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| CASE REPORT |
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| Year : 2022 | Volume
: 17
| Issue : 4 | Page : 963-965 |
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An unusual cause of vocal fold cyst in a 15-year-old boy
Santosh Kumar Swain1, Debasmita Dubey2
1 Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
2 Medical Research Laboratory, IMS and SUM Hospital, Siksha “O” Anusandhan University, Bhubaneswar, Odisha, India
| Date of Submission | 27-Jul-2022 |
| Date of Decision | 14-Sep-2022 |
| Date of Acceptance | 16-Sep-2022 |
| Date of Web Publication | 10-Feb-2023 |
Correspondence Address:
Prof. Santosh Kumar Swain
Department of Otorhinolaryngology and Head and Neck Surgery, IMS and SUM Hospital, Siksha “O” Anusandhan University, K8, Kalinga Nagar, Bhubaneswar - 751 003, Odisha
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jdmimsu.jdmimsu_331_22
Vocal fold cysts are benign lesions of the larynx. Vocal fold cysts can be unilateral or bilateral and often confused with vocal nodules, particularly when symmetrical. The most common clinical presentation of this lesion is hoarseness of voice. The vocal fold cyst is usually secondary to vocal abuse. Endoscopic examination or videostroboscopy is an important tool for clinical confirmation of the vocal fold cyst. Transoral microlaryngeal surgery followed by speech therapy is an ideal treatment option for vocal fold cysts. Playing with a flute for a prolonged period is rarely reported with vocal fold cyst. Here, we report a case of true vocal fold cyst I in a 15-year-old boy who regularly practices flute.
Keywords: Dysphonia, flute, microlaryngeal surgery, vocal fold cyst
How to cite this article:
Swain SK, Dubey D. An unusual cause of vocal fold cyst in a 15-year-old boy. J Datta Meghe Inst Med Sci Univ 2022;17:963-5 |
| Introduction | |  |
The vocal fold cysts are common laryngeal lesions found in routine clinical practice.[1] These benign laryngeal lesions are a significant contributor to dysphonia.[1] The vocal fold cysts are common in the adult age group, especially with high vocal overuse; however, these lesions can also be seen in children.[1] The histological study of the mucous cysts shows that the lining of the vocal cyst is covered by the ciliated columnar epithelium.[2] The vocal fold cysts are classified into two subtypes such as epidermic or mucous retention cysts. Endoscopic examination or videostroboscopy is a very useful tool toward the diagnosis of cystic lesions of the vocal fold. The wave of the vocal fold mucosa is decreased and even not seen over the cystic lesion, an important characteristic of the vocal fold cyst.[3] Microlaryngeal surgery under general anesthesia with microflap excision of the cyst wall and contents is the usual course of treatment for vocal fold cysts.[4] There are several causes of vocal fold cyst including the important one, overuse of voice.[5] Flute players are reported with the presentation of vocal fold cyst. Here, this case report presents with vocal fold cyst in a 15-year-old flutist.
| Case Report | | |
A 15-year-old boy visited the otorhinolaryngology clinic and presented with change in voice since 1 month. Parents of the child told no evidence of breathing difficulty or difficulty in swallowing by the child during the past 1 month. He had no addiction to smoking and alcohol. He had no history of thyroid diseases and no other systemic diseases. He was a student in his profession and practicing flute for the past 5 years. Fiberoptic nasopharyngolaryngoscopy examination of the larynx showed a smooth pale-colored soft tissue attached to the left vocal fold at the anterior one third. The anterior commissure was unaffected, and there was no involvement of the supraglottic region. The right vocal fold was completely normal. There was no evidence of cervical lymphadenopathy. The larynx as a whole was within the normal limits; however, the bilateral vocal folds were totally movable. A contrast-enhanced computed tomography scan of the neck [Figure 1] revealed thickening of the left vocal fold and a mass that protruded inferomedially from the anterior aspect of the left vocal fold, but no involvement of the anterior commissure, paraglottic space, and no neck node enlargement. A clinical diagnosis of the left fold cyst was made, and the patient was undergoing microlaryngeal surgery under general anesthesia. The vocal fold cystic mass was exposed after fixing the microlaryngoscope. The intraoperative endoscopic picture showed the left vocal fold cyst [Figure 2]. The cyst was completely excised from the left vocal fold with a single shot fired from CO2 LASER (Light amplification by stimulated emission of radiation). The cyst was sent for histopathological study and confirmed the diagnosis of vocal fold cyst. The patient's symptoms eased, and a fiberoptic nasopharyngolaryngoscopy revealed that the vocal fold cystic lesion had disappeared. After a checkup 6 months later, he had no symptoms at all. | Figure 1: CT scan of the neck showing the left vocal fold cyst. CT: Computed tomography
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| Discussion | | |
Vocal fold cysts are benign vocal fold lesions and are common in adult females.[6] This is probably due to the larger number of adult females are in the teaching profession and a higher preoccupation with vocal performance.[7] The vocal fold cyst can be either mucous retention or epidermoid cysts. Epidermoid cysts are believed to develop from squamous epithelium invagination, either congenitally or as a result of phonotrauma.[8] The mucous retention cysts are associated with blockage of the ducts of the mucous gland that may be occurred due to inflammatory or phonotraumatic causes. Although they can induce contact swelling on the opposite side, the vocal fold cysts are typically unilateral, but can also be bilateral and are first frequently misinterpreted as vocal fold nodules. In this case, the vocal fold cyst is found on the left side and mild contact swelling in the contralateral side. The retention cyst, which develops when a glandular excretory canal is blocked, is lined by cuboidal or flattened epithelium, and the malformation cyst is lined by ciliated pseudostratified or squamous epithelium. The vocal fold cyst is frequently found in the superficial layer of the lamina propria.[9] Vocal fold cysts are often found in association with other lesions of the larynx, especially with minor structural lesions. There are association of the vocal fold polyps in 25% cases of the vocal fold cysts.[10] When a vocal fold cyst is accompanied with early hemorrhage and causes bilateral vibratory interference, it frequently protrudes into the vibratory margin, increases the mass of the cover, and occasionally increases stiffness.[11] The majority of vocal fold cysts are retention cysts and are typically brought on by damage to the mucous gland duct.[11] Acquired vocal fold cysts may have glandular, ciliary, or oncocytic epithelial linings. Congenital cysts frequently have squamous or respiratory epithelial lining and are epidermoid in nature.
Voice abuse is an important etiology for causing a vocal fold cyst. Flutists often produce certain continuous humming sounds inside the larynx and vibrate the vocal fold. This overuse of voice that causes excess vocal fold vibration over years can result in pathological changes like a cyst on the vocal fold.[12] Young flute players often play flute in high tones that may produce a thin, shrill, and sharp quality sound in the glottic airway. This type of sound for a prolonged period of years can result in vocal fold pathologies like a vocal nodule or vocal fold cysts.[12] The flute is one of the oldest and most popular instruments in the history of music. It is about two feet long, initially made of wood and nowadays is made of silver or gold. It seems to be a long, thin tube with many openings. To produce sound, the flutist blows air across the mouthpiece's tiny hole. Symptoms vary with vocal fold size and age of the patient. Hoarseness and dyspnea are common symptoms in vocal fold cysts. The patient often presents with a change of voice at an early stage of the lesion, making them easily recognizable even when the very small size of 5 mm.[2] The vocal fold polyp, vocal nodule, reactive lesion, malignant lesion, and rheumatological lesions of the vocal fold are among the differential diagnoses of vocal fold cyst.[13]
The indirect laryngoscopy, rigid angled endoscopic examination, fiberoptic nasopharyngolaryngoscopy, and videostroboscopy are helpful for the diagnosis of the vocal fold cyst. In videostroboscopy, a significant reduction of the mucosal waves is seen on the lesion of the vocal fold.[7] Early diagnosis is often crucial for preventing this morbid clinical entity. The treatment of the cyst of vocal fold is conservative with speech therapy and the elimination of risk factors in the early stage of the lesion.[7] If the conservative treatment fails or larger size vocal fold cyst, microlaryngeal surgery is required. In this case, the patient underwent laser-assisted microlaryngeal surgery for complete excision of the vocal fold cyst followed by postoperative speech therapy. Speech therapy followed by surgery is very effective to get a normal voice early. Although vocal fold cyst requires surgical intervention, some need speech therapy for 4–6 weeks.[14] However, the patient underwent microlaryngeal surgery and biopsy in case of failed conservative treatment like speech therapy. The cystic lesion was excised, and the speech therapy was started after surgery with significant improvement of voice and complete resolution of hoarseness of voice. The laser is a useful technique that removes the cyst with its epithelium or removes the cyst with preservation of the epithelium. To stop a recurrence, the vocal fold cyst's sac needs to be removed.[9] Misdiagnosis and insufficient care can result in compromised vocal fold function and voice impairment. The patient in this case report illustrated the significance of considering a diagnosis before treating this case by demonstrating a vocal fold cyst in a healthy adolescent with a job as a flute player. Vocal fold cysts could develop as a result of prolonged flute playing.
| Conclusion | | |
Cyst in the vocal fold of the larynx is a common clinical entity among professional voice abusers. Cyst of the vocal fold is a rare incidence, specifically among the flute players. The causative agent is often due to prolonged playing of the flute, which may be an important etiology behind the development of the vocal fold cyst. The vocal fold cyst is simple to identify and treat. Hoarseness of voice is a common symptom in patients with vocal fold cysts. Playing with a flute for a long period can result in development of the vocal fold cyst. Appropriate vocal hygiene should be maintained by the professionals playing flute. Awareness of the early identification of this pathological lesion like vocal fold cyst is essential in a flute player as the management needs an accurate diagnosis and cessation of risk factors. The treatment of vocal fold cyst requires microlaryngeal surgery for its complete removal.
Ethical issues
Written informed consent has been taken from the participating patient.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published, and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.
Takeaway points
The laser is a useful technique that removes the vocal fold cyst with its epithelium or removes the cyst with preservation of the epithelium.
To stop a recurrence, the vocal fold cyst's sac needs to be removed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
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