Voice Therapy For Managing Vocal Fold Polyps and Cysts

Newswise — The vocal folds or cords are the true centers of voice production and injury to this sharp-edged fold of mucous membrane not caused by a tumor can impair communication and have important public health implications. Past studies reveal that three in ten of the general public had at least one voice disorder in their lifetime, with six percent now having a current voice disorder. Some seven percent of those afflicted with this disorder have missed one or more workdays.

Benign vocal fold lesions caused by polyps and cysts also have a significant negative impact on the patient's quality of life. Yet the most appropriate treatment for vocal fold polyps and cysts has not been determined. What is known is that excessive voice use can increase the stress at the mid-membranous vocal folds and leads to producing nodules, polyps, or cysts; what is uncertain is the impact voice therapy has on polyps and cysts.

Voice therapy is effective at minimizing detrimental vocal behaviors resulting in voice improvement as evidenced through past research focusing on non-organic voice disorders, muscle tension dysphonia (MTD), and nodules. In contrast, the treatment suggested for polyps and cysts consists of a combination of phonomicrosurgery and voice therapy. However, it is not known how often surgery is required, which patients are likely to respond to voice therapy, and who needs surgery. As a result, no consensus exists within the physician-specialist community regarding the recommendation for voice therapy as first-line treatment for polyps and cysts. A recent survey of ear, nose, and throat specialists found that 91 percent of respondents use voice therapy as first line treatment in nodules, but respondents were divided about using voice therapy in polyps and cysts.

If voice therapy were effective in treating polyps and cysts, the need for surgery and its inherent risks would be reduced. Conversely, if voice therapy did not improve the altered voice production then patients could be directed to operative intervention without prolonged delays while waiting to see if voice therapy helped. To clarify this dilemma, voice specialists set out to test the hypothesis that voice therapy is effective in treating vocal fold polyps and cysts. The authors of "Utility of Voice Therapy in the Management of Vocal Fold Polyps and Cysts," are Seth M. Cohen MD MPH, from the Duke University Medical Center, Division of Otolaryngology " Head & Neck Surgery, Durham, NC; and C. Gaelyn Garrett MD at Vanderbilt University Medical Center, Vanderbilt Voice Center, Nashville, TN. Their findings are being presented at the 110th Annual Meeting & OTO EXPO of the American Academy of Otolaryngology—Head and Neck Surgery Foundation, being held September 17-20, 2006, at the Metro Toronto Convention Centre, Toronto, Canada.

MethodsA medical records search at the Vanderbilt Voice Center were examined from January 2002 to September 2005 for vocal fold nodules and vocal fold polyps. Patients with a diagnosis of a vocal fold cyst or vocal fold polyp who had a trial of at least two sessions of speaking and/or singing voice therapy were included. Patients without a trial of voice therapy, no follow-up after initial evaluation, or with vocal fold nodules, Reinkes edema, leukoplakia, or granulomas were excluded.

Voice therapy was determined by the individual therapists and included managing vocal hygiene, breath support, laryngeal tension, and pitch. Medical management of other conditions (allergic rhinitis, GERD) was performed when necessary. Videostroboscopies were reviewed to confirm diagnosis. Demographic information, diagnosis, MTD, allergy and GER treatment, singing status, length of hoarseness, follow-up, and videostroboscopy parameters were collected. Voice improvement was the main outcome measure and was defined as the patient, at last follow-up, feeling that his/her voice improved sufficiently to meet his/her daily voice needs. Statistical analysis was performed with SigmaStat 2.03. Chi-square statistics or the Fisher Exact test was performed to assess associations between categorical data and the main outcome measure. The Rank Sum test analyzed the relationship between continuous variables and the main outcome measure. Multi-variate analysis was performed with multiple logistic regression.

Results57 patients meeting the inclusion criteria were identified. The mean age was 36 years with a range of 15 to 72 years with 22.8 percent male and 77.2 percent female. Patients had hoarseness for a mean 14.5 months and a range of one to 60 months. Cysts were diagnosed in 26.3 percent of patients and polyps in 73.7 percent. Voice improvement with voice therapy was achieved in 49.1 percent of patients, regardless of diagnosis. Four lesions, one cyst and three polyps, completely resolved. Surgery was required in one half of the subjects. Patients were followed for a mean 7.9 months with a range of two to 36 months. Comparisons were made between patients with translucent or partially transparent polyps against those with fibrotic, hyaline or hemorrhagic polyps. That comparison found:

(1) Patients with translucent or partially transparent polyps were roughly three times as likely to have an improved voice after therapy compared to those with fibrotic, hyaline or hemorrhagic polyps.

(2) The translucent polyp patient group were more likely to achieve complete vocal fold closure than those with fibrotic, hyaline or hemorrhagic polyps (54.5 percent versus 7.7 percent and 16.7 percent, respectively).

(3) After controlling for vocal fold closure, patients with translucent polyps were more likely to have an improved voice after voice therapy than those with fibrotic, hyaline or hemorrhagic polyps. The length of patients' hoarseness was not associated with voice improvement. Sex, smoking status, allergy treatment, singing status, mucosal wave, and GER treatment were not statistically significantly related to whether the voice improved after voice therapy.

ConclusionsThis research effort was undertaken to determine how often voice therapy results in hoarseness resolution in patients with polyps and cysts and to identify patients likely to respond to voice therapy. The results revealed that voice therapy was effective in improving patients' voices. Almost half of patients with vocal fold polyps and cysts had an improved voice at their last follow-up. While chronic dysphonia or altered voice for more than 12 months has been previously shown to be less responsive to voice therapy, this study found no association between length of hoarseness and treatment response.

Since only four lesions were completely resolved, the researchers believe that lesion disappearance is not essential for voice improvement. Although no differences were seen between polyps and cysts, polyp type was associated with voice improvement. Specifically, patients with translucent polyps were more than three times as likely to experience an improved voice than those with fibrotic, hyaline or hemorrhagic polyps. This may be due to the fact that translucent polyps may be more immature and more likely to respond to voice therapy. Other trends potentially related to voice improvement were identified. Using the voice in a more efficient manner, a patient's voice may improve despite the persistence of the polyp or cyst. Vocal fold closure may be important. Patients attaining vocal fold closure were 1.7 times more likely to have an improved voice after voice therapy.

Therefore, this study finds that voice therapy, as a first-line treatment, is effective in improving hoarseness in patients with vocal fold polyps and cysts. Patients with translucent polyps, objective findings of muscle tension dysphonia, and complete vocal fold closure, may be more likely to positively respond to voice therapy. These features may serve as a guide for laryngologists, allowing them to more efficiently direct patients unlikely to benefit from voice therapy to surgical treatment and recommending those likely to respond to a more in-depth voice therapy protocol.

Note: The American Academy of Otolaryngology—Head and Neck Surgery does not necessarily recommend the findings of this research study.