Vocal Polyps and Nodules Treatment &

Management
Background
Confronted with symptoms of dysphonia, the clinician is charged with accurate diagnosis and
timely institution of appropriate therapeutic intervention. Vocal fold lesions are a common cause
of hoarseness. A more thorough understanding of these benign lesions has been the goal of
laryngologists and voice scientists over the last several decades, since Hirano's description of the
complex layered microanatomy of the human vocal fold.
Several distinct pathologic entities are encompassed in this broad category, including laryngeal
papillomatosis, intracordal cysts, sulcus vocalis, vascular ectasia, as well as vocal fold nodules
(VFNs) and vocal fold polyps (VFPs). Each of these entities has an attendant clinical
presentation; each presents diagnostic and treatment challenges. This article focuses specifically
on vocal fold nodules (VFNs) and vocal fold polyps (VFPs).

History of the Procedure

A thorough history of all patients presenting with a voice symptom is essential. A complete
medical history must include a chief problem and history of present illness, which requires the
patient to articulate the exact quality, timing, frequency, and task-specific nature and
exacerbating or ameliorating factors of their voice problems. A review of past medical and social
history and present medications is necessary to identify potential contributing factors, such as
thyroid disease, smoking history, caffeine use, and/or use of prescription or over-the-counter
(OTC) medications. A unique portion of the vocal history is the careful attention paid to patterns
of vocal behavior (including occupational use and recreational and social behaviors) that may
provide clues to contributory vocal overuse, vocal misuse, and vocal abuse (ie, phonotrauma), as
well as the state of vocal hygiene.
Careful attention to voice-use history in immediate proximity to the onset of the symptom can
offer clues to the nature of the problem. In the case of singers, understanding the patient's singing
history and level of vocal training (as well as performance style and setting) is essential in
formulating an accurate differential diagnosis.
A characteristic history of present illness referable to either vocal fold polyps (VFPs) or vocal
fold nodules (VFNs) may include subjective symptoms of breathy, weak, raspy, or hoarse voice
quality. The patient may also report a change in the baseline vocal pitch with limited vocal range.
Patients may report increased effort and fatigue associated with voice production. Singers
commonly note decreased voice quality and singing endurance, loss of upper registers, and
difficulty with precise vocal control.

Problem
Vocal fold nodules (VFNs), depicted in the video below, are localized, benign, superficial
growths on the medial surface of the true vocal folds (TVFs) that are commonly believed the
result of phonotrauma. Nodules are bilateral with a classic location at the junction of the anterior
and middle third of the vocal fold (ie, the midpoint of the membranous vocal fold). Nodules are
most often observed in women aged 20-50 years, but they are also found commonly in children
(more frequently in boys than in girls) who are prone to excessive shouting or screaming.[1, 2, 3]
In this patient with hoarseness, opposing nodules are clearly seen at the anterior
one third of the true vocal cords. These responded nicely to outpatient nonsurgical
treatment (voice therapy). Video courtesy of Vijay R Ramakrishnan, MD.

Vocal fold polyps (VFPs) are generally unilateral and have a broad spectrum of appearances,
from hemorrhagic to edematous, pedunculated to sessile, and gelatinous to hyalinized. Vocal fold
polyps (VFPs) are believed to result from phonotrauma; however, they are also recognized to
potentially arise from a single episode of hemorrhage. In 1995, Dikkers et al found that the
combination of signs of recent bleeding and depositions of fibrin and iron pigment in
macrophages resided almost exclusively in polyps when compared with other benign lesions.[4]
Moreover, approximately a third of the vocal polyps in their sample showed evidence of
capillary proliferation, further lending credence to the theory of bleeds as the inciting event. The
video below depicts a pedunculated hemorrhagic polyp along the anterior right true vocal fold.
Along the anterior right true vocal fold, a pedunculated hemorrhagic polyp is seen.
Surgical treatment is indicated. Video courtesy of Vijay R Ramakrishnan, MD.

Vocal fold polyps (VFPs) typically involve the free edge of the vocal fold mucosa, although they
may also be found along the superior or inferior borders. Occasionally, a more diffuse pattern
termed polypoid degeneration is observed as well. This pattern is referred to as Reinke edema
and is generally considered a separate pathologic entity. For the purposes of this article,
comments are limited to isolated focal lesions of the true vocal fold (TVF).
Both nodules and polyps may interrupt the vibratory patterns of the vocal fold by increasing the
mass and reducing the pliability of the overlying cover (ie, cover/body theory of vocal fold
vibration), as well as by impeding proper closure of the membranous folds throughout the glottic
cycle.

Etiology
Nonneoplastic lesions of the vocal folds are presumed to represent a response to vocal trauma
(more specifically, phonotrauma in the case of vocal fold polyps and vocal fold nodules). A 1999
survey performed by Hogikyan et al elicited opinions of the professional groups most involved
with the care of the voice (including laryngologists, speech language pathologists, and singing
teachers) to gauge the prevalence of opinions regarding the specific entity of VFNs.[5] The survey
found that the prevailing and nearly unanimous belief follows: "Practices that constitute either

abuse or misuse of the speaking and/or singing voice were felt by all groups to be of greatest
importance in causing vocal fold nodules in singers."
For the sake of clarity, vocal abuse refers to vocal behaviors that are practiced under
circumstances that lead to trauma of the laryngeal mucosa. Excessive talking, prolonged and
excessive loudness, use of inappropriate pitch, excessive cough, and throat clearing are some of
these vocally abusive behaviors.
Vocal misuse involves abnormal vocal behaviors that cause stress or trauma to the larynx. Such
practices include the use of excessive tension and effort while phonating, hard glottal attacks,
and ventricular phonation. The concept of vocal overuse is self-explanatory.
In the effort to substantiate these traditional clinical beliefs regarding the etiology of vocal
lesions, in 1987 Gray et al undertook the task of creating an animal model in which to study the
pathologic process.[6] In an experiment designed to simulate phonotrauma, canines were
hyperphonated artificially for periods of 2, 4, and 6 hours, after which the ultrastructure of their
vocal fold was examined under electron microscopy to determine early anatomic changes related
to phonotrauma.
With 2 hours of persistent phonation, Gray et al demonstrated reproducible structural changes
that were absent in the control animals. The inherent shortcoming of such studies lies in the
inability to perform longitudinal follow-up of the pathologic changes due to phonotrauma and,
more importantly, the uncertainties of extrapolating data to humans (ie, given the behavioral
differences between the canines in Gray's study protocol and normal human vocal behaviors as
well as differences in vocal fold microanatomy).
In 2000, Andrade tested these causal behavioral assumptions by designing a retrospective study
that attempted to correlate the frequency of specific, observed, vocally traumatic behavior (ie,
hard glottal attack) with the type and extent of clinically visible vocal pathology.[7] The
investigators hypothesized that a higher frequency of hard glottal attack would be found in
patients exhibiting muscle tension dysphonia (MTD) and/or vocal fold lesions than would be
found in normal speakers.
Further, investigators hypothesized that the frequency of these behaviors would correlate
positively with the presence and severity (unilateral versus bilateral) of the observed vocal fold
pathology. Results of Andrade's study confirmed a higher frequency of hard glottal attack in the
disordered groups than in the controls. On the other hand, the study did not demonstrate a
difference in frequency between the purely MTD group and those with lesions or between the
unilateral and bilateral lesion groups.
In a large retrospective study of pediatric voice patients, Shah et al (2005) found that
hyperfunctional vocal behaviors correlated with vocal fold nodule size, but the presence or
absence of signs of reflux disease did not.[8] With a parent-rated standardized scale Roy et al
(2006) confirmed that children with vocal fold nodules rate as "outgoing" or "extroverted" and
scored significantly higher than controls on the "social scale."[9]

The literature notes other clinical associations with VFNs. Some authors have mentioned an
anecdotal association between the presence of anterior glottic microwebs and nodules.
Additionally, the contributory role of gastroesophagopharyngeal reflux in the pathogenesis of
VFN has been studied.
In 1998, Kuhn et al compared a small cohort of patients with VFN against volunteers with
normal health.[10] Both groups were studied with barium esophagraphy and ambulatory, 24-hour,
3-site pharyngoesophageal pH monitoring. Kuhn found that the prevalence of pharyngeal reflux
events was significantly higher in patients with VFN compared with normal controls. Vibrationinduced elevations in capillary pressure have also been hypothesized to cause vocal nodules and
associated edema.[11] These results supports voice therapy aimed at reducing vibratory amplitude.

Presentation
As previously mentioned, the clinical presentation of benign vocal fold lesions is most
commonly associated with a voice change.[12] Typical presenting symptoms include generalized
and persistent hoarseness, change in voice quality, and increased effort in producing the voice.
The laryngeal examination may show either unilateral or bilateral lesions of the TVF.
Because it has the ability to demonstrate subtle differences in the appearance, pliability, and
mucosal wave characteristics (ie, symmetry, periodicity, amplitude, vertical phase difference) of
the TVF cover, videostrobolaryngoscopy is far more sensitive for detecting and differentiating
laryngeal lesions when compared with other indirect laryngoscopy techniques.
Diagnostically, nodules do not tend to significantly disturb propagation of the mucosal wave on
stroboscopy, but they may contribute to incomplete closure during the glottic cycle, depending
upon their size.
Polyps have various appearances but generally are unilateral and much more likely to interfere
with proper closure of the glottis during phonation and to cause a more noticeable change in the
quality of the speaking/singing voice. The potential location of polyps on the superior and
infraglottic (as well as the medial) surface of the cord makes the ability to separately visualize
both upper and lower vertical lips of the cord on videostroboscopic examination all the more
important to their detection.

Vocal fold polyp (VFP) found during office videostroboscopy.

Indications
Indications for surgical intervention in benign TVF mucosal lesions are relative. Even in the
most casual of voice users, the proposition of surgical intervention should never be taken lightly,
especially given the ever-present potential for poor healing or irreversible scarring, which causes
permanent change in the speaking/singing voice.
In general, vocal fold microsurgery is considered for cases in which the patient remains
unacceptably vocally impaired despite compliance with a medical treatment and voice therapy
regimen. Rare instances may also occur, in which the lesion (typically, a large polyp) threatens
the patency of the airway. In these cases, the polyp's vocal impact is a distant secondary
consideration. In other specific instances (eg, extremely long history of voice limitations,
mucosal injury clearly resulting from a one-time event, clearly irreversible pathology), surgery
may appropriately be considered at initial diagnosis. Even in this setting, however, the patient
may benefit from one or more voice therapy sessions or from optimal preoperative education and
postoperative compliance with the rehabilitative regimen.
The importance of careful patient selection cannot be overstated. At a minimum, rudimentary
vocal education and a commitment to compliance with a preoperative and postoperative vocal
regimen is required of any surgical candidate. This regimen routinely includes limitation of
vocally damaging behavior and observance of improved vocal hygiene with respect to alcohol,
caffeine, tobacco, and hydration. The patient must be committed to the recommended courses of
both preoperative and postoperative voice therapy (and singing instruction as appropriate) and to
the prescribed course of perioperative vocal rest that allows for optimal surgical healing and
results. In the most general of terms, patients who do not meet these criteria are poor operative
candidates; therefore, surgery is relatively contraindicated.

Relevant Anatomy
Advances in modern phonomicrosurgical techniques have largely stemmed from improved
understanding of the complex microarchitecture of the TVF as described by Hirano. More
specifically, understanding of the role of the layered architecture to normal voice production has
led to surgical techniques designed for maximal preservation of the normal structure.
The TVF is composed of 5 individually identifiable layers. The deepest layer consists of the
thyroarytenoid muscle body. This muscle is capable of contraction and serves to voluntarily
stiffen and thicken the vibratory margin of the cord. Overlying the muscle is a region referred to
as the lamina propria (LP), which can be divided into 3 portions (ie, superficial, middle, deep)
based on the molecular compositions of each. The deep layer of the LP is largely comprised of
densely crowded collagen fibers. The middle layer has some collagen but is distinguished by its
high elastin content.
The deep and middle layers of the LP blend imperceptibly on operative dissection to form a
structure commonly referred to as the vocal ligament, a recognized and important landmark in
vocal fold surgery, as well as a transition zone between the body (muscle) and the cover
(epithelium and superficial LP) of the TVF.

The superficial LP is composed of mostly amorphous ground substance and a few fibrils. The
importance of this layer (which is not well appreciated on traditional hematoxylin and eosin
[H&E] staining) to normal vibratory behavior of the TVF has been progressively elucidated over
the last 30 years. The most superficial of the layers is the stratified squamous epithelial cover that
overlies the LP.

Contraindications
The patient must be committed to the recommended courses of both preoperative and
postoperative voice therapy (and singing instruction as appropriate) and to the prescribed course
of perioperative vocal rest that allows for optimal surgical healing and results. In the most
general of terms, patients who do not meet these criteria are poor operative candidates; therefore,
surgery would be relatively contraindicated.

Other Tests
No specific laboratory studies are singularly diagnostic of these conditions. Measurements within
a voice laboratory, including aerodynamic, acoustic, and videostroboscopic baselines (as well as
a high-quality audio recording of the patient's voice) are all helpful for appropriate pretreatment
and posttreatment documentation. Lastly, clinician and patient perceptual measures are
commonly performed to more subjectively gauge the impact of the vocal disability and
improvement.

Diagnostic Procedures
Videostrobolaryngoscopy is far more sensitive for detecting laryngeal lesions when compared
with other indirect laryngoscopy techniques because of its ability to demonstrate subtle
differences in the appearance, pliability, and mucosal wave characteristics (ie, symmetry,
periodicity, amplitude, vertical phase difference) of the TVF cover.

Histologic Findings
On a structural level, a significant body of work has been performed to identify pathologic
structural characteristics of benign vocal cord lesions and from this to infer pathogenesis.
Immunohistochemical characterization of the extracellular matrix of excised, clinically
diagnosed, benign laryngeal lesions revealed nodules to more commonly have a thickened
basement membrane zone (BMZ) and dense fibronectin arrangement within the superficial
lamina propria (LP), as compared with those diagnosed as polyps. These polypoid lesions tended
to exhibit an unaltered BMZ thickness and to have fibronectin depositions clustered around
neovasculature.
These patterns of structural deviation from the normal layered microanatomy of the TVF have
been reported previously. In 1995, Gray et al formulated a theory of causation and pathologic
response, hypothesizing as follows: "The vocal folds sustain enough injury to lead to BMZ

disruption and injury to the superficial layer of the lamina propria. The injury, if repetitive, leads
to aberrant healing and a fibroblastic response involving increased fibronectin deposition."[13]
On an ultrastructural level, nodules tend to demonstrate epithelial changes in the form of
increased thickness, gaping of the intracellular junctions, and absence of the basal lamina. These
changes were much less prominent in the polyps examined. Conversely, polyps tended to show
variable pathologic patterns; some demonstrated marked vascularity, and others had hyaline
stromal changes. The authors interpreted differences as perhaps indicative of a more longstanding exposure to injurious agents in the case of VFNs; they interpreted "microstromal
hemorrhages" as potentially playing a role in the formation of VFPs. Gray et al speculated that
the heterogeneous findings might be due to the stage in the life cycle of the polyp examined.[6]

Medical Therapy
Treatment options for vocal fold nodules (VFNs) and vocal fold polyps (VFPs) include both
invasive and noninvasive techniques.[14] Prevailing thought reflects the opinion that the etiologic
mechanisms of both lesions are most directly related to vocal use and technique. Therefore,
attention to correcting the underlying causative factors, largely through voice therapy and
education, plays an integral role in any treatment plan of action.
Education regarding proper vocal hygiene and hydration and avoidance of vocal abuse, misuse,
and overuse is a necessary baseline. The patient must comprehend how specific behaviors or
patterns thereof may have contributed or may in the future contribute to vocal fold lesions.
Intervention in the form of voice therapy to correct these usage issues may be all that is required
with the vast majority of vocal fold nodules (VFNs), as well as some small vocal fold polyps
(VFPs).
As previously noted, with the exception of lesions affecting the patency of the airway or those in
which the diagnosis of malignancy is entertained, the indication for surgical therapy is
unacceptable vocal impairment despite compliance with medical treatment and appropriate voice
therapy. Clearly, the level of acceptable vocal impairment varies widely between individuals
depending on professional and personal voice usage patterns and demands.

Surgical Therapy
Several authors have published papers relating to phonosurgical techniques for removal of
benign lesions. Although the surgical removal of nodules is relatively uncommon,
recommendations for such a procedure include minimal normal tissue disruption, with an end
point of a straight medial TVF edge without divots or remaining excess tissue. Given that
surgery for vocal fold nodules (VFNs) is rare, fewer than 5% of cases, and should be considered
only after a thorough nonsurgical treatment regimen is unsuccessful, the remainder of this
discussion focuses on techniques described for vocal fold polyp (VFP) removal.
Much debate continues regarding the relative merits of cold steel versus carbon dioxide laser
removal of benign laryngeal pathology. Both techniques have the known potential to cause
scarring with disruption of the lamina propria (LP). Despite the advent of high-magnification

operative microscopes, microlaryngeal instrumentation, and the refinement of microspot

manipulators for the carbon dioxide laser, both techniques require extreme care and a skilled
surgeon to avoid potentially devastating vocal complications. The laser, however, introduces the
additional risk of peripheral tissue damage by means of dissipated thermal energy, in addition to
the inherent danger of a potentially catastrophic airway fire. These factors must always be
considered when opting for this technique. Over the course of the last decade, sentiment and
editorial preferences have tended to favor the use of cold steel instrumentation, undoubtedly
owing to the decreased risk of peripheral thermal damage.
Two publications have readdressed this issue. In 2000, Benninger published his data from a
randomized, prospective, blinded study that compared aerodynamic, perceptual, and
videostroboscopic measures between microspot carbon dioxide laser excision and cold steel
microdissection of a variety of benign lesions of the vocal fold.[15] His data showed no
demonstrable difference in postoperative perceptual and videostroboscopic parameters or in the
recovery time between the 2 techniques. The author, however, makes the point that only the
increased precision allowed by the development of the microspot manipulator allows for the
accuracy necessary to perform such delicate phonosurgery.
In 1999, Remacle et al published data on the use of the carbon dioxide laser in the treatment of
251 patients with benign vocal fold lesions.[16] He concluded that the use of the microspot carbon
dioxide laser is safe and effective. Notably, his study did not attempt to compare outcomes for
various surgical techniques.
In 2005, Ragab et al published a prospective controlled study of outcomes from a cohort of
surgical patients with vocal fold nodules and polyps, randomized to either cold knife or
radiosurgical (radiofrequency) excision groups.[17] No significant differences in postoperative
subjective and perceptual voice measures, surgical complications, or the course of recovery was
noted between the 2 groups. The authors argue that this technique, already used for other ENT
surgical applications, combines the hemostatic benefits of laser excision with a tactile input of
cold steel instrumentation.
Many publications have extolled the virtues of cold steel instrumentation for the surgical
excision of VFPs. The concept of vocal fold microflap surgery for the treatment of TVF lesions
has been reported since the mid to late 1980s. Review of the technique has shown its efficacy in
the treatment of selected benign vocal pathologies.
With specific attention to the subepithelial pathology observed in VFPs, a subepithelial microflap
resection technique has recently been described. This method seeks to preserve the overlying
epithelial cover, while removing the underlying polypoid tissue via a superolateral cordotomy
approach. The publication describes a series of 40 patients who showed clinical postoperative
improvement, but it does not attempt a comparison with the less technically demanding
superficial amputation technique. In theory, by maintaining the native epithelial lining and
eliminating the need for secondary reepithelialization, this technique should lead to faster
healing.

The author's technique of choice is the subepithelial microflap, when feasible. In many cases
with a narrowly based pedunculated polypoid lesion, this technique is impractical and
unnecessary. A simple superficial excision, sparing the underlying uninvolved LP and
minimizing the epithelial loss, is generally sufficient. To accurately achieve these goals,
however, high-powered binocular visualization and delicate microlaryngeal instrumentation is
required.

This picture shows the surgical view of a vocal fold polyp

(VFP) as observed via high-power microlaryngoscopy.

In the microflap technique, an incision in made along the superior surface of the lesion, near the
interface of the normal and abnormal tissues. Dissection is then performed in separate planes to
isolate the lesion. A plane of dissection is developed between the overlying epithelium and the
diseased underlying tissue. The goal of this maneuver is to spare uninvolved epithelium to
resurface the resulting defect from excision. The second dissection plane is more arbitrary and is
created between the diseased lamina propria and the laterally located uninvolved tissue of the
same layer. After the diseased tissue is removed, the spared epithelium is trimmed and laid back
over the defect to optimally oppose the epithelial layers and limit healing by secondary intention.
In general, no suturing is required to maintain flap position.

Preoperative Details
Preoperative management of vocal fold polyps is largely dependent upon the practitioner;
however, some general rules do apply. Surgery for most lesions is not considered until a
nonsurgical therapeutic approach (eg, behavioral voice therapy) has proven unsuccessful in
yielding the desired voice outcome. Additionally, voice therapy serves as the only technique
available that addresses the common behavioral causes of these lesions, decreasing their
likelihood of recurrence. Other nonsurgical interventions designed to assess the reversibility of
acute lesions include steroid therapy and voice rest. These 2 interventions are primarily aimed at
separating acute dynamic lesions of the vocal fold from stable chronic lesions that are likely to
require surgical excision.
If indeed surgical intervention is required, an examination a short time prior to the procedure is
advisable. All lesions of the vocal fold are subject to some degree of physical change that may
significantly alter the scope of the recommended procedure, or in some cases, obviate the need
for surgery all together. Preoperatively, the physician must obtain a detailed informed consent for
the procedure. Counseling should be based upon the physician's experience with similar clinical
situations, including all reasonable vocal expectations, limitations, and potential surgical

complications. Video documentation of preoperative findings and a high-quality voice sample is

essential for accurate record keeping as well as good medicolegal practice.

Postoperative Details
Postoperative and therapeutic follow-up regimens vary widely following treatment of vocal fold
nodules (VFNs) and vocal fold polyps (VFPs). In cases treated nonsurgically, the timing of
interval clinical examinations depends on the chosen frequency of voice therapy, patient
compliance, and the degree to which the patient can apply therapeutic techniques in everyday
life. Following operative intervention, the prescribed regimen is equally variable.
The length of voice rest and postoperative voice therapy depends completely on size and position
of the lesion, surgical technique employed, degree of necessary re-epithelization, and a series of
patient-related factors. These factors include (1) occupational and personal vocal demands; (2)
characteristics of vocal use, misuse, or abuse; (3) medications; and (4) systemic illnesses.
Surgeons usually prescribe a course of voice rest to coincide with the projected time required for
postoperative epithelization and edema resolution. Thereafter, a graduated schedule of voice use
is often instituted, ideally concluding with the full return of voice quality and endurance,
satisfying the patient's vocal demands.

This picture is a postoperative surgical view immediately

following microsurgical removal of vocal fold polyp (VFP).

Videostroboscopy of postoperative vocal fold polyp (VFP). This is an image from
office examination of the same patient as in Image 3, 6 days following VFP removal.
Note the straight edge of the vocal fold (right side of image).

Complications
The surgeon is charged with communicating a myriad of potential surgical complications to a
prospective surgical candidate. The most common complications include tongue numbness,
altered taste, and minor trauma to the teeth, oral cavity, and pharynx during rigid laryngoscopy.
Risks associated with phonomicrosurgery include the potential for worsened voice quality,
bleeding, infection, dental trauma, and oropharyngeal injury due to laryngeal suspension, and,
most notably, scar formation due to overaggressive tissue resection or patient factors during the
healing period. These potential complications must then be balanced against the proposed gain
from the surgery on a case-by-case basis.

Outcome and Prognosis

With respect to vocal fold nodules (VFNs) and vocal fold polyps (VFPs), treatment often results
in vocal improvement. With respect to vocal fold nodules (VFNs), Murray et al demonstrated a
beneficial effect of voice therapy when compared with observation alone. No prospective
randomized studies compare the natural history of VFPs to the outcomes of standardized
treatment regimens. However, relatively convincing evidence within the literature supports the
safety and efficacy of these techniques in improving perceptual, aerodynamic, and stroboscopic
parameters (based on the growing aggregate of reported surgical series of patients managed
operatively with conservative phonomicrosurgery).
In 1996, Bastian reported his personal surgical series of 62 singers who had undergone
microsurgery (the second-largest series reported in this patient population at the time).[18] Even
within this high-risk population, evidence supported the safety and efficacy of surgical therapy.
However, note that perhaps the most striking element of the study was the meticulous patient
selection process, as well as preoperative and postoperative therapeutic and behavioral regimens.
Reportedly, all singers within the series were able to return to a level of public singing at least
equal to that experienced preoperatively.
Given the presumed pathophysiology, the long-term prognosis for patients with vocal fold
nodules (VFNs) and vocal fold polyps (VFPs) appears dependent on maintenance of hygienic
vocal behaviors. Patients unable or unwilling to participate in this fashion are arguably poor
candidates for surgical intervention.

Future and Controversies

Undoubtedly, the debate over ideal surgical techniques, instrumentation, and therapeutic
regimens will continue as more data become available. Further research of bioimplantable
materials will ideally render the potentially disastrous vocal complications of phonosurgery, such
as scarring and loss of vibratory capacity, easier to treat.