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Babak Larian, M.D.
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In order to better understand the voice disorders described below, it is helpful to have a general knowledge of the mechanics of normal voice production. Enclosed within the thyroid cartilage is the larynx, which consists of the vocal folds and supporting muscle and cartilage. The vocal folds — or vocal cords, as they are more commonly known outside the medical profession — serve various functions. In addition to opening to allow breathing and closing to prevent food from entering the lungs during swallowing, the vocal folds are responsible for producing sound. As air from the lungs passes through the partially closed vocal folds, it vibrates the outer covering known as the mucosa. This thin membrane is attached to a substructure called the superficial lamina propria, or Reinke's layer, which supports the mucosa and allows it to remain pliable enough to vibrate properly. Any abnormality that disrupts this vibration causes a interference in creation of sound and thus causes hoarseness (dysphonia). Listed below are a number problems that can cause voice disturbance:
A vocal fold cyst is a fluid-filled growth located underneath the mucosa, the covering of the vocal fold. Usually, the fluid inside is mucus, and it is a popular theory that vocal fold cysts are the result of a blocked mucus gland. Because vocal fold cysts most often occur at the midpoint of the vocal fold, many experts believe that continual stress on the vocal folds from voice use may promote blockage of the mucus glands and thereby contribute to the development of cysts.
Although possible, it is rare that a vocal cyst disappears on its own. Usually, surgical removal by a surgeon highly experienced in dealing with voice and swallowing disorders is indicated. Complete removal of the cyst is imperative to avoid recurrence. Additionally, great care is taken during the removal of the cyst to prevent scarring of the mucosa. Voice therapy before or following surgery is helpful in order to correct the patterns of voice misuse that led to the development of the cyst.
Typically located at the mid portion of the vocal fold, vocal fold polyps, like cysts, are believed to be caused by stress on the vocal folds. This stress may be accumulative or the result of heavy or improper voice use. Although a vocal fold polyp is a benign (non-cancerous) lesion, it is imperative that a biopsy be performed to determine whether it is anything more serious. Occasionally, cancerous lesion appear similar to a polyp.
Voice rest may allow swelling in the area to subside enough for one to regain the use of his or her normal voice. Unless the underlying problem is treated, however, the condition usually returns. Surgical removal, therefore, is the most effective form of treatment. Voice and swallowing disorders specialists (otolaryngologists) also often recommend voice therapy following surgical treatment in order to correct the patterns of voice misuse that led to the development of the polyp.
When otolaryngologists use the term "reflux," they are referring to laryngopharyngeal acid reflux, rather than gastroesophageal reflux disease, or GERD. While the process is the same, the two terms refer instead to the effects. Laryngopharyngeal reflux occurs when digestive acid and enzymes from the stomach flow upward (backward) into the esophagus and reach the larynx (voice box). The acid and enzymes can cause considerable irritation and injury to the vocal folds and may contribute to the development of vocal fold granuloma. The irritation causes significant edema of the voice box extend down unto the vocal cords themselves. This is a very common problem, and is a major factor causing hoarseness and even swallowing problems.
There is, unfortunately, no "quick fix" for reflux. Dietary changes, which may involve the exclusion of fatty, greasy, or sugary foods from the diet as well as nicotine, alcohol, sodas and caffeine, can be helpful. Additionally, a voice and swallowing disorders specialist may prescribe an anti-reflux medication. Such medications include the proton pump inhibitors, Nexium™, Prevacid™, Protonix™, Aciphex™, and Prilosec™; and the H2-blockers, Zantac™, Tagamet™, and Pepcid ™.
Laryngeal cancer is the growth of malignant cells on the tissues of the larynx. Beginning in the larynx, laryngeal cancer can spread to the deeper tissues of the larynx and possibly to other areas of the neck and body. The vast majority of laryngeal cancer cases are caused by smoking. Cancer that occurs in the vocal folds commonly causes hoarseness. Symptoms of cancer in other areas of the larynx include difficulty breathing and coughing up blood.
If diagnosed early, laryngeal cancer has a high cure rate. Possible treatments include surgery, radiation, chemotherapy, and combination therapy. When determining the most suitable type of treatment, head and neck surgeons take into account a number of factors, such as the size and extent of the cancer. Recent advances in endoscopic and laser technology allow removal of tumors through an endoscope placed through the mouth as opposed an open surgery through the neck. Endoscopic Laser Micro-Surgery is truly an innovative technique that helps patient avoid difficult open surgical techniques.
Symmetrical lesions occurring at the front half of both vocal folds, nodules are non-cancerous masses that may be caused by heavy voice use. They are essentially calluses formed on the surface of vocal cords because of the impact of vocal cords hitting each other hard due to voice abuse. Consequently, professional and amateur singers are prone to developing nodules. Rarely found in men, nodules are most often discovered in women and pre-adolescent boys. This suggests that the size of the larynx may be a factor in the development of nodules. Hoarseness and other voice changes are common symptoms, as the presence of nodules tends to disturb the normal vibration of the vocal fold.
Although voice rest can be helpful in that it may allow swelling to subside and restore normal voice function, it does not address the root cause. Surgery to remove the nodules by an expert in voice and swallowing disorders may also prove temporarily effective; however, if the patient returns to his or her usual manner of voice use, the nodules will most likely return. Voice therapy, then, is typically the treatment of choice. Through identifying the particular habits that lead to the formation of nodules and learning to adopt alternative vocal behaviors, the patient may effectively manage their condition.
Caused by the papilloma virus, a papilloma appears in the larynx as a warty lesion. Because not everyone who carries the virus develops papillomas, experts believe that a person's immune system has some bearing on the growth of a papilloma. Individuals may come into contact with the virus as infants during their passage through the birth canal, so the presence of the disease in young children is not uncommon. Hoarseness is a common indicator of a papilloma. Difficulty breathing, too, may be an indicator if the papilloma has grown to a significant size and blocks the airway.
Surgical removal of the papilloma by a surgeon who has experience treating voice and swallowing disorders may alleviate symptoms; however, the growth is most likely to return. Thus, the benefits of repeat removal must be carefully weighed against the possible dangers of the surgery, such as scarring and impaired voice function. For those that suffer frequent and disruptive recurrences, investigational therapy may be considered.
Contrary to popular belief, laryngitis is not a specific diagnosis; nor is the term interchangeable with "hoarseness." Laryngitis refers to an inflammation of the vocal folds, regardless of the underlying cause. If laryngitis persists longer than two or three weeks, a thorough investigation into the cause by an expert in voice and swallowing disorders (otolaryngologist) is recommended, especially if the patient is a smoker.
When it accompanies other symptoms of the common cold or flu, laryngitis typically resolves itself. If the condition persists, treatment is determined by the diagnosis of the root cause, may it be reflux, polyps, cysts, or some other voice disorder.
A granuloma is a benign (non-cancerous) lesion that typically grows over the vocal process, an area of cartilage that is located behind the vocal fold and beneath the membrane that covers the larynx. When speaking, singing, and coughing, the vocal process of one vocal fold continually comes into contact with the other. The irritation that occurs may give rise to a granuloma. Irritation due to laryngopharyngeal reflux is also a common cause of granuloma. Symptoms of a granuloma may include hoarseness and other voice changes, pain, and the sensation of a foreign object being lodged in the throat.
Treatment of a granuloma depends entirely on the determined cause. If reflux is to blame, changes in diet and prescription medication may improve the condition. Granulomas that arise from vocal fold trauma may be treated through voice therapy, which aims to correct harmful vocal behaviors. If medical treatment is not fruitful a simple surgery to remove the granuloma may be done, but reflux treatment must continue after surgery otherwise there is a chance of the granuloma recurring.
As age inevitably affects other parts of the body, it takes a toll on the structures of the larynx. This occurs in two main ways: the muscle of the vocal fold atrophies (loses bulk) and the network of tissues, known as the superficial lamina propria, that supports the vibration of the vocal fold becomes less flexible. This may result in loss of projection and decreased resonance.
Voice therapy can often help to improve voice quality in aging patients. If changes in voice behavior do not result in adequate improvement, vocal fold injections may be a viable form of treatment when performed by a highly trained expert in voice and swallowing disorders. This involves the injection of a substance such as collagen or fat to increase the bulk of the vocal folds.
The tiny blood vessels of the vocal fold may rupture and bleed when traumatized by the intense physical stress placed on the vocal fold by loud or sustained voicing. As the blood spreads to the superficial lamina propria, it may interfere with proper vibration of the vocal fold. While there is no pain associated with vocal fold hemorrhage, hoarseness is often a symptom.
Vocal fold hemorrhage that occurs as an isolated incident is usually treated with voice rest. If, however, the hemorrhage is recurrent, the underlying cause must be investigated and addressed. Harmful voice behavior that leads to repeated vocal fold hemorrhage can be corrected with voice therapy. If the recurrence is caused by a physical abnormality of the vocal fold, microlaryngoscopic surgery to correct the irregularity may be indicated.
In Latin, sulcus means "furrow" and vocalis means "vocal." The term sulcus vocalis describes a condition in which there is a furrow, or indentation, in the vocal fold due to a thinning in the superficial lamina propria. This refers to the layer of tissue just beneath the outer covering of the vocal fold that is responsible for supporting the vibration of the vocal fold. Accordingly, this disorder causes hoarseness and sometimes changes in pitch. Usually manifesting during adolescence, sulcus vocalis is typically a lifelong condition.
At this time, there is no treatment for sulcus vocalis that is popularly accepted and completely reliable. Some specialists in the field of voice and swallowing disorders (otolaryngologists) advocate the removal of the furrowed area, to be replaced by surrounding tissues. However, this method may cause scarring that could actually increase the level of hoarseness. Others prefer to inject the vocal fold with collagen, fat, or another biocompatible material to close the gap left by the sulcus.
Vocal Fold Scar
Scarring of the vocal fold due to surgery, disease, or accident impedes the ability of the superficial laminia propria to ensure the flexibility of the mucosa, the covering of the vocal folds. Since the vibration of the mucosa is what allows the vocal fold to produce sound, vocal fold scarring may cause hoarseness or other vocal abnormalities.
Observing certain precautions before and after surgery of the larynx may help to reduce the likelihood of scarring. Patients should quit smoking and control laryngopharyngeal reflux, if present, before surgery. After surgery, adequate voice rest is essential, as is, in many cases, voice therapy. In cases in which scarring is already present, voice therapy may be effective to reduce the effects of the scarring upon the voice. Surgical revision of the scar may be risky, even by a surgeon experienced in the treatment of voice and swallowing disorders, since further damage could occur.
Also known as polypoid cordites, Reinke's edema is a swelling of the superficial laminia propria (also called the Reinke's layer). Since it is found almost exclusively in smokers, Reinke's disorder may be caused by continual exposure to cigarette smoke. Symptoms include a lowering in pitch and impaired breathing.
Whether a patient's Reinke's edema is in the early stages or is an advanced case, the first step of treatment is to stop smoking. If symptoms do not significantly improve, surgery may be necessary. In cases that call for surgery, the patient must also quit smoking to reduce the chances of recurrence.
Vocal Fold Paralysis
Damage to the recurrent laryngeal nerve, which travels from the brain to the chest and back up through the larynx, is responsible for paralysis of the vocal folds. Paralyzed vocal folds lose the ability to open or close. Because the nerve on the left side is longer than the one on the right, vocal fold paralysis most often affects the left vocal fold. The condition, however, may occur on both sides (bilateral vocal fold paralysis). The most common causes of vocal fold paralysis are injury to the recurrent laryngeal nerve during surgery, pressure from a growing tumor, or inflammation caused by a viral infection.
Treatment of either unilateral or bilateral vocal fold paralysis depends on the cause of the condition. Some cases resolve themselves; accordingly, otolaryngologists typically recommend postponing any type of corrective surgery for six months to a year to give the vocal folds time to heal themselves. In cases of bilateral vocal fold paralysis that significantly restrict breathing ability, an emergency tracheostomy by an otolaryngologist (an expert in voice and swallowing disorders) may be performed.
A neurologic disease the cause of which is unknown, spasmodic dysphonia causes the involuntary movement of the vocal folds. Depending on the type of spasmodic dysphonia, the vocal folds may either inappropriately come together or come apart during the use of one's voice. The condition is usually found in adults and typically affects the function of the larynx during just one type of activity. For instance, some sufferers of spasmodic dysphonia only experience adverse symptoms when speaking, not when singing, or performing non-vocal functions such as breathing or swallowing. Furthermore, the condition may worsen in times of emotional stress. This may lead some to the erroneous conclusion that the condition is psychological.
Although there is no cure for spasmodic dysphonia, treatments are available that can improve its symptoms. Injections of botulinum toxin (most commonly known as the active ingredient in BOTOX® Cosmetic) into the vocal folds through the skin of the neck may lessen the involuntary movement that characterizes the disorder. This is a simple in-office procedure the effects of which can last up to three months.