Vocal Polyps and Nodules Treatment & Management

Treatment options for vocal fold nodules (VFNs) and vocal fold polyps (VFPs) include invasive and noninvasive techniques. ^[7] 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. ^[21] 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 VFNs, as well as with some small VFPs.

A prospective cohort study by Wang et al indicated that in many patients, vocal fold steroid injections are a beneficial long-term treatment for vocal fold polyps and nodules. The study involved 189 patients, including 72 with VFNs, 72 with VFPs, and 45 with mucous retention cysts. The investigators found that after 2 years, the injections were still effective in half of the patients (although two patients were lost to follow-up by the end of the first year), including in 54%, 49%, and 43% of polyp, nodule, and cyst cases, respectively. ^[22]

A literature review by Dassé and De Monès Del Pujol indicated that first-line, in-office, awake treatment with low-dose, submucosal triamcinolone acetonide injections (0.1-0.3 mL) can provide at least transient improvement in exudative vocal fold lesions. Lesions in the study consisted of polyps, nodules, and Reinke edema, with a significant reduction in lesion volume found in more than 90% of cases and all studies reporting significant vocal improvement in subjects. Relapse rates of 4-31% were noted, with time to relapse varying from between 1 to 40 months. ^[23]

A retrospective report by Wu et al showed that 82% of study patients who had VFNs or VFPs and used their voice professionally experienced lesion resolution following vocal fold steroid injection. Substantial resolution was defined as a reduction in lesion size of more than 50%. The investigators also evaluated treatment outcomes in nonprofessional voice users with VFNs or VFPs and found substantial resolution in 79% of these patients. ^[24]

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 the presence of 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.

Several authors have published papers relating to phonosurgical techniques for removal of benign lesions. ^[25] Although the surgical removal of nodules is relatively uncommon, recommendations for such a procedure include minimal normal tissue disruption, with an endpoint 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.

A retrospective study by Agarwal et al indicated that, as measured using the Voice Handicap Index-10 (VHI-10), patients with VFPs experience greater short-term improvement through surgery employed alone or in combination with voice therapy (mean improvement 12.5 and 12.3, respectively) than with voice therapy alone (mean improvement 2.84). ^[26]

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. ^[27] 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. ^[28] 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.

Another report, a retrospective study by Mizuta et al, compared angiolytic laser surgery outcomes with those of microflap surgery in the treatment of vocal polyps and suggested that both techniques are similarly effective. The report, which assessed results in 20 patients who underwent the angiolytic laser procedure, along with those in 34 individuals who underwent microflap surgery, found that polyps completely resolved after just one laser procedure in 17 patients and after two procedures in the remaining three. The laser surgery’s effects on aerodynamic and acoustic functions were reported to be similar to those of microflap surgery. ^[29]

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. ^[30] 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 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.

This picture shows the surgical view of a vocal fold polyp (VFP) as observed via high-power microlaryngoscopy.

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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 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. ^[21] 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 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.

This picture is a postoperative surgical view immediately following microsurgical removal of vocal fold polyp (VFP).

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Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from office examination of the same patient as in Image 3, 6 days following VFP removal. Note the straight edge of the vocal fold (right side of image).

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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.

With respect to vocal fold nodules (VFNs) and vocal fold polyps (VFPs), treatment often results in vocal improvement. With respect to vocal fold nodules (VFNs), Murray et al demonstrated a beneficial effect of voice therapy when compared with observation alone. No prospective randomized studies compare the natural history of VFPs to the outcomes of standardized treatment regimens. However, relatively convincing evidence within the literature supports the safety and efficacy of these techniques in improving perceptual, aerodynamic, and stroboscopic parameters (based on the growing aggregate of reported surgical series of patients managed operatively with conservative phonomicrosurgery).

In 1996, Bastian reported his personal surgical series of 62 singers who had undergone microsurgery (the second-largest series reported in this patient population at the time). ^[31] Even within this high-risk population, evidence supported the safety and efficacy of surgical therapy. However, note that perhaps the most striking element of the study was the meticulous patient selection process, as well as preoperative and postoperative therapeutic and behavioral regimens. Reportedly, all singers within the series were able to return to a level of public singing at least equal to that experienced preoperatively.

A literature review by Barsties V. Latoszek et al reported that in patients with VFPs who were treated with phonosurgery, behavioral voice therapy, or a combination of both (in which phonosurgery was followed by voice therapy), phonosurgery and combination therapy were similarly effective, with both being more beneficial than voice therapy alone. All three, however, produced significant voice improvements. The greatest improvements in hoarseness, jitter, shimmer, maximum phonation time, and the physical subscale of the VHI-30 were associated with combination therapy. Phonosurgery alone led to the largest improvements in the emotional and functional subscales of the VHI-30. ^[32]

Given the presumed pathophysiology, the long-term prognosis for patients with VFNs and VFPs appears dependent on maintenance of hygienic vocal behaviors. Patients unable or unwilling to participate in this fashion are arguably poor candidates for surgical intervention.

Undoubtedly, the debate over ideal surgical techniques, instrumentation, and therapeutic regimens will continue as more data become available. Further research of bioimplantable materials will ideally render the potentially disastrous vocal complications of phonosurgery, such as scarring and loss of vibratory capacity, easier to treat.