Laryngeal Polyps, Cysts, and Sulci

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Laryngeal Polyps, Cysts, and Sulci

Laryngology, Voice and Swallowing
Author Credentials 

Original author: 
Melin Tan, MD
Montefiore Medical Center
3400 Bainbridge Avenue
3rd Floor
Bronx, NY 10467
Phone 718-920-4646
Fax 718-401-9014
Email: mtangel@montefiore.org or melintangeller@gmail.com

Update by:
Patrick O. McGarey, MD
Fellow, Laryngology and Voice Disorders
Department of Otolaryngology-Head and Neck Surgery
UT Health San Antonio Voice Center
San Antonio, Texas

Module Summary

Nodules, Polyps, Cysts and Sulci generally occur within the phonatory epithelium or lamina propria of the true vocal fold.  An impaired vocal fold edge compromises apposition of the vocal fold edges and may impair the vibratory surface of the vocal folds.   These benign lesions yield an inefficient glottis manifesting as dysphonia.  Diagnosis is heavily dependent on history and exam findings, namely stroboscopy.  Treatment is individualized with consideration of the subjective patient’s voice handicap and the practitioner’s perceptual rating, the patient’s voice demand and the potential for improvement of voicing habits and technique, and likelihood for resolution without surgical intervention.  Management may include voice rest, voice modification, voice therapy, adjunct medications for concurrent pathology or symptomatic relief of throat symptoms.  Phonosurgery is often the ultimate solution for polyps, cysts, and large mature nodules.  Keen knowledge of both surgical technique as well as perioperative care is imperative.  

 

Module Learning Objectives 
  1. Review the histologic structure of the vocal folds.
  2. Identify the pathogenesis of benign vocal fold lesions.
  3. Be familiar with terminology of benign vocal fold lesions and how they differ clinically.
  4. Appreciate the options for medical and behavioral management of benign vocal fold lesions.
  5. Describe risks and benefits of phonosurgery.

Anatomy

Learning Objectives 
  1. Know the Cover-Body Theory.
  2. Understand that different vocal fold vibration patterns are dependent on different combinations of cover and body stiffness.
  3. Understand the classification of different types of vocal fold polyps, cysts, and sulci. 

 

References 
  1. Hirano M.  Morphologic structure of the vocal cord as vibrator and its variations. Folia Phoniatr. 1974; 26, 89-94.
  2. Story BH and Titze IR.  Voice simulation with a body-cover model of the vocal folds. J. Acoust. Soc. Am. 1995; 10.1121/1.412234 97,1249-1260.
  3. Rosen CA et al.  A nomenclature paradigm for benign mid-membranous vocal fold lesions.  Laryngoscope 2012; 122(6):1335-41.
  4. Giovanni A, Chanteret C, Lagier A.  Sulcus vocalis: a review.  Eur Arch Otorhinolaryngol. 2007 Apr;264(4):337-44. Epub 2007 Jan 13.

Pathogenesis

Learning Objectives 
  1. Understand the phonotraumatic nature of benign vocal fold lesions.
References 
  1. Gray SD, Hammond E, Hanson DF.  Benign pathologic responses of the larynx. Ann Otol Rhinol Laryngol. 1995 Jan;104(1):13-8.  
  2. Johns MM. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, cysts. Curr Opin Otolaryngol Head Neck Surg 2003; 11:456-461.

Incidence

Learning Objectives 
  1. True incidence is unknown.  Nodules, polyps, cysts and sulci are more prevalent in those who either have a high voice demand or who abuse and overuse their voice.
References 
  1. Schwartz SR et al. Clinical practice guideline: hoarseness (dysphonia). Otolaryngol Head Neck Surg. 2009; 141(3 Suppl2): S1-S31.

Genetics

Learning Objectives 

There is no genetic predisposition to benign vocal fold lesions.

 

Patient Evaluation

Learning Objectives 
  1. Understand the principles of stroboscopy.
  2. Explain the pros and cons of laryngoscopy with flexible and rigid laryngoscopes.
References 
  1. Woo P, Casper J et al.  Diagnostic value of stroboscopic examination in hoarse patients.  J Voice. 1991; 4:231-238.
  2. Cornut G, Bouchayer M.  Assessing Dysphonia.  The Role of Videostroboscopy [An Interactive Video Textbook].  Lincoln Park, NJ: KayPENTAX;2004.
  3. Roehm PC, Rosen C.  Dynamic voice assessment using flexible laryngoscopy – how I do it: a targeted problem and its solution.  Am J Otolaryngol 25:138-141.

Measurement of Functional Status

Learning Objectives 
  1. Review the Voice Handicap Index (VHI) and the abbreviated version, VHI-10.
  2. Be familiar with GRBAS scale.
  3. Recognize the value of acoustic and aerodynamic measurements.
References 
  1. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and validation of the voice handicap index-10.  Laryngoscope. 2004;111(9);1549-1556.
  2. DeBodt MS, Wuyts FL, Van de Heyning PH, Croux C. Test-retest study of the GRBAS scale: Influence of experience and professional background on perceptual rating of voice quality. J Voice.  1997;11(1);74-80.
  3. Mehta DD, Hillman RE. Voice assessment: Updates on perceptual, acoustic, aerodynamic and endoscopic imaging methods. Curr Opin Otolaryngol Head Neck Surg. 2008; 16(3):211-215.

Imaging

Learning Objectives 

Laryngeal stroboscopic images are paramount to any other imaging modality. 

Pathology

Learning Objectives 
  1. Recognize that pathologic classification of benign vocal fold lesions is dependent on clinical judgement and experience.

 

References 
  1. Rosen CA et al.  A nomenclature paradigm for benign mid-membranous vocal fold lesions.  Laryngoscope 2012; 122(6):1335-41.
  2. Cipriani NA, Martin DE Corey JP, Portugal L, Caballero N, Lester R, Anthony B, Taxy JB.  The clinicopathologic spectrum of benign mass lesions of the vocal fold due to vocal abuse.  Int J Surg Pathol.  2011; 19(5):583-7.

Treatment

Learning Objectives 

Voice Therapy

  1. Be able to identify relative probability of successful voice outcome with voice therapy for vocal fold polyps, cysts, and sulci.

 

References 
  1. Cohen SM, Garrett CG.  Utility of voice therapy in the management of vocal fold polyps and cysts.  Otolaryngol Head Neck Surg.  2007 May;136(5): 742-6.
  2. Nakagawa H, Miyamoto M, Kusuyama T, Mori Y, Fukuda H.  Resolution of vocal fold polyps with conservative treatment.  J Voice. 2012 May;26(3): e107-10.
  3. Schindler A, Mozzanica F, Maruzzi P, Atac M, De Cristofaro V, Ottaviani F.  Multidimensional assessment of vocal changes in benign vocal fold lesions after voice therapy.  Auris Nasus Larynx. 2013 Jun;40(3):291-7.
  4. Tibbetts KM, Dominguez LM, Simpson CB.  Impact of Perioperative Voice Therapy on Outcomes in the Surgical Management of Vocal Fold Cysts.  J Voice. 2018 May;32(3):347-351.

Surgical Therapies

Learning Objectives 

Subepithelial steroid injection for vocal fold polyps

  1. Be able to describe the injection technique for subepithelial steroid injection.
  2. Know that there is some data supporting this technique for the treatment of vocal fold polyps.

 

Laser ablation of vocal fold polyps

  1. Be able to describe the treatment principles of the photoangiolytic laser.
  2. Know that in-office treatment of vocal fold polyps with photoangiolytic laser ablation is safe and effective, but has tradeoffs compared to microflap excision.

 

Phonomicrosurgery: Polyps and Cysts

  1. Be able to describe microflap technique as it relates to vocal fold histology.
  2. Know that if the underlying phonotraumatic behavior is not addressed, there is higher chance of lesion recurrence.

 

Sulci

  1. Know that the success rate for surgical treatment of vocal fold sulcus is low
  2. Be able to describe the different techniques for surgical treatment of vocal fold sulcus
References 

Subepithelial steroid injection for vocal fold polyps

  1. Hsu YB, Lan MC, Chang SY.  Percutaneous corticosteroid injection for vocal fold polyp.  Arch Otolaryngol Head Neck Surg.  2009 Aug;135(8): 776-780.  
  2. Wang CT, Lai MS, Cheng PW.  Long-term Surveillance Following Intralesional Steroid Injection for Benign Vocal Fold Lesions.  JAMA Otolaryngol Head Neck Surg. 2017 Jun 1;143(6):589-594.

 

Laser ablation of vocal fold polyps

  1. Zeitels, S.M., Akst, L., Burns, J. A., Hillman, R. E., Broadhurst, M.S., Anderson, R. R., Pulsed Angiolytic Laser Treatment of Ectasias and Varices in Singers. Ann Otol Rhinol Laryngol, 2006. 115: p. 571-580.
  2. Lin YH, Wang CT, Lin FC, Liao LJ, Lo WC, Cheng PW.  Treatment Outcomes and Adverse Events Following In-Office Angiolytic Laser With or Without Concurrent Polypectomy for Vocal Fold Polyps. JAMA Otolaryngol Head Neck Surg. 2018 Mar 1;144(3):222-230.

 

Phonomicrosurgery: Polyps and Cysts

  1. Courey MS, Gardner GM, Stone RE, Ossoff RH.  Endoscopic vocal fold microflap: a three-year experience.  Ann Otol Rhinol Laryngol. 1995 Apr;104(4 Pt 1):267-73.
  2. Hochman, I.I., Zeitels, S.M., Phonomicrosurgical Management of Vocal Fold Polyps: The Subepithelial Microflap Resection technique. Journal of Voice, 2000. 14: p. 112-118.
  3. Akbulut S, Gartner-Schmidt JL, Gillespie AI, Young VN, Smith LJ, Rosen CA.  Voice outcomes following treatment of benign midmembranous vocal fold lesions using a nomenclature paradigm.  Laryngoscope. 2016 Feb;126(2):415-20.

 

Sulci

  1. Welham NV, Choi SH, Dailey SH, Ford CN, Jiang JJ, Bless DM. Prospective multi‐arm evaluation of surgical treatments for vocal fold scar and pathologic sulcus vocalis. Laryngoscope 2011; 121:1252–1260.
  2. Mallur PS, Gartner‐Schmidt J, Rosen CA. Voice outcomes following the gray minithyrotomy. Ann Otol Rhinol Laryngol2012; 121:490–496.
  3. Karle WE, Helman SN, Cooper A, Zhang Y, Pitman MJ.  Temporalis Fascia Transplantation for Sulcus Vocalis and Vocal Fold Scar: Long-Term Outcomes.  Ann Otol Rhinol Laryngol. 2018 Apr;127(4):223-228.
  4. Dailey SH, Ford CN.  Surgical management of sulcus vocalis and vocal fold scarring.  Otolaryngol Clin North Am. 2006 Feb;39(1):23-42.

 

 

Rehabilitation

Learning Objectives 
  1. Understand the pros and cons of voice rest after phonomicrosurgery.
  2. Be familiar with the medical armamentarium helpful in the post-operative period.
References 
  1. Joshi A, Johns MM 3rd.  Current practices for voice rest recommendations after phonomicrosurgery.  Laryngoscope. 2018 May;128(5):1170-1175.
  2. Kaneko M, Shiromoto O, Fujiu-Kurachi M, Kishimoto Y, Tateya I, Hirano S.  Optimal Duration for Voice Rest After Vocal Fold Surgery: Randomized Controlled Clinical Study.  J Voice. 2017 Jan;31(1):97-103.
  3. Emerich KA, Spiegel JR, Sataloff RT.  Phonomicrosurgery III: pre-and post-operative care.  Otolaryngol Clin North Am.  2000;33(5):1071-1081.

Case Studies

  1. A 36-year old female elementary school teacher presents with persistently raspy voice for as long as she can remember.  She feels that her voice has progressively gotten worse over the winter months with frequent episodes of complete loss of voice.  She experiences vocal fatigue with worsening of voice at the end of the day.  There is pain in the front of her neck at the end of the day as well and she notes a general ache in her voice.  Her VHI-10 is 36.  Using the GRBAS scale, she has a grade 2 dysphonia that is rough 2 and breathy 2 in quality.  Her laryngeal videostroboscopy reveals bilateral mid-fold nodules with moderate supraglottic compression, an hourglass configuration, decreased mucosal wave bilaterally and decreased amplitude.  How would you counsel this patient?  When she inquires about surgical intervention, how would you counsel her?

 

  1. A 48-year old attorney describes a change in voice that occurred one month ago while he was defending a client in a court trial, while also battling an upper respiratory infection.  He reports cough, congestion and sore throat that was self-limited.  He took over the counter cold medications and continued to work, needing to project his voice in the courtroom.  He lost his voice for 3 days completely, after which his voice improved but he has not experienced complete resolution of the hoarseness.  He otherwise feels well now.  His VHI-10 is 14.  Using the GRBAS scale, he has a grade 1 dysphonia that is rough 1, breathy 1 and strained 1 in quality.  His laryngeal videostroboscopy reveals a large right mid-fold hemorrhagic polyp, an hourglass configuration with a decreased mucosal wave on the right side, normal amplitude on the right side, and normal vocal fold vibration on the left side.  What are this patient’s options for treatment?  If he opts for phonosurgery, what recommendations would you make for peri-operative care?

Complications

Learning Objectives 
  1. Know the potential complications of microscopic direct laryngoscopy. 
  2. Be familiar with the potential complications of endoscopic angiolytic laser surgery
References 
  1. Bastian RW.  Vocal fold microsurgery in singers.  J Voice.  1996; 10(4):389-404.
  2. Del Signore AG, Shah RN, Gupta N, Altman KW, Woo P.  Complications and failures of office-based endoscopic angiolytic laser surgery treatment.  J Voice.  2016 Nov;30(6):744-750.

Review

Review Questions 
  1. What patient populations are more likely to be afflicted with a vocal fold nodule, polyp, cyst or sulcus?
  2. How would you counsel a patient with vocal fold nodules, polyps, cysts or sulci with regard to their vocal hygiene?
  3. What are the risks and benefits of phonosurgery?
  4. When would you consider using a photoangiolytic laser to treat a benign lesion of the vocal fold?
  5. What are the relative rates of success of voice therapy for treatment of benign lesions of the vocal fold? 
Resources 

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