A, Large (category 3); B, medium (category 2); C, small (category 1); D, resolved (category 0).
A, Hemorrhagic; B, organized; C, translucent.
Nearly half of the polyps that resolved did so within 3 months, and more than 80% of polyps that disappeared did so in 8 months. Only a small portion of polyps resolved after this time frame.
Jeong W, Lee SJ, Lee WY, Chang H, Ahn S. Conservative Management for Vocal Fold Polyps. JAMA Otolaryngol Head Neck Surg. 2014;140(5):448-452. doi:10.1001/jamaoto.2014.243
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Classically, surgery has been the mainstay of management for vocal fold (VF) polyps. However, a significant portion of patients experience spontaneous regression and may not require surgery.
To report the results of conservative management for VF polyps, identify patients with polyps that are more likely to resolve, and describe the time course of resolution.
Design, Setting, and Participants
In this case series of 248 patients with VF polyps conducted presenting to a tertiary referral center, 94 patients were treated conservatively with at least 3 months of follow-up. All laryngoscopy photodocumentation and medical records were reviewed retrospectively.
Conservative management with close follow-up.
Main Outcomes and Measures
Time course and resolution of VF polyps.
Of 94 VF polyps, 43 (46%) showed a clinically significant reduction in size, and 36 (38%) resolved completely without requiring surgery. Multivariate analysis showed that VF polyps were most likely to resolve in female patients and in those with small-sized polyp and shorter symptom duration. Of the resolved polyps, 44% and 81% were resolved at 3 months and 8 months, respectively.
Conclusions and Relevance
Selected patients with VF polyp may benefit from conservative management, especially female patients and those with small, recent-onset polyps. The majority of polyps that resolve do so within 8 months, which can assist clinical decision making and counseling.
Vocal fold (VF) polyps are one of the most commonly encountered benign lesions of the larynx. Although VF polyps are benign and nonneoplastic in nature; they may cause significant voice disturbances, often requiring surgical removal under general anesthesia. Considering the benign nature of the disease, conservative management could be considered. Classically, surgery is the preferred method of treatment in the majority of cases.1 Accordingly, only a small portion of laryngologists responded that they would implement conservative measures (voice therapy) as the first line of treatment for patients with VF polyp.2
In our practice, we noticed that a considerable number of VF polyps resolved with time. The observed time intervals occurred as a result of surgical wait times or patients choosing regular follow-up instead of surgery. Some recent studies have reported similar findings, and several of these have suggested the use of voice therapy for selected patients.3,4
In the present study, we aimed to demonstrate the feasibility of conservative management of VF polyps by observing their natural course. We also analyzed factors influencing spontaneous resolution of VF polyps and the time course for resolution. In doing so, we sought to practically implement our findings in clinical decision making.
The study was approved by the institutional review board of Seoul National University Bundang Hospital, which also approved the waiver of patient informed consent.
Our study group consisted of a consecutive case series of patients presenting to a tertiary care center catering to both referred patients and patients from the community. Between May 2003 and June 2012, 248 patients were diagnosed as having VF polyp. Included in this category were mid-membranous benign exophytic VF lesions, which would generally be accepted as a polyp. Any lesions in doubt of this typical finding were excluded from the analysis. Laryngoscopy results were documented in all clinical sessions and archived in the PACS (Picture Archiving and Communication System).
Follow-up intervals were usually 2 to 3 months apart but varied depending on patient preference and distance of the patient’s residence from the hospital. Patients who were followed up for at least 3 months with conservative management were included in the analysis. Laryngoscopy images were retrieved, and medical records were retrospectively analyzed. Reinke edema, other benign VF lesions (eg, cysts, nodules, contact granulomas), and paralyzed or immobile VFs were excluded from the study.
The size of the polyp was determined as follows (Figure 1): large (category 3), larger than one-third of the overall VF length; medium (category 2), smaller than one-third of the overall VF length; small (category 1), pinpoint size; and resolved (category 0). According to the size criteria, changes in polyp size were defined as follows: complete remission, no remnant polyp at the last follow-up (end point category 0); partial remission, decreased size but remaining lesion (category 3→2, category 3→1, category 2→1); and stable disease, no change or increased size category (partial remission and stable disease were grouped together in the persistent group).
The polyp morphology and color were also considered. Polyps were categorized as hemorrhagic, organized, and translucent (Figure 2). The reflux finding score (RFS) was evaluated with the initial laryngoscopy finding according to Belafsky et al.5 An RFS of 7 or higher was regarded as indicating a high possibility of laryngopharyngeal reflux.
Statistical analysis was performed using the PASW Statistics 18 program (IBM). A logistic regression model (Enter method) was used for multivariate analysis. A Kaplan-Meier plot was used to analyze the natural course and time-dependent outcome for VF polyps. P < .05 was considered statistically significant.
Among 248 patients with VF polyp, 94 were observed or managed conservatively for at least 3 months and 154 underwent surgery. The mean (SD) age was 56.62 (12.26) years and 50.83 (13.13) years for conservatively managed patients and patients undergoing surgery, respectively (P = .001). The male to female ratio was 1.29:1 and 1.83:1 for conservatively managed patients and patients undergoing surgery, respectively (P = .19). The median follow-up period was 7.2 months (range, 3-60 months), and the mean follow-up interval was 3.01 months for conservatively managed patients. Conservative measures included vocal hygiene, dietary and lifestyle modifications for laryngopharyngeal reflux, and proton pump inhibitors.
The initial size of the polyp was large in 21% of the cases, medium in 57%, and small in 22%. Hemorrhagic, organized, and translucent polyps accounted for 47%, 28%, and 25% of lesions, respectively. The RFS was 7 or higher in 78% of the cases. The polyp completely disappeared (complete remission) in 36 patients (38%), shrank (partial remission) in 7 patients (7%), and was persistent (stable disease) in 51 patients (54%). The improvement rate and resolution rate of polyps followed for more than 3 months was 46% and 38%, respectively.
Factors attributable to polyp resolution were analyzed using univariate analysis (Table 1). Female patients, patients with initial small polyp size, and patients with shorter symptom duration were more likely to have complete resolution of the polyp. These 3 attributes were valid by multivariate analysis (Table 2).
We also investigated the time-dependent course of VF polyps. Figure 3 represents the temporal distribution of spontaneous resolution of polyps. Of the 36 patients in whom the polyp had eventually disappeared, the polyp had resolved completely by the 3-month follow-up examination in 16 patients (44%) and by the 8-month follow-up examination in 29 patients (81%).
In our study, we were able to confirm that a considerable number of patients (46%) with VF polyps improved over time. Our results showed that female patients, patients with recent onset, and patients with small polyps were most likely to experience resolution of the lesion. Our findings are in concordance with the results of several other studies.4,6 Furthermore, our series demonstrated that the majority of polyps that resolve do so within 8 months from presentation.
Most of the literature regarding management of VF polyps focuses on surgical removal of the disease.6 Considering that general anesthesia and surgery itself is not without complications and that the cost and socioeconomic impact of surgery cannot be neglected, patients may benefit from avoiding unnecessary operations. However, only a small number of studies has addressed this issue to date.7
Several studies raised the possibility that immediate surgery may not be appropriate for all patients. Cohen and colleagues8 presented one of the first studies reporting the utility of voice therapy as the first line treatment for VF polyps. However, their report comprised both cysts and polyps and reported only the improvement of symptoms.
More-recent large case series focused on the utility of voice therapy as the main treatment strategy.6,9 Their primary end point was improvement in voice quality. In our series, we chose complete resolution of the polyp as the significant end point because we considered the decision for surgery a more important clinical issue than improvement of voice quality. Voice therapy was not prescribed in our series because of the limited capacity of our institution’s voice laboratory. Consequently, the possible confounding effect of voice therapy on the outcomes in the current case series could be eliminated, further validating our results. A recent review article by Garrett and Francis7 showed that voice therapy may or may not be important in the conservative approach for VF polyps. However, the role of voice therapy and vocal hygiene in any voice-related condition should not be overlooked. Hence, the role of voice therapy in the conservative management of VF polyps remains to be investigated.
Two recent reports call for detailed attention.3,4 Nakagawa and colleagues4 reported similar findings to those from our study. They conservatively treated 132 patients with VF polyp. After a mean duration of 5.1 months, 55 patients achieved complete resolution, while 29 patients experienced a reduction of their lesion after a mean duration of 4.1 months. The rate of resolution (41.7%) is comparable to our result (38.3%). They also found that female patients and patients with small-sized polyps and shorter duration of symptoms had a better chance of improvement with conservative management, which is in concordance with our findings. In addition, they reported that they did not detect an influence of voice therapy on patients in their case series. They concluded that VF polyps may be treated conservatively in selected patients.
Our study revealed an additional dimension of VF polyp resolution, the time course. In the clinic, 2 factors are important when counseling patients regarding their options. The first is identifying patients who would benefit by postponing surgery. The second requires determining, for patients who opt to postpone surgery, how long they should wait before reconsidering the operation. In our study, nearly half of all patients who eventually achieved complete remission had the polyp resolve within 3 months and 80% of them had the polyp resolve within 8 months. This is a significant finding that can be applied to patient counseling in the clinical setting. In a report by Klein and colleagues,3 although the numbers were small, polyps that eventually resolved did so within 9 months, which is in concordance with our data.
How some polyps regress is not clearly known, most probably because the phenomenon itself has not been well described. A possible explanation is that the interstitial material underlying the polyp undergoes resorption, which fits well with the finding that small polyps of recent onset have a better chance of resolving. Laryngopharyngeal reflux was prevalent in our case series; however, the laryngopharyngeal reflux itself or the use of proton pump inhibitors did not affect the natural course of the polyp. We have had patients with a pedunculated polyp who reported sudden improvement of voice following an episode of severe coughing. This may be due to mechanical removal of the polyp. However, it does not explain regression in most of the patients included in this series. The mechanism underlying spontaneous regression needs further investigation.
The major limitation of our study is the innate retrospective nature of the design. Patients undergoing conservative management may have been subject to selection bias. Moreover, patients were assigned to various conservative management schemes based on physical examination findings and concomitant conditions such as laryngopharyngeal reflux. Another limitation of this study is that voice evaluation results were not available. Vocal traits associated with polyp resolution could not be analyzed in this series. Despite the shortcomings, several significant factors were identified in the multivariate analysis, by which we could deduce a projected time frame for resolution of VF polyps. We believe that these data may serve as a basis for further prospective randomized studies.
In summary, 38% of the VF polyps resolved completely without surgery. Female patients and patients with recent onset and small polyps had a statistically significant tendency for spontaneous resolution. Hemorrhagic polyps were not associated with spontaneous regression. Of the polyps that spontaneously resolved, 44% and 81% did so at 3 and 8 months, respectively.
Watchful waiting for a limited course of time could be considered for selected patients with VF polyps. Our results show that the majority of polyps that spontaneously resolve do so within 8 months, which can assist in clinical decision making.
Corresponding Author: Soon-Hyun Ahn, MD, Department of Otorhinolaryngology–Head & Neck Surgery, Seoul National University College of Medicine, Seoul National University Bundang Hospital, 300 Gumi-dong, Bundang-gu, Seongnam 463-707, Korea (email@example.com).
Submitted for Publication: November 5, 2013; final revision received January 22, 2014; accepted February 5, 2014.
Published Online: March 27, 2014. doi:10.1001/jamaoto.2014.243.
Author Contributions: Drs Jeong and Ahn had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Jeong, Chang, Ahn.
Acquisition, analysis, or interpretation of data: Jeong, S. J. Lee, W. Y. Lee.
Drafting of the manuscript: Jeong.
Critical revision of the manuscript for important intellectual content: S. J. Lee, W. Y. Lee, Chang, Ahn.
Statistical analysis: Jeong, S. J. Lee.
Administrative, technical, or material support: W. Y. Lee, Ahn.
Study supervision: Chang, Ahn.
Conflict of Interest Disclosures: None reported.