'Iceberg' cyst of the right vocal fold. (Laryngoscopic Clinic).

A 41-year-old woman with a history of gastroesophageal reflux disease and cholecystitis came to the voice clinic with dysphonia of 1 year's duration. She also complained of vocal fatigue, pain with prolonged voice use, and a globus sensation. Her head and neck examination was unremarkable. Laryngovideostroboscopy, however, revealed a lesion in the middle of the right vocal fold and changes consistent with laryngopharyngeal reflux disease (LPRD). The lesion featured a significant elevation of the superior surface of the vocal fold, as well as an intracordal component (figure 1). The vocal fold was stiff and exhibited a decreased mucosal wave.

The patient received LPRD treatment and preoperative voice therapy. She then underwent microlaryngoscopy for excision of the cyst. Examination under the microscope showed that the contents of the cyst protruded from the superior surface of the vocal fold. The cyst had a significant intracordal component that was found intraoperatively to extend to the vocal ligament (figure 2). A small posterior incision was made, and the cyst was dissected free circumferentially and off the vocal ligament. Following cyst removal, the epithelial edges of the cyst's extrusion site were uncurled and freshened.

Postoperatively, the patient was kept on voice rest for 5 days and continued on LPRD treatment. At her 1-week follow-up examination, the patient reported a significant improvement in the quality of her voice. Repeat laryngovideostroboscopy showed excellent healing at the surgical site and a return of her mucosal wave (figure 3). She underwent further postoperative voice therapy to maximize her vocal recovery.

This case represents an interesting variant of a vocal fold cyst: a partial extrusion of the cyst through the epithelium and fixation to the vocal ligament. Besides this variation, this case also illustrates the management issue with respect to the epithelial edges at the site of the extrusion. We managed this unique problem by performing a conservative excision of the epithelial rim at the extrusion site.

From the Department of Otolaryngology, University of Pittsburgh School of Medicine (Dr. Apicella and Dr. Rosen), the University of Pittsburgh Voice Center (Dr. Rosen), and the Department of Communication Science and Disorders, University of Pittsburgh School of Health and Rehabilitation Sciences (Dr. Rosen).