The Laryngoscope

V
C 2012 The American Laryngological,
Rhinological and Otological Society, Inc.

A Nomenclature Paradigm for Benign Midmembranous

Vocal Fold Lesions

Clark A. Rosen, MD, FACS; Jackie Gartner-Schmidt, PhD; Bridget Hathaway, MD; C. Blake Simpson, MD;
Gregory N. Postma, MD; Mark Courey, MD; Robert T. Sataloff, MD, DMA

Objectives/Hypothesis: There is a significant lack of uniform agreement regarding nomenclature for benign vocal fold
lesions (BVFLs). This confusion results in difficulty for clinicians communicating with their patients and with each other. In
addition, BVFL research and comparison of treatment methods are hampered by the lack of a detailed and uniform BVFL
nomenclature.
Study Design: Clinical consensus conferences were held to develop an initial BVFL nomenclature paradigm. Perceptual
video analysis was performed to validate the stroboscopy component of the paradigm.
Methods: The culmination of the consensus conferences and the video-perceptual analysis was used to evaluate the
BVFL nomenclature paradigm using a retrospective review of patients with BVFL.
Results: An initial BVFL nomenclature paradigm was proposed utilizing detailed definitions relating to vocal fold lesion
morphology, stroboscopy, response to voice therapy and intraoperative findings. Video-perceptual analysis of stroboscopy
demonstrated that the proposed binary stroboscopy system used in the BVFL nomenclature paradigm was valid and widely
applicable. Retrospective review of 45 patients with BVFL followed to the conclusion of treatment demonstrated that slight
modifications of the initial BVFL nomenclature paradigm were required. With the modified BVFL nomenclature paradigm,
96% of the patients fit into the predicted pattern and definitions of the BVFL nomenclature system.
Conclusions: This study has validated a multidimensional BVFL nomenclature paradigm. This vocal fold nomenclature
paradigm includes nine distinct vocal fold lesions: vocal fold nodules, vocal fold polyp, pseudocyst, vocal fold cyst (subepithe-
lial or ligament), nonspecific vocal fold lesion, vocal fold fibrous mass (subepithelial or ligament), and reactive lesion.
Key Words: Vocal cord nodules, vocal fold lesions, voice handicap, voice therapy, vocal cord polyp.
Level of Evidence: 2c.
Laryngoscope, 122:1335–1341, 2012

INTRODUCTION For the purposes of this study, BVFL refers to unilateral

Substantial confusion exists regarding the nomen-
clature of benign vocal fold lesions (BVFLs).1,2 There is
no consensus on specific labels for BVFL, nor are the
most commonly used terms defined.3 There is a need for
a defined nomenclature for the purpose of improving
communication among clinicians and with patients.4,5
Furthermore, precise definitions of BVFL will facilitate
clinical research of voice disorders and may lead to a
better understanding of outcomes for BVFL treatment.
From the University of Pittsburgh Voice Center (C.A.R., J.G.-S., B.H.),
Department of Otolaryngology, University of Pittsburgh School of
Medicine, Pittsburgh, Pennsylvania; Otolaryngology–Head and Neck
Surgery (C.B.S.), University of Texas Health Sciences Center, San
Antonio, Texas; Department of Otolaryngology (G.N.P.), MCG Center for
Voice and Swallowing Disorders, Georgia Health Sciences Center, Augusta,
Georgia; Department of Otolaryngology (M.C.), University of California San
Francisco, San Francisco, California; and Department of Otolaryngology–
Head and Neck Surgery (R . T.S.), Drexel University, Philadelphia,
Pennsylvania, U.S.A.
Editor’s Note: This Manuscript was accepted for publication July
22, 2011.
Poster presentation at American Laryngological Association Meet-
ing, Chicago, Illinois, U.S.A., April 27–28, 2011.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Clark A. Rosen, MD, FACS, University of
Pittsburgh Voice Center, Department of Otolaryngology, UPMC Mercy,
B-11500, Pittsburgh, PA 15219. E-mail: RosenCA@upmc.edu
DOI: 10.1002/lary.22421
or bilateral lesions of the midmembranous portion of the
vocal fold that are located deep to grossly appearing nor-
mal epithelium.
The objectives of this study were to develop a para-
digm of BVFL nomenclature using multidimensional
definitions for each lesion and to validate this paradigm
by retrospectively applying it to a cohort of patients with
BVFL. Given the essential role of stroboscopy in the
evaluation of BVFL and as a salient component of the
paradigm, an investigation was undertaken into whether
there was consensus among clinicians as to what consti-
tutes normal and abnormal stroboscopy findings with
respect to vibratory properties of the mucosa of patients
with BVFL.
MATERIALS AND METHODS
Perceptual Analysis of Vibratory Properties of
the Mucosa on Stroboscopy
Before we retrospectively tested this theoretic paradigm
on patients with BVFL, one preliminary assumption had to be
validated: Could vibratory properties of the vocal fold mucosa
associated with BVFL be reliably judged by laryngologists and
otolaryngologists?
Stroboscopically viewed vibratory properties of the mucosa
were defined as normal or mildly reduced (A) or significantly
reduced (B). Stroboscopy examinations of patients with BVFL

Laryngoscope 122: June 2012 Rosen et al.: BVFL Nomenclature Paradigm

1335
were reviewed by a laryngologist (C.A.R.) and a speech-language
pathologist (J.G.S.). Laryngostroboscopy examinations using both
rigid and flexible examinations with audio were reviewed. For
the purpose of analysis, the A or B assessment was reached by
consensus. Left and right vocal folds were assessed separately.
Twelve examinations were selected and arranged in random
order as a composite video to include the following left/right
stroboscopy examination examples: A/A (5 cases), A/B (6 cases),
and B/B (1 case). Three examinations were repeated to assess
intrarater reliability for a total of 15 cases. The reviewers
included three experienced laryngologists and three general oto-
laryngologists (with stroboscopy experience). Members of the
general otolaryngology group were familiar with stroboscopy
but estimated they performed or reviewed less than 150 strobo-
scopy exams per year. All reviewers were instructed to assess
the right and left vocal folds separately for each examination
and rate the vibratory properties of the mucosa as either A or
B. Each reviewer was given a written description of the A and
B vibratory properties of the mucosa and two sample video
cases (Appendix I).
Statistical analysis was performed using SPSS 12.0 (SPSS
Inc., Chicago, IL). Differences between individual raters and
groups were assessed with an analysis of variance (ANOVA),
and reliability analysis was used to determine correlation
coefficients.
Retrospective Validation of Paradigm
Institutional review board approval was obtained from the
University of Pittsburgh to review BVFL patient information.
The University of Pittsburgh Voice Center database was
searched for all patients with BVFL diagnosed in 2003. All
patients with adequate follow-up (e.g., at least 6 months) to be
classified using the BVFL paradigm were included. The initial
stroboscopy examination for each patient was reviewed blindly
by three of the authors (B.H., J.G.S., C.A.R.) to grade the vibratory
properties of the mucosa (A or B). Medical records were
reviewed to determine the treatments employed (voice therapy,
voice rest, antireflux therapy, surgery) and the response to
treatment. Intraoperative findings were reviewed for those
patients who underwent surgery for their BVFL. For patients
managed nonoperatively, posttherapy videostroboscopy exams
were reviewed blindly to determine whether the lesions
changed in size in response to treatment. Voice Handicap
Index-10 (VHI-10) data were also recorded for patients pre- and
posttreatment (nonsurgical).6 A paired sample t test was per-
formed on the pre- and posttreatment VHI-10 data (Excel 5.0;
Microsoft Corp., Redmond, WA).
All patient decisions were made with the overall philoso-
phy of using nonsurgical therapy (voice therapy, rest, and
medical treatment) before possible surgery when clinically
appropriate and physically possible.7 Reflux treatment was pro-
vided based on the results of the clinical assessment of patient
self-report and physical examination findings. Treatment for
reflux consisted of a daily proton pump inhibitor (actual drug
varied based on insurance), gastroesophageal reflux disease/
laryngeal pharyngeal reflux (LPR) behavior modification, and
ranitidine (300 mg) at night.
Paradigm Development
Clinical consensus meetings were held with a panel of lar-
yngologists (C.A.R., C.B.S., R.T.S., M.C., G.N.P.) to create a BVFL
nomenclature paradigm based on multiple clinical criteria
including lesion morphology, stroboscopic features, response to
voice therapy, and intraoperative findings (when available). The
proposed BVFL nomenclature paradigm was based, in part, on
Laryngoscope 122: June 2012
1336
existing verbiage of BVFL and refined according to the clinical
experience of the panelists. An emphasis was placed on creating
a system that would appropriately differentiate the most com-
mon midmembranous BVFLs and be clinically appropriate and
applicable for most voice-care practices.
Initial BVFL Paradigm Development
The nomenclature system developed for BVFL was
intended to apply to adult patients with chronic dysphonia (not
acute). In terms of morphology, the pathology to be defined was
limited to midmembranous vocal fold with normal overlying epi-
thelium, thus excluding vocal fold granuloma lesions and
epithelial diseases such as keratosis and malignancy. General-
ized inflammatory processes, such as Reinke’s edema and acute
laryngitis, were excluded from this classification system.
Given the common use of stroboscopy during voice evalua-
tion and the potential value for stratification of BVFL,
vibratory properties of the vocal fold mucosa from stroboscopy
were used in the paradigm. A binary assessment of mucosal
wave was created to assist in differentiating various lesions.
The vibratory properties of the mucosa were classified as nor-
mal or mildly reduced (termed A) versus significantly reduced
(termed B).
Voice therapy is frequently employed in the treatment of
BVFL. Voice therapy should be done by an individual with spe-
cialization in assessment and rehabilitation of patients with
voice disorders, that is, a speech-language pathologist or pho-
niatrist. Certain lesions demonstrate a good response to voice
therapy by reducing in size. Other lesions do not show signifi-
cant change with this intervention. Thus, we elected to use
response to voice therapy as another method to delineate BVFL
classification.
Further differentiation of BVFL was accomplished with
intraoperative palpation and an exploratory cordotomy (micro-
flap approach) when clinically indicated. Cordotomy involves
incising and elevating the mucosa in the area of the lesion. The
pathology can then be determined to be localized to either the
subepithelial space (SE) or the vocal ligament (lig). A lesion
that is adherent to the undersurface of the mucosa is classified
as being in the SE, and a lesion adherent to the deeper aspects
of the vocal fold is classified as being on or within the lig.
Finally, BVFLs were further differentiated according to the
physical features of the lesions found at surgery. For example,
if a discrete capsule was present, the lesion was defined as a
cyst. In contrast, an unencapsulated mass of amorphous fibrous
tissue was defined as a fibrous mass (FM). Both of these lesions
can occur in either the SE or lig region of the vocal fold.
RESULTS
BVFL Definitions and Characteristics
Vocal fold nodules. Vocal fold nodules are bilat-
eral lesions. Complete symmetry is not required. A key
stroboscopic feature for vocal fold nodules is normal or
minimal impairment of the vibratory properties of the
mucosa (A). Vocal fold nodules respond favorably to voice
therapy and reduced voice demands with either complete
resolution or substantive diminution of the size of the
lesions. These lesions are treated nonoperatively. In
addition, any BVFLs that do not respond to voice ther-
apy, by definition, cannot be vocal fold nodules.
Vocal fold polyp. Vocal fold polyp is exophytic and
often translucent or hemorrhagic. It is usually unilateral
but may be bilateral and can be pedunculated or sessile.
Rosen et al.: BVFL Nomenclature Paradigm
The overlying mucosa is typically thin and atrophic.
Operative exploration with a cordotomy reveals a gelati-
nous substance without encapsulation within the SE.
Vibratory properties of the mucosa on stroboscopy are
usually normal or minimally reduced (A). Most polyps do
not resolve or become smaller with voice rest or voice
therapy.
Vocal fold cyst (VFC). The vocal fold cyst (VFC)
lesion may be within the SE or the lig. It is usually uni-
lateral but may be bilateral. Significant reduction in
vibratory properties of the mucosa (B) is typically seen
on stroboscopic examination, particularly when the
lesion involves the lig (VFC-lig). A VFC is confirmed
when cordotomy and microflap elevation reveal an
encapsulated lesion. VFC lesions typically do not resolve
or become smaller with voice rest or voice therapy.
Fibrous mass. The FM lesion is typically amor-
phous and without discrete encapsulation. It has a
focal point within the vocal fold (midmembranous) as
seen by stroboscopy and can be palpated intraopera-
tively. FMs can be found in the SE or involve the lig
(FM-SE or FM-lig). Typically, the FM shows significant
diminution of mucosal wave vibratory activity (B). This
lesion is composed of fibrous material, often with
prominent vascularity within the lesion. Exploratory
cordotomy often reveals an indistinct extension of the
pathology anteriorly and/or posteriorly from the focal
mass of fibrous material. The FM is typically pale or
gray in color. The dense fibrous nature of this lesion
will often lead to difficulties distinguishing the lesion
from the lig. Most FM lesions do not respond to voice
therapy.
Reactive vocal fold lesion. A reactive vocal fold
lesion has to be paired with a contralateral vocal fold
lesion (i.e., VFC, polyp, or FM). It is, by definition, uni-
lateral. Stroboscopy shows normal or minimal reduction
in vibratory properties of the mucosa (A), often in con-
trast to the contralateral lesion (i.e., cyst, FM). A
reactive vocal fold lesion may have a cup-and-saucer
appearance, with the contralateral lesion indenting the
reactive vocal fold lesion at the point of maximum con-
tact. The size of the reactive lesion with respect to the
contralateral lesion is highly variable. A reactive lesion
typically will respond to voice therapy or voice rest. Usu-
ally the reactive lesion is smaller but at times can be
larger than the inciting lesion.
Pseudocyst. A pseudocyst is an SE lesion associ-
ated with chronic glottal incompetence (i.e., vocal scar,
paresis, or paralysis). It is typically unilateral but can
be bilateral. The lesion is very superficial in nature and
may even appear intraepithelial. The lesion is clear with
a blister appearance that is composed of a semisolid
fluid underneath thinned epithelium without encapsula-
tion. Typically, vibratory properties of the mucosa are
normal to minimally reduced. A pseudocyst does not
respond to voice therapy. If a pseudocyst is surgically
removed without correction of the underlying glottal
incompetence, there is a high rate of recidivism.
Figure 1 demonstrates how the proposed multidi-
mensional BVFL nomenclature paradigm is used in a
clinical scenario. It must be stressed that this paradigm
Laryngoscope 122: June 2012
was developed to classify or define most BVFL accu-
rately, not to become a clinical or diagnostic guideline.
Stroboscopy, response to voice therapy, and surgical find-
ings are included because these are commonly used
clinical tools in the authors’ clinical experience.
Perceptual Analysis of Vibratory Properties of
the Mucosa on Stroboscopy
For the group of three laryngologists, the correla-
tion coefficient was 0.868, and for the general
otolaryngology group it was 0.826. These scores suggest
very good correlation. Reviewers matched the consensus
designation by the authors (A or B) in 151 of 180
(83.9%) of the vocal folds examined. Reviewers matched
the established designation in 88 of 100 (81.5%) cases
defined as A and 63 of 72 (87.5%) cases defined as B.
This difference was not statistically significant.
To assess intrarater reliability, three different video
segments were repeated in the series of cases for a total
of six vocal folds (each examined by six reviewers). Only
one of the repeated cases was scored differently by a sin-
gle reviewer. Thirty-five of 36 vocal folds were scored
consistently on repeat viewing. The average interrater
correlation coefficient for all reviewers was 0.932. Thus,
all reviewers had an excellent intrarater reliability.
Differences between the laryngologists and general
otolaryngologist reviewers were also examined. The lar-
yngology group matched the prestudy designation in 78
of 90 (86.7%) of the vocal folds examined. The general
otolaryngology group matched the prestudy designation
in 73 of 90 (81.1%) of the vocal folds. ANOVA revealed
no significant differences between these two groups.
There were also no significant differences between the
six reviewers when assessed individually.
Retrospective Validation of BVFL Paradigm
Ninety-three patients with BVFL were identified in
the University of Pittsburgh Voice Center database.
Forty-eight patients were excluded due to inadequate
follow-up (30 patients), age less than 18 years (5
patients), other laryngeal abnormalities (10 patients), or
inadequate stroboscopy exams (3 patients). Thus, the
study consisted of 45 patients with BVFL.
Blinded review (c.a.r., j.g.s.) of the pretreatment
stroboscopy examinations found that 30 patients had min-
imal or no reduction in vibratory properties of the
mucosa (A). This group included 26 patients with bilat-
eral lesions (A/A) and four patients with unilateral
lesions. Of the patients with bilateral lesions, 12 patients
were post hoc classified as having vocal fold nodules; that
is, they improved symptomatically and the lesions
decreased in size or resolved with voice therapy as judged
by blinded review of post-therapy stroboscopy examina-
tions. Of the 26 patients who had bilateral lesions, only
two patients had unilateral improvement with voice ther-
apy. There was also a group of 13 patients (12 with
bilateral and 1 with unilateral lesions) who responded to
voice therapy symptomatically, but the lesions did not
change in size. Thus another BVFL category had to be
Rosen et al.: BVFL Nomenclature Paradigm
1337
 Fig. 1. Initial benign vocal fold
lesion nomenclature paradigm. TVF
¼ true vocal fold; Mid-mem VF ¼
midmembranous vocal fold; SE ¼
subepithelial.

defined to incorporate patients who have symptomatic Response to Voice Therapy

improvement after voice therapy (restoration of vocal Overall, 38 of 45 (84%) patients had voice therapy.
function/significant reduction of dysphonia) that does Of patients with no or minimal reduction in vibratory
not correlate with a significant change in the lesions on properties of the mucosa (A) on initial stroboscopy exam,
clinical examination. This patient group revealed a gap all had voice therapy, and 27 of 30 (90%) patients
in our original paradigm. This group was post facto improved with voice therapy (nodules and NSVFL). Of
classified to have nonspecific vocal fold lesion (NSVFL). patients with significant reduction in vibratory proper-
Of the four patients with unilateral lesions and mini- ties of the mucosa on initial stroboscopy exam, eight of
mal or no reduction in vibratory properties of the 15 (53%) had voice therapy, and three of eight (38%)
mucosa (A) on initial exam, three did not respond to
voice therapy. The three patients with unilateral
lesions who did not respond to voice therapy and the
two patients who only had unilateral lesion response to TABLE I.
voice therapy underwent cordotomy and vocal fold ex- Incidence of Benign Vocal Fold Lesions.
ploration (n ¼ 5). Of these five patients, one had an SE No. %
FM and four had a polyp. NSVFL 16 36
Fifteen patients had significant reduction in vibra- Vocal fold nodules 12 27
tory properties of the mucosa in at least one vocal fold on
Vocal fold fibrous mass (subepithelial) 8 18
initial stroboscopy exam (B). Three of these patients had
Vocal fold polyp 6 13
symptomatic improvement with voice therapy without
change in lesion size and were therefore added to the Vocal fold cysts (ligament) 2 4
NSVFL group. Five patients with initial B stroboscopy Vocal fold cysts (subepithelial) 1 2
examinations did not respond to voice therapy and had Vocal fold fibrous mass (ligament) 0 0
vocal fold exploration along with seven patients who did Pseudocyst 0 0
not undergo voice therapy (because of a variety of clinical Total 100
factors). Of these 12 patients, two had a VFC involving Reactive lesion* 11 24 (of above total)
the ligament, one had an SE cyst, seven had an SE FM,
*A reactive vocal fold lesion occurs paired with a contralateral vocal
and two had a vocal fold polyp. No patient was found to fold lesion (i.e., vocal fold cyst, polyp, or fibrous mass).
have a pseudocyst or FM-lig. NSVFL ¼ nonspecific vocal fold lesion.

Laryngoscope 122: June 2012 Rosen et al.: BVFL Nomenclature Paradigm

1338
Fig. 2. Modified benign vocal fold lesion nomenclature paradigm with patient distribution. TVF ¼ true vocal fold; Mid-mem VF ¼ midmem-
branous vocal fold; NSVFL ¼ nonspecific vocal fold lesion; SE ¼ subepithelial. (Note: two patients with a vocal fold polyp had a ‘‘B’’ strobe
and thus are not depicted in the final paradigm.)

improved with voice therapy (NSVFL). In total, 30 of 45 VHI-10

(67%) responded favorably to voice therapy. The average of pretreatment VHI-10 scores for
In this patient cohort, voice therapy involved both patients with A initial stroboscopy examinations was 14,
indirect and direct rehabilitative techniques.8 Indirect compared with 21 for those with initial B stroboscopy
voice therapy approaches do not involve any direct work examinations. Two groups of patients had symptomatic
on correcting faulty voice production. In contrast, direct improvement with nonsurgical therapy: those with vocal
voice therapy concentrated on directly modifying aspects fold nodules and those with NSVFL. VHI-10 data for
of faulty voice production. Direct voice therapy involved these two groups (pre- and post-therapy) are shown in
techniques taken from the general therapies of resonant Table II. The vocal fold nodules and NSVFL patient
voice and flow phonation.9 The general techniques of groups had statistically significant (improved) VHI-10
indirect voice therapy involved managing such items as scores following nonsurgical treatment.
dehydration, LPR, psychosocial issues, environmental
issues, motivation/compliance problems, as well as edu-
cating the patients about their laryngeal mechanism.
TABLE II.
Patients were seen, on average, for four to six therapy Voice Handicap Index-10 Results Following Nonsurgical Therapy
sessions. for Benign Vocal Fold Lesions.
Mean Dif*
No. Pretreatment Posttreatment P Value
LPR Treatment
Nineteen of 45 (42%) patients were treated medi- Nodules 12 15.00 7.25 .006†
cally for LPR. Fourteen of 27 (52%) of the patients who NSVFL 15 12.75 6.85 .020†
symptomatically improved with voice therapy were also NSFVL and Nodules 27 14.00 7.00 .00006†
treated with medical therapy for LPR. Five of 17 (29%)
*Mean Dif ¼ pre– to post–Voice Handicap Index-10; NSVFL ¼ non-
of the patients undergoing vocal fold exploration also specific vocal fold lesion.
were treated medically for LPR. †
Statistically significant.

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1339
DISCUSSION
This study represents a proposal for a clinically
based, defined nomenclature paradigm for BVFL. The
retrospective application of this proposed paradigm
revealed that modifications were necessary to increase
the clinical applicability and validity (Fig. 2). First, a
group that was designated NSVFL was created to
account for those patients who had symptomatic
improvement with conservative therapy (nonsurgical)
without resolution or diminution of lesion size. Patients
in these groups had persistent lesions, but the lesions
could not be defined further (without surgical explora-
tion). The benign nature of these lesions as well as the
reduction of voice symptoms made surgery avoidable.
Therefore, a definitive diagnosis of BVFL was not
reached when the patients improved with nonsurgical
therapy; instead, these patients were described as hav-
ing NSVFL. The diagnostic options for the lesions in this
group included VFC (SE or lig), vocal fold polyp, or FM
(SE or lig).
The initial paradigm hypothesized that SE lesions,
including FMs and cysts, would not cause significant
reduction in vibratory properties of the mucosa on stro-
boscopy (A). Retrospective clinical review revealed that
seven of eight patients with SE FMs and the one patient
with an SE cyst had significant reduction of vibratory
properties of the mucosa (B) on initial stroboscopy. In
addition, two of six patients with vocal fold polyps had
significant reduction of vibratory properties of the mu-
cosa on initial stroboscopy. This resulted in 10 of 45
patients deviating from the course predicted by the ini-
tial paradigm. Given the preponderance of patients with
SE FMs and cysts with abnormal vibratory properties of
the mucosa (B), a modification of the initial paradigm
was required (Fig. 2), adding cyst-SE and FM-SE to the
B arm of the paradigm. By modifying the paradigm to
include SE FM and cyst as lesions that may be associ-
ated with significant reduction in vibratory properties of
the mucosa (B), the accuracy of the paradigm improved
with only two of 45 patients in the retrospective review
deviating from the course predicted by the paradigm.
These patients had a vocal fold polyp, which typically
does not cause significant reduction in vibratory proper-
ties of the mucosa (B), although if the lesion is
particularly large and thus disrupts vocal fold closure
and vibration, a B mucosal wave can be seen.
The perceptual analysis of mucosal wave on strobo-
scopy validated the A and B definitions as a valid
component of the BVFL paradigm. Clinicians familiar
with stroboscopy, including laryngologists and general
otolaryngologists, generally agreed as to what consti-
tuted normal or mild (A) versus significantly reduced
vibratory properties of the mucosa (B). Importantly, stro-
boscopy was only one of the clinical components used to
differentiate BVFL in the proposed paradigm. Lesion
morphology, response to voice therapy, and intraopera-
tive findings were equally important in differentiating
various BVFLs and thus ultimately accurately classify-
ing the BVFL. Glottal closure pattern as seen during
stroboscopy was intentionally not used in the BVFL no-
menclature paradigm, as this observation would not
Laryngoscope 122: June 2012
1340
have differentiated the various lesion categories. In
other words, most patients had an hourglass configura-
tion pattern despite their ultimate classification.
This study also demonstrates the importance of con-
servative therapy, including voice therapy and antireflux
therapy, in the treatment of BVFLs. Sixteen of 45
patients (36%) improved symptomatically with conserva-
tive therapy despite having no significant change in
their lesions (NSVFL). Conservative therapy allowed
these patients with NSVFL to avoid surgery. In addition,
12 patients with vocal fold nodules had symptomatic
improvement as well as diminution in lesion size from
conservative therapy. Overall, 30 of 45 (67%) patients
improved with conservative therapy (nonsurgical
treatment).
The pre- and posttreatment VHI-10 scores support
the patients’ self-report of clinical improvement. VHI-10
data were not calculated for the patients treated with
surgery because this information is not germane to the
objective of the study. The major limitation of this cur-
rent study relates to its retrospective nature, primarily
the lack of standardization in treatment; voice therapy
was not standardized, and different therapists and tech-
niques were used. In addition, not every patient received
LPR treatment or voice therapy.
We emphasize that this nomenclature paradigm for
BVFL is not intended to be a treatment guideline.
Rather the intent was to develop a classification system
for BVFL to facilitate further study and understanding
of these lesions and communication between voice-care
professionals.
The clinical validation of the proposed BVFL para-
digm involved a relatively small number of patients.
Thus, no patients in the study cohort were found with a
pseudocyst or an FM-lig. The authors’ clinical experience
suggests that these lesions occur but are less common
than other BVFLs.
CONCLUSION
A classification system for BVFL employing multi-
ple criteria (stroboscopy, response to voice therapy, and
operative findings) was developed for BVFL. This is the
first rigorously defined report of the incidence of differ-
ent types of BVFL. Conservative therapy resulted in
symptomatic improvement for the majority of patients
with BVFL. Nine distinct BVFLs are defined with this
system: vocal fold nodules, vocal fold polyp, VFC (SE or
lig), vocal fold FM (SE or lig), reactive lesion, NSVFL,
and pseudocyst.
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APPENDIX I
Stroboscopy Rating Instructions and Evaluation
Form
Instructions. The video clips can be viewed on
Windows (using Media Player) or Macintosh (using
Quick Time) systems. Sound is included with each video.
Please use the following codes in your evaluation of
each vocal fold.
A – normal or mildly reduced mucosal wave vibratory
activity
B – severely reduced mucosal wave vibratory
activity
Example Cases
The first case is an example of A vibratory proper-
ties of the mucosa in both vocal folds scored as right
TVF A and left TVF A. The second case is a patient who
has severely reduced mucosal wave vibratory activity of
the right midmembranous true vocal fold. The vibratory
properties of the mucosa of the left vocal fold are essen-
tially normal. Thus, the case would be scored as right
TVF B and left TVF A.
Research Cases: 1–15
Review the remaining 15 cases one at a time. Each
video clip can be viewed multiple times by selecting
Repeat option under the Play heading in the toolbar. Re-
cord your observations on the sheets provided using the
A or B designations for each vocal fold separately.
Case One
Please evaluate the mucosal wave vibratory activity
for each vocal fold separately and circle A or B according
to the following definitions.
A – normal or mildly reduced mucosal wave vibratory
activity
B – severely reduced mucosal wave vibratory
activity
Right VF
A
B
Left VF
A
B

Laryngoscope 122: June 2012 Rosen et al.: BVFL Nomenclature Paradigm

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