Voice Rest Versus Hypofunctional Whispering After Phonosurgery

Background: Benign vocal fold lesions (polyps, cysts, and Reinke's edema) are among the most common organic causes of dysphonia and are frequently treated with microlaryngeal phonosurgery. The optimal postoperative voice behavior protocol remains debated. Absolute voice rest has traditionally been recommended to protect the healing vocal fold mucosa, but growing evidence suggests that its theoretical advantage may not translate into superior clinical outcomes, and complete silence imposes a considerable psychosocial burden. Studies directly comparing hypofunctional whispering with absolute voice rest using a prospective randomized design are limited.

Objective: To compare the effects of two postoperative voice behavior protocols applied for five days after phonosurgery for benign vocal fold lesions - absolute voice rest versus communication limited to hypofunctional whispering - on patient-reported voice outcomes, acoustic parameters, aerodynamic measurements, perceptual evaluation, and videolaryngostroboscopic findings.

Design: Prospective, single-center, randomized, parallel-group controlled trial conducted in the Department of Otorhinolaryngology - Head and Neck Surgery at Marmara University School of Medicine.

Participants: Patients with benign vocal fold lesions (polyp, cyst, or Reinke's edema) scheduled for microlaryngeal surgery who met the inclusion criteria. Sixteen patients were enrolled and analyzed.

Randomization and Blinding: Patients were allocated 1:1 into two groups using computer-based random number generation, performed after preoperative assessment and immediately before surgery. Due to the nature of the intervention, blinding of patients and the surgical team was not possible. However, perceptual (CAPE-V) recordings were rated by two independent speech-language pathologists, and videolaryngostroboscopic recordings by two independent laryngologists, all blinded to group assignment.

Interventions: All patients underwent suspension microlaryngoscopy under general anesthesia by a single surgeon, using a microflap technique with preservation of the superficial layer of the lamina propria. Group 1 observed absolute voice rest for five postoperative days; Group 2 followed a hypofunctional whispering protocol (soft, low-effort whispering) for five postoperative days. From postoperative day six onward, both groups received the same standardized voice therapy protocol delivered by an experienced speech-language pathologist.

Outcome Measures: The primary outcome was the change in Voice Handicap Index-30 (VHI-30) total score from baseline to postoperative month 3, with the established minimal clinically important difference (MCID) of 18 points used as a reference. Secondary outcomes included Voice-Related Quality of Life (V-RQOL), Acoustic Voice Quality Index (AVQI) and traditional acoustic parameters (F0, jitter, shimmer, HNR), aerodynamic measurements (maximum phonation time and s/z ratio), perceptual evaluation according to the CAPE-V protocol, and videolaryngostroboscopic findings scored with the VALI protocol. All assessments were performed at three time points: preoperatively, postoperative month 1, and postoperative month 3. At the end of the five-day protocol period, patients completed a structured questionnaire assessing protocol compliance, quality of life, and satisfaction.

Statistical Analysis: Between-group and within-time comparisons were performed using linear mixed model analysis, with time, group, and time-by-group interaction as fixed effects and patient as a random effect. The difference between the two protocols was assessed via the significance of the time-by-group interaction term. Questionnaire comparisons were analyzed using Mann-Whitney U and Fisher exact tests. The proportion of patients exceeding the VHI-30 MCID threshold was compared using the chi-square test.

Inclusion criteria

• Age 18 years or older
• Diagnosis of a benign vocal fold lesion (vocal fold polyp, cyst, or Reinke's edema)
• Scheduled for microlaryngeal (phonosurgery) surgery under general anesthesia
• Able to complete voice assessments and comply with the assigned postoperative voice behavior protocol
• Provided written informed consent

Exclusion criteria

• Malignant or premalignant vocal fold lesions
• Previous laryngeal surgery or radiotherapy to the head and neck
• Neurological voice disorders (e.g., vocal fold paralysis, spasmodic dysphonia)
• Significant psychiatric or cognitive impairment preventing protocol compliance
• Active smoking without cessation in Reinke's edema cases where required (if applicable)
• Inability or unwillingness to attend follow-up assessments