Overview:
A vocal fold cyst is a benign, collection of fluid that is located within the membrane of the vocal fold. The vocal folds are lined with many small glands that secrete mucous to help the vocal folds move easily, but when they do not drain properly the fluid build up into a sac-like structure, or a cyst.
There are two types of vocal fold cysts: mucus retention cysts and epidermoid cysts. Mucus retention cysts are often translucent and lines with cuboidal or columnar epithelium cells. Epidermoid cysts contain epithelium cells or keratin.
Vocal fold cycts often occur only on one vocal fold, but can occur bilaterally as well. The presence of a cyst on one vocal fold can irritate the opposite fold and cause it to swell. They can occur anywhere along the length of the vocal fold, however it is most common for them to occur in the middle. Vocal fold cysts are usually spherical in shape, white or translucent in color, and look like a mound within the fold itself.
As vocal fold cysts occur just below the surface of the vocal fold, they interrupt sound production by causing voice changes or hoarseness.
Cause:
Epidermoid Cysts:
Epidermoid cysts may be caused by vocal misuse, from an injury to the mucuos membrane, or from developmental problems before birth.
Mucus Retention Cysts:
Mucus retention cysts may occur spontaneously in some people. They may also be the result of poor vocal hygeine: when mucus-producing glands become obstructed and unable to secrete, i.e., after an upper respiratory infection.
Symptoms:
Vocal fold cysts affect the mucosal wave, which is essential for sound production. A wide variety of symptoms can exist with vocal fold cysts and can include the following:
- Hoarseness
- Increased effort to speak
- Easily fatigued when speaking
- Pain or soreness with vocal use
- Singers report abrupt loss of voice, breaks at certain pitches, or diplophonia (the production of two tones simultaneously)
- Dysphonia (an unaturally deep or rough quality of voice) that becomes increasingly severe with vocal use when the lesions are between the vocal folds
- Periods of aphonia following vocal overuse
- Sometimes one's singing voice remains unaffected while his/her speaking voice is compromised
- Stridor
- Aspiration
- Globus sensation
- Dysphagia
Diagnosis:
Videostroboscopy is essential in making the diagnosis of a cyst. Vocal fold cysts will create asymmetric-looking vocal folds which will be be visible during a videostroboscopy. In addition, the mucousal wave will be significantly decreased unlike vocal fold polyps.
Steroid treatments, which reduce the overlying (and sometimes camouflaging) inflammation while leaving the cyst unchanged, making its diagnosis easier.
Treatment:
Medical:
The key to identifying intracordal cysts is minimizing surrounding edema and inflammation. This can be accomplished through the following:
- Modified voice use
- Improved vocal hygiene
- Medication aids in accomplishing reduced edema and inflammation
- A 2-week period of vocal rest
In addition, any co-occuring medical conditions which may affect the voice (e.g., reflux, laryngitis, allergies) should be evaluated anr treated.
Speech therapy is essential for all patients in order to address vocal misuse and one's vocal hygeine. In addition, patients with vocal fold cysts often have other compounding functional issues that need to be addressed through speech therapy.
Speech therapy is essential for all patients in order to address vocal misuse and one's vocal hygeine. In addition, patients with vocal fold cysts often have other compounding functional issues that need to be addressed through speech therapy.
Surgical:
Surgery is an option for patients whose lesions show no improvment following exhaustive medical and speech therapy. Although nodules and polyps may respond to conservative management, vocal cysts typically do not, making surgery a more common treatment for this type of voice issue. Delaying insurgical treatment can potentially lead to the progression of the cyst formation and scarring between the vocal folds.
The goal of surgery is to remove the cyst, preserve the mucosal cover, and only minimally disrupt the underlying tissue if necessary. In addition, the deep layers of the lamina propria, which hold fibroblasts that produce extracellular proteins, should be avoided in order to prevent scarring along the vocal ligament and damaging of the mucosal cover.
Pre-Operation:
Surgery is reserved for patients with unresolving lesions that cause troublesome dysphonia. Medical and speech therapy directed at reducing vocal trauma through improved technique and vocal hygiene are involved in reducing mechanical trauma. It should be noted that patients must endure a three-month period of vocal rest for at least 3 months post-surgery.
Intra-Operation:
The lateral microflap is a surgical technique that is used when the cyst is deep within the vocal fold next to the vocal ligament and the overlying mucosa is normal. The advantage of the lateral microflap is that the incision and the subsequent scar are lateral to the medial surface of the vocal fold. In addition, the unaffected portion of the vocal ligament is often used to orient the flap.
The medial microflap is a surgical technique used for lesions that involve a discrete portion of the vocal fold and appear to separate easily from the underlying vocal ligament. This approach allows for a shorter flap and can be used to treat mucosa that is overlying a lesion.
At the end of the procedure, triamcinolone acetate may be injected into the flap in order to further minimize scar formation. With both techniques, most patients experience return of mucosal wave and are satisfied with voice quality.
The medial microflap is a surgical technique used for lesions that involve a discrete portion of the vocal fold and appear to separate easily from the underlying vocal ligament. This approach allows for a shorter flap and can be used to treat mucosa that is overlying a lesion.
At the end of the procedure, triamcinolone acetate may be injected into the flap in order to further minimize scar formation. With both techniques, most patients experience return of mucosal wave and are satisfied with voice quality.
Post-Operation:
For two weeks after microflap surgery, a patient must follow strict vocal rest. For those whose surgery was more extensive, corticosteroids may be prescribed. All patients will be given antibiotics for one week, and a mild narcotic pain medication. Symptoms of reflux will be treated with a proton-pump inhibitor.
Follow-Up:
Patients will be examined 2-, 4-, 8-, and 12-weeks following surgery. At the 2-week postoperative visit, a videostroboscopy will be given and the patient will resume their speech therapy. A gradual return to voice use occurs over the first few weeks, increasing by 5-minute intervals twice daily. Singers may begin to work after 1 month, but are cautioned to decrease vocal work if they feel any discomfort or strain.
Most patients can expect 90% of their functional surgical result after approximately 3 months.
Most patients can expect 90% of their functional surgical result after approximately 3 months.
Complications:
Complications are related either to laryngoscopy or to vocal fold mucosal injury. Pressure effects from suspension laryngoscopy may result in the following:
Deep-plane dissection or exposure of the vocal ligament can result in the following:
- Tongue numbness
- Altered taste
- Oropharyngeal, mucosal, or dental injuries
Deep-plane dissection or exposure of the vocal ligament can result in the following:
- Scarring of the mucosa
- Fibrosis of the mucosa with
- Loss of mucosal wave
- Glottal insufficiency
Outcome/Prognosis:
Following surgery in the most extreme cases, patients are found to have improved contouring of their vocal folds, better glottal closure, and improved mucosal wave propagation.References:
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