Management of Vocal Keratosis
Excisional biopsy via microlaryngoscopy is the preferred initial treatment for vocal keratosis, as it provides both definitive histological diagnosis to rule out malignancy and potential cure of the lesion. 1
Initial Diagnostic and Therapeutic Approach
Excisional biopsy is the gold standard for managing vocal keratosis because it simultaneously identifies the exact pathology (ranging from simple keratosis to carcinoma in situ or microinvasive cancer) and treats the lesion. 1
All vocal cord keratotic lesions represent part of a sequential continuum that includes keratosis, atypia, carcinoma in situ, and microinvasive cancer, making histological confirmation essential. 1
CO2 laser surgery is the preferred surgical modality for most cases, with the specific technique tailored to the clinical classification of the lesion. 2
Clinical Classification-Based Treatment Algorithm
The treatment approach should be determined by the morphological characteristics and clinical presentation:
Type I (Inflammatory leukoplakia): Conservative medical management with voice rest and anti-inflammatory therapy is sufficient, with vocal cord morphology and voice quality recovering without surgery. 2
Type II (Frictional polyps): CO2 laser submucosal cordectomy is the treatment of choice. 2
Type III (Sulcus vocalis): Mucosal slicing with dredging is recommended. 2
Type IV (Simple leukokeratosis): Partial subligamental cordectomy with CO2 laser or transmuscular cordectomy is indicated, as this type carries the highest risk of malignant transformation (6.5% in one series). 2
Management of Inadequate Margins
If excisional biopsy margins are inadequate, two treatment options exist: re-excision or radiotherapy. 1
Radiotherapy should only be used when voice conservation is paramount, as it is not the first-line approach. 1
For hyperkeratotic lesions, two or three cycles of curettage may be necessary to ensure adequate treatment when diagnostic uncertainty exists. 3
Critical Follow-Up Considerations
All patients require indefinite lifelong surveillance regardless of initial treatment success, as vocal keratosis is part of the aerodigestive tract cancer diathesis. 1
Cessation of smoking does not eliminate the potential for disease progression, though it should still be strongly encouraged. 1
The surgical cure rate with appropriate CO2 laser techniques reaches 90.9%, with a recurrence rate of 9.1% and malignant transformation rate of 6.5%. 2
Benign keratomas treated with excisional biopsy alone show excellent long-term outcomes, with minimal recurrence (2 out of 57 patients in one series) and no progression to invasive carcinoma over follow-up periods extending to 16.5 years. 4
Important Clinical Pitfalls
Never assume a keratotic vocal cord lesion is benign based on appearance alone—histological confirmation is mandatory to exclude carcinoma in situ or early invasive disease. 1
Vocal cord keratosis differs fundamentally from cutaneous actinic keratosis and requires laryngoscopic surgical intervention rather than topical therapies. 1, 2
The goal is to maximize voice quality preservation while ensuring complete lesion removal and accurate pathological diagnosis. 2