Efficacy and Safety of Adjunctive Steroid Injection After Microsurgical Removal of Benign Vocal Fold Lesions Jung-Hae Cho, Sang-Yeon Kim, Young-Hoon Joo, Young-Hak Park, Woo-Seob Hwang, and Dong-Il Sun, Seoul, Republic of Korea Summary: Objective. This study aims to investigate the clinical efficacy and safety of immediate intralesional steroid injection in patients undergoing laryngeal microsurgery (LMS) for benign vocal fold lesions (BVFLs). Study design. This is a single-institution, retrospective cohort study. Methods. Patients were divided into two groups according to whether or not they received adjunctive steroid injec- tion after LMS. We evaluated the outcomes using objective, perceptual voice analysis and videostroboscopy. We also analyzed clinical parameters and identified risk factors associated with persistent dysphonia after LMS. Results. The study included a total of 211 patients with BVFLs (82 men and 129 women), which comprised 136 vocal polyps (64.5%), 49 nodules (23.2%), and 30 cysts (14.2%); 84 patients (39.8 %) had intralesional steroid ad- ministration combined with LMS. The overall results for postoperative voice parameters in both groups were significantly improved. On videostroboscopic examination, the rate of recurrent lesions was lower in the group that received ad- junctive steroid injection than in the group with only LMS (P = 0.014). In the multivariate analysis, older age (compared to <50 years of age; odds ratio [OR] = 2.697, 95% confidence interval [CI]: 1.300–5.595, P = 0.008) and duration of hoarseness longer than 6 months (compared to <3 months; OR = 2.729, 95% CI: 1.193–6.242, P = 0.017) were iden- tified as independent risk factors associated with persistent dysphonia. Nevertheless, adjunctive steroid injection was associated with a 0.3-fold (OR = 0.345, 95% CI: 0.152–0.784, P = 0.011) lower risk of persistent dysphonia. Conclusion. Steroid injection combined with LMS in the treatment of BVFLs was safe and associated with im- proved voice quality. Key Words: Laryngeal microsurgery–Injection–Steroid–Benign vocal fold lesion–Dysphonia. INTRODUCTION Most benign vocal fold lesions (BVFLs), such as vocal polyps, nodules, and cysts, result from an abnormal inflamma- tory response after trauma (phonotrauma, iatrogenic, or phonomicrosurgical). 1 Voice therapy including vocal hygiene is the first treatment of choice in most patients with BVFLs. Re- cently, vocal fold steroid injection has emerged as an alternative treatment option for BVFLs. 2 However, difficulty in precise in- jection and the gag reflex resulting from a percutaneous approach under local anesthesia remain problematic. In addition, the re- currence rate after steroid injection is relatively high and repeated injection is needed. 2 Laryngeal microsurgery (LMS) has been widely used to restore voice quality and allow accurate diagnosis of BVFLs. An LMS is a quick and definitive surgical treatment but has some unde- sirable postoperative complications, such as persistent dysphonia. 3 Although various factors such as smoking and voice demand may affect vocal fold wound healing, persistent dysphonia or a more deteriorated quality of voice following LMS has been known to develop due to postoperative vocal fold adhesion, scarring, or fibrosis. Steroids have traditionally been used in the treatment of acute inflammatory disease of the upper airway, specifically the larynx, to decrease edema. Therefore, we hypothesized that adjunctive steroid injection might enhance the therapeutic effect of LMS for BVFLs. However, there have been only a few studies, which included small numbers of patients, on the effect of intralesional steroid administration during LMS. 4,5 The aim of this study was to investigate the efficacy and safety of adjunctive steroid in- jection after LMS for BVFLs. METHODS Study subjects Our study was approved by the Institutional Review Board of the Catholic University of Korea, Seoul, Korea. We reviewed the medical records of consecutive patients who underwent LMS for BVFLs between January 2013 and December 2015. Patients with biopsy- proven vocal fold polyps, cysts, and nodules were included. Exclusion criteria included patients who had (1) diffuse polypo- sis, precancerous lesions such as hyperkeratosis, and squamous dysplasia; (2) a previous history of phonomicrosurgery for BVFLs; (3) accompanying structural and functional vocal fold abnormali- ties such as vocal atrophy, sulcus vocalis, vocal fold scarring, and vocal fold paralysis; (4) prior history and present diagnosis of another pathology such as laryngeal tuberculosis, cancer, and connective tissue diseases; and (4) received voice therapy after or before LMS. The study included 211 patients who completed the preoperative and 3-month postoperative voice assessments. All patients had un- dergone a routine laryngologic examination followed by videolaryngostroboscopy using a 70° rigid laryngoscope con- Accepted for publication January 6, 2017. The English in this document has been checked by at least two professional editors, both native speakers of English. For a certificate, please see: http://www.textcheck.com/ certificate/NBCZis. From the Department of Otolaryngology-Head and Neck Surgery, College of Medi- cine, The Catholic University of Korea, Seoul, Republic of Korea. Address correspondence and reprint requests to Dong-Il Sun, Department of Otolaryngology-Head and Neck Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul, 06591, Republic of Korea. E-mail: hnsdi@catholic.ac.kr Journal ofVoice, Vol. ■■, No. ■■, pp. ■■-■■ 0892-1997 © 2017 The Voice Foundation. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jvoice.2017.01.003 ARTICLE IN PRESS