Vocal Fold Cyst: Causes and Cures

Significance Statement

Vocal fold masses are common for professional voice users, but with early intervention through voice therapy and proper voice care, they can often be managed or prevented. When necessary, surgery can provide relief and improve voice function, but prevention remains the best strategy for maintaining vocal health.

This 32-year-old female music teacher and mezzo-soprano professional singer presented with a 2-year history of dysphonia, throat pain, and heartburn. Those symptoms had begun suddenly during her pregnancy. While pregnant, she conducted virtual music lessons due to COVID-19. That created substantial voice strain, which was exacerbated by her voice misuse.

Her voice complaints included voice fatigue and difficulty accessing her middle and upper range, which impaired her singing. Despite experiencing gradual recovery over time, she remained unsatisfied with the quality of her voice. She admitted to not taking singing lessons regularly and to not using warm-up and cool-down voice exercises, although she knew that she should.

Strobovideolaryngoscopy showed a right vocal fold cyst and a reactive lesion on the left vocal fold, both contributing to glottic insufficiency (Figure 1).

Figure 1.

This is a strobovideolaryngoscopy view of a right vocal cyst with a left reactive mass, prior to surgical intervention. There is no obvious scar at the base of the cyst, but arytenoid erythema consistent with reflux is present.

Despite seeking care from multiple otolaryngologists and undergoing voice therapy and reflux management, she remained unhappy with her voice quality and endurance. Ultimately, surgical intervention was recommended. Both vocal fold masses were excised, and a right homograft fascia implant was placed to improve vocal fold closure. She resumed voice therapy after surgery and has had essentially-normal voice for more than a year following her procedure.

Vocal fold cysts are common and particularly troublesome for professional voice users, especially singers, actors, voice teachers, and others who rely heavily on their voice for their careers.^1,2 Vocal fold masses can develop from voice misuse, poor vocal techniques, and excessive voice strain over time, as illustrated in the case of the 32-year-old mezzo-soprano music teacher, as well as from other causes of phono-trauma. Our patient’s voice symptoms began when she was subjected to intense voice use during pregnancy, compounded by the demands of virtual teaching during the COVID-19 pandemic. These factors, along with a history of previous and ongoing voice abuse, led to the trauma that caused her vocal fold cyst.

The patient did not follow recommended voice care practices consistently, such as proper warm-ups and cool-downs. Pregnancy-related changes, along with associated increased reflux and the voice demands of virtual teaching, contributed to her voice fatigue and dysphonia. ³

Management of vocal fold masses typically begins with voice therapy and medical management of related conditions such as reflux. Voice therapy focuses on retraining the individual to use the voice more efficiently, utilizing techniques that reduce trauma to the vocal folds. Voice therapy can lead to substantial improvement without the need for surgery.^4,5 For this patient, however, despite undergoing voice therapy and reflux management, her voice did not return to the level she desired until she underwent surgery followed by additional voice therapy.

Prevention is key to reducing the risk of vocal fold masses in professional voice users. Proper voice techniques and good vocal hygiene practices are crucial. ⁶ Proper hydration, avoiding vocal misuse (such as prolonged improper singing technique, and yelling or speaking loudly), and managing underlying conditions such as reflux are also important preventive measures.

This case highlights the importance of vocal hygiene, especially for professional voice users, and the complex interaction between voice strain, physical health conditions (such as pregnancy), and the impact of inadequate voice care. ⁷ Despite conservative treatments and therapy, surgical management became necessary to restore both her voice function and quality of life.