Bamboo node: primary vocal fold lesion as evidence of autoimmune disease

Mechanisms and management of cough in interstitial lung disease

INTRODUCTION

Many patients with interstitial lung diseases (ILDs), especially fibrotic ILDs, experience chronic cough. It negatively impacts both physical and psychological well-being. Effective treatment options are limited.

AREAS COVERED

The pathophysiology of chronic cough in IPF is complex and involves multiple mechanisms, including mechanical distortion of airways, parenchyma, and nerve fibers. The pathophysiology of cough in other fibrosing ILDs is poorly understood and involves various pathways. The purpose of this review is to highlight mechanisms of chronic cough and to present therapeutic evidence for its management in the most commonly occurring diffuse fibrosing lung diseases including idiopathic pulmonary fibrosis (IPF), connective tissue disease-related interstitial lung disease (CTD-ILD), sarcoidosis-related ILD (Sc-ILD), chronic hypersensitivity pneumonitis-related ILD (CHP-ILD), and post-COVID-19-related interstitial lung disease (PC-ILD).

EXPERT OPINION

This review guides the management of chronic cough in fibrosing ILDs. In this era of precision medicine, chronic cough management should be individualized in each interstitial lung disease.

Autoimmune Associated Vocal Fold Lesions: A Systematic Review

OBJECTIVE

While Autoimmune Associated Vocal Fold Lesions (AaVFLs) have been described in many reports, there is no consensus on best practices in management. The purpose of this systematic review is to clarify the characteristics and treatment of dysphonia in the setting of AaVFLs.

STUDY DESIGN

Systematic review METHODS: Pubmed and OVIDMedline and Google Scholar were searched, including terms related to (1) Vocal fold/cord, rheumatoid node/nodule, bamboo nodes/nodules, laryngeal deposits/nodes/nodules and (2) Autoimmune diseases/syndromes, connective tissue disease.

RESULTS

Twenty-one studies with 83 patients diagnosed with AaVFLs were included. AaVFLs occurred predominantly in females in the 4th or 5th decade of life, with an overall mean age of 39.8 (SD = 12.8). Autoimmune or connective tissue disease was established prior to presentation to an otolaryngologist in 75.9% (44/58) of patients. Bilateral lesions were present in 83.8% (57/68) of patients. Treatment modalities included medical therapy alone (28.1%), voice therapy alone (17.5%), surgical treatment alone (7.0%), combination of medical and voice therapy (33.3%), and combination of surgical, medical and voice therapy (7.0%). All patients treated with voice therapy had voice improvement; lower rates were seen with solo medical (4/14 improved, 28.6%) or surgical therapy (3/6 improved, 50%).

CONCLUSION

AaVFLs occur predominantly in women in their 30's to 50's and are associated with a variety of autoimmune conditions. A significant number of patients (25%) present to the Otolaryngologist without an established autoimmune diagnosis. While treatment outcomes are not robustly reported, a significant number of patients with AAVFLs treated with voice therapy alone or voice therapy in combination with other treatment modalities (medical or surgical) experience subjective improvement in voice quality and function.

Rare Diseases of Larynx, Trachea and Thyroid

This review article covers data on rare diseases of the larynx, the trachea and the thyroid. In particular, congenital malformations, rare manifestations of inflammatory laryngeal disorders, benign and malignant epithelial as well as non-epithelial tumors, laryngeal and tracheal manifestations of general diseases and, finally, thyroid disorders are discussed. The individual chapters contain an overview of the data situation in the literature, the clinical appearance of each disorder, important key points for diagnosis and therapy and a statement on the prognosis of the disease. Finally, the authors indicate on study registers and self-help groups.

Bamboo Nodes as an Autoimmune Disease Laryngeal Manifestation. Case Series

INTRODUCTION

Bamboo nodes are transverse creamy-yellow subepithelial nodes in the vocal folds (VF) midpoint, usually bilateral, resembling a bamboo stem. They appear almost exclusively in females, and are associated with underlying autoimmune diseases.

CASE SUMMARY

Six female patients, 45.5 years median age, with underlying autoimmune diseases, consulted due to dysphonia. The laryngeal stroboscopy showed bilateral VF bamboo nodes in four patients, and unilateral in the remaining two. VF mobility was normal in all patients, while the mucosal wave was impaired in four of them. Treatment with speech therapy and proton pump inhibitors was indicated. All the patients were referred for rheumatologic evaluation and immunosuppressive treatment optimization. Follow-up in five patients showed vocal function self-perception and GRBAS scores improvement.

DISCUSSION

VF bamboo nodes are an infrequent cause for dysphonia, associated with phonotrauma and autoimmune diseases. Speech therapy and a rheumatologic workup must be indicated, for immunosuppressive treatment enhancement.

Effects of Rheumatoid Arthritis on the Larynx

Introduction:

The aim of the present study was to compare the videolaryngostroboscopic findings between patients with rheumatoid arthritis and vocally healthy controls.

Materials and Methods:

This case-control descriptive study was performed on 113 people, including 50 patients with rheumatoid arthritis and 63 controls. The participants were subjected to videolaryngostroboscopic examinations in order to evaluate fundamental frequency, different structural vocal lesions, patterns of glottal closure, subglottal changes, supraglottis appearance, and movement patterns of the arytenoid cartilage. The obtained results were compared between the two research groups. Data analysis was performed in the Statistical Package for the Social Sciences, version 24.0. A p-value less than 0.05 was considered statistically significant.

Results:

The results revealed a statistically significant difference between the two groups in terms of the complete pattern (P=0.00) and strained state of glottal closure (P=0.00), pattern of subglottal changes (χ²=25.98, df=2; P<0.001), and movement patterns of the arytenoid (χ²=21.16, df=1; P<0.001). Additionally, based on the obtained frequencies, the two groups showed significant differences regarding the normal state of the larynx (P=0.00), hypertrophy of vocal fold (P=0.007), epithelial change (P=0.007), and Reinke's edema (P=0.001). However, the videolaryngostroboscopic examination results revealed no significant difference between the two groups in terms of polyp (P=0.20), nodule (P=0.57), sulcus vocalis (P=0.08), cyst (P=0.45), and atrophy of vocal folds (P=0.45).

Conclusion:

It seems that rheumatoid arthritis affects the patterns of arytenoids movement, some kinds of glottal closure patterns, and subglottal changes. As the results indicated, the occurrence of some laryngeal structural changes was higher in patients with rheumatoid arthritis than in individuals without this disorder.

The involvement of vocal cords in rheumatoid arthritis: a clinical case

Rheumatoid arthritis rarely involves the cricoarytenoid joint, symptoms of varying severity ranging from foreign body sensation, fullness or tension in the throat, hoarseness, odynophagia, speech or cough pain to stridor and respiratory distress during bilateral paralysis of the vocal cords. We are reporting a case of rheumatoid arthritis with bilateral involvement of the vocal cords. The diagnosis was clinically made and confirmed by endolaryngoscopy, responding to antirheumatic treatment but coming to the stage of permanent tracheotomy.

Unilateral bamboo node of the vocal fold associated with anti-SS-A and anti-SS-B antibody

Voice disorder is occasionally associated with systemic autoimmune diseases. Bamboo nodes of the vocal fold have a characteristic bamboo-shaped appearance and strongly indicate the presence of an underlying autoimmune disorder. Both mechanical and immunologic mechanisms are assumed to be involved in the pathogenesis of vocal disorder. We present a 27-year-old woman with hoarseness, sore throat, and a unilateral bamboo node of the vocal fold. Serum anti-SS-A and -SS-B antibodies were positive, but she had no systemic signs or symptoms suggestive of Sjögren's syndrome. Oral systemic glucocorticoid treatment was not effective, but surgical resection improved her hoarseness. Histopathologic findings of the resected vocal node revealed fibrosis with hyaline degeneration. Thereafter, she had no recurrence of hoarseness for 2 years. Bamboo nodes of the vocal fold may occur without definitive autoimmune diseases, although immunologic abnormalities such as autoantibody-positivity may occur.

Epidemiology of Swallowing Disorders in Rheumatoid Arthritis: Prevalence, Risk Factors, and Quality of Life Burden

Objective:

This investigation examined the prevalence, symptoms, risk factors, and quality-of-life burden of swallowing disorders in rheumatoid arthritis (RA), a chronic, progressive autoimmune inflammatory disease.

Methods:

One hundred individuals with RA (84 women, 16 men; mean age = 61.1 years, SD = 13.1) were interviewed regarding the presence, nature, and impact of swallowing symptoms and disorders. Associations between swallowing disorders, medical factors, RA disease severity, and quality of life were examined.

Results:

Forty-one percent of participants reported a current swallowing disorder that began gradually and was longstanding (most experiencing symptoms on a daily basis for at least 4 years). Symptoms compatible with solid food dysphagia contributed disproportionately to reporting a current swallowing disorder. Risk factors for dysphagia included a self-reported voice disorder, thyroid problems, esophageal reflux, and being physically inactive. Swallowing disorders increased with self-reported RA disease severity and contributed to a significantly greater burden on overall quality of life.

Conclusion:

Chronic, longstanding swallowing disorders are common in individuals with RA and appear to increase with disease severity. Those individuals with dysphagia reported greater reductions in quality of life as compared to those without, highlighting the need for improved awareness, exploration, and management of swallowing disorders in this population.

Bamboo Nodes of Vocal Folds: A Description of 10 Cases and Review of the Literature

OBJECTIVE

Bamboo nodes are vocal fold lesions, mostly associated with autoimmune diseases.

PATIENTS AND METHODS

This is a retrospective clinical study including 10 patients with bamboo nodes. Data were collected regarding associated autoimmune disorder and type of treatment. A systematic review of the literature was conducted.

RESULTS

All patients were women, with hoarseness as the most frequent symptom. There was in most cases an associated autoimmune disease: 3 patients with systemic lupus erythematosus; 3 with rheumatoid arthritis; 1 with Sjögren syndrome; 1 with Hashimoto disease; and 1 with mixed connective tissue disease. Four patients were treated with speech therapy, 3 with oral steroids, 1 with speech therapy and oral steroids combined, 1 with oral steroids and laryngeal steroid injections, and 1 had oral steroids, surgery, and speech therapy. Speech therapy was the first-line treatment.

CONCLUSION

Bamboo nodes should be looked for in every patient with a diagnosis of autoimmune disease complaining of dysphonia.

The prevalence of dysphonia and dysphagia in patients affected by immunomediated diseases and the role of psychometric tests

This cross-sectional investigation examined the prevalence and severity of dysphonia, globus pharyngeus, and dysphagia in patients affected by immunomediated (IM) diseases. Seventy subjects were administered the Voice Handicap Index (VHI) (scale 0-4), Glasgow-Edinburgh Throat Scale (GETS) (scale from 0 to 7) for globus pharyngeus assessment, and modified Swallowing Outcomes After Revised Laryngectomy (SOAL) (scale 0, 1, 2) to test swallowing symptoms. VHI: the mean percentage of answers with a score greater than 1 (corresponding to a frequency of situation's occurrence "sometimes," "almost always," or "always") was 25.7, 26.7, and 44.1% for functional, emotional, and physical groups of sub-items respectively. GETS: the mean percentage of answers with a score ≥ 3 was 60.85%, significantly higher if compared with that of answers with a score < 3 (40.14%). The mean percentages of answers with a score 0-2, 3-4, and 5-7 were 40.1, 16.7, and 43.7% respectively. SOAL: a mean of 57.9% of answers gained a symptomatic score (1 ["a little"] or 2 ["a lot"]) and 41.9%, the score 0. The difference was statistically significant (p < 0.05). The first two most recurrent items with a score 2 ("a lot") were "Do you have a problem swallowing dry food?" (46%) and "Do you have a problem swallowing solid food?" (36%). The study represents the first to describe the globus pharyngeus symptoms in IM population. Moreover, it allows to confirm the recurrence of dysphonia and dysphagia in this type of patients. Particularly, it has been demonstrated that the alteration of swallowing function is related to solid and dry food. The self-assessment questionnaires proved as a useful tool to early detection of dysfunctions in order to avoid further deterioration of quality of life and to prevent serious life-threatening complications.

The Voice of Autoimmunity: Antisynthetase Syndrome Manifesting as Vocal Fold Bamboo Nodes

OBJECTIVES

To describe a case of vocal fold bamboo nodes leading to the diagnosis of antisynthetase syndrome, a rare autoimmune disorder. To highlight the link between these laryngeal lesions and autoimmunity.

METHODS

A case of vocal fold bamboo nodes in a patient with long-standing interstitial lung disease is presented. The presence of these characteristic lesions prompted a rheumatologic workup that led to the diagnosis of a rare autoimmune disorder.

RESULTS

The patient was ultimately diagnosed with antisynthetase syndrome, a rare condition characterized by inflammatory myositis and interstitial lung disease. She was treated with steroids and immunosuppressive agents with improvement in her symptoms and clinical findings.

CONCLUSIONS

Vocal fold bamboo nodes are pathognomonic signs of autoimmunity. Management consists primarily of medical treatment of the underlying systemic disorder. Intralesional steroid injection or phonomicrosurgical excision may be considered for refractory cases.

[The autoimmune rheumatic disease and laryngeal pathology]

Vocal disorders make up one of the autoimmune pathological conditions characterized by multiple organ system dysfunction. Laryngeal pathology in this condition has an autoimmune nature; it is highly diverse and poorly explored. The objective of the present work based on the analysis of the relevant literature publications was to study clinical manifestations of the autoimmune rheumatic disease affecting the larynx. 'Bamboo nodes' on the vocal folds is a rare manifestation of laryngeal autoimmune diseases. We found out references to 49 cases of this condition in the available literature. All the patients were women presenting with autoimmune diseases. The present review highlights the problems pertaining to etiology of 'bamboo nodes' on the vocal folds and the method for the treatment of this condition.

Preliminary Evaluation of Stroboscopy System Using Multiple Light Sources for Observation of Pathological Vocal Fold Oscillatory Pattern

Objectives:

Laryngostroboscopy is used to check the oscillatory patterns of the vocal folds. However, the use of one single flash timing cannot give a clear view of abnormal vocal fold oscillations that have multiple fundamental frequencies. Visualization of such complex vocal fold movements will be helpful in the diagnosis of diplophonia, a pathological condition in which the vocal folds produce multiple tones at the same time.

Methods:

We developed a new stroboscopy-based technique using multiple light-emitting diodes (LEDs) and image analysis. Specific flash timings for each LED, suitable for accurate visualization, were determined on a computer according to an algorithm based on frequency analysis. The image analysis extracted the necessary parts of the captured images to yield a clear slow-motion view of the oscillations. The series of visualization procedures took advantage of the narrow-spectrum light property of LEDs, thereby yielding a degradation-free picture.

Results:

Feasibility tests using a mechanical vocal fold model demonstrated that this computer-assisted system allows observation of the pathological oscillatory patterns as one single video. They would not be clearly visualized by conventional stroboscopy.

Conclusions:

Because of its relatively simple use and inexpensive construction, the proposed technique can become one potential option for clinical assessment of pathological vocal fold oscillations.

Parameters of the assessment of voice quality and clinical manifestation of rheumatoid arthritis

PURPOSE

The aim of the study was to investigate the voice quality parameters in 72 rheumatoid arthritis (RA) patients and their relationships with the clinical manifestations and disease activity. The control group consisted of 30 healthy subjects.

MATERIAL AND METHODS

All RA patients were evaluated by extensive clinical, laboratory and radiographic studies. The phoniatric assessment included the analysis of vocal folds vibrations by digital stroboscopy (DS) of the larynx using HRES ENDOCAM 5562 system, digital kymography (DKG) and High-Speed Digital Imaging (HSDI) technique. The acoustic voice analysis was conducted using DiagnoScope Specialist program.

RESULTS

Voice quality disorders were registered in 32 (44.44%) RA patients and observed more frequently in patients with moderate and severe activity (DAS28≥3.2) than in mild RA. In digital stroboscopy, confirmed by digital kymography, the hypofunctional dysphonia was observed especially in patients with DAS28≥3.2. Outcomes of the subjective assessment of voice quality were in accordance with the objective parameters and acoustic voice examination.

CONCLUSIONS

In RA patients the most frequent voice quality disorders with hypofunctional dysphonia were registered. The relationships between voice quality disorders, clinical activity and radiographic progression of RA patients were observed. Digital stroboscopy, digital kymography, High-Speed Digital Imaging and acoustic voice analysis used in the complex diagnosis of RA confirmed the presence of pathological changes in the larynx. There is a need of cooperation between rheumatologists and phoniatricians in the diagnosis and treatment of dysphonia in RA patients.

Descriptive Epidemiology of Voice Disorders in Rheumatoid Arthritis: Prevalence, Risk Factors, and Quality of Life Burden

OBJECTIVES

Rheumatoid arthritis (RA) is an autoimmune inflammatory disease which may adversely affect phonatory function. This study aimed to establish the prevalence, risks, and quality of life effects of voice disorders in RA.

STUDY DESIGN

This is a cross-sectional, descriptive epidemiology study.

METHODS

One hundred individuals with RA underwent a telephone interview to determine the frequency, severity, risks associated with, and quality of life burden of voice disorders. The results were analyzed using summary statistics, frequencies, chi-square tests, regression analysis, and risk ratios (P < 0.05).

RESULTS

Thirty-five percent of participants with RA reported a current voice disorder which was chronic and long-standing in most cases. The prevalence of a current voice disorder did not significantly differ across age, sex, medication use, voice use patterns, medical history, or RA severity. These chronic voice disorders produced significant adverse effects on both voice-related quality of life and short form 36 health-related quality of life scales. Specific voice symptoms such as "voice-related discomfort" and "chronic throat dryness" contributed disproportionately to the quality of life burden. Of those participants with a voice disorder, only 37% had ever sought professional help to improve their voice.

CONCLUSIONS

These results indicate that voice disorders are common in RA and produce significant adverse effects on quality of life. Further research is necessary to better understand the origin of these disorders and their potential response to treatment.

Voice, Speech, and Laryngeal Features of Primary Sjögren’s Syndrome

Objective:

This study examined voice, speech, and laryngeal characteristics in primary Sjögren’s syndrome (pSS).

Methods:

Eleven patients (10 female, 1 male; mean [SD] age = 57 [14] years) from The University of Utah Division of Rheumatology provided connected speech and sustained vowel samples. Analyses included the Multi-Dimensional Voice Profile, the Analysis of Dysphonia in Speech and Voice, and dysphonia severity, speech clarity, and videolaryngostroboscopy ratings.

Results:

Shimmer, amplitude perturbation quotient, and average fundamental frequency differed significantly from normative values ( P < .01). Cepstral Spectral Index of Dysphonia values indicated mild-to-moderate dysphonia in connected speech (mean [SD] = 20.26 [8.36]) and sustained vowels (mean [SD] = 16.91 [11.08]). Ratings of dysphonia severity and speech clarity using 10-cm visual analog scales suggested mild-to-moderate dysphonia in connected speech (mean [SD] = 2.11 [1.72]) and sustained vowels (mean [SD] = 3.13 [2.20]) and mildly reduced speech clarity (mean [SD] = 1.46 [1.36]). Videolaryngostroboscopic ratings indicated mild-to-moderate dryness and mild reductions in overall laryngeal function. Voice Handicap Index scores indicated mild-to-moderate voice symptoms (mean [SD] = 43 [23]).

Conclusion:

Individuals with pSS may experience dysphonia and articulatory imprecision, typically in the mild-to-moderate range. These findings have implications for diagnostic and referral practices in pSS.

Glucocorticoids in laryngology: a review

OBJECTIVES/HYPOTHESIS

To provide the otolaryngologist an evidence-based sound review of glucocorticoid use for laryngeal pathology.

STUDY DESIGN

Review of contemporary peer-reviewed literature as well as review articles.

METHODS

A review of the literature regarding glucocorticoids as a therapeutic intervention for the treatment of benign laryngeal pathology and laryngeal manifestations of systemic disease was performed. Review included both systemic administration as well as local injection.

RESULTS

Glucocorticoids, administered in the critical care setting for planned extubation, markedly reducing the risk of reintubation and remain a rudimentary pharmacologic adjunct in laryngeal manifestations of common autoimmune and inflammatory disorders. Intralesional injection has reduced the rate of surgical intervention for benign inflammatory primary laryngeal pathology.

CONCLUSIONS

Glucocorticoids are effective in the treatment of a number of laryngeal pathologies, through both systemic and intralesional administration. However, a clear consensus for utilization of glucocorticoids in the treatment of specific laryngeal disorders has yet to be published.

Laryngeal Involvement in Connective Tissue Disorders. Is it Important for Patient Management?

Connective tissue disorders (CTDs) involve multiple organ systems and may have a significant impact on the overall health and quality of life of the affected individuals. The present paper aims to review the current knowledge on the laryngeal manifestations of CDTs, and describe the available diagnostic and treatment options. Systematic literature review in Medline and other database sources. Information from related books was also included. Prospective controlled, double-blind prospective, prospective, and transversal cohort studies, case series, case reports, systematic reviews, and consensus papers. Laryngeal involvement mostly occurs in rheumatoid arthritis (13-75% of patients). It is not uncommon in active and progressive clinical course, though can also occur in silent or inactive CDTs. The crico-arytenoid joint is the most commonly affected site. Common symptoms include throat pain, dyphonia and hoarseness. Careful clinical assessment of the larynx by flexible naso-endoscopy, video-stroboscopy, or direct laryngoscopy, and appropriate imaging are required for pertinent patient management. Stridor is a sign of a life-threatening condition, and may require prompt surgical intervention. However, mild symptomatology may mislead clinicians, and the related diagnosis may be significantly delayed. The current evidence as identified in the present study suggest that laryngeal manifestations of CDTs are often underdiagnosed, due to a range of non- specific symptoms. A multidisciplinary team approach with ENT input is necessary to improve the overall patient management.

Glottic bamboo nodules from systemic lupus erythematosus

Bamboo nodules of the glottis are of late being described as a distinct entity seen in patients with autoimmune diseases. We report the symptoms, clinical features, and management of a case of bamboo nodules of the glottis in a patient with systemic lupus erythematosus. We discuss the pathogenesis and management of this condition on the basis of a review of the medical literature.

Diagnostic and therapeutic pitfalls in benign vocal fold diseases

More than half of patients presenting with hoarseness show benign vocal fold changes. The clinician should be familiar with the anatomy, physiology and functional aspects of voice disorders and also the modern diagnostic and therapeutic possibilities in order to ensure an optimal and patient specific management. This review article focuses on the diagnostic and therapeutic limitations and difficulties of treatment of benign vocal fold tumors, the management and prevention of scarred vocal folds and the issue of unilateral vocal fold paresis.

Pulmonary manifestations of Sjögren's syndrome

Sjögren's syndrome (SS) is primarily defined by its impact on the oral and ocular system resulting in xerostomia and xerophthalmia. However, SS can also manifest throughout the respiratory system. Subclinical pulmonary involvement is common. Clinically significant involvement can result in a 4-fold increased risk of death. Thus, recognizing the many potential presentations of SS in the lung is critical in caring for patients with SS. Additionally, SS should be included in the differential diagnosis of a number of forms of interstitial lung disease.

Laryngeal assessment by videolaryngostroboscopy in patients with rheumatoid arthritis

AIM

To evaluate the larynx involvement in patients with rheumatoid arthritis (RA) in a clinical setting and correlate with the different clinical features related to more aggressive disease.

METHODS

Cross-sectional study including 36 consecutive patients with RA. Reflux symptoms were evaluated by the Reflux Symptom Index (RSI) and vocal cord impairment by the Voice Handicap Index-10 (VHI-10). Laryngeal involvement was done by videolaryngostroboscopy (VLS).

RESULTS

The mean age was 56,3 ± 14 years with a mean disease duration of 2,6 ± 3,1 years (range 0-16 years). Voice use was considered as professional users in 33%. Twenty-four (67%) out of 36 patients had abnormal findings of VLS. One patient had larynx nodules (bamboo nodules). Eleven patients (31%) were diagnosed with muscle tension dysphonia, and there were symptoms and signs of pharyngeal-laryngeal reflux in 23 (64%) patients. No signs of cricoarytenoid joint impairment was found.

CONCLUSIONS

Organic larynx involvement was uncommon in patients with RA. However symptoms and signs of pharyngeal-laryngeal reflux were seen in around 60% of patients. There was no correlation between the clinical phenotype, severity of disease, immunological profile or treatment with VLS findings.

Laryngeal manifestations of rheumatoid arthritis

Rheumatoid arthritis is a destructive autoimmune disease that affects 3% of the adult population. It is characterized by the formation of both articular and extra-articular lesions with predilection for small joints. There are ubiquitous reports on the head and neck manifestations of RA with emphasis on the larynx. The laryngeal presenting features of this systemic disease may mimic a plethora of medical conditions, inflammatory and neoplastic. The main phonatory and respiratory symptoms are often subtle and misleading. This paper represents a literature review of the laryngeal manifestations of RA with emphasis on the clinical symptoms, laryngeal findings, diagnosis, and treatment. An early diagnosis of laryngeal involvement may prevent drastic complications.

HYDRATION RECOVERY OF CANINE THYROARYTENOID MUSCLE TISSUE AFTER VARYING LEVELS OF DEHYDRATION

We observed and calculated the solid and liquid volumes and mass parameters of canine vocal fold thyroarytenoid (TA) muscle at tissue dehydration levels of 30% and 70% followed by a complete rehydration to examine the effects of hydration recovery with respect to biphasic properties of the TA muscle in relation to the vocal fold lamina propria. Twenty samples of TA muscle were harvested from 10 canine larynges. Each sample group was subjected to either 30% or 70% dehydration. Following dehydration, the samples rehydrated until the tissue mass stabilized. The solid volume and mass fraction, liquid volume and mass fraction, liquid–solid volume and mass ratios, and degree of hydration recovery were calculated. Median liquid–solid volume ratios were significantly different between the 30% and 70% groups after rehydration and between the medians of 30% and 70% liquid–solid mass ratios after rehydration. The means of solid mass fraction, liquid mass fraction, solid volume fraction, and liquid volume fraction all displayed statistically significant differences. Irreversible tissue damage undergone via severe dehydration of the TA muscle indicates the anatomical and physiological similarity between the TA muscle and the lamina propria. The results imply the significance of the biphasic theory in the construction of biomechanical models.

Bamboo nodes associated with mixed connective tissue disease as a cause of hoarseness

Vocal fold lesions related to autoimmune diseases are rheumatoid nodules and, to a lesser extent, bamboo nodes. Mostly transverse, they are located in the middle third of the vocal cord and exhibit a yellowish appearance. The characteristic shape of these lesions led to their name. These vocal fold deposits may interfere with the normal vibratory cycle during phonation and thus may be an unusual cause of hoarseness. We present a 43-year-old woman with known mixed connective tissue disease and a dysphonia. Laryngostroboscopy showed bamboo nodes as described above. We applied several laryngeal injections of cortisone as described previously in the literature. Since this treatment did not lead to a sufficient voice improvement, we attempted to surgically remove the deposits. After the surgery, the voice improved considerably. In all patients with rheumatic diseases who suffer from a rough, breathy, or unstable voice, a laryngostroboscopic examination should be done. If, however, a bamboo node lesion of the vocal folds is found by the laryngologists, an associated autoimmune disorder must be assumed, and adequate diagnostic procedures have to be initiated. Local laryngeal injections (1–3 times) with steroids should be the first line of therapy. In unsuccessful cases, subsequent surgery can be a useful treatment of bamboo nodes to stabilize and improve voice quality.

Cause of vocal fold scar

PURPOSE OF REVIEW

The prolonged debilitation, loss of income, and decrement in quality of life caused by vocal fold scar is exacerbated by our inability to successfully treat this difficult problem. As technology focuses on developing innovative treatments, we need to fully appreciate and understand the mechanisms giving rise to glottal scar, on both a macroscopic and microscopic level. This review examines recent literature pertaining to the gross and molecular mechanisms which give rise to vocal fold scar.

RECENT FINDINGS

Mechanisms of vocal fold scar production have been examined in both macroscopic and microscopic detail. Trauma and injury involving any aspect of the lamina propria, particularly the deeper layers, may result in epithelial tethering and scar formation. At the molecular level, early inflammatory cytokines activate and recruit fibroblasts which then drive the fibrotic cascade. Transforming growth factor-β enhances fibrosis and is balanced by tissue matrix metalloproteinases and hepatocyte growth factor activity. Molecular signaling offers novel opportunities to intervene in scar formation.

SUMMARY

New work investigating the cause of vocal fold scar identifies complex molecular processes leading to fibrosis in the lamina propria. Improved mechanistic understanding offers insight into prevention strategies and possible targets for antifibrotic therapies that may help prevent or treat this debilitating condition.

Laryngeal involvement in juvenile idiopathic arthritis patients

Juvenile idiopathic arthritis (JIA) is an autoimmune diseases characterized by chronic arthritis and systemic manifestations. Autoimmune diseases can affect the upper airways including the larynx. The aim of this study was to investigate laryngeal involvement in JIA patients and its possible association with JIA disease parameters. Fifty consecutive JIA patients were screened for laryngeal abnormalities using flexible fiberoptic laryngoscope and laryngeal computerized tomography. Laryngeal abnormalities were detected in nine (18%) of our cases, with cricoarytenoiditis in six cases (12%) and a rheumatoid nodule in the pyriform fossa in only one case (2%). Diffuse congestion and edema of the posterior part of the larynx with normal vocal cord mobility was detected in two cases (4%). In our study, laryngeal abnormalities were significantly higher in patients with polyarticular seropositive disease subtype and also were significantly higher in patients with longer disease duration, higher disease activity scores, and those with erosive disease. JIA may affect the larynx. Laryngeal involvement in JIA patients is more in polyarticular seropositive cases. JIA patients have to be subjected to thorough otolaryngologic examination for early diagnosis and prompt management.

Hoarseness Due to Bamboo Nodes in Patients with Autoimmune Diseases: A Review of Literature

SUMMARY

This is a retrospective report on clinical features, laryngoscopic examinations, and follow-up markers of laryngeal manifestation described as bamboo nodes in three female patients with transverse cystic lesions of the vocal folds, treated with logopedic therapy. This study examines logopedic and phoniatric aspects in patients with submucosal "bamboo joint-like nodes" of both vocal folds, and reveals an improvement of different voice quality features after conservative traditional voice therapy. There still exists no standard treatment regimen in patients with rheumatoid disease of the larynx; a lack of consensus is most evident in the role of voice therapy. We would like to emphasize the favorable impact of logopedic therapy in benign laryngeal disorders with underlying autoimmune diseases.

Common Diagnoses and Treatments in Professional Voice Users

Common problems among all patients seen by the laryngologist are also common among professional voice users. These include laryngopharyngeal reflux, muscle tension dysphonia, fibrovascular vocal fold lesions (eg, nodules and polyps), cysts, vocal fold scarring, changes in vocal fold mobility, and age-related changes. Microvascular lesions and their associated sequelae of vocal fold hemorrhage and laryngitis due to voice overuse are more common among professional voice users. Much more common among professional voice users is the negative impact that voice problems have on their ability to work, on their overall sense of well-being, and sometimes on their very sense of self. This article reviews the diagnosis and treatment options for these and other problems among professional voice users, describing the relevant roles of medical treatment, voice therapy, and surgery. The common scenario of multiple concomitant entities contributing to a symptom complex is underscored. Emphasis is placed on gaining insight into the "whole" patient so that individualized management plans can be developed. Videos of select diagnoses accompany this content online.

[Bamboo nodes as the cause of dysphonias in autoimmune diseases]

BACKGROUND

In rare cases, dysphonia can be caused by vocal fold deposits called "bamboo nodes." They often feature a transverse yellowish appearance of the middle third of the vocal cord, resembling a bamboo node. Typical histologic signs are similar to rheumatoid nodules.

CASE REPORT

We report on a 43-year-old woman with known Sharp syndrome and dysphonia. Laryngoscopy showed transverse deposits on both vocal folds. The diagnosis of bamboo nodes was made and treatment initiated.

DISCUSSION/CONCLUSION

Laryngeal deposits should be suspected and a thorough laryngostroboscopic examination carried out whenever a patient with an autoimmune disease presents with a rough and unstable voice. Because the patients may have hoarseness as their primary symptom, it is important for otolaryngologists to be familiar with this disorder. Further autoimmune investigation should be established. A combination of local laryngeal therapy with steroids and subsequent surgery seems to be a useful treatment approach for bamboo nodes. To our knowledge this is the first description of a patient with Sharp syndrome and bamboo nodes.

Prevalence and relative risk of dysphonia in rheumatoid arthritis

SUMMARY

Laryngeal involvement in rheumatoid arthritis is not uncommon and may include cricoarytenoid arthritis or vocal fold lesions such as vocal fold rheumatoid nodules or bamboo nodes. Dysphonia or voicing problems can be the result of such laryngeal involvement. This cohort study investigates the prevalence and the relative risk of dysphonia when suffering from rheumatoid arthritis compared to that of healthy subjects. One hundred and sixty-six subjects with rheumatic arthritis and 148 healthy control subjects completed two quality-of-life questionnaires: the Voice Handicap Index and a three-item outcome scale. Both instruments measure the quality of the voice itself and the extent of impairment resulting from dysphonia as experienced by the patient in social and occupational settings. Patients proved to have statistically significant higher prevalence and relative risk of dysphonia. Depending on the questionnaire being used, prevalence data of dysphonia in patients varied between 12% and 27%, whereas the healthy subjects showed prevalence data varying from about 3% to 8%. A patient's relative risk varied from about 3 to 4 when compared to healthy subjects. Patients suffering from rheumatoid arthritis have a clearly higher risk of dysphonia compared to healthy subjects.

Laryngeal assessment in rheumatic disease patients

Rheumatic diseases usually promote several systemic disorders, which can affect blood vessels, mucosa and serosa of the aerodigestive tract. Scarce laryngeal involvement has been described in these patients and this study aims at investigating laryngeal alterations found in patients with rheumatic diseases. Study design: transversal cohort. Material and method: A transversal study was developed with systemic lupus erythematous, systemic sclerosis and mixed connective tissue disease’s patients. They were evaluated by means of clinical examinations and videolaryngoestroboscopy. Results: Twenty-seven patients were included in the study, 26 succeeded in completing the videolaryngoestroboscopy. Laryngeal abnormalities were seen in 11 of 12 patients with lupus, in all 11 patients with sclerodermia and in 3 patients with mixed connective tissue disease. Vocal fold bamboo node was observed in 5 patients and 92.3% of all patients presented laryngeal signs of gastroesophageal reflux disease. Conclusion: We noticed 5 vocal fold bamboo nodes and gastroesophageal reflux disease in almost all patients.

Avaliação laríngea em pacientes reumatológicos

As doenças reumáticas produzem alterações sistêmicas e podem, por isso, comprometer os vasos sangüíneos, as serosas e as mucosas de todo o trato aerodigestivo. Casos esporádicos de acometimento laríngeo por doenças reumáticas têm sido descritos. Esse estudo tem por objetivo avaliar e descrever as alterações laríngeas encontradas em pacientes reumatológicos. FORMA DE ESTUDO: coorte transversal. MATERIAL E MÉTODO: Estudo transversal com pacientes portadores de lúpus eritematoso sistêmico, esclerodermia e doença mista do tecido conjuntivo. Os pacientes submeteram-se a exame clínico otorrinolaringológico e à videolaringoestroboscopia. RESULTADOS: Foram incluídos no estudo 27 pacientes sendo que 26 conseguiram realizar a videolaringoestroboscopia. Alterações laríngeas foram observadas em 11 dos 12 pacientes portadores de lúpus, nos 11 pacientes portadores de esclerodermia e nos 3 pacientes portadores de doença mista do tecido conjuntivo. Lesões sugestivas de nódulo em bambu foram identificados em 5 pacientes e 92,3% dos pacientes apresentaram sinais laríngeos de síndrome faringolaríngea do refluxo. CONCLUSÃO: Neste estudo identificamos 5 lesões sugestivas de nódulos em bambu e sinais laríngeos de refluxo em quase todos os pacientes.

Sjögren's disease

In summary, Sjögren's syndrome is a chronic autoimmune disorder characterized by lymphocytic infiltration of the exocrine glands, particularly the salivary and lacrimal glands. The sicca complex of xerophthalmia and xerostomia are the hallmark features of Sjögren's symptomatology. In addition to these hallmark symptoms of oral and ocular dryness, one third of patients with Sjögren's syndrome present with extraglandular manifestations. Many osf these extraglandular manifestations, as well as the sicca symptoms, have otolaryngologic relevance. Because patients with Sjögren's syndrome may present with vague or nonspecific head and neck complaints, ranging from oral dryness to hoarseness to hearing loss, an otolaryngologist's high index of suspicion for this disorder may prevent delay in diagnosis, allow appropriate diagnostic evaluation, and optimize therapeutic intervention.