World Voice Day 2023: Q&A | What are benign vocal fold lesions and how are they treated?

Thomas L. Carroll, MDEver have a “rough” voice day? We all experience short-lived voice changes the morning after attending a loud concert, sporting event, or evening meal in a loud restaurant. If this has happened to you, there is a good chance you developed small bumps on your vocal folds that many would call “nodules.” Without ongoing heavy voice use, these fleeting lesions resolve fairly quickly, and the voice returns to normal. But what happens when a person forms nodules or has another injury to the delicate vocal mechanism and cannot rest the voice or back off from heavy voice use?

Benign vocal fold lesions (BVFLs) are focal changes to the vibratory layer (lamina propria) of the vocal fold, or the vocal cord, that result in limitations of normal vibration and lead to symptoms including hoarseness, throat clearing, decreased vocal range (can’t hit the high notes), vocal effort, and vocal fatigue. Depending on the size and depth of the BVFL, the symptoms can vary from mild and inconvenient to severe and debilitating. The most common names given to BVFLs are nodules, polyps, and cysts. In addition, fibrous mass and pseudocyst are terms more commonly used by voice-specific clinicians.¹

Many otolaryngologists describe how BVLFs evolve from a common injurious event or behavior, while others also believe they can form from normal voice use when talking on top of existing inflammation and swelling from a viral laryngitis, chronic allergies, or reflux that effects the throat.² No matter how or why they start, BVFLs may be predestined to become a polyp or cyst from the beginning or are theorized to be diagnosed at any point along a spectrum of an evolving lesion (i.e., from nodule to polyp to cyst).³ The vast majority of people who present with BVFLs do not report one event where their voice changed, rather a worsening of symptoms over time that has led them to seek care.

Whether they share a common origin after an injurious vocal event or from normal use in the setting of existing inflammation, BVFLs can have non-distinct appearances on laryngoscopy with stroboscopy (the technological tool used to see vibration of the vocal folds in the outpatient, office setting). For this reason, many laryngologists do not give BVFLs specific names until they either resolve without surgery (nodules or nonspecific vocal fold lesions) or with surgery where either microscopic appearance or pathology report can fine tune the diagnosis to one of the three most common results: fibrous mass/scarring, polyp, or cyst. With high definition videostroboscopy in the office and what can be appreciated under the microscope, it is less common for a laryngologist to call lesions “nodules;” rather, laryngologists give a diagnosis of a clearer, dominant unilateral BVFL and an opposing, reactive lesion (akin to a callous forming from the trauma of the primary BFVL hitting it). The term “nodules,” considered by most to be symmetric and plural by definition, remains widely accepted. This is often a reflection of the technology available as many otolaryngologists do not routinely use high-definition flexible laryngoscopes and videostroboscopy in the office setting.

Treatment of BVFLs usually involves voice therapy with a speech-language pathologist at some stage of care. A surgical intervention to remove the offending BVFL is performed when necessary. The order of therapy versus surgical treatment administered first depends on the patient and pathology. Some patients will do well with voice therapy alone (typically small- to medium-sized lesions), while others with larger BVFLs may require excision before therapy can be completed successfully. Voice therapists who work independently of a laryngologist and are sent a patient with a BVFL that proves not to be amenable to improvement with therapy will often offer education about what to expect from the treatment process to the patient; the therapist hopefully can feel empowered to advocate for earlier procedural or surgical intervention on the patient’s behalf with an intended plan to resume therapy postoperatively. Upfront voice therapy is always worth a try if both the patient is motivated and the therapist sees the potential for improvement at the onset; if one of these two ingredients is missing, the otolaryngologist may need to intervene or refer for surgical care sooner rather than later.

Surgical management of BVFLs is not without risk but is offered when the patient has pursued all other options. Traditionally, BVFLs are removed in the operating room using microlaryngeal techniques under suspension laryngoscopy. A small incision is made next to the lesion, the lesion is dissected from the surrounding normal structures, the lesion is removed, and the overlying normal tissue is replaced. Achieving all these steps is the goal, but this is not always possible. With unintentional, but often unavoidable, loss of normal tissue and the resultant scarring that must occur as the vocal fold heals, the surgeon and patient must be ready for issues with healing postoperatively. Although the routine outcome is often favorable and as expected, the risk of scar formation is often a superior trade-off to what the patient was experiencing from the BVFL preoperatively; but postoperative voice therapy and steroid injections into the forming scar can often mediate these postoperative healing issues to some degree. Newer techniques employing lasers in the office to ablate or soften certain BVFLs are becoming more common, especially for lesions with a vascular or inflammatory component (i.e., hemorrhagic polyps, newer scar/fibrous masses).⁴

References

1. Naunheim M, Carroll T. Benign vocal fold lesions: update on nomenclature, cause, diagnosis, and treatment. Curr Opin Otolaryngol Head Neck Surg. 2017;25 (6):453-458. doi: 10.1097/MOO.0000000000000408
2. Lechien JR, Saussez S, Nacci A, et al. Association between laryngopharyngeal reflux and benign vocal folds lesions: a systematic review. Laryngoscope. 2019;129(9):E329-E341. doi:10.1002/lary.27932
3. Johns M. Update on the etiology, diagnosis, and treatment of vocal fold nodules, polyps, and cysts. Curr Opin Otolaryngol Head Neck. 2003;11(6):456-461. Cited in: Journals@Ovid Full Text. Accessed February 01, 2023. https://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=ovftf&NEWS=N&AN=00020840-200312000-00009
4. Shoffel‐Havakuk H, Sadoughi B, Sulica L, Johns MM. In-office procedures for the treatment of benign vocal fold lesions in the awake patient: A contemporary review. Laryngoscope. 2019;129(9):2131-2138. doi:10.1002/lary.27731