Understanding Vocal Fold Scarring

Key Glossary Terms

Vocal Fold Scar
Abnormal scar tissue in the vibrating layer of the vocal fold that causes voice problems

Lamina Propria
Vibrating component of the vocal folds that covers the vocal fold muscle or body; the lamina propria is composed of three layers: superficial, intermediate, and deep lamina propria

Mucosal Wave
Wave-like motion of the vibrating layer of the vocal fold as seen upon slow motion-like viewing through stroboscopy

Stroboscopy
Laryngoscopy with synchronized strobe light that provides a slow motion-like view of vocal fold vibration (mucosal wave); stroboscopy is the key tool used to analyze vocal fold vibration

Glossary

Vocal fold scar is scar tissue or "disorganized structure or scaffolding" in the vibrating layer of the vocal fold. Vocal fold scar results from the body's attempts to repair an injury – as would occur in the rest of the body – to the vocal fold. (For more information, see Anatomy & Physiology of Voice Production.)

Scarring can range from mild to severe, and can occur in one spot or along the full length of the vocal fold. The degree of scarring usually correlates with the degree of loss of ability to vibrate (viscoelasticity) – which then correlates with the degree of voice problems.

• Injury can result from "wear and tear" or stress on the vocal folds during:
  • Demanding voice use (by preachers, singers, teachers, etc.)
  • Voice use over time (aging)
  • Voice misuse (poor singing technique, forceful speaking)
  • Voice abuse (loud screaming)
• Injury can be worse in the presence of other vocal fold problems, such as reflux laryngitis.
• Scar tissue can also result from the repair process following surgery on the vocal folds.

Vocal fold scarring alters the pliability of the vocal folds, impeding their ability to vibrate as they become "stiffer."

• The special components (cells, proteins, matrix scaffolding) and organization of the lamina propria layers (superficial, intermediate, and deep) are all crucial in vocal fold vibration. Any changes in any of these components, in any combination, results in decreased pliability, thus altering vocal fold vibration.
• Vocal fold vibration is the key element of sound production during speaking and singing. Any changes in the vocal folds' ability to vibrate results in voice symptoms.
• Altered vocal fold vibration – depending on severity and extent – can cause a range of symptoms such as hoarseness, breathy voice, increased effort to speak, and voice fatigue.

• Vocal fold web: Also known as glottic web or laryngeal web
• Sulcus vocalis: A Latin term that literally means a groove, or sulcus, within the vocal fold.
  • In sulcus vocalis there is a loss of the superficial lamina propria along the medial edge of the vocal fold that makes contact during vocal fold vibration. This results in a linear furrow (depression) along the edge of the vocal fold.
  • This area of sulcus has poor vibratory ability and does not typically contribute to vocal fold closure.
  • The condition results in severe of hoarseness characterized by breathy, weak, and rough voice quality.
  • Sulcus vocalis can be either congenital or acquired. Acquired sulcus vocalis is thought to be much more common and occurs as a result of phonotrauma to the vocal folds (injury from voice misuse/abuse/overuse).
  • The symptoms and treatment options for sulcus vocalis are the same as they are for vocal fold scar. A relatively new but not widely accepted surgery, called "mucosal slicing technique," has been advocated for patients with severe sulcus vocalis. Its success, however, remains to be evaluated.

• Most severe postsurgical vocal fold scarring cases occur in patients who have had surgery for extensive disease of the vocal folds – cancerous or non-cancerous.
• When large, benign lesions such as vocal fold polyps, cysts or Reinke's edema are surgically treated, vocal fold scarring often occurs. This postoperative scarring is due to:
  • The extensive nature of the surgery required to remove the lesions
  • The presence of undetected scar tissue and fibrosis within the vocal fold that often coexists with other more obvious vocal fold lesion(s)
• About one to two percent of patients will develop significant vocal fold scarring following the smallest, most delicate, precise type of vocal fold surgery.
• CO2 laser surgery can cause vocal fold scarring due to the heat damage from the laser to the surrounding tissues of the vocal folds.
  • Not all laser surgery results in vocal fold scarring; the laser can be used in a very precise and safe fashion.
  • To minimize vocal fold scarring, the CO2 laser used must be of small spot size and well-maintained for optimal accuracy.
• Extensive or excessive vocal fold scarring can also occur from non-laser surgery of the vocal folds performed with poor surgical technique, for example "vocal cord / vocal fold stripping".
• Other complicating factors of voice surgery resulting in vocal fold scar can be premature or excessive early voice use that hinders the normal healing process following surgery. Strict patient compliance with postoperative instructions is extremely important to prevent vocal fold scarring following surgery.

Injury to the vocal folds may occur following the use of a breathing tube or from fractures or chemical injuries to the larynx. These injuries will invariably cause vocal fold scar tissue to form if unrecognized and not treated in a timely fashion.

Radiation therapy for cancer of the vocal folds typically results in some degree of vocal fold scarring and fibrosis. If there is a very large, extensive cancer, treatment with either radiation or surgery will result in moderate to severe vocal fold scarring.

Smoking, radiation therapy, diabetes, immune deficiency, and other systemic diseases can delay healing of laryngeal wounds and promote scar formation. These factors do not directly create a scar, rather they create irritation and/or negatively affect wound healing. Thus, normal healing does not occur, increasing the likelihood that scar tissue will form. All stages of wound healing must be optimized to prevent scar formation.

• Non-surgical injuries to the vocal folds can occur due to phonotrauma resulting from voice abuse/misuse/overuse. Injury can also occur from chronic coughing or frequent throat clearing.
• Phonotrauma can result from a variety of activities such as:
  • Singing when sick
  • Screaming or yelling
  • Talking above background noise
  • Singing out of range
  • Changing singing style

Key Information

"Singing Sick"
Anecdotally, voice physicians have observed that many vocal fold injuries occur when singers sing while their vocal folds are swollen during an infection, such as an upper respiratory infection or a cold. This is often referred to as "singing sick." Most voice care professionals recommend minimal to no voice use when there is an upper respiratory infection that affects the voice.

Inflammation of the vocal folds due to exposure to stomach fluids can delay the normal healing process, resulting in vocal fold scarring. The presence of reflux laryngitis is also suspected to aggravate vocal fold scarring from phonotrauma.

Systemic diseases (e.g., sarcoidosis, amyloidosis, tuberculosis, Wegener's disease) can affect the larynx and vocal folds, causing lesions that result in scarring and subsequent loss of vocal fold mucosal wave.

Vocal fold scarring may be congenital (birth defect). In this situation, a child is born with a severely hoarse voice from congenital scarring or vocal fold abnormality.

Key Information

Vocal Fold Scarring Can Occur in Anyone

Vocal fold scarring can occur in children as well as adults and in men as well as women. The exact incidence is unknown, partly due to a difficulty in diagnosis. In addition, many patients may have a vocal fold scar that is not clinically significant.

Demands on Voice Often Determine Medical Consultation

The gravity of the voice problem due to vocal fold scarring is related to an individual's vocal demands and extent of the scarring. A minor degree of scarring might not affect the average individual to the point where evaluation and medical care are sought; the same degree of scarring might, however, be completely disabling to a professional singer.

Symptoms Similar to Other Voice Disorders

The symptoms associated with vocal fold scarring are similar to those of other voice disorders. Therefore, medical evaluation is imperative when symptoms of a voice disorder occur.