eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Laryngology

Vocal Fold Cysts: Treatment

Author: John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
Coauthor(s): Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Contributor Information and Disclosures

Updated: Sep 8, 2008

Treatment

Medical Therapy

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.

Surgical Therapy

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 (see Intraoperative details).

Diagnostic direct microlaryngoscopy should also be considered when the diagnosis is uncertain or when a neoplastic process cannot be excluded.

Preoperative Details

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.

Intraoperative Details

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.

Postoperative Details

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.

Follow-up

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

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.

More on Vocal Fold Cysts

Overview: Vocal Fold Cysts
Workup: Vocal Fold Cysts
Treatment: Vocal Fold Cysts
Follow-up: Vocal Fold Cysts
Multimedia: Vocal Fold Cysts
References
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References

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Further Reading

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Keywords

vocal fold cysts, vocal cord, cysts, epidermoid cysts, mucus retention cysts, benign vocal lesions, benign vocal disorders, intracordal cysts, dysphonia, aphonia, diplophonia, Reinke space, vocal fold

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Contributor Information and Disclosures

Author

John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center
John Schweinfurth, MD is a member of the following medical societies: American Academy of Otolaryngic Allergy, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Robert Ossoff, DMD, MD, MS, Chair, Professor, Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center
Robert Ossoff, DMD, MD, MS is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Chest Physicians, American College of Surgeons, American Laryngological Association, American Laryngological Rhinological and Otological Society, American Medical Association, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, Sigma Xi, and Southeastern Surgical Congress
Disclosure: Nothing to disclose.

Medical Editor

Clark A Rosen, MD, Director, University of Pittsburgh Voice Center; Associate Professor, Department of Otolaryngology and Communication Science and Disorders, University of Pittsburgh School of Medicine
Clark A Rosen, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, and Pennsylvania Medical Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Robert M Kellman, MD, Professor and Chair, Department of Otolaryngology and Communication Sciences, State University of New York, Upstate Medical University
Robert M Kellman, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Physician Executives, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Medical Society of the State of New York
Disclosure: GE Healthcare Honoraria Review panel membership

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine
Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, and American Head and Neck Society
Disclosure: Covidien Corp Consulting fee Consulting; US Tobacco Corporation unstricted gift unknown

 
 
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