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4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
4.3 Blue Laser Therapy ofVocal
Fold Cysts
4.3.1 Introduction
Vocal fold cysts are sac-like lesions of the vocal
folds located in the supercial layer of the lamina
propria. These are categorized as epidermoid cysts
or mucus retention cysts. Epidermoid cysts can be
either congenital or post-traumatic. Congenital
epidermoid cysts develop from subepithelial cell
rests derived from the fourth and sixth branchial
arches, whereas traumatic vocal fold cysts result
from involution or ingrowth of keratin into the
supercial layer of the lamina propria [2, 3, 11].
Mucoid cysts arise secondary to occlusion of ducts
of mucus glands and are encountered most often
on the inferior surface or free edge of the vocal
fold. Vocal fold cysts are more common in females
and may occur at any age. The size of the cyst has
been linked to uctuations in sex hormones with
worsening of voice symptoms toward the end of
the menstrual cycle [55].
Patients with vocal fold cysts usually present
with dysphonia that is gradual in onset and associated with voice fatigue. History of phonotrauma
such as voice abuse, cough, or repetitive throat
clearing may be present. Other symptoms commonly reported by professional voice users include
decrease in voice efciency, inability to sustain a
note, loss of high notes, and difculty in transition
between voice registers. In a study on seven singers (four females and three males) with vocal fold
masses, Echternach etal. reported irregularities in
the passaggio that improved following therapy
[56]. On perceptual evaluation, the voice is
described as rough and at times breathy. Large cyst
may cause diplophonia as described above in the
section on vocal fold polyps. The perceptual voice
changes are accompanied by an increase in the
perturbation parameters, shimmer, and jitter and
increases in noise-to- harmonic ratio and voice turbulence index [57]. On laryngeal examination,
cysts of the vocal fold can be unilateral or bilateral.
They are often misdiagnosed as nodules especially
when there is a reactive lesion on the contralateral
vocal fold. Laryngeal videostroboscopic examination shows asymmetry, often with impairment or
reduction of mucosal waves at the site of the
lesion. Typically, uid can be seen within the
lesion. Scar and indentation may be present at the
base of the lesion and in the reactive lesion at the
contact point on the contralateral vocal fold.
Although the lesion is usually limited to the supercial layer of the lamina propria, it may also
adhere to the mucosal cover and/or vocal ligament
resulting in decrease or absence of mucosal waves.
Common causes for the adherence of the cyst to
the deep structures of the vocal fold include bleeding and inammation around the wall of the cyst
associated with repeated phonotrauma which ultimately led to scar formation [58]. In a study on the
videostroboscopic ndings in subjects with various lesions of the vocal folds, Shohet etal. reported
a decrease or absence of mucosal waves in all
patients with vocal fold cysts [59]. The authors
stressed the added value of laryngeal videostroboscopic examination in differentiating vocal fold
cysts from other lesions of the vocal folds. In cases
with no scar with normal malleability of the vocal
fold cover, the cyst can show an “egg in a soup”
sign during phonation [2]. A better way to visualize the cyst in some cases is to ask the patient to
sing moderately a high note. This phonatory task
elongates the vocal fold and thins the vocal fold
cover, thus allowing better appreciation of the
nature and boundaries of the cyst. However, some
cysts are more obvious elsewhere in the voice
range, and strobovideolaryngoscopy should be
performed at various frequencies and intensities.
Incomplete closure of the vocal folds also may be
observed in case of large cyst, or with a cyst (s)
located on the free edge of the vocal fold.
Treatment of vocal fold cysts is multidisciplinary. Surgical excision usually is required to
optimize voice although voice therapy should be
initiated pre-operatively to address the compensatory hyperfunctional laryngeal behavior and teach
vocal hygiene. Reactive lesions often improve
through voice therapy, and inammation of the
cyst also may improve revealing that the lesion is
smaller than thought initially. This may alter surgical intervention. The benets and risks of phonosurgery need to be discussed with the patient
before surgical intervention. Traditionally surgery
consists of making a mucosal incision lateral to the
4.3 Blue Laser Therapy ofVocal Fold Cysts
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lesion and raising a microap that allows dissection of the cyst from its surrounding structures.
Minimizing injury to the vocal ligament during
dissection is essential. The anterior and posterior
poles of the cyst often are tangled in thick connective tissues. These may be severed using cutting
lasers or cold steel instruments. The mucosal lining of the vocal fold is preserved, when possible,
to reduce trauma to the deep structures of the lamina propria during phonation [60–62]. An alternative treatment is marsupialization of the vocal fold
cyst by removing part of its wall [63, 64], but
recurrence after this technique is a concern.
The reform in laryngeal practice toward
ofce-based surgery has broadened the treatment
options for patients with vocal fold cysts. Using a
diode laser or a photoangiolytic laser, the lesion
can be partially excised or marsupialized in an
ofce setting [65, 66]. Of course, the same technique can be used in the operating room. After
having introduced the laser glass ber through
the working channel of the exible endoscope, an
incision is made on the most prominent mucosal
surface of the lesion using the laser in a contact
mode. The mucus within the cyst is aspirated
using a suction catheter or drained by pressure
using the distal end of the exible endoscope. In
2020, Gao etal. reported the use of KTP laser in
treating four cases of vocal fold mucus retention
cysts. There was a marked reduction in VHI-10
score by 12.5 and a decrease in the size of the
lesion in all four cases [65]. Similarly, in 2021,
Hamdan etal. reported the successful use of thulium laser in the in-ofce treatment of three cases
of vocal fold mucus retention cysts. Following
marsupialization of the wall of the cysts, the
mucus content was suctioned using a small catheter that was introduced through the working
channel of the exible endoscope. The tip of the
endoscope was also used to milk the free edge of
the vocal fold at the site of the lesion. On follow up there was complete regression of the vocal
fold cyst in all three cases with preservation of
vocal fold cover malleability [66]. Additional
research is needed to determine the efcacy of
blue laser treatment of exophytic vocal fold
lesions compared with the efcacy of traditional
resection. Either technique can be performed in
the ofce or in the operating room, and more evidence is needed to conrm or refute the suspected
benets of each approach.
4.3.2 Case Presentations
4.3.2.1 Case 1: Right Vocal Fold Mucus
Retention Cyst
A 57-year-old male patient presented to the
Voice Clinic (ALH) with hoarseness of a few
months’ duration. He reported work-related
voice overuse and abuse but denied any history of smoking. Medical history was positive
for gastroesophageal reflux disease treated
with proton-pump inhibitor. The Voice
Handicap Index-10 (VHI- 10) score was 37.
Perceptual evaluation revealed grade 3 dysphonia with a score of 2 for breathiness, 2 for
roughness, and 1 for strain. Acoustic analysis
showed a fundamental frequency (F0) of
159.02Hz, habitual pitch (HP) of 149.48Hz,
jitter 1.87, shimmer: 6.33, noise-to-harmonic
ratio (NHR): 0.148, voice turbulence index
(VTI): 0.066. His maximum phonation time
(MPT) was 8.83 s. Laryngeal examination
using the flexible nasopharyngoscope showed
a mucus retention cyst at the anterior half of
the right vocal fold and a reactive lesion on the
Fig. 4.28 Endoscopic view of the larynx showing a
mucus retention cyst at the free edge of the right vocal
fold. Note the reactive lesion on the contralateral vocal
fold
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4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
left vocal fold (Fig.4.28). The patient underwent blue laser therapy for his lesion under
local anesthesia using the 400nm glass fiber
in contact mode. The wall of the cyst was
opened using the tip of the glass fiber and the
mucus content was suctioned and milked from
the cyst by pressure using the distal end of the
endoscope (Fig.4.29, Video 4.11). Laryngeal
examination 3 weeks after the surgery showed
complete regression of the cyst with only mild
residual edema and redness at the site of the
Fig. 4.29 Endoscopic view showing the glass ber in
contact with the surface of the vocal fold cyst, opening the
wall of the cyst (see Video 4.11)
surgery (Fig. 4.30). Laryngeal videostroboscopic examination revealed complete closure
of the vocal folds during phonation with
improvement in the mucosal waves (Video
4.12). The patient had a drop in his VHI-10
score to 2 and a decrease in jitter to 0.70 and in
shimmer to 1.67. His voice quality on perceptual evaluation was almost normal.
4.3.2.2 Case 2: Right Sub-cordal Mass
A 48-year-old male singer with a history of LPR
presented with dysphonia despite having had
extensive voice therapy. He had multiple laryngeal procedures, including left vocal fold cyst
removal, right vocal fold mass resection, laryngocele excision, and a series of 3 of 5 uorouracil injection. His laryngeal examination
demonstrated bilateral right larger than left subcordal mass as well as anterior web. In operating room, the pathology was conrmed visually
(Fig. 4.31). The anterior web was vaporized
with blue laser in contact and non-contact mode
at 6 W, 40ms pulsed, 300 ms pulse duration
(Fig. 4.32). Blue laser was used to vaporize
right sub-cordal mass. The right sub-cordal
mass was not disturbed during this procedure,
but staged surgery for the left had been discussed (Fig.4.33). A total 240J were used during the procedure.
Fig. 4.30 Follow-up view of the larynx 3weeks after the
surgery showing complete regression of the right vocal
fold cyst with residual edema. (Video 4.12 Laryngeal videostroboscopic examination showing complete regression
of the lesion with good closure of the vocal folds during
phonation) (▶ https://doi.org/10.1007/000- an7)
Fig. 4.31 Intraoperative microscopic view showing
bilateral right larger than left sub-cordal mass. (Video
4.13 Intraoperative video showing right sub-cordal mass
vaporizing using blue laser)
(▶ https://doi.org/10.1007/000- an8)
4.3 Blue Laser Therapy of Vocal Fold Cysts
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Fig. 4.32 Intraoperative microscopic view showing anterior web vaporization using blue laser. (Video 4.14
Surgical video showing submucosal treatment of left
vocal fold brotic mass using blue laser in contact and
non-contact modes) (▶ https://doi.org/10.1007/000- an9)
Fig. 4.33 Intra-operative microscopic view showing
vaporization of the right anterior sub-cordal mass by blue
laser
The area of resection was injected with a mixture of 5 Fluorouracil with triamcinolone. See
below for nal surgical view (Fig. 4.34, Video
4.13). His exam motion 6months after surgery
demonstrated improvement with his vocal fold
vibration and no sub-cordal mass recurrence
(Fig.4.35).
Fig. 4.34 Intraoperative microscopic view showing complete right sub-cordal mass vaporizing
Fig. 4.35 Laryngeal examination showing no sub-cordal
mass recurrence 6months after the laser treatment
4.3.2.3 Case 3: Left Vocal Fold
FibroticMass
An 18-year-old woman presented with a history
of stable LPR, dysphonia, glottic insufciency,
and bilateral vocal fold masses with scar. She
had reached maximal improvement with voice
therapy and superb reux control. She was
taken to the operating room for microdirect
laryngoscopy with submucosal treatment of
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4 Blue Laser Therapy ofExudative Lesions oftheVocal Folds
brotic mass with blue laser. Blue laser treatment focused on the left vocal fold as intraoperative palpation conrmed the left mass and
scar to be rm (Figs.4.36, 4.37, 4.38 and Video
4.14). A total 34.4J were used during the procedure. Regression of the rm, brotic left
vocal fold lesion, and preservation of the vibratory margin mucosa were seen 6months after
surgery (Fig.4.39).
Fig. 4.38 Intraoperative, post-treatment, still image
showing regression of left vocal fold brotic mass with
preservation of vibratory margin mucosa. Soft pliability
had been restored
Fig. 4.36 Intraoperative, pre-treatment still image. Note
the left true vocal fold brotic mass
Fig. 4.37 Intraoperative, mid-treatment still image of
submucosal blue laser treatment of left vocal fold brotic
mass. The blue laser was set at 6W, 40ms pulse duration,
300ms pulse pause
Fig. 4.39 Videostroboscopic still image 6months after
surgery showing regression of the rm, brotic left vocal
fold lesion and preservation of the vibratory margin
mucosa
4.4 Surgical Steps inOceBased Blue Laser Therapy
ofExudative Lesions
oftheVocal Folds
Step 1: The patient is seated in the upright posi-
tion in a standard examination chair commonly used in otolaryngology practice. A pad
References
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behind his or her head may be placed to stabilize the head during the procedure.
Step 2: Topical anesthesia to the larynx and phar-
ynx is applied using the transnasal, transoral,
or percutaneous cervical approach.
Step 3: A exible laryngoscope with a working
channel and a side-port suction is introduced
through the nasal cavity to perform indirect
laryngoscopy.
Step 4: The laser glass ber is introduced through
the working channel until the tip of the ber is
seen at the end of the endoscope. Note that the
introduction of the glass ber is done while
the scope is not exed to avoid injury to the
working channel. The glass ber can be
introduced when the exible endoscope is
either in the nasal cavity or before inserting
the endoscope into the nose.
Step 5: The exible endoscope with the glass
ber is introduced through the nasopharynx,
oropharynx, and hypopharynx until the targeted lesion is observed.
Step 6: The glass ber is pushed further distally
and directed toward the lesion.
Step 7: The laser is used in the non-contact mode,
near-contact, or contact mode depending on
the type of pathology. In case of vocal fold
polyps, the laser is used in a non-contact mode
to induce blanching of the lesion, particularly
when it is hemorrhagic. In case of Reinke’s
edema, the authors (ALH) and (RTS) use the
non-contact mode to treat the submucosal
microvasculature on the superior surface of
the lesion, and then the contact mode and
interstitial mode to vaporize the gelatinous
substance within the Reinke’s space. The tip
of the glass ber is kept inside the submucosal
space for 2–3s, but the time varies with the
size of the lesion. For a vocal fold mucus
retention cyst, the tip of the glass ber is used
to incise the wall of the cyst after having
treated the lesion in a non-contact mode at the
start of the procedure.
Step 8: Steroid injection such as 0.1–0.2mL of
dexamethasone 10 mg/mL may be administered at the surgical bed toward the end of the
surgery. The efcacy of steroid injection
remains unproven, but it is used commonly for
surgery in the operating room and in the ofce,
and it does not appear to cause adverse effects.
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Blue Laser Therapy ofVocal
https://t.me/medicina_free
Process Granuloma
5
5.1 Introduction
Vocal process granuloma is a non-neoplastic
lesion of the posterior glottis. It was rst described
by Chevalier Jackson in 1928 as a contact ulcer
of the vocal process. Since then, several synonyms have been used to denote the same pathology among which is pyogenic granuloma, peptic
granuloma, inammatory polyps, intubation
granuloma, and contact ulcer [1–6]. On histologic examination, vocal process granuloma is
not a true granulomatous lesion and lacks mononuclear and multinuclear histiocytes commonly
seen in a granulomatous process. The lesion consists of granulation tissue and brosis covered by
an intact or ulcerated epithelium. In a histomorphological analysis of 149 laryngeal granuloma, Luzar etal. reported epithelial hyperplasia,
atrophic epithelium, and abnormal hyperplasia in
65.8%, 16.1%, and 4.7% of the cases, respectively [7]. Notably, there was no atypical hyperplasia or carcinoma in any of the cases.
Vocal process granuloma is more common in
men than in women with a high prevalence in the
fourth and fth decades of life. Children can be
affected at any age, particularly following a traumatic laryngeal manipulation [8]. The etiology of
vocal process granuloma is multifaceted. The
most common causes are mechanical injury to
the mucosal lining, gastroesophageal/laryngopharyngeal reux, and phonotrauma. It is estimated that 30–50% of patients with vocal process
granuloma have a history of laryngeal manipulation such as difcult or prolonged intubation [5,
6, 9]. It is also well established that a large per-
centage of patients with vocal process granuloma
report symptoms of heartburn and regurgitation
suggestive of reux disease and esophageal dysfunction [10, 11]. Both acidic and non-acidic gastroduodenal contents can injure the defenseless
mucosal lining of the larynx resulting in ulceration and mass proliferation. The insult to the
mucosal lining triggers an inammatory cascade
that leads to proliferation of capillaries with collagen formation and non-specic remodeling of
the underlying cartilage often referred to as
osteosclerosis [3, 12]. Another etiologic factor of
vocal process granuloma is phonotrauma. Hard
glottal attack, persistent cough, and excess vocal
loading may precipitate injury to the mucosal lin-
Supplementary Information The online version contains supplementary material available at https://doi.
org/10.1007/978- 3- 031- 35283- 6_5. The videos can be
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© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
A.-L. Hamdan et al., Blue Laser Surgery in Laryngology,
https://doi.org/10.1007/978-3-031-35283-6_5
49
50
https://t.me/medicina_free
5 Blue Laser Therapy ofVocal Process Granuloma
ing of the vocal process and lead to inammation
with mass formation. This is not surprising given
the high prevalence of hard glottal attack in
patients with structural and functional voice disorders [13]. In a review of 41 cases of vocal process granuloma, Shoffel-Havakuk etal. reported
vocal abuse and psychological stress in 41% and
37% of the cases, respectively [11].
The clinical presentation of patients with
vocal process granuloma varies with more than
2/3 of affected patients being asymptomatic
[11]. The most reported symptoms are repetitive
throat clearing, globus sensation, foreign body
sensation, cough, dysphagia, and odynophagia.
A change in voice quality is an infrequent symptom and when present the voice is perceived as
low pitch voice and at times breathy [14]. In
cases of a large obstructive lesion, patients may
also present with dyspnea and stridor. The diagnosis of vocal process granuloma is based on
laryngeal examination. The lesion can be unilateral or bilateral, sessile or pedunculated with or
without ulceration. In iatrogenic cases, the
lesion is more likely to be pedunculated in comparison to spontaneous vocal process granulomas. Note that signs of reux can be observed
on laryngeal examination in almost 29% of the
cases [11]. Several grading systems for vocal
process granuloma have been suggested based
on the surface appearance of the lesion and its
extension [15]. The predictive value of these
classications in regard to treatment is not well
established.
Different treatment strategies for vocal process granuloma have been described. These
include behavioral modications, surgical excision using cold steel instruments or lasers, intralesional steroid injections, and the use of
botulinum toxin injections. Karkos et al. conducted a systematic review on the management
strategies of vocal process granuloma and showed
that conservative treatment is the rst approach
adopted by otolaryngologists [16]. Conservative
therapy consists primarily of behavior modication such as improvement in vocal hygiene and
phonatory habits, in addition to the treatment of
co-existing diseases such as laryngopharyngeal
reux. Ylitalo and Hammarberg investigated the
impact of voice therapy in 19 patients with vocal
process granulomas and reported a signicant
decrease in vocal fry and hyperfunction [14]. The
voice rehabilitation program consisted of breathing and relaxation exercises, in addition to correction of laryngeal hyperfunctional behavior
using the “the accent method” described by
Smith and Thyme in 1978 [17]. In patients who
fail conservative therapy, surgical excision is usually offered. Traditionally, surgery is performed
in the operating room under general anesthesia.
More than one surgical intervention is often
needed and the recurrence rate is high [18, 19].
The use of lasers has been advocated by some to
reduce the recurrence rate. In 2008, Lin et al.
reported the successful use of potassium titanyl
phosphate (KTP) laser in the operating room in
12 cases of intubation vocal process granuloma.
All patients had regression of the lesion after
more than one year follow-up, with marked
improvement in their voice perceptual evaluation
[20].
With the introduction of the exible endoscope with a working channel, ofce-based laser
therapy has gained popularity as a safe and alternative treatment of vocal process granuloma.
Different types of lasers delivered via glass
bers have been used with main preference for
photoangiolytic lasers given their high afnity to
oxyhemoglobin. In 2006, Rees et al. reported
their experience with the pulse dye laser (PDL)
in the management of 131 patients including 18
with vocal process granuloma. The authors noted
that in-ofce therapy was the preferred treatment
method in 87% of the patients [21]. That same
year, Zeitels etal. described the successful use of
thulium laser in 2 cases of vocal process granuloma [22]. In 2007, Koufman etal. reported a
success rate of 68% in a cohort of 33 patients
treated using different types of lasers [23].
Mouadeb and Belafsky also reported the use of
ofce-based PDL in the treatment of 47 patients,
8 of whom had vocal process granuloma. Twothirds of their study group were successfully
treated and only one-third required surgical
intervention in the operating room [24]. In 2014,
Mascarella and Young reported the combined
use of KTP laser and cup forceps in-ofce in a
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