Benign vocal fold lesions (BVFL) including nodules, polyps and cysts account for 11–22% of patients presenting with voice disorders [1,2] and cause dysphonia by preventing vocal fold closure, impacting on vibratory characteristics and increasing compensatory muscle tension [3▪,4]. Morphological features of common lesions and risk factors are summarized in Table 1. Behavioural factors are highly significant in the development of these lesions , which typically arise in the mid vibrating portion of the vocal fold as a result of excessive or aggressive adduction of the vocal folds  or as a consequence of exposure to laryngeal irritants [7,8]. Addressing behavioural elements should be a routine aspect of management in BVFLs [9,10▪]. Both the Royal College of Speech and Language Therapists  and the European Laryngological Society  advocate voice therapy in the management of BVFLs, however, no clinical guidelines exist to outline therapeutic input.
Treatment for BVFLs historically has been variable, including surgery, pharmacological management, voice therapy or a combination of these approaches. For vocal fold nodules, consensus opinion , retrospective data  and prospective evidence  has supported voice therapy as the primary treatment, with phonosurgery being undertaken where nodules are fibrotic and resistant to voice therapy [3▪]. Conversely survey data (n = 1208) suggests that primary phonosurgery has been the predominant treatment for vocal fold polyps (41%) and cysts (53%) in the past .
For primary muscle tension dysphonia (also termed functional dysphonia), a combination of indirect (advice giving) and direct therapy (altering phonation patterns) is frequently undertaken [24–27]. A meta-analysis in a Cochrane Systematic Review for adults with functional dysphonia concludes; ‘there is moderate evidence for the effectiveness of a combination of direct and indirect voice therapy when compared to no intervention’. It cannot be assumed that this can apply to patients with BVFLs as the pathophysiological changes associated with BVFLs, wound healing and epithelial mobilization following phonosurgery must be given due consideration. These factors present additional and unique complexities for patients with BVFLs participating in voice therapy either as primary or adjunct treatment.
The consequence of failing to understand and implement optimum management pathways for this population is profound. Financial expenditure is high because of surgical costs, time off work, and follow-up appointments . Risk of lesion recurrence is greater if the underlying causal factors are not appropriately addressed [30▪] and psychological distress, already documented to be inflated in those with voice disorders is highest among those with BVFLs .
VOICE OUTCOMES AFTER PHONOSURGERY
The recent Clinical Practice Guidelines: Hoarseness Update [32▪] from the American Academy of Otolaryngology, Head and Neck surgery state: ‘Clinicians should advocate for surgery as a therapeutic option for patients with dysphonia with conditions amenable to surgical intervention, such as suspected malignancy, symptomatic benign vocal fold lesions that do not respond to conservative management, or glottic insufficiency’ (p. 421). These recommendations are based on a review of observational studies demonstrating a preponderance of benefit from surgery over harm [10▪,33,34,14,35].
Jensen and Rasmussen  report a series of 97 patients with vocal fold nodules, polyps and cysts. Phonosurgery resulted in the successful removal of lesions in 96 patients, with one anterior commissure lesion being left untreated because of the high risk of anterior web development. Furthermore, voice quality improved in all bar one patient who had a complex vocal fold cyst and sulcus presentation. Similarly, Wang et al. report 100% disappearance of vocal fold polyps 4 months after phonosurgery, coupled with significantly lower Voice Handicap Index (VHI) scores (a patient-reported outcome measure) suggesting functional improvement following phonosurgery.
The type of lesion and extent of surgery are likely to influence the degree of improvement. Phonosurgery for superficial lesions, such as vocal fold polyps results in a greater likelihood of postoperative voice satisfaction . Although all 224 patients in a mixed aetiology cohort had improved function after phonosurgery those with deeper lesions (classified as subepithelial fibrous masses) reported the smallest improvements . Furthermore, lesion type will influence the pace of vocal rehabilitation. Do Amaral Catani et al. reported that 96% of patients with superficial lesions improved by 1 month compared with only 3.2% of patients with deep lesions. By 3 months, however, 99 and 92.4%, respectively, showed improved functional voice. This highlights the importance of classifying patients according to lesion type in research, and the need to manage patients’ expectations regarding likely recovery times.
Recent studies have examined the impact of steroids, proton pump inhibitors or surgical technique on phonosurgical outcomes. The addition of adjunct steroid injection for vocal fold nodules, polyps and cysts made no significant difference to acoustic, perceptual or patient-reported outcomes with both groups in this retrospective study showing significant improvements. However, steroid injection was associated with a reduced risk of persistent hoarseness . Lansoprazole (15 mg twice daily for 2 months) following phonosurgery for polyps resulted in no greater improvement in VHI or perceptual scores than in those who received surgery alone in Lee et al.'s randomized controlled trial (RCT) . The use of glue to repair microflaps after surgery for more complex lesions, such as sulci showed significant improvement in the early recovery of vocal fold vibration but this did not translate into differences in functional recovery as measured by the VHI-10 (shortened version) .
VOICE THERAPY AS A PREVENTIVE INTERVENTION
The evidence for voice therapy as an effective treatment for vocal fold nodules has been synthesized in Mansuri et al.'s [42▪] recent systematic review. It concludes that voice therapy is an effective intervention for the management of vocal fold nodules and reflects survey data on clinical practice . However, this systematic review also highlights the need for longer term follow-up, improved methodological rigour and higher quality study designs.
Voice therapy can reduce polyp size (53%) or result in complete lesion disappearance (30.3%) negating surgical intervention . It can improve voice quality for small nonhaemorrhagic polyps , improve acoustic findings  and reduce symptoms in some patients . However, in stark contrast, 70 patients undergoing eight sessions of preoperative voice therapy in Barillari et al.'s RCT  showed no reduction in lesion size on laryngostroboscopy and all patients progressed to surgical intervention. A lack of detail as to the content of preoperative intervention prevents further speculation as to why these findings may be so contradictory.
De Vasconcelos et al.[30▪] compared voice therapy constituting lip and tongue trills with phonosurgery. Three out of five patients (60%) improved with voice therapy and did not require phonosurgery. Similarly, retrospective data on 92 patients with vocal fold polyps demonstrated that after an average 3.3 sessions of voice therapy (range 1–7) over 1–4 months, polyp size shrunk by more than 50% in 43.8% of patients who no longer required surgery [10▪]. Univariate analysis of this cohort revealed that female individuals had a better response to voice therapy than male individuals, smaller polyps responded better than medium or large polyps and in patients with small polyps, those with sessile polyps more frequently improved with voice therapy compared with pedunculated polyps. Neither age nor smoking status, perceptual nor acoustic voice measures were significant predictive factors.
In summary, primary voice therapy for vocal fold polyps and nodules is promising but variability in findings remain. Variation, coupled with low-quality evidence (typically levels 3 and 4), small numbers and methodological failings in many studies mean that further exploration is required. Confounding factors in the studies presented exists which reduces the confidence with which results can be believed. One such confounding factor may be in the content and timing of voice therapy provided.
VOICE THERAPY AS AN ADJUNCT TO SURGERY
Where phonsurgery is desirable or required, voice therapy can be delivered preoperatively and/or postoperatively. There is a growing body of literature examining the impact of voice therapy as an adjunct treatment. If proven to be effective, this has the potential to enhance surgical outcomes, reduce follow-up appointments and prevent lesion recurrence.
The role of preoperative intervention is multifactorial and includes preparing the patient for surgery, managing expectations, providing information and education regarding normal voice and BVFLs, advising on voice care regimes and tackling any contributory factors or compensatory mechanisms. Sahin et al. present a large collection of data (n = 211) demonstrating improved functional and perceptual outcomes in participants with polyps who underwent 10 sessions of preoperative voice therapy twice a week prior to surgery, compared with surgery alone. Such intensive and prolonged preoperative therapy may not be feasible in the NHS setting and thus the generalizability of these findings to the UK setting may be called into question. Regardless of the number of sessions given, Tang and Thibeault [47▪] suggest that preoperative voice therapy can enhance voice outcomes. Participants with mixed diagnoses including nodules, polyps and cysts receiving at least one preoperative voice therapy session showed a greater reduction in VHI scores compared with those receiving postoperative voice therapy only. It is likely that preoperative intervention allows therapists to manage expectations and set realistic postoperative goals. The opportunity to establish a postive therapeutic relationship may also contribute to a greater perceived function. Tang and Thibeault gave no information about how treatment groups were establised leading to a risk of selection bias.
The role for postoperative voice therapy can be divided up into the immediate postoperative period constituting voice rest and vocal care and ongoing rehabilitation.
There is no agreed consensus on voice rest duration after phonosurgery. A UK survey found that 1–2 days absolutely voice rest (AVR) was most frequently prescribed but there was a high spread of responses with many surgeons recommending 7 days AVR . A balance must be achieved between ‘rest,’ to allow preliminary vocal fold healing to occur [49,50] and ‘remobilization,’ to re-establish flexibility in the mucosal wave of the vocal fold. Early mobilization is well evidenced in orthopedic literature  but the extent to which this can be applied to the unique morphological qualities of vocal fold epithelium is unclear. Kaneko et al. undertook a RCT specifically investigating voice rest and compared 3 and 7 days AVR in 31 participants of mixed BVFL diagnoses . Participants received only one postoperative voice therapy session. Those in the 3-day group had improved NMWA (Normalised Mucosal Wave Amplitude) scores at 6 months, representing better functional recovery of the mucosa. However, other outcomes including VHI showed no difference between groups. On the basis of their results, the authors conclude that 3 days of voice rest followed by therapeutic stimulation should be recommended following phonosurgery. Small sample sizes weaken the randomization status and statistical power of this study and varied diagnoses of participants acts as a confounding variable. Surgical techniques will differ, impacting on wound healing and thus potentially the necessary voice rest time.
Regardless of the recommendation made by the surgeon, patient adherence to voice rest is variable. Patients in a RCT were allocated to either 7 days relative voice rest (RVR) or 7 days absolute voice rest (AVR) . Unsurprisingly, patients on RVR used their voices more than those randomized to AVR (7% average phonation time vs. 3%) but there was no statistical difference in long-term voice outcomes between groups. AVR patients found it harder to adhere to the recommendation, leading the authors to suggest that AVR may not be necessary for vocal recovery. Once again, small sample sizes and mixed diagnoses restrict the confidence that we can have when interpreting and applying results. However, RVR is frequently recommended in clinical practice .
Ongoing vocal rehabilitation follows a period of absolute or relative voice rest and when delivered, frequently constitutes both indirect and direct therapy [37,38,45,46,52,54–56]. Intervention is highly variable in terms of content, timing and access to therapy but low-level evidence suggests that access to postoperative voice therapy improves patient-reported outcomes when compared with no postoperative intervention in a vocal fold polyp cohort [57▪]. The combination of indirect and direct components potentially allows patients to recognize and understand their voice problem more clearly, and therefore, avoid the voice misuse and abuse, which has contributed to the vocal fold mucosa trauma. No significant difference was seen in the voice outcomes for patients with mucous retention cysts in two groups who did and did not receive postoperative voice therapy . Selection bias may account for the findings in this retrospective review, with only those unhappy with their voice seeking out additional voice therapy. Furthermore, mucus retention cysts are not always associated with phonotrauma and arguably voice therapy has a more extended role with phonotraumatic lesions.
Studies investigating voice outcomes following phonosurgery frequently fail to describe voice therapy content but where included most protocols adopt a range of techniques aimed at addressing the underlying contributory factors and any negative compensatory laryngeal gestures. For nonphonotraumatic lesions, re-establishing the mucosal wave and ensuring that the laryngeal gesture is efficient may be primary aims.
Phonosurgery combined with traditional voice therapy aimed at preventing ‘exaggerated vocal fold contact and facilitating relaxed phonation’ was compared with ‘Voice Therapy Expulsion Training’ in Barillari et al.'s RCT (p. 379.e14). Both groups showed improved perceptual ratings and quality-of-life scores at 12 months but those who underwent expulsion training as opposed to surgery had better outcomes at 2 and 6 months, suggesting a potential role for alternative treatment options.
Preoperative and postoperative voice therapy appears to result in improved patient perception of function [45,46,47▪,59,60]. At least one of the outcomes reported in the studies cited is favourable. At face value, this appears promising, however, recurrent threats to internal validity exist and the relative impact of surgery, voice therapy and other factors remains unclear. A robust synthesis of voice outcomes in these studies is prevented because of poor descriptions of intervention protocols, the use of varied and at times unvalidated outcome measures and heterogeneous inclusion criteria (including lesion types) across studies.
Phonosurgery for BVFLs can give significant improvement in voice outcomes. Growing evidence for the effectiveness of voice therapy means that it is reasonable to offer all patients with BVFLs a period of preoperative intervention. Research supports assertions that voice therapy can eliminate vocal fold nodules and polyps in many cases. Voice therapy for vocal fold cysts and more complex BVFLs is under researched but may enable the individual to compensate better, negating the need for surgery. Our understanding of the component parts of therapy and the relative benefits of this remains unclear. Further research is needed to assess the effectiveness of preoperative and postoperative voice therapy and this will rely on first developing an increased understanding of the component parts of a voice therapy intervention. The Medical Research Council's Framework for developing and evaluating complex interventions  provides a helpful model to structure this research.
Financial support and sponsorship
Health Education England/National Institute of Health Research, Integrated Clinical Academic Programme for nonmedical healthcare professionals.
Conflicts of interest
There are no conflicts of interest.
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Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
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