Laryngology and Voice: Stroboscopy, Lesions, and Red Flags
Scope
Laryngology and voice disorders tests dysphonia evaluation, videostroboscopy, benign mucosal lesions, laryngeal malignancy, and airway decision-making. The board expects you to separate behavioral, inflammatory, structural, and neurologic causes before recommending surgery.
Core rules
- Persistent dysphonia longer than 4 weeks, especially in a smoker, requires flexible laryngoscopy. Videostroboscopy adds mucosal wave and glottic closure information.
- Vocal fold nodules are bilateral at the mid-membranous junction and cause an hourglass glottic closure. Voice therapy is first-line; surgery is reserved for failure after adequate therapy.
- Polyps are often unilateral and may follow a single vocal trauma; cysts are subepithelial and require excision rather than repeated therapy alone.
- Reinke edema is associated with smoking and reflux; treat the cause and consider microflap surgery.
- Muscle tension dysphonia shows hyperfunctional supraglottic squeezing with preserved mucosal waves; voice therapy is the main treatment.
- Spasmodic dysphonia: adductor type causes strained-strangled breaks; botulinum toxin is first-line.
- Red flags include leukoplakia, erythroplakia, a fixed vocal fold, and a neck node; biopsy in the operating room.
Worked example
A teacher has 6 months of dysphonia and bilateral symmetric mid-membranous swelling with hourglass closure. The diagnosis is vocal fold nodules. Prescribe voice therapy for 6 to 8 weeks, hydration, and amplification, and treat reflux only if symptomatic. Surgery is considered only after failed therapy and persistent disabling dysphonia.
Traps
Diagnosing nodules without stroboscopy; missing malignancy in a smoker; treating leukoplakia with antireflux medication alone; failing to check vocal fold mobility; and operating before voice therapy.