Vocal Fold Pseudocyst: Results of 46 Cases Undergoing a Uniform Treatment Algorithm

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1 The Laryngoscope VC 2013 The American Laryngological, Rhinological and Otological Society, Inc. Vocal Fold Pseudocyst: Results of 46 Cases Undergoing a Uniform Treatment Algorithm Christine Estes, MM, MA; Lucian Sulica, MD Objectives/Hypothesis: To describe treatment results and identify predictors of the need for surgical intervention in patients with vocal fold pseudocyst. Study Design: Retrospective cohort study with longitudinal followup via survey. Methods: Clinical records were reviewed for demographic information, VHI-10 score, and degree of severity of dysphonia. Videostroboscopic examinations were evaluated for presence of vocal fold pseudocyst, along with additional clinical variables, including laterality, reactive lesion, paresis, varix, and hemorrhage. Follow-up surveys were sent to all participants to evaluate current VHI-10 score and degree of vocal limitation. Results were analyzed to determine predictors of surgery and recurrence of pathology. Results: Forty-six patients (41F:5M) with pseudocyst (40 unilateral: 6 bilateral) were reviewed. Twenty-three (50%) had reactive lesions, nineteen (41%) had paresis by clinical criteria, 10 (22%) had varices, and 6 (13%) had hemorrhage on examination. All underwent initial behavioral management (2 12 sessions of voice therapy; mean of 8 sessions). Seventeen (37%) eventually required surgical intervention. No demographic or clinical variables proved predictive of surgical intervention. Follow-up surveys were completed by 63% of patients, and 79% agreed with the statement that they were not professionally limited by their voices. Conclusion: This experience supports behavioral management as an initial intervention in patients with pseudocyst, sufficient by itself to restore vocal function in approximately two out of three patients. Neither initial severity nor any of the studied clinical findings predicted the need for surgery. The large majority of patients with pseudocyst are able to be treated effectively without impact in their professional function. Key Words: Pseudocyst, voice disorder, dysphonia, polyp, phonotrauma, vocal fold, vocal fold lesion, vocal fold paresis, vocal fold pseudocyst. Level of Evidence: 4 Laryngoscope, 124: , 2014 From the Sean Parker Institute for Voice Disorders, Department of Otolaryngology - Head and Neck Surgery, Weill Cornell Medical College, New York, New York, U.S.A Editor s Note: This Manuscript was accepted for publication September 23, Presented at the 2013 Meeting of the American Laryngological Association, Orlando, Florida, U.S.A,, April 9 10, The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Lucian Sulica, MD, Dept of Otolaryngology Head & Neck Surgery 1305 York Ave, 5th Floor, New York, NY lus2005@med.cornell.edu DOI: /lary INTRODUCTION A pseudocyst is a benign phonotraumatic lesion of the membranous vocal fold with a fusiform, translucent, blister-like appearance. 1 It is typically composed of a semisolid material beneath a thinned epithelium without the presence of a capsule. The latter feature distinguishes it from a cyst and results in its name. The term was initially used by Bouchayer et al. 2 in a study analyzing multiple benign lesions, and further characterized by Rosen et al., who note a relationship to paresis and other conditions of glottic insufficiency. 1 A pseudocyst, like other benign membranous vocal fold lesions, causes dysphonia by means of its mass effect. In general, symptoms are less severe and more variable than those of other lesions, such as hemorrhagic polyps, because the pseudocyst sometimes retains some pliability with phonatory vocal fold vibration and impacts vocal fold vibration relatively little. 1 Treatment recommendations range from voice therapy 3 to microsurgical removal 1 to medialization laryngoplasty, recommended by authors who believe that pseudocysts are invariably related to paresis. 4 As with many mucosal lesions, assessment of intervention is complicated by nonstandardized nomenclature. The same pathology has been referred to as paresis podule, 4 polyp, 3 unilateral nodule, localized Reinke s edema, 4 and polypoid degeneration in various publications a plethora of names that are often unclear and encourage the conflation of pseudocysts with other pathologies, principally hemorrhagic polyps or edema of Reinke s space. The current study seeks to clarify treatment recommendations for patients with vocal fold pseudocysts through a retrospective review of cases undergoing uniform treatment. On one hand, this study seeks to assess the efficacy of behavioral intervention in the treatment of vocal fold pseudocysts, defined as patient satisfaction with voice quality and return to vocational and avocational vocal demands without the need for surgical intervention. On the other, the study seeks to identify clinical

2 Fig. 1. A through F demonstrate examples of pseudocysts as discussed in this article. and demographic factors that predict the need for surgical intervention and potentially obviate behavioral management. MATERIALS AND METHODS The Weill Cornell Medical College Institutional Review Board approved this study. All patients with pseudocysts (Fig. 1) presenting to the laryngology service of an urban university medical center between January 1, 2010, and March 31, 2012, were identified from the senior author s (L.S.) database. Each patient underwent laryngeal videostroboscopy via transnasal flexible laryngoscopy or rigid transoral laryngoscopy as part of the initial evaluation process. The examination technique remained consistent for each patient across all visits. All patients were referred for behavioral management/voice therapy following definitive diagnosis. In some instances, a short period of vocal rest and/or medical management was required to reduce inflammation or hemorrhage before definite diagnosis of vocal fold pseudocyst could be made (Fig. 2). Voice therapy was provided by MA-, MS- or PhD-level certified speech-language pathologists specializing in voice disorders. Therapy consisted of education, vocal hygiene recommendations, relief of laryngeal or other maladaptive muscular tension, elimination of harmful vocal behaviors, breathing techniques, and/or motor learning of healthy vocal production. Such techniques were applied in functional contexts to aid in generalization. Patients were reassessed after a course of voice therapy (range: 2 to 12 weekly sessions; mean: 8 sessions). Patients who found that their symptoms remained limiting in their personal and professional voice use, and in whom significant further improvement was deemed unlikely by the treatment team of the speech-language pathologist and laryngologist, were offered surgical intervention. Surgery consisted of microlaryngoscopic removal of the pseudocyst and other mucosal pathology, but no other procedures. Pseudocyst removal consisted of epithelial incision at the superolateral border of the pathology, evacuation of pseudocyst contents, and epithelial redraping with removal of excess material. After surgery, patients were evaluated according to usual protocol at our center at 1 week (end of voice rest), 1 month, and 3 months. They were then discharged from regular visits with instructions to return in case of voice change lasting more than 1 week. Postsurgical follow-up data and examinations were reviewed to determine if there was a recurrence of the pseudocyst or presence of a new pathology. Medical records were reviewed to identify demographic information including gender, age, and occupation, along with pretreatment Voice Handicap Index 10 (VHI-10) scores to quantify the degree of impairment the pathology created in the patient s day-to-day life. The initial stroboscopic examination (or the diagnostic examination, for those patients whose diagnosis was made on subsequent visits) with audio for each patient was re-reviewed blindly by the treating laryngologist in order to verify diagnosis along with other clinical variables. These included the presence/ absence of a contralateral reactive lesion (as opposed to bilateral pseudocysts) (Fig. 3), paresis (contralateral, ipsilateral), varix (contralateral, ipsilateral, bilateral) (Fig. 4); and hemorrhage (contralateral, ipsilateral) (Fig. 5). Paresis was identified clinically based on specific criteria. In order from those of greatest to least importance, these were: 1) atrophy, as demonstrated Fig. 2. An example of a patient who required a brief period of medical management and voice rest prior to definitive diagnosis. This 29-year-old musical theater performer presented with acute hemorrhage (Fig. 2A). Only after 10 days was it possible to diagnose the pseudocyst, in this case with bilateral varices (Fig. 2B). 1181

3 Fig. 3. A C. Three examples of patients with pseudocysts and contralateral lesions. Fig. 4. A C.Three examples of varices. Figure 4A shows a point varix within the pseudocyst itself. Figure 4B shows a linear varix on the opposite vocal fold (as well as a very small reactive lesion). Figure 4C shows two varices lateral to the pseudocyst. by vocal fold thinning and/or dilatation of the ventricle; 2) unilateral ventricular fold hyperfunction; 3) presence of a contact lesion; 4) impaired adduction; 5) phase difference/asymmetry of the mucosal wave; and 6) glottic axis deviation (Fig. 6). Each patient s reported level of satisfaction and ability to resume voice use for professional and avocational purposes were reviewed. These were determined through patient report at the time of completion of voice therapy, as well as through a follow-up survey process. This survey consisted of the VHI-10 and follow-up questions generated to evaluate degree of functional impairment, mainly with regard to profession, experienced posttreatment (Table I). An Analysis of Variance (ANOVA) was performed to assess associations between variables and the main outcome measure. Additional chi-square analysis was performed to determine if the severity of dysphonia or VHI-10 score correlated with choice of surgery. RESULTS Forty-six patients with a diagnosis of vocal fold pseudocyst were identified. Forty-one participants were female (89%) and five participants were male (11%). The mean age was 28.5, with an age range of 18 to 67. Thirty-seven of forty-six patients involved in this study were professional performers or full-time performing arts students, and an additional five patients had professions that would be characterized as vocally demanding, including two teachers, two attorneys, and one customer service telephone operator. The remaining four participants stated that their careers were not vocally demanding; however, they noted that there was some degree of limitation in terms of voice use vocationally and avocationally. The mean VHI-10 score of participants was 14.6 (of 40), ranging from 0 to 37. The degree of dysphonia based on audio-perceptual assessment was classified in the categories of normal, mild, moderate, and marked. Nine patients (19.6%) were evaluated as having to have normal voice, 21 patients (45.6%) had mild dysphonia, 13 (28.3%) patients had moderate dysphonia, and three (6.5%) patients had marked/severe dysphonia. Seven patients (15.2%) required voice rest and/or medical management before a definitive diagnosis of vocal fold pseudocyst could be made. In these cases, edema, hemorrhage, mucosal thickening, or excessive secretions as a process of inflammation obscured the view of the mucosal lesion(s), so follow-up was required after the inflammation was managed in order to make a clear diagnosis. All patients who required such Fig. 5. A C. Three examples of hemorrhage. Figure 5A shows a hemorrhage limited to the base of the pseudocyst. Figure 5B shows a more generalized hemorrhage of the right vocal fold. It is the same patient as in Figure 2. Figure 5C shows a very subtle hemorrhage around the base of the left-sided pseudocyst. The discolorations on the right are varices. 1182

4 Fig. 6. A C. Three examples of paresis. Figure 6A shows atrophy of the left vocal fold with dilatation of the ventricle strongly suggestive of left-sided paresis. Figure 6B shows right ventricular fold hyperfunction and a dilated left ventricle suggestive of left paresis, as well as a resolving hemorrhage on the right. Figure 6C shows a dilated left ventricle. It goes almost without saying that most criteria for the diagnosis of pseudocyst are dynamic and are ill-represented in still images. treatment were seen within 6 to 11 days, at which time a definitive diagnosis of vocal fold pseudocyst was made. The presence or absence of given examination features identified in the initial clinical evaluation were compared to features identified in the blinded review, yielding 184 judgments (46 evaluations 3 4 characteristics); 160 were in agreement, yielding an intrarater agreement score of 87%. Forty patients (87%) were diagnosed with a unilateral pseudocyst and six patients (13%) were diagnosed with bilateral pseudocysts. Of the 40 patients diagnosed with a unilateral pseudocyst, 23 (57.5%) presented with a contralateral reactive lesion. Nineteen patients (41.3%) presented with clinical findings consistent with unilateral paresis at the time of initial evaluation, based on the aforementioned clinical criteria. Of this subset of patients, 16 patients presented with a unilateral pseudocyst (8 contralateral, 8 ipsilateral). The remaining three patients presented with unilateral paresis concurrent with bilateral pseudocysts. Ten patients (21.7%) presented with varices at the time of initial evaluation (4 contralateral, 4 ipsilateral, 2 bilateral). Six patients (13%) presented with a unilateral vocal fold hemorrhage at the time of initial evaluation (1 contralateral, 3 ipsilateral, 2 unilateral with bilateral pseudocysts). In two cases of recurrent hemorrhage, patients were actively recommended surgery independent of their baseline voice quality. These patients represent those who received fewer sessions of voice therapy prior to surgical intervention. Of all participants, 29 (63%) returned to voice use following treatment via voice therapy alone. Seventeen (37%) participants chose surgical intervention (1 male, 16 female). Of the 17 patients who chose surgical intervention, 2 (11.8%) patients experienced recurrence of a pseudocyst within a 2-year period. In one case, a female performer who originally presented with a unilateral pseudocyst with ipsilateral hemorrhage returned with bilateral pseudocysts approximately 2 years after surgery. In the other case, a male performer originally diagnosed with bilateral pseudocysts concurrent with ipsilateral paresis, and contralateral varix and hemorrhage, returned with a unilateral pseudocyst and hemorrhage approximately 2 years after surgery. Analysis via ANOVA was performed to determine whether there was a significant difference between patients who returned to voice use following voice therapy alone compared to those who chose surgical intervention in the context of demographic, audioperceptual, and diagnostic variables. Given the low number of male participants, gender was not separated for statistical analysis. Table II summarizes statistical findings. Additional chi-square analysis was performed to determine if the degree of dysphonia or the severity of VHI-10 score correlated with choice of surgical intervention. These findings are summarized in Table III. TABLE I. Posttreatment Survey Completed by Study Participants. The following questions refer to your experience since your last visit to weill Cornell Medical College (WCMC) Since my last visit to WCMC for my voice problem I can participate in my profession without Agree Somewhat Agree Neutral Somewhat disagree Disagree vocal limitation. I have experienced voice problems. Never Rarely Sometimes Often Constanty I missed_work days in the past year Never >7 due to my problem. I sought medical attention from a Never >5 non-wcmc ENT_times. I sought voice therapy with a non-wcmc therapist_times. Never >5 1183

5 TABLE II. Statistical Analysis of Variables Examined in Relation to Choice of Surgical Intervention (via ANOVA). Variable n Chose Surgery Did Not Choose Surgery P Value Occupation Performer (40.5%) 22 (59.5%) 0.61 Other vocally demanding 5 3 (60%) 2 (40%) Nonvocally Demanding 4 1 (25%) 3 (75%) Dysphonia Normal 9 2 (77.8%) 7 (22.2%) 0.61 Dysphonic (mild, moderate, (40.5%) 22 (59.5%) marked) VHI-10 Score* Normal 13 3 (21.1%) 10 (76.9%) 0.29 Abnormal (>11) (35.7%) 18 (64.3%) Laterality Bilateral 6 3 (50%) 3 (50%) 0.68 Unilateral (35%) 26 (65%) Concurrent Clinical Findings Reactive lesion 23 6 (26.1%) 17 (73.9%) 0.23 Unilateral paresis 19 7 (36.8%) 12 (63.2%) 0.18 Varix 10 8 (80%) 2 (20%) 0.68 Hemorrhage 6 4 (66.7%) 2 (33.3%) 0.7 *Note: VHI-10 data unavailable for five patients. VHI 5 Voice Handicap Index. Statistical analysis did not reveal a significant difference between patients who chose to undergo surgical intervention and those who returned to voice use following behavioral intervention at the 90% confidence interval level; however, of all variables analyzed, the presence of unilateral paresis was identified in a high number of patients presenting with pseudocysts, and it was the most predictive of surgical intervention. Additionally, vascular-related pathologies such as varices and hemorrhage were not observed in a high number of patients presenting with pseudocysts, but a high percentage of these patients eventually underwent surgical intervention. Of the 46 patients involved in this study, 29 (63%) patients completed a posttreatment VHI-10 and answered additional follow-up questions. VHI-10 scores decreased from the initial pretreatment mean of 14.6 to 8.4 (53.9%), indicating an overall improvement from pretreatment values that were maintained following the resolution of voice therapy and/or surgery. Scores ranged from 0 to 18. Patients who had undergone surgery had mean VHI-10 scores that were slightly lower than those who underwent behavioral intervention alone (6.2 and 9.1, respectively); however, both means fall within normal limits (VHI ). Four patients had VHI-10 scores above normal limits, two patients of whom had surgery and two patients of whom were treated solely via behavioral therapy. Responses to I can participate in my profession without limitation (since last visit) were as follows: 37.9% agree, 41.4% somewhat agree, 6.9% neutral, 13.8% somewhat disagree, 0% disagree, suggesting that most individuals are able to return to their professions with little-to-no vocal limitation. Responses were similar between patients who underwent surgery compared to those who participated solely in behavioral treatment. Responses to I have experienced voice problems (since last visit) included 27.6% never, 48.3% rarely, 24.1% sometimes, and 0% often or constantly. Again, patients who were treated via behavioral management alone provided responses similar to those who chose surgical intervention. When asked about days of work missed TABLE III. Chi-Square Analysis of Degree of Dysphonia and VHI-10 Score. Variable n Chose Surgery Did Not Choose Surgery P Value Degree of Dysphonia Normal 9 2 (77.8%) 7 (22.2%) 0.93 Mild 21 9 (42.9%) 12 (57.1%) Moderate 13 4 (30.8%) 9 (69.2%) Marked 3 2 (66.7%) 1 (33.3%) VHI-10 Score (of 41 patients)* (21.1%) 10 (76.9%) (31.6%) 13 (68.4%) (57.1%) 3 (42.9%) (0%) 2 (100%) VHI 5 Voice Handicap Index. 1184

6 due to voice problems, 75.9% of patients stated that they have never missed work due to a voice problem, while 24.1% stated that they missed work two to four times per year. Those who stated that they missed work two to four times per year only received behavioral treatment alone. All patients responded that they never saw an otolaryngologist other than the treating otolaryngologist involved in this study, and 6.9% of patients who responded stated that they sought voice therapy with an outside provider following completion of voice therapy at this institution. Of those who sought therapy elsewhere (2 patients), both were treated solely via behavioral management. DISCUSSION Vocal fold pseudocysts are a subset of benign lesions that have received limited specific attention in the laryngology literature. In their review, Koufman and Belafsky found that pseudocysts appear most commonly in females in their fourth decade. 4 The large majority of patients in the current study were also female, although younger. It appears that females are predisposed to vocal fold pseudocysts, although the reason is unclear. The high occurrence of pseudocysts with paresis noted by both Koufman 4 and Rosen et al. 1 suggests an explanation. It is possible that the posterior glottic insufficiency, which is normal and even characteristic in a subset of female larynges, functions as a sort of pseudo-paresis, creating analogous phonotraumatic stress that predisposes women to the formation of pseudocysts. Other demographic information, particularly concerning occupational voice demand, about patients with vocal fold pseudocysts is absent from the literature. In our study, the overwhelming majority of patients were performers. In part, this may be an artifact of social and geographic aspects of our practice, but it does suggest that performers are more likely to present with voice change due to pseudocyst. Whether this is due to a higher incidence in this patient group or simply to a higher likelihood to seek evaluation for voice changes that would go unnoticed in a nonperformer is not clear. We suspect the latter, based on the relatively mild voice disturbance from this lesion, as reflected in VHI scores and perceptual assessments. Many patients described in this study, including some who ultimately chose to undergo surgery for their vocal fold lesion, had VHI-10 scores in the normal range or had voice described as normal by audioperceptual assessment. However, all presented for evaluation because of their own perception of a voice problem. This problem may have involved one or more of several factors, including but not limited to voice quality, limitation of range, consistency, and/or stamina, and may have been restricted to singing voice. The VHI-10 generally performs poorly in the evaluation of a singing voice problem. 6 The clinicians audioperceptual determination of degree of dysphonia is typically derived from spoken voice use over the relatively short period of time that the patient is evaluated in the office; thus, it may also not adequately describe dysphonia in singing voice, the condition for which many of these patients sought medical attention, nor can it assess consistency and stamina over the course of one or more performances. Survey data reported by Rosen et al 1 reveals a common clinical opinion that pseudocysts are associated with glottic insufficiency (e.g., paralysis, paresis), and that there is a high rate of recurrence if this insufficiency is not addressed. Based on a study that included nine patients diagnosed with unilateral vocal fold pseudocysts, Koufman and Belafsky noted paresis as a frequent concurrent finding once all compensatory vocal behaviors (e.g., secondary muscle tension dysphonia) were removed. 4 The investigators also suggested that vocal fold medialization through surgical laryngoplasty and/or injection augmentation is necessary in order to prevent a recurrence following surgical removal. Results of the current study are broadly consistent with these views regarding the high prevalence of paresis, although paresis was not nearly as uniform a finding as it was in Koufman & Belafsky. We note, however, that only one patient with paresis experienced postsurgical recurrence. This patient also presented with several other concurrent clinical findings, including vocal fold hemorrhage; therefore, it is difficult to determine the importance of paresis in the recurrence. Although surgical recurrence is not the principal focus of this study, it appears that the vast majority of patients did not require medialization or augmentation to prevent recurrence, even though they all returned to their previous level of vocal demand. Surgical outcomes are currently the subject of a prospective investigation at our center. In this study, vocal fold paresis was determined by the presence of certain clinical features rather than laryngeal electromyography (LEMG) findings. This reflects clinical practice in our center, based on our belief that LEMG lacks sensitivity for this diagnosis. This in turn is informed principally by our experience of symptomatic improvement after trial injection augmentation in patients with clinical features and symptoms of vocal fold paresis but with normal LEMG findings. Neuromuscular pathophysiology offer potential explanations for this phenomenon. In paresis, as opposed to paralysis, frankly abnormal findings such as fibrillations, positive sharp waves, and polyphasic motor unit action potentials may not be present at all, or if present, may not be discernible against the signal of preserved muscle activity. Furthermore, maximal interference pattern in striated muscle is typically present at only 30% of maximal isometric contraction, 7 leaving open the possibility that even fairly substantial paresis may be completely overlooked by electromyography. Thus, while LEMG specificity for vocal fold paresis is almost certainly very high, its sensitivity is probably less and potentially quite low. While the omission of LEMG is a potential source for error in our assessment, we suggest that dependence on LEMG may overlook many cases of paresis. Further investigation is certainly needed on this clinically relevant issue. Cohen and Garrett 3 studied the behavioral management of a variety of benign phonotraumatic lesions. Their description of a translucent polyp as a polyp 1185

7 filled with edematous-appearing fluid, along with a supporting photographic example, appears consistent with vocal fold pseudocyst. They noted that patients with translucent polyps had an 81.8% response rate to voice therapy, a significantly higher response than those with what they designated as other types of vocal fold polyps (25% for hemorrhagic polyps, 15.4% for fibrotic, hyaline polyps). This is in contrast to the flat assertion of Rosen et al. 1 that pseudocysts do not respond to voice surgery and invariably require surgery. We find that pseudocysts are generally responsive to behavioral management; only one out of three patients ultimately felt it necessary to undergo surgery. It is important to understand, though, that the pseudocyst does not resolve with voice therapy. Behavioral management simply offers patients the insight and tools to manage their voice use and other inflammatory factors such that the pseudocyst does not result in meaningful limitations in their voice use. As most patients in the current study are performers whose vocal demand was significant, this is not a negligible result despite the persistence of the lesion in examination. Thus, in common with the study of Cohen and Garrett, 3 our study supports the role of behavioral intervention as the initial intervention in patients with vocal fold pseudocysts, along with any necessary medical treatment. Responses from follow-up surveys further support that behavioral intervention is effective for most individuals presenting with vocal fold pseudocyst, and only the minority require surgical intervention to return to functional and professional voice use. Because pseudocysts are closely associated with conditions of glottic insufficiency, the suggestion that behavioral management is in many cases effective in addressing mild glottic insufficiency and its consequences is implicit in these results. This subject requires focused study on its own, of course. The secondary aim of the current study was to determine if other factors, including perceived degree of dysphonia, pretreatment VHI-10 scores, or concurrent clinical findings including laterality, reactive lesion, paresis, varix, and hemorrhage were predictive of the need for surgical intervention. Statistical findings were not significant for any factors, although there is some suggestion that patients presenting with varices/hemorrhage are more likely to require surgical intervention. A larger sample size would be necessary to determine if presence of vascular-related pathologies has any statistical significance related to surgical need. Information from the current study would be enhanced by prospective study of a larger sample with the addition of acoustic and aerodynamic measurements and standardized behavioral treatment protocols. CONCLUSION Most patients presenting with vocal fold pseudocysts, including performers and other professional voice users, are likely to return to voice use without significant limitation following behavioral management alone, given an appropriate course of therapy and adherence to recommendations. Neither initial degree of dysphonia nor occupational demand, nor any of the studied examination findings namely hemorrhage, paresis and contralateral lesions, predicted the need for surgical intervention. BIBLIOGRAPHY 1. Rosen C, Gartner-Schmidt J, Hathaway B, et al. A nomenclature paradigm for benign midmembranous vocal fold lesions. Laryngoscope 2012;122: Bouchayer M, Cornut G, Witzig E, Loire R, Roch JB, Bastian RW. Epidermoid cysts, sulci, and mucosal bridges of the true vocal cord: a report of 157 cases. Laryngoscope 1985;95: Cohen S, Garrett CG. Utility of voice therapy in the management of vocal fold polyps and cysts. Otolaryngol Head Neck Surg 2007;136: Koufman J, Belafsky P. Unilateral or localized Reinke s edema (pseudocyst) as a manifestation of vocal fold paresis: The paresis podule. Laryngoscope 2001;111: Arffa RE, Krishna P, Gartner-Schmidt J, Rosen CA. Normative values for the Voice Handicap Index-10. J Voice 2012;26: Rosen CA, Murry T. Voice handicap index in singers. J Voice 2000;14: Campbell WW. Needle electrode examination. In Campbell WW, Essentials of electrodiagnostic medicine. Baltimore, MD: Williams & Wilkins; 1999: