Laryngology and Voice
Core rules
Benign vocal fold lesions have distinct patterns: nodules are usually bilateral at the junction of the anterior and middle thirds from phonotrauma; polyps are often unilateral; Reinke's edema is linked to smoking; cysts are subepithelial; recurrent respiratory papillomatosis is caused by HPV 6 and 11. Dysphonia assessment includes history, laryngoscopy and stroboscopy. Voice therapy is first-line for nodules and muscle tension dysphonia; surgery is reserved for persistent or obstructive lesions. Airway stenosis is graded by Cotton-Myer: grade I up to 50 percent obstruction, II 51–70 percent, III 71–99 percent, and IV no detectable lumen. Tracheostomy is indicated for prolonged ventilation, upper airway obstruction, or airway protection; cuff pressure should be monitored to avoid mucosal ischemia. Swallowing disorders are assessed by FEES or videofluoroscopy, with aspiration precautions and therapy.
Worked example
A teacher develops progressive hoarseness. Stroboscopy shows bilateral mid-membranous nodules. The first step is voice therapy with hydration and vocal hygiene, not immediate excision. Surgery is considered only if nodules persist after adequate therapy and cause significant impairment.
Traps
Do not operate first on typical vocal nodules. In a smoker, persistent hoarseness requires laryngoscopy to exclude malignancy. Avoid laser ignition hazards in the airway. Overinflation of a tracheostomy cuff causes tracheal injury. Papillomatosis recurs and requires repeated clearance, not a single cure.