Voice Therapy First Line Treatment for Vocal Cord Nodules

In the new century, the American public has gained a new appreciation of the voice as a vital communication instrument. A decline in voice quality is not accepted as inevitable; accordingly, a diagnostic evaluation by a specialist will find that polyps, nodules and cysts are common acquired benign lesions of the vocal folds.

Despite this, clinical evidence assessing the effectiveness of therapy for these lesions, particularly non-surgical interventions undertaken outside of the operating room remains sparse. These non-technical measures stand to assume a new importance as it becomes more evident that the cause of these lesions likely encompasses multiple cofactors, not only behavioral, but also environmental and possibly inherited. Due to this lack of information, clinical practices surrounding the surgical treatment of benign vocal fold lesions often are determined by tradition, habit or an accident during training. The standard of care is unclear under these circumstances, and indeed, a consensus among practitioners may not exist.

A new study set out to describe current care now undertaken by the medical and surgical community, with special attention to identify areas of disagreement or lack of uniformity in order to shape future inquiry. The authors of "Management of Benign Vocal Fold Lesions: A Survey of Current Opinion and Practice," Lucian Sulica MD and Alison Behrman PhD CCC-SLP will present their findings at the 124th Annual Meeting of the American Laryngological Association http://alahns.org/ May 2-3, 2003 at the Gaylord Opryland Hotel, Nashville, TN. Drs. Sulica and Behrman are from the Center for the Voice, Department of Otolaryngology, The New York Eye & Ear Infirmary and the Beth Israel Medical Center (Dr. Sulica) in New York, NY.

Methodology: In September 2001, a 16-item blind survey regarding management of benign vocal fold lesions was mailed to all active United States members of the American Academy of Otolaryngology--Head and Neck Surgery, the national medical society representing more than 10,000 ear, nose, and throat specialists. Instructions accompanying the survey specified that all of the questions related only to vocal fold nodules, polyps and cysts and excluded all other laryngeal pathologies. Respondents were asked to report the number of years in practice and the number of surgeries for benign mucosal lesions performed within the previous twelve months. Treatment practice questions included the use of of voice therapy, CO2 laser, microscopy, antireflux medications, steroids, antibiotics, and various diagnostic procedures.

Questions that addressed the frequency of use of a specific treatment or technique used a Likert 5-point scale with end anchors of one equaling "never" and five equaling "always". The middle value ("3") indicates that the respondent did not have a consistent opinion defining position on a statement, but rather the opinion is dependent upon other factors individual to the patient and not measured by this survey.

Results: A total of 1,333 surveys (18.2 percent) were returned from the total mailing of 7,321. Of these, 1,208 (16.5 percent) were completed, as the remaining 125 respondents indicated that they did not treat patients with voice disorders. The mean number of practice years of the respondents was 13 (SD = 9.7). The mean number of surgeries performed within the past 12 months for nodules, polyp or cyst of the vocal folds was 11.5 (SD = 15.6) with a range of 0 to 100. Approximately 65 percent of the respondents had performed 10 or fewer surgeries within the past 12 months. Only 20 (less than two percent) reported having performed 50 or more procedures. Key findings included:

Voice therapy: Approximately 91 percent of respondents (1,101) would likely recommend voice therapy as initial treatment for nodules, and conversely, 89 percent (1,075) would not recommend surgical excision. Some 41 percent (501) would favor excision as the initial treatment for polyps, and 53 percent (635) for cyst. Approximately 30 percent (366) preferred voice therapy as initial treatment for polyps, and 22 percent (270) for cyst. When voice therapy assumed a complementary role to surgery, respondents once again indicated a clear preference for voice therapy for nodules, either preoperatively (71 percent; 852) or postoperatively (69 percent; 834).

Diagnostic evaluation: With the exception of stroboscopy, over 50 percent of the respondents never conduct any of the diagnostic tests listed, including voice recording. Even stroboscopy is unlikely to be used by over 56 percent (683) of respondents. A small number of respondents commented that they would use stroboscopy or other tests if available.

Surgical technique: the microscope and CO2 laser: The overwhelming majority of respondents use magnification for surgery of all lesions (86 percent; 1,035). Opinion on the use of laser was less unanimous, and did not differ significantly according to lesion type. Nevertheless, on average, 34 percent (410) never use a laser during surgery. When combined with those who are unlikely to use a laser, this rises to 57 percent. Approximately 21 percent indicated that they were likely to use a laser. The remaining 18 percent were neutral.

Adjunctive medical therapy: Neither the use of antireflux medication such as H2-blockers or proton-pump inhibitors, nor of antibiotics, nor of steroids differs according to lesion type. Rather, opinion seems to be independent of the vocal fold pathology. On average, 46 percent (556) of respondents favored the use of antireflux medications in the management of nodules, polyps and cysts. Twenty-two percent (260) did not habitually prescribe reflux medication, and the practice of the remainder varied too much to characterize one way or the other. Approximately 36 percent (434) often or always used intravenous steroids, while 49 percent (586) used them rarely or never. Nineteen percent (234) favored the use of oral steroids perioperatively, while 61 percent (739) did not.

Conclusions: Treatment for benign mucosal lesions of the vocal folds has traditionally consisted of two modalities: voice therapy and surgery. Among specialists, voice therapy is clearly the treatment of choice for vocal fold nodules. It is intended to address hyperfunctional vocal behaviors that cause excessively forceful and prolonged collision of the mid-membranous vocal fold mucosa that are thought to be important causative factors. Opinion regarding utility in other lesions is considerably less uniform, reflecting the lack of published data showing efficacy. Some prescribe voice therapy routinely for all operative patients, regardless of lesion type. Still others may use a more nuanced approach, but rely consistently on some kind of behavioral intervention. Disagreement is also noted regarding the use of laser, oral steroids and antibiotics. Other than voice therapy as initial intervention for nodules, no statistically significant differences by lesion type exist regarding use of voice therapy, laser, or any medication.