Literature Review
To make the present review more didactic, the findings are presented according to
the topics described in the previous paragraph.
1. Prevalence
Regarding the prevalence of laryngeal diseases, Woo et al[17] conducted a study in South Korea that found abnormal laryngoscopic results in 1.96%
of the population. Vocal polyps were the second most prevalent laryngeal lesion (0.3–0.6%),
after vocal nodules (1.0–1.7%). The authors found no significant differences in age
range or gender for any of the lesions.
Considering only the study population, several articles reported a predominance of
vocal polyps in women.[2]
[6]
[18]
[19]
[20]
[21] The authors explain that this predominance is due to the greater discomfort caused
by vocal changes and the consequent increase in medical visits by women,[18]
[19] anatomic differences between genders,[20] or vocal behaviors inherent to each culture.[21]
Klein et al,[15] reported a higher prevalence of hemorrhagic vocal polyps in men (69.0%; mean age
of 48.3 years old) than in women (31.0%; mean age of 39.6 years old). The greater
difference in incidence between genders in patients with polyps, according to the
literature, was 71.3% in men and 28.7% in women, aged between 17 and 59 years old
(mean of 42.1 ± 10.4 years old).[22]
Also, in terms of vocal polyp prevalence in relation to gender, a recent study that
characterized benign vocal fold lesions demonstrated a predominance of vocal polyps
in male patients (55.1%), in a sample of 147 participants (p < 0.0001). The authors reported that mechanical strain generated during the characteristic
production of low-pitched sounds in men occurs in deeper parts of the lamina propria,
causing the rupture of blood vessels and hemorrhage, predisposing them to vocal polyps.[23]
Filho et al[24] analyzed the characteristics of vocal polyps in patients submitted to laryngeal
surgery and found 67.7% of angiomatous polyps and 32.3% of gelatinous polyps (54.8%
in men and 45.2% in women). The following results were significant: predominance of
angiomatous polyps in men (65.1%) and of gelatinous polyps in women (66.7%); frequency
of mid-sized angiomatous (68.2%) and small gelatinous polyps (56.7%); location of
angiomatous polyps in the middle third of the vocal fold (51.4%) and of gelatinous
polyps in the posterior third (36.7%); greater occurrence of minor structural alterations
(MSAs) in the vocal fold cover in angiomatous polyps (47.6%) compared with their gelatinous
counterparts (20.0%); and the predominance of both types in the right vocal fold (p = 0.009).
2. Etiology
The main etiology of polyps is phonotraumatic. Individuals inadequately using or abusing
their voice, whether by talking excessively or at high intensity, are more susceptible
to developing morphological changes in the vocal folds, which favors the emergence
of lesions.[25]
The etiological relationship between smoking and vocal fold polyps has been widely
studied. Some authors consider smoking as the primary factor for the development of
vocal fold polyps, mainly when associated with vocal abuse.[22]
[26] Gnjatic et al[22] studied patients with vocal fold polyps and found that 67.5% of the subjects were
active smokers, and that vocal abuse was reported by 59.0% of the participants. According
to Effat et al,[26] vocal fold polyps in smokers are larger than those in non-smokers because tobacco
compromises the vocal fold epithelium and increases hyaline degeneration in the polyp.
Unilateral or bilateral vocal fold paresis has been described as the etiological factor
of vocal polyps. Akbulut et al[27] identified paresis in 48.6% of the patients with polyps, using laryngeal electromyography.
The neuropathy described was observed in the upper laryngeal nerves and/or in the
recurrent laryngeal nerve. The authors report that vocal fold paresis can generate
excessive forces in unaffected muscles to complete glottic closure, thereby causing
mechanical trauma to the vocal folds. Excessive mechanical trauma contributes to polyp
development and paresis can cause lesion recurrence in some patients. However, further
studies are needed, since the relationship between paresis and vocal fold polyps is
not fully understood.
Given the phonotraumatic aspect of vocal polyps, previous anatomic alterations in
the vocal folds, such as MSAs, may cause the emergence of hematomas and the development
of lesions. Several studies have reported minor structural alterations in patients
with vocal polyps, with a probable etiological relationship.[28]
[29]
[30]
The relationship between vocal polyps and MSA is fairly frequent. Sakae et al[28] identified the presence of MSA in 23,5% of the subjects diagnosed with vocal polyps
who were submitted to laryngeal surgery. Likewise, Eckley et al[29] found that 51,5% of the subjects with vocal polyps who were submitted to laryngeal
surgery had MSA. The most frequent MSA found in these studies was sulcus volcalis,
which corresponded to 50%, according to Sakae et al[28], and 70%, as specified by Eckley et al[29]. Sakae et al[28] suggested a careful exploration of both vocal folds during the vocal polyp intraoperative
period in search of these alterations.
Corroborating this suggestion, Byeon et al[30] reported that polyp recurrence may be related to the presence of sulcus vocalis.
In their study, 16.7% of the patients with sulcus vocalis associated with polyps exhibited
lesion recurrence, in contrast with only 3.1% without sulcus vocalis (p = 0.027), in addition to the former displaying less vocal improvement. The authors
state that the possible coexistence of sulcus vocalis in patients with polyps should
be considered to devise the best therapy, aimed at enhancing the vocal quality and
preventing the recurrence of polyps.
Despite the different incidence levels reported by Sakae et al[28] (23.5%) and Eckley et al[29] (51.5%), there is a consensus regarding the higher frequency of sulcus vocalis,
including similar levels when only MSAs are considered. This is due to the aerodynamic
changes that the sulcus causes in the vocal folds, resulting in irregular air flow
and mucosal wave in the region of the sulcus. This phenomenon promotes increased impact
stress to the exposed Reinke area, leading to the emergence of the polyp in the portion
immediately above the sulcus, which also explains the significantly higher polyp recurrence
rate in patients with associated sulcus vocalis.[30]
A new perspective is emerging regarding the etiology of vocal fold polyps. Several
authors have recently identified the significant presence of the protein ADAM33 in
vocal polyp tissue submitted to histological analysis. This protein is a disintegrin
and metalloproteinase protein related to angiogenesis and tissue remodeling and may
be an important factor for the development of chronic inflammation in the vocal folds.
The authors suggest more studies on ADAM33 and its interference in vocal fold polyps,
with the aim of making it the newest therapeutic target.[31]
Pharyngeal-laryngeal reflux has also been suggested as a risk factor for vocal fold
polyp development. A study with 32 patients submitted to laryngeal surgery for vocal
polyp biopsy investigating pepsin by immunohistochemical staining revealed a significantly
higher presence of pepsin (75%) in patients with vocal polyps when compared with the
control group (31.25%).[32] According to the authors, this intergroup difference suggests a probable etiological
relationship between pharyngeal-laryngeal reflux and vocal polyps.
3. Histology
Regarding the histology of vocal polyps, some authors state that histological analysis
cannot differentiate them from nodules.[33]
[34]
[35] Marcotullio et al[33] reported that these lesions seem to be part of a unique histological process in
different phases, in which the nodule corresponds to the initial phase of the lesion
and the polyp is a more advanced phase of the same lesion, making it necessary to
determine the unilateral or bilateral macroscopic characteristics to differentiate
them. According to Wallis et al,[34] despite the significant presence of telangiectasia on the vocal polyps and the size
of the biopsy specimen, which is generally larger than 0.3 cm, no definitive distinction
can be made between nodules and polyps. Similarly, Cipriani et al[35] found that the histopathological classification of nodules, polyps, and Reinke edema
is neither clinically reproducible nor histologically unique. and that their treatment
is based solely on clinical judgment.
On the other hand, Martins et al[2] demonstrated that vocal polyps exhibit morphological changes, such as swelling in
the lamina propria, an increase of the blood vessels and inflammation, in addition
to a thinner basal membrane in some areas and a thick subepithelial layer of collagen
fibers. The immunohistochemical techniques with laminin, fibronectin and collagen
IV show vascular proliferation of the lamina propria, a determining factor for vocal
polyps.[2]
In a recent literature review, Cielo et al[3] compared all the data published on normal vocal folds and organofunctional disorders
such as nodules, polyps, and Reinke edema. Regarding the histological characteristics
of vocal polyps, the authors found an increase in mass at the lesion site, mucosal
stiffness, elastic fiber direction in the mucosa perpendicular to the free edge of
the vocal fold, a decrease in hyaluronic acid and an increase in fibronectin in the
mucosa, epithelial lining exhibiting keratosis, basal membrane thickening with abnormal
levels of type IV collagen and fibronectin, Reinke space with vascular lesion and
fluid extravasation, in addition to unaltered vocal ligament and thyroarytenoid muscle.
Similarly, Nunes et al[1] described nodules with a predominance of epithelial alterations, fibrosis in the
lamina propria and basal membrane thickening, while in polyps, the changes were limited
to the lamina propria, with swelling and vascular aspects.
Although some authors[33]
[34]
[35] do not consider the possibility of histological differentiation in relation to other
organofunctional lesions, there is a consensus regarding the main histological characteristics
of polyps, such as the absence of epithelial alterations, the presence of swelling
in the lamina propria, inflammation, and an increase in vascular aspects.
4. Physiopathology and vocal characteristics
Regarding the vibratory characteristics of vocal folds with polyps, Cielo et al[3] described the following specific behaviors: vibration aperiodicity; irregular glottis
configuration related to phonation or incomplete glottal closure, depending on the
location and size of the polyp; reduced or absent mucosal wave amplitude at the lesion
site; vibration asymmetry between vocal folds; and high vibratory irregularity on
the free edge of the vocal folds. Regarding the vocal characteristics, they reported
hoarseness and breathiness, and rarely roughness; adequate to low fundamental frequency;
increased noise in the acoustic aspects; and moderate dysphonia.
Similarly, Yamauchi et al[36] identified the following in patients with polyps compared with individuals with
no vocal fold lesions: evident asymmetry; smaller mucosal wave amplitude, magnitude
and persistence, as well as a worse glottal closure. The authors reported that the
decrease in amplitude and mucosal wave, as well as the phase delay, may be due to
the effect of the polyp mass. Thus, the observed asymmetry results from the asymmetry
of the vocal fold mass, the tension and the mucoelasticity in unilateral polyps.
According to Zhang et al,[37] the presence of vocal polyps disrupts glottic closure, increasing the airflow directly
to the glottis to compensate for the inefficient glottic closure. Thus, polyp size
and stiffness interfere directly in the vibratory pattern of the vocal polyp, producing
more hoarseness. While large polyps tend to induce subharmonics and chaos, small polyps
may not influence the periodicity of vocal fold vibrations.
The selected studies demonstrate that the most evident vibratory characteristic of
vocal folds with polyps is aperiodicity, caused by the presence of a unilateral lesion,
with a direct relationship between lesion size and stiffness.[3]
[36]
[37] However, other macroscopic characteristics of vocal fold polyps corroborate the
vibratory irregularity, such as location, type and position in the vocal fold.
Regarding the macroscopic characteristics of vocal polyps, Dursun et al[6] analyzed the morphological type, location, position, and size of the polyps, as
well as the presence of a contralateral lesion. The authors reported the following
results: gelatinous polyps tend to have a wide base; polyps on the upper face of the
vocal fold are generally hemorrhagic; small polyps are frequently located on the middle
third of the vocal fold and have a wide base; and polyps with a contralateral reactive
lesion are located on the free edge of the vocal fold.
The authors also investigated the influence of these characteristics on the vocal
quality of the patients and found lower jitter values in patients with small polyps
and a significantly higher noise-harmonic ratio (NHR) in patients with polyps on the
anterior third of the vocal fold or with pedunculated polyps. They concluded that,
although some of the macroscopic characteristics interfered in the vocal quality of
the patients, it was difficult to isolate their individual effects.[6] Vasconcelos et al[38] found no relationship between polyp size and vocal alterations. The authors identified
small polyps in individuals with moderate vocal changes and large polyps in those
with mild vocal alterations. This may be due to the multidimensional nature of the
voice, which is subject to the interference of several associated factors, not only
to the size of the lesion.
5. Treatment
Despite the priority of traditional laryngeal microsurgery and the scientific advances
in terms of the surgical techniques used, other treatment alternatives for vocal fold
polyps have produced positive results, such as conservative medical treatment,[21] the use of endoscopic laser,[39]
[40]
[41] steroid injection,[42]
[43]
[44] flexible laryngostroboscopic surgery,[45]
[46] acupuncture,[47] and vocal health orientation associated with antireflux medication.[5]
Conservative medical treatment was described in a study that analyzed 42 cases diagnosed
with vocal polyps, in which 4 with angiomatous polyps and 2 with gelatinous polyps
exhibited complete lesion regression after intervention with steroid and/or antiulcer
drugs. Thus, the authors concluded that not all types of polyps require surgical removal,
mainly when they are small.[21]
Many studies have shown positive results for endoscopic laser treatment of vocal fold
polyps.[39]
[40]
[41] According to Ivey et al,[39] the effectiveness of this technique in angiomatous polyps is due to their photocoagulative
property, primarily in small lesions. However, other authors found that, one month
after the laser application, the lesions were significantly smaller for all types
of polyps.[40]
In a recent article, green laser (GL) was also used in the treatment of vocal fold
polyps. Mizuta et al[41] compared the postoperative vocal effect of GL surgery using the microflap technique,
which consists of subepithelial resection of the sessile polyp, conserving the epithelial
tissue, considered standard procedure in laryngeal surgery for vocal polyps. The authors
underscore similar vocal results and complete polyp resolution with the two aforementioned
techniques.
In relation to polyp treatment using percutaneous corticosteroid injection, Hsu et
al[42] demonstrated that 59% of the patients treated with this technique exhibited complete
lesion remission, and 32% obtained sufficient improvements in stroboscopic and vocal
parameters to forego laryngeal surgery. The authors confirmed significant vocal improvements
and that percutaneous corticosteroid injection is a minimally invasive procedure with
low morbidity that promotes a better cost-benefit relationship when compared with
traditional laryngeal microsurgery using suspension laryngoscopy.
In a meta-analysis on the vocal fold steroid injection, its effectiveness ranged from
82 to 98%, considering all the lesions as benign, albeit with lesion recurrence in
up to 30% of the patients. The authors did not assess the effectiveness of the technique
for single lesions but considered the group of benign lesions as a whole, including
nodules, polyps, cysts, and Reinke edema, in addition to vocal fold scars.[43] In this review, the authors analyzed studies using the vocal fold steroid injection
with transoral approach under endoscopic guidance or percutaneous application.
Nevertheless, a recent study found that injecting steroids in patients with polyps
may help to delay or to avoid laryngeal surgery but does not substitute it. Only some
of the patients (< 20%) with polyps exhibited complete lesion remission. The main
factors that interfered negatively in the results of the treatment with the use of
this technique were symptom duration of > 12 months and the presence of laryngopharyngeal
reflux.[44]
Laryngeal surgery using flexible laryngostroboscopy does not require general anesthesia
like traditional laryngeal macrosurgery with a suspension laryngoscope. Lan et al[45] performed a retrospective study in patients with vocal polyps submitted to this
technique and observed statistically significant results in all the parameters evaluated,
except acoustic assessment. The authors found no surgical complications or polyp recurrence
6 months after the surgery. They concluded that the low-cost technique is effective,
with minimal surgical risk, and is indicated primarily for patients at high risk for
general anesthesia. Another study, with a prospective design and sample composed only
of patients with pedunculated polyps, found 100% satisfaction in relation to mucosal
wave recovery and absence of lesion after the intervention. However, the authors affirm
that this technique must only be applied to patients with good tolerance to nasal
fibroscopy.[46]
A new therapeutic perspective has recently emerged. A study conducted in China demonstrated
that acupuncture at voice-related points may improve the vocal function and significantly
reduce the size of phototraumatic lesions, including vocal fold polyps. The authors
also considered that changes in vocal behavior induced by speech therapy were essential
for the patients to be able to maintain the effect obtained by acupuncture.[47]
Conservative otolaryngologic treatment consists of observing/monitoring the patient,
associated or not with vocal health instruction and/or antireflux medication. In a
study by Jeong et al,[5] participants who were being observed or monitored were awaiting laryngeal surgery.
Individuals with more than seven signs of laryngopharyngeal reflux received vocal
health instruction, antireflux orientation in terms of diet and lifestyle, and were
medicated with a proton-pump inhibitor. While waiting for surgery, 38% of the participants
displayed complete lesion remission between 3 and 8 months after the initial diagnosis.
The authors reported that women with small polyps and short duration of symptoms were
more likely to experience spontaneous remission. Thus, they suggest that patients
with vocal polyps be observed and monitored for a preestablished period before indicating
surgery.[5]
Prescribing speech therapy after laryngeal microsurgery for vocal polyps is common
practice in clinical laryngology.[48]
[49] Behavioral treatment shows great importance, including for the prevention of polyp
recurrence. According to Cecatto et al,[49] the therapeutic success in patients with vocal fold polyps submitted to surgery
depends on the skill of the surgeon, on the postoperative care, and on the correct
medication, in addition to complete speech therapy follow-up (vocal health and speech
therapy).
Postoperative speech therapy has also been used in less invasive procedures. Lin et
al[50] described better vocal results in patients with polyps submitted to speech therapy
after laser intervention, when compared with patients who did not undergo vocal rehabilitation.
Likewise, Petrović-Lazić et al[51] suggested the use of speech therapy after vocal polyp endolaryngeal intervention.
The authors found that vocal hygiene instruction and changes in inadequate vocal behaviors
were determining factors for improvements in acoustic and vocal parameters after surgery.
A recent study performed with 55 patients with polyps submitted to laryngeal surgery
reported that those who underwent speech therapy after surgery showed an improved
self-assessment and vocal stability.[52]
A 6-year longitudinal follow-up study demonstrated that patients with vocal polyps
exhibited enhanced voice quality immediately after surgery and over the ensuing months,
for vocal and acoustic parameters. However, they showed a worsening trend in subsequent
years, likely due to a resumption of abusive vocal behaviors.[53] In these cases, behavioral treatment could have represented an important difference.
Speech therapy after vocal polyp surgery to restore vocal behavior is also considered
essential by Gökcan et al,[48] as well as absolute vocal rest for 7 days and relative rest for 3 to 6 weeks. In
a study by Ju et al,[54] postoperative speech therapy demonstrated a significant result in the voice handicap
index (VHI), proving that it can improve the vocal discomfort of the patients, as
well as their emotional responses and daily self-perception.
On the other hand, many authors suggest speech therapy as the primary indication for
treating vocal polyps.[4]
[7]
[14]
[15]
[16]
[55]
[56]
[57]
[58]
[59]
[60] After his literature review, Jonhs[7] stated that, regardless of the maturity of the polypoid lesion, speech therapy should
be proposed in all cases of vocal behavior alterations. He underscored that it should
be prioritized for laryngeal surgery regardless of whether the cause is intensive,
inadequate or abusive voice use. The author states that surgical treatment should
only be considered when maximum behavioral intervention is not satisfactory and suggests
that the first-line treatment should emphasize maximum phonatory efficiency, associated
with a decline in vibratory trauma.
One of the first studies conducted on the effectiveness of speech therapy in the primary
treatment of vocal polyps was performed by Cohen et al.[4] The most significant vocal improvement occurred in patients with translucent (81.8%)
compared with fibrous (15.4%) and hemorrhagic polyps (25%) (p = 0.002). Those with muscle tension dysphonia (MTD) and complete vocal closure in
video laryngoscopy also obtained significant results (p = 0.001). It is important to underscore that, in this study, patients received individualized
speech therapy, with a focus on vocal health, respiratory support, laryngeal tension,
and pitch adjustment. The authors concluded that speech therapy as the first-line
treatment for vocal polyps is effective in improving dysphonia, thereby avoiding laryngeal
surgery in ∼ 50% of the participants.
The effects obtained after vocal health orientation were analyzed in 175 patients
diagnosed with vocal fold polyps. The treatment should focus on vocal production,
polyp physiopathology, inadequate vocal behavior, and the respective individualized
orientations. The authors concluded that vocal health orientation as initial treatment
can avoid surgery in up to 38% of the cases and underscore that this conduct should
be adopted primarily in non-smokers with small polyps, given that the best responses
were observed under these conditions.[14]
Based on reports that some vocal polyps disappear spontaneously, Klein et al[15] conducted a retrospective study in 29 patients with hemorrhagic polyps. Nine of
the patients with small and medium-sized polyps underwent speech therapy and reported
improvement in the initial symptoms and satisfaction with their vocal quality after
an average of 4.4 months of treatment, with lesion regression and no recurrence. The
authors concluded that small and medium-sized hemorrhagic polyps can be resolved with
minimum or conservative treatment and that speech therapy alone should be considered
as an option.
Regarding the characteristics of vocal polyps that influence voice quality and speech
therapy results, Cho et al[55] conducted a study that investigated the relationship between predictive factors
of vocal quality and suggested treatment guidelines. Among the results obtained is
that speech therapy was positive for most patients (66%), reabsorbing or reducing
the polyp size to up to half of the original size. Polyp size was the only clinicomorphological
factor that interfered in vocal quality, and polyp dimension and color also affected
the results of the speech therapy. Based on the description of these findings, they
emphasize that individuals with small whitish polyps should be initially referred
to speech therapy. They added that large polyps should be surgically removed and that
the patients should be sent to postoperative speech therapy.
Chronic vocal abuse, low perceptual score or edematous polyps were the primary factors
related to successful speech therapy in a study by Iwaki et al,[56] thereby avoiding surgery in 60% of the sample. Speech therapy was conducted for
3 months, accompanied by vocal health orientation, resonance, yawning and sigh techniques,
in addition to voice projection and expression exercises. The main findings observed
were improved voice in auditory perceptual assessment, primarily in roughness and
enhanced subjective symptoms in 90% of the participants.
According to Nakagawa et al,[16] complete resolution and decreased polyp size showed a relationship with gender,
predominantly women, mean symptom duration of around three months, in addition to
small and medium-sized polyps. The result demonstrated that it was impossible to determine
the superiority of speech therapy due to the absence of a control group and methodological
rigor. However, vocal polyps were resolved in 63.7% of the patients submitted to conservative
treatment. Madazio et al[57] added that speech therapy can be considered the first treatment option for vocal
polyps, especially in women, with small translucent polyps, complete glottic closure
and muscle tension.
Similarly, a recent retrospective cohort study of 92 patients with vocal polyps using
univariate and multivariate analysis showed that speech therapy is more effective
in women and small sessile polyps. The authors found successful vocal treatment in
43.8% of the participants, based on laughing and breathing exercises, and vocal hygiene.[58]
Regarding vocal alterations, Schindler et al[59] performed a prospective study in patients with benign vocal fold lesions, including
3 gelatinous polyps, with the aim of analyzing vocal changes in this group after 10
sessions of direct and indirect speech therapy. The difference in this study was the
use of a multidimensional protocol proposed by the European Laryngological Society
and the Italian Society of Phoniatrics and Logopedics, which includes video laryngoscopy,
auditory perception assessment (grade, roughness, breathiness, asthenia, strain and
instability [GRBASI]), acoustic assessment including spectrography, jitter, shimmer,
noise-harmonic ratio (NHR), and fundamental frequency (F0), aerodynamic assessment (maximum phonation time [MPT]), and vocal self-assessment
(VHI) to evaluate the patients before and after the intervention.
Speech therapy was individualized, according to the needs of each patient, consisting
of vocal hygiene orientation and vocal techniques, including humming, resonant voice
therapy, yawning and sigh, and laryngeal manipulation. Although the absence of lesions
was not observed in any of the study participants after speech therapy, the authors
obtained significant vocal improvement in jitter and NHR, in addition to vocal self-assessment
(VHI). According to the authors, presurgical speech therapy may contribute to a greater
adherence to behavioral changes, in addition to sufficient vocal improvement to make
surgery unnecessary.[59]
In a later study, this same research group found that, despite the absence of total
gelatinous polyp regression with speech therapy, 9 patients (45%) exhibited a > 50%
decline in polyp size, associated with satisfaction with the resulting vocal quality.
The gelatinous polyp group improved significantly in the severity of general dysphonia
(p = 0.002), asthenia (p = 0.014), shimmer (p = 0.005) and VHI (p = 0.049), in addition to an increase in F0 in women (p = 0.031). The authors concluded that speech therapy significantly enhances auditory
perception and acoustic assessment, as well as the vocal self-assessment of patients
with benign vocal fold lesions, in addition to reducing the size of gelatinous polyps.
As such, it is suggested that the use of speech therapy during the preoperative period
may avoid surgery in certain patients.[60]
Garrett et al[61] conducted a literature review on the effectiveness of vocal polyp treatment. The
authors concluded that establishing the best treatment – speech therapy or surgery
– is not as important as determining when the conservative treatment is sufficient
to eliminate the risks inherent to surgery. The articles analyzed in this study demonstrated
that the traditional approach can be successfully applied in patients with vocal polyps,
primarily small ones. On the other hand, surgery should be recommended for patients
with large polyps or for those who need immediate treatment. Finally, it is suggested
that treatment decisions should be shared with the patient, to explain the potential
of a conservative treatment. Similarly, an integrative literature review study on
the effectiveness of speech therapy in the treatment of vocal polyps showed complete
or partial lesion resolution associated with vocal satisfaction in 38 to 100% of the
participants in the articles analyzed, with the best results obtained in recent small
lesions.[62]
A study conducted by Adrián et al[63] investigated the effectiveness of speech therapy in organofunctional dysphonias.
Patients diagnosed with nodule, angiomatous polyps or incomplete glottal closure caused
by diminished muscle tone were analyzed. All the subjects were submitted to 2 speech
therapy sessions for 3 months (24 sessions) using direct and indirect approaches.
The results demonstrated that speech therapy was effective, including the three individuals
that exhibited angiomatous polyps and obtained total lesion regression at the end
of the treatment. However, the authors were cautious in confirming the effectiveness
of speech therapy as a treatment for this type of lesion, since surgery is considered
the gold standard.
Reinforcing the premise of the effectiveness of speech therapy in the treatment of
polyps, a clinical prospective study was conducted by Vasconcelos et al[38] in five patients with vocal polyps. A vocal treatment protocol was followed based
on the sonorous lips and tongue trill techniques and vocal health orientation, in
10 weekly therapy sessions. The authors found that the initial speech therapy for
vocal fold polyps was effective in 3 out of 5 participants (60%) and avoided laryngeal
surgery in 4 of the subjects (80%). Thus, they concluded that speech therapy should
be considered as a treatment option for vocal polyps, regardless of the lesion size
or of the degree of the initial dysphonia.[38] However, despite the methodological quality of the study, the small sample size
shows the need for a more robust investigation to confirm the effectiveness of speech
therapy in patients with vocal fold polyps.
Despite the phonotraumatic origin of vocal polyps, a recent randomized clinical study
performed in Italy found that speech therapy obtained the best results in relation
to the quality of life of a patient 1 year after the treatment, when compared with
surgery. The authors recommended that the voice therapy expulsion technique be considered
as a possible non-invasive and well-tolerated treatment.[64] However, this type of treatment may be questionable because the exercises needed
to perform the technique reinforce abusive vocal behavior.
