Phonomicrosurgery in performing artists has historically been approached with great trepidation, and vocal outcome data are sparse. The vocal liability of surgically disturbing the superficial lamina propria (SLP) and epithelium must be balanced with the inherent detrimental vocal effect of the lesion(s). A prospective investigation was performed on 185 performing artists who underwent phonomicrosurgical resection of 365 lesions: 201 nodules, 71 polyps, 66 varices and ectasias, 13 cysts, 8 keratotic lesions. 2 granulomas, 2 Reinke's edema, and 2 papillomas. Nearly all patients with SLP lesions reported improvement in their postsurgical vocal function. This subjective result was supported by objective acoustic and aerodynamic measures. All postsurgical objective vocal function measures fell within normal limits, including a few that displayed presurgical abnormalities. However, given the relative insensitivity of standard objective measures to assess higher-level vocal performance-related factors, it is even more noteworthy that 8 of 24 objective measures displayed statistically significant postsurgical improvements in vocal function. Such changes in objective measures mostly reflect overall enhancement in the efficiency of voice production. Phonomicrosurgical resection of vocal fold lesions in performing artists is enjoying an expanding role because of a variety of improvements in diagnostic assessment, surgical instrumentation and techniques, and specialized rehabilitation. Most of these lesions are the result of phonotrauma and arise within the SLP. Successful management depends on prudent patient selection and counseling, ultraprecise technique, and vigorous vocal rehabilitation. Furthermore, an understanding of the vocal function and dysfunction of this high-performance population provides all otolaryngologists who manage laryngeal problems with valuable information that they can extrapolate for use in their practices.
LangmaidSW. Langmaid on certain forms of vocal disability. Trans Am Laryngol Assoc1880; 2: 108–18.
2.
LangmaidSW. Submucous hemorrhage of the vocal cords. Trans Am Laryngol Assoc1897; 19: 17–23.
3.
KnightFI. Singer's nodes. Trans Am Laryngol Assoc1894; 16: 118–23.
4.
MillerFE. Corditis cantorum: A contribution to the study of the etiology, pathology, and treatment of singers' nodes, or nodules on the vocal cords. Trans Am Laryngol Rhinol Otol Assoc1903; 9: 185–214.
5.
MillerFE. An original research on the cause of vocal nodules. Trans Am Laryngol Rhinol Otol Assoc1906; 12: 96–118.
6.
LewinG. Allg Med Cent Zeit1861; 30: 654.
7.
ZeitelsSMSataloffRT. Phonosurgery: Considerations for the performing artist and voice teacher. J Singing1998; 54: 45–8.
8.
KirsteinA. Resume: autoscopy of the larynx and trachea (direct examination without mirror). Philadelphia, Pa: FA Davis Co, 1897: 57–8.
9.
ZeitelsSMVaughanCW. “External counterpressure” and “internal distention” for optimal laryngoscopic exposure of the anterior glottal commissure. Ann Otol Rhinol Laryngol1994; 103: 669–75.
10.
PriestREWesolowskiS. Direct laryngoscopy under general anesthesia. Trans Am Acad Opthalmol Otolaryngol1960; 64: 639–48.
11.
OertelM. Das laryngo-stroboskop und die Laryngo-Stroboskpische Untersuchung. Arch Laryngol Rhinol1895; 3: 1–16.
12.
HiranoM. Phonosurgery: Basic and clinical investigations. Otologia (Fukuoka)1975; 21: 239–442.
13.
HiranoM. Structure and vibratory behavior of the vocal fold. In: SawashimaMCooperF, eds. Dynamic aspects of speech production. Tokyo, Japan: University of Tokyo, 1977: 13–30.
14.
HiranoM. Phonosurgical anatomy of the larynx. In: FordCBlessD, eds. Phonosurgery. New York, NY: Raven, 1991: 25–41.
15.
IsshikiN. Phonosurgery: theory and practice. Tokyo, Japan: Springer-Verlag, 1989.
16.
StrongMSVaughanCW. Vocal cord nodules and polyps — The role of surgical treatment. Laryngoscope1971; 81: 911–23.
17.
BouchayerMCornutG. Instrumental microscopy of benign lesions of the vocal folds. In: FordCBlessD, eds. Phonosurgery. New York, NY: Raven, 1991: 25–41.
SataloffRTSpiegelJRHeuerRJ. Laryngeal minimicroflap: A new technique and reassessment of the microflap saga. J Voice1995; 9: 198–204.
20.
ZeitelsSMVaughanCW. A submucosal true vocal fold infusion needle. Otolaryngol Head Neck Surg1991; 105: 478–9.
21.
ZeitelsSM. Microflap excisional biopsy for atypia and microinvasive glottic cancer. Oper Techn Otolaryngol Head Neck Surg1993; 4: 218–22.
22.
ZeitelsSM. Premalignant epithelium and microinvasive cancer of the vocal fold: The evolution of phonomicrosurgical management. Laryngoscope1995; 105(suppl 67).
23.
ZeitelsSM. Laser versus cold instruments for microlaryngoscopic surgery. Laryngoscope1996; 106: 545–52.
24.
CoureyMSGardnerGMStoneREOssoffRH. Endoscopic vocal fold microflap: A three-year experience. Ann Otol Rhinol Laryngol1995; 104: 267–73.
25.
BastianRW. Vocal fold microsurgery in singers. J Voice1996; 10: 389–404.
26.
ZeitelsSM. Phonosurgery — Past, present, and future. Oper Techn Otolaryngol Head Neck Surg1998; 9: 179.
27.
ZeitelsSM. Phonomicrosurgery I: Principles and equipment. Otolaryngol Clin North Am2000; 33: 1047–62.
28.
ZeitelsSM. Atlas of phonomicrosurgery and other endolaryngeal procedures for benign and malignant disease. San Diego, Calif: Singular, 2001.
29.
CornutGBouchayerM. Phonosurgery for singers. J Voice1989; 3: 269–76.
30.
DikkersFG. Benign lesions of the vocal folds: histopathological aspects. Groningen, the Netherlands, Van Denderen, 1994: 32.
31.
VaughanCW. Vocal fold exposure in phonosurgery. J Voice1993; 7: 189–94.
32.
ZeitelsSM. A universal modular glottiscope system: The evolution of a century of design and technique for direct laryngoscopy. Ann Otol Rhinol LaryngolSuppl1999; 108(suppl 179).
33.
JacksonC. Peroral endoscopy and laryngeal surgery. St Louis, Mo: Laryngoscope Co, 1915: 77–88.
34.
HochmanIIZeitelsSM. Exposure and visualization of the glottis for phonomicrosurgery. Oper Techn Otolaryngol Head Neck Surg1998; 9: 192–5.
35.
HochmanIIZeitelsSMHeatonJT. Analysis of the forces and position required for direct laryngoscopic exposure of the anterior vocal folds. Ann Otol Rhinol Laryngol1999; 108: 715–24.
36.
BruningsW. Direct laryngoscopy, bronchoscopy, and esophagoscopy. London: Bailliere, Tindall, & Cox, 1912: 110–5.
37.
HochmanISataloffRTHillmanREZeitelsSM. Ectasias and varices of the vocal folds: Clearing the striking zone. Ann Otol Rhinol Laryngol1999; 108: 10–6.
38.
KassESHillmanREZeitelsSM. Vocal fold submucosal infusion technique in phonomicrosurgery. Ann Otol Rhinol Laryngol1996; 105: 341–7.
39.
GrayS. Vocal fold physiology: acoustic, perceptual, and physiological aspects of voice mechanisms. San Diego, Calif: Singular, 1989: 21–7.
40.
GraySDHammondEHansonDF. Benign pathologic responses of the larynx. Ann Otol Rhinol Laryngol1995; 104: 13–8.
41.
ZeitelsSMHillmanREBuntingGWVaughnT. Reinke's edema: Phonatory mechanisms and management strategies. Ann Otol Rhinol Laryngol1997; 106: 533–43.
42.
HochmanIIZeitelsSM. Phonomicrosurgical management of vocal fold polyps: The subepithelial microflap resection technique. J Voice2000; 14: 112–8.
43.
ColdenDZeitelsSMHillmanREJarboeJBuntingGSpanouK. Stroboscopic assessment of vocal fold keratosis and glottic cancer. Ann Otol Rhinol Laryngol2001; 110: 293–8.
RiceCC. When should singers having vocal disability be allowed to resume work?. Trans Am Laryngol Assoc1912; 34: 119–27.
46.
HolmbergEBHillmanREHammarbergBSoderstenMDoyleP. Efficacy of a behaviorally based voice therapy for vocal nodules: Progressive changes in voice quality and vocal physiology. J Voice2001; 15: 395–412.
47.
TitzeIR. Vocal fold physiology: frontiers in basic science. San Diego, Calif: Singular, 1993: 37–81.
48.
BishopJ. Experimental researches into the physiology of the human voice. Lond Edinb Philosoph Mag J Sci1836.
49.
TearneyGJBrezinskiMESouthernJFBoumaBEBoppartSAFujimotoJG. Optical biopsy in human urologic tissue using optical coherence tomography. J Urol1997; 157: 1915–9.
50.
BoumaBETearneyGJComptonCCNishiokaNS. High-resolution imaging of the human esophagus and stomach in vivo using optical coherence tomography. Gastrointest Endosc2000; 51: 467–74.
51.
RogersonARClarkKFBandiSRBaneB. Voice and healing after vocal fold epithelium removal by CO2 laser vs. microlaryngeal stripping. Otolaryngol Head Neck Surg1996; 115: 352–9.
52.
BenningerMS. Microdissection or microspot CO2 laser for limited vocal fold benign lesions: A prospective randomized trial. Laryngoscope2000; 110(suppl 92).
53.
GraySDTitzeIRChanRHammondTH. Vocal fold proteoglycans and their influence on biomechanics. Laryngoscope1999; 109: 845–54.
54.
GraySDTitzeIRAlipourFHammondTH. Biomechanical and histologic observations of vocal fold fibrous proteins. Ann Otol Rhinol Laryngol2000; 109: 77–85.
55.
ChanRWGraySDTitzeIR. The importance of hyaluronic acid in vocal fold biomechanics. Otolaryngol Head Neck Surg2001; 124: 607–14.
56.
VacantiJPLangerR. Tissue engineering: The design and fabrication of living replacement devices for surgical reconstruction and transplantation. Lancet1999; 354(suppl): S132–S134.
57.
KambeyandaDSingerLCronkS. Potential problems associated with use of speech recognition products. Assist Technol1997; 9: 95–101.
58.
HaxerMJGuinnLWHogikyanND. Use of speech recognition software: A vocal endurance test for the new millenium?. J Voice2001; 15: 231–6.
59.
MacArthurCJKearnsGHHealyGB. Voice quality after laryngotracheal reconstruction. Arch Otolaryngol Head Neck Surg1994; 120: 641–7.
60.
SmithMEMarshJHCottonRTMyerCMIII. Voice problems after pediatric laryngotracheal reconstruction: Videolaryngostroboscopic, acoustic, and perceptual assessment. Int J Pediatr Otorhinolaryngol1993; 25: 173–81.
61.
FrancoisMDumontANarcyP. Longitudinal survey of voice quality after pediatric laryngotracheoplasty. Int J Pediatr Otorhinolaryngol1997; 40: 163–72.
62.
ZeitelsSMJarboeJFrancoRA. Phonosurgical reconstruction of early glottic cancer. Laryngoscope2001; 111: 1862–5.
63.
LehmanJJBlessDMBrandenburgJH. An objective assessment of voice production after radiation therapy for stage I squamous cell carcinoma of the glottis. Otolaryngol Head Neck Surg1988; 98: 121–9.
