Papillomata masquerading as vocal fold nodules.

A 42-year-old elementary school guidance counselor suddenly developed hoarseness approximately 7 years before seeking medical attention. She was evaluated at that time at another institution, and she was diagnosed with bilateral vocal fold nodules. She subsequently underwent voice therapy for 2 years. After she experienced no subjective or objective improvement in her voice quality, she underwent excision of the vocal fold masses in August 1996. She resumed voice therapy shortly after surgery. Her voice quality improved substantially following surgery, and it remained stable until February 1997, when she developed hoarseness. She was told that her vocal fold nodules had recurred and that she had reflux laryngitis.

The patient was referred to the senior author (R.T.S.) in October 1998. At that time, she complained of vocal fatigue and hoarseness. She said that she wanted to improve her vocal quality enough to be able to return to singing in her church choir.

Our initial examination revealed a moderately hoarse and breathy voice. Strobovideolaryngoscopy detected a broad-based, solid, white mass in the striking zone on the right vocal fold and a broad-based fibrotic-appearing mass along the superior surface of the left vocal fold lateral to the region of the striking zone (figure). There were varicosities on the superior surface of the left vocal fold, including one that extended perpendicularly to the vibratory margin. The arytenoids were bright red and edematous with posterior cobblestoning, consistent with reflux laryngitis. Bilateral vocal fold scarring was apparent under stroboscopic examination.

Our initial treatment included aggressive antireflux treatment and voice therapy. Despite excellent patient compliance, no improvement in vocal fold pathology occurred. The patient was taken to the operating room and underwent an excision of the bilateral vocal fold masses, vaporization of the bilateral laterally positioned varicosities, and bilateral vocal fold steroid injection in the area of the vocal fold scar. Histopathologic evaluation revealed the presence of human papillomavirus. Two months following her surgery, her voice was still moderately hoarse. A laryngeal examination demonstrated recurrent bilateral vocal fold masses that were consistent with papilloma.

This case illustrates the need for caution in the diagnosis and management of vocal fold lesions commonly grouped in the category of vocal fold nodules. In this patient's management, the focus on vocal quality and patient satisfaction will remain paramount. However, she now will require regular surveillance for any recurrence of papillomata, viral typing at the time of any future surgery, and close followup to ensure that she does not develop laryngeal cancer.