Cases Demonstrate Difficulty of Treating Tricky Vocal Fold Cysts

Gayle Woodson, MD, Chair of the Otolaryngology-Head and Neck Division at Southern Illinois University in Springfield, said that in cases in which patients have not been abusing their voices and have no history of voice problems, the lesion might be more likely to go away on its own, without surgery. I think the history of the patient makes some difference, she said.

Jamie A. Koufman, MD, Director of the Voice Institute of New York, who moderated the panel and presented the cases, said that she considered the lesion to be a pseudocyst, and not a polyp, because it was unilateral; associated with a bowed, hypomobile vocal fold; and seemed to be seen within that clinical constellation.

Dr. Koufman did remove the lesion, and the patient began voice therapy. After two and a half months, the patient started to develop a new lesion. Dr. Koufman then performed a bilateral medialization and reported, She’s been fine ever since.

I think a lot of these patients have glottal closure problems and that’s why they develop striking-zone pathology, she said.

Dr. Woodson asked how, without enough closure, there could be trauma that leads to the lesion. Her opinion, Dr. Koufman said, was that the strain on the laryngeal muscles from trying to achieve closure creates more severe shearing force. This will lead to injury on one side, which has the effect of protecting the other side, which continues to work and divert the air to the injured side. That, in turn, leads to more injury on the problem side.

It’s very similar to saloon doors, she said. If you were to take one of the wooden doors off and hang a bunch of balloons in its place, and blow air through there, the good door would never move again. The surface area of the injured, balloon side, would take all the heat. So I think that’s what happens.

Case 2: Recurrent Laryngitis

Another case involved a 45-year-old film producer who was otherwise healthy. She had had lifelong problems with recurrent laryngitis and had had a raspy voice since her school days. In the past year, her voice symptoms had gotten worse and become chronic. Her score on the glottal closure index was a dismal 20, the maximum score.

Everyone agreed that what was found on the right vocal fold was a keratin cyst-the real deal cyst, Dr. Koufman said (see Figure 2).