Return to: Management of Specific Voice Disorders; Laryngeal Surgery (Benign Disease) Protocols
Also see: Case Example Vocal Fold Cyst Surgery
DEFINITIONS and ETIOLOGY: subepidermal epithelial-lined sacs within the lamina propria
- Mucous retention cysts (more common than epidermoid cysts): Develop when a mucous gland duct becomes obstructed to retain glandular secretions (Altman 2007).
- Epidermoid cysts (rare): Contain accumulated keratin. Develop either from congenital cell nests in the subepithelium of the fourth and sixth branchial arches or from healing injured mucosa burying epithelium (Altman 2007).
EPIDEMIOLOGY
- More common in female, possible variation in size with menstrual cycle.
- More common in professional voice users (particularly for epidermal cysts rather than mucous retention cyst).
HISTOPATHOLOGY:
- Mucous retention cyst: cysts are covered in doublelayered cylindrical, cuboidal or flattened ductal epithelium.
- Epidermoid cyst: cysts are lined with atrophic keratinising epithelium with intraluminal stratified basophilic keratin scales.
CLINICAL PRESENTATION
- Symptoms
- Hoarseness, breathiness, vocal fatigue, inability to produce voice with soft volume and decreased vocal range.
- Signs
- Strobolaryngoscopy findings
- asymmetric vocal folds with occasional evidence of subepithelial mass causing significantly decreased or absent mucosal wave
- In contrast to cysts, the mucosal wave is often preserved with vocal fold polyps (Altman 2007)
- asymmetric vocal folds with occasional evidence of subepithelial mass causing significantly decreased or absent mucosal wave
- Strobolaryngoscopy findings
MANAGEMENT
- Review of Recent Literature
- Marsupialization - management of retention cysts (mucus content) - treated with Microendoscopy with Marsupialization (Hsu 2009)
- Procedure done in 25 patients:
- Removal of a 'disk-like portion of the cystic wall and overlying mucosa'
- Residual cystic lining at the base overlying the vocal ligament is preserved intact (no microsutures)
- 7 treated with concurrent medialization laryngoplasty with strap muscle transposition
- 23/25 patients with subjective vocal improvement, recurrent cyst in 1/25
- Authors conclude 'standard method of treatment for vocal fold cysts still not well established
- Rationale for their approach: total removal difficult and increases risk of compromising the vocal ligament
- They conclude that total enucleation of the cyst often results in vocal fold deficit, sulcus formation, scarring
- Procedure done in 25 patients:
- Microflap subepithelial dissection with subepithelial infusion (Burns 2009)
- Procedure done in 10 patients (singers)
- Infuse saline with 1/10,000 epinephrine
- Cordotomy followed by blunt dissection between cyst capsule and underlying normal superficial lamina propria (SLP; ie. Reinke space) when possible
- Endeavor to avoid cyst rupture; if it happens, the decompressed capsule may be dissected from the epithelial basement membrane
- Every attempt is made to preserve the overlying epithelium.
- 2 weeks of complete voice rest
- Improved contour to vocal cord, better glottic closure, and improved mucosal wave propagation
- All 10 singers returned to high performance vocal activities within 6 weeks of surgery
- Investigators experience:
- Recommend against draining the cyst w/o resection: higher recurrence
- Problems with microdissection for removal: the cyst replacing substantial amounts of the "SLP" and diminished pliability may result from microdissection
- Good results seen in these investigators experience with attention to key maneuvers (in addition to above):
- Small amount of soft tissue left at the anterior and posterior aspects of the cyst to provide a purchase for retraction - avoid rupture of cyst
- Sharp dissection may be necessary if greater degrees of inflammation present
- Counsel the patients about possibility of the voice worsening with the procedure
- Procedure done in 10 patients (singers)
- Marsupialization - management of retention cysts (mucus content) - treated with Microendoscopy with Marsupialization (Hsu 2009)
- U of Iowa Approach
- Patients with dysphonia and clinical findings of benign vocal fold lesions are evaluated through the multidisciplinary VOICE CLINIC
- Includes Speech Pathologist and Otolaryngologist with videostrobosocpy and vocal function analysis
- Selected cases (singers) may warrant inclusion of a vocologist as well as visitors - such as the patient's singing teacher
- Vocal fold cysts (classic presentation)
- Voice therapy as initial treatment (2 sessions per week for six weeks - modify according to response)
- Handouts: Handout: Voice Conservation, Handout: Esophageal Reflux Precautions, Handout: Homeopathic Throat Soothers + other
- Consider surgery
- Persistence of symptoms associated with identifiable lesions after adequate course of voice therapy
- In general: ensure the vocal behavior is appropriate before offering surgery
- Operative intervention for nodules : see video
- Vocal fold polyps and cysts (classic presentations) see also: Polyps Nodules Cysts
- Voice therapy may offered as an alternative to surgery if appropriately analyzed patients
- Observation without intervention is an option if malignancy and airway compromise are considered unlikely; followup evaluation usually suggested
- Voice therapy is suggested treatment for patients with evidence for voice disorders that are identified in addition to the presence of the lesion
- Voice therapy before surgery is considered to diminish risk of recurrence after surgery
- Indications for surgery
- Desires of well informed patient after counseling about options.
- Concern about malignancy (biopsy)
- Concern about airway compromise (large polyps, Reinke's space edema - see examples)
- Patients with dysphonia and clinical findings of benign vocal fold lesions are evaluated through the multidisciplinary VOICE CLINIC
REFERENCES
Hsu C-M, Armas GL, and Su C-Y: Marsupialization of Vocal Fold Retention Cysts: Voice Assessment and Surgical Outcomes Annals of Otology, Rhinology & Laryngology 118(4):270-275
Burns JA, Hillman RE, Stadelman-Cohen T, Zeitels SM.Phonomicrosurgical treatment of intracordal vocal-fold cysts in singers Laryngoscope. 2009 Feb;119(2):419-22.
Altman KW: Vocal Fold Masses in Otolaryngol Clin N Am 40 (2007) 1091-1108
Gale N, Cardesa A, Zidar N. Larynx and hypopharynx. In: Cardesa A, Slootweg P, eds. Pathology of head and neck. Springer Berlin Heidelberg; 2006:197-234. 10.1007/3-540-30629-3.