Treatment of Vocal Cord Dysplasia
The primary treatment for vocal cord dysplasia is endoscopic surgical excision with the aim of achieving tumor-free margins while preserving laryngeal function. 1 This approach provides both diagnostic and therapeutic benefits by removing the abnormal tissue while preserving voice quality.
Diagnosis and Evaluation
Before treatment, proper evaluation is essential:
- Laryngoscopy: Required for all patients with dysphonia persisting beyond 4 weeks or immediately if serious underlying cause is suspected 2, 3
- Enhanced visualization with stroboscopy: Can alter diagnosis in up to 47% of cases by revealing functional abnormalities not visible with standard laryngoscopy 2
- Risk factors requiring expedited evaluation: Recent head/neck/chest surgery, recent endotracheal intubation, presence of neck mass, respiratory distress/stridor, history of tobacco use, professional voice user status 3
Treatment Algorithm Based on Severity
1. Mild to Moderate Dysplasia
- Primary treatment: Endoscopic excision 1
- Follow-up: Close surveillance to monitor for recurrence
- Voice therapy: Should be considered after surgical intervention to optimize vocal outcomes 2
2. Severe Dysplasia and Carcinoma in situ
- Primary treatment: More extensive endoscopic resection with possible laser resection and/or ablation 1
- Follow-up: More intensive surveillance due to higher risk of progression to invasive cancer
- Recurrence management: Repeat excision for localized recurrence; consider radiation therapy for diffuse or multiple recurrences 4
3. Early Invasive Cancer (T1-T2)
- Treatment options:
- Selection factors: Tumor location, extent of involvement, patient preference, voice preservation goals 3
Important Considerations
- Surgical margins: Surgery should achieve tumor-free margins. Positive or close margins should be addressed with re-resection rather than adjuvant radiation therapy 3
- Single-modality treatment: Initial surgical excisions should be planned without anticipated need for postoperative radiation therapy 3
- Margin requirements: 4-5mm for open surgical resections and ≤2mm for endoscopic resections 3
- Avoid combined therapy: Surgery that anticipates the need for postoperative RT to treat close or involved tumor margins is not an acceptable treatment approach 3
Voice Preservation Strategies
- Endoscopic approaches: Preferred when feasible as they spare more tissue and generally provide better functional results 3
- Voice therapy: Strongly recommended for patients with hoarseness that reduces voice-related quality of life 2
- Voice assessment: All patients should undergo pre-treatment evaluation of voice function to guide treatment selection 3
Follow-up and Surveillance
- Regular follow-up: Essential as invasive carcinoma may develop many years after the initial diagnosis 4
- Higher risk features: Diffuse lesions and well-differentiated forms of severe dysplasia have the highest incidence of progression to invasive carcinoma regardless of treatment type 4
- Documentation: Resolution, improvement, or worsening of symptoms after treatment should be recorded 2
Pitfalls and Caveats
- Misdiagnosis risk: Vocal cord dysplasia can be misdiagnosed as other conditions; proper visualization with laryngoscopy is essential before treatment 5
- Smoking cessation: Critical as continued smoking is associated with worse outcomes and higher recurrence rates 3
- Avoid empiric treatments: The American Academy of Otolaryngology-Head and Neck Surgery recommends against routinely prescribing antibiotics, antireflux medications, or corticosteroids for hoarseness without proper diagnosis 2
- Professional voice users: May require more urgent evaluation and specialized treatment approaches due to occupational impact 2
By following this treatment algorithm and considering these important factors, clinicians can effectively manage vocal cord dysplasia while maximizing voice preservation and minimizing the risk of progression to invasive carcinoma.