Anterior commissure microwebs associated with vocal nodules: detection, prevalence, and significance

Vocal fold nodules are a common cause of dysphonia generally attributed to vocal abuse. Anterior commissure microwebs have been reported as an incidental finding in surgical patients with nodules. In a series of 105 nodule patients evaluated at the University of Wisconsin Clinical Science Center voice laboratory (1987-1992), 11 microwebs were identified. Ten of these microweb patients were among the 20 nodule patients who did not respond to voice therapy and underwent microsurgery. In patients with nodules whose hoarseness is refractory to voice therapy, symptoms that occur early in life suggest the presence of occult vocal fold pathology. Microweb detection requires a high index of suspicion, observation during maximal vocal fold abduction, and clearance of secretions from the anterior commissure. Definitive identification is facilitated by gentle separation of the anterior vocal folds during direct microlaryngoscopy. The presence of these tiny shelves of tissue might be coincidental, or they might represent another expression of the tissue response to traumatic factors known to produce vocal nodules. We found little difference in vocal function parameters between two similar groups of nodule patients, one with and one without associated microwebs. Further work is needed to determine the significance of microwebs.