rc o m a .4
S u rp rise d b y th e sp o n ta n e o u s re g re ssio n o f th is
le sio n , w ith n o sim ila r b ib lio g ra p h ic c ita tio n s, th e a u th o rs
m a k e th is c o m m u n ic a tio n a n a le rt. A n g y o m a to u s v o c a l
p o ly p u s sp o n ta n e o u s re g re ssio n p o ssib ly o c c u rs w ith
g re a te r p ro b a b ility in n e w c a se s w ith n o p re v io u s v o c a l
fu n c tio n c o m p la in ts. M a c ro sc o p ic a lly b e n ig n le sio n s lik e
th is sh o u ld b e c a re fu lly o b se rv e d b e fo re su rg e ry is
re c o m m e n d e d , in o rd e r to a v o id u n n e c e ssa ry in te rv e n tio n s.
T h is is a su g g e ste d n e w ro u tin e in th e m a n a g e m e n t o f th e se
le sio n s.
C O N C L U S IO N
P h y sic ia n s sh o u ld b e a le rte d to th e fa c t th a t su rg ic a l
re c o m m e n d a tio n s m u st b e m o re a c c u ra te a n d c a u tio u s in
b e n ig n p a th o lo g ie s.
S a o P a u lo M e d ic a l J o u r n a l/R P M 1 1 4 ( 3 ) : 1 1 6 2 - 1 1 6 5 , 1 9 9 6
L O U R E N < ;O , E A . & C O S T A , L .H .C . - A n g y o m a to u s v o c a l p o ly p u s
1165
REFERENCES
1 . K le in sa sse r O . M ic ro la rin g o sc o p ia e m ic ro c iru rg ia d a la rin g e , 2 a e d . S a o P a u lo : E d . M a n o le , 1 9 7 7 :8 7 -9 5 .
2 . R o sa i, 1 . S u rg ic a l P a th o lo g y . 7 th e d . T h e C . V . M o sb y C o m p a n y , 1 9 8 9 ;(1 ):2 4 7 -8 .
3 . L e h m a n n W , P id o u x 1 M , W id m a n n 1 1 . L a ry n x M ic ro la ry n g o sc o p y a n d H isto p a th o lo g y . S w itz e rla n d : In p h a rz a m M e d ic a l P u b lic a tio n s, 1 9 8 1 ; 6 8 -9 . 4 . T o b o n H , M c In ty re -S e ltm a n K , R u b in o M . P o ly p o sis
v a g in a lis o f p re g n a n c y . A rc h P a th o l L a b M e d 1 9 8 9 ; 1 1 3 (1 2 ): 1 3 9 1 -3 .
L O U R E N v O , E A & C O S T A , L .H .C . - A n g y o m a to u s v o c a l p o ly p u s
-A c o m p le te s p o n ta n e o u s r e g r e s s io n
