Surgery or Rehabilitation: A Randomized Clinical Trial

Comparing the Treatment of Vocal Fold Polyps via

Phonosurgery and Traditional Voice Therapy with
“Voice Therapy Expulsion” Training
*Maria Rosaria Barillari, †Umberto Volpe, ‡Giuseppina Mirra, ‡Francesco Giugliano, and *Umberto Barillari,
*†‡Naples, Italy

Summary: Objective. Phonomicrosurgery is generally considered to be the treatment of choice for removing vocal
fold polyps. However, specific techniques of voice therapy may represent, in selected cases and under certain condi-
tions, a noninvasive therapeutic option for the treatment of such laryngeal lesions. The aim of the present study is to
longitudinally assess, in terms of clinical outcomes and quality of life, two groups of patients with cordal polyps, treated
either with standard surgery plus standard voice therapy or with a specific training of voice therapy alone, which we
have called “Voice Therapy Expulsion.”
Study design. This study is a randomized controlled trial.
Methods. A total of 150 patients with vocal fold polyps were randomly assigned to either standard surgery or “voice
therapy expulsion” protocol. The trial was carried out at the Division of Phoniatrics and Audiology of the Second Uni-
versity of Naples and at the Division of Communication Disorders of Local Health Unit (3 Naples South) from January
2010 to December 2013. A thorough phoniatric evaluation, including laryngostroboscopy, acoustic voice analysis, global
grade of dysphonia, instability, roughness, breathiness, asthenia, and strain scale, Voice Handicap Index, and Voice-
Related Quality of Life, was performed by using standardized tools, at baseline, at the end of the treatment, and up to
1 year after treatment.
Results. We found no significant differences between the two experimental groups in terms of clinical outcomes and
personal satisfaction. However, “Voice Therapy Expulsion” was associated with higher scores for quality of life at end-
point evaluation.
Conclusions. Besides phonosurgery, this specific “Voice Therapy Expulsion” technique should be considered as a
valid, noninvasive, and well-tolerated therapeutic option for the treatment of selected patients with vocal fold polyps.
Key Words: vocal fold polyp–phonosurgery–speech therapy–voice therapy excision–vocal cord lesions.

INTRODUCTION
Polyps of the true vocal fold, either pedunculated or sessile, are
common benign and focal vocal fold lesions, often translucent
or hemorrhagic and usually unilateral1,2; they are generally located
on the free edge of the vocal folds, at the junction of the ante-
rior and the middle third, with varying size and aspect.3,4 The
clinical picture is mainly characterized by hoarseness, which
worsens in case of vocal strain or upper airway phlogosis.5
Phonomicrosurgery usually represents the preferred treat-
ment for removing these lesions,6,7 whereas voice therapy often
plays a complementary role, both before and after surgery.8,9
Literature tends to support the idea that voice therapy may
represent a valid alternative therapeutic option for selected cases
of vocal fold polyps; in particular, Cohen and Garrett,10 in a
Accepted for publication July 6, 2016.
Disclosure: Authors have no conflict of interest to declare, as well as any financial or
personal relationship with other people or organizations that could inappropriately influ-
ence their actions.
From the *Division of Phoniatrics and Audiology, Department of Mental and Physical
Health and Preventive Medicine, University of Naples SUN, Naples, Italy; †Department
of Psychiatry, University of Naples SUN, Naples, Italy; and the ‡Local Health Unit 3, Naples,
Italy.
Address correspondence and reprint requests to Maria Rosaria Barillari, Division of
Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive
Medicine, University of Naples SUN, Via L. De Crecchio, 3 - 80138 Naples, Italy. E-mail:
mariarosaria.barillari@unina2.it
Journal of Voice, Vol. 31, No. 3, pp. 379.e13–379.e20
0892-1997
© 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jvoice.2016.07.002
sample of 57 patients with vocal fold polyps, found that 49.1%
of the patients achieved symptom resolution with voice therapy
alone (especially those with translucent polyps); in a recent clin-
ical case series, Srirompotong et al11 also reported that “small”
vocal fold polyps were particularly responsive to voice therapy.
Klein et al12 retrospectively observed 34 subjects with hemor-
rhagic polyps and found that 56.3% of subjects who were treated
only with voice therapy experienced a complete resolution of
the lesion. A more recent case series was described by Jeong et
al,13 who reported that 94 patients with vocal fold polyps were
treated conservatively and that 46% of them showed a clinical-
ly significant reduction in size, whereas 38% resolved completely
without requiring surgery. Similarly, Nakagawa et al14 studied
132 patients with vocal fold polyps and reported that about 10%
of them resolved without surgery, suggesting that conservative
voice treatment represents a relevant therapeutic option, partic-
ularly for female patients with smaller and more recent-onset
lesions.
Overall, previous studies on the topic tend to support the idea
that conservative therapeutic approaches to vocal fold polyps,
in terms of standard voice therapy, may represent a valid and
noninvasive alternative to surgical treatment (furthermore, it might
be better tolerated by patients, as it entails fewer complica-
tions). However, specific techniques of voice therapy were
developed in the past to favor, in some cases, the nonsurgical
excision of benign vocal fold lesions; Arnoux-Sindt 15 in
379.e14
particular was the first to plan a rehabilitation protocol for treat-
ment of postintubation granulomas, which was then adopted and
modified by other authors with good results, in absence of re-
currences; the technique aims first to induce ischemia of the
peduncle and then expel the lesion through a series of “repeat-
ed microtraumas.” Recurrent oscillatory movements of the
pedunculated lesions, called by the authors “bell clapper-like
movement,”15 induce ischemia and subsequent excision of the
peduncle itself, which is expelled out of the patient’s mouth
through coughing. Bergamini et al16 have then extended the use
of Arnoux-Sindt’s technique to all granulomas, including those
arising during the early postoperative period after cordectomy
and those related to laryngopharyngeal reflux, and reported good
outcomes in terms of both symptoms control and subsequent re-
lapses; as far as safety is concerned, no special precautions were
necessary and no significant risks were reported.
However, to the best of our knowledge, there are no previ-
ous studies investigating specifically the use of such a nonsurgical
technique to excise pedunculated vocal fold lesions. The avail-
able literature on the treatment of pedunculated polyps with
treatments alternative to phonomicrosurgery is still relatively
scarce, and further studies are needed to assess the validity and
indications of nonsurgical approaches to vocal fold lesions.
The aim of this study was to investigate the treatment outcome
for a large sample of patients with vocal fold polyps randomly
assigned to either “Voice Therapy Expulsion” (VTE) protocol
or classical Surgical Therapy (ST), in terms of resolution of the
lesion and vocal symptomatology, personal satisfaction, and
quality of life.
MATERIALS AND METHODS
Selection procedures
Patients were recruited among those consecutively attending the
Division of Phoniatrics and Audiology of the Second Univer-
sity of Naples and the Division of Communication Disorders of
Local Health Unit 3 (Naples—South area), from January 2010
to December 2013. All patients presented a clinical diagnosis
of dysphonia related to the presence of unilateral vocal fold polyps
(as confirmed by a histologic examination).
Exclusion criteria were the following: (1) age below 18 or
above 65 years; (2) bilateral vocal fold lesions, Reinke edema,
leukoplakia/eritroplakia, granulomas, sessile lesions, and vocal
cord tumors (as the original technique by Arnoux-Sindt15 was
applied to unilateral pedunculated lesions only); (3) comorbid
diagnosis of laryngopharyngeal reflux/gastroesophageal reflux
disease, as confirmed by Reflux Finding Score17 >7 and by a pos-
itive 24-hour pH impedance test; and (4) any other major medical
condition.
Based on the abovementioned criteria, all patients with dys-
phonia related to the presence of pedunculated and unilateral
cordal polyps, located on the free edge of the vocal fold, were
included in the study.
Informed consent to participate in the experimental proce-
dures, which conformed to the ethical principles for medical
research endorsed in the Declaration of Helsinki, was obtained
from all patients.
Journal of Voice, Vol. 31, No. 3, 2017
Therapeutic procedures
All consecutive patients included in the study were randomly
allocated to either phonosurgery or VTE by a trained laryngologist
(F.G.) who was blinded to diagnosis and was not directly in-
volved in the therapeutic or rehabilitation procedures.
Surgical Therapy
Half the patients were treated with CO2 laser phonosurgery18,19 at
the Service of Phonosurgery, University of Naples SUN (SuperPulse
SurgiTouch CO2 Laser, Digital AcuBlade, Lumenis Surgical) per-
formed by a trained phonosurgeon experienced in cold instrument
microsurgical techniques. Surgery was complemented by 16 stan-
dard voice therapy sessions, which are very different from the VTE
protocol performed in the groups of patients treated conserva-
tively; in particular, in the month before surgery, patients underwent
eight sessions (about 1 month) of standard voice therapy (30 minutes
each, twice a week) up to 5 days before surgical treatment; eight
sessions of standard voice therapy were delivered after 15 days
from surgery (30 minutes each, twice a week), and absolute voice
rest was prescribed for the first week immediately after surgery.
All sessions were performed by the same qualified speech-
language pathologist (G.M.), with specialization in assessment and
rehabilitation of patients with voice disorders, and included a general
approach to voice counseling, relaxation training, vocal function
exercises, breath support, and vocal hygiene management (pre-
vention of misuse and abuse of the voice). Respiratory and phonatory
exercises were used throughout traditional pre- and postsurgical
voice therapies to prevent exaggerated vocal fold contact and fa-
cilitate relaxed phonation.
Voice Therapy Expulsion
This protocol was developed by modifying the rehabilitation
model proposed by Arnoux-Sindt15 and Bergamini et al.16 In detail,
patients subjected to the VTE alone underwent two different ther-
apeutic phases. The first phase aimed at the mechanical removal
of the polyp (ie, pars destruens) and consisted in training the
patient to use exclusively designed techniques (ie, repetitive
“microtraumatism” exercises); it was performed for a minimum
of 5 to a maximum of 10 sessions (30 minutes each, twice a week)
and, if after the first 10 sessions the polyp had not been ex-
pelled with voice therapy alone, the patient was excluded from
the study and subjected to standard surgical excision of the lesion.
Details concerning the basic and additional techniques used in
the pars destruens of the protocol to induce the ischemia of the
peduncle and the expulsion of the lesion are all listed in Table 1.
The second phase, which consists in a training program very
similar to standard voice therapy sessions (ie, pars construens),
was performed for another 10 sessions (30 minutes each, twice
a week) after the expulsion of the lesion, with no induction of
repetitive “microtraumatisms”; this training included voice coun-
seling, relaxation training, vocal function exercises, breath support,
and vocal hygiene management, and it played a crucial role for
patients in raising awareness on voice control, in recognizing
deviant vocal behaviors, and in producing correct vocal emis-
sion in various communicative settings. The voice therapy program
was designed to induce behavioral changes, and it may reduce
the impact of predisposing factors for vocal fold polyps
Maria Rosaria Barillari et al Voice Therapy for Vocal Fold Polyps 379.e15

TABLE 1.
Basic and Auxiliary Techniques Used for Voice Therapy Expulsion (“Repetitive Microtraumatisms”).
Basic Techniques
Coughing: Repeated coughing with or without vowel use. Use of the vowel
guarantees the effectiveness of coughing on the cordal plane, avoiding the
discharge of forces focusing mainly on the plane of the false cords. This method is
detrimental to the fiber tissue of the peduncle in a lateral-to-medial direction.

Raclage (Scraping): Repeated episodes. As for coughing, it is necessary for the

friction to occur on the cordal plane, avoiding the discharge of forces focusing
mainly on the plane of the false cords or at the pharyngeal veil level. This method,
with the “friction” effect, is detrimental to the tissue fibers of the peduncle in an
anterior-to-posterior direction.

Auxiliary Techniques
Vigorous and fast inspiration and expiration: The repeated mobilization of the
peduncle of the lesion induced by respiratory movements may cause its thinning;
this effect is called “wire” effect, and can encourage the detachment of the
formation. This method is detrimental to the tissue fibers of the peduncle in an
inferior-to-superior direction.

Emission of vowel with aspirated start and then saccadized, to move the polyp
toward the top; in this case the forceful glottal closure (guillotine effect) may
determine microtraumas of the peduncle tissue.

Emission of sonorized vowels in inspiration and expiration: This is a combination of

the two previous techniques because the inspiratory glottal closure brings about a
thinning of the peduncle, whereas the following aspirated start pushes it toward
the top; the consequent forceful glottal closure produces a microtrauma of the
peduncle. So the combined effect of “wire” and “guillotine” can facilitate the
detachment of the lesion.
379.e16
(excessive phonatory efforts and voice misuse/abuse). Patients
are also trained to maintain good hydration and lubrication of
the vocal fold, which helps to adequately moisten the larynx and
to decrease abnormal secretion; those induced changes enable
the mucosa to vibrate more comfortably upon initiating phona-
tion and protect the vocal fold cover from injury.20,21
The total duration of VTE was about 3 months, including both
the pars destruens and the pars construens. All the sessions of
voice therapy were performed by the same trained speech-
language therapist (G.M.).
During all voice therapy sessions of the pars destruens, ac-
cording to Bergamini et al, the patient was in a sitting position
with both elbows on knees and with the head bent forward; this
posture helps to support the effort required from the execution
of some techniques (ie, it facilitates coughing and the expul-
sion of the lesion and it avoids the risk of swallowing the polyps
itself). The expulsion of the lesion occurred through the pa-
tient’s coughing, and the tissue was sent for histologic evaluation
to confirm the diagnosis. None of the included subjects re-
ported any trouble during these procedures, and no one swallowed
the polyp.
Further to the above protocol, patients were instructed to
perform further vocal exercises at home (ie, repeating selected
“basic techniques” for 15 minutes, three times a day) for a
maximum of 5 weeks (or up to the lesion expulsion). Out of 70
patients, 12 individuals managed to expel the polyp during home
exercises; those subjects, immediately after the expulsion, were
recalled to our clinic and submitted to a further laryngoscopy
(to check the local larynx status); they were also asked to bring
in the polyp for further histologic tests to confirm the diagnosis.
During the initial phase of the VTE’s pars destruens, all pa-
tients were monitored with a flexible endoscopic examination
to ensure that the patient was able to induce the correct vocal
fold movements (repetitive microtraumas), as per VTE protocol.
Phoniatric evaluation
To confirm the diagnosis, anamnestic and functional evalua-
tions, including pneumophonic coordination, respiration
during phonation and during rest, general tone and general posture,
videolaryngostroboscopy examination, and acoustic voice
analysis, were performed by two trained laryngologists
(U.B. and M.R.B) with a trained speech therapist (G.M.).
Laryngovideostroboscopic examination was performed by means
of a Storz 70° rigid optic (KARL STORZ GmbH & Co. KG,
Tuttingen, Germany; diameter: 5,6 mm; equipped with an ATMOS
Endo-Stroboscope L - ATMOS Medizin Technik GmbH & Co
KG, Lenzkirch, Germany) and operated through the endoscop-
ic software Daisy (2014; ver. 3.6.15, Amplifon SPA, Milan, Italy)
with videoendoscopy module (OMVISIA, 2014, ver. 2.0.8 -
Amplifon SPA Milan, Italy). During the initial phase of the VTE’s
pars destruens, all patients were monitored with a flexible en-
doscopic examination (Xion EF-N 3.4 nasopharyngoscope -
XION GmbH, Berlin, Germany) to ensure that the patients were
able to induce the correct vocal fold movements (repetitive
microtraumas), as per VTE protocol.
The acoustic analysis of voice was performed using the Multi-
Speech program (version 3700, Kay Elemetrics Corp., Lincoln
Journal of Voice, Vol. 31, No. 3, 2017
Park, NJ, USA), which carries out voice spectrography; all the
voices were recorded using a microphone positioned approxi-
mately 15 cm from the mouth, slightly below the chin, to reduce
airflow effects. Spectrograms of the sustained vowels [a], [e],
[i], [o], and [u] were recorded at FFT-1024 (Fast Fourier Trans-
form) points ranging from 0 to 8 kHz, with a sampling frequency
of 20,000 Hz. The acoustic voice analysis was performed ac-
cording to the criteria set by Yanagihara.22
The auditory assessment of deviant voice quality was per-
formed by means of the global grade of dysphonia, instability,
roughness, breathiness, asthenia, and strain (GIRBAS) scale,23 which
provides information concerning six vocal parameters; for each
parameter, a score ranging from 0 (euphonia) to 3 (severe degree
of dysphonia) is provided, whereas in the case of the presence of
a whisper, the patient was marked as aphonic. The administration
of the GIRBAS scale and the endoscopic examinations were per-
formed by the same trained laryngologists (U.B. and M.R.B.).
The subjective self-assessment of voice was obtained using
the Italian version of the Voice Handicap Index (VHI24,25), which
assesses the subject’s perception of disability, handicap, and dis-
tress related to voice disorders. The VHI consists of 30 questions,
each with a 5-point scale, to quantify the subjective functional,
physical, and emotional impact of a voice disorder on a pa-
tient’s quality of life.
Quality of life
The quality of life was evaluated by a trained psychiatrist (U.V.)
who used the Voice-Related Quality of Life (V-RQOL)
measure26,27 to assess the patients’ perception of the impact of
the voice problem on their quality of life; the scale consists of
10 questions, each with a 5-point scale, exploring the emotion-
al (four items) and physical (six items) impacts of a voice disorder
on a patient’s quality of life.
The above described evaluation protocol was performed at base-
line (T0) and at the end of the treatment in all patients of both
groups; in particular, when the lesion was expelled, a further la-
ryngoscopy alone was performed (after about 5–7 days from the
expulsion, T1) to assess the clinical conditions of the larynx, and
the entire evaluation protocol was repeated at 2 (T2), 6 (T6), and
12 months (T12) after the expulsion of the polyp (T1) in all pa-
tients. For patients assigned to ST, T1 was standardized (40 days,
after the initial assessment), whereas for patients assigned to VTE,
there was a slight variation (>26 days T1 <42 days) depending
on the individual clinical response to the phoniatric treatment
protocol. Furthermore, patients assigned to ST also underwent
laryngoscopy and evaluation of perceived disability, handicap,
and distress by means of the VHI, after the eight preoperative
sessions of standard voice therapy.
Statistical analysis
Descriptive statistics and Student t test were performed to eval-
uate possible differences between the two experimental groups,
compared with the main sociodemographic and the basic clin-
ical characteristics. For categorical variables, chi-square test was
used.
After having checked for normality of distribution, a repeat-
ed measures multiple analysis of variance was performed to assess
Maria Rosaria Barillari et al Voice Therapy for Vocal Fold Polyps 379.e17

the presence of between-group significant differences on clin-

TABLE 3.
ical and quality of life indices. Morpho-functional Characteristics of Cordal Polyp and
The significance level was set at P ≤ 0.05 for all analyses. Glottic Plane in the Experimental Groups

RESULTS ST Group VTE Group

We originally assessed for eligibility of 200 patients with vocal (n = 70) (n = 70) P Value
fold polyps; however, 39 patients did not conform to the inclusion/ Appearance
exclusion criteria. One patient had to be excluded because he Fibrous 25 (36%) 26 (37%) 0.59
had a high anesthesiological risk. Ten patients declined to par- Angiomatous 5 (7%) 2 (3%)
ticipate in the study. The remaining 150 were randomly allocated Fibro-angiomatous 35 (50%) 36 (51%)
Gelatinous 5 (7%) 6 (9%)
to either ST or VTE groups. However, five patients did not
Position of vocal folds
succeed in completing the VTE intervention, whereas two pa- Right cord, III A 24 (34%) 25 (36%) 0.58
tients in the ST group withdrew consent just before surgery. Three Right cord, III M 22 (32%) 23 (33%)
patients in the ST group did not complete the follow-up evalu- Left cord, III A 14 (20%) 16 (23%)
ations and were thus excluded from final analyses. The final Left cord, III M 10 (14%) 6 (8%)
sample consisted of 140 patients (67 men, 73 women), equally Notes: The P values were calculated by means of chi-square test.
distributed in each treatment group (N = 70). III A, anterior third of the vocal cord; III M, middle third of the vocal cord.
The sociodemographic and basic clinical characteristics of the Fibrous, lesion consisting of cellular fibrous tissue, frequently with foci
of fairly dense collagen or hyaline material (or both); Angiomatous, red
two groups at baseline are reported in Table 2; in brief, none lesion consisting mainly of blood vessels; Fibro-angiomatous, pinkish lesion
of the abovementioned characteristics showed any statistically consisting of both dilated blood vessels and fibrous tissue; Gelatinous,
significant differences between the VTE and the ST groups. The translucent lesion consisting mainly of delicate, loose and edematous con-
nective tissue.
initial clinical picture was mainly characterized by dysphonia, Abbreviations: ST, surgical therapy; VTE, voice therapy expulsion.
coughing, and hoarseness in both groups.
The structural characteristics of the polyps in both groups are
summarized in Table 3. As for the morphology of the individ- firmed at baseline (T0) the presence of a dynamic abnormality
ual lesions, in our sample we found a prevalence of fibro- of glottic plane, with mildly reduced mucosal wave vibratory
angiomatous polyps, whereas angiomatous polyps are the least activity of the true vocal fold affected by the lesion,1 as well as
represented; as far as the position of the lesion was concerned, normal vibratory properties of the mucosa of the contralateral
all polyps were situated on the free edge of the vocal cord (in vocal fold. When the lesion is particularly large and it disrupts
particular, most often at the junction of the anterior and the middle vocal fold closure and vibration, a severely reduced mucosal wave
third of the right vocal cord) in both groups. vibratory activity could be seen.
Stroboscopic examination evaluated the regularity and am- Spectrography at T0 showed mixed results (Table 4), al-
plitude of the vocal fold movement, periodicity, symmetry of though a prevalence of type 2 spectrography was observed in
vocal fold abduction and vibration, glottic closure, and mucosal both groups; in the VTE group, there was also a prevalence of
wave characteristics; in the majority of patients, this exam con- a “type 3” spectrographic trace when compared with the ST group.
Through laryngostroboscopic examination at T2 (ie, the first post-
treatment evaluation, performed at 2 months after the removal
TABLE 2.
of the lesion), we found resolution of the lesion and symptoms
Sociodemographic and Basic Clinical Characteristics of
with a normalization of the clinical picture, as well as normal
the Sample
vibratory properties of the mucosa of the vocal folds in both
ST Group VTE Group 2 groups; the T2 evaluation regarding the spectrographic charac-
(n = 70) (n = 70) P Value teristics also showed a recovery of the harmonic structure across
Age (years) ± SD 43.1 ± 11.8 42.4 ± 15.8 0.79 the entire spectrum, with no disharmonic component in the ma-
Gender [N male 33 (47,1%) 33 (47,1%) 0.97 jority of our patients and a prevalence of type 1 spectrogram in
(%male)] both groups (Table 4).
Use of voice Patients assigned to ST did not show any significant change
Speech/normal (%) 48 (69%) 45 (64%) 0.45 in the lesion size (as confirmed by laryngoscopy, performed after
Professional (%) 22 (31%) 25 (36%)
the eight preoperative standard voice therapy sessions) and had
Previous surgical 0 (0%) 2 (3%) 0.09
a slightly better VHI total score after preoperative sessions of
excision [N(%)]
Cigarette smoking 38 (54%) 34 (48%) 0,72 standard voice therapy; however, the VHI change did not turn
[N(%)] out to be statistically significant, and thus, for all patients in the
Coughing [N(%)] 56 (80%) 55 (78,5%) 0,12 ST group the surgical treatment was confirmed.
Voice clearing [N(%)] 68 (97%) 63 (90%) 0.13 Overall, we observed an immediate positive change already
Abbreviations: SD, standard deviation; ST, surgical therapy; VTE, voice at 2 months after both interventions in all patients, in terms of
therapy expulsion. reduction of global grade of dysphonia (GIRBAS scale, “G”
Notes: The P values were calculated by means of t test (for continuous score), vocal disability (as expressed by the VHI total score),
variables) or chi-square test (for categorical ones).
and the quality of life (represented by the V-RQOL total score),
379.e18 Journal of Voice, Vol. 31, No. 3, 2017

amelioration in terms of “G” score and quality of life,

TABLE 4.
Spectrographic Typization of Patients From Both Exper-
although subjects treated with VTE showed a significantly higher
imental Groups Pre- and Posttreatment score for quality of life at 2 (T2) and 6 months (T6) than sub-
jects in the ST group, indicating that VTE may be more favorably
ST Group VTE Group perceived; the results in terms of reduction of disability related
(n = 70) (n = 70) P Value to the presence of the polyp (VHI total score) are relatively similar
Pretreatment <0.001 at T2, T6, and T12 in both groups.
spectrographic The occurrence of occasional relapses was signaled in four
analysis patients in the ST group and in one patient in the VTE group.
Type 1 0 (0%) 0 (0%)
Type 2 61 (88%) 43 (62%)
Type 3 9 (12%) 27 (38%) DISCUSSION
Type 4 0 (0%) 0 (0%) Phonosurgeons still tend to consider surgery as the first choice
Posttreatment <0.04 treatment for removing vocal fold polyps.6–8 As an example,
spectrographic
Nakagawa et al14 reported that, out of 644 patients with vocal
analysis
fold polyps, only 132 (mostly patients who declined surgery or
Type 1 60 (86%) 65 (93%)
Type 2 10 (14%) 5 (7%) who were at high risk for either surgery or general anesthesia)
Type 3 0 (0%) 0 (0%) were treated conservatively (ie, standard voice therapy and/or
Type 4 0 (0%) 0 (0%) steroid medication) with good results. Scientific literature on voice
Notes: Spectrographic analysis followed the classification proposed by
therapy approaches for vocal fold polyps remains unclear, and
Yanagihara (22): type 1 (the regular harmonic components are mixed with nonsurgical treatments for these laryngeal lesions are still seen
the noise component chiefly in the formant region of the vowels); type 2 as a second-line approach, to be proposed only to patients with
(the noise components in the second formants of [e] and [i] predomi-
nate over the harmonic components, and slight additional noise
a specific clinical profile (ie, lesions with recent onset and small
components appear in the frequency region above 3000 Hz in the vowels in dimensions).
[e] and [i]); type 3 (the second formants of [e] and [i] are totally replaced Klein et al12 instead reported the complete resolution of the
by noise components, and the additional noise components above 3000 Hz
further intensify their energy and expand their range) and; type 4 (the
lesions with non-ST in 9 out of 16 small-to-medium-sized hem-
second formants of [a], [e], and [i] are replaced by noise components, and orrhagic polyps in subjects with recent onset of symptoms who
even the first formants of all vowels often lose their periodic compo- chose conservative management and avoided the risks of general
nents, which are supplemented by noise components).
Abbreviations: ST, surgical therapy; VTE, voice therapy expulsion.
anesthesia or surgery; similarly, Cohen and Garrett10 con-
firmed the utility of voice therapy in the management of vocal
fold polyps and cysts, showing evidence that 25% of subjects
although this effect was slightly more marked in the VTE group with hemorrhagic polyps responded to voice therapy, which was
(Table 5); in brief, patients who underwent VTE training had a effective in improving hoarseness in patients with vocal fold
statistically significantly greater improvement of global grade polyps, even when proposed as a “first-line” treatment.
of dysphonia (G score at T0 = 2.40 ± 0.52; at T2 = 0.31 ± 0.46; Definitive treatment guidelines for choosing ST or conserva-
F1,138 = 6,94; P < 0.009); a slight reduction of disability related tive treatment for vocal fold polyps have not been established
to the presence of polyps (VHI total score at T0 = 61.33 ± 2.22; yet. However, more recent-onset vocal polyps of a small size,
at T2 = 16.14 ± 1.05; F1,138 = 1,31; P < 0.254) in the function- with hemorrhagic features, and occurring in women reportedly
al, physical, and emotional domain; and a significant enhancement show a better response to voice therapy or vocal hygiene
of voice-related quality of life (V-RQOL total score at education.20–28
T0 = 21.07 ± 2.0; at T2 = 2.21 ± 0.93; F1,138 = 4,43; P < 0.037) Our study demonstrated that VTE treatment of laryngeal
when compared with the surgically treated group. polyps, irrespective of the onset, features, and dimensions of the
As shown in Figure 1, the follow-up at 12 months (T12) re- lesion, represents a valid, safe, and well-tolerated therapeutic al-
vealed that both therapeutic approaches induced a final ternative to surgery. This evidence is in line with the positive

TABLE 5.
Psychometric Evaluation Before (T0) and 2 Months After Therapeutic Intervention (T2)
T0 T2
ST Group VTE Group ST Group VTE Group
(n = 70) (n = 70) (n = 70) (n = 70) P Value
GIRBAS “G score” 2.59 ± 0.50 2.40 ± 0.52 0.40 ± 0.60 0.31 ± 0.46 <0.009
VHI total score 60.97 ± 2.19 61.33 ± 2.22 16.64 ± 1.64 16.14 ± 1.05 <0.25
V-RQOL total score 21.60 ± 0.80 21.07 ± 2.0 2.72 ± 0.66 2.21 ± 0.93 <0.04
Notes: All values are expressed as mean ± standard deviation.
Abbreviations: GIRBAS “G score”, global grade of dysphonia; ST, surgical therapy; T0, baseline evaluation; T2, evaluation at 2months, after the interven-
tion; VHI, Voice Handicap Index; V-RQOL, Voice-Related Quality of Life; VTE, voice therapy expulsion.
Maria Rosaria Barillari et al Voice Therapy for Vocal Fold Polyps
FIGURE 1. Follow-up evaluation after surgical excision or voice therapy expulsion.
(A) GIRBAS, “G” score, global grade of dysphonia; (B) VHI, Voice Handicap Index; (C) VRQOL, Voice-Related Quality of Life; VTE, voice
therapy expulsion; ST, surgical therapy. T2, 2 months after the expulsion of the polyp; T6, 6 months after the expulsion of the polyp; T12, 12
months after the expulsion of the polyp.
results reported in early attempts to treat laryngeal granulomas,16
but it extends the indication of voice therapy rehabilitation to
other pedunculated lesions of the vocal folds. A possible limi-
tation of our study may be the exclusion of some laryngeal lesions
listed in criterion “(2)”; in our clinical experience, the VTE treat-
ment (which in its “pars destruens” is supposed to induce
peduncular ischemia to favor the detachment of the lesion itself)
may yet be useful in some cases but less likely to be beneficial
for patients with sessile lesions (which usually respond better
to a standard voice therapy treatment); however, the possible out-
comes of the application of the VTE technique on bilateral vocal
fold lesions should be specifically explored in further con-
trolled studies.
Furthermore, we also revealed that the VTE technique is better
tolerated by patients and is able to induce a greater ameliora-
tion of subjective quality of life compared with laryngeal surgery.
This might be due to the avoidance of the classical “surgical risks”
(vocal fold scarring, permanent hoarseness, and recurrence of
the lesion) and postoperative recovery limitations (eg, absolute
voice rest). Furthermore, it entails fewer costs. Of course, surgery
still represents the best option for patients who need a more rapid
resolution of the symptoms.12
Another interesting result observed in our sample is the low
frequency of relapses after VTE: four patients assigned to ST
and only one patient assigned to VTE had a relapse at the 12-
month follow-up; a possible explanation for a lower number of
relapses for patients who underwent nonsurgical treatment might
lie in the fact that this approach promotes a more natural balance
of the vocal fold cover, obtained through the use of “physio-
logical” mechanisms such as coughing and scraping, which are
already present as the organism’s reaction;28 in general, the reasons
for the cordal cover lesions are to be found in high levels of
subglottal pressure, together with a constantly high contact time,
as well as in the (perpendicular) impact force between the vocal
cords during adduction.29–31 Our experience showed that “guided”
coughing and scraping (pars destruens), monitored by means
of flexible endoscopic examination, do not produce “lesional
effects” on the cordal cover; indeed, they favor the expulsion
of the polyp. Furthermore, the pars construens will help the pa-
379.e19
tients to monitor their voice more effectively and help in reducing
the impact of small abnormalities of the vocal fold, possibly
present after the polyp expulsion.
CONCLUSIONS
In conclusion, the reported results of our rehabilitation conser-
vative VTE protocol for the treatment of vocal fold polyps are
in line with the positive results reported in previous literature
for the treatment of posterior laryngeal granulomas, and it may
represent a noninvasive, effective, economical, well-tolerated,
and easy-to-implement approach, which should also be pro-
posed to patients presenting benign, pedunculated, and unilateral
vocal fold lesions. Rehabilitation and conservative approaches
also showed clear advantages in terms of individual quality of
life when compared with surgical approaches.
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