What is a pseudocyst?
A pseudocyst is a specific and clearly demarcated mass (“mass” simply means lump, and does not imply cancer or precancerous lesion) almost always found at the midpoint the vocal cord. This typical location suggests that pseudocysts, like many other benign vocal fold lesions, are the result of phonotrauma, the physical stresses on the vocal fold which occur with heavy voice use or voice use under adverse circumstances. It is not clear why a pseudocyst forms instead of another lesion related to phonotrauma, like a polyp. The theory that pseudocysts are also related to underlying vocal fold paresis has been advanced, but this has not been proven.
What are the symptoms of a pseudocyst?
Pseudocysts cause painless hoarseness. In contrast to other masses, the hoarseness from pseudocysts is less pronounced, and may be intermittent. This is because the pseudocyst usually retains some flexibility and vibrates along with the rest of the vocal fold, whereas a polyp or a cyst generally does not. A pseudocyst may cause a voice change only when it is swollen, so patients may report hoarseness only after heavy voice use or during a cold or allergy season. Clinically, a large number patients who have pseudocyst are vocalists, probably because the resulting hoarseness is typically mild enough to be evident only to someone who is very aware of and bothered by small changes in voice quality.
Figure 1. Right vocal fold pseudocyst during breathing (left) and voicing (right). The translucent nature of the lesion is apparent during voicing.
What does a pseudocyst look like?
A pseudocyst looks like a transparent, sac-like lesion on the edge of the vocal fold. If inflamed or swollen, it may appear more opaque, with a reddish hue. It is sometimes associated with a vocal fold hemorrhage in which case it may be red, indistinguishable from a polyp. Only when the blood resolves does it become apparent that it is a pseudocyst.
Figure 2: Left vocal fold pseudocyst during breathing (left) and voicing (right). Because this pseudocyst is broader it is not immediately evident during breathing. When the vocal folds are apposed in voicing, the bulge on the edge of the left vocal fold is clear.
How is a pseudocyst treated?
Not all pseudocysts require surgery. In some individuals, it is enough to minimize inflammation, and the pseudocyst will retain enough flexibility to minimally impact the voice. This is done through voice therapy to minimize phonotrauma, and control of medical factors like allergies and acid reflux, when present. A trial of medical and behavioral management is appropriate in almost every individual with pseudocysts.
When persistently bothersome, or when exacerbations remain frequent and difficult to control after voice therapy, pseudocysts may be successfully removed by means of microlaryngoscopic surgery. As always, whether an individual should take this step depends on the level of vocal disability – what may be crippling hoarseness to a vocalist may be of no consequence to someone else. Pseudocysts are superficial lesions with a generally low risk of scarring, and most performers are able to return to performance without difficulty afterwards. Although there is little evidence to support the use of voice therapy in conjunction with surgery, most laryngologists feel that it is advisable in order to attain the best outcome and reduce the chances of forming another polyp by continuing the voice habits that led to the first one.