White, fibrous submucosal nodules of the vocal cords. Also called “bamboo nodes.” Rheumatoid nodules in other areas of the body (elbows, knuckles, etc.) are almost always seen with rheumatoid arthritis. They can be seen in the context of other auto-immune disorders and are sometimes seen before that disorder is diagnosed.
Treatment can involve supportive measures, steroid injection of the vocal cords, or—when nodules are large and persistent in spite of systemic management of a diagnosable auto-immune disorder, if any—surgical removal using a technique similar to that used when removing an epidermoid or mucus retention cyst.
Photos of rheumatoid nodules:
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 lesions are indicated by dotted lines.
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.
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.
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.
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.