- Email: [email protected]
Resolution of Vocal Fold Polyps With Conservative Treatment
Resolution of Vocal Fold Polyps With Conservative Treatment *Hideki Nakagawa, †Makoto Miyamoto, ‡Toshiyuki Kusuyama, §Yuko Mori, and §Hiroyuki Fukuda, *zxTokyo, and yOsaka, Japan
Summary: Objectives. Vocal fold polyp is generally thought to require surgical removal. However, a certain proportion of polyps resolve with conservative treatment. This study was performed to clarify the frequency of spontaneous resolution of vocal fold polyp and identify features associated with polyps that are likely to resolve without surgery. Study Design. Retrospective study. Methods. A review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008. Results. Of 644 patients with the diagnosis of vocal fold polyp, 132 received conservative treatment, 433 were treated surgically, and 79 dropped out without attending for further consultation after the initial visit. Of those treated conservatively, 55 experienced complete resolution after a mean of 5.1 months of follow-up from the outset, and 29 showed lesion shrinkage after a mean of 4.1 months of follow-up. Polyps that resolved with conservative therapy were more likely than those that remained unchanged or enlarged to occur in women, be smaller, and have a shorter duration of symptoms. We could not determine the superiority of voice therapy. Conclusions. At least 9.7% of vocal fold polyps might resolve without surgery. Conservative treatment should be considered as an option for selected patients with smaller and more recent-onset polyps. Key Words: Vocal fold polyp–Voice therapy–Laryngomicrosurgery–Remission.
INTRODUCTION Vocal fold polyps are common benign laryngeal lesions, which can result in persistent hoarseness. They are red, white, or translucent elevated lesions located on the free edge of the true vocal fold at the junction of the anterior and middle third. They are thought to develop from vocal abuse, which causes rupture of the vessels in the superficial layer of the lamina propria, resulting in hematoma. Edema and inflammatory cell infiltration then result from this phonotrauma leading to the formation of new matrix. The presence of the lesion inhibits approximation of the vocal folds at the closed phase of the glottal cycle resulting in increased vocal effort and hoarseness. The increase in subglottic pressure and intralaryngeal muscle hyperfunction are thought to augment further phonotrauma, leading to persistent polyps. Surgery is preferred by many for vocal fold polyps.1 However, some phonosurgeons have observed that a certain proportion of polyps resolve without surgery.2–5 The number of reported cases is few, so the frequency of resolution and detailed characteristics of polyps that resolve are not well known. Moreover, there is no consensus with respect to recommending voice therapy for vocal fold polyps.6 The aim of this retrospective study was to clarify the frequency of spontaneous resolution of vocal fold polyps and characteristics associated with polyps that can be resolved Accepted for publication July 18, 2011. From the *Department of Otolaryngology, Seibo International Catholic Hospital, Tokyo, Japan; yDepartment of Otolaryngology-Head and Neck Surgery, Kansai Medical University, Osaka, Japan; zTokyo Voice Clinic, Tokyo, Japan; and the xTokyo Voice Center, International University of Health and Welfare, Tokyo, Japan. Address correspondence and reprint requests to Hideki Nakagawa, Department of Otolaryngology, Seibo International Catholic Hospital, 2-5-1 Nakaochiai, Shinjuku-ku, Tokyo 161-8521, Japan. E-mail: [email protected] Journal of Voice, Vol. 26, No. 3, pp. e107-e110 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.07.005
conservatively, with the ultimate goal of establishing a more accurate treatment strategy. MATERIALS AND METHODS This study was approved by the Institutional Review Board of Tokyo Voice Center, International University of Health and Welfare. We conducted a retrospective review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008. Vocal fold polyps were defined as persistent, unilateral, midmusculomembranous, true vocal fold lesions with typical hemorrhagic, fibrotic, or translucent characteristics. We excluded patients without follow-up after initial evaluation and those with bilateral vocal fold nodules, Reinke’s edema, leukoplakia, or granulomas. At the time of presentation, videostroboscopic analysis was performed by trained laryngologists to confirm the diagnosis. The polyps were subdivided by size into three categories: small (pinpoint base), medium (base greater than pinpoint size but less than one-third the length of the vocal fold), and large (base greater than one-third the length of the vocal fold), according to Klein et al.2 At this center, as at many medical facilities, vocal fold polyps are typically treated with laryngomicrosurgery. Most patients are referred for surgery by otolaryngologists outside the facility. Conservative treatment is indicated in patients who decline surgery, are at high risk for either operation or general anesthesia, or whose lesions improve while surgery is awaited. Among those treated conservatively, voice therapy or medication, or both were performed in accordance with the patients’ wishes. The voice therapy protocol was determined by the individual voice therapist but included the same general approach of counseling, managing vocal hygiene, and breath support. All patients were treated by trained speech therapists at a single institution with the intervals of the session of 1–4 weeks.
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Medication included a short course of steroid administration and/or steroid inhalation therapy. Statistical analysis was performed with Statview 4.5 (Abacus Software, Burlington, MA). Unpaired t test and chi-squared test were performed to assess associations between the surgical and nonsurgical groups. RESULTS Of 644 patients with the diagnosis of vocal fold polyp, we identified 132 who received conservative treatment. Regarding those excluded, 433 patients were treated surgically, and 79 did not attend for further consultation after the initial diagnosis. The average age of patients in the conservative treatment group was 47.8 years with a range of 20–83 years. Of the 132 patients, 74 were female (56.1%) and 58 were male (43.9%). At presentation, patients had experienced hoarseness for a mean of 7.3 months with a range of 0 days (polyp found incidentally at the consultation) to 20 years. On videostroboscopy, 26 polyps were large, 58 were medium-sized, and 48 were small (Table 1). Of the 132 patients who underwent conservative treatment, 55 (41.7%) demonstrated complete resolution of the polyps after a mean of 5.1 months of follow-up, and 29 (21.9%) had lesion shrinkage and were satisfied with the outcome in terms of their voice after a mean of 4.1 months of follow-up (Table 2). The remaining 48 (36.4%) patients showed no change or enlargement of the lesions, 17 of them were fairly satisfied with their voice despite the existence of the polyps, and 31 of them, including 14 to whom surgery was recommended, dropped out after a mean of 3.2 months of follow-up. Comparing those who showed complete remission with those who showed neither remission nor shrinkage, the former group had a greater proportion of women (58.2% vs 41.7%), small lesions (45.4% vs 22.9%), and a shorter duration of symptom (2.8 weeks vs 13.9 weeks). Figure 1 shows representative findings of a vocal fold polyp that underwent complete remission. None of the patients who experienced complete resolution of polyps returned with lesion recurrence. Voice therapy was performed for 38 patients, 24 of them received medication and 14 were treated by voice therapy only.
Ten (26.3%) patients who received voice therapy showed complete remission and eight (21.1%) showed lesion shrinkage. On the other hand, of the 94 patients who did not have voice therapy, 45 (47.9%) experienced complete remission, 20 (21.3%) showed lesion shrinkage. Thirty-four of them received medication, and the remaining 60 patients received neither voice therapy nor medication (Table 3). The average age of the surgical treatment group was 46.7 years with a range of 8–81 years; 234 of 433 subjects were female (54.0%) and 199 were male (46.0%). Patients had experienced hoarseness for a mean of 9.8 months and a range of 0 days (polyp found incidentally at the consultation) to 15 years. On videostroboscopy, 180 polyps were large, 206 were medium sized, and 47 were small (Table 1). The duration between first consultation and excision averaged 1.4 months. Total followup period after laryngomicrosurgery averaged 4.9 months. Most subjects reported vocal improvement but 26 (6.0%) experienced lesion recurrence. DISCUSSION Vocal fold polyp is a common disorder of the larynx, typically observed as unilateral masses of the free edge of the vocal fold. Most phonosurgeons consider surgery to be the mainstay of treatment of these lesions.1 On the other hand, a certain number of patients experience complete remission or lesion shrinkage without surgery. In a series of 16 patients who underwent conservative therapy for vocal fold hemorrhagic polyps, Klein et al2 reported that nine patients experienced lesion resolution. In other series, 4 of 57 polyps and cysts completely resolved with voice therapy,3 lesion remission was seen for 4 of 42 vocal polyps treated conservatively.4 The present study found that 55 of 132 patients treated conservatively experienced complete remission of their polyps. Including surgically treated patients, at least 55 of 565 (9.7%) showed complete remission conservatively. Comparing patients in the present study who showed complete remission with those who did not show either remission or shrinkage, the former group had a greater proportion of women, small lesions, and a shorter duration of symptoms.
TABLE 1. Characteristics of Patients Diagnosed With Vocal Fold Polyp Treatment Number of patients, n Mean age (y) Age range (y) Number of women (%) Number of men (%) Mean duration of symptoms (mo) Size of polyp Large, n Medium, n Small, n * Unpaired t test. y Chi-squared test.
Conservative
Surgical
132 47.8 20–83 74 (56.1%) 58 (43.9%) 7.3
433 46.7 8–81 234 (54.0%) 199 (46.0%) 9.8
26 (19.7%) 58 (43.9%) 48 (36.4%)
180 (41.6%) 206 (47.6%) 47 (10.8%)
P Value 0.4* 0.7y 0.2*
Hideki Nakagawa, et al
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Resolution of Vocal Fold Polyps With Conservative Treatment
TABLE 2. Outcome of Conservative Treatment Outcome Number of patients, n Mean age (years) Age range (years) Number of women (%) Number of men (%) Mean duration of symptoms (mo) Size of polyp Large, n Medium, n Small, n Follow-up period until remission (shrinkage) (mo)
CR
S
NC
55 53.3 22–83 32 (58.2%) 23 (41.8%) 2.8
29 50.0 20–77 22 (75.9%) 7 (24.1%) 2.8
48 40.1 21–67 20 (41.7%) 28 (58.3%) 15.0
3 (5.5%) 27 (49.1%) 25 (45.4%) 5.1
5 (17.3%) 13 (44.8%) 11 (37.9%) 4.1
18 (37.5%) 19 (39.6%) 11 (22.9%) 6.0*
Abbreviations: CR, complete remission; S, shrinkage; NC, no change in size or enlargement. * Mean follow-up period.
Similarly, Klein et al stated that patients with a recent onset of symptoms and a small polyp may represent the group best suited for nonsurgical therapy because the resolution rate is correlated to the duration of the lesion, with new polyps more
FIGURE 1. Appearance of the vocal folds in a 50-year-old woman. A. Appearance at the first visit. A hemispherical polyp is seen on the free edge of the right vocal fold. B. Appearance at follow-up, 2.5 months later. The polyp has completely resolved.
likely to resolve than older ones.2 It is unclear why lesions in women are more likely to resolve than those in men. One possible reason is that female patients may be better at avoiding vocal abuse, resulting in lower subglottic pressure and a reduced tendency for laryngeal muscle hyperfunction. The exact process by which vocal fold polyps undergo resolution is unknown. It is surmised that the underlying tissue remodeling involved in polyp formation eventually leads to absorption of the polyp back into the mucosal fold.7 Another possibility is that ongoing phonotrauma continues to narrow the polyp base as the lesion matures and the shearing forces during phonation may eventually tear the polyp from the folds.2 The present retrospective study could not show voice therapy as an effective treatment of vocal fold polyps. Cohen and Garrett3 stated that voice therapy as a first line treatment is effective in improving hoarseness in patients with vocal fold polyps. However, they did not compare the objects with the patients who did not have voice therapy trial. Analysis of a survey of members of the American Academy of OtolaryngologyHead and Neck Surgery demonstrated a substantial lack of consensus regarding the use of voice therapy for vocal fold polyps.6 The efficacy of steroid therapy for the vocal fold polyps has been mentioned,8 however, it was not proved by the present study. The retrospective nature of the present study means that it is difficult to eliminate bias; hence, further studies will be needed to verify the effectiveness of voice therapy for vocal fold polyps. The resolution of vocal fold polyps by conservative treatment took an average of 5.1 months. In contrast, one of the greatest benefits of surgery is a quick recovery, and operative treatment is accordingly recommended for patients for whom this is an important consideration. On the other hand, although laryngomicrosurgery is considered a standard treatment for vocal fold polyp, there are costs and risks associated with general anesthesia, hospitalization, strict postoperative voice rest, and of course, the operation itself, including vocal fold scarring. Conservative treatment should therefore be considered as an option for selected patients with smaller and more recent polyps.
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TABLE 3. Outcome of Conservative Treatment Treatment
CR
S
NC
Total
VT With medication Without medication
10 (26.3%) 6 (25.0%) 4 (28.6%)
8 (21.1%) 6 (25.0%) 2 (14.3%)
20 (52.6%) 12 (50.0%) 8 (57.1%)
38 24 14
Non-VT With medication Without medication
45 (47.9%) 15 (44.1%) 30 (50.0%)
20 (21.3%) 9 (26.5%) 11 (18.3%)
29 (30.8%) 10 (29.4%) 19 (31.7%)
94 34 60
Abbreviations: CR, complete remission; S, shrinkage; NC, no change in size or enlargement; VT, voice therapy.
CONCLUSION Our findings suggest that about 10% of vocal fold polyps could be resolved with conservative treatment. Although the standard treatment for these lesions is undoubtedly surgery, it is important to avoid unnecessary operations. If polyps are relatively small or of recent onset, it may be reasonable to observe the patient for several months with the expectation of resolution, as long as there is no demand for quick recovery. Further studies incorporating aerodynamic measurements and acoustic analysis, preferably prospective randomized controlled trials, will be necessary to provide more precise information regarding the likelihood of resolution of vocal fold polyps. REFERENCES 1. Benjamin B. Vocal cord polyps. In: Benjamin B, ed. Endolaryngeal Surgery. London, UK: Martin Dunitz; 1998:237–240.
2. Klein AM, Lehmann M, Hapner ER, Johns MM 3rd. Spontaneous resolution of hemorrhagic polyps of the true vocal fold. J Voice. 2009;23: 132–135. 3. Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Head Neck Surg. 2007;136:742–746. 4. Srirompotong S, Saeseow P, Vatanasapt P. Small vocal cord polyps: completely resolved with conservative treatment. Southeast Asian J Trop Med Public Health. 2004;35:169–171. 5. Lourenc¸o EA, Costa LH. Angyomatous vocal polypus–a complete spontaneous regression. Sao Paulo Med J. 1996;114:1162–1165. 6. Sulica L, Behrman A. Management of benign vocal fold lesions: a survey of current opinion and practice. Ann Otol Rhinol Laryngol. 2003;112: 827–833. 7. Courey MS, Shohet JA, Scott MA, Ossoff RH. Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol. 1996; 105:525–531. 8. Sataloff RT. Structural abnormalities of the larynx. In: Sataloff RT, ed. Professional Voice: The Science and Art of Clinical Care. 2nd ed. San Diego, CA: Singular Publishing Group; 1997:509–540.
Summary: Objectives. Vocal fold polyp is generally thought to require surgical removal. However, a certain proportion of polyps resolve with conservative treatment. This study was performed to clarify the frequency of spontaneous resolution of vocal fold polyp and identify features associated with polyps that are likely to resolve without surgery. Study Design. Retrospective study. Methods. A review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008. Results. Of 644 patients with the diagnosis of vocal fold polyp, 132 received conservative treatment, 433 were treated surgically, and 79 dropped out without attending for further consultation after the initial visit. Of those treated conservatively, 55 experienced complete resolution after a mean of 5.1 months of follow-up from the outset, and 29 showed lesion shrinkage after a mean of 4.1 months of follow-up. Polyps that resolved with conservative therapy were more likely than those that remained unchanged or enlarged to occur in women, be smaller, and have a shorter duration of symptoms. We could not determine the superiority of voice therapy. Conclusions. At least 9.7% of vocal fold polyps might resolve without surgery. Conservative treatment should be considered as an option for selected patients with smaller and more recent-onset polyps. Key Words: Vocal fold polyp–Voice therapy–Laryngomicrosurgery–Remission.
INTRODUCTION Vocal fold polyps are common benign laryngeal lesions, which can result in persistent hoarseness. They are red, white, or translucent elevated lesions located on the free edge of the true vocal fold at the junction of the anterior and middle third. They are thought to develop from vocal abuse, which causes rupture of the vessels in the superficial layer of the lamina propria, resulting in hematoma. Edema and inflammatory cell infiltration then result from this phonotrauma leading to the formation of new matrix. The presence of the lesion inhibits approximation of the vocal folds at the closed phase of the glottal cycle resulting in increased vocal effort and hoarseness. The increase in subglottic pressure and intralaryngeal muscle hyperfunction are thought to augment further phonotrauma, leading to persistent polyps. Surgery is preferred by many for vocal fold polyps.1 However, some phonosurgeons have observed that a certain proportion of polyps resolve without surgery.2–5 The number of reported cases is few, so the frequency of resolution and detailed characteristics of polyps that resolve are not well known. Moreover, there is no consensus with respect to recommending voice therapy for vocal fold polyps.6 The aim of this retrospective study was to clarify the frequency of spontaneous resolution of vocal fold polyps and characteristics associated with polyps that can be resolved Accepted for publication July 18, 2011. From the *Department of Otolaryngology, Seibo International Catholic Hospital, Tokyo, Japan; yDepartment of Otolaryngology-Head and Neck Surgery, Kansai Medical University, Osaka, Japan; zTokyo Voice Clinic, Tokyo, Japan; and the xTokyo Voice Center, International University of Health and Welfare, Tokyo, Japan. Address correspondence and reprint requests to Hideki Nakagawa, Department of Otolaryngology, Seibo International Catholic Hospital, 2-5-1 Nakaochiai, Shinjuku-ku, Tokyo 161-8521, Japan. E-mail: [email protected] Journal of Voice, Vol. 26, No. 3, pp. e107-e110 0892-1997/$36.00 Ó 2012 The Voice Foundation doi:10.1016/j.jvoice.2011.07.005
conservatively, with the ultimate goal of establishing a more accurate treatment strategy. MATERIALS AND METHODS This study was approved by the Institutional Review Board of Tokyo Voice Center, International University of Health and Welfare. We conducted a retrospective review of the medical records of patients diagnosed with vocal fold polyps in Tokyo Voice Center from January 2001 to December 2008. Vocal fold polyps were defined as persistent, unilateral, midmusculomembranous, true vocal fold lesions with typical hemorrhagic, fibrotic, or translucent characteristics. We excluded patients without follow-up after initial evaluation and those with bilateral vocal fold nodules, Reinke’s edema, leukoplakia, or granulomas. At the time of presentation, videostroboscopic analysis was performed by trained laryngologists to confirm the diagnosis. The polyps were subdivided by size into three categories: small (pinpoint base), medium (base greater than pinpoint size but less than one-third the length of the vocal fold), and large (base greater than one-third the length of the vocal fold), according to Klein et al.2 At this center, as at many medical facilities, vocal fold polyps are typically treated with laryngomicrosurgery. Most patients are referred for surgery by otolaryngologists outside the facility. Conservative treatment is indicated in patients who decline surgery, are at high risk for either operation or general anesthesia, or whose lesions improve while surgery is awaited. Among those treated conservatively, voice therapy or medication, or both were performed in accordance with the patients’ wishes. The voice therapy protocol was determined by the individual voice therapist but included the same general approach of counseling, managing vocal hygiene, and breath support. All patients were treated by trained speech therapists at a single institution with the intervals of the session of 1–4 weeks.
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Journal of Voice, Vol. 26, No. 3, 2012
Medication included a short course of steroid administration and/or steroid inhalation therapy. Statistical analysis was performed with Statview 4.5 (Abacus Software, Burlington, MA). Unpaired t test and chi-squared test were performed to assess associations between the surgical and nonsurgical groups. RESULTS Of 644 patients with the diagnosis of vocal fold polyp, we identified 132 who received conservative treatment. Regarding those excluded, 433 patients were treated surgically, and 79 did not attend for further consultation after the initial diagnosis. The average age of patients in the conservative treatment group was 47.8 years with a range of 20–83 years. Of the 132 patients, 74 were female (56.1%) and 58 were male (43.9%). At presentation, patients had experienced hoarseness for a mean of 7.3 months with a range of 0 days (polyp found incidentally at the consultation) to 20 years. On videostroboscopy, 26 polyps were large, 58 were medium-sized, and 48 were small (Table 1). Of the 132 patients who underwent conservative treatment, 55 (41.7%) demonstrated complete resolution of the polyps after a mean of 5.1 months of follow-up, and 29 (21.9%) had lesion shrinkage and were satisfied with the outcome in terms of their voice after a mean of 4.1 months of follow-up (Table 2). The remaining 48 (36.4%) patients showed no change or enlargement of the lesions, 17 of them were fairly satisfied with their voice despite the existence of the polyps, and 31 of them, including 14 to whom surgery was recommended, dropped out after a mean of 3.2 months of follow-up. Comparing those who showed complete remission with those who showed neither remission nor shrinkage, the former group had a greater proportion of women (58.2% vs 41.7%), small lesions (45.4% vs 22.9%), and a shorter duration of symptom (2.8 weeks vs 13.9 weeks). Figure 1 shows representative findings of a vocal fold polyp that underwent complete remission. None of the patients who experienced complete resolution of polyps returned with lesion recurrence. Voice therapy was performed for 38 patients, 24 of them received medication and 14 were treated by voice therapy only.
Ten (26.3%) patients who received voice therapy showed complete remission and eight (21.1%) showed lesion shrinkage. On the other hand, of the 94 patients who did not have voice therapy, 45 (47.9%) experienced complete remission, 20 (21.3%) showed lesion shrinkage. Thirty-four of them received medication, and the remaining 60 patients received neither voice therapy nor medication (Table 3). The average age of the surgical treatment group was 46.7 years with a range of 8–81 years; 234 of 433 subjects were female (54.0%) and 199 were male (46.0%). Patients had experienced hoarseness for a mean of 9.8 months and a range of 0 days (polyp found incidentally at the consultation) to 15 years. On videostroboscopy, 180 polyps were large, 206 were medium sized, and 47 were small (Table 1). The duration between first consultation and excision averaged 1.4 months. Total followup period after laryngomicrosurgery averaged 4.9 months. Most subjects reported vocal improvement but 26 (6.0%) experienced lesion recurrence. DISCUSSION Vocal fold polyp is a common disorder of the larynx, typically observed as unilateral masses of the free edge of the vocal fold. Most phonosurgeons consider surgery to be the mainstay of treatment of these lesions.1 On the other hand, a certain number of patients experience complete remission or lesion shrinkage without surgery. In a series of 16 patients who underwent conservative therapy for vocal fold hemorrhagic polyps, Klein et al2 reported that nine patients experienced lesion resolution. In other series, 4 of 57 polyps and cysts completely resolved with voice therapy,3 lesion remission was seen for 4 of 42 vocal polyps treated conservatively.4 The present study found that 55 of 132 patients treated conservatively experienced complete remission of their polyps. Including surgically treated patients, at least 55 of 565 (9.7%) showed complete remission conservatively. Comparing patients in the present study who showed complete remission with those who did not show either remission or shrinkage, the former group had a greater proportion of women, small lesions, and a shorter duration of symptoms.
TABLE 1. Characteristics of Patients Diagnosed With Vocal Fold Polyp Treatment Number of patients, n Mean age (y) Age range (y) Number of women (%) Number of men (%) Mean duration of symptoms (mo) Size of polyp Large, n Medium, n Small, n * Unpaired t test. y Chi-squared test.
Conservative
Surgical
132 47.8 20–83 74 (56.1%) 58 (43.9%) 7.3
433 46.7 8–81 234 (54.0%) 199 (46.0%) 9.8
26 (19.7%) 58 (43.9%) 48 (36.4%)
180 (41.6%) 206 (47.6%) 47 (10.8%)
P Value 0.4* 0.7y 0.2*
Hideki Nakagawa, et al
e109
Resolution of Vocal Fold Polyps With Conservative Treatment
TABLE 2. Outcome of Conservative Treatment Outcome Number of patients, n Mean age (years) Age range (years) Number of women (%) Number of men (%) Mean duration of symptoms (mo) Size of polyp Large, n Medium, n Small, n Follow-up period until remission (shrinkage) (mo)
CR
S
NC
55 53.3 22–83 32 (58.2%) 23 (41.8%) 2.8
29 50.0 20–77 22 (75.9%) 7 (24.1%) 2.8
48 40.1 21–67 20 (41.7%) 28 (58.3%) 15.0
3 (5.5%) 27 (49.1%) 25 (45.4%) 5.1
5 (17.3%) 13 (44.8%) 11 (37.9%) 4.1
18 (37.5%) 19 (39.6%) 11 (22.9%) 6.0*
Abbreviations: CR, complete remission; S, shrinkage; NC, no change in size or enlargement. * Mean follow-up period.
Similarly, Klein et al stated that patients with a recent onset of symptoms and a small polyp may represent the group best suited for nonsurgical therapy because the resolution rate is correlated to the duration of the lesion, with new polyps more
FIGURE 1. Appearance of the vocal folds in a 50-year-old woman. A. Appearance at the first visit. A hemispherical polyp is seen on the free edge of the right vocal fold. B. Appearance at follow-up, 2.5 months later. The polyp has completely resolved.
likely to resolve than older ones.2 It is unclear why lesions in women are more likely to resolve than those in men. One possible reason is that female patients may be better at avoiding vocal abuse, resulting in lower subglottic pressure and a reduced tendency for laryngeal muscle hyperfunction. The exact process by which vocal fold polyps undergo resolution is unknown. It is surmised that the underlying tissue remodeling involved in polyp formation eventually leads to absorption of the polyp back into the mucosal fold.7 Another possibility is that ongoing phonotrauma continues to narrow the polyp base as the lesion matures and the shearing forces during phonation may eventually tear the polyp from the folds.2 The present retrospective study could not show voice therapy as an effective treatment of vocal fold polyps. Cohen and Garrett3 stated that voice therapy as a first line treatment is effective in improving hoarseness in patients with vocal fold polyps. However, they did not compare the objects with the patients who did not have voice therapy trial. Analysis of a survey of members of the American Academy of OtolaryngologyHead and Neck Surgery demonstrated a substantial lack of consensus regarding the use of voice therapy for vocal fold polyps.6 The efficacy of steroid therapy for the vocal fold polyps has been mentioned,8 however, it was not proved by the present study. The retrospective nature of the present study means that it is difficult to eliminate bias; hence, further studies will be needed to verify the effectiveness of voice therapy for vocal fold polyps. The resolution of vocal fold polyps by conservative treatment took an average of 5.1 months. In contrast, one of the greatest benefits of surgery is a quick recovery, and operative treatment is accordingly recommended for patients for whom this is an important consideration. On the other hand, although laryngomicrosurgery is considered a standard treatment for vocal fold polyp, there are costs and risks associated with general anesthesia, hospitalization, strict postoperative voice rest, and of course, the operation itself, including vocal fold scarring. Conservative treatment should therefore be considered as an option for selected patients with smaller and more recent polyps.
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TABLE 3. Outcome of Conservative Treatment Treatment
CR
S
NC
Total
VT With medication Without medication
10 (26.3%) 6 (25.0%) 4 (28.6%)
8 (21.1%) 6 (25.0%) 2 (14.3%)
20 (52.6%) 12 (50.0%) 8 (57.1%)
38 24 14
Non-VT With medication Without medication
45 (47.9%) 15 (44.1%) 30 (50.0%)
20 (21.3%) 9 (26.5%) 11 (18.3%)
29 (30.8%) 10 (29.4%) 19 (31.7%)
94 34 60
Abbreviations: CR, complete remission; S, shrinkage; NC, no change in size or enlargement; VT, voice therapy.
CONCLUSION Our findings suggest that about 10% of vocal fold polyps could be resolved with conservative treatment. Although the standard treatment for these lesions is undoubtedly surgery, it is important to avoid unnecessary operations. If polyps are relatively small or of recent onset, it may be reasonable to observe the patient for several months with the expectation of resolution, as long as there is no demand for quick recovery. Further studies incorporating aerodynamic measurements and acoustic analysis, preferably prospective randomized controlled trials, will be necessary to provide more precise information regarding the likelihood of resolution of vocal fold polyps. REFERENCES 1. Benjamin B. Vocal cord polyps. In: Benjamin B, ed. Endolaryngeal Surgery. London, UK: Martin Dunitz; 1998:237–240.
2. Klein AM, Lehmann M, Hapner ER, Johns MM 3rd. Spontaneous resolution of hemorrhagic polyps of the true vocal fold. J Voice. 2009;23: 132–135. 3. Cohen SM, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Head Neck Surg. 2007;136:742–746. 4. Srirompotong S, Saeseow P, Vatanasapt P. Small vocal cord polyps: completely resolved with conservative treatment. Southeast Asian J Trop Med Public Health. 2004;35:169–171. 5. Lourenc¸o EA, Costa LH. Angyomatous vocal polypus–a complete spontaneous regression. Sao Paulo Med J. 1996;114:1162–1165. 6. Sulica L, Behrman A. Management of benign vocal fold lesions: a survey of current opinion and practice. Ann Otol Rhinol Laryngol. 2003;112: 827–833. 7. Courey MS, Shohet JA, Scott MA, Ossoff RH. Immunohistochemical characterization of benign laryngeal lesions. Ann Otol Rhinol Laryngol. 1996; 105:525–531. 8. Sataloff RT. Structural abnormalities of the larynx. In: Sataloff RT, ed. Professional Voice: The Science and Art of Clinical Care. 2nd ed. San Diego, CA: Singular Publishing Group; 1997:509–540.