What are the treatment options for vocal cord disease?

Treatment Options for Vocal Cord Disease

Treatment for vocal cord disease must be tailored to the specific pathology identified on diagnostic laryngoscopy, with voice therapy serving as first-line treatment for most benign conditions, botulinum toxin injections for spasmodic dysphonia, and surgical intervention reserved for malignancy, refractory benign lesions, or glottic insufficiency. 1

Mandatory Diagnostic Step Before Treatment

• Diagnostic laryngoscopy must be performed before initiating any treatment to identify the underlying pathology and guide appropriate intervention 1, 2
• Results must be documented and communicated to the speech-language pathologist (SLP) if voice therapy is planned 2
• Empiric treatment without direct visualization of the vocal folds is not recommended 3

Treatment Algorithm by Pathology

Benign Soft Tissue Lesions (Nodules, Polyps, Cysts)

• Voice therapy is the primary first-line treatment for vocal nodules, polyps, and other phonotraumatic lesions, as many are self-limited or reversible with behavioral modification 1, 2, 4
• Conservative management includes voice therapy delivered by certified SLPs in 1-2 sessions weekly for 4-8 weeks 2
• Direct techniques include vocal function exercises (pitch glides, sustained phonation), resonant voice therapy (humming, nasal consonants), and laryngeal manipulation with circumlaryngeal massage 2
• Indirect approaches emphasize vocal hygiene (adequate hydration, avoidance of tobacco/alcohol), identification of harmful behaviors (throat clearing, shouting), and communication counseling 2, 4
• Surgery is reserved only when conservative management fails to achieve satisfactory voice results and surgical intervention can improve outcomes 1, 4
• For superficial white lesions (leukoplakia) on mobile vocal folds, trial conservative therapy with avoidance of irritants before biopsy 1

Glottic Insufficiency (Vocal Fold Paralysis/Paresis)

• Surgical management through medialization laryngoplasty is the primary treatment for glottic insufficiency causing weak, breathy hoarseness with poor cough and reduced airway protection 1
• Injection laryngoplasty with temporary agents (bovine collagen or hyaluronic acid gel) provides vocal rehabilitation while allowing time for neural recovery, with 80-95% of patients showing improvement 1
• Randomized controlled trial data shows both temporary injectables significantly improve subjective and objective vocal parameters, with 26% requiring repeat injection over 24 months 1
• Semi-permanent implants (silicone or hydroxylapatite paste) are used when vocal recovery is unlikely, with 94-100% of patients showing significant improvement in quality of life measures at 6 months 1
• Polytetrafluoroethylene as permanent injectable is not recommended due to association with foreign body granulomas causing voice deterioration and airway compromise 1
• Voice therapy can be used alone or combined with injection/framework procedures to help patients compensate for altered laryngeal physiology 2

Spasmodic Dysphonia (Laryngeal Dystonia)

• Botulinum toxin injection is the treatment of choice for spasmodic dysphonia, causing transient flaccid paralysis by inhibiting acetylcholine release and reducing spasm 1, 5
• This recommendation is based on randomized controlled trials with preponderance of benefit over harm, resulting in moderate improvement in self-perceived dysphonia, mental health, and social functioning 1, 5
• Voice therapy should be offered as adjunct to botulinum toxin to address compensatory behaviors and maximize functional outcomes 2, 5
• Surgical treatment for laryngeal dystonia is infrequently performed due to widespread acceptance of botulinum toxin as first-line treatment 1

Muscle Tension Dysphonia (MTD)

• Voice therapy is highly effective as primary treatment for MTD, targeting abnormal muscle patterns without anatomic laryngeal changes 1, 2
• Voice therapy demonstrated effectiveness compared to vocal hygiene alone in randomized trials 1
• Combined direct and indirect approaches with psychological counseling are essential when psychosocial factors contribute 2

Vocal Cord Dysfunction (Paradoxical Vocal Fold Motion)

• Speech therapy with relaxed-throat breathing patterns is first-line treatment for purely functional vocal cord dysfunction 1, 6, 7, 8
• Therapeutic breathing maneuvers and vocal cord relaxation techniques are primary therapy for dyspnea occurring with vocal cord dysfunction 8
• Underlying triggers must be optimally treated, particularly asthma, gastroesophageal reflux disease, and postnasal drip 6, 7, 8
• Respiratory assessment by physician including spirometry should precede speech therapy referral 1

Parkinson's Disease-Related Dysphonia

• Lee Silverman Voice Treatment (LSVT LOUD®) is the most effective specialized method for treating reduced vocal intensity and monotone speech in Parkinson's disease 2
• Specialized voice therapy has demonstrated effectiveness in multiple studies 1

Suspected Malignancy

• Prompt biopsy is required for highly suspicious lesions with increased vasculature, ulceration, or exophytic growth 1
• Surgical management beyond biopsy for confirmed laryngeal cancer involves larynx-preservation strategies or total laryngectomy depending on stage and location 1

Pediatric Considerations

• Vocal nodules and polyps in children typically resolve during normal development, making voice therapy the primary treatment with surgery having limited role 2, 4
• Children under 2 years may not participate effectively in voice therapy; family education and counseling become primary interventions 1, 2

Critical Pitfalls to Avoid

• Never treat dysphonia empirically without laryngoscopy - this delays diagnosis of malignancy and leads to inappropriate treatment 1, 3
• Avoid polytetrafluoroethylene as permanent injectable due to granuloma formation 1
• Do not perform surgery as first-line for benign lesions when voice therapy may eliminate need for surgery entirely 1, 4
• Recognize that psychiatric comorbidity in functional disorders is often secondary rather than causal 1

Pre- and Post-Operative Voice Therapy

• Voice therapy enhances surgical outcomes when used before and after procedures like vocal fold injection, laryngoplasty, and thyroplasty 1, 2
• Voice therapy is beneficial when combined with medical treatments including allergy management, asthma therapy, and antireflux therapy 1

Finding Qualified Providers

• Certified and licensed speech-language pathologists are the appropriate professionals to deliver voice therapy, located through ASHA's ProFind search engine 2