Prevalence of Benign Vocal Fold Lesions: Long-Term Results From a Single European Institution.

OBJECTIVES/HYPOTHESIS: Hoarseness and limited voice capacity are often associated with benign vocal fold (VF) lesions. Despite their high clinical prevalence, epidemiological investigations focusing on these structural alterations are rare. The aim of the study was to present current European data on five typical lesion types (VF nodules, polyp, cyst, contact granuloma, Reinke´s edema). STUDY DESIGN: Retrospective investigation. METHODS: Video recordings of laryngoscopies from all patients with one of the above-mentioned VF pathologies were subjected to a review process. Data collected arose from a single institution over a period of 13 years. They were evaluated statistically with respect to lesion type, sex, age at first diagnosis, and affected side. RESULTS: In a total of 535 patients, VF polyps occurred most frequently, followed by Reinke's edema and nodules. Each of the lesion types studied was significantly associated with sex and, except VF cysts, all diagnoses were also significantly related to age. Female sex was a risk factor for VF nodules, cysts, and Reinke's edema, whereas male sex was associated with polyps and contact granulomas. VF nodules occurred predominantly in young patients, VF polyps in middle-aged, Reinke's edema, and contact granulomas in later adulthood. The predominantly affected side (bilateral, right, or left VF) depended on sex. CONCLUSIONS: Different prevalences from previous studies resulted from inconsistencies in terms of classification framework, terminology, and definition. In addition to endoscopic findings, socio-cultural backgrounds must also be considered when studying benign VF lesions. Prophylactic voice care education for all populations and concomitant efficacy studies are required. Further research is needed to verify possible correlations between sex and the affected side. A non-binary view could broaden the spectrum of phoniatric research issues.

Association of Genre of Singing and Phonotraumatic Vocal Fold Lesions in Singers.

OBJECTIVES/HYPOTHESIS: To determine if (1) the likelihood of presenting with phonotraumatic lesions differs by singing genre in treatment-seeking singers and (2) if the distribution of phonotraumatic lesion types differs by singing genre. STUDY TYPE: Retrospective. METHODS: Records of singers who presented with a voice complaint over the course of 2.5 years (June 2017-December 2019) were reviewed to determine the proportion of those with phonotraumatic lesions as a function of genre (Study 1). Separately, the lesion types and genres of singers diagnosed with phonotraumatic lesions over a 9-year period (July 2011-March 2020) were determined (Study 2). RESULTS: In Study 1, 191 of 712 (26.8%) dysphonic singers were diagnosed with phonotraumatic lesions. Country/folk, gospel/jazz, and musical theater singers were more likely to present with phonotraumatic lesions. In Study 2, in 443 singers with phonotraumatic lesions, polyps and pseudocysts, but not nodules, were found to be distributed unequally across genres (χ2 p = 0.006, p < 0.0001, p = 0.064, respectively). Praise/worship singers had significantly higher proportions of polyps compared to choral singers (OR 4.8 [95% CI 1.9-12.5]) or compared to musical theater singers (OR 7.2 [95% CI 2.5-20.8]). Opera singers had significantly higher proportions of pseudocysts than choral singers (OR 3.1 [95% CI 1.5-6.1]) or musical theater singers (OR 3.7 [95% CI 1.8-7.6]). CONCLUSIONS: The higher incidence of polyps in praise/worship singers likely reflects the more emphatic nature of singing and the tendency for acute injury. The higher incidence of pseudocysts in opera singers may reflect a more chronic nature of injury. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:1683-1689, 2023.

Voice Therapy Expectations for Injured Singers.

OBJECTIVES/HYPOTHESIS: Voice therapy is a mainstay treatment modality in the management of phonotrauma in singers. However, the typical duration of therapy an injured singer undergoes is unknown. The primary aims of the study were to determine (1) the number of therapy sessions preceding a decision for surgery and (2) the number of sessions and length of time to achieve improvement in singers who did not undergo surgery. Whether specific singer factors were associated with the length of therapy was also investigated. STUDY DESIGN: Retrospective. METHODS: Records of singers with phonotraumatic vocal fold lesions seen over a 9-year period at a tertiary care voice center were reviewed. RESULTS: Sixty singers who underwent surgery and 183 singers who did not undergo surgery were included in the final analysis. In nearly ¾ of the surgical patients, five or fewer voice therapy sessions were completed prior to the decision for surgery. Singers who did not undergo surgery required on average 3-4 sessions before noting improvement. Over 60% of the non-surgical singers improved within 3 months and 84% were judged to be improved by 6 months. Lesion type, professional/amateur status, formal voice training, and having a current voice teacher/coach were not associated with the length of voice therapy. CONCLUSIONS: The length of voice therapy prior to decision for surgery was limited, and so was the length of therapy leading to initial improvement in singers who did not require surgery. These findings provide a framework for voice therapy expectations and could be reassuring for this unique population.

Profile of Injured Singers: Expectations and Insights.

OBJECTIVES: To discover patterns of phonotraumatic lesions in singers and investigate factors that differentiate those who underwent surgery from those who did not. We hypothesized that 1) lesion type distribution differs by age, sex, singer classification (professional/amateur), and history of formal voice training; 2) the likelihood of surgery is associated with singer classification and voice training. STUDY DESIGN: Retrospective. METHODS: Retrospective review of 438 singers with phonotraumatic lesions over a 9-year period. Lesion type distribution was analyzed with respect to sex, age, singer classification, and voice training. The association of eventual surgery with these factors was also analyzed. RESULTS: Nodules accounted for over half of the cohort (58%), followed by pseudocysts (20%), polyps (14%), and cysts (4%). Nearly two of every three injured female singers, but fewer than one out of every three injured male singers, had nodules. In contrast, over half of the injured males had polyps, whereas only 6% of injured females had polyps. In females, polyps occurred at a later age, and in males, nodules occurred at a younger age compared to other lesion types. Only 14% of the total cohort eventually underwent surgery. Professional singers without formal voice training were almost eight times more likely to have undergone surgery than amateur singers with voice training. CONCLUSIONS: Professional singers were more likely to undergo surgery than amateurs, and formal voice training was associated with a lower likelihood of surgery. The observation that polyps tended to occur in older women may have implications for the pathogenesis of vocal fold polyps. LEVEL OF EVIDENCE: 4 Laryngoscope, 132:2180-2186, 2022.

Glycogenic Acanthosis: An Unusual Cause of Vocal Fold Leukoplakia.

Glycogenic acanthosis is a common benign lesion of the esophagus; however, reports of extra-esophageal manifestations are exceedingly rare. This case represents the first report of laryngeal glycogenic acanthosis found in a living patient, presenting as vocal fold leukoplakia. Glycogenic acanthosis may be considered among the differential diagnoses of conditions presenting as vocal fold leukoplakia. Laryngoscope, 132:1641-1643, 2022.

Gender Differences in Vocal Fold Mass Treatment.

OBJECTIVE: The purpose of the study was to examine gender-related differences in benign vocal fold mass treatment. METHODS: Adult patient with vocal fold mass diagnosed on strobovideolaryngoscopy examination were reviewed retrospectively. Patient demographics, past medical history, laboratory data, and examination findings during the initial visit and at follow-up were collected. The duration of voice therapy and the prevalence of surgery were analyzed for males and females. RESULTS: One hundred and fifty-eight patients (76 male and 82 female) were included. The percentage of professional voice users differed significantly between males and females. Vocal folds of females had a higher percent of reactive masses present. Females were also more likely to have a pseudocyst. Vocal folds of males showed a higher percent of masses of unspecified category on strobovideolaryngoscopy examination. A significantly greater proportion of females had abnormal high shimmer values, and abnormal low maximum phonation time; and a significantly greater proportion of females compared to males chose to participate in voice therapy. The average number of voice therapy sessions for males did not differ, nor did duration of voice therapy. A similar proportion of males and females underwent surgical mass excision. The treatment plan completed differed significantly between males and females with a higher percentage of males choosing to receive no treatment. For 45.54% of males and 59.70% of females the treatment plan consisted of voice therapy only. For 33.33% of males and 37.31% of females, the treatment plan included both voice therapy and surgery. Although gender was the strongest predictor for participation in voice therapy, professional voice uses also predicted participation in voice therapy in both men and women significantly. Professional singing in particular was not a significant predictor for participation in voice therapy. Males were significantly more likely than females to be lost to follow-up before treatment outcome could be assessed CONCLUSION: More females than males were found to have pseudocysts while more males than females had unspecified masses. Females and professional voice users were more willing than males to utilize voice therapy. No difference was found between males and females who decided to have surgery. The best treatment regimen for vocal fold mass is a combination of voice therapy and surgery, when necessary, but gender-specific differences merit further research as well as reconsideration of therapy approaches and strategies to optimize patient compliance.

The Impact of a Vocal Loading Task on Voice Characteristics of Female Speakers With Benign Vocal Fold Lesions.

OBJECTIVES: To examine the effect of a vocal loading task on measures of vocal structure and function in females with benign vocal fold lesions (BVFLs) and determine if change is observed in voice and lesion characteristics. STUDY DESIGN: Prospective cohort study. METHODS: Twenty-eight (n = 28) female subjects with phonotraumatic BVFLs completed a vocal loading task of 30 minutes of reading aloud at 75-85 dBA. Multidimensional voice evaluation was completed pre- and post-load, including audio and videostroboscopy recordings and images for expert perceptual ratings and acoustic and aerodynamic evaluation. Subjects also scored themselves using a 10 cm visual analogue scale for Perceived Phonatory Effort, and completed the Evaluation of Ability to Voice Easily, a 12 item self-report scale of current perceived speaking voice function. An exploratory rather than confirmatory approach to data analysis was adopted. The direction and magnitude of the change scores (pre- to post-load) for each individual, across a wide variety of instrumental and self-report measures, were assessed against a Minimal Clinically Important Difference criteria. RESULTS: Observations of change and the direction of change in vocal response of individuals with BVFLs to 30 minutes of loud vocal load was variable. Minimal to no change was noted for participants pre- to post-load as rated perceptually, for auditory and videostroboscopy samples. For most instrumental measures, change was shown for many participants including an overall improvement in aerodynamic and acoustic measures of function and efficiency post-load for 20 participants (77%) and decline in function for 4 participants (15%). Self-reported effort and vocal function post-load was multidirectional with similar numbers of participants reporting no change, improved function or a decline. CONCLUSION: Subjects with BVFLs demonstrate change in vocal function following 30 minutes of vocal load. While this change can be variable and multidirectional, overall improvement was observed in instrumental measures of function and efficiency for most participants. Some participants perceived this change to be an increase in effort, some a reduction in effort and some perceived no change. Improved vocal function despite relative lesion stability can seemingly occur after loading in some pathological voices.

Recurrence of benign phonotraumatic vocal fold lesions after microlaryngoscopy.

OBJECTIVES: To determine recurrence rates for benign phonotraumatic vocal fold lesions after microlaryngoscopic surgery. STUDY DESIGN: Retrospective review. METHODS: Records of adults who underwent microlaryngoscopy between 2006 and 2017 for vocal fold cysts, midfold masses, polyps, pseudocysts, sulcus vocalis (Ford type 3), and varices were reviewed for demographics, medical history, treatment, and lesion recurrence. Patients operated for nonphonotraumatic lesions (e.g., granuloma, keratosis/leukoplakia, papilloma) were excluded. Stroboscopic examinations were re-reviewed to confirm diagnosis and outcome. RESULTS: Five hundred ten adults (223 male:287 female; mean age 40.3 ± 14.9 years) were included. Overall, 62 of 510 (12.2%) recurred (median time to recurrence: 70.0 months). Of these, 44 (71.0%) recurred to the same lesion type and 49 (79.0%) to the same side. Recurrence rates by initial lesion type were as follows: cysts, two of 92 (2.2%); midfold masses, four of 18 (22.2%); polyps, 25 of 235 (10.6%); pseudocysts, 30 of 145 (20.7%); sulcus vocalis, one of 18 (5.6%); and varices, zero of two (0%) (χ 2 = 28.7, degrees of freedom [df] = 5, P < 0.001). No significant difference in recurrence existed between males (21 of 223, 9.4%) and females (41 of 287, 14.3%). However, young adults (17 of 86, 19.8%) had significantly higher recurrence rates compared to middle-aged (12 of 155, 7.7%) and older adults (3/60, 5.0%) (χ 2 = 9.5, df = 3, P = 0.023). Of 62 recurrences, 18 were re-operated and four re-recurred. CONCLUSION: Benign phonotraumatic vocal fold lesions recur at variable rates. This variation suggests pathophysiologic differences between categories that may not be entirely explained by behavioral factors. LEVEL OF EVIDENCE: 4 Laryngoscope, 130: 1989-1995, 2020.

Impact of Perioperative Voice Therapy on Outcomes in the Surgical Management of Vocal Fold Cysts.

INTRODUCTION: Vocal fold cysts are benign mid-membranous lesions of the true vocal fold, classified as mucus retention or epidermal inclusion cysts. Treatment is surgical excision with or without postoperative voice therapy. METHODS: A retrospective review was performed of the demographics, treatment approach, and outcomes of patients treated for vocal fold cysts between 2009 and 2014. Voice Handicap Index (VHI)-10 scores before and after treatment were compared using the Wilcoxon Rank-Sum test and the two-tailed Student's t test. Videostroboscopy examinations were reviewed for posttreatment changes in vibratory characteristics of the vocal folds. RESULTS: Twenty-five patients were identified, and one was excluded for incomplete records. Mean age was 41.9 years (66.7% female), and mean follow-up time was 5.58 months. Microflap excision was pursued by 21/24 (87.5%) patients, with 14 patients (58.3%) undergoing perioperative voice therapy. One cyst recurred. Two patients elected for observation, and their cysts persisted. VHI-10 decreased from 23.8 to 6.6 (P < 0.001) overall. There was a statistically significant reduction in VHI-10 in patients undergoing surgery with and without postoperative voice therapy (P < 0.004 and 0.001), but there was no significant difference between these two groups. Mucosal wave was classified as normal or improved in the majority. Cysts were characterized as mucus retention cysts in 19/21 (90%) and as epidermal inclusion cysts in 2/21 (10%). CONCLUSIONS: Vocal fold cysts impact mucosal wave and glottic closure. Surgical excision resulted in low rates of recurrence, and in improvement in the mucosal wave and VHI-10. Perioperative voice therapy did not offer a significant benefit. Mucus retention cysts were the majority, in contrast to other published studies.

Efficacy and Safety of Adjunctive Steroid Injection After Microsurgical Removal of Benign Vocal Fold Lesions.

OBJECTIVE: This study aims to investigate the clinical efficacy and safety of immediate intralesional steroid injection in patients undergoing laryngeal microsurgery (LMS) for benign vocal fold lesions (BVFLs). STUDY DESIGN: This is a single-institution, retrospective cohort study. METHODS: Patients were divided into two groups according to whether or not they received adjunctive steroid injection after LMS. We evaluated the outcomes using objective, perceptual voice analysis and videostroboscopy. We also analyzed clinical parameters and identified risk factors associated with persistent dysphonia after LMS. RESULTS: The study included a total of 211 patients with BVFLs (82 men and 129 women), which comprised 136 vocal polyps (64.5%), 49 nodules (23.2%), and 30 cysts (14.2%); 84 patients (39.8 %) had intralesional steroid administration combined with LMS. The overall results for postoperative voice parameters in both groups were significantly improved. On videostroboscopic examination, the rate of recurrent lesions was lower in the group that received adjunctive steroid injection than in the group with only LMS (P = 0.014). In the multivariate analysis, older age (compared to <50 years of age; odds ratio [OR] = 2.697, 95% confidence interval [CI]: 1.300-5.595, P = 0.008) and duration of hoarseness longer than 6 months (compared to <3 months; OR = 2.729, 95% CI: 1.193-6.242, P = 0.017) were identified as independent risk factors associated with persistent dysphonia. Nevertheless, adjunctive steroid injection was associated with a 0.3-fold (OR = 0.345, 95% CI: 0.152-0.784, P = 0.011) lower risk of persistent dysphonia. CONCLUSION: Steroid injection combined with LMS in the treatment of BVFLs was safe and associated with improved voice quality.

Gender and age in benign vocal fold lesions.

OBJECTIVE/HYPOTHESIS: Certain lesions appear to occur predominantly in one gender or in younger or older patients. We examined a large sample from a treatment-seeking population to describe gender and age associations of an array of benign vocal fold lesions. STUDY DESIGN: Retrospective review. METHODS: The medical records and evaluations of all adult patients presenting for care over a 5-year period were examined for demographic characteristics and lesion type. A total of 641 lesions in 602 patients were grouped into 13 broad categories, and prevalence was compared between male and female patients and three age groups. RESULTS: Pseudocysts and bilateral midfold lesions occurred principally in young (18-39 years old) females (P < 0.0001). Reinke's edema was found in older (> 39 years old) women (P < 0.012). Polyps, contact lesions, leukoplakia (all P < 0.0001), and sulcus (P < 0.0002) were found predominantly in men. CONCLUSION: Certain benign mucosal lesions are strongly associated with age and especially with gender. These differences may be explained by intrinsic differences in laryngeal anatomy and phonatory physiology in these groups, including differences in phonatory frequency and air pressure, and in the ability of the membranous vocal fold to withstand phonotrauma. Such inherent differences have implications for treatment expectations and approaches.

Vocal improvement after voice therapy in the treatment of benign vocal fold lesions.

Benign vocal fold lesions are common in the general population, and have important public health implications and impact on patient quality of life. Nowadays, phonomicrosurgery is the most common treatment of these lesions. Voice therapy is generally associated in order to minimize detrimental vocal behaviours that increase the stress at the mid-membranous vocal folds. Nonetheless, the most appropriate standard of care for treating benign vocal fold lesion has not been established. The aim of this study was to analyze voice changes in a group of dysphonic patients affected by benign vocal fold lesions, evaluated with a multidimensional protocol before and after voice therapy. Sixteen consecutive patients, 12 females and 4 males, with a mean age of 49.7 years were enrolled. Each subject had 10 voice therapy sessions with an experienced speech/language pathologist for a period of 1-2 months, and was evaluated before and at the end of voice therapy with a multidimensional protocol that included self-assessment measures and videostroboscopic, perceptual, aerodynamic and acoustic ratings. Videostroboscopic examination did not reveal resolution of the initial pathology in any case. No improvement was observed in aerodynamic and perceptual ratings. A clear and significant improvement was visible on Wilcoxon signed-rank test for the mean values of Jitt%, Noise to Harmonic Ratio (NHR) and Voice Handicap Index (VHI) scores. Even if it is possible that, for benign vocal fold lesions, only a minor improvement of voice quality can be achieved after voice therapy, rehabilitation treatment still seems useful as demonstrated by improvement in self-assessment measures. If voice therapy is provided as an initial treatment to the patients with benign vocal fold lesions, this may lead to an improvement in the perceived voice quality, making surgical intervention unnecessary. This is one of the first reports on the efficacy of voice therapy in the management of benign vocal fold lesions; further studies are needed to confirm these preliminary data.

A Study of the Availability and Parameters of Videokymography / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Examining vibrations of the vocal fold is very important in patients with voice changes. The newly developed videokymography (VKG) takes images in real time and records irregular vibrations of the vocal fold. However, there are few data on VKG findings. We studied VKG to evaluate the vibratory characteristics of the vocal fold in benign vocal fold lesions and normal subjects. MATERIALS AND METHODS: Normal subjects (N=20) and patients (N=100) with laryngeal lesions were evaluated. Unique vibratory patterns, blurred demarcation of the mucosal propagation, decreased margin amplitudes, asymmetry in phase or amplitude, and different contact sites were observed in each benign vocal-fold lesion. RESULTS: There were several differences between subjects with normal and with laryngeal lesion. VKG depicted the tiny difference which were not exactly found by the stroboscope. CONCLUSIONS: We found that each type of laryngeal lesion has specific characteristics which can be revealed by VKG examination. These characteristics could be quantified and used to objectively evaluate VKG findings. This research shows that VKG can be used as a supplementary diagnostic tool.

The Study of Bilateral Venign Vocal Fold Lesions / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Benign vocal fold lesions are a common cause of voice dysfunction. Successful treatment of these diseases is primarily accomplished through voice therapy and surgical treatment. But many clinicians are faced with cases where problems persist in spite of treatment. The one cause of treatment failure in benign vocal fold lesions may be the bilateral lesions each vocal fold has different lesion. Authors studied to evaluate the possibility of persisted voice dysfunction in bilateral benign vocal fold lesions. MATERIALS AND METHODS: Strobovideolaryngoscopy findings of 128 patients with bilateral benign vocal fold lesions were reviewed. We evaluate to see if lesions in each vocal fold of one patient were the same or not. The treatment methods for each lesion were classified. We compare the treatment methods for each lesion with those already performed on the patients. RESULTS: In cases with nodule in one vocal fold, we observed 8 edema, 2 epidermoid cyst in the opposite vocal fold. In cases with reinke's edema on both vocal fold, we observed combined lesion, such as 1 epidermoid cyst, 1 hyperkeratosis. In cases with sulcus vocalis on both vocal fold, we observed combined lesion, such as 3 nodules, 4 polyps, 6 edema. We observed 2 cases with epidermoid cyst in one side and edema in opposite vocal fold, 5 cases with bilateral vocal nodule and combined varices in one side, 2 cases with bilateral laryngeal edema and combined hyperkeratosis in one side. CONCLUSION: Bilateral benign vocal fold lesions sometimes have more than 2 laryngeal diseases for which the treatment modality is different. Clinician should know the lesion precisely in each vocal fold, and treatment plan should be also made in according to the lesion in each vocal fold.