Abstract
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) microwebs were identified in 11 patients. Ten of these patients with microwebs and nodules failed to respond to voice therapy and the microweb was identified at direct microlaryngoscopy. Microwebs were identified in 10 of the 20 patients who underwent surgery for vocal nodules. The presence of these tiny shelves of tissue might be coincidental or might be related to coexistent vocal fold pathology. Changes induced by anterior commissure microwebs, including shortening of the vibrating segment and possible restriction in vertical ex cur sion, theoretically alter the mechanics of vocal fold vibration to favor nodule formation. Symptoms occurring early in life, in a patient with nodules whose hoarseness is refractory to voice therapy, suggests the presence of an occult microweb. Detection requires a high index of suspicion, ob ser va tion during maximal vocal fold abduction, and clearing of secretions from the anterior commissure. Definitive identification is facilitated by gentle separation of the anterior vocal folds during direct microlaryngoscopy.

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