Research Article
Folia Phoniatr Logop
DOI: 10.1159/000502477
Laryngeal Microsurgery for the
Treatment of Vocal Nodules and Cysts in
Dysphonic Children
Regina Helena Garcia Martins Dândara Bernardo Siqueira
Norimar Hernanes Dias Andrea Cristina Joia Gramuglia
Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery, Botucatu Medical School, University
of Estadual Paulista, Botucatu, Brazil
Keywords
Voice disorders · Children · Surgery · Dysphonia
Abstract
Introduction: Vocal nodules and cysts are frequent causes of
infantile dysphonia. Vocal therapy is the first treatment. Mi-
crosurgery has restricted indications, especially for nodules.
Objective: To describe our experience with microsurgery for
nodules and cysts in children. Methods: Dysphonic children
(aged 4–18 years) with the diagnosis of nodules and vocal
cysts were initially selected. Of these children, only those
were included who had undergone microsurgery. For nod-
ules and cysts, the microsurgery was indicated in cases of
failure of vocal therapy and in cases of voice worsening or
doubts about the diagnosis. All children were submitted to
auditory perceptual vocal analysis and videolaryngostrobos-
copy (before and after surgery, after 6 months). Surgical out-
comes were: total improvement (disappearance of vocal
symptoms and of the laryngeal lesions); partial improve-
ment (partial improvement of symptoms and/or mainte-
nance of lesions); no improvement (maintenance or worsen-
ing of the symptoms and/or persistence of the lesions).
­Results: There were 78 children with vocal nodules and 27
© 2019 S. Karger AG, Basel
E-Mail karger@karger.com
www.karger.com/fpl
Received: March 6, 2019
Accepted after revision: August 5, 2019
Published online: September 19, 2019
children with vocal cysts. Surgery was indicated for 12 chil-
dren with vocal nodules (15.4%) and 12 children with cysts
(44.4%). Total improvement registered for nodules and cysts
was 75 and 83.4%, respectively. Partial improvement for
both lesions was 25 and 16.6%, respectively. Conclusion:
The best outcome for laryngeal microsurgery in dysphonic
children was for vocal cysts. So, we encourage laryngologists
for this conduct in vocal cysts. The success of microsurgery
for vocal nodules was lower, and in these cases voice therapy
seems to be the best treatment. © 2019 S. Karger AG, Basel
Introduction
Dysphonia in children is commonly caused by vocal
cord nodules (38–78%) and vocal cysts (15–21%) [1–4].
A vocal nodule (Fig. 1) is associated with inadequate vocal
habits and vocal abuse, in which frequent traumatic col-
lision of the vocal folds results in injury to the epithelium
and superficial layers of the lamina propria [5]. The vocal
nodule is more prevalent in boys and is rarely diagnosed
in adult men, due to the natural reabsorption of the lesion
after puberty [5, 6]. Of the 91 adolescents of both genders
137.73.144.138 - 9/21/2019 2:42:26 AM
Dr. Regina Helena Garcia Martins
Department of Ophthalmology, Otorhinolaryngology, Head and Neck Surgery
Botucatu Medical School, University of Estadual Paulista
King's College London
Distrito de Rubião Junior s/n, Botucatu, SP 18618-970 (Brazil)
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E-Mail rmartins @ fmb.unesp.br
 Color version available online
Color version available online
Fig. 1. Bilateral vocal nodules (arrows). Fig. 2. Vocal cyst in right vocal fold (arrow).

Table 1. Laryngeal diagnosis and sex Table 2. Laryngeal diagnosis, mean age (±SD) and sex

Laryngeal diagnosis Boys, n (%) Girls, n (%) Total, n (%) Laryngeal Age according to sex, years p value
diagnosis boys girls
Vocal nodules 55 (52.38) 23 (21.90) 78 (72.28)
Vocal cyst 15 (14.29) 12 (11.43) 27 (25.71)
Vocal nodules 9.69±2.36 9.70±2.57 0.842
Total 70 (66.67) 35 (33.33) 105 (100.00) Vocal cyst 10.53±2.80 12.50±3.92 0.141

with the diagnoses of vocal nodules in childhood called Table 3. Laryngeal diagnosis and microsurgery
by De Bodt et al. [6] for a new evaluation after adoles-
cence, only 8% of the boys persisted with vocal symptoms, Laryngeal diagnosis Microsurgery, n (%)
and 7% remained with structural abnormalities at vide- Vocal nodules 12/78 (15.38)
olaryngoscopy. Vocal cyst 12/27 (44.44)
Voice therapy is the first treatment for vocal nodules;
Total 24/105 (22.85)
however, few studies detail the techniques, number of ses-
sions or duration of treatment [6]. The treatment is long
and requires changes in vocal habits, which may result in
discouraging and abandonment of the treatment.
Microsurgery for vocal nodules in children is reserved The objective of this study was to present our experi-
to special conditions such as dubious diagnoses, complete ence with laryngeal microsurgery for vocal nodules and
failure after voice therapy or significant worsening of vo- cysts in children.
cal symptoms [7, 8].
Epidermal vocal cysts (Fig. 2) are the second most fre-
quent cause of infantile dysphonia. They correspond to Methods
an invagination of epithelial cells in the subepithelial
plane of the mucosa of the vocal folds [9–11]. The treat- This study was approved by the Internal Review Board of our
University (protocol No. 59230016.5.0000.5411).
ment of vocal cysts in children is also controversial among Dysphonic children aged 4–18 years were selected who were
the authors, and voice therapy is not always effective [9– seen at the Voice Disorders Outpatient Clinic of the Otorhinolar-
12]. yngology Sector of the University between January 2012 and No-
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2 Folia Phoniatr Logop Martins/Siqueira/Dias/Gramuglia

DOI: 10.1159/000502477
King's College London
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 Table 4. Mean of auditory perceptual vocal analysis (GRBASI scale) in the pre- and postsurgery periods and la-
ryngeal lesion
Laryngeal lesion G R
pre post pre post
Vocal nodules 2.0* 1.3 1.7 1.1
Vocal cysts 1.87 1.0 1.62* 0.62
* p < 0.001.
vember 2017. Inclusion criteria: children with the diagnoses of vo-
cal nodules and cyst, who had undergone microsurgery. Exclusion
criteria: children who did not cooperate with the exam, who did
not attend the follow-up or who attended voice therapy in an in-
consistent or irregular condition. In order to evaluate the results
of the surgery (outcome), we analyzed the vocal symptoms, audi-
tory-perceptual vocal parameters (GRBASI scale; G –degree of
hoarseness; R – roughness; B – breathlessness; A – asthenia; S –
strain; I – instability), acoustic vocal parameters, videolaryn-
gostroboscopy and the size of the lesions (mm2), based on the area
measurements (length × width; ImageJ software). The size of the
lesions was analyzed by 2 blinded reviewers. Children and parents
were asked about vocal symptoms. The results of pre- and postsur-
gery vocal parameters and videolaryngostroboscopies were ana-
lyzed and compared by 3 blinded qualified speech therapists to the
pre- and poststatus.
The surgical results were divided into 3 outcomes: total im-
provement – complete disappearance of vocal symptoms and le-
sions; partial improvement – partial improvement of the symp-
toms and/or maintenance of laryngeal lesions; no improvement –
maintenance or worsening of vocal symptoms and/or persistence
of laryngeal lesions.
All children had 20–24 weekly sessions of voice therapy before
and after the surgery. Initially the vocal therapy programming was
discussed and explained to the child and parents.
Topics such as normal vocal and respiratory physiology were
presented, using appropriate language for children. The impact
of voice disorders on vocal function was presented. The vocal
therapy itself consisted of exercises in 20–24 individual weekly
sessions (once a week) lasting 40–45 min (before and after sur-
gery), using techniques of nasal sound production, vibrating
sounds, basal sounds, yawning, sighing, chewing and production
of fricative sounds. Parental participation in speech therapy ses-
sions was always encouraged. Parents were encouraged to per-
form the same exercises with their children at home during daily
activities.
The laryngeal diagnoses of dysphonia were confirmed by vide-
olaryngostroboscopy conducted with a rigid telescope (8 mm in
diameter, 70°, Asap, Germany) or flexible nasofibroscope (3.5 mm,
Olympus, Japan) coupled to a videolaryngoscopy image capture
system (XE-50, Eco V 50W X-TFT/USB, ILO Electronic GmbH,
Carl Zeiss, Germany; Asap microcamera, Germany; professional
lapel microphone Leson, Brazil) and a stroboscope system (Endo-
Stroboscope, Atmos, MedizinTechnik GmbH & Co. KG, Ger­
many).
Surgical Treatment for Vocal Nodules and
Cysts
B A S I
pre post pre post pre post pre post
1.5 1.1 0 0 1.0 0.3 0.9 0.3
1.50 0.87 0.12 0 0.62 0.25 0.50 0.37
The auditory-perceptual vocal evaluation was performed using
the GRBASI scale [13]. Vocal parameters were recorded during
spontaneous speech and sustained phonation of the vowel /a/.
GRBASI scale results were quantified through a 0–3 intensity score
by 3 blinded professionals with experience in voice assessments.
There should have been an agreement between at least 2 of them.
Statistical analysis compared the difference in age using the
Student t test and the difference in categorical variables using the
χ2 test. We set statistical significance at p ≤ 0.05.
Results
Among the 162 dysphonic children seen during the
study period, 105 met the inclusion criteria. So, we se-
lected 105 dysphonic children (boys = 70; girls = 35) with
the diagnosis of vocal nodules (n = 78; 72.28%) and cysts
(n = 27; 25.71%) (Table 1).
The mean age (±SD) was 10.5 (±3.0) years (minimum
5; maximum 18 years). The mean age was discretely low-
er for nodules, without statistical difference between the
sexes (Table 2).
Vocal nodules were diagnosed in 78 children of whom
12 underwent surgery (15.38%). The youngest child un-
dergoing microsurgery for vocal nodule was 9 years old.
Of the 27 children diagnosed with cysts, 12 underwent
surgery (44.44%), all with epidermal cysts (Table 3). The
youngest child was 7 years old. For vocal nodules and
cysts, the microsurgery was indicated in cases of worsen-
ing or no improvement of symptoms after voice therapy.
Tables 4 and 5 list the auditory-perceptual and acous-
tic vocal analysis in 2 moments (before and after surgery)
for both lesions, respectively. There was improvement of
the auditory perceptual parameters after surgery, espe-
cially the G parameter for nodules and the R parameter
for cysts (Table 4). There was improvement of the acous-
tic parameters in both lesions after surgery except for f0
in the nodules (Table 5).
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Folia Phoniatr Logop 3
DOI: 10.1159/000502477
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Table 5. Acoustic parameters (median; SD) of pre- and postsur- Table 6. Outcomes after surgery for vocal nodules and cysts
gery assessments
Laryngeal Total Partial No
Parameters Moments Vocal nodules Vocal cysts lesion improvement, improvement, improvement,
n (%) n (%) n (%)
f0, Hz pre 220.50 (6.49) 2.17.00 (3.44)
post 222.33 (14.13) 2.28.33 (5.94) Vocal nodules 9/12 (75.00) 3/12 (25.00) 0/12 (0.00)
p value 0.577 <0.001 Vocal cyst 10/12 (83.34)* 2/12 (16.66) 0/12 (0.00)
Jitter, % pre 2.79 (0.48) 3.10 (0.55) Total 19/24 (79.16) 5/24 (20.83) 0/29 (0.00)
post 1.22 (0.25) 1.99 (0.58)
p value <0.001 <0.001 * p = 0.013.
PPQ pre 1.37 (0.38) 3.37 (0.40)
post 0.73 (0.25) 1.25 (0.24)
p value <0.001 <0.001
Shimmer, % pre 4.90 (0.54) 5.30 (0.57) Table 7. Size of the vocal nodules and cysts before and after surgery
post 3.38 (0.34) 3.15 (0.57) (area measurement, median, SD; in mm2)
p value <0.001 <0.001
Lesions Before After p value
APQ pre 3.78 (0.45) 4.10 (0.58)
post 2.71 (0.44) 2.15 (0.44)
Vocal nodule 4.92 (1.0) 0.42 (0.79) <0.001
p value <0.001 <0.001
Vocal cyst 6.03 (2.80) 0.25 (0.62) <0.001
NHR pre 0.17 (0.14) 1.40 (0.46)
post 0.15 (0.08) 0.24 (0.36)
p value <0.429 <0.001
SPI pre 11.97 (0.70) 12.29 (0.51) The most frequent surgery indication was for vocal
post 11.59 (0.55) 10.62 (0.68)
p value <0.035 <0.001
cysts (44.44%). After 6 months, complete improvement
of symptoms and of lesions was observed in 83.34% of
f0, fundamental frequency; PPQ, pitch perturbation quotient; these children, a result that was considered quite satisfac-
APQ, amplitude perturbation quotient; NHR, noise-to-harmonic tory, suggesting that, for vocal cysts, this is the best man-
ratio; SPI, soft phonation index. agement, even in children. The rupture of its slim capsule
during surgery can justify the persistence of vocal symp-
toms after surgery of vocal cysts in some cases, as verified
in 2 children of our study. For vocal cysts we adopted the
Table 6 presents the outcomes after surgery for vocal lateral microflap technique, advocated by most authors,
nodules and cysts, based on the evolution of symptoms always maintaining delicate dissection and restraint to
and of the endoscopic exams. For each lesion, surgery was the lesion [13]. The youngest child submitted to cyst sur-
performed on 12 children. The highest number of chil- gery in our series was 7 years old, and we believe that,
dren with the best outcome (total vocal improvement) ­depending on the severity of vocal impairment, the mi-
was observed in vocal cysts (83.34%; p = 0.013). This same crosurgery for cyst could be indicated even in younger
outcome was observed in 75% of nodules. children. We do not know with clarity the ability of re-
Table 7 shows the measurements of lesions per area generation of the structures of the lamina propria of the
(mm2). There is an expressive decrease in the size of both vocal folds of the child; so, we emphasize the need for
lesions in the postoperative period. delicate and cautious manipulation, as also pointed out
by other authors [14]. The vocal therapy is little effective
in cases of cyst [15, 16].
Discussion Vocal nodules were the most frequent laryngeal le-
sions (n = 78), corroborating the findings of other authors
In this study we presented the results of laryngeal mi- [8, 17–19]. In our study, surgical indications for vocal
crosurgery in children with the most frequent lesions, nodules were restricted to 12 cases (15.38%). Nodules are
­vocal nodules and cysts. Our sample consisted of 105 phonotraumatic lesions; thus, voice therapy is the first
­dysphonic children, and microsurgery was indicated in treatment. Vocal therapy basically consists of changing
24 cases (22.85%). vocal habits, maintaining vocal hygiene, increasing hy-
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DOI: 10.1159/000502477
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dration and avoiding to clear the throat [15, 16]. In this
study, all children submitted to microsurgery for nodules
had preoperative voice therapy, and the surgery was re-
stricted to those who did not achieve success after this
treatment. The results of microsurgery in vocal nodules
showed total improvement of symptoms, vocal analysis
and lesions in 75%, as well as by the reduction of lesion
size or their total elimination, demonstrating that the sur-
gical indication was adequate for these selected children.
Therefore, we highlight that the success of the surgical
treatment of vocal nodules depends on several factors,
such as adherence to postoperative voice therapy, chang-
es in phonatory habits and family collaboration [15, 16].
Failures in any of these can negatively affect recovery and
be responsible for the recurrence of the lesions and of
symptoms, as observed in 25% of our children.
We highlight that spontaneous reabsorption may oc-
cur in vocal nodules without any treatment, consequent
to the gradual growth of laryngeal structures and changes
in phonatory habits after adolescence. So, surgical indica-
tion is therefore restricted to selected cases and, when-
ever possible, should be postponed until after adoles-
cence. Mori [8] compared the different types of treatment
for vocal nodules in children: vocal therapy (n = 122),
vocal hygiene (n = 47), microsurgery (n = 43) and expect-
ant (n = 47). After 10 months, the author observed voice
improvement in: vocal hygiene (16%), voice therapy
(52%) and surgery (89%). The author found evident im-
provement in vocal qualities after puberty for all treat-
ment modalities.
According to Birchall and Carding [19] there is no lev-
el of evidence I for vocal nodule treatment. The authors
emphasize that the most recent systematic reviews in-
clude only nonrandomized interventional studies. For
nodules the authors are unanimous in initiating treat-
ment with speech therapy, whose result is proportional to
the size of the lesions. However, the evidence for the ef-
ficacy of surgery for all nodules is limited.
Landa et al. [20] presented their results with laryngeal
microsurgery in 51 children (30 boys; 21 girls) aged 9–16
years. The surgical indications were: nodules (n = 12),
cysts (n = 17), sulcus (n = 14) and mucosal bridge (n = 1).
The results of the surgery were evaluated after 6 months,
and the complete improvement of vocal symptoms and
of lesions for each type of lesion were: vocal nodules 83%,
cysts 65%, sulcus 85% and mucosal bridge 100%. Com-
paring these results with ours, we observed that these
were more satisfactory for nodules and less satisfactory
for cysts. The authors reinforce the importance of previ-
ous voice therapy for these lesions and they emphasize
Surgical Treatment for Vocal Nodules and
Cysts
that, although there is no consensus regarding the best
age to operate these children, it should never be done be-
fore the age of 9 due to the immaturity of the structures
of the lamina propria. Although we agree, we also believe
that the age limit for vocal cyst surgery should be recon-
sidered. In these lesions, the intensity of dysphonia is an
important factor, and surgery can be indicated in young-
er children.
According to Hron et al. [14], the choice of treatment
of vocal nodules in children should be individualized and
depends on the degree of vocal involvement and the mo-
tivation of the child to the treatment proposals, especially
for speech therapy, which should always be considered as
the first choice; this conduct is also adopted by us. The
surgical technique for vocal nodules in children does not
differ from that in adults; however, the vocal rest required
in the postoperative period for adequate regeneration of
the mucosa over the vocal folds is not always respected by
the child, which may impair the success of the surgery.
For this reason, microsurgery is reserved for selected chil-
dren. The authors consider that the outcomes of micro-
surgery in children are usually evaluated only through
questionnaires. However, in our work, we described au-
ditory and acoustic perceptual vocal analyses, videolaryn-
goscopy examinations and quantified lesion sizes in the
preoperative and postoperative states, making the results
more convincing.
Conclusions
The best outcome for laryngeal microsurgery in dys-
phonic children was for vocal cysts. So, we encourage lar-
yngologists to adopt this method in cases of vocal cysts.
The success of microsurgery for vocal nodules was lower.
In these cases, voice therapy seems to be the best treat-
ment.
Statement of Ethics
The parents of all children gave their written consent to use the
data for research and publication.
Disclosure Statement
There are no conflicts of interest.
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