What is the appropriate evaluation and treatment approach for an adult patient presenting with symptoms of vocal cord dysfunction, such as hoarseness, breathiness, or difficulty swallowing, considering various vocal cord pathologies, including benign conditions and laryngeal cancer?

Evaluation and Management of Vocal Cord Pathology

Initial Evaluation

Any patient with hoarseness lasting longer than 2 weeks requires direct visualization of the larynx by laryngoscopy, as empirical treatment without visualization is not recommended. 1

Key History Elements to Assess

• Recent surgical procedures involving the neck or affecting the recurrent laryngeal nerve (cardiac surgery causes vocal cord injury in 1.4% of cases, with left nerve more commonly affected) 1
• Recent endotracheal intubation (94% of patients intubated >4 days have laryngeal injury; 44% develop vocal fold granulomas within 4 weeks of extubation) 1
• Tobacco use history (associated with polypoid lesions and 28% malignancy rate in patients >60 years after excluding self-limited disease) 1
• Occupational voice use (teachers have >50% prevalence of hoarseness; singers and vocal performers require specialized consideration) 1
• Age considerations (presbylarynx common in elderly; 15-24% prevalence in children with 77% having vocal nodules) 1

Laryngoscopy Findings Requiring Immediate Action

Perform surgical biopsy immediately if malignancy is suspected, particularly with: 1, 2

• Increased vascularity
• Ulceration
• Exophytic growth
• Age >60 years with tobacco history

For superficial white lesions (leukoplakia) on mobile vocal folds, a trial of conservative therapy with irritant avoidance and treatment of laryngeal candidiasis should precede biopsy. 1

Treatment Algorithm by Pathology

Benign Soft Tissue Lesions (Polyps, Cysts, Nodules)

Conservative management is the primary treatment approach, with surgery reserved only for cases refractory to conservative therapy. 1, 3

First-Line Conservative Management (4-8 weeks):

• Voice therapy with certified speech-language pathologist, 1-2 sessions weekly 1, 2, 3

  • Eliminates harmful vocal behaviors
  • Addresses behavioral and muscular issues contributing to dysphonia
  • Effective across all age groups (children >2 years to older adults) 1

• Vocal hygiene education 3, 4

  • Adequate hydration 3
  • Avoidance of tobacco and alcohol 3
  • Treatment of underlying conditions (reflux, allergies, asthma) 1

Surgical Intervention Criteria:

Surgery is indicated only when satisfactory voice cannot be achieved with conservative management AND voice may be improved surgically. 1, 3

• Surgery improves subjective voice-related quality of life and objective vocal parameters 1, 3
• Failure to address underlying etiologies leads to postsurgical recurrence 1

Pediatric-Specific Considerations:

In children, nodules typically resolve during normal development; voice therapy is primary treatment with surgery having limited role. 1, 3

• Surgery reserved only for severe cases refractory to conservative treatment 1, 3
• Children <2 years cannot participate effectively in voice therapy; family education and counseling are beneficial 1

Vocal Cord Ulcers

Treat primarily with conservative medical management; surgery only if malignancy cannot be excluded. 2

• Antireflux medications 2
• Voice rest 2
• Voice therapy (1-2 sessions weekly for 4-8 weeks) 2

Glottic Insufficiency (Paralysis, Paresis, Presbylarynx)

Surgical medialization is the primary treatment for symptomatic glottic insufficiency causing weak, breathy voice with poor cough and reduced airway protection. 1

• Voice therapy can improve outcomes when combined with vocal fold injection medialization or laryngoplasty 1
• Up to 30% of hoarseness in older adults is due to vocal fold changes (glottic insufficiency) 1

Muscle Tension Dysphonia (MTD)

Voice therapy is more effective than vocal hygiene alone for MTD. 1

• MTD constitutes 10-40% of voice center caseloads 1
• Characterized by abnormal voice quality without anatomic laryngeal changes 1

Neurologic Conditions

• Parkinson's disease-related dysphonia: Specialized voice therapy is effective 1
• Spasmodic dysphonia: Voice therapy as adjunct to botulinum toxin 1
• Unilateral vocal fold paralysis: Voice therapy effective 1

Paradoxical Vocal Fold Dysfunction/Vocal Cord Dysfunction

Therapeutic breathing maneuvers and vocal cord relaxation techniques are first-line therapy. 5, 6

• Specialized voice therapy effective for paradoxical vocal fold dysfunction/cough 1
• Treat underlying triggers: asthma, gastroesophageal reflux, postnasal drip 5, 7, 6
• Heliox for acute episodes 6

Recurrent Respiratory Papillomatosis

Surgery is necessary in management. 1

Suspected Malignancy

Surgical biopsy with histopathologic evaluation is mandatory to confirm diagnosis. 1

• Highly suspicious lesions require prompt biopsy 1
• Discussion of surgical management of laryngeal cancer is beyond routine dysphonia management 1

Common Pitfalls to Avoid

• Never treat hoarseness empirically without laryngoscopy if symptoms persist >2 weeks 1, 4
• Do not use antibiotics or corticosteroids empirically for hoarseness 8
• Do not proceed directly to surgery for benign lesions without adequate trial of conservative management 1, 3
• Do not delay biopsy in high-risk patients (age >60, tobacco use, suspicious lesions) as this results in higher cancer staging, more aggressive treatment needs, and reduced survival 1