Objective An increasing number of vocal fold cysts excised, as compared to polyps, over the last decade led us to review these cases. We found a statistically significant increase in cysts excised as compared to polyps, over the latter 5‐year period (2013–2017). This prompted us to analyze possible factors responsible for this increase. We also performed a histological study of the normative distribution pattern of seromucinous glands in the apparently normal vocal folds. Methods A retrospective review of all cysts and polyps excised over a 10‐year period was performed. Patient demographics, air‐pollution levels, videostroboscopic findings and histologic analysis of pathology were reviewed. Findings were compared between the initial and latter 5‐year period of all cysts excised. The second part of the study entailed a histological study of the presence and distribution pattern of seromucinous glands in 40 apparently normal fresh frozen cadaver vocal folds. Results There was a statistically significant (P = .035) increase of mucous retention cysts excised as compared to polyps over the latter 5‐year period. Decreased laryngeal hydration was a significant associated finding in cysts excised over the decade as compared to polyps. Striking zone lesions, suggestive of vocal abuse, were seen in a majority of patients of both polyps and cysts excised over the decade. Air pollution had significantly increased in India over the latter 5‐year period. Vocal fold histology in cadavers revealed a presence of seromucinous glands in 32.50% (13/40) with 25.00% (10/40) present in the Superficial Lamina Propria (SLP). Conclusion Decreased laryngeal hydration, vocal abuse and mucous glands present in the SLP may be predisposing factors towards mucous retention cyst formation. An increase in number of these cysts excised over the latter 5‐year period was seen as was increased air pollution. Level of Evidence 3b for the first part of study and NA for the second part of the study Laryngoscope, 130:986–991, 2020

We thank the authors for their comments regarding our article "A 10-Year Study of the Etiopathogenesis of Cysts With a Study of Seromucinous Glands in Vocal folds." 1 Here are our responses.They have incorrectly stated our definition of decreased/inadequate laryngeal hydration as "daily consumption of ≤ 4 glasses of water/beverages." (p2) We considered inadequate laryngeal hydration as ≤4 glasses of water or consumption of >8 beverages (tea/coffee/cola) a day." 1(p2) Excessive tea/coffee/cola has a dehydrating action and cannot be grouped with water. 2,3 In addition, we did not use the term "VF dehydration." (p2) Regarding medication and daily activity causing dehydration, the personal history taken of all patients included this history. There was no medication used that results in obvious decreased hydration; all diabetic patients were well controlled, and none of our patients were athletes. Although humidity varies in each region, our study revealed decreased laryngeal hydration as a significant associated finding in cysts excised as compared to polyps excised, 1 wherein the patients operated for both cysts and polyps hailed from geographically similar areas. Regarding the reflux finding score (RFS), in the peer-reviewed article by Belafsky et al., 4 the study reveals that although each item alone was unable to predict the presence or absence of laryngo-pharyngeal reflux (LPR), the total RFS score was highly suggestive of LPR. 5 We have clearly stated what we mean by striking zone lesions "(junction of anterior one third and posterior two thirds of the vocal fold)" 1(p2) and that diagnosis was by stroboscopy. This diagnosis was made having seen the entire vocal fold, including the anterior commissure, by flexible or rigid stroboscopy or both.Regarding the experience of the laryngologist improving over time, our study was a retrospective one for which the laryngologist had a 25-year experience at the time of study. The final diagnosis was based on histopathology of cysts and polyps excised. 1 Regarding not differentiating between mucous and epidermoid cysts, in our study not only have we differentiated between them and given the statistics for both types of cysts separately, but we have further described them into the four histopathological types based on Koren's 6 classification. Both the Martin et al. 7 and Milutinovic and Vasiljevic's 8 studies have concluded a role of phonotrauma for mucous retention cysts, so it is incorrect to state that the articles referred to by us have not differentiated in the types of cysts when discussing phonotrauma. "One study being characterized by a higher proportion of EC" does not hold any ground because Milutinovic and Vasiljevic's study concludes a functional aspect to the etiology of retention cysts, as does our study. NUPUR KAPOOR NERURKAR, MS (ENT)

Introduction Sclerosing inflammatory pseudotumor of the temporal bone is a rare fibro-inflammatory, benign albeit locally aggressive pathological entity.  Case Report We report a case of Sclerosing inflammatory pseudotumor of the temporal bone, simulating a cholesteatoma. A 61-year-old female presented with right otalgia, hearing loss, facial pain and imbalance. Ear microscopy revealed a pulsatile mass in the external auditory canal. HRCT temporal bone and MRI reported soft tissue mass in the right middle ear and mastoid air cells, causing attenuation of the ossicles with erosion through the tegmen and mastoid cortex. The patient underwent canal wall down tympanomastoidectomy. The histopathology with immunohistochemistry was consistent with IgG4 related sclerosing inflammatory pseudotumor. Discussion This case report explores the similarities as well as the clinical differences between cholesteatoma and IgG4 sclerosing inflammatory pseudotumor of temporal bone, along with the diagnostic and treatment challenges. It is often mistaken for neoplasm or cholesteatoma, hence should be considered as a differential diagnosis.

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