The Laryngoscope

© 2019 The American Laryngological,

Rhinological and Otological Society, Inc.

Recurrence of Benign Phonotraumatic Vocal Fold Lesions After

Microlaryngoscopy

Mark Lee, BA, BS ; Lucian Sulica, MD

Objectives: To determine recurrence rates for benign phonotraumatic vocal fold lesions after microlaryngoscopic
surgery.
Study Design: Retrospective review.
Methods: Records of adults who underwent microlaryngoscopy between 2006 and 2017 for vocal fold cysts, midfold
masses, polyps, pseudocysts, sulcus vocalis (Ford type 3), and varices were reviewed for demographics, medical history, treat-
ment, and lesion recurrence. Patients operated for nonphonotraumatic lesions (e.g., granuloma, keratosis/leukoplakia, papil-
loma) were excluded. Stroboscopic examinations were re-reviewed to confirm diagnosis and outcome.
Results: Five hundred ten adults (223 male:287 female; mean age 40.3  14.9 years) were included. Overall, 62 of 510
(12.2%) recurred (median time to recurrence: 70.0 months). Of these, 44 (71.0%) recurred to the same lesion type and
49 (79.0%) to the same side. Recurrence rates by initial lesion type were as follows: cysts, two of 92 (2.2%); midfold masses,
four of 18 (22.2%); polyps, 25 of 235 (10.6%); pseudocysts, 30 of 145 (20.7%); sulcus vocalis, one of 18 (5.6%); and varices,
zero of two (0%) (χ 2 = 28.7, degrees of freedom [df] = 5, P < 0.001). No significant difference in recurrence existed between
males (21 of 223, 9.4%) and females (41 of 287, 14.3%). However, young adults (17 of 86, 19.8%) had significantly higher
recurrence rates compared to middle-aged (12 of 155, 7.7%) and older adults (3/60, 5.0%) (χ 2 = 9.5, df = 3, P = 0.023). Of
62 recurrences, 18 were re-operated and four re-recurred.
Conclusion: Benign phonotraumatic vocal fold lesions recur at variable rates. This variation suggests pathophysiologic
differences between categories that may not be entirely explained by behavioral factors.
Key Words: Vocal polyp, vocal cyst, vocal fold mass, benign vocal fold lesion, microlaryngoscopy, phonotrauma,
recurrence.
Level of Evidence: 4
Laryngoscope, 00:1–7, 2019

INTRODUCTION function, including patient perception of voice handicap and

Benign vocal fold lesions comprise a diverse group of
pathologies with varying etiologies, such as phonotrauma,
reflux, and smoking. Among these, several are known to fre-
quently recur after surgical removal, including papilloma,
granuloma, and leukoplakia, a characteristic attributable to
the persistence of etiologic factors. In contrast, lesions
attributed to phonotrauma, or the physical stresses of pho-
nation on the layered microstructure of the vocal fold, are
not generally regarded as recurrent provided that appropri-
ate behavioral changes are made. Microlaryngoscopic
removal, whether as primary treatment or after behavioral
management, is generally considered curative if not risk-
free. Postoperative improvements in measures of vocal
From the Weill Cornell Medical College (M.L.); The Sean Parker
Institute for the Voice, Department of Otolaryngology–Head & Neck
Surgery, Weill Cornell Medical College (L.S.), New York, New York, U.S.A.
Institution where work was performed: The Sean Parker Institute
for the Voice, Weill Cornell Medical College, New York, New York, U.S.A.
Editor’s Note: This Manuscript was accepted for publication on
September 19, 2019.
Presented at the 2019 American Laryngological Association Annual
Meeting, Austin, Texas, U.S.A., May 1–3, 2019.
The authors have no funding, financial relationships, or conflicts of
interest to disclose.
Send correspondence to Lucian Sulica, MD, The Sean Parker Insti-
tute for the Voice, 240 East 59th Street, New York, NY 10022.
E-mail: lus2005@med.cornell.edu
DOI: 10.1002/lary.28349
acoustic/aerodynamic parameters, have been widely docu-
mented.1,2 Postoperative recurrence, on the other hand, has
almost never been the focus of study. When reported at all,
it is usually mentioned incidentally in studies with rela-
tively short follow-up periods that rarely extend beyond the
period of surgical recovery and rehabilitation.
Recurrence is an integral measure of treatment suc-
cess and an important consideration in the decision to
undergo surgical intervention. Careful study may suggest
prognostic factors, provide insights into the pathophysiol-
ogy of these lesions, and guide treatment modifications
for reducing risk of recurrence. The purpose of this inves-
tigation is to determine recurrence rates for a wide array
of benign vocal fold lesions using a large sample of surgi-
cal patients. In addition, we seek to identify clinical fac-
tors that may affect recurrence rates.
MATERIALS AND METHODS
The protocol for this study was approved by the institu-
tional review board. The study population, drawn from the surgi-
cal catalog of the senior investigator (L.S.) from March 1, 2006 to
October 31, 2017, includes patients between 18 and 99 years old
who underwent at least one microlaryngoscopic excision of a
benign phonotraumatic vocal fold lesion (including polyp, cyst,
midfold mass, pseudocyst, sulcus vocalis [Ford type 3], and varix)
and had both pre- and postoperative stroboscopic examinations.

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Fig. 1. A 36-year-old saleswoman presented with 6 months of hoarseness. Initial examination (left) showed left-sided polyp and right-sided
reactive lesion, subsequently excised. Vocal symptoms resolved postoperatively. Three years later, patient returned with recurrent left-sided
polyp (right). Vocal symptoms improved with voice therapy. The patient did not pursue further treatment, although some mucosal irregularity
persisted. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Patients treated for malignant or premalignant disease were not
included, nor were those with papilloma, granuloma, and
Reinke’s edema; these pathologies already are well understood to
have high rates of residual disease and recurrence. Amyloid,
scar, and nondysplastic keratosis were excluded due to small
group sizes. Surgical interventions consisted exclusively of micro-
scopic cold-knife excisions under general anesthesia. This study
did not include laser cases, CO2 or angiolytic, in the operating
room or the office. The patients’ first microlaryngoscopic surger-
ies at our institution were used as the index intervention even if
they had a prior procedure elsewhere. In the case of midfold
masses and pseudocysts, surgery was often preceded by voice
therapy. This was less likely for other lesions, although voice
therapy was universally recommended postoperatively.
The patients’ electronic medical records and stroboscopic
examinations were reviewed for demographics, medical histories,
disease characteristics, treatments, and lesion recurrences. Patient
demographics include gender, age, and primary occupation at the
time of first surgery at our institution. Occupation was stratified by
level of vocal demand: vocal performer (e.g., professional actor or
vocalist), high-intensity voice user (e.g., teacher or fitness instruc-
tor), and routine voice user (e.g., accountant), with acknowledge-
ment of considerable intragroup variability in voice utilization.
Smoking status prior to surgery was also obtained. Disease charac-
teristics include history of prior benign vocal fold lesions or
microlaryngoscopic surgery, laterality, and number of diagnoses.
Diagnoses were made by a fellowship-trained laryngologist
during the course of treatment. Lesions were characterized
according to the following diagnostic schema: Cyst was defined as
an encapsulated subepithelial mass. Polyp referred to a well-
defined sessile or pedunculated subepithelial lesion at the mid-
point of the membranous vocal fold, which was commonly hemor-
rhagic but also could be fibrotic (Fig. 1). A pseudocyst was
defined as a fusiform translucent lesion on the vibratory margin
of the vocal fold (Fig. 2). A sulcus vocalis was defined as a focal
invagination of epithelium appearing as a furrow or groove and
corresponding to a type 3 lesion according to the Ford classifica-
tion (Fig. 3).3 A varix was an enlarged subepithelial blood vessel.
Midfold mass was a heterogeneous category that encompasses a
broad spectrum of subepithelial fibrotic change centered at the

Fig. 2. A 27-year-old musical theater performer presented with hoarseness and loss of upper register for 2 months. Initial evaluation (left)
showed bilateral pseudocysts, subsequently excised. Similar symptoms recurred 4 months later, 2 months after returning to performance.
Evaluation (right) showed recurrence of pseudocyst on the left side. The patient underwent repeat surgery and has not recurred in 3 years.
[Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

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Fig. 3. A 20-year-old college student presented with rough voice quality and easy overuse hoarseness for at least 2 years. Stroboscopic
examination (left) showed bilateral phonotraumatic change revealed to be sulcus vocalis at surgical exploration. Symptoms improved but did
not resolve after excision. The patient returned 1 year later with worsening hoarseness. Evaluation (right) revealed recurrence of sulcus vocalis
on the left. This case has been previously published.21 [Color figure can be viewed in the online issue, which is available at www.
laryngoscope.com.]

midpoint of the membranous vocal fold. A midfold mass can be
bilateral or more rarely unilateral; lesions elsewhere termed nod-
ules fit within this category.
In the case of any ambiguity regarding diagnoses, preopera-
tive stroboscopic exams were re-reviewed by the laryngologist to
confirm diagnoses. Examinations were re-reviewed if patients
had a diagnosis other than cyst, polyp, and pseudocyst, or if they
had two or more lesions (except if the second lesion was a reac-
tive lesion). When patients had more than one diagnosis, a
primary diagnosis was designated for the purpose of analysis.
Treatment parameters analyzed included compliance with post-
operative voice rest, compliance with postoperative smoking ces-
sation, and attendance to postoperative voice therapy.
Surgery typically consisted of cold-knife complete excision
of the lesion in a layered fashion. Epithelial incision is made over
the lesion, and the lesion is separated from its attachments to
deeper tissues of the vocal fold. Decision to preserve overlying
epithelium depends on the condition of the epithelium and the

TABLE I.
Sample Description.
Total Sample Cyst Midfold Mass† Polyp Pseudocyst Sulcus Vocalis Varix
Variable n (%) n (%) n (%) n (%) n (%) n (%) n (%)

Gender (N = 510)
Male 223 (44) 31 (34) 3 (17) 162 (69) 18 (12) 7 (39) 2 (100)
Female 287 (56) 61 (66) 15 (83) 73 (31) 127 (88) 11 (61) 0 (0)
Age at time of surgery (N = 510)
Young adults (18 to 25 years) 86 (17) 7 (8) 5 (28) 25 (11) 44 (30) 5 (28) 0 (0)
Adults (26 to 40 years) 209 (41) 23 (25) 8 (44) 91 (39) 79 (55) 7 (39) 1 (50)
Middle-aged adults (41 to 60 years) 155 (30) 38 (41) 5 (28) 88 (37) 18 (12) 5 (28) 1 (50)
Older adults (61+ years) 60 (12) 24 (26) 0 (0) 31 (13) 4 (3) 1 (6) 0 (0)
Occupation at time of surgery (N = 501)
Voice performer 151 (30) 12 (13) 5 (28) 41 (18) 84 (58) 7 (41) 2 (100)
High-intensity voice user 132 (26) 20 (22) 6 (33) 65 (28) 35 (24) 6 (35) 0 (0)
Routine voice user 218 (44) 59 (65) 7 (39) 123 (54) 25 (17) 4 (24) 0 (0)
Smoking status at time of surgery (N = 506)
Never smoker 373 (74) 65 (71) 11 (61) 154 (66) 127 (89) 14 (78) 2 (100)
Past smoker 91 (18) 21 (23) 6 (33) 48 (20) 13 (9) 3 (17) 0 (0)
Current smoker 42 (8) 5 (6) 1 (6) 33 (14) 2 (1) 1 (6) 0 (0)
Surgical treatment prior to presentation (N = 510)
Yes 24 (5) 5 (5) 0 (0) 12 (5) 7 (5) 0 (0) 0 (0)
No 486 (95) 87 (95) 18 (100) 223 (95) 138 (95) 18 (100) 2 (100)

†
Includes fibrous mass, mass, midfold mass, epithelial thickening, fibrosis, fibrovascular mass, and reactive lesion.

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 TABLE II.
Disease Characteristics (N = 510).
Laterality Number of Diagnoses
Total Unilateral Bilateral† One Diagnosis Primary Diagnosis
Primary Diagnosis n (%) n (%)‡ n (%)‡ n (%)‡ n (%)‡

Cyst 92 (18.0) 73 (79.3) 19 (20.7) 74 (80.4) 18 (19.6)

Midfold mass§ 18 (3.5) 3 (16.7) 15 (83.3) 16 (88.9) 2 (11.1)
Polyp 235 (46.1) 157 (66.8) 78 (33.2) 183 (77.9) 52 (22.1)
Pseudocyst 145 (28.4) 50 (34.5) 95 (65.5) 103 (71.0) 42 (29.0)
Sulcus vocalis 18 (3.5) 12 (66.7) 6 (33.3) 17 (94.4) 1 (5.6)
Varix 2 (0.4) 0 (0.0) 2 (100) 0 (0.0) 2 (100)

†
Any diagnoses on both vocal cords.
‡
Row percentages.
§
Includes fibrous mass, mass, midfold mass, epithelial thickening, fibrosis, fibrovascular mass, and reactive lesion.

anticipated size of the surgical defect if it is sacrificed. In the

TABLE III.
case of polyp, epithelial preservation was the exception, whereas
Recurrence of Benign Vocal Fold Lesions by Diagnoses and Other
it was nearly always preserved in cysts and sulcus lesions. Epi- Clinical Factors.
thelial preservation was variable in cases of pseudocyst and
midfold fibrous mass. Once all pathologic material is resected, no Recurrence
Comparison
attempt at epithelial reapproximation is made. Patients observe Variable n/N (%) χ 2
df P Value
a week of postoperative voice rest, followed by gradual return to
normal voice use under the direction of the voice therapist and Primary diagnosis
the surgeon over 4 or more weeks. Patients are routinely Cyst 2/92 (2.2) 28.7 5 0.000
followed until 3 months have elapsed from surgery. After that Midfold mass† 4/18 (22.2)
period, they are instructed to return if they experience voice
Polyp 25/235 (10.6)
change lasting more than a week.
Recurrence was defined as the development of any benign Pseudocyst 30/145 (20.7)
vocal fold lesion on either vocal fold after the complete surgical Sulcus vocalis 1/18 (5.6)
removal of a lesion at our institution documented by postopera- Varix 0/2 (0.0)
tive stroboscopy. No time limit was set on recurrence. In all cases Gender
of recurrence, stroboscopic exams from the pre- and postopera-
Male 21/223 (9.4) 0.72 1 0.397
tive visit and at the time of recurrence were re-reviewed by the
laryngologist, principally to distinguish recurrence from residual Female 41/287 (14.3)
disease. Date of recurrence was the date when lesions were first Age at time of surgery
identified by stroboscopy. Young adults 17/86 (19.8) 9.52 3 0.023
Adults 30/209 (14.4)
Middle-aged adults 12/155 (7.7)
Statistical Analyses
The data was analyzed using SPSS 25 (SPSS Inc., Chicago, Older adults 3/60 (5.0)
IL). Descriptive statistics were provided for measures of patients’ Occupation at time of surgery
demographics, past medical histories, disease characteristics, Vocal performer 28/151 (18.5) 4.25 2 0.119
treatment parameters, and recurrence characteristics. The High-intensity voice user 15/132 (11.4)
Kaplan-Meier product limit method and Cox proportional haz-
Routine voice user 18/218 (8.3)
ards model were used to estimate median times to recurrence
and to test for differences in recurrence rates by diagnoses and Smoking status at time of surgery
other clinical factors. In the time to recurrence models, the event Never smoker 51/373 (13.7) 4.18 2 0.124
was recurrence and the censor was lost to follow-up. All tests of Past smoker 7/91 (7.7)
hypothesis were two-sided and evaluated at a significance level Current smoker 4/42 (9.5)
of P < 0.05.
Laterality
Unilateral 27/295 (9.2) 3.43 1 0.064
Bilateral 35/215 (16.3)
RESULTS
Number of diagnoses
A total of 510 patients were included. Patients were
One 41/393 (10.4) 3.56 1 0.059
followed for an average of 13.7 months (standard devia-
Two or more 21/117 (17.9)
tion [SD] = 22.3, minimum = 0.1, maximum = 119.8).
Patient demographics and past medical history are sum- Attended voice therapy after surgery
marized in Table I. The average age of the sample was No 4/32 (12.5) 0.00 1 0.986
40.3 years (SD = 14.9, minimum = 18, maximum = 84). Yes 50/362 (13.8)
Data on occupation and history of smoking was not avail- †
Includes fibrous mass, mass, midfold mass, epithelial thickening,
able for a small number of patients. Twenty-four patients fibrosis, fibrovascular mass, and reactive lesion.
had previous microlaryngoscopic surgery (4.7%) for df = degrees of freedom.

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 TABLE IV.
Recurrence Characteristics and Treatment.
Same Side As Initial Surgery for Recurrence Voice Therapy for Recurrence Surgery/Therapy for Recurrence
Primary Recurrence Diagnosis n/N (%) n/N (%) n/N (%) n/N (%)

Cyst 0/0 0/0 0/0 0/0

Midfold mass† 9/13 (69.2) 1/13 (7.7) 6/13 (46.2) 7/13 (53.8)
Polyp 11/14 (78.6) 7/14 (50.0) 7/14 (50.0) 10/14 (71.4)
Pseudocyst 28/32 (87.5) 10/32 (31.3) 13/32 (40.6) 15/32 (46.9)
Sulcus vocalis 1/1 (100) 0/1 (0.0) 0/1 (0.0) 0/1 (0.0)
Vascular‡ 0/2 (0.0) 0/2 (0.0) 1/2 (50.0) 1/2 (50.0)

†
Includes fibrous mass, mass, midfold mass, epithelial thickening, fibrosis, fibrovascular mass, and reactive lesion.
‡
Includes hemorrhage, varices, and ectasia.

benign vocal fold lesions at an outside institution.
Twenty-one patients had one prior surgery, whereas one
patient each had two, three, and four prior surgeries.
Table II provides descriptive statistics on disease charac-
teristics. The majority of patients had disease on only one
vocal fold (n = 295, 57.8%). A total of 391 patients had
one diagnosis (76.7%); 110 had two diagnoses (21.6%);
and nine had three diagnoses (1.8%). Available data sug-
gests that the large majority of patients were compliant
with postoperative voice rest (319 of 330, 96.7%) and voice
therapy (362 of 394, 91.9%). Only a minority of patients
were compliant with smoking cessation (6 of 17, 35.3%).
A total of 62 out of 510 patients had recurrence
(12.2%). The median time to recurrence was 70.0 months
(95% confidence interval = 55.5, 84.6). Table III presents
recurrence rates by diagnoses and clinical factors. There
were statistically significant differences in recurrence
rates by primary diagnosis. Age at the time of surgery
was a significant predictor for recurrence. Young adults
(18–25) and adults (26–40) were more likely than middle-
aged adults (41–60) and older adults (61+) to develop
recurrence. Although not statistically significant, vocal
performers had higher rates of recurrence than high-
intensity and routine voice users. There were trends
(P < 0.1) for higher recurrence rates for bilateral disease
compared to unilateral and for multiple diagnoses com-
pared to single diagnosis. Five out of the 24 patients
(20.8%) who previously underwent microlaryngoscopic
resection at an outside institution recurred after re-
section at our institution.
Recurrence characteristics and treatments are pres-
ented in Table IV. Fifty-eight patients had one diagnosis
at recurrence (93.5%), whereas four had two diagnoses
(6.5%). The most frequent primary diagnosis at recur-
rence was pseudocyst (n = 32, 51.6%), followed by polyp
(n = 14, 22.6%), midfold mass (n = 13, 21.0%), varix/hem-
orrhage (n = 2, 3.2%), and sulcus vocalis (Ford type 3;
n = 1, 1.6%). Of the 62 patients who developed recur-
rence, 46 recurred with unilateral disease (74.2%). The
majority of patients developed recurrence on the same
side as the initial lesion (n = 49, 79.0%), whereas nine
developed a lesion on the opposite side (14.5%) and four
on both the same and opposite side (6.5%). A total of
44 patients (71.0%) recurred with same lesion type.
Thirty-eight patients (61.3%) recurred both on the same
side and with the same primary diagnosis. Forty-four
patients did not undergo a subsequent surgery (71.0%),
whereas 15 had one additional surgery (24.2%); two had
two additional surgeries (3.2%); and one had three addi-
tional surgeries (1.6%). Fifty-eight patients recurred
only once (93.5%); two had two recurrences (3.2%); and
two had three recurrences (3.2%). Overall, 43.5% of
recurrence patients (27 of 62) had postoperative voice
therapy, and 53.2% (33 of 62) had postoperative voice
therapy and/or repeat surgery. Table V compares initial
and recurrent diagnoses.

TABLE V.
Recurrence Diagnosis by Initial Primary Diagnosis (N = 63).
Recurrence
†
Cyst Midfold Mass Polyp Pseudocyst Sulcus Vocalis Vascular‡
N= 0 13 14 32 1 2 Table Legend

Initial Cyst 2 0 1 1 0 0 0 82%–100%

Midfold mass† 4 0 4 0 0 0 0 67%–81%
Polyp 25 0 4 13 6 0 2 50%–66%
Pseudocyst 30 0 4 0 26 0 0 34%–49%
Sulcus vocalis 1 0 0 0 0 1 0 17%–33%
Varix 0 0 0 0 0 0 0 0%–16%

†
Includes fibrous mass, mass, midfold mass, epithelial thickening, fibrosis, fibrovascular mass, and reactive lesion.
‡
Includes hemorrhage, varices, and ectasia.

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DISCUSSION
By definition, benign phonotraumatic vocal fold lesions
are generally thought to arise from mechanical trauma to
the membranous vocal folds from phonatory vibration,
followed by tissue remodeling.1 Despite this theorized com-
mon etiology, benign vocal lesions vary considerably in clini-
cal features and behavior. One hypothesis is that different
diagnoses correlate with different stages of tissue remo-
deling.1,4 A prior study described pronounced gender and
age differences among lesion types, suggesting that biologic
differences play an important role.5 Recurrence rates offer
another window into differences between diagnoses.
Lesion types evaluated in this article recur in three
broad groups. Cysts and sulcus vocalis (Ford type 3) recur-
rences are least common, 2.2% and 5.6%, respectively. This
is broadly consistent with recurrence rates for cysts
reported elsewhere, from 3.0 to 4.8%.6–8 Recurrence of sul-
cus vocalis is not reported in the literature. Vocal fold
polyps recurred at an intermediate rate: 10.6%. Rates
reported in the literature after microsurgery or laser treat-
ment are notably lower, varying from 2.5% to 5.9%.9–14
These lower rates are probably a function of relatively lim-
ited follow-up periods not exceeding 11 months and usually
shorter. This is in contrast to our median time to recurrence
of 70 months. Of interest, Byeon et al.11 reported a higher
recurrence rate of 16.7% (3 of 18) when polyps co-occurred
with sulcus vocalis, compared to a rate of 3.1% (8 of 262) in
patients without sulcus vocalis. We were unable to corrobo-
rate this in our population because patients were analyzed
by primary diagnosis alone; however, at least two patients
in the recurrence group did have prominent sulcus lesions.
Midfold masses and pseudocysts recurred at the highest
rate in our study (> 20%). In a study of nodules
corresponding to our category of midfold masses for which
patients were followed for an average of more than 5 years,
recurrent lesions were noted in 18% of patients.15 A still
higher proportion (30%) reported a return of hoarseness.
Our experience over a similar period of time virtually mir-
rors this. Indeed, nodules are commonly regarded as a
lesion that occasionally recurs after surgery.1 Pseudocysts
have been more rarely studied as a separate category. Prior
reports of our experience with this lesion comprise cases
also included in this article and thus similar recurrence
rates, although differences in method of evaluation generate
some variation.16,17
The variation in recurrence rates suggest important
differences in pathophysiology. Recurrence of cysts and sul-
cus vocalis (Ford type 3) very likely depend on technical
errors at excision in which small sections of the lesion enve-
lope are retained in the vocal fold rather than any behav-
ioral factor. Polyp recurrences, on the other hand, are
probably more fully determined by behavioral factors
predisposing to further phonotrauma. Thus, recurrence rates
for polyps would be expected to be in proportion with expo-
sure to etiologic factors, which is supported by the differ-
ences between low short-term recurrence rates reported in
the literature and higher long-term rates in this paper. The
relatively higher recurrence rates in pseudocysts and
midfold masses may be principally determined by inherent
anatomic and physiologic predisposition to phonotraumatic
damage. Relevant to this, we observe that both midfold
Laryngoscope 00: 2019
6
masses and pseudocysts occur overwhelmingly in women, a
group in whom higher fundamental frequency and conse-
quent increase in collisional trauma is generally thought to
predispose to phonotraumatic injury.18 A high incidence of
paresis has been noted in patients with pseudocysts.19 Many
women have been noted to have incomplete posterior glottic
closure, a finding generally considered to be physiologic. We
have proposed elsewhere that this posterior glottic insuffi-
ciency functions as a sort of pseudo-paresis that further pre-
disposes to phonotraumatic injury,16 a hypothesis supported
by simulated three-dimensional models of vocal fold clo-
sure.20 In this model, posterior glottic insufficiency leads to
increased phonation threshold pressure, which in turn
increased phonotraumatic shearing and stress. The effects of
these intrinsic high fundamental frequency and glottic
insufficiency—whether from paresis or physiologic posterior
gap—are constant and can only be incompletely addressed
through behavioral change.
Most recurrences are same-lesion recurrences, fur-
ther suggesting that lesion types are distinct and result
from specific factors that tend to be constant in each
patient rather than a histopathologic process arrested at
different phases, as proposed by Marcotullio et al.4
We sought to evaluate the effect of a range of other
factors besides lesion type. Of these, only younger age
proved significant, probably because a large proportion of
the younger patients at our center were musical theater
performers and disproportionately represent a population
at risk for phonotraumatic injury. Voice therapy adherence
appeared to make no impact, although the overwhelming
majority of patients were compliant. Bilateral disease and
multiple diagnoses did not achieve statistical significance;
nonetheless, they had a suggestive correlation with recur-
rence and may represent higher grade damage to the mem-
branous vocal folds and thus a predisposition to develop
further lesions. Interpretations of these correlations should
be made with caution because diagnoses are highly con-
founded with gender, age, occupation, laterality, and num-
ber of diagnoses, as shown by our study and others.5
We note that recurrence is not automatically synony-
mous to treatment failure. Recurrences are often small,
minimally symptomatic, and sometimes clinically insig-
nificant. Although the overall recurrence rate is relatively
high (12.2%), the large majority of patients (71.0%) do not
need subsequent surgery. Thus, microlaryngoscopy is
highly successful at controlling benign phonotraumatic
lesions. Although our study did not show a statistically
significant improvement in lesion recurrence with voice
therapy, we do not regard this finding as conclusive. The
role of behavioral management in the treatment of
lesions, which are at least in part behaviorally deter-
mined, remains compelling, although its effect on lesion
recurrence is still not fully understood.
There are several limitations to this study. First,
recurrences are relatively rare events; therefore, despite
having a large sample overall, recurrence estimates for
some smaller subgroups were imprecise. Second, 23% of
our patients had more than one diagnosis. Analysis
according to primary diagnosis may have overlooked rela-
tionships between lesion types and other factors influenc-
ing recurrence. A limitation that stems from any
Lee and Sulica: Recurrence of Benign of Lesions
retrospective survey is potential loss to follow-up. Patients
are routinely followed up to 3 months postsurgery at our
institution. To be counted among the recurrences beyond
that interval, patients had to present on their own initia-
tive. Patients may have chosen to go to another institution
or to defer care altogether. Thus, recurrence rates pres-
ented here should be thought of as minimums. Future pro-
spective studies would be valuable in refining our
estimates. The age and occupation subgroups are to some
extent arbitrarily defined, and significant intragroup vari-
ability exists. More rigorous measures of voice use and
voice demand are needed in laryngology in general and
would certainly be useful to refine any study assessing the
impact of phonotrauma.
This study offers information regarding lesion recur-
rence across a spectrum of benign lesions in a large surgical
cohort encompassing a diverse group of patients of both
genders, all age groups, and different occupational vocal
demand. We use this information as an integral part of pre-
operative counseling. In particular, in patients with lesions
that are more likely to recur, we emphasize the role of sur-
gery as offering a reset rather than a cure in order to under-
line the importance of behavioral insight and adjunctive
behavioral management. In particular, behavioral treat-
ment is ripe for further study in the recurrence of mucosal
disease.
CONCLUSION
Postoperative rates of recurrence of benign pho-
notraumatic lesions vary significantly between diagnoses,
suggesting important differences in pathophysiology.
Midfold masses and pseudocysts have the highest rate, prob-
ably determined by intrinsic physiologic factors. Polyps recur
at an intermediate rate, likely most strongly influenced by
phonotrauma. Sulcus vocalis (Ford type 3) and cysts have
the lowest rates of recurrence, which likely are the result of
technical errors at excision. Our study further suggests
higher rates of recurrence in younger adults and those with
greater vocal demand, bilateral disease, and multiple diag-
noses. These findings can be used to create realistic clinical
expectations and present ready subjects for further
investigation.
Laryngoscope 00: 2019
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