The Laryngoscope

C 2014 The American Laryngological,

V
Rhinological and Otological Society, Inc.

Gender and Age in Benign Vocal Fold Lesions

Alisa Zhukhovitskaya, MD; Danielle Battaglia, BA; Sid M. Khosla, MD; Thomas Murry, PhD;
Lucian Sulica, MD

Objective/Hypothesis: Certain lesions appear to occur predominantly in one gender or in younger or older patients.
We examined a large sample from a treatment-seeking population to describe gender and age associations of an array of
benign vocal fold lesions.
Study Design: Retrospective review.
Methods: The medical records and evaluations of all adult patients presenting for care over a 5-year period were exam-
ined for demographic characteristics and lesion type. A total of 641 lesions in 602 patients were grouped into 13 broad cate-
gories, and prevalence was compared between male and female patients and three age groups.
Results: Pseudocysts and bilateral midfold lesions occurred principally in young (1839 years old) females
(P < 0.0001). Reinkes edema was found in older (>39 years old) women (P < 0.012). Polyps, contact lesions, leukoplakia (all
P < 0.0001), and sulcus (P < 0.0002) were found predominantly in men.
Conclusion: Certain benign mucosal lesions are strongly associated with age and especially with gender. These differen-
ces may be explained by intrinsic differences in laryngeal anatomy and phonatory physiology in these groups, including dif-
ferences in phonatory frequency and air pressure, and in the ability of the membranous vocal fold to withstand
phonotrauma. Such inherent differences have implications for treatment expectations and approaches.
Key Words: phonotrauma, age, gender, polyp, pseudocyst, nodule, contact lesion, benign vocal fold lesion.
Level of Evidence: 4.
Laryngoscope, 125:191196, 2015

INTRODUCTION Although associations between lesions and demographic

Benign mucosal lesions are a group of acquired
structural abnormalities of the glottis, typically resulting
from trauma or irritation. Most are manifestations of tis-
sue injury from phonatory vibration, termed phono-
trauma. Others are consequences of irritants such as
cigarette smoke or laryngopharyngeal reflux. These fac-
tors are generally well-recognized andappropriately
are routinely addressed in the management of these
lesions. Clinical practice suggests that additional factors
may influence the development of certain lesions beyond
sources of trauma or irritation extrinsic to the larynx
and have implications for treatment. For example, it is
commonly observed that specific lesions such as nodules
and pseudocysts are more prevalent in females, and
others are more prominent in certain age groups.13
From the Department of Surgery, North Shore - Long Island Jew-
ish Health System (A.Z.), Bronx; Sean Parker Institute for the Voice, Weill
Cornell Medical College (T.M., L.S.), New York, New York; the Florida Atlan-
tic University (D.B.), Boca Raton, Florida; and the Department of Otolaryn-
gologyHead and Neck Surgery, University of Cincinnati College of Medicine
(S.M.K.), Cincinnati, Ohio, U.S.A.
Editors Note: This Manuscript was accepted for publication
August 12, 2014.
Presented at the American Laryngological Association Annual
Meeting at the Combined Otolaryngological Spring Meetings (COSM),
Las Vegas, Nevada, U.S.A, May 14, 2014.
The authors have no funding, financial relationships, or conflicts
of interest to disclose.
Send correspondence to Lucian Sulica, MD, Department of Otolaryn-
gologyHead and Neck Surgery 1305 York Avenue, 5th Floor, New York,
NY 10021. E-mail: lus2005@med.cornell.edu
DOI: 10.1002/lary.24911
factors have been identified in the past, age and gender
have not been systematically examined. The purpose of
this investigation is to describe gender and age associa-
tions in a large, treatment-seeking population at a uni-
versity voice center and to offer possible explanations for
such associations.
MATERIALS AND METHODS
This study was approved by the institutional review board
of Weill Cornell Medical College, New York, NY. New adult (
18 years old) patients who presented over a 5-year period (April
29, 2008April 18, 2013) with a voice complaint and were diag-
nosed with a benign vocal fold lesion during their initial visit
were identified from the senior authors (L.S.) database. Diagno-
sis was assigned by a single fellowship-trained laryngologist
following transnasal flexible or transoral rigid laryngeal video-
stroboscopy. Medical records were reviewed for patients age,
primary and secondary diagnoses, date of visit, chief complaint,
duration of complaint, inciting factors, previous diagnoses and
treatments, Voice Handicap Index-10 score, 4 substance use his-
tory, relevant medical and surgical history, and relevant medi-
cations. Whether the patient was a professional performer was
recorded as well.
Patients were classified according to age, gender, and lesion
type. Lesion definitions were broadly consistent with those in the
current literature.57 A contact lesion was defined as a mucosal
irregularity over the vocal process of thearytenoid cartilage and
included both contact ulcer and granuloma. A contact ulcer was
a superficial ulcerated area on the medial surface of thearyte-
noid. Granuloma was an exophytic mass arising from the vocal
process of arytenoid cartilage. Midfold mass is a heterogeneous
category that encompasses a broad spectrum of subepithelial

Laryngoscope 125: January 2015 Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age
191

Fig. 1. Bilateral midfold masses.
change. Typical features include subepithelial fibrous thickening
at the midpoint of the membranous vocal fold, usually less well-
defined than a polyp, which often extends anteriorly and posteri-
orly along the vibratory margin. A midfold mass can be bilateral
and approximately symmetric or, more rarely, unilateral. Lesions
elsewhere termed nodules fit within this category, as do midfold
lesions that do not easily conform to another category. Cyst was
defined as an encapsulated-appearing subepithelial mass. Polyp
referred to a well-defined sessile or pedunculated subepithelial
lesion at the midpoint of the membranous vocal fold, which could
be hemorrhagic and/or fibrotic. A pseudocyst was defined as fusi-
form translucent lesion on the vibratory margin of the vocal fold.
A sulcus was defined as a focal invagination of epithelium,
caused by tighter than usual epithelial adhesion to the deep tis-
sue of the vocal fold, appearing as a furrow or groove. Hemor-
rhage referred to subepithelial extravasation of blood without
focal mass effect. Reinkes edema was a proliferation of superfi-
cial lamina propria material over the entire length of one or both
vocal folds. Leukoplakia referred to a white-appearing area of
epithelial change; it does not imply anything about histology
other than the presence of keratosis. Scar was a heterogeneous
category of lesions characterized by permanent change to the
lamina propria featuring hypodynamic areas of mucosa, typically
without mass effect. A reactive lesion was defined as a unilateral
focal thickening of the mucosa at the midpoint of the membra-
nous vocal fold, which in judgment of the clinician resulted from
trauma from a contralateral lesion. Lastly, bamboo lesions were
subepithelial rheumatoid deposits with a characteristic linear
appearance of the superior surface of the vocal fold. Journal lim-
its preclude the inclusion of illustrations of all lesion types. The
following figures show examples of the three lesion types that we
Fig. 2. Vocal fold polyp (right).
Laryngoscope 125: January 2015
192
Fig. 3. Vocal fold pseudocyst (left).
judged most likely to be used ambiguously in clinical practice:
bilateral midfold masses (BMM) (Fig. 1), polyp (Fig. 2), and pseu-
docyst (Fig. 3).
The stroboscopic examinations of 127 patients with
lesions, the categorization of which was not clear on the review
of the database, were re-reviewed blindly by the laryngologist.
For no more than 15 patients, the first visit exam was not diag-
nostic (usually because of acute inflammation or edema), and a
follow-up exam was used to categorize the lesion. Most of the
re-reviewed lesions were categorized as BMM or unilateral mid-
fold mass (UMM).
Patients diagnosed with a malignancy in addition to a
lesion of interest were excluded. In patients with two or more
pathologies of interest, the lesions were analyzed separately.
Because of the variation in the number of subjects in each
diagnostic category, chi square analysis was performed with age
and gender analyzed for each diagnostic category. The preva-
lence of various lesions was compared among male and female
patients, as well as between the three age groups using
chi-squared analysis. An alpha level of .05 was selected as a
reference for statistical significance. A Dunn correction was per-
formed for the multiple chi-square analyses, and the tables
reflect the corrected values. The corrected alpha values were
0.029 for gender comparisons and 0.023 for age comparisons.
RESULTS
Table I describes the demographic characteristics of
the study population. Table II and Figure 4 represent
the prevalence of lesions by gender. For purposes of
analysis, patients were divided into three age groups:
TABLE I.
Gender and Age Groups Studied.
602 patients
Total 641 lesions
Gender (cohort) 372 female (61.8%)
230 male (38.2%)
Gender (lesion) 396 female (61.8%)
245 male (38.2%)
Age (cohort) Mean 5 41.09 (1887 years old)
Age group (lesion) 349 (54.4%): 1839 years old
187 (29.2%): 4059 years old
105 (16.4%): 601 years old
Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age
 TABLE II. and UMM were all associated with male gender. Cyst
Lesion Type, Gender, Chi Square Value, and Level Of Significance and scar showed no statistically significant association
for Genders (Corrected Alpha: 0.029). with gender. No lesion had a statistically significant
P Value association with age alone.
Lesion Type (N) Male (%) Female (%) v2 (df 5 1) Reactive lesion, hemorrhage, and bamboo lesion
showed no statistically significant association with
BMM (95) 9 (9.5%) 86 (90.5%) 33.21 P < 0.0001
either age or gender; however, the number of patients
Contact (37) 29 (78.4%) 8 (21.6%) 25.3 P < 0.0001 with these diagnoses was small.
Cyst (43) 16 (37.2%) 27 (62.6%) 0.018 P > 0.8
Polyp (147) 81 (55.1%) 66 (44.9%) 17.79 P < 0.0001
Pseudocyst (126) 16 (12.7%) 110 (87.3%) 34.71 P < 0.0001 DISCUSSION
Reinkes 9 (20%) 36 (80%) 6.314 P < 0.012 In this analysis, we focus on gender and age associ-
Edema (45) ations of benign vocal fold lesions, often noted in passing
Scar (26) 12 (46.2%) 14 (53.8%) 0.697 P > 0.4 in other articles addressing specific lesion types.
Sulcus (52) 33 (63.5%) 19 (36.5%) 14.06 P < 0.0002 Whereas none of the data presented is likely to surprise
UMM (23) 14 (60.9%) 9 (39.1%) 5.01 P < 0.025 seasoned clinicians, it suggests degrees of association
between lesions and age and gender that may be inad-
Hemorrhage (17) 6 (35.3%) 11 (64.7%) 0.058 P > 0.8
equately described by current pathophysiologic concepts.
Leukoplakia (23) 19 (82.6%) 4 (17.4%) 19.21 P < 0.0001
Benign mucosal lesions are considered to result from tis-
Bamboo (3) 0 (0%) 3 (100% 1.85 P > 0.18
sue injury by factors extrinsic to the larynx, principally
Reactive 1 (25%) 3 (75%) 0.295 P > 0.3 vocal behaviors and irritants such as cigarette smoke
lesion (4)
and gastric acid reflux. These are considered to be fairly
Total (641) 245 (38.2%) 396 (61.8%)
homogenous factors. For example, phonotrauma, or the
BMM 5 bilateral midfold masses; df 5 degrees of freedom; physical stress on the vocal fold during phonation,
UMM 5 unilateral midfold mass. although certainly a product of the amount and intensity
of voice use, is considered to exert its effects on laryn-
geal tissues with little variation from individual larynx
young (1839 years old), middle-aged (4059 years old), to individual larynx. Yet this conception does not
and older (601 years old). Table III and Figure 5 show account for the heterogeneous array of phonotraumatic
the prevalence of each lesion type in the three age lesions found clinically. When we note clear predisposi-
groups. BMM were associated with female gender and tions to develop certain types of lesions by gender or
young age. The diagnosis of pseudocyst had similar asso- age, it is reasonable to turn to these features to seek
ciations. Reinkes edema was found to be associated with explanations for lesion differences.
female gender and middle and older age groups. Leuko-
plakia was associated with both male gender and the
oldest age group. Vocal polyps were associated with male Lesions in Women
gender. Females report a greater rate of voice disorders in
Certain lesions had statistically significant associa- general and are found to have a disproportionately
tions with gender only. Contact lesions, keratosis, sulcus, higher rate of benign vocal fold pathologies.1,2 Female

TABLE III.
Lesion Type, Age Groups, Chi Square Value, and Significance Lever for Each Age Group (Corrected Alpha: 0.023).
Lesion Type (N) 1839 Years Old (%) 4059 Years Old (%) 601 Years Old (%) v2 P Value (df 5 2)

BMM (95) 81 (85.3%) 11 (11.6%) 3 (3.2%) 36.89 P < 0.0001

Contact (37) 14 (37.8%) 14 (37.8%) 9 (24.3%) 4.23 P > 0.1
Cyst (43) 12 (27.9%) 20 (46.5%) 11 (25.6%) 12.17 P < 0.024
Polyp (147) 68 (46.3%) 57 (38.8%) 22 (15%) 6.59 P < 0.038
Pseudocyst (126) 100 (79.4%) 20 (15.9%) 6 (4.8%) 32.5 P < 0.0001
Reinkes Edema (45) 7 (15.6%) 21 (46.7%) 17 (37.8%) 29.7 P < 0.0001
Scar (26) 8 (30.8%) 10 (38.5%) 8 (30.8%) 6.71 P < 0.036
Sulcus (52) 23 (44.2%) 15 (28.8%) 14 (26.9%) 4.50 P > 0.1
UMM (23) 17 (73.9%) 4 (17.4%) 2 (8.7%) 3.54 P > 0.17
Hemorrhage (17) 10 (58.8%) 6 (35.3%) 1 (5.9%) 1.42 P > 0.49
Leukoplakia (23) 4 (17.4%) 8 (34.8%) 11 (47.8%) 29.89 P < 0.0001
Bamboo (3) 0 (0%) 2 (66.7%) 1 (33.3%) 3.6 P > 0.16
Reactive lesion (4) 4 (100%) 0 (0%) 0 (0%) 3.35 P > 0.18
Total (641) 349 (54.4%) 187 (29.2%) 105 (16.4%)

BMM 5 bilateral midfold masses; df 5 degrees of freedom; UMM 5 unilateral midfold mass.

Laryngoscope 125: January 2015 Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age
193

predisposition to phonotraumatic injury is usually
explained on the basis of the higher fundamental fre-
quency and consequent increase in collisional trauma.8
Hirano et al. compared fundamental frequencies in
women with nodules (bilateral midfold masses, in the
language of this article) and polyps pre- and postexcision
of the lesions.9 A statistically significant difference in
the fundamental frequency was observed between the
lesions as well as pre- and postexcision. Women with
nodules had higher fundamental frequencies. Although
the fundamental frequencies prior to the development of
the lesion could not be determined, the authors hypothe-
sized that mechanical stress experienced during high-
pitched vibration is confined to the edge of the vocal
fold, predisposing to the formation of nodules via activa-
tion of subepithelial fibroblasts and consequent excessive
collagenous fiber deposition.9 Butler et al. observed that
female vocal folds tend to have less hyaluronic acid in
Laryngoscope 125: January 2015
194
Fig. 4. Prevalence of lesions in males and
females. Asterisk indicates statistically signifi-
cant difference (P<0.05).
BMM 5 bilateral midfold masses; UMM 5 uni-
lateral midfold mass.
the superficial layer of the lamina propria, and thus less
shock-absorbing capacity to withstand vibratory trauma
of phonation as well as decreased capacity for tissue
repair, amplifying the potential from damage related to
high frequency.10
Among our patients, pseudocysts and BMM proved
to occur overwhelmingly in women. The chronic nature
of these lesions is consistent with the factors believed to
characterize female phonotrauma. Whereas the midfold
mass association is well-known, the pseudocyst finding
is less self-evident. Common clinical opinion holds that
development of pseudocysts is related to paresis.3,11
Koufman and Belafsky reported that all 13 patients
with pseudocysts in their report had paresis, and sug-
gested that the lesion results from effortful closure in
the striking zone because of paresis-related glottic insuf-
ficiency.3 They further proposed that the lesion may be
protective against further damage because it bears more
Fig. 5. Prevalence of lesions in three age
groups. Asterisk indicates statistically signifi-
cant difference (P<0.05).
BMM 5 bilateral midfold masses; UMM 5 uni-
lateral midfold mass.
Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age
of the shearing forces of increased subglottal pressure
due to asymmetrical distribution. However, they did not
account for the fact that all patients but one in their
report were female.
Incomplete posterior glottic closure in women with
normal voices has been observed in numerous studies,
and the finding is generally considered to be physiologic;
in some studies, this closure pattern predominates.12,13
We have elsewhere proposed that physiologic posterior
glottic insufficiency functions as a sort of pseudo-paresis
that predisposes females to phonotraumatic injury and
development of pseudocyst.14 This hypothesis is sup-
ported by extensive study of physiologically normal
female vocal-fold closure patterns. Simulated three-
dimensional models of vocal fold edge shapes and closure
patterns provide evidence of a physiologic posterior glot-
tic insufficiency, common to females, which leads to
increased phonation threshold pressure, and in turn
increased phonotraumatic shearing and stress.15 Inter-
estingly, this was proposed to explain the mechanism for
the formation of BMM. The pathophysiology of pseudo-
cyst formation may mimic that of nodules and explain
why pseudocysts develop in neurologically intact female
larynges. It may also provide a common explanation for
the strong association of both pseudocysts and nodules
with the female gender. Furthermore, posterior glottic
insufficiency may offer a better explanation than
increased fundamental frequency alone for the presence
of chronic phonotraumatic lesions only in some women;
high fundamental frequency (relative to males) is a rela-
tively uniform characteristic in women, but insufficiency
is only present in some.
Reinkes edema was also associated with female
gender, consistent with previous literature.1,1619
Because the characteristic rough, low-pitched voice of
patients with Reinkes edema is more disturbing in
women, it is not clear to what extent the association
with female patients is explained by the disproportionate
representation of women in the treatment seeking-
population. Smoking appears to be a necessary but not
sufficient condition for the formation of Reinkes edema;
other factors may include phonotrauma and gastro-
esophageal reflux. However, none of these explain
female predominance. Kravos et al. have proposed that
sex hormones increase the permeability of the vessel
walls in the vocal folds, a fundamental mechanism
believed to underlie the formation of Reinkes edema.20
Lesions in Men
Consistent with other studies,17,21,22 we found pol-
yps associated with the male gender. In common with
others, we propose that this can be explained by
mechanical stress. In the previously discussed study
comparing pre- and postexcision frequencies in women
with nodules and polyps, women who developed polyps
exhibited lower fundamental frequencies. Hirano et al.
hypothesized that low-pitch stress affected the deeper
portion of the vocal fold, predisposing to the rupture of
blood vessels present in the deeper portion of the super-
ficial lamina propria and causing hemorrhage, ulti-
Laryngoscope 125: January 2015
mately predisposing to polyps.9 The study does not
discuss males; however, because men are known to have
low-pitched voices relative to women, we can extrapolate
that male vocal folds are likely to experience similar
mechanical stresses.
Males demonstrated a higher prevalence of contact
lesions, including ulcers and granuloma, again in agree-
ment with existing literature.1,2326 The female-pattern
incomplete posterior glottic closure discussed earlier
obviously minimizes or eliminates the collisional trauma
at the vocal process of the arytenoid cartilage, which is
the root cause of contact ulcers and granulomas.12,13
Conversely, the relatively larger male arytenoid cartilage
with more prominent vocal process is prone to such
injury. Increase in vocal intensity by adduction in males
may cause strong compressional forces at the vocal proc-
esses of the arytenoid cartilages.27 Von Leden and Moore
observed that at lower pitch there is more prolonged
approximation of the vocal folds, leading to even more
potential for injury in an area where there is little pro-
tective soft tissue cover to cushion impact trauma.28
The association of leukoplakia with male gender is
probably explained simply by the historically higher
prevalence of smoking in males rather than by any
intrinsic gender-based predisposition.29 The reason for
the association with sulcus is less clear and not consist-
ent in previously reported series.3032
Lesions Related to Age
Both pseudocysts and BMM were associated with
the youngest age category. Factors that helped explain
the female predisposition to these lesions also explain
this relationship. For reasons that remain unexplained,
posterior glottic insufficiency is found in young women
more frequently than in the elderly.33 Older women have
also been found to have lower fundamental frequencies
than younger women, a change attributed to menopause-
related thickening of the lamina propria increasing the
mass of the vibratory portion of the vocal fold.34 The
remaining associations with middle-aged and older age
groups can be satisfactorily explained by the cumulative
effects of exposure to irritants (leukoplakia, Reinkes
edema).
Treatment Implications
As one would expect when pathologic factors
involved in the formation of benign vocal fold lesions are
presumed to be affecting larynges uniformly, treatment
has been administered fairly homogenously from individ-
ual to individual. Fortunately, the usual components of
voice therapy: education, vocal hygiene, relief of muscle
tension, and elimination of harmful vocal behaviors, are
generally useful in addressing phonotraumatic damage.
An awareness of intrinsic differences in laryngeal mech-
anisms of phonotrauma may allow a more gender-
specific approach.
The implications for surgical management are per-
haps even more thought-provoking. Surgery for benign
vocal-fold lesions is currently aimed at restoring normal
Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age
195
phonatory anatomy and function. When the normal or
physiologic condition itself predisposes to injury, surgery
to address intrinsic factors can be contemplated. Kouf-
man and Belafsky have already strongly advocated for
augmentation procedures in pseudocyst patients on their
assumption that all have paresis.3 If the same prob-
lemglottic insufficiencyexists in normal larynges, for
example, as modeled by the work of Dejonckere and
Kob, might women who have midfold masses or pseudo-
cysts stand to benefit from an intervention to minimize
this insufficiency?15 Certainly, much investigation and
some prudence and forethought are necessary before
embarking on surgery to enhance rather than restore
glottic function, but a sound rationale for such an inter-
vention may result from an expanded appreciation of
factors underlying phonatory stresses on the glottis.
Perhaps the most immediate benefit from an
explicit appreciation of the existence of intrinsic laryn-
geal anatomic and physiologic factors in the formation of
benign vocal fold lesions is the ability to impart this to
patients. Some patients, particularly performers, are
quick to blame themselves for their vocal predicaments,
a natural consequence of explanations that emphasize
terms such as vocal abuse. Understanding that fault
may not lie entirely with vocal behaviors, and that
patients probably have a differential ability to withstand
phonotrauma, not only based on gender and age but also
from individual to individual, so that the same vocal
demand is more likely result in injury in one person
than another, may yield constructive insight as well as
help avoid inappropriate self-blame. Patients may also
have unrealistic expectations of a cure resulting from
treatment. Clinically, the scenario arises most often in
patients with BMM, who believe that their lesions will
disappear with voice rest or surgery, or perceive their
periodic exacerbations as separate, unrelated events
rather than exacerbations of a single, chronic process.
Individuals with intrinsic laryngeal features underlying
their pathologies may be educated regarding the chronic
nature of a problem that they may have considered to be
acute, and about the redoubled importance of behavioral
management under such circumstances.
CONCLUSION
Certain benign mucosal lesions are strongly associ-
ated with age and especially with gender. BMM and
pseudocysts are found overwhelmingly in young
womenand Reinkes edema in older women. Hemor-
rhagic polyps, contact lesions, leukoplakia, and sulcus
predominantly occur in men. These differences may be
explained by intrinsic differences in laryngeal anatomy
and phonatory physiology in these groups, including dif-
ferences in phonatory frequency and air pressure, and in
the ability of the membranous vocal fold to absorb pho-
notrauma. Such inherent differences have implications
for treatment expectations and approaches.
Laryngoscope 125: January 2015
196
BIBLIOGRAPHY
1. Coyle SM, Weinrich BD, Stemple JC. Shifts in relative prevalence of laryn-
geal pathology in a treatment-seeking population. J Voice 2001;15:
424440.
2. Herrington-Hall BL, Lee L, Stemple JC, Niemi KR, McHone MM. Descrip-
tion of laryngeal pathologies by age, sex, and occupation in a treatment-
seeking sample. J Speech Hear Disord 1988;53:5764.
3. Koufman JA, Belafsky PC. Unilateral or localized Reinkes edema (pseudo-
cyst) as a manifestation of vocal fold paresis: the paresis podule. Laryn-
goscope 2001;111:576580.
4. Rosen CA, Lee AS, Osborne J, Zullo T, Murry T. Development and valida-
tion of the voice handicap index-10. Laryngoscope 2004;114:15491556.
5. Vedolini K, Rosen CA, Branski RC. eds. Classification Manual for Voice
Disorders-I. Mahwah, NJ: Lawrence Erlbaum Associates; 2006.
6. Woo P. Stroboscopy. San Diego, CA: Plural Publishing; 2010.
7. Rosen CA, Murry T. Nomenclature of voice disorders and vocal pathology.
Otolaryngol Clin North Am 2000;33:10351046.
8. Titze IR. Physiologic and acoustic differences between male and female
voices. J Acoust Soc Am 1989;85:16991707.
9. Hirano M, Kurita S, Matsuo K, Nagata K. Laryngeal tissue reaction to
stress. In: Lawrence V, ed. 9th Symposium on Care of the Professional
Voice. New York, NY: The Voice Foundation; 1980:1020.
10. Butler JE, Hammond TH, Gray SD. Gender-related differences of hyal-
uronic acid distribution in the human vocal fold. Laryngoscope 2001;111:
907911.
11. Rosen CA, Gartner-Schmidt J, Hathaway B, et al. A nomenclature para-
digm for benign midmembranous vocal fold lesions. Laryngoscope 2012;
122:13351341.
12. Schneider B, Bigenzahn W. Influence of glottal closure configuration on
vocal efficacy in young normal-speaking women. J Voice 2003;17:468480.
13. Pontes P, Kyrillos L, Behlau M, De Biase N, Pontes A. Vocal nodules and
laryngeal morphology. J Voice 2002;16:408414.
14. Estes C, Sulica L. Vocal fold pseudocyst: Results of 46 cases undergoing a
uniform treatment algorithm. Laryngoscope 2014;124:11801186. doi:
10.1002/lary.24451. Epub 2013.
15. Dejonckere PH, Kob M. Pathogenesis of vocal fold nodules: new insights
from a modelling approach. Folia Phoniatr Logop 2009;61:171179.
16. Van Houtte E, Van Lierde K, DHaeseleer E, Claeys S. The prevalence of
laryngeal pathology in a treatment-seeking population with dysphonia.
Laryngoscope 2010;120:306312.
17. Lehmann W, Pampurik J, Guyot JP. Laryngeal pathologies observed in
microlaryngoscopy. ORL J Otorhinolaryngol Relat Spec 1989;51:206215.
18. Honda K, Haji T, Maruyama H. Functional results of Reinkes edema sur-
gery using a microdebrider. Ann Otol Rhinol Laryngol 2010;119:3236.
19. Nielsen VM, Hojslet PE, Karlsmose M. Surgical treatment of Reinkes
oedema (long-term results). The J Laryngol Otol 1986;100:187190.
20. Kravos A, Hocevar-Boltezar I, Gersak K. Serum levels of sex hormones in
males with Reinkes edema. Eur Arch Otorhinolaryngol 2013;270:233238.
21. Nagata K, Kurita S, Yasumoto S, Maeda T, Kawasaki H, Hirano M. Vocal
fold polyps and nodules. A 10-year review of 1,156 patients. Auris Nasus
Larynx 1983;(10 suppl):S27S35.
22. Kleinsasser O. Pathogenesis of vocal cord polyps. Ann Otol Rhinol Laryn-
gol 1982;91:378381.
23. Kiese-Himmel C, Kruse E. Sociodemographic variables of a German sam-
ple of patients with contact granuloma. J Voice 1995;9:449452.
24. Brodnitz F. Contact ulcer of the larynx. Arch Otolaryngol 1960;72:746752.
25. Watterson T H-MH, McFarlane SC. A demographic description of laryn-
geal contact ulcer patients. J Voice 1990;4:7579.
26. Svensson G, Schalen L, Fex S. Pathogenesis of idiopathic contact granu-
loma of the larynx. Results of a prospective clinical study. Acta Otolaryn-
gol Suppl 1988;449:123125.
27. Titze IR. Principles of Voice Production. Englewood Cliffs, NJ: Prentice
Hall; 1994.
28. Von Leden H, Moore P. Contact ulcer of the larynx. Experimental observa-
tions. Arch Otolaryngol 1960;72:746752.
29. U.S. Department of Health and Human Services. The Health Consequen-
ces of Smoking 50 Years of Progress: A Report of the Surgeon General.
Atlanta, GA: US Department of Health and Human Services, Centers
for Disease Control and Prevention, National Center for Chronic Disease
Prevention and Health Promotion, Office on Smoking and Health; 2014.
30. Itoh T, Kawasaki H, Morikawa I, Hirano M. Vocal fold furrows. A 10-year
review of 240 patients. Auris Nasus Larynx 1983;(10 suppl):S17S26.
31. Ford CN, Inagi K, Khidr A, Bless DM, Gilchrist KW. Sulcus vocalis: a
rational analytical approach to diagnosis and management. Ann Otol
Rhinol Laryngol1996;105:189200.
32. Yilmaz T. Sulcus vocalis: excision, primary suture and medialization lar-
yngoplasty: personal experience with 44 cases. Eur Arch Otorhinolar-
yngol 2012;269:23812389.
33. Linville SE. Glottal gap configurations in two age groups of women.
J Speech Hear Res 1992;35:12091215.
34. Honjo I, Isshiki N. Laryngoscopic and voice characteristics of aged per-
sons. Arch Otolaryngol 1980;106:149150.
Zhukhovitskaya et al.: Benign VF Lesions: Gender and Age