Anterior Vocal Fold Scar

Significance Statement

The musculomembranous portion of the vocal folds is involved with phonation. Vocal fold scar is the replacement of the layered epithelium of the vocal folds with fibrous tissue. This can result from inflammatory, infectious, traumatic, and other processes. Scar of the anterior portion of the vocal fold results in a reduction of the mucosal wave. This can be detrimental to voice quality and is difficult to treat successfully.

Anterior Vocal Fold Scar

This 63-year-old female with frequent voice use as a teacher and singer presented with hoarseness intermittently over 20 years. Throughout that time, she was diagnosed with multiple laryngeal pathologies including benign vocal fold masses, glottic insufficiency, vocal fold ectasia, and vocal fold scar. These problems were thought to be secondary to a combination of chronic voice abuse/misuse, uncontrolled laryngopharyngeal reflux, and poor vocal hygiene. She was managed initially with voice therapy and anti-reflux medications, but her symptoms persisted. She had several microlaryngeal surgical procedures to address her pathologies with temporary relief in hoarseness followed by gradual return. On exam in the office, she was noted to have a bilateral vocal fold scar, right greater than left. She was treated with a set of 5-FU injections and then a set of FloGraft (Applied Biologics, Scottsdale, AZ) injections. The patient reported improvement in her voice sustained during 1 year of follow-up after these interventions. There was also an improvement in vocal fold stiffness on videostroboscopy (Figure 1).

Figure 1.

Showing anterior vocal fold scar.

Discussion

The true vocal folds are made up of several layers: squamous epithelium, superficial, intermediate, and deep layers of lamina propria, and the thyroarytenoid muscle. ¹ Vocal fold scar is fibrous tissue deposition in the lamina propria that results in poor vibratory function of the mucosa and often glottic insufficiency. ² This is often due to repeated poor voice use, and it can be due to iatrogenic injury from laryngeal surgery. Several interventions have been used to address vocal fold scars depending on the clinical presentation of the patient. These include voice therapy, anti-reflux medications, autologous fat augmentation, injection of collagen-based materials, medialization procedures, and others.^3,4 FloGraft is an allograft acellular matrix containing amniotic membrane and growth factors that can create a biological environment to promote tissue healing. This can be injected into the scar to help promote the growth of healthy tissue. The chemotherapy drug 5-fluorouracil (5-FU) helps to inhibit the proliferation of fibroblasts ⁵ and is useful in the treatment of scar tissue. This patient reported improvement in symptoms of hoarseness and overall satisfaction with voice after treatment with a course of both 5-FU and FloGraft injections. Improvement also was noted on stroboscopy which revealed less vocal fold stiffness. This intervention led to acceptable outcomes without the need for more aggressive treatment such as scar resection or fat implantation.