Vocal fold nodules (VFNs), depicted in the video below, are localized, benign, superficial growths on the medial surface of the true vocal folds (TVFs) that are commonly believed to result from phonotrauma. Nodules are bilateral with a classic location at the junction of the anterior and middle third of the vocal fold (ie, the midpoint of the membranous vocal fold). Nodules are most often observed in women aged 20-50 years, but they are also found commonly in children (more frequently in boys than in girls) who are prone to excessive shouting or screaming.[1, 2, 3] Videostrobolaryngoscopy can be used to detect laryngeal lesions. Treatment options for VFNs and vocal fold polyps (VFPs) include invasive and noninvasive techniques,[4] although surgery for VFNs is rare (fewer than 5% of cases).
View Video
In this patient with hoarseness, opposing nodules are clearly seen at the anterior one third of the true vocal cords. These responded nicely to outpatient nonsurgical treatment (voice therapy). Video courtesy of Vijay R Ramakrishnan, MD.
Confronted with symptoms of dysphonia, the clinician is charged with accurate diagnosis and timely institution of appropriate therapeutic intervention. Vocal fold lesions are a common cause of hoarseness. A more thorough understanding of these benign lesions has been the goal of laryngologists and voice scientists over the last several decades, since Hirano's description of the complex layered microanatomy of the human vocal fold.
Several distinct pathologic entities are encompassed in this broad category, including laryngeal papillomatosis, intracordal cysts, sulcus vocalis, and vascular ectasia, as well as VFNs and vocal fold polyps VFPs. Each of these entities has an attendant clinical presentation; each presents diagnostic and treatment challenges. This article focuses specifically on vocal fold nodules VFNs and vocal fold polyps VFPs.[5]
Workup
Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared with other indirect laryngoscopy techniques. Measurements within a voice laboratory, including aerodynamic, acoustic, and videostroboscopic baselines (as well as a high-quality audio recording of the patient's voice) are all helpful for appropriate pretreatment and posttreatment documentation of VFNs and VFPs. Also, clinician and patient perceptual measures are commonly performed to more subjectively gauge the impact of the vocal disability and improvement.
Management
Intervention in the form of voice therapy to correct vocal use issues may be all that is required to address the vast majority of VFNs, as well as some small VFPs.
Although the surgical removal of VFNs is relatively uncommon, recommendations for such a procedure include minimal normal tissue disruption, with an endpoint of a straight medial TVF edge without divots or remaining excess tissue.
Much debate continues regarding the relative merits of cold steel versus carbon dioxide laser removal of benign laryngeal pathology. Both techniques have the known potential to cause scarring with disruption of the lamina propria (LP). Despite the advent of high-magnification operative microscopes, microlaryngeal instrumentation, and the refinement of microspot manipulators for the carbon dioxide laser, both techniques require extreme care and a skilled surgeon to avoid potentially devastating vocal complications.
A thorough history of all patients presenting with a voice symptom is essential. A complete medical history must include a chief problem and history of present illness, which requires the patient to articulate the exact quality, timing, frequency, and task-specific nature and exacerbating or ameliorating factors of their voice problems. A review of past medical and social history and present medications is necessary to identify potential contributing factors, such as thyroid disease, smoking history, caffeine use, and/or use of prescription or over-the-counter (OTC) medications. A unique portion of the vocal history is the careful attention paid to patterns of vocal behavior (including occupational use and recreational and social behaviors) that may provide clues to contributory vocal overuse, vocal misuse, and vocal abuse (ie, phonotrauma), as well as the state of vocal hygiene.
Careful attention to voice-use history in immediate proximity to the onset of the symptom can offer clues to the nature of the problem. In the case of singers, understanding the patient's singing history and level of vocal training (as well as performance style and setting) is essential in formulating an accurate differential diagnosis.
A characteristic history of present illness referable to either vocal fold polyps (VFPs) or vocal fold nodules (VFNs) may include subjective symptoms of breathy, weak, raspy, or hoarse voice quality. The patient may also report a change in the baseline vocal pitch with limited vocal range. Patients may report increased effort and fatigue associated with voice production. Singers commonly note decreased voice quality and singing endurance, loss of upper registers, and difficulty with precise vocal control.
Vocal fold polyps (VFPs) are generally unilateral and have a broad spectrum of appearances, from hemorrhagic to edematous, pedunculated to sessile, and gelatinous to hyalinized. Vocal fold polyps (VFPs) are believed to result from phonotrauma; however, they are also recognized to potentially arise from a single episode of hemorrhage. In 1995, Dikkers et al found that the combination of signs of recent bleeding and depositions of fibrin and iron pigment in macrophages resided almost exclusively in polyps when compared with other benign lesions.[6] Moreover, approximately a third of the vocal polyps in their sample showed evidence of capillary proliferation, further lending credence to the theory of bleeds as the inciting event. The video below depicts a pedunculated hemorrhagic polyp along the anterior right true vocal fold.
View Video
Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen. Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.
Vocal fold polyps (VFPs) typically involve the free edge of the vocal fold mucosa, although they may also be found along the superior or inferior borders. Occasionally, a more diffuse pattern termed polypoid degeneration is observed as well. This pattern is referred to as Reinke edema and is generally considered a separate pathologic entity. For the purposes of this article, comments are limited to isolated focal lesions of the true vocal fold (TVF).
Both nodules and polyps may interrupt the vibratory patterns of the vocal fold by increasing the mass and reducing the pliability of the overlying cover (ie, cover/body theory of vocal fold vibration), as well as by impeding proper closure of the membranous folds throughout the glottic cycle.
Nonneoplastic lesions of the vocal folds are presumed to represent a response to vocal trauma (more specifically, phonotrauma in the case of vocal fold polyps and vocal fold nodules). A 1999 survey performed by Hogikyan et al elicited opinions of the professional groups most involved with the care of the voice (including laryngologists, speech language pathologists, and singing teachers) to gauge the prevalence of opinions regarding the specific entity of VFNs.[7] The survey found that the prevailing and nearly unanimous belief follows: "Practices that constitute either abuse or misuse of the speaking and/or singing voice were felt by all groups to be of greatest importance in causing vocal fold nodules in singers."
For the sake of clarity, vocal abuse refers to vocal behaviors that are practiced under circumstances that lead to trauma of the laryngeal mucosa. Excessive talking, prolonged and excessive loudness, use of inappropriate pitch, excessive cough, and throat clearing are some of these vocally abusive behaviors.
Vocal misuse involves abnormal vocal behaviors that cause stress or trauma to the larynx. Such practices include the use of excessive tension and effort while phonating, hard glottal attacks, and ventricular phonation. The concept of vocal overuse is self-explanatory.
In the effort to substantiate these traditional clinical beliefs regarding the etiology of vocal lesions, in 1987 Gray et al undertook the task of creating an animal model in which to study the pathologic process.[8] In an experiment designed to simulate phonotrauma, canines were hyperphonated artificially for periods of 2, 4, and 6 hours, after which the ultrastructure of their vocal fold was examined under electron microscopy to determine early anatomic changes related to phonotrauma.
With 2 hours of persistent phonation, Gray et al demonstrated reproducible structural changes that were absent in the control animals. The inherent shortcoming of such studies lies in the inability to perform longitudinal follow-up of the pathologic changes due to phonotrauma and, more importantly, the uncertainties of extrapolating data to humans (ie, given the behavioral differences between the canines in Gray's study protocol and normal human vocal behaviors as well as differences in vocal fold microanatomy).
In 2000, Andrade tested these causal behavioral assumptions by designing a retrospective study that attempted to correlate the frequency of specific, observed, vocally traumatic behavior (ie, hard glottal attack) with the type and extent of clinically visible vocal pathology.[9] The investigators hypothesized that a higher frequency of hard glottal attack would be found in patients exhibiting muscle tension dysphonia (MTD) and/or vocal fold lesions than would be found in normal speakers.
Further, investigators hypothesized that the frequency of these behaviors would correlate positively with the presence and severity (unilateral versus bilateral) of the observed vocal fold pathology. Results of Andrade's study confirmed a higher frequency of hard glottal attack in the disordered groups than in the controls. On the other hand, the study did not demonstrate a difference in frequency between the purely MTD group and those with lesions or between the unilateral and bilateral lesion groups.
In a large retrospective study of pediatric voice patients, Shah et al (2005) found that hyperfunctional vocal behaviors correlated with vocal fold nodule size, but the presence or absence of signs of reflux disease did not.[10] With a parent-rated standardized scale Roy et al (2006) confirmed that children with vocal fold nodules rate as "outgoing" or "extroverted" and scored significantly higher than controls on the "social scale."[11]
The literature notes other clinical associations with VFNs. Some authors have mentioned an anecdotal association between the presence of anterior glottic microwebs and nodules. Additionally, the contributory role of gastroesophagopharyngeal reflux in the pathogenesis of VFN has been studied.
In 1998, Kuhn et al compared a small cohort of patients with VFN against volunteers with normal health.[12] Both groups were studied with barium esophagraphy and ambulatory, 24-hour, 3-site pharyngoesophageal pH monitoring. Kuhn found that the prevalence of pharyngeal reflux events was significantly higher in patients with VFN compared with normal controls. Vibration-induced elevations in capillary pressure have also been hypothesized to cause vocal nodules and associated edema.[13] These results supports voice therapy aimed at reducing vibratory amplitude.
A literature review by Lechien et al indicated that laryngopharyngeal reflux increases the risk of VFN or VFP formation or development of Reinke edema, via caustic mucosal injury that makes the vocal fold mucosa more susceptible to injury. However, the investigators noted that data limitations hampered their ability to derive definitive conclusions.[14]
As previously mentioned, the clinical presentation of benign vocal fold lesions is most commonly associated with a voice change.[15] Typical presenting symptoms include generalized and persistent hoarseness, change in voice quality, and increased effort in producing the voice. The laryngeal examination may show either unilateral or bilateral lesions of the TVF.
Because it has the ability to demonstrate subtle differences in the appearance, pliability, and mucosal wave characteristics (ie, symmetry, periodicity, amplitude, vertical phase difference) of the TVF cover, videostrobolaryngoscopy is far more sensitive for detecting and differentiating laryngeal lesions when compared with other indirect laryngoscopy techniques.
Diagnostically, nodules do not tend to significantly disturb propagation of the mucosal wave on stroboscopy, but they may contribute to incomplete closure during the glottic cycle, depending upon their size.
Polyps have various appearances but generally are unilateral and much more likely to interfere with proper closure of the glottis during phonation and to cause a more noticeable change in the quality of the speaking/singing voice. The potential location of polyps on the superior and infraglottic (as well as the medial) surface of the cord makes the ability to separately visualize both upper and lower vertical lips of the cord on videostroboscopic examination all the more important to their detection.
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Vocal fold polyp (VFP) found during office videostroboscopy.
Indications for surgical intervention in benign TVF mucosal lesions are relative. Even in the most casual of voice users, the proposition of surgical intervention should never be taken lightly, especially given the ever-present potential for poor healing or irreversible scarring, which causes permanent change in the speaking/singing voice.
In general, vocal fold microsurgery is considered for cases in which the patient remains unacceptably vocally impaired despite compliance with a medical treatment and voice therapy regimen. Rare instances may also occur, in which the lesion (typically, a large polyp) threatens the patency of the airway. In these cases, the polyp's vocal impact is a distant secondary consideration. In other specific instances (eg, extremely long history of voice limitations, mucosal injury clearly resulting from a one-time event, clearly irreversible pathology), surgery may appropriately be considered at initial diagnosis. Even in this setting, however, the patient may benefit from one or more voice therapy sessions or from optimal preoperative education and postoperative compliance with the rehabilitative regimen.
The importance of careful patient selection cannot be overstated. At a minimum, rudimentary vocal education and a commitment to compliance with a preoperative and postoperative vocal regimen is required of any surgical candidate. This regimen routinely includes limitation of vocally damaging behavior and observance of improved vocal hygiene with respect to alcohol, caffeine, tobacco, and hydration. The patient must be committed to the recommended courses of both preoperative and postoperative voice therapy (and singing instruction as appropriate) and to the prescribed course of perioperative vocal rest that allows for optimal surgical healing and results. In the most general of terms, patients who do not meet these criteria are poor operative candidates; therefore, surgery is relatively contraindicated.
Advances in modern phonomicrosurgical techniques have largely stemmed from improved understanding of the complex microarchitecture of the TVF as described by Hirano. More specifically, understanding of the role of the layered architecture to normal voice production has led to surgical techniques designed for maximal preservation of the normal structure.
The TVF is composed of 5 individually identifiable layers. The deepest layer consists of the thyroarytenoid muscle body. This muscle is capable of contraction and serves to voluntarily stiffen and thicken the vibratory margin of the cord. Overlying the muscle is a region referred to as the lamina propria (LP), which can be divided into 3 portions (ie, superficial, middle, deep) based on the molecular compositions of each. The deep layer of the LP is largely comprised of densely crowded collagen fibers. The middle layer has some collagen but is distinguished by its high elastin content.
The deep and middle layers of the LP blend imperceptibly on operative dissection to form a structure commonly referred to as the vocal ligament, a recognized and important landmark in vocal fold surgery, as well as a transition zone between the body (muscle) and the cover (epithelium and superficial LP) of the TVF.
The superficial LP is composed of mostly amorphous ground substance and a few fibrils. The importance of this layer (which is not well appreciated on traditional hematoxylin and eosin [H&E] staining) to normal vibratory behavior of the TVF has been progressively elucidated over the last 30 years. The most superficial of the layers is the stratified squamous epithelial cover that overlies the LP.
The patient must be committed to the recommended courses of both preoperative and postoperative voice therapy (and singing instruction as appropriate) and to the prescribed course of perioperative vocal rest that allows for optimal surgical healing and results. In the most general of terms, patients who do not meet these criteria are poor operative candidates; therefore, surgery would be relatively contraindicated.
Gomaa et al studied the value of high-resolution ultrasonography in the diagnosis of laryngeal lesions that had already been detected with rigid endoscopy. They concluded that it is an alternative technique for diagnosing some lesions, particularly small subglottic lesions.[16]
No specific laboratory studies are singularly diagnostic of these conditions. Measurements within a voice laboratory, including aerodynamic, acoustic, and videostroboscopic baselines (as well as a high-quality audio recording of the patient's voice) are all helpful for appropriate pretreatment and posttreatment documentation. Lastly, clinician and patient perceptual measures are commonly performed to more subjectively gauge the impact of the vocal disability and improvement.
Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared with other indirect laryngoscopy techniques because of its ability to demonstrate subtle differences in the appearance, pliability, and mucosal wave characteristics (ie, symmetry, periodicity, amplitude, vertical phase difference) of the TVF cover.
On a structural level, a significant body of work has been performed to identify pathologic structural characteristics of benign vocal cord lesions and from this to infer pathogenesis. Immunohistochemical characterization of the extracellular matrix of excised, clinically diagnosed, benign laryngeal lesions revealed nodules to more commonly have a thickened basement membrane zone (BMZ) and dense fibronectin arrangement within the superficial lamina propria (LP), as compared with those diagnosed as polyps. These polypoid lesions tended to exhibit an unaltered BMZ thickness and to have fibronectin depositions clustered around neovasculature.
These patterns of structural deviation from the normal layered microanatomy of the TVF have been reported previously. In 1995, Gray et al formulated a theory of causation and pathologic response, hypothesizing as follows: "The vocal folds sustain enough injury to lead to BMZ disruption and injury to the superficial layer of the lamina propria. The injury, if repetitive, leads to aberrant healing and a fibroblastic response involving increased fibronectin deposition."[17]
On an ultrastructural level, nodules tend to demonstrate epithelial changes in the form of increased thickness, gaping of the intracellular junctions, and absence of the basal lamina. These changes were much less prominent in the polyps examined. Conversely, polyps tended to show variable pathologic patterns; some demonstrated marked vascularity, and others had hyaline stromal changes. The authors interpreted differences as perhaps indicative of a more long-standing exposure to injurious agents in the case of VFNs; they interpreted "microstromal hemorrhages" as potentially playing a role in the formation of VFPs. Gray et al speculated that the heterogeneous findings might be due to the stage in the life cycle of the polyp examined.[8]
A prospective, histopathologic study by Effat and Milad indicated that in comparison with vocal polyps in nonsmokers, those in people who do smoke tend to be larger and to display increased keratinization, dysplasia, basement membrane thinning, and hyaline degeneration. The study examined polyps from 29 patients, including smokers and nonsmokers.[18]
Treatment options for vocal fold nodules (VFNs) and vocal fold polyps (VFPs) include invasive and noninvasive techniques.[4] Prevailing thought reflects the opinion that the etiologic mechanisms of both lesions are most directly related to vocal use and technique. Therefore, attention to correcting the underlying causative factors, largely through voice therapy and education, plays an integral role in any treatment plan of action.
Education regarding proper vocal hygiene and hydration and avoidance of vocal abuse, misuse, and overuse is a necessary baseline.[19] The patient must comprehend how specific behaviors or patterns thereof may have contributed or may in the future contribute to vocal fold lesions. Intervention in the form of voice therapy to correct these usage issues may be all that is required with the vast majority of vocal fold nodules (VFNs), as well as some small vocal fold polyps (VFPs).
A prospective cohort study by Wang et al indicated that in many patients, vocal fold steroid injections are a beneficial long-term treatment for vocal fold polyps and nodules. The study involved 189 patients, including 72 with vocal fold nodules, 72 with vocal fold polyps, and 45 with mucus-retention cysts. The investigators found that after 2 years, the injections were still effective in half of the patients (although two patients were lost to follow-up by the end of the first year), including in 54%, 49%, and 43% of polyp, nodule, and cyst cases, respectively.[20]
As previously noted, with the exception of lesions affecting the patency of the airway or those in which the diagnosis of malignancy is entertained, the indication for surgical therapy is unacceptable vocal impairment despite compliance with medical treatment and appropriate voice therapy. Clearly, the level of acceptable vocal impairment varies widely between individuals depending on professional and personal voice usage patterns and demands.
Several authors have published papers relating to phonosurgical techniques for removal of benign lesions.[21] Although the surgical removal of nodules is relatively uncommon, recommendations for such a procedure include minimal normal tissue disruption, with an endpoint of a straight medial TVF edge without divots or remaining excess tissue. Given that surgery for vocal fold nodules (VFNs) is rare, fewer than 5% of cases, and should be considered only after a thorough nonsurgical treatment regimen is unsuccessful, the remainder of this discussion focuses on techniques described for vocal fold polyp (VFP) removal.
A retrospective study by Agarwal et al indicated that, as measured using the Voice Handicap Index-10, patients with VFPs experience greater short-term improvement through surgery employed alone or in combination with voice therapy (mean improvement 12.5 and 12.3, respectively) than with voice therapy alone (mean improvement 2.84).[22]
Much debate continues regarding the relative merits of cold steel versus carbon dioxide laser removal of benign laryngeal pathology. Both techniques have the known potential to cause scarring with disruption of the lamina propria (LP). Despite the advent of high-magnification operative microscopes, microlaryngeal instrumentation, and the refinement of microspot manipulators for the carbon dioxide laser, both techniques require extreme care and a skilled surgeon to avoid potentially devastating vocal complications. The laser, however, introduces the additional risk of peripheral tissue damage by means of dissipated thermal energy, in addition to the inherent danger of a potentially catastrophic airway fire. These factors must always be considered when opting for this technique. Over the course of the last decade, sentiment and editorial preferences have tended to favor the use of cold steel instrumentation, undoubtedly owing to the decreased risk of peripheral thermal damage.
Two publications have readdressed this issue. In 2000, Benninger published his data from a randomized, prospective, blinded study that compared aerodynamic, perceptual, and videostroboscopic measures between microspot carbon dioxide laser excision and cold steel microdissection of a variety of benign lesions of the vocal fold.[23] His data showed no demonstrable difference in postoperative perceptual and videostroboscopic parameters or in the recovery time between the 2 techniques. The author, however, makes the point that only the increased precision allowed by the development of the microspot manipulator allows for the accuracy necessary to perform such delicate phonosurgery.
In 1999, Remacle et al published data on the use of the carbon dioxide laser in the treatment of 251 patients with benign vocal fold lesions.[24] He concluded that the use of the microspot carbon dioxide laser is safe and effective. Notably, his study did not attempt to compare outcomes for various surgical techniques.
Another report, a retrospective study by Mizuta et al, compared angiolytic laser surgery outcomes with those of microflap surgery in the treatment of vocal polyps and suggested that both techniques are similarly effective. The report, which assessed results in 20 patients who underwent the angiolytic laser procedure, along with those in 34 individuals who underwent microflap surgery, found that polyps completely resolved after just one laser procedure in 17 patients and after two procedures in the remaining three. The laser surgery’s effects on aerodynamic and acoustic functions were reported to be similar to those of microflap surgery.[25]
In 2005, Ragab et al published a prospective controlled study of outcomes from a cohort of surgical patients with vocal fold nodules and polyps, randomized to either cold knife or radiosurgical (radiofrequency) excision groups.[26] No significant differences in postoperative subjective and perceptual voice measures, surgical complications, or the course of recovery was noted between the 2 groups. The authors argue that this technique, already used for other ENT surgical applications, combines the hemostatic benefits of laser excision with a tactile input of cold steel instrumentation.
Many publications have extolled the virtues of cold steel instrumentation for the surgical excision of VFPs. The concept of vocal fold microflap surgery for the treatment of TVF lesions has been reported since the mid to late 1980s. Review of the technique has shown its efficacy in the treatment of selected benign vocal pathologies.
With specific attention to the subepithelial pathology observed in VFPs, a subepithelial microflap resection technique has recently been described. This method seeks to preserve the overlying epithelial cover, while removing the underlying polypoid tissue via a superolateral cordotomy approach. The publication describes a series of 40 patients who showed clinical postoperative improvement, but it does not attempt a comparison with the less technically demanding superficial amputation technique. In theory, by maintaining the native epithelial lining and eliminating the need for secondary reepithelialization, this technique should lead to faster healing.
The author's technique of choice is the subepithelial microflap, when feasible. In many cases with a narrowly based pedunculated polypoid lesion, this technique is impractical and unnecessary. A simple superficial excision, sparing the underlying uninvolved LP and minimizing the epithelial loss, is generally sufficient. To accurately achieve these goals, however, high-powered binocular visualization and delicate microlaryngeal instrumentation is required.
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This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.
In the microflap technique, an incision in made along the superior surface of the lesion, near the interface of the normal and abnormal tissues. Dissection is then performed in separate planes to isolate the lesion. A plane of dissection is developed between the overlying epithelium and the diseased underlying tissue. The goal of this maneuver is to spare uninvolved epithelium to resurface the resulting defect from excision. The second dissection plane is more arbitrary and is created between the diseased lamina propria and the laterally located uninvolved tissue of the same layer. After the diseased tissue is removed, the spared epithelium is trimmed and laid back over the defect to optimally oppose the epithelial layers and limit healing by secondary intention. In general, no suturing is required to maintain flap position.
Preoperative management of vocal fold polyps is largely dependent upon the practitioner; however, some general rules do apply. Surgery for most lesions is not considered until a nonsurgical therapeutic approach (eg, behavioral voice therapy) has proven unsuccessful in yielding the desired voice outcome. Additionally, voice therapy serves as the only technique available that addresses the common behavioral causes of these lesions, decreasing their likelihood of recurrence. Other nonsurgical interventions designed to assess the reversibility of acute lesions include steroid therapy and voice rest.[19] These 2 interventions are primarily aimed at separating acute dynamic lesions of the vocal fold from stable chronic lesions that are likely to require surgical excision.
If indeed surgical intervention is required, an examination a short time prior to the procedure is advisable. All lesions of the vocal fold are subject to some degree of physical change that may significantly alter the scope of the recommended procedure, or in some cases, obviate the need for surgery all together. Preoperatively, the physician must obtain a detailed informed consent for the procedure. Counseling should be based upon the physician's experience with similar clinical situations, including all reasonable vocal expectations, limitations, and potential surgical complications. Video documentation of preoperative findings and a high-quality voice sample is essential for accurate record keeping as well as good medicolegal practice.
Postoperative and therapeutic follow-up regimens vary widely following treatment of vocal fold nodules (VFNs) and vocal fold polyps (VFPs). In cases treated nonsurgically, the timing of interval clinical examinations depends on the chosen frequency of voice therapy, patient compliance, and the degree to which the patient can apply therapeutic techniques in everyday life. Following operative intervention, the prescribed regimen is equally variable.
The length of voice rest and postoperative voice therapy depends completely on size and position of the lesion, surgical technique employed, degree of necessary re-epithelization, and a series of patient-related factors. These factors include (1) occupational and personal vocal demands; (2) characteristics of vocal use, misuse, or abuse; (3) medications; and (4) systemic illnesses. Surgeons usually prescribe a course of voice rest to coincide with the projected time required for postoperative epithelization and edema resolution. Thereafter, a graduated schedule of voice use is often instituted, ideally concluding with the full return of voice quality and endurance, satisfying the patient's vocal demands.
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This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).
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Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from office examination of the same patient as in Image 3, 6 days following....
The surgeon is charged with communicating a myriad of potential surgical complications to a prospective surgical candidate. The most common complications include tongue numbness, altered taste, and minor trauma to the teeth, oral cavity, and pharynx during rigid laryngoscopy. Risks associated with phonomicrosurgery include the potential for worsened voice quality, bleeding, infection, dental trauma, and oropharyngeal injury due to laryngeal suspension, and, most notably, scar formation due to overaggressive tissue resection or patient factors during the healing period. These potential complications must then be balanced against the proposed gain from the surgery on a case-by-case basis.
With respect to vocal fold nodules (VFNs) and vocal fold polyps (VFPs), treatment often results in vocal improvement. With respect to vocal fold nodules (VFNs), Murray et al demonstrated a beneficial effect of voice therapy when compared with observation alone. No prospective randomized studies compare the natural history of VFPs to the outcomes of standardized treatment regimens. However, relatively convincing evidence within the literature supports the safety and efficacy of these techniques in improving perceptual, aerodynamic, and stroboscopic parameters (based on the growing aggregate of reported surgical series of patients managed operatively with conservative phonomicrosurgery).
In 1996, Bastian reported his personal surgical series of 62 singers who had undergone microsurgery (the second-largest series reported in this patient population at the time).[27] Even within this high-risk population, evidence supported the safety and efficacy of surgical therapy. However, note that perhaps the most striking element of the study was the meticulous patient selection process, as well as preoperative and postoperative therapeutic and behavioral regimens. Reportedly, all singers within the series were able to return to a level of public singing at least equal to that experienced preoperatively.
Given the presumed pathophysiology, the long-term prognosis for patients with vocal fold nodules (VFNs) and vocal fold polyps (VFPs) appears dependent on maintenance of hygienic vocal behaviors. Patients unable or unwilling to participate in this fashion are arguably poor candidates for surgical intervention.
Undoubtedly, the debate over ideal surgical techniques, instrumentation, and therapeutic regimens will continue as more data become available. Further research of bioimplantable materials will ideally render the potentially disastrous vocal complications of phonosurgery, such as scarring and loss of vibratory capacity, easier to treat.
Robert A Buckmire, MD, Associate Professor,Department of Otolaryngology-Head and Neck Surgery, University of North Carolina; Chief, Divison of Voice and Swallowing Disorders, Director, University of North Carolina Voice Center
Disclosure: Nothing to disclose.
Specialty Editors
Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Received salary from Medscape for employment. for: Medscape.
Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York Upstate Medical University
Disclosure: Nothing to disclose.
Chief Editor
Arlen D Meyers, MD, MBA, Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine
Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;The Physicians Edge;Sync-n-Scale;mCharts<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; .
Additional Contributors
John Schweinfurth, MD, Professor, Department of Otolaryngology, University of Mississippi Medical Center
Disclosure: Nothing to disclose.
Acknowledgements
Medscape Reference thanks Vijay R Ramakrishnan, MD, Assistant Professor, Department of Otolaryngology, University of Colorado School of Medicine, for assistance with the video contribution to this article.
In this patient with hoarseness, opposing nodules are clearly seen at the anterior one third of the true vocal cords. These responded nicely to outpatient nonsurgical treatment (voice therapy). Video courtesy of Vijay R Ramakrishnan, MD.
Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen. Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.
Vocal fold polyp (VFP) found during office videostroboscopy.
This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.
This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).
Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from office examination of the same patient as in Image 3, 6 days following VFP removal. Note the straight edge of the vocal fold (right side of image).
Vocal fold polyp (VFP) found during office videostroboscopy.
This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.
This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).
Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from office examination of the same patient as in Image 3, 6 days following VFP removal. Note the straight edge of the vocal fold (right side of image).
Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen. Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.
In this patient with hoarseness, opposing nodules are clearly seen at the anterior one third of the true vocal cords. These responded nicely to outpatient nonsurgical treatment (voice therapy). Video courtesy of Vijay R Ramakrishnan, MD.
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