A large left vocal fold mass. (Laryngoscopic Clinic).

A 52-year-old appeals officer for the Internal Revenue Service reported a 2-year history of frequent throat clearing and a "froggy" voice. He had been examined initially by his primary care physician, who diagnosed the condition as an upper respiratory infection and recommended guaifenesin. The patient was later evaluated by an otolaryngologist, who diagnosed gastroesophageal reflux disease (GERD) and prescribed an antacid. A second otolaryngologist diagnosed the patient with left vocal fold paresis and GERD, and he started the patient on a proton-pump inhibitor. Findings on computed tomography of the neck and chest were normal.

When the patient's voice symptoms worsened, he came to our office. He complained of intermittent severe hoarseness, voice cracking, and decreased volume. He also reported an intermittent globus sensation and frequent throat clearing.

Stroboscopic examination revealed moderate supraglottic hyperfunction with a decrease in anteroposterior supraglottic distance and a decrease in lateral supraglottic distance with phonation, suggesting muscle-tension dysphasia. There was a decrease in the longitudinal tension of the right vocal fold. The patient also exhibited mild erythema and edema of the arytenoids and mild posterior laryngeal cobblestoning, which was suggestive of laryngopharyngeal reflux. On the left true vocal fold was a broad-based mass that originated in the striking zone near the middle of the vocal fold (figure). The mass prolapsed intermittently above and below the glottis, alternately obscuring and compressing the right true vocal fold.

Rigid stroboscopic examination identified stiffness of the left true vocal fold in the area of the attachment of the mass. The right true vocal fold could not be assessed adequately because of the large size of the mass. Laryngeal electromyography revealed 40% reduction of recruitment in the distribution of the right superior laryngeal nerve. This finding was consistent with the stroboscopic finding of a decrease in longitudinal tension on that side.

Surgery was scheduled, but first the patient was instructed to undergo a few voice therapy sessions to eliminate the hyperfunction and to prepare him for safe voice use following the operation. The patient was brought to the operating room for microdirect laryngoscopy and resection of the left vocal fold mass. After the laryngoscope was suspended, the base of the mass was infused with saline/epinephrine and a small incision was made on the superior surface at its attachment. Delicate blunt dissection was used to separate the mass from the underlying lamina propria of the vocal fold. This was followed by sharp division of the inferior mucosal attachment. Prominent varicose vessels on the superior surface of the left vocal fold were resected with a vascular knife.

Postoperatively, the patient was placed on voice rest for 1 week and then allowed to gradually increase his voice use under the supervision of our voice therapy team. Follow-up stroboscopic examinations revealed an area of mild left vocal fold stiffness, but the patient's voice quality improved markedly. He has continued voice therapy and aggressive antireflux therapy.

From the Department of Otolaryngology, Graduate Hospital, and the Department of Otolaryngology, Thomas Jefferson University, Philadelphia (Dr. Anderson and Dr. Sataloff), and the American Institute for Voice and Ear Research. Philadelphia (Ms. Hawkshaw).