Otolaryngol Clin N Am

40 (2007) 1091–1108

Vocal Fold Masses

Kenneth W. Altman, MD, PhD, FACS
Department of Otolaryngology, The Mount Sinai School of Medicine, One Gustave L.
Levy Place, Box 1189, New York, NY 10029, USA

Although many performers consider vocal fold masses, such as nodules, the
bane of their existence, it is rare that these lesions are true career-breakers. It is
essential, however, that the many issues contributing to the development of
these lesions be identified and a multidisciplinary approach instituted to
obtain the best possible and most consistent outcome. In the context of the
professional voice, lesions are generally benign and inflammatory, but profes-
sional voice users often engage in carcinogenic activities, such as smoking, al-
cohol abuse, and use or abuse of recreational drugs. Such behaviors increase
the risk for malignancies and the possibility of such cannot be overlooked.
Also, the title of this article, vocal fold masses, has been chosen to reinforce
the concept that these inflammatory conditions add weight to the vocal folds
and impair vocal closure. This article reviews the multifactorial contributions
to voice disorders with emphasis on the pathophysiology of vocal masses, de-
scribes the resulting effects on voice function, and elaborates on the types of
masses encountered in professional voice users.

Multifactorial contributions to developing vocal masses

Voice use demands (overuse) and vocal technique (misuse) are central to
the trauma and pathogenesis of vocal fold masses in professional voice
users. Common to performers and other professionals is a passion for com-
munication that often pushes the scope of voice use relating to amount of
time, intensity, frequency of use, vocal range, and more advanced tech-
niques. Young performers, in particular, usually use their voices in many
different roles that include self-management and day jobs also requiring
their voices. The blossoming use of cellular telephones, especially in loud
public environments, significantly adds to this sustained and repetitive vocal
trauma. Trauma and subsequent inflammation manifest as vocal limitations

E-mail address: kenneth.altman@mountsinai.org

0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.otc.2007.05.011 oto.theclinics.com
1092 ALTMAN

that frustrate the professional voice user, and there is a tendency to try to
exceed these limitations.
Paying tribute to these personality factors in the pathogenesis of nodules
and polyps, Yano and colleagues 1982 [1] recognized significantly higher ex-
troversion scores on Maudsley Personality Inventory in these patients. More
recently, Roy and colleagues [2] used the Multidimensional Personality
Questionnaire to evaluate personality features distinct to functional dyspho-
nia and those who have vocal nodules. They determined that the functional
dysphonia group was introverted, stress-reactive, alienated, and unhappy.
In contrast, the vocal nodules group was considered to be socially dominant,
stress-reactive, aggressive, and impulsive.
Based on the multifactorial nature of voice disorders, underlying medical
conditions, medications, and the environment add to the synergy in pathogen-
esis of vocal fold masses. With the larynx at the epicenter, the significant inter-
relations of the respiratory and upper gastrointestinal tracts also predispose
the vocal folds to further damage. These contributing diseases include rhinitis,
allergy, sinusitis, asthma, bronchitis, laryngopharyngeal reflux, and others
discussed elsewhere in this issue. Environmental factors include allergens,
dust and other particulates, tobacco smoke, and a host of occupational
irritants.
Principal to medical conditions that contribute to inflammatory vocal le-
sions is laryngopharyngeal reflux (LPR). There are many examples in the lit-
erature; Kuhn and colleagues [3] studied 11 patients who had vocal nodules
using 24-hour simultaneous three-site pharyngoesophageal pH monitoring.
They found pharyngeal acid reflux events in 7 patients in that 24-hour pe-
riod (one to four episodes) compared with 2 of 11 controls studied (one
to two episodes). In a follow-up study by Ulualp and colleagues [4], 9 pa-
tients who had vocal nodules and posterior laryngitis underwent similar
evaluation, in which 78% were found to have pharyngeal acid reflux (signif-
icantly higher than controls). It is believed that the baseline inflammation
resulting from LPR episodes predisposes the vocal folds to the stresses
from vocal overuse and misuse.
In a series of allergy patients who had laryngeal disease, Hocevar-Boltezar
and colleagues [5] found that treatment of 70 patients who had laryngitis and
positive allergy skin tests resulted in an improved outcome compared with 5
patients who did not receive treatment, suggesting that hypersensitivity to in-
halatory and nutritional allergens makes laryngeal mucosa more susceptible
to the adverse action of other factors. This example also reinforces the syner-
gistic effects contributing to the development of vocal fold masses.

Pathophysiology, shearing stress, and compensation

Because vocal overuse and misuse are central to the development of vocal
fold masses, it is important to understand how biomechanical factors work
 VOCAL FOLD MASSES 1093

on the membranous vocal folds to produce such lesions. Jiang and col-
leagues [6] developed a mathematical computer-based model to describe
the vibratory response of the vocal folds during phonation using the finite
element method. They found that in normal phonation, mechanical stress
was the least at the midpoint of the membranous vocal fold and highest
at tendon attachments. In contrast, during hyperfunctional dysphonia there
was an increase in the second mode of vibration, resulting in incomplete ap-
proximation of the vocal folds posteriorly and increased stress at the loca-
tion between vibratory segments. In other words, when there was
increased stiffness in the body of the vocal folds, the midpoint of the mem-
branous vocal folds encountered higher shearing stresses.
Furthermore, when there was already a nodule or mass, it produced
a high mechanical stress at its base during vibration. The authors concluded
that intraepithelial stress plays an important role in the pathogenesis of nod-
ules and other masses, and that an abnormal vibratory mode may be more
damaging than a high intensity of vibration [6].
In a follow-up study using a self-oscillating model, mechanical stress was
noted to periodically undulate with the vibration of the vocal folds, and that
vocal impact caused a jump in the normal stress value [7]. The model was
also able to confirm that stress was significantly higher on the surface of
the vocal folds compared with that under the surface. These models rein-
force the concept of how vocal impact results in vibratory trauma to the vo-
cal folds, and that stresses are compounded once a lesion is present.
Many lesions can result (at least in part) from this process, including nod-
ules, polyps, and cysts, but other pathology should be considered, such as
reactive lesions, intracordal scarring, feeding varices, and reparative granu-
loma. The direct effect of the vocal mass is to add weight to the vocal fold,
which decreases its vibratory qualities and frequency as demonstrated on
strobolaryngoscopy. There is a clinical decrease in phonatory pitch along
with an abbreviated pitch range, as demonstrated on voice function testing.
The presence of the mass causes impaired vocal phase closure during pho-
nation, resulting in excess air egress. Clinically, this adds to a breathy qual-
ity of the voice, but also contributes to vocal fatigue. Disruption of vocal
fold vibration and phase closure often leads to phase asymmetry (depending
on the specific lesion), which adds to a grainy quality of the voice.
At this point in the development of the vocal mass, there is a self-perpet-
uating cycle of inflammation and trauma. Although behavioral qualities
contribute to the initial vocal trauma that leads to the development of
this process, the presence of a lesion can result in compensatory muscle ten-
sion in an effort to reduce excess air flow through the glottis. Altman and
colleagues [8] reviewed 150 patients who had muscle tension dysphonia, in
which 34 had polyps, 20 had nodules, and 12 had vocal cysts. They found
a significant degree of compensatory muscle hyperconstriction in this popu-
lation. Nevertheless, the multifactorial contributions and spectrum of le-
sions that may result emphasize the importance of strobolaryngoscopy in
1094 ALTMAN

assessment and multidisciplinary approach with speech and voice therapy,

medical, and surgical options.

Prevalence of vocal masses and dysphonia in voice professionals

Teachers are perhaps the largest group of voice professionals who seem
to be at higher risk for the development of hoarseness and vocal masses. Sul-
kowski and Kowalska [9] analyzed 1261 cases of occupational voice disor-
ders referred for otolaryngologic evaluation in Poland over a 5-year
period. Some 66% of these patients were primary school teachers, and
55% of referrals were 51 to 60 years of age. Overall, vocal nodules were
found in 4.2%. In a Finnish study, Smolander and Huttunen [10] surveyed
181 teachers, of whom 42% reported frequent voice symptoms, and 10%
had history of vocal nodules.
Because the evolution of these lesions is complex and the laryngologist
initially evaluates patients after they have experienced voice limitations
over a period of time, it is uncommon to have an isolated lesion without
concomitant or confounding findings. Similarly, nodules are often a ‘‘waste-
basket’’ diagnosis for those clinicians unskilled to differentiate between nod-
ules, polyps, cysts, reactive lesions, and intracordal scarring. Although it
may be a matter of semantics what to name a lesion, the description is nev-
ertheless helpful in considering prognosis and therapeutic plan.
Nagata and colleagues [11] reviewed their 10-year experience with 1156
patients and found 372 who had nodules and 784 who had polyps. Sataloff
and colleagues [12] reviewed their experience with videostroboscopy on 377
patients and found nodules in 32, polyps in 4, cysts in 8, granulomas in 3,
Reinke edema in 4, and scar in 32. An in-depth discussion of these vocal
fold masses follows. Discussion about each of these masses follows with rel-
evance to diagnosis and prognosis.

Nodules
Vocal nodules are defined as bilateral symmetric epithelial swelling of the
anterior/mid third of the true vocal folds.
(Access Video on Nodules in online version of this article at: http://www.Oto.TheClinics.
com.)

Demographically, these are seen in children, adolescents, and predomi-

nantly female adults working in professions with high voice demands. Sar-
fati [13] evaluated 90 French teachers referred for vocal disorders, and
pathology was found in two thirds overall, with pseudocysts or nodules in
one third overall.
De Bodt and colleagues [14] characterized evolution of these nodules
from childhood to adolescence. They examined a group of 34 post-
 VOCAL FOLD MASSES 1095

mutational adolescents who had a prior diagnosis of vocal fold nodules.

These nodules were still present in 47% of girls but only 7% of boys. The
degree of dysphonia in childhood and the presence of allergy were also pre-
dictors of persisting voice complaints in adolescence. This study reinforces
multifactorial contributions to the development of these lesions, including
behavior. The female preponderance from childhood to adolescence, cou-
pled with adult female preponderance in other studies, further confirms
that females are at particular risk. Perhaps the softer intensity of female voi-
ces leads to more hyperfunction in adult professional environments with
louder background noise.
One additional note is made of preponderance of nodules in patients who
have congenital microweb. Ruiz and colleagues [15] reviewed a sample of
107 patients who had vocal nodules and recognized microweb in 9.4%, al-
though the presence of microweb did not affect nodule location. Although
this is a small portion of those patients who develop nodules, it does imply
that the clinician should have a heightened awareness of the presence of mi-
crowebs, which may have additional implications of treatment and
prognosis.
The pathophysiology of vocal nodules relies on the mid-membranous vo-
cal fold experiencing maximal shearing and collision forces. This location
corresponds to the junction of the anterior to middle vocal folds (because
the posterior third of the vocal folds is coupled to the vocal process of the
arytenoids). This repeated collision initially results in localized vascular con-
gestion with edema. Eventually hyalinization of Reinke space with thicken-
ing of overlying epithelium occurs with the development of epithelial
hyperplasia.
Consequently, the histology of nodules is distinct from polyps and other
vocal lesions. Kotby and colleagues [16] collected 11 patients who had nod-
ules (all female) to characterize this histology. Nodules are generally acellu-
lar, with thickening of epithelium over a matrix with abundant fibrin and
organized collagen. Polyps also have a more pronounced epithelial reaction
and a more dense fibrous stroma than polyps. Immunohistochemical char-
acterization of nodules reveals a thickened basement membrane zone rich in
collagen type IV and more intense fibronectin staining [17].
Patients who have vocal nodules present with chronic hoarseness, often
with repeated episodes of more severe voice loss. Singers may complain of
a loss of ability to sing high notes softly, with frequent voice breaks, in-
creased breathiness, and vocal fatigue. Strobolaryngoscopy reveals bilateral
symmetric superficial swelling of the vocal folds at the striking zone junction
of the anterior to middle thirds (Fig. 1A). There is slightly decreased ampli-
tude of the mucosal wave, but the wave is generally symmetric. Because
there is hourglass-shaped glottal closure, there is consequently decreased
phase closure (Fig. 1B).
The mucus layer on the surface of the vocal folds is also important for
lubrication and reducing friction. Patients who have vocal nodules may
1096 ALTMAN

Fig. 1. Vocal nodules in a classical singer (A) during inspiration, and (B) during phonation.
Note the hourglass configuration with pinpoint phase closure on strobolaryngoscopy.

subsequently have irregular vibration of the surface mucus layer, perhaps re-
sulting in drying, leading to impaired lubrication and an exacerbation of the
surface stresses leading to the formation of nodules [18]. In addition, abnor-
mal or excess mucus has been anecdotally noted by the author to be respon-
sible for increased voice breaks in singers when transitioning through the
passaggio (ascending glissando from the chest voice into the head voice).
When considering treatment options for a patient who has vocal nodules,
it is useful to discuss with the patient a simple analogy of a carpenter using
a hammer over a long period of time without gloves. As a result, calluses
form at the areas of maximal impact with the hand. Using this analogy,
one may expect that conservative (nonsurgical) treatment would be applica-
ble to the patient who has true vocal nodules.
Hogikyan and colleagues [19] recognized a consensus among otolaryngol-
ogists, speech pathologists, and teachers of singing regarding the treatment
of singers who have nodules. Addressing voice use demands, improper tech-
nique, optimizing other contributing factors, and coordinating care were be-
lieved to be paramount.
Indications for microsurgical treatment include longstanding nodules,
particularly when other factors, including speech therapy, have been maxi-
mized, and suspicion of a primary lesion with a reactive callus on the other
vocal fold. Microsurgical technique is addressed elsewhere; it is imperative
to preserve normal anatomy, keeping the plane of dissection superficial,
and to minimize trauma to the lamina propria.

Polyps
Vocal polyps are unilateral, occasionally pedunculated masses encountered
on the true vocal fold. They occur more often in males, after intense intermit-
tent voice abuse, history of aspirin or anticoagulant use, or other vocal
trauma, such as endotracheal intubation. Kotby and colleagues [16] reviewed
19 patients who had polyps, of whom 16 (84%) were male. The pathophysiol-
ogy is believed to be attributable to breakage of a capillary in Reinke space
 VOCAL FOLD MASSES 1097

(superficial lamina propria) with subsequent extravasation of blood, resultant

local edema, and ultimate organization with hyalinized stroma.
The resulting mass may be broad-based or pedunculated, and hemor-
rhagic versus nonhemorrhagic (Fig. 2).
(Access Video on Pre-op Excision of Bilateral Polyps in online version of this article at:
http://www.Oto.TheClinics.com)

Hemorrhagic polyps may also have a feeding blood vessel, or varix.

(Access Video on Hemorrhagic Polyp in online version of this article at: http://www.Oto.
TheClinics.com)

Although the gross appearance may vary, the lesion is generally consid-
ered to be an outpouching of inflamed and organized Reinke space. A super-
ficial nonhemorrhagic, broad-based polyp may therefore be interpreted as
or called a pseudocyst.
Pathologically, polyps are acellular, with thickened epithelium over su-
perficial lamina propria and increased vascularity in an abundant delicate
fibrin stromal matrix. They have more vasculature and less organized colla-
gen than nodules, but the distinction may be difficult for the pathologist [20].
Immunohistochemistry studies reveal clustered fibronectin and disruption of
laminar pattern suggesting diffuse injury in the region of the polyp [17].
On strobolaryngoscopy, vocal folds with small polyps generally have in-
tact mucosal waves but phase asymmetry because of the impaired phase clo-
sure and the mass effect of the polyp. Vocal folds with larger polyps have
more prominent decreased mucosal wave amplitude. Thibeault and col-
leagues [21] characterized gene expression in vocal polyps compared with
Reinke edema. They found evidence of enhanced expression of extracellular
matrix proteins in vocal polyps corresponding to increased mucosal wave
stiffness observed on strobolaryngoscopy.
Both nodules and polyps result in excess air egress during phonation (with
a relatively breathy voice), and earlier vocal fatigue, frequent voice breaks in

Fig. 2. Vocal polyps. (A) Hemorrhagic. (B) Broad-based, nonhemorrhagic.

1098 ALTMAN

singers, and worsening hoarseness with high-pitched soft phonation. As such,

this decreased vocal efficiency with decreased mucosal wave phase closure has
been quantified with decreased subglottal and acoustic power [22]. Because
polyps are asymmetric masses of the vocal folds, they are more prone to result
in chaotic vibrations and aperiodic mucosal waves [23].
In the treatment of patients who have vocal polyps, all of the factors that
contribute to voice disorders should be addressed from a multidisciplinary
perspective, and polyps are usually addressed with microsurgery. An evolving
treatment modality for particularly hemorrhagic polyps is the use of office-
based technology using lasers. The wavelength of the lasers is well absorbed
by hemoglobin, and damage to the epithelium is minimal. In one recent pilot
study evaluating the use of the pulsed-dye laser (585 nm), small vascular
polyps showed greater potential for resolution over larger polyps [24].
There have also been reports (and anecdotal observation by the author of
this article and others) that small vocal polyps may completely resolve with
conservative nonsurgical treatment [25]. One would expect that smaller le-
sions and those that have been present for shorter periods of time may be
more prone to regression, especially in patients who are more compliant
with treatment.

Cysts
Cysts are subepidermal epithelial-lined sacs located within the lamina prop-
ria, and may be mucus retention or epidermoid in origin. Mucus retention
cysts form when a mucous gland duct becomes obstructed (usually during
an upper respiratory infection or with overuse), retaining glandular secretions.
(Access Video on Pre-op Subepithelial/Mucous Retention Cyst in online version of this
article at: http://www.Oto.TheClinics.com.)

Epidermoid cysts develop either from congenital cell rests in the subepi-
thelium of the fourth and sixth branchial arches or from healing injured mu-
cosa burying epithelium.
(Access Video on Left Cyst, Right Nodule in online version of this article at: http://www.
Oto.TheClinics.com.)

A ruptured cyst may result in scarring within the lamina propria or in

a sulcus. A cyst may also irritate the contralateral vocal fold, producing a -
reactive lesion on that vocal fold.
The history of a patient who has a vocal cyst is similar to those of patients
who have nodules and polyps, but with less vocal limitation than expected
from its size. The voice often sounds diplophonic (particularly with epider-
moid cysts), whereby there is great pitch instability and there is splitting of
the fundamental frequency overtones. As with nodules and polyps, this is
usually accompanied by vocal hyperfunction, which is often compensatory.
 VOCAL FOLD MASSES 1099

Bouchayer and colleagues [26] reviewed their experience with 157 cases of
cysts, sulci, and mucosal bridges over a 10-year period. Cysts were present in
78, and more commonly in females. Female professional singers may note
increasing vocal limitation and voice roughness when they are premenstrual
[27], and there is anecdotal evidence of varying cyst size with the female
monthly cycle. Consequently, many phonosurgeons exercise caution when
operating on premenstrual women.
On strobolaryngoscopy, the vocal folds appear asymmetric with occa-
sional evidence of the subepithelial mass (Fig. 3). Because of displacement
of lamina propria, there is significant decreased or absent mucosal wave
on the side of the cyst. Phase closure depends on the cyst size and whether
there is the development of a contralateral reactive callus.
Shohet and colleagues [28] compared stroboscopic findings between cysts
and polyps. They determined that the mucosal wave was the most important
parameter in differentiating cysts from polyps. They also found the mucosal
wave to be diminished or absent in 100% of vocal fold cysts, and the wave
to be present in 80% of polyps.
Treatment again requires a multidisciplinary approach addressing factors
that contribute to voice disorders. Although it is imperative to respect vocal
limitations, a true cyst does not resolve with conservative management. The
phonosurgical approach is discussed elsewhere in this issue, but requires
more extensive dissection because the cyst is in the submucosal plane. The
cyst may also be associated with intracordal scarring, requiring a more elab-
orate dissection. Consequently, recovery of the mucosal wave is prolonged
and may never return to being completely normal.
Furthermore, leaving behind a minute fragment of epithelium in the cyst
sac may result in recurrence of the cyst. Some vocal professionals have been
know to have cysts that do not cause substantial limitation to their singing
careers and have been observed without surgery. Consideration of surgery in

Fig. 3. Vocal cyst.

1100 ALTMAN

a vocal professional with this complex lesion should not be taken lightly,
therefore, and there should be a lengthy discussion of the risks and alterna-
tives to surgery.

Reactive lesions
The presence of a unilateral vocal fold lesion results in hourglass-shaped
closure of the membranous vocal folds during phonation. Consequently,
there are extra shearing forces on the contralateral vocal fold that may pro-
duce a reactive callus with epithelial hyperplasia. A unilateral lesion with re-
active callus formation may appear as bilateral lesions, such as nodules, that
may confound the diagnosis, prognosis, and ultimate management.
Rosen and colleagues [29] evaluated a series of 85 patients who had bilat-
eral vocal fold lesions and found 21 to have nodules and 64 to have a unilat-
eral vocal fold lesion with a contralateral reactive lesion (UVFL/RL). When
comparing patients who had nodules to those who had UVFL/RL, they
found statistically significant differences in (1) symmetry of vocal fold vibra-
tion, (2) amplitude perturbations, (3) estimated subglottic pressure, and (4)
voice handicap index as tools to differentiate nodules from UVFL/RL.
It is important to distinguish bilateral lesions, such as nodules, from a pri-
mary lesion with reactive callus, from the standpoint of prognosis and sur-
gical planning.
(Access Video on Left Cyst, Right Nodule in online version of this article at: http://www.
Oto.TheClinics.com.)

Fig. 4A shows an example of a singer who has a left vocal polyp and re-
active right vocal fold broad-based edema/callus. After a 1-month period of
reducing voice use, speech therapy, and treatment of LPR, Fig. 4B shows
significant improvement in the right reactive callus. As such, contralateral
reactive lesions are often not removed in microsurgery for the primary le-
sion, because the reactive lesion tends to resolve with conservative
management.

Intracordal scarring
Repeated inflammation, vocal trauma, vocal hemorrhage, and the pres-
ence of an intracordal cyst predispose to scarring in Reinke space. Intracor-
dal scarring is often found in association with a cyst, particularly if it is
epidermoid in origin and has ruptured. Intracordal scarring may also be
found after vocal surgery involving the lamina propria, with the use of
the CO2 laser, and after repeated epithelial procedures, such as those for ma-
lignancy, leukoplakia, and papilloma.
(Access Video on Left Vocal Fold Scar in online version of this article at: http://www.Oto.
TheClinics.com.)
 VOCAL FOLD MASSES 1101

Fig. 4. (A) Left vocal polyp (on right of image) with reactive callus on the right vocal fold. (B)
Resolution of the reactive callus after 1 month of voice reduction, speech therapy, and treat-
ment of LPR.

Discussion on vocal sulcus (epithelial scarring) goes beyond the scope of

this article, although it can certainly affect the professional voice [30].
Intracordal scarring is suspected on strobolaryngoscopy when there is
markedly reduced or absent mucosal wave (usually asymmetric), which often
affects phase closure. From a professional voice standpoint, it is crucial to dif-
ferentiate between an uncomplicated subepithelial cyst and an intracordal
scar, because the latter is a more complex problem with worse prognosis for
professional voice rehabilitation. A convex subepithelial fullness of the mem-
branous vocal fold may warrant exploratory microflap surgery to tease out re-
maining cyst sac and adynamic fibrous components. Because the extracellular
matrix components of the lamina propria largely determine the biomechanical
properties of the vocal folds (and subsequent voice quality), there has been sig-
nificant recent interest in functional soft tissue replacement substances [31].

Feeding varices and hemorrhage

Varices and ectasias of the vocal fold are aberrant vessels of the microcir-
culation within the superficial lamina propria. Although they are not true
masses, they develop as a result of the same multifactorial and shearing
forces that lead to masses, and they also predispose to the development of
polyps and vocal hemorrhage. Fig. 5A and B show strobolaryngoscopic
examples of a varix and hemorrhage.
Treatment options for these aberrant vessels have traditionally included
microdissection and the use of the CO2 laser, which lead to an increased risk
for postoperative scarring or sulcus. More recently, there has been renewed
interest in the use of pulsed angiolytic lasers that have a wavelength within
the specific absorption of oxyhemoglobin, because this has the potential of se-
lectively ablating microvessels without damage to the overlying epithelium.
Hirano and colleagues [32] demonstrated the use of the KTP laser (532 nm
1102 ALTMAN

Fig. 5. (A) Vocal varix, and (B) vocal fold hemorrhage (both on the patient’s right; left of the
figure)

wavelength) on 12 patients who had microvascular and hemorrhagic lesions

and found no adverse scarring or reduction in the mucosal wave postopera-
tively. Zeitels and colleagues [33] also recognized the potential for the pulsed
KTP and the 585-nm pulsed-dye laser in a series of 39 patients.

Granulomas
Although vocal process granulomas are not on the membranous vocal fold
and often do not cause vocal symptoms, it is important for the clinician to un-
derstand differences with other vocal fold masses. Vocal process granulomas
occur in response to trauma, most commonly from LPR, exacerbating chronic
cough, or throat clearing. They may also occur after endotracheal intubation
resulting in contact ulceration, or by forceful glottal closure when compensat-
ing for vocal paresis or presbylaryngia. Kiese-Himmel and Kruse [34] docu-
mented a male predominance with 27 out of 28 patients who had contact
granuloma being male.
The granuloma may appear as solitary or bilobed (Fig. 6) and often does
not affect mucosal wave or phase closure on strobolaryngoscopy (unless
there is underlying vocal paresis, presbylaryngia, or sulcus).
(Access Video on Vocal Process Granuloma in online version of this article at: http://www.
Oto.TheClinics.com.)

Treatment relies on addressing the underlying LPR, other factors, and

vocal process impact on cough or phonation. Botox to the thyroarytenoid
muscle has also been shown to be helpful in reducing the glottal impact in
cases refractory to LPR treatment and speech therapy. Because there is
a high recurrence rate after surgical excision, surgery is reserved for cases
in which the lesion is (1) enlarging; (2) compromising the voice, breathing,
or swallowing; or (3) suspicious for malignancy.
 VOCAL FOLD MASSES 1103

Fig. 6. Left vocal process granuloma.

Papilloma
Respiratory papillomatosis is an infection caused by human papillomavi-
rus (HPV), which is also known to more commonly cause cervical, vaginal, pe-
nile, and anal warts. Although relatively uncommon in the larynx, it is still
considered to be among the most common laryngeal neoplasms. There are
more than 50 strains of HPV, but HPV 6 and 11 are among the most common
in the larynx. As with genital warts, there is an approximately 2% likelihood of
malignant degeneration in laryngeal papilloma, most commonly found with
strains HPV 16 and 18. Once the wart is manifested, there is overall about
a 10% likelihood of spread to the trachea or other sites, depending on the num-
ber of surgical procedures necessary to control the disease.
HPV appears as a cauliflower-like exophytic protuberance, most com-
monly found at the transition between columnar and squamous epithelium
(Fig. 7). Because pathologic specimens reveal multiple fronds of fibrovascu-
lar stalks, papilloma also has vascular stippling on the mass. Early forms
may have a superficial spreading presentation, again with vascular stippling
seen on laryngoscopy, providing a clue to the underlying disease.
(Access Videos on bilateral papilloma in online version of this article at: http://www.Oto.
TheClinics.com.)

Strobolaryngoscopy is exceptionally helpful in making an early diagnosis,

especially when recurring disease is suspected, because the mass effect of
thickened diseased epithelium can present with a decreased mucosal wave.
There are many controversies related to papilloma and HPV, including
a high prevalence of greater than 40% with HPV-positive serology but still
relatively low overt infection rates, suggesting an important role of host im-
mune recognition [35]. The many treatments for papilloma go beyond the
scope of this discussion, although shaver excision and CO2 laser excision
are also used in select instances. The greater depth of penetration of the laser
1104 ALTMAN

Fig. 7. Vocal fold papilloma involving the left vocal fold.

than is visibly apparent increases the risk for scarring and implantation of
the virus (an epithelial disease) into deeper tissues of the vocal fold and
use of the CO2 laser is avoided in most centers. Pulsed-dye lasers are now
considered the mainstay. The emerging use of the HPV vaccine for the
most common strains and cidofovir injections to control regrowth are excit-
ing options for protection from acquiring the disease and for treatment.

Polypoid corditis
Polypoid corditis, vocal polyposis, and Reinke edema are terms that refer
to a proliferation or redundancy of the superficial lamina propria (Reinke
space). It is often seen in patients who have chronic irritant exposure,
such as tobacco smoke, laryngopharyngeal reflux, and sometimes occupa-
tional exposures. Polypoid corditis appears as an outpouching of the mem-
branous vocal folds with an edematous, almost water-balloon appearance
(Fig. 8). Strobolaryngoscopy reveals decreased mucosal wave because of
the mass effect of the edema, often with phase asymmetry because of
ball-valving and asymmetric edema. Treatment is aimed at reducing airway
obstruction while preserving voice quality. Surgically, it is paramount to
preserve some epithelium and remaining superficial lamina propria so that
patients may maintain some degree of mucosal wave postoperatively. It is
also imperative to stage procedures in patients who have bilateral disease
to reduce the likelihood of postsurgical anterior web formation [36] Cessa-
tion of smoking and control of reflux disease are important factors in pre-
venting recurrence of the disease after surgical excision and should be
instituted before surgery to maximize the postoperative outcome.

Leukoplakia and dysplasia

Leukoplakia, or white plaque, refers to a spectrum of diseases affecting
the vocal fold epithelium, and includes hyperkeratosis, dysplasia, and early
 VOCAL FOLD MASSES 1105

Fig. 8. Bilateral polypoid corditis.

verrucous changes. Overall, when leukoplakia is present there is an 8% to

14% likelihood of developing malignancy in such lesions. The pathophysi-
ology is still unknown, but it is likely that chronic irritation and genetic pre-
disposition form a synergy in such patients. The plaque may present initially
with subtle hyperkeratotic epithelium resulting in decreased or sluggish mu-
cosal wave on strobolaryngoscopy (Fig. 9A). Progression, particularly with
dysplastic or premalignant changes, may be exophytic in a surrounding bed
of erythema (Fig. 9B). Microflap excision, carbon-dioxide lasers, and
pulsed-dye lasers are all treatment options, but appropriate pathologic stag-
ing must be performed because the visual appearance does not always cor-
respond to the degree of dysplasia [37]. Treatment of hyperkeratosis and
mild dysplasia is centered on eradication of disease while preserving neigh-
boring normal anatomy and voice quality. Severe dysplasia and carcinoma
in situ must be treated more aggressively.

Fig. 9. (A) Broad superficial leukoplakia blanketing bilateral vocal folds, and (B) discrete leu-
koplakia with severe dysplasia and microinvasion seen in a bed of erythematous vocal folds.
1106 ALTMAN

Fig. 10. Vocal fold squamous cell carcinoma.

Vocal fold carcinoma

Squamous call carcinoma is by far the most common form of laryngeal
malignancy. Those patients who have a history of tobacco smoking account
for about 90% of cases, and the likelihood is far greater with a concurrent
history of excess alcohol consumption. There are also anecdotal and indirect
data to support the role of laryngopharyngeal reflux in causing and com-
pounding the development of vocal fold carcinoma. Any mass lesion in a pa-
tient who has such a history should therefore raise the appropriate level of
suspicion.
Features of squamous carcinoma include exophytic, ulcerative, and infil-
trative. Consequently, one may see on strobolaryngoscopy an area of focally
decreased mucosal wave at the site of an exophytic epithelial lesion (Fig. 10).
This area is distinguished from papilloma, which remains an epithelial dis-
ease, whereas carcinoma tends to infiltrate into the lamina propria, account-
ing for the decreased mucosal wave. Also, the fibrovascular fronds seen in
papilloma are generally softer than the exophytic mass produced in carci-
noma, so carcinoma would have more of a detrimental effect on phase clo-
sure seen in strobolaryngoscopy. Distinguishing carcinoma from
leukoplakia is more challenging because leukoplakia may form a continuum
from keratosis to severe dysplasia to microinvasive disease. Nevertheless,
the degree of clinical suspicion and evidence of microinvasion with focally
decreased mucosal wave should mandate further evaluation [38].

Summary
There are several vocal masses that can affect the professional voice. It is
important to understand the multifactorial contributions and pathogenesis
of each to determine prognosis. Strobolaryngoscopy plays a crucial role in
differentiating the spectrum of masses and in guiding optimal management.
 VOCAL FOLD MASSES 1107

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