Vocal Fold Scar – New Classification Proposal

Vocal Fold Scar – New Classification Proposal

¹Jeferson Sampaio d’Ávila, ²Daniel Vasconcelos d’Ávila, ³Antônio Roberto Ferreira Setton, ⁴Carlos Rodolfo de Góis, ⁵Lauro Roberto de Azevedo Setton, ⁶Davi Vasconcelos d’Ávila

¹Federal University of Sergipe (UFS), Aracaju-SE, Brazil. Otorhinolaryngologist from the Pontifical Catholic University of Rio de Janeiro (PUC)of Sergipe (UFS)

²Tiradentes University-SE (UNIT-SE), Brazil. Otorhinolaryngologist from the University of São Paulo (FMUSP). Master’s and PhD from FMUSP. Fellowship in Pharyngolaryngology at FMUSP Professor of Otorhinolaryngology at Tiradentes University – SE, Brazil Aracaju-SE

³Federal University of Sergipe (UFS), Brazil. Otorhinolaryngologist from Santa Casa de Misericórdia de Maceió. PhD from the Federal University of Sergipe (UFS). Coordinator of the Hearing Health and Cochlear Implant Service at São José Hospital – Otocenter, Brazil, Aracaju-SE

⁴Federal University of Sergipe (UFS), Brazil. Otorhinolaryngologist from Otorrinos Hospital. PhD from the Federal University of Sergipe (UFS). Professor of Otorhinolaryngology at the Federal University of Sergipe (UFS), Brazil, Aracaju-SE

⁵Tiradentes University (UNIT-SE), Brazil Physician from Tiradentes University (UNIT-SE). Otorhinolaryngology resident at Santo Antônio Hospital – Obras sociais Irmã Dulce (OSID) – Salvador-BA

⁶Tiradentes University-SE (UNIT-SE), Brasil.  Medical student at Tiradentes University (SE), Aracaju – SE, Brazil

DOI: https://doi.org/10.51244/IJRSI.2025.1215000121P

Received: 19 April 2025; Accepted: 06 August 2025; Published: 02 September 2025

SUMMARY

Background: There are several types of scars on the vocal folds, for multiple causes. Strobe videolaryngoscopy is the safest and most elucidative diagnostic method, as it evaluates the mobility of the vocal folds and the tissue analysis of the lesion. Treatments such as speech therapy, topical application and infiltration of substances, as well as surgeries are proposed alone or in combination. Objective: To present a new classification of vocal fold scars, taking into account structural changes within and outside the vocal fold boundaries. Method: To characterize scars that exceed the anatomical limits of the vocal folds, such as synechiae and granulomatous lesions, considered hypertrophic and exuberant. Classify the types of granulomas in terms of appearance and location. To classify the different types of synechiae resulting from reflux complication, iatrogenic surgical trauma, and post-radiotherapy. Compare intra-tissue scars with extra-tissue scars. Result and Conclusion: Proof of the efficacy of this didactic systematization with the use of videolaryngoscopy and microscopy associated with rigid endoscopy in the intraoperative period, with a better understanding of the disease and programming of the most appropriate therapeutic regimen.

INTRODUCTION

There are several types of vocal fold scars caused by multiple etiologies, including those resulting from infectious and inflammatory processes, external laryngeal trauma, and various iatrogenic events. The literature generally discusses scars in relation to the histopathological ultrastructure of the vocal fold and their impact on vocal function. Intracordal scarring is the most frequently addressed due to the consequent dysphonia, particularly with respect to its effect on professional voice users.

In the reviewed literature, a lack of publications and consensus was observed regarding the classification of vocal fold and glottic region scars. A publication by the American Laryngological Association and the European Laryngological Society in 2019 proposed a shared classification for vocal fold scars with altered histological structure. This work has become a reference for clinical and therapeutic parameters in laryngology. (1)

Furthermore, there is a noticeable scarcity of references addressing extracordal scarring processes organic scars that are visually detectable via endoscopic examination and their related classification systems. (2,3).

European and American Classification of Vocal Cord Scar

The consensus among academic societies is that vocal fold scarring is initially regarded as a challenging benign laryngeal disorder. The classification proposed is based on the depth and lateral extent of the scar, comprising four types: type I, characterized by atrophy of the superficial lamina propria with or without epithelial involvement; type II, in which the epithelium, lamina propria, and vocalis muscle are affected; type III, where the scar is located at the anterior commissure; and type IV, which includes extensive scarring along the anteroposterior and rostrocaudal axes, with significant loss of vocal fold mass. This is considered a comprehensive framework, as it objectively encompasses all existing iatrogenic and non-iatrogenic etiologies (1). It establishes that tissue alterations can occur in any layer of the vocal fold, from the epithelium to the vocal muscle. Due to tissue contraction associated with scarring, fixation of structures may occur, leading to reduced movement and vocal fold mobility. Consequently, dysphonia varies depending on the depth and extent of cellular involvement. It is important to note that this study refers exclusively to intratissue scarring, which remains within the anatomical limits of the vocal fold. The vocal characteristics, as assessed using the GRBAS scale, typically include hoarseness due to air escape, roughness caused by fixation of internal structures, breathiness due to lack of glottic coaptation, asthenia resulting from compensatory effort, and absence of strain (1).

Method: Proposal for Clinical Systematization of Vocal Cord Scars

The objective of this study is to present a new progressive proposal that facilitates the understanding of the disease and provides a training tool for laryngology. The clinical evidence of scars extending beyond the anatomical limits of the vocal folds—invading the glottic space and not previously referenced in the reviewed literature—justifies the present investigation. This study will present glottic and vocal fold scarring that exceeds the anatomical boundaries of the vocal folds, including synechiae and various granulomatous lesions, which are hypertrophic and exuberant. These lesions result from iatrogenic surgical trauma and post-radiotherapy effects. (13). A comparison between intratissue and extratissue scarring will also be demonstrated. (3,4,5)

This classification system was applied over a ten-year period, with analysis of 342 patients who underwent laryngeal microsurgery. Of these, 53 patients (15%) were diagnosed with leukoplakia and carcinoma, and 6 (2%) with granulomas. All of these 59 patients (17%) presented extratissue scars of varying forms and dimensions, indicating that 17% of the total laryngeal microsurgery cases were affected by some type of scar.

A total of 59 extracordal scars were identified, associated with varying degrees of organic-functional dysphonia and motor dysphagia. No cases of dyspnea were identified in the present study. Figure 1.

Figure 1 – Intracordal scar. Source: authors

Extrachordal scarring occurs when the scar lesion does not respect the classic anatomical limits, exceeding them and presenting with visible and detectable organic alterations on endoscopic examinations of the larynx, with obstructive potential in relation to the occupation of the glottic cleft. (2,6,7,8,9). Figures 2, 3, 4, 5.

Figure 2 – Anterior Commissure Synechiae – D’Avila Area I. Source: authors

Figures 3, 4, 5  – Posterior Glottic Granulomas. Source: authors

The anatomical regions most affected by synechiae are d’Avila Areas I and II, respectively. Regarding granuloma, d’Avila Area III was the most affected, predominantly located at the vocal process, consistent with the literature. (2,11,12).  Figures 6, 7, 8.

Figure 6 – D’Avila I Area

Figure 7 – D’Avila II Area

Figure 8 – D’Avila III Area D’Avila et al, 2003

Patients affected by synechiae, who did not present with respiratory insufficiency, were followed for monitoring of the underlying disease as well as the synechiae themselves. Patients diagnosed with granulomas were initially managed through clinical treatment, and in cases of therapeutic failure, they underwent the d’Avila Surgical Technique Variant, which proved effective in resolving the condition (2).

We recognize as limitations of this study the need to increase the sample size and to achieve a more specific differentiation of extracordal scars, so that the protocol can be reproduced with greater reliability by other institutions. (Table 1).

Table 1 presents the basic differences between the classifications.

Table 1 – Classification (New Proposal) – Vocal fold scar

RESULTS AND CONCLUSION

The application of this methodological systematization in daily practice over a period of 10 consecutive years resulted in a better understanding of the disease’s pathophysiology and the development of the safest therapeutic regimen. Therefore, the routine application of this new diagnostic systematization in clinical and surgical practice is recommended.

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