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

1. Mucous retention cysts (more common than epidermoid cysts): Develop when a mucous gland duct becomes obstructed to retain glandular secretions (Altman 2007).
2. 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

1. More common in female, possible variation in size with menstrual cycle.
2. More common in professional voice users (particularly for epidermal cysts rather than mucous retention cyst).

HISTOPATHOLOGY:

1. Mucous retention cyst: cysts are covered in doublelayered cylindrical, cuboidal or flattened ductal epithelium.
2. Epidermoid cyst: cysts are lined with atrophic keratinising epithelium with intraluminal stratified basophilic keratin scales.

CLINICAL PRESENTATION

1. Symptoms
   1. Hoarseness, breathiness, vocal fatigue, inability to produce voice with soft volume and decreased vocal range.
2. Signs
   1. Strobolaryngoscopy findings
      1. asymmetric vocal folds with occasional evidence of subepithelial mass causing significantly decreased or absent mucosal wave
         1. In contrast to cysts, the mucosal wave is often preserved with vocal fold polyps (Altman 2007)

MANAGEMENT

1. Review of Recent Literature
   1.  Marsupialization - management of retention cysts (mucus content) - treated with Microendoscopy with Marsupialization (Hsu 2009)
      1. Procedure done in 25 patients:
         1. Removal of a 'disk-like portion of the cystic wall and overlying mucosa'
         2. Residual cystic lining at the base overlying the vocal ligament is preserved intact (no microsutures)
         3. 7 treated with concurrent medialization laryngoplasty with strap muscle transposition
         4. 23/25 patients with subjective vocal improvement, recurrent cyst in 1/25
      2. Authors conclude 'standard method of treatment for vocal fold cysts still not well established
         1. Rationale for their approach: total removal difficult and increases risk of compromising the vocal ligament
         2. They conclude that total enucleation of the cyst often results in vocal fold deficit, sulcus formation, scarring
   2.  Microflap subepithelial dissection with subepithelial infusion (Burns 2009)
      1. Procedure done in 10 patients (singers)
         1. Infuse saline with 1/10,000 epinephrine
         2. Cordotomy followed by blunt dissection between cyst capsule and underlying normal superficial lamina propria (SLP; ie. Reinke space) when possible
         3. Endeavor to avoid cyst rupture; if it happens, the decompressed capsule may be dissected from the epithelial basement membrane
         4. Every attempt is made to preserve the overlying epithelium.
         5. 2 weeks of complete voice rest
      2. Improved contour to vocal cord, better glottic closure, and improved mucosal wave propagation
         1. All 10 singers returned to high performance vocal activities within 6 weeks of surgery
         2. Investigators experience:
            1. Recommend against draining the cyst w/o resection: higher recurrence
            2. Problems with microdissection for removal: the cyst replacing substantial amounts of the "SLP" and diminished pliability may result from microdissection
            3. Good results seen in these investigators experience with attention to key maneuvers (in addition to above):
               1. 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
               2. Sharp dissection may be necessary if greater degrees of inflammation present
               3. Counsel the patients about possibility of the voice worsening with the procedure
2. U of Iowa Approach
   1. Patients with dysphonia and clinical findings of benign vocal fold lesions are evaluated through the multidisciplinary VOICE CLINIC
      1. Includes Speech Pathologist and Otolaryngologist with videostrobosocpy and vocal function analysis
      2. Selected cases (singers) may warrant inclusion of a vocologist as well as visitors - such as the patient's singing teacher
   2. Vocal fold cysts (classic presentation)
      1. Voice therapy as initial treatment (2 sessions per week for six weeks - modify according to response)
      2. Handouts: Handout: Voice Conservation, Handout: Esophageal Reflux Precautions, Handout: Homeopathic Throat Soothers + other
      3. Consider surgery
         1. Persistence of symptoms associated with identifiable lesions after adequate course of voice therapy
         2. In general: ensure the vocal behavior is appropriate before offering surgery
         3. Operative intervention for nodules : see video
   3. Vocal fold polyps and cysts (classic presentations) see also: Polyps Nodules Cysts
      1. Voice therapy may offered as an alternative to surgery if appropriately analyzed patients
      2. Observation without intervention is an option if malignancy and airway compromise are considered unlikely; followup evaluation usually suggested
      3. Voice therapy is suggested treatment for patients with evidence for voice disorders that are identified in addition to the presence of the lesion
      4. Voice therapy before surgery is considered to diminish risk of recurrence after surgery
      5. Indications for surgery
         1. Desires of well informed patient after counseling about options.
         2. Concern about malignancy (biopsy)
         3. Concern about airway compromise (large polyps, Reinke's space edema - see examples)

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.