Is Surgery Necessary for All Vocal Fold Polyps?
Is Surgery Necessary for All Vocal Fold Polyps?
Vocal fold polyps are benign nonneoplastic lesions thought to occur as a result of vocal abuse, misuse, or overuse. Similar to vocal fold nodules and cysts, these lesions result in significant disability, especially among those who require voice for their vocation. Current treatment includes conservative (i.e., nonsurgical) and surgical approaches. Most laryngologists agree that conservative voice therapy is an effective first-line approach for vocal fold nodules. However, no consensus exists regarding vocal fold polyps. In fact, a 2003 survey of members of the American Academy of Otolaryngology–Head & Neck Surgery found that only 30% of respondents recommended voice therapy as the initial treatment for polyps. Variation in treatment is perpetuated by either lack of data or its dissemination. As such, it is important to review the evidence surrounding the effectiveness of conservative management at improving voice quality in patients with vocal fold polyps.
Key studies are reviewed and summarized in Table 1. In these studies, improvement was assessed either by self-report of voice quality or by demonstrating polyp size reduction or resolution. All describe how patient characteristics, polyp morphology, and associated medical conditions relate to outcome.
|Study||N||Sizeb (N)||Polyp Character||Treatment||Primary Outcome||Mean Follow-Up||Improved||Predictors|
|Cohen et al 2007||42||NR||1. Translucent||Voice therapy||Self-report*a||7.9 mo. (Range 2–36)||45.2%||Translucent|
|Yun et al. 2007||175 ||Small: ≤ ⅛ (26)||1. Hemorrhagic2. Nonhemorrhagic||Vocal hygiene||50% ↓ size||NR[≥3 mo.]||38% [20%]||Polyp size Smoking status|
|Medium: ⅛– ⅙ (76)|
|Large: ⅙– ¼ (46)|
|Huge: > ⅓ (27)|
|Klein et al. 2009||14c||Small: pinpoint||1. Hemorrhagic||Voice therapy||Polyp resolution||≥12 mo. (N = 9) 8 mo. (Range 1.2–13; N = 5)||64.2%||NA|
|Medium: < ⅓|
|Large: > ⅓|
|Cho et al. 2011||158||Small: < ⅓ (77)||1. Hemorrhagic2. Nonhemorrhagic||Voice therapy||50% ↓ size||NR||65.8%||Polyp size Vocal Fold Color|
|Medium: ¼– ⅓ (34)|
|Large: > ⅓ (47)|
|Nakagawa et al. 2012||132||Small: pinpoint (48)||NR||Voice therapy||1. Polyp resolution2. Shrinkage||5.1 mo.||1. 41.7%2. 21.9%||NA|
|Medium: < ⅓ (58)|
|Large: > ⅓ (26)|
Over a 3-year period, Cohen & Garrett assessed 42 consecutive patients who underwent voice therapy for vocal fold polyps and found that 45% had significant voice improvement while the remainder required surgery to achieve desired improvement. Patients with translucent polyps were significantly more likely to improve with voice therapy compared to hyaline or hemorrhagic types: 54% versus 7.7% and 16.7%, respectively. No other variable including smoking status, allergy and reflux treatment, vibratory characteristics, singing status, and length of hoarseness was associated with improved outcome. Thus, authors advocate voice therapy as an appropriate initial treatment option for all patients with vocal fold polyps, understanding that those with translucent polyps may have higher likelihood of avoiding surgery.
Klein et al. in 2009 reported on the clinical course of 29 consecutive patients with hemorrhagic polyps. At presentation, patients were offered either 1) surgery with limited preoperative voice therapy and vocal hygiene education, or 2) voice therapy and vocal hygiene education as the primary treatment modality. Thirteen (44%) elected for immediate surgical excision (7 medium, 6 large polyps), 14 (48%) with small and medium sized polyps chose nonsurgical treatment. Nine of those who declined surgery and chose conservative treatment had resolution of their polyps (64.2%) within a mean 4.4 months of initial evaluation. None subsequently required surgical invention. The remainder (N = 5) had no significant change in polyp size or voice with conservative therapy within a mean 8 months of follow-up. Recognizing the small sample size and potential for bias, the conclusion was that those seeking rapid resolution of symptoms and those with large polyps prefer surgery.
Polyp size also predicted response to vocal hygiene education alone in a study of 340 consecutive patients by Yun et al. Rather than initially offering surgery, clinicians provided a standardized formal educational session describing good vocal habits, normal voice production, and benefits of proper vocal hygiene. Of 175 patients with 3 months follow-up, 38% had improvement defined as a ≥50% reduction in polyp size. Even in the group without reduced polyp size, a significant number of patients reported subjective voice improvement. In multivariate analysis, smaller polyp size and nonsmoking status significantly increased odds of improvement using their conservative approach. Interestingly, no actual voice therapy was performed on patients enrolled in this study. The results support a conservative approach even when formal voice therapy is not readily available.
Two recent studies also found polyp size to influence outcomes with conservative nonsurgical management. In the first, authors concluded that voice therapy is more effective in patients with small polyps in the absence of associated vocal fold erythema. In patients with intermediate sized polyps, other factors should be weighed in the surgical decision-making process (i.e., presence of erythema/edema, MTD, smoking). In their cohort of 158 patients, there was no differential response to therapy based on polyp character (e.g., translucent, hemorrhagic). Likewise, in a review of 644 patients with vocal fold polyps that underwent immediate surgery (433) or conservative treatment (132), 55% of those treated with conservative therapy had complete resolution, and an additional 21.9% of polyps reduced in size at a mean 5.1 months follow-up. Due in part to the large number of patients choosing surgery or lost to follow up, the authors conservatively concluded that about 9.7% of polyps might resolve with voice therapy and vocal hygiene measures alone despite reporting that approximately 64% of those deferring surgery had improvement, thereby obviating the need for further intervention.
From a clinical standpoint, it is not a question of whether voice therapy or surgical management offers the best outcome, but whether a conservative approach can offer sufficient improvement to eliminate the inherent risks of surgery. Based on the observational studies described earlier, conservative approaches can be used with success in patients with vocal fold polyps. As expected, smaller lesions tend to be most responsive to vocal hygiene measures with or without voice therapy. Surgery remains a viable initial option for those with larger polyps and in those who require a rapid definitive approach. Nonetheless, the shared decision-making process should always include counseling regarding the potentially curative role of conservative therapy.
All of the cited studies are level 4.