Vocal fold pseudocysts are phonotraumatic lesions, developing from mechanical stresses from voicing in the presence of glottic insufficiency. They may occur unilaterally or bilaterally — presentations which have generally been assumed to represent the same phonotraumatic injury process. While unilateral vocal fold pseudocysts have been thought to result from vocal fold paresis (weakness), no explanation has been proposed for bilateral lesions. In a new study published in The Laryngoscope, laryngologists from NewYork-Presbyterian and Weill Cornell Medicine analyzed patients with unilateral and bilateral vocal fold pseudocysts to gain insights into the pathogenesis of these lesions.
Their findings shed light on sex-based differences in the presentation of these lesions and associated paresis. Below, lead author Christine Clark, MD, a laryngologist in the Sean Parker Institute for the Voice at NewYork-Presbyterian and Weill Cornell Medicine, describes this study and its implications for clinical care.
Research Background
Vocal fold pseudocysts are benign lesions that may occur on one or both vocal folds. They are frequently encountered in vocal performers, who may be more attuned to subtle voice changes. Symptoms are adequately managed with voice therapy alone in about two-thirds of patients, though the lesions themselves persist. The remaining third undergo surgery, though the rate of recurrence after surgical treatment is up to 33%.
At the Sean Parker Institute for the Voice at NewYork-Presbyterian and Weill Cornell Medicine, our laryngologists see a high volume of patients with voice, swallowing, and airway complaints. Based on prior work by Dr. Lucian Sulica at our Institute, we knew that the bilateral variant of vocal fold pseudocysts tends to occur predominantly in females. While the unilateral variant is occasionally seen in females, we noticed it was occurring in a higher proportion of male patients. In addition, other studies have suggested that vocal fold paresis — a slight motion impairment in one of the vocal folds — may cause or at least be correlated with the unilateral variant. In our retrospective study, we analyzed sex-based differences in unilateral versus bilateral vocal fold pseudocysts and the relationship to vocal fold paresis for each type of lesion.
Research Methods and Key Findings
We examined patient demographics, laryngeal stroboscopic findings, management strategies, and treatment outcomes for 87 adults with unilateral and 109 with bilateral vocal fold pseudocysts evaluated between 2018 and 2023 at NewYork-Presbyterian and Weill Cornell Medicine.
The average age of the patients was 29-30 years. Seventy-six percent of them were vocal performers, and 87.8% were female. Bilateral pseudocysts occurred almost exclusively in women and with a relative absence of paresis. Men were more likely to have unilateral pseudocysts, which occurred often with the presence of paresis. Treatment was similar between patients with regard to the rates of voice therapy, surgery, and postoperative recurrence.
Although we generally approach vocal fold pseudocysts in the same way, it is clear that there are key differences in how and why they form and who is affected by them. This may inform future treatment decisions.
— Dr. Christine Clark
Future Implications
Our findings add to the understanding of the pathogenesis of vocal fold pseudocysts. They suggest that unilateral and bilateral lesions evolve differently, although they may share glottic insufficiency as a predisposing factor. In women, this is primarily caused by physiologic posterior insufficiency — generating bilateral, symmetric phonotraumatic
stress with bilateral, symmetric consequences.
Although we generally approach these vocal fold lesions in the same way, our findings suggest that there are key differences in how and why they form and who is affected by them, which may inform future treatment decisions.
Physicians should consider referring any patient with a voice change that persists for four weeks for evaluation by an otolaryngologist who can perform diagnostic laryngoscopy or laryngeal videostroboscopy. These tests are the gold standard for assessing the larynx in someone with voice changes.
