What is the treatment for vocal cord ulcers?

Treatment of Vocal Cord Ulcers

Vocal cord ulcers should be treated primarily with conservative medical management including antireflux medications, voice rest, and voice therapy, with surgery reserved only for cases where malignancy cannot be excluded. 1, 2

Initial Conservative Management

First-Line Medical Therapy

• Antireflux medications (proton pump inhibitors) are the cornerstone of treatment, as gastroesophageal reflux is a major causative factor in vocal cord ulceration 3, 4
• Initiate high-dose PPI therapy immediately upon diagnosis, as earlier treatment initiation correlates with better voice outcomes 2
• Continue antireflux therapy for at least 2-3 months, as average time to ulcer resolution is 2.25 months 2

Voice Rest and Therapy

• Prescribe strict voice rest initially, particularly in the acute phase 5, 2
• Refer to a certified speech-language pathologist for voice therapy consisting of 1-2 sessions weekly for 4-8 weeks 1
• Voice therapy should eliminate harmful vocal behaviors and assist in vocal fold wound healing 1

Additional Medical Interventions

• Corticosteroids should be considered as adjunctive therapy, particularly in acute presentations with significant inflammation 5
• Inhaled corticosteroids may be beneficial in select cases 4
• Consider antimicrobial therapy (antibiotics, antivirals, or antifungals) only if there is clear evidence of infectious etiology 2

Identifying the Underlying Cause

Common Etiologies to Address

• Phonotrauma/vocal abuse is the most common cause (96.2% of cases) and requires behavioral modification 4
• Gastroesophageal reflux contributes in 71.8% of cases and must be aggressively treated 4
• Intubation trauma should be suspected in patients with recent mechanical ventilation 5, 3
• Systemic inflammatory conditions (e.g., Behçet's disease) are rare but important to exclude in refractory cases 6

Surgical Considerations

When to Biopsy

• Perform surgical biopsy immediately if malignancy is suspected, particularly in patients with: 1
  • Age over 60 years (28% malignancy rate in this population) 1
  • History of tobacco use 1
  • Lesions with increased vasculature, ulceration, or exophytic growth 1

When Surgery is NOT Indicated

• Surgery is not appropriate for benign vocal cord ulcers that respond to conservative management 1
• Vocal process granulomas specifically should be managed conservatively, as they have no premalignant potential and surgery often leads to recurrence 3

Expected Outcomes and Timeline

Recovery Expectations

• Most patients (95%) show improvement in Voice Handicap Index-10 scores with conservative treatment 2
• Ulcer resolution typically occurs by 2.25 months, but complete voice recovery may take up to 2.7 months 2
• Only 50% of patients achieve completely "normal" voice quality, even after ulcer healing 2
• Persistent decreased mucosal wave vibration occurs in 65% of patients despite ulcer resolution 2

Prognostic Factors

• Younger age, shorter symptom duration before treatment, and antireflux therapy are significant predictors of better voice outcomes 2
• Recurrence is uncommon (68.4% of laryngologists report low recurrence rates) when underlying causes are adequately addressed 4

Common Pitfalls to Avoid

• Do not delay treatment: Earlier initiation significantly improves outcomes 2
• Do not assume all ulcers are benign: Always maintain high suspicion for malignancy in high-risk patients and biopsy promptly 1
• Do not stop treatment prematurely: Continue therapy for at least 2-3 months even if symptoms improve earlier 2
• Do not rush to surgery: Conservative management is effective in the vast majority of cases 3, 4
• Do not neglect voice therapy: This is essential for preventing recurrence, particularly in phonotrauma-related ulcers 1, 4