eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vocal Polyps and Nodules: Treatment

Author: Robert A Buckmire, MD, Associate Professor, Department of Otolaryngology-Head and Neck Surgery, University of North Carolina; Chief, Division of Voice and Swallowing Disorders, Director, University of North Carolina Voice Center
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Updated: Sep 8, 2008

Treatment

Medical Therapy

Treatment options for vocal fold nodules (VFNs) and vocal fold polyps (VFPs) include both invasive and noninvasive techniques. 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. 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).

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.

Surgical Therapy

Several authors have published papers relating to phonosurgical techniques for removal of benign lesions. Although the surgical removal of nodules is relatively uncommon, recommendations for such a procedure include minimal normal tissue disruption, with an end point 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.

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.¹⁰ 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.¹¹ 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.

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.¹² 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.

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 Details

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. 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 Details

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.

Complications

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.

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