Vocal Fold Polyp

A vocal fold polyp is a benign, usually unilateral, sessile or pedunculated mass arising from the superficial layer of the lamina propria (Reinke space) at the junction of the anterior and middle thirds of the membranous fold.

• Principal causes are phonotrauma (shouting, prolonged loud voice use, voice abuse in teachers, singers, vendors, preachers), cigarette smoking, laryngopharyngeal reflux, and acute vocal fold haemorrhage that organises into a lesion.
• Histological variants: gelatinous or myxoid (translucent, oedematous stroma), haemorrhagic or angiomatous (dilated, thin walled vessels with fibrin and haemosiderin), hyalinised or fibrous (collagen and hyaline deposition), and mixed.
• Commoner in adults aged 20 to 50 years, and in men who smoke; children rarely develop true polyps.
• Malignant transformation does not occur in a typical polyp, but a unilateral mass in a smoker with persistent hoarseness must be proven benign.

• Chronic or recurrent hoarseness that is rough and breathy, with reduced pitch range and vocal fatigue.
• Diplophonia (two simultaneous pitches) when the mass vibrates independently of the fold.
• Voice breaks, effortful phonation, and throat clearing.
• Large pedunculated polyps may flip into the glottis during inspiration and cause cough, a choking sensation, or rarely inspiratory stridor.
• Sudden worsening after a shouting episode suggests haemorrhage into the lesion.
• Pain is not typical; pain, otalgia, or dysphagia should prompt a search for another diagnosis.

• Flexible or rigid laryngoscopy shows a smooth, rounded, translucent, grey, pink or red mass on the free edge or upper surface of one fold. Large lesions can hang below the glottic plane.
• Videostroboscopy: reduced or absent mucosal wave over the lesion, incomplete glottic closure, and often a reactive contact lesion (erythema or small nodule) on the opposite fold at the point of impact.
• Differential diagnosis: vocal fold nodules (bilateral, symmetrical, at the junction of anterior and middle thirds), vocal fold cyst (firm, yellow white, subepithelial), papilloma (exophytic, wart like), granuloma (posterior, vocal process), leukoplakia and early glottic carcinoma (fixed, irregular, stiff fold), and Reinke oedema (diffuse, bilateral).
• Histology is mandatory for any lesion that is firm, fixed, leukoplakic, irregular, or associated with a heavy smoking history. All excised tissue should be sent for histology.
• Voice assessment before treatment: perceptual grading, maximum phonation time, jitter and shimmer, and a patient reported voice handicap score for later comparison.
• Screen for reflux symptoms (heartburn, globus, throat clearing, post-nasal drip).

• Conservative first step for small lesions without a suspicious appearance, for 6 to 12 weeks:
  • Smoking cessation, avoidance of shouting and whispering, limited loud voice use, and adequate hydration (at least 2 litres daily) with humidification.
  • Voice therapy by a speech and language therapist, usually 6 to 8 sessions over 8 to 12 weeks, focusing on vocal hygiene, breath support, and resonant voice technique. Haemorrhagic and small gelatinous polyps may regress.
  • If reflux is suspected, omeprazole 20 mg to 40 mg orally once daily before breakfast, or esomeprazole 40 mg once daily, for 8 to 12 weeks, with head-of-bed elevation, avoidance of late meals, and reduction of caffeine, alcohol, and fatty foods.
• Surgery is indicated for persistent symptoms after therapy, large or pedunculated polyps, fibrous polyps that do not regress, airway obstruction, occupational voice need, or diagnostic uncertainty.
  • Microlaryngoscopy under general anaesthesia (small endotracheal tube or jet ventilation), cold steel microflap excision or microscissor excision preserving the maximum amount of normal mucosa and avoiding injury to the vocal ligament and deeper lamina propria. Laser excision is acceptable but thermal depth must be limited.
  • Pedunculated polyps: grasp lightly at the base and divide the pedicle; avoid stripping the fold.
  • Send all tissue for histology.
• Postoperative care: relative voice rest for 3 to 7 days (no whispering, no throat clearing), then graded return to voice use with postoperative voice therapy, humidification, and continued reflux treatment. Re-examine with stroboscopy at 4 to 6 weeks; most patients return to normal or near normal voice.
• Perioperative analgesia: paracetamol 1 g orally every 6 hours (maximum 4 g per day). Avoid aspirin and NSAIDs in the first week after surgery of a haemorrhagic lesion.
• Recurrence is related to continued voice abuse, smoking, and reflux; treat these contributors.
• Complications: scarring with a stiff fold, persistent dysphonia, and recurrence.