Misdiagnosis of Vocal Fold Nodules

Abstract

Introduction: Benign vocal fold masses (BVMs) include nodules, polyps, cysts, and other pathology. Nevertheless, some otolaryngologists and other physicians utilize “vocal fold nodules” as an umbrella diagnosis for vocal fold masses. Patients subsequently evaluated by a laryngologist are found to have a different vocal fold mass, which often has a different prognosis and treatment plan compared to nodules. Objective: The purpose of this study was to investigate the rate at which vocal fold nodules are misdiagnosed. Methods: Adult voice patients who presented to our voice center having been evaluated elsewhere by an otolaryngologist and diagnosed with vocal fold nodules, or prenodules, were included in this retrospective study. Strobovideolaryngoscopy (SVL) footage from each patient’s first visit or prior to any treatment at our center was compiled and de-identified. Three blinded physician raters evaluated the videos to determine if the mass(es) was/were nodules on a binary scale, with 1 indicating a nodule. If the mass was not a nodule (0), the raters were asked to identify it based on a list of five different mass types. Results: There were 56 cases (11 male and 45 female) included in the retrospective cohort. The average age was 38 ± 14.8 with a range of 11–65. Reliability between all raters was fair (κ = 0.3). Individually raters 1 and 2 had very good reliability (κ = 1) and rater 3 had good reliability (κ = 0.6). In 100% of cases, two raters agreed that none of the masses were nodules. Only one rater identified two masses as vocal fold nodules, indicating that at least 97% of cases were not vocal fold nodules and had been misdiagnosed. The most frequently identified mass and the most frequently agreed upon mass by all raters was vocal fold cyst or pseudocyst, followed by fibrous mass. Only one rater was unable to identify the mass type in some cases (n = 7). Conclusion: Vocal fold nodules are frequently misdiagnosed. Proper identification of vocal fold masses requires high levels of expertise and SVL. Since treatment of BVMs varies with mass type, accurate diagnosis is essential.