A 35-Year-Old Singer With a Vocal Fold Polyp and a Performance in 2 Weeks
A 35-year-old professional singer presents with hoarseness for 3 weeks. She has a performance in 2 weeks and is anxious to recover. She reports that she has been singing more than usual and has had a recent upper respiratory tract infection. On flexible nasendoscopy, there is a 3 mm polyp on the left vocal fold at the junction of the anterior and middle thirds. The right vocal fold is normal. There is no mass or leukoplakia. She smokes 5 cigarettes a day and drinks alcohol socially. She asks for surgery before her performance.
1. What is your diagnosis, and what is the role of surgery at this stage?
Read the worked answer
The diagnosis is a vocal fold polyp, likely related to vocal abuse and recent infection. It is a benign, reactive lesion.
Role of surgery: Surgery is not indicated before the performance unless the airway is compromised or there is suspicion of malignancy. The risks of surgery include scarring, stiffness, and a potentially worse voice, especially in a professional singer. The recovery period is typically 1–2 weeks of voice rest, which would conflict with the performance.
Initial management:
- Voice rest (relative) and vocal hygiene.
- Treat reflux if present.
- Hydration and humidification.
- Avoid smoking and alcohol.
- Speech therapy with a singing teacher or speech-language pathologist.
- Reassess in 4–6 weeks. Many polyps resolve with conservative management.
If the polyp persists and causes significant voice impairment, surgery (phonomicrosurgery) can be considered after the performance.
2. How would you counsel her about the performance and the risk of malignancy?
Read the worked answer
- Performance: Explain that singing with a polyp may worsen the lesion and cause vocal fatigue. Advise modified vocal use, amplification, and avoiding strenuous singing. If she chooses to perform, she should have a warm-up, hydrate, and rest her voice between songs.
- Malignancy risk: A 3 mm polyp without leukoplakia in a 35-year-old is unlikely to be malignant, but smoking is a risk factor. Advise smoking cessation and follow-up. If the lesion persists or changes, biopsy is warranted.
- Shared decision-making: Discuss the options (conservative management vs. surgery) and the risks and benefits of each.
- Documentation: Record the discussion and the patient's choice.
3. What are the principles of phonomicrosurgery, and what postoperative care is needed?
Read the worked answer
Principles:
- Preserve the vocal ligament and mucosa. Use microflap technique to remove the polyp with minimal trauma.
- Avoid excessive cautery and preserve the basement membrane.
- Achieve hemostasis with careful technique.
- Use cold instruments rather than laser where possible to reduce thermal injury.
Postoperative care:
- Voice rest for 5–7 days (relative or absolute depending on the surgeon).
- Speech therapy after voice rest to optimize technique.
- Avoid smoking and irritants.
- Follow-up at 2–4 weeks with nasendoscopy.
- Gradual return to singing over 4–6 weeks, guided by symptoms.