Bamboo nodes on trees compared to vocal cord nodulesRheumatoid nodules are white, fibrous submucosal nodules that can be located on the vocal cords. In that location, they are sometimes described as “bamboo nodes,” because they can be multiple, as seen in the figure to the right.

Rheumatoid nodules in other parts of the body tend to occur at pressure points such as at the elbow, knuckles, or flexor surfaces of the forearms. They are seen in some location in an estimated 25% of persons diagnosed with rheumatoid arthritis (RA). Pathological specimens show fibrosis and palisading granuloma formation. Use of methotrexate for RA is known to increase the occurrence of rheumatoid nodules.

Characteristics of Rheumatoid Nodules of the Vocal Cords

Features that distinguish rheumatoid nodules from the only other potential diagnosis (epidermoid cyst) are the medial-to-lateral oval or bamboo joint-like orientation of the submucosal lesion. An epidermoid cyst is either spherical—or if slowly leaking contents, oval—in an anterior-posterior orientation. Other distinguishing features of rheumatoid nodules are not only their bilaterality, but the presence of multiple lesions on each fold.

Diagnosis of Rheumatoid Nodules

Vocal cord rheumatoid nodules can be the sole initial harbinger of subsequent autoimmune disease before the patient has any other symptoms besides hoarseness. In one case at Bastian Voice Institute, rheumatoid arthritis was diagnosed a few years later; in another, systemic lupus erythematosis with severe renal involvement was diagnosed only 5 or more years after the initial voice complaint and findings of rheumatoid nodules.

Treatment of Rheumatoid Nodules

In other body sites, steroid injection, surgical removal, and more recently rituximab have been utilized for symptomatic rheumatoid nodules, such as at the elbows. In the vocal cords, intralesional injection of triamcinolone has anecdotally provided significant benefit to voice, at least in the short term of weeks to a couple of months.

Dissection of a very large rheumatoid nodules in one case gave surprisingly good voice results but in other cases, neutral to poor results. Of course, in order for the patient to experience surgery as having been beneficial, the stiffening effects of incision and dissection must be less than the stiffening effect of nodules themselves.

Multiple Rheumatoid Nodules Under 3 Kinds of Light

Visual Portfolio, Posts & Image Gallery for WordPress

Standard light, submucosal lesions seen (1 of 4)

Young middle-aged woman with chronic severe hoarseness. In abducted (breathing) position under standard light, one can see irregular margins but more importantly, whitish submucosal lesions with the classic appearance of rheumatoid nodules.

Narrow band light, accentuated capillaries (2 of 4)

Under narrow band light, the overlying capillaries are accentuated, and submucosal masses remain obvious.

Strobe light, nodules (3 of 4)

During open (breathing) position, but under strobe light, another view of these classic, multiple, medial-to-lateral “bamboo” nodules.

Strobe light during phonation (4 of 4)

During phonation also under strobe light, the submucosal masses dramatically inhibit oscillatory flexibility of the mucosa, and prevent accurate margin match at the same time.

Rheumatoid Nodules and Crohn’s Disease

Visual Portfolio, Posts & Image Gallery for WordPress

Woman with hoarseness (1 of 4)

Woman in middle age with very noticeable hoarseness. Standard light view not highly revealing.

White submucosal markings (2 of 4)

At very high pitch, one can see edge irregularity especially on the left side (right of photo). Note in addition faint white submucosal markings.

Submucosal lesions (3 of 4)

Under strobe light at high pitch, the medial-to-lateral white submucosal lesion on the left vocal cord (right of photo) is indicated by dotted lines. Additional mottled areas are not marked.

Remission from Crohn's (4 of 4)

At this high pitch, there is an independent vibrating segment involving the area of the brackets. A scratchy, diplophonic voice quality is heard at this pitch. Based upon these findings and additional questions, the patient revealed that she considers herself to be in remission from Crohn's Disease, after having been on Remicade and prednisone a year earlier.

This Subtle, Submucosal Mass is made more Evident with High Pitch. It is likely a Rheumatoid Nodule

Visual Portfolio, Posts & Image Gallery for WordPress

Submucosal mass (1 of 4)

This young woman has abandoned her strong avocational interest in singing years earlier due to chronic and apparently unresolvable hoarseness. Speaking voice can pass for normal. Consistent with submucosal pathology, her swelling checks become abruptly (rather than gradually) impaired as she sings up the scale. Even in this breathing position, the left vocal cord (right of photo) appears to have a whitish submucosal mass.

Open phase (2 of 4)

At F#4 (370 Hz) under strobe light, open phase of vibration. The lesion remains indistinct.

Closed phase (3 of 4)

Closed phase of vibration, same pitch.

Much higher pitch (4 of 4)

At the much higher pitch of E5 (659 Hz), the mucosa is stretched and thinned so that the lesion is much more visible (right of photo). This is likely a rheumatoid nodule. The only other oval submucosal white lesion is an open epidermoid cyst, but the axis of the oval is always anterior-posterior rather than medial-lateral.