Vocal Fold Cyst

A vocal fold cyst is an epithelium lined, fluid or keratin filled sac in the superficial lamina propria of the vocal fold, usually unilateral and at the middle third of the free edge.

• Two types: mucous retention cysts (from obstructed mucus gland ducts, thin walled, filled with clear or mucoid fluid) and epidermoid (inclusion) cysts (keratinising squamous lining filled with caseous keratin debris, often congenital or from epithelial trapping after trauma).
• Cysts may be subepithelial (lying in the superficial lamina propria) or ligamentous (deeper, adherent to the vocal ligament).
• Associated findings: sulcus vocalis (a longitudinal groove, often adjacent to an epidermoid cyst), reactive contralateral nodule or erythema, and intermittent rupture with discharge of contents.
• Typically presents in the second to fourth decades in both sexes and is more resistant to voice therapy alone than nodules or polyps.

• Persistent hoarseness, usually lifelong or of long standing, with a breathy or rough quality and reduced vocal efficiency.
• Vocal fatigue, reduced pitch range, and limited ability to project the voice.
• Voice may be unchanged for years then deteriorate after infection, trauma, or heavy voice use.
• Occasionally discovered incidentally in a person with minimal symptoms.

• Laryngoscopy may show only a subtle fullness or a yellow white submucosal bulge on the superior surface of the fold. Cysts are frequently missed on routine indirect examination.
• Videostroboscopy is the key investigation: a localised area of reduced or absent mucosal wave over the cyst with a normal wave elsewhere, stiffness, and phase asymmetry; the contralateral fold often shows a reactive swelling or nodular thickening.
• Distinguishing features: a polyp is visible and exophytic, a nodule is bilateral, a cyst is submucosal and firm, and a sulcus shows a groove with absent wave.
• Diagnosis is often confirmed at microlaryngoscopy with palpation: the cyst feels like a firm, mobile nodule under the mucosa. Histology confirms a cyst wall with squamous or ciliated epithelium and contents.
• If the mass is fixed, irregular, or leukoplakic, take a biopsy to exclude carcinoma.

• Voice therapy alone rarely resolves a true cyst, but 6 to 8 sessions can improve compensation, vocal hygiene, and posture, and is used before surgery and as a trial for mild symptoms.
• Surgery is the definitive treatment for symptomatic cysts:
  • Microlaryngoscopy with a small superior (supra ligamentous) cordotomy or microflap: incise the epithelium on the superior surface of the fold, develop the plane between the cyst wall and lamina propria with fine blunt dissection, and remove the cyst intact without rupture. Rupture leaves lining and recurrent cyst.
  • Preserve the vocal ligament and as much overlying mucosa as possible; replace the flap and use fibrin glue or leave to heal.
  • If a sulcus or epidermoid pocket is present, careful excision of the pocket with flap closure is needed.
  • Treat the reactive contralateral lesion conservatively; it usually resolves after removal of the cyst.
• Postoperative care: complete voice rest for 5 to 7 days, then gradual return with voice therapy, humidification, and reflux control (omeprazole 20 mg once daily if indicated). Review with stroboscopy at 4 to 6 weeks.
• Analgesia: paracetamol 1 g orally every 6 hours as needed.
• Outcomes: most patients have improved voice; mild stiffness may persist in ligamentous or deep cysts. Recurrence occurs when the cyst wall is left behind.
• Complications: scarring, reduced mucosal wave, persistent dysphonia, and recurrence.