Vocal Fold Cysts Treatment & Management
- Author: John Schweinfurth, MD; Chief Editor: Arlen D Meyers, MD, MBA more...
The key to identifying intracordal cysts is minimizing surrounding edema and inflammation. Modified voice use, vocal hygiene, and, often, medication aid in accomplishing reduced edema and inflammation. Thus, the subtle stroboscopic appearance of a significant intracordal cyst may be revealed. Patients may be placed on a 2-week period of vocal rest, perhaps accompanied by a high-dose corticosteroid taper. Steroid treatment reduces the overlying and sometimes camouflaging inflammation and swelling while leaving the cyst unchanged, thus making its diagnosis easier.
Evaluating and treating any intercurrent medical conditions affecting the voice (eg, reflux laryngitis, allergic rhinitis) are also essential. In addition, patients with vocal fold cysts often have compounding functional issues that need to be addressed, both preoperatively and postoperatively, with expert speech-language intervention.
Surgery is reserved for patients with lesions that show no reversibility with exhaustive medical and speech therapy. Although nodules and polyps may respond to conservative management, vocal cysts typically do not. Delay in surgical treatment and continued trauma can potentially lead to progression of cyst formation and intracordal scarring. The goal of surgical excision is preservation of the mucosal cover with minimal disruption of the underlying tissue. In addition, the deep layers of the lamina propria harbor fibroblasts that produce extracellular proteins. Avoid this layer to prevent scarring along the vocal ligament and tethering of the mucosal cover. The microflap approach to the excision of benign laryngeal lesions was developed with these goals in mind.
A study by Jensen and Rasmussen indicated that microscopic phonosurgery is an effective treatment for benign vocal fold lesions, including cysts. The study included 97 patients who underwent the surgery for vocal fold polyps, cysts, nodules, or edema, with data from postoperative clinical evaluation available for 89 of these individuals. In 85% of the patients, postoperative voice quality was reported to be unaffected, while in 13% of patients, voice quality was improved but moderately affected, and in one patient, with a cyst and sulcus vocalis, voice quality was severely affected.
Diagnostic direct microlaryngoscopy should be considered when the diagnosis of vocal fold cyst is uncertain or when a neoplastic process cannot be excluded.
Evaluate patients presenting with dysphonia through indirect laryngoscopy and videostroboscopy, with particular attention paid to vocal fold mobility, glottic closure, and the presence, amplitude, and symmetry of the vocal fold mucosal wave. Benign vocal lesions are first treated by reversing the conditions and patterns of abuse that initially created them. Surgery is reserved for patients with unresolving lesions that cause troublesome dysphonia. All known sources of mechanical trauma are maximally reduced prior to considering surgical therapy to determine reversibility and, hopefully, to prevent postoperative recurrence. Medical and speech therapy directed at reducing vocal trauma through improved technique and vocal hygiene are involved in reducing mechanical trauma. Surgical candidates must be willing to postpone speaking and singing engagements for at least 3 months postoperatively.
The lateral microflap is used when the lesion is adherent to the vocal ligament and the overlying mucosa is normal. The advantage of the lateral microflap is that the incision and the subsequent scar are lateral to the medial surface of the vocal fold. In addition, the uninvolved portion of the vocal ligament may be used to orient the flap, and dissection may proceed from known to unknown. The medial microflap is indicated for lesions that involve a discrete portion of the vocal fold and appear to separate easily from the underlying vocal ligament on palpation. This approach allows for a shorter flap and can be used to treat redundant or adherent mucosa overlying a lesion. At the conclusion of the procedure, a solution of triamcinolone acetate may be injected into the flap. This is thought to further minimize scar formation. With both techniques, most patients experience return of mucosal wave and are satisfied with voice quality.
Place the patient on strict voice rest for 2 weeks after microflap surgery. Patients with more extensive dissections may be placed on a short course of corticosteroids. Administer a 7-day course of antibiotics and a mild narcotic for pain relief to all patients. Treat patients with symptoms or findings of laryngopharyngeal reflux with a proton-pump–inhibiting agent.
Reexamine patients at 2, 4, 8, and 12 weeks postsurgery. At the 2-week postoperative visit, perform videostroboscopy and have the patient resume therapy with the speech pathologist. A gradual return to voice use occurs over the first few weeks, increasing by 5-minute intervals twice daily. Singers may begin to work with the vocal pedagogue (ie, singing teacher) at 1 month, but they are cautioned to decrease vocal work if they feel any discomfort or strain. Most patients can expect 90% of their functional surgical result at approximately 3 months.
Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may result in tongue numbness, altered taste, and oropharyngeal, mucosal, and dental injuries. Deep-plane dissection or exposure of the vocal ligament can result in scarring and fibrosis of the mucosa with loss of mucosal wave and glottal insufficiency. Injudicious use of the laser can result in a wide zone of thermal damage with mucosal scarring and fibrosis, unintended burn injuries, and endotracheal tube fires. The best way to treat scarring is to prevent it. Use of microflap techniques avoids a raw mucosal surface that heals by secondary intention. Avoidance of the deeper layers of the lamina propria and vocal ligament minimizes the fibroblastic response.
Outcome and Prognosis
Using the microflap technique described above, Courey et al found that 85% of patients with an absent wave preoperatively regained their mucosal wave, while 97% percent of patients with an intact preoperative wave retained this important parameter. Blinded comparison of preoperative and postoperative voice samples from this series showed that the postoperative voice was rated as better in 100% (48 of 48) of patients. Although long-term results in these patients remain excellent, continued emphasis should be placed on the prevention of pathology (eg, voice training, good vocal hygiene, maintenance of systemic health).
Future and Controversies
Some authors have expressed concern that elevating a microflap may lead to disruption of the attachment of the basement membrane to the superficial layer of the lamina propria through interlinked collagen loops. The mini-microflap was described to minimize tissue manipulation and prevent possible basement membrane injury. The plane of the microflap is in the superficial layer of the lamina propria deep to the basement membrane and likely leaves these attachments untouched. This is demonstrated by the observation of blood vessels within the flap, which clearly reside deep to the basement membrane. Other authors have proposed entering the vocal fold through an anterior, submucosal approach through the thyroid cartilage that obviates the need for an incision in the epithelium. Endoscopes placed into the Reinke space in cadavers allowed for surgery of lesions of the lamina propria. This approach could potentially minimize vocal scarring associated with mucosal incisions and raising subepithelial flaps.
Determining whether the traditional or newer mini-microflap procedures damage or protect the basement membrane or whether basement membrane injury hampers voice is difficult. Results with the microflap have been excellent, with return of good-to-excellent voice and mucosal wave in most patients. Use of the laser in the surgical treatment of benign nodules, polyps, or cysts to minimize scar formation is minimal.
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