Ectasia

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Vocal cord polyp with capillary ectasia, After speech therapy the vocal swelling has reduced in size. An ectasia remains., Surgical view of the dilated capillary ectasia on the left vocal cord., After excision vocal cord margins are straight.

Case study (multiple photos): A female elementary school music teacher in her 40s notes two years of loss of singing capabilities for five months after school starts. She has definate improvement over the summer when she uses her voice less. She has had problems with high soft singing for a longer period. She has voice fatigue. On a previous ENT exam, a physician told her that she had nodules and recommended Speech therapy. This did not help according to patient. Medical history Soprano 10 years vocal training tobacco - none alcohol - none caffeine - none Medications - muscle relaxants She reports average talkativeness: 4/7 and average loudness: 4/7 vocal commitments: 6 hours talking at work choir practice 3 hours per week choir perfomance 1 hour per week Vocal capabilities testing Reading voice: clear sounding Anchor pitch (F0) - F3# Low pitch - F3# High pitch - A5 pianissimo mucosal ceiling (onset delays and breathiness) - C5 onset delay, F5 loss of entrainment diplophonia - no Her Stroboscopic Examination of the larynx is pictured above: before, during and after surgery In the initial picture she has broad based swellings along both vibratory margins with a hemorrhage on left noted during open phase of strobe and an ectasia on right. The swellings are clear and translucent.


Summary:
Behavioral modification is the initial treatment of these mucosal lesions and is likely a lifelong treatment for this patient. It is seldom someone can change their personality but it is possible for someone to manage their behavior. She is a severely impaired singer, yet it is usually not the singing that is the problem. More often it is the amount of talking that goes on daily. She rates herself a 4 and 4 on the talkativeness and loudness scales, but does talk and sing extensively at school. This usage carries over into home life with choral practice and performance. Many times managing talkativeness will reduce a vocal fold swelling to an acceptable size such that the voice becomes dependable and acceptable to the patient, though the capillary ectasia on the vibratory margin makes this a difficult managment problem since that will likely swell with moderate usage or rupture intermittantly. Speech therapy was again tried and was very helpful in controlling the amount and style of vocal use yet failed to prevent repeated hemorrhage. After behavioral management, surgery was indicated since the patient desired further improvement. Surgery is directed at removing only the mucosal lesion and preserving as much of the intermediate and deep layers of the vocal fold as possible. With an appropriately delicate touch, these polyps were removed successfully. Lasering of the vessel on the vocal fold margin successfully removed these ectasias. She experienced a substantial improvement.