Portuguese Version

Year:  2001  Vol. 67   Ed. 3 - (14º)

Artigos Originais

Pages: 387 to 392

Nasal Obstruction and Vocal Nodules.

Author(s): Roberto C. Meirelles*.

Keywords: nasal obstructionn, vocal nodules, nasal physiology

Abstract:
Study desing: Clinical retrospective. Material and method: The author evaluates the incidence of the pharyngeal or nasal obstruction in 208 patients with vocal nodules. Results: He finds 113 (54,3%) cases with seven obstructive conditions: septal deviation; allergic rhinitis; turbinates bone alterations; vasomotor rhinitis; adenoid or tonsil hypertrophy; nasal polyps; Killian antrochoanal polyp. A higher incidence of septal deviation, turbinate bone alterations and vasomotor rhinitis was found in old or fibrosous nodules while allergic rhinitis and septal deviation were more frequency present in recent or edematous nodules. Conclusion: He discusses the results and outlines the importance of nasal respiration to reach efficacy in the treatment of vocal nodules.

INTRODUCTION

The treatment of vocal nodules is based on vocal rehabilitation, among other techniques. In 1988, we noticed that two patients did not improve quality of breathing during vocal therapy. After carefully examining them, we found nasal obstruction in both patients, one with allergic rhinitis and the other with septal deviation. After treating nasal obstruction, patients improved their breathing pattern and, consequently, their voice. Based on this observation, we investigated the correlation with vocal nodules - nasal obstruction by conducting comprehensive nose and pharynx exams and investigating obstructive factors in patients with vocal nodules. We found a significant percentage of nasal or pharyngeal obstruction. The literature has never objectively addressed this correlation.

The first references to it date back from 1868, when Tuerck defined nodule as a form of localized chronic laryngitis, corresponding to a small inflammatory tissue mass located on the junction of the middle and anterior thirds on the free margin of the vocal folds16. Vocal nodules are addressed with different terms, known as laryngeal nodules, singers', priest's nodules, shout nodules, nodous corditis and nodular laryngitis16.

The key factors for nodule etiology are permanent vocal abuse, hyperkinetic phonation, professional voice use, glottic conformation, anterior microweb and frequent production of high sounds9. Patients present, in variable degrees, anxiety, nervousness, irritability and anguish, which influence physiology of phonation17. Gastroesophageal reflux has also been confirmed as a player as a result of its high prevalence in patients with vocal nodules5.

The basic symptom is dysphonia9. At the beginning, symptoms may be exclusively pharyngeal, such as dryness, parestesia, throat clearing, sore throat and secretion in the pharynx, requiring friction in the region to force it out15. Neck muscle pain and fatigue are also noticed. Next, there are hoarseness, present after vocal effort, and finally, constant dysphonia8. The main vocal alterations are hoarse and low voice, vocal fatigue, variation of vocal intensity, difficulties in singing voice, cracking voice, episodes of aphonia, and painful phonation9,8,1.

Nodule lesions are classified into four main groups, according to laryngoscopic aspect9: 1) True nodule - they are localized thickening of the mucosa, normally bilateral, frequently asymmetrical and located a little below the free margin of the vocal fold. There are two main presentations - a) regular, round and pinkish, with translucent mucosa at the level of the nodule, sometimes associated with vascular corditis and hematoma. It is normally found in recent dysphonia and also called young or edematous affection. b) irregular, with whitish and thick aspect. It is more frequent than the previous type and corresponds to old and fibrous nodules. The second type of nodules (2) is spindle-shaped mucous thickening - it surges as a spindle edema, extending forwards and backwards, quite similar to the regular nodule. 3) Unilateral serous pseudocyst - it differs from retention mucous cyst and from inclusion epidermic cyst. It is translucent, with hyperkeratotic epithelium. It is present in the region where nodules regular are located and there is frequently a tiny contralateral nodular lesion. 4) Prenodular lesions - they present inflammatory aspect on the nodular point with mucous secretion adhered to it, even after phonation and cough. The mucous thickening is minimal and it is reduced or absence at stroboscopy, although the closure deficit remains (hourglass glottis)9.

Histopathology is the best method to define type of lesion26.

The treatment relies on vocal rest, voice therapy, cessation of smoking, alcohol use and pharyngolaryngeal irritation substances, treatment of neurological, endocrine and psychological diseases, and surgery25.

Vocal reeducation aims at obtaining .balance of thoracic system, laryngeal muscles, regulation of breathing dynamic, control of blowing production and adjustment of resonance cavities5. Surgery is indicated in cases of vocal therapy failure, for true and old nodules, pseudocysts and mucous thickness, and for nodules with suspicion of malignancy9,8,12. In children, they are rarely surgical cases1.

MATERIAL AND METHOD

Two hundred and eight cases were screened by the Otorhinolaryngology Service at Policlinica de Botafogo (181) and Hospital Universitário Pedro Ernesto (27), from 1985 to 1996. All patients were seen by the same examiner.

The diagnosis of nodules was based on laryngoscopy, performed with 70° or 90° telescope and light. Nasal exam was conducted with nasal speculum, photophore and endoscopy with rigid telescope 30° and 70° before and after mucosal retraction with vasoconstrictor solution at 1:80,000. If necessary, we performed CT scan to check anatomy of nasal-sinusal complex.

Patients were selected for the study and classified into groups of true nodules, fibrous or old nodules and edematous and recent nodules, according to the classification previously reported.

RESULTS AND DISCUSSION

The most significant fact that motivated the conduction of this study was the finding that 113 patients (54.3%) had nasal obstructive alteration, out of a total of 208 selected cases with vocal fold nodules (Table 1).

Most of the patients were female patients, amounting to 181 cases. Fibrous nodules were present in 72 patients (63.8%), whereas the edematous type was present in 41 cases (36.2%) (Table 2).

The most affected age range was 30 to 39 years, followed by 40 to 49 years (Table 3). Although nodules are commonly found in young women in the third decade of life12,34 it was not the range in which most of our cases concentrated. One possible explanation could be delay in receiving medical assistance and fluctuating symptoms noticed in initial cases.

The most common symptom was hoarseness, present in 100% of the cases (Table 4). Pharyngeal symptoms, present in 82.3% of the cases, may derive from effort and vocal abuse or from nasal obstruction itself20. As to the latter, it was noticed that only seven (46%) out of 15 patients with bilateral nasal obstruction complained of it, whereas 35 (85%) out of 41 patients with unilateral nasal obstruction referred discomfort and showed on which side. We believe that it may be explained by the fact that it is easier to notice an unilateral nasal obstruction because one side breathes well, than to observe alternate obstruction. In such cases, the patients complained of complete nasal obstruction. Overall, we found 56 patients (49.5%) with nasal obstruction and only 42 (37.1%) complained of the symptom and some only after being asked. Only these data suffice to highlight the importance of a detailed exam of the nose.

There were seven main types of nasal or pharyngeal alterations detected (Table 5): septum deviation, allergic rhinitis, turbinate bone alterations, vasomotor rhinitis, adenoid and tonsil hypertrophy, nasal polyposis, and Killian antrochoanal polyp. The three most common abnormalities were septum deviation (50.4%), allergic rhinitis (36.3%), and structural alterations of nasal turbinate (15.9%). In the group of vasomotor rhinitis (13.3%), there were six cases (5.3%) of drug-related rhinitis. In Table 5, we can see that some patients had more than one obstructive alteration and that is why the sum up of percentages exceeds 100%.

As to correlation between aspect of nodule and nasal pathology, we observed that in the older (fibrous) nodules the most frequent lesions were, in decreasing order, septum deviation, turbinate bone alterations and vasomotor rhinitis. In recent (edematous) nodules, the most common nasal disease was allergic rhinitis, followed by septum deviation. These data made us wonder if recent nodules would be part of the respiratory allergic picture, but we noticed that they remained in place, even after specific therapy for acute episodes of allergy, when nasal symptoms disappeared temporarily. In the present series, allergic rhinitis had a key role, despite the reduced number of cases, leading us to the conclusion that the aggression to the laryngeal mucosa makes it more vulnerable to other aggressive agents, such as cigarette smoking, endocrine pathologies, vocal misuse, gastroesophageal reflux and air irritating agents, which has already been identified for patients with nodules, polyps, Reinke's edema and noninfectious laryngitis11.

TABLE 1 - Total of patients.

Key: n = total number of patients.


TABLE 2 - Types of nodule.



TABLE 3 - Age.



TABLE 4 - Signs and symptoms.



TABLE 5 - Causes of obstruction.

It seems that subjects with nasal mucosa affections, such as allergic and vasomotor rhinitis may somehow aggravate their laryngeal picture because of the vulnerability of the vocal fold mucosa and due to the fact that they develop more true recent nodules. The recent nodule could be a typical and specific form of presentation of allergic pictures in the vocal fold mucosa. Conversely, there are patients with recent nodules and no allergy, which made us conclude that there is no definite correlation. Nevertheless, it is important to always investigate the presence of allergy in cases of nodules, present in 36.3 % of the patients. In another study, the authors found 75 % of organic alterations in patients with allergic rhinitis, among them, the nodule13.

Higher prevalence of nasal breathing than mouth breathing and the abnormalities resultant from chronic oral breathing are cited a number of times.

Mouth breathing is the anti-physiological substitute that should be employed only in emergency or under excessive ventilation consumption19. Long periods of mouth breathing are inefficient and require more energy for alveolar ventilation21, since nasal breathing is slower and deeper, with more thoracic expansion and lower breathing rates10. Nasal reflexes also regulate the resistance of lower airways, influencing bronchial and laryngeal status, as well as dilation of thorax22. It has been confirmed that there is reduction of oxygen pressure, lower pulmonary distensibility, and increase of pulmonary resistance in patients with nasal obstruction29.

Appropriate nasal breathing is important for good functioning of larynx, pharynx, swallowing and general well-being. It is easy to see that by remembering school teachers who do not know (or can not) use nasal breathing during phonation and suffer from laryngeal and pharyngeal common problems20. Signs and symptoms of nasal obstruction vary a lot: headache, otalgia, hearing loss, halitosis, cacosmia, bronchitis, bronchiectasis, laryngitis, dysphonia, pharyngitis, dysphagia, hyposmia, ageusia, aerophagia, heartburn, palpitation, weight loss, facial and thoracic deformities, and emotional disorders20.

It has already been stated that the inspired air reaches the larynx saturated with water and at 30° C temperature24. Humidification is a result of good nasal functioning3; therefore, suppression of nasal filter, when the inspired air is not humidified, purified and filtered, facilitates the deposit of dust, dirty and germs on the laryngeal mucosa, causing local inflammatory reactior8.

There is an interesting mechanism to explain nasal obstruction, suggesting that the air stimulus that surrounds the nasal fossa expand the lung homolaterally, by a reflex arc from the hypothalamus. The compression of the lung, on the pther hand, results in nasal congestion on the same side. It explains nasal congestion on the lower side when we sleep: it is due to hypothalamus reflex arc and not only passive gravitation forces30.

Correct breathing is essential for the success of voice therapy in patients with nodules, 26° 5. Vocal production is a result of the coordinated action of the pulmonary bellows, laryngeal vibration and correct placement of air into the resonance chambers23. In order to have coordination of these three factors, it is necessary to have appropriate body position, efficient diaphragm contraction, good mobility of the thoracic cavity, quality of pulmonary parenchyma, permeability of lower airways, integrity of the muscle, articulation and ligament systems of the larynx, appropriate mouth, pharyngeal, laryngeal, nasal and sinusal morphology, in addition to adequate tongue, palate, lips and face muscles, and anatomic and functional integrity of temporomandibular joint. Another important element is unimpaired sensitive auditory afferent pathways33.

Air flow is an essential part in the vocal production of patients with nodules, because inefficient voices have air flow disorders14.

The presence of functional disorders and nodules has been correlated with some types of inefficient pulmonary breathing patterns6. Superior breathing., which restricts pulmonary expansion and favors thoracic deepening, is predominant in subjects with hyperlordosis. Upper thoracic pattern is followed by cervical affection, sternocleidomastoid, scalene and facial muscle tension and nostrils, laryngeal and pharyngeal closure. Finally, there is the abdominal pattern that blocks the expansion of the lower ribs. The lowest incidence of nodules is noticed in patients with complete breathing pattern6. In a study, there were 80% of the patients with upper thoracic breathing pattern and 19 % with rigidity during breathing among subjects with vocal nodules32. We did not check type of breathing pattern in our study.

Larynx in children with nodules has high glottic air flow and is followed by a significant increase in pulmonary expiratory volume27. We also noticed that there was an increase in air glottic flow during reading in women with nodules, and they needed more air volume when reading syllables and words28.

Alterations of general healthy state, allergy and ENT infections may favor or aggravate vocal misuse, which remains as the main factor8. In 25% of the cases, dysph6nia from nodules is associated with upper airway diseases, especially infections and nasal obstructions. True nodules are rare, because what is more frequently observed is hyper-secretion of the free margin of vocal folds, with pre-nodular aspect. Clinical treatment of upper airway infections and nasal obstructions were associated to voice therapy in 33% of the cases of nodules4. In 77 children with nodules, 31 had a chronic history of otitis media, tonsillitis and adenoiditis and six had allergy31. In 34 children with nodules, there were 11 cases of adenotonsillar hypertrophy, two cases of adenoid hypertrophy, one case of antrochoanal polyp and one case of nasal polyposis, amounting to 44.1%. Only one case had history of tonsillar infection and another of sinusitis, both recurrent infections (5.8%).

However, all viral infections of upper airways aggravate the dysphonia at different levels.

One factor that hinders vocal therapy is anterior microweb, normally an accidental surgical finding in patients with nodules, which should be carefully investigated and requires observation after cleaning laryngeal secretions. What has not been defined yet is whether it predisposes to the onset of nodule7. It was found in 7% of the cases and associated with failure in vocal treatment2.

Nasal obstruction is a prevalent factor in patients with vocal fold nodules and we should always investigate carefully the nose18.

There is clinical suspicion that nasal obstruction is a predisposing factor for the surge of nodules, similarly to factors such as emotional and endocrine status and glottic conformation, although the main elements are still vocal misuse and abuse.

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* Joint Professor and Coordinator of the Discipline of Otorhinolaryngology, Hospital Universitário Pedro Ernesto, Universidade do Estado do Rio de Janeiro. Ph.D. in Otorhinolaryngology, Faculdade de Medicina, Universidade de São Paulo. Head of the Clinical Service of Otorhinolaryngology, Policlínica de Botafogo, Rio de Janeiro /RJ

Address correspondence to: Rua Siqueira Campos, 43 - Grupo 1125 - Copacabana - 22031-070 Rio de Janeiro /RJ.
Tel: (55 21) 548-5543 / 549-2969 - Fax: (55 21) 554-6397
E-mail: meirelles@radnet.com.br
Article submitted on January 6, 1999. Article accepted on February 16, 2001.

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