Voice Disorders

Symptoms:

The above changes may result in loss of projection and resonance of voice which is perceived as sounding "old."

Treatment:

Voice therapy is the most appropriate initial treatment of age-related voice changes. Voice therapy is aimed at correcting behaviors that cause vocal fold irritation, such as habitual loud-talking or throat clearing. Often, mild hoarseness may be overcome with improved voicing techniques.

If the results of voice therapy prove unsatisfactory, injection of the vocal folds, with substances such as collagen or fat, may be considered to increase the bulkiness of the vocal folds. This intervention can improve the steadiness, strength, and endurance of the voice. However, most substances injected into the vocal folds are slowly absorbed and the results are temporary. Therefore, injections are needed periodically to maintain the quality of the voice.

Symptoms:

Symptoms of Laryngeal Cancer vary based on the exact location of the lesion in the larynx. Hoarse voice, coughing up blood (hemoptysis), noisy breathing and difficulty breathing are some presenting symptoms.

Treatment:

Laryngeal Cancer has a high cure rate if diagnosed early. The size, extent and type of cancer help determine the best treatment option. Laryngeal Cancer may be treated with surgery, radiation therapy, chemotherapy or a combination of these. The goals of treatment are to cure the disease while preserving the voice and swallowing.

Symptoms:

The size and location of the vocal fold Cyst affect the degree of disruption of vocal fold vibration and subsequently, the severity of hoarseness. It is rare to experience any pain. Occasionally, the voice change may be accompanied by a sensation of a foreign body in the area of the voice box (sense of a "lump in the throat") and a feeling of the need to clear the throat or cough.

Treatment:

Voice rest often reduces the hoarseness due to reduction of surrounding swelling.

However, since it is rare for a Cyst to resolve on its own, removal of the Cyst is often recommended. Surgery followed by voice therapy is the most commonly recommended treatment for vocal fold Cysts. Micro-laryngoscopy is the most precise means of operating on the vocal folds. All surgery is performed under general anesthesia, via a laryngoscope, an instrument inserted through the mouth to view the larynx directly. There are no skin incisions. A microscope is used for magnification of the field of surgery and micro-instruments are utilized. Complete removal of the Cyst is required in order to avoid recurrence. In addition, overlying mucosa must be preserved and draped over the area where the Cyst was removed to minimize the chance of scarring.

Following surgery, medication and/or voice therapy are often prescribed to eliminate the vocal fold irritation and misuse that led to development of the Cyst.

Symptoms:

Hoarseness, chronic throat clearing, throat pain, coughing (occasionally blood-tinged), and a foreign body sensation (sense of a "lump in the throat") are common symptoms. Granulomas are one of the few vocal fold growths that can be painful.

Treatment:

Treatment depends on the cause of the Granuloma and is tailored to correct or prevent the irritation that resulted in the growth. Often, control of Laryngopharyngeal Reflux and voice therapy results in slow regress of the growth. Voice therapy is aimed at correcting behaviors that cause vocal fold irritation, such as habitual loud-talking or throat clearing.

When reflux control and voice therapy fail to resolve the Granuloma, alternative treatments including Botulinum toxin injection of the vocal folds or surgical removal of the growth are considered. The goal of Botulinum toxin injection is to weaken the vocal fold and decrease movement, thus reducing the irritation. Surgery is generally the last treatment of choice and is used in cases where very large Granulomas are obstructing the airway or taking a long time to resolve. Surgery without treatment of the underlying factors that caused the Granuloma often results in recurrence of the Granuloma.

Symptoms:

The hoarseness caused by Hemorrhage usually develops over a very short period of time. Hemorrhage often occurs as a result of a specific event that required strenuous use of the voice such as a musical performance or speaking loudly. There is no pain associated with vocal fold hemorrhage; hoarseness is often the only symptom.

Treatment:

For isolated incidents, voice rest is usually the only treatment needed. With time and decreased use of voice, the collection of blood in the outer layer of the vocal fold resolves and the voice returns to normal.

For recurrent Hemorrhage of the vocal fold, the underlying cause must be investigated and treated. If misuse of the voice is the source of the repeated vocal fold Hemorrhage, voice therapy may be useful.

If the repeated Hemorrhage is caused by irregularity of the vocal fold, micro-laryngoscopy may be necessary to remove or repair the irregularities or blood vessels prone to bleeding. Micro-laryngoscopy is the most precise means of operating on the vocal folds. All surgery is done under general anesthesia via a laryngoscope, an instrument inserted through the mouth to view the larynx directly. There are no skin incisions. A microscope is used for magnification of the field of surgery and micro-instruments are utilized.

Symptoms:

Laryngitis often results in hoarseness that is aggravated by voice use. Laryngitis may be short term (acute) or long term (chronic).

Acute Laryngitis is more likely to result from infection or voice misuse. If the reason for the Laryngitis is infectious, there may also be other symptoms such as fever, cough and a sore throat.

Chronic Laryngitis is more likely to be due to acid reflux disease or a vocal fold lesion. If the hoarseness persists beyond two weeks, the vocal folds should be examined and visualized in order to identify the reason for the change in the voice.

Treatment:

Treatment of Laryngitis is based on the source of the inflammation and length of time the patient has been experiencing the symptoms. Infectious Laryngitis is largely secondary to a viral source, and is usually treated conservatively with voice rest and hydration. Medications are not commonly prescribed, since bacterial or fungal Laryngitis are fairly rare.

Laryngitis secondary to misuse of voice (vocal trauma) is also treated conservatively with voice rest and hydration. If there is recurrent vocal trauma and Laryngitis, voice therapy is prescribed to eliminate the vocal misuse.

Treatment for chronic Laryngitis is often more complicated, and may involve multiple modes of therapy, including voice therapy, medication, and occasionally surgery. Any hoarseness that persists beyond two weeks requires an examination of the vocal folds, especially in smokers, who have a high risk of Laryngeal Cancer.

Symptoms:

The main symptom is painless hoarseness. The presence of Nodules disturbs the normal vibration and closure of the vocal folds resulting in hoarseness. The hoarseness usually worsens with voice use (voice fatigue) and improves with voice rest.

Treatment:

Voice rest often improves the hoarseness due to reduction of surrounding swelling but does not shrink the Nodules. Similarly, anti-inflammatory medications, such as steroids, reduce swelling, but do not address the root of the problem.

Voice therapy is the treatment of choice for these lesions and is highly effective in resolving the majority of Nodules. The goal of voice therapy is to make the patient aware of the type of voice use that has led to the problem, and to find strategies to limit the irritation.

Nodules are a condition that needs to be managed over time. With correct voice use, the Nodules shrink; however repeat vocal misuse often results in recurrence of the Nodules. The less advanced the Nodules, the easier they are to cure.

On rare occasions, patients may need surgery to remove advanced lesions. Surgery is reserved for patients in whom voice therapy has been unsuccessful. Surgery does not, however, preclude voice therapy. If lesions are removed, and the underlying causes are not addressed, the patient is at risk for recurrence of the Nodules.

Symptoms:

The main symptom is painless hoarseness. The presence of Papillomas disturbs the normal vibration and closure of the vocal folds resulting in hoarseness. Larger lesions can obstruct the larynx resulting in difficulty breathing.

Laryngeal Papillomas are seen more in young children, who are exposed to the Human Papilloma Virus (genital warts) during passage through the birth canal. Adults often acquire Papillomas through intimate contact. Growths in adults are generally less aggressive than in children as the Papillomas in adults grow slower and are less likely to grow outside of the larynx.

Treatment:

There is no cure for Laryngeal Papillomas. Surgical removal of the Papilloma helps to alleviate symptoms and remains the mainstay of treatment. Papillomas are very resilient lesions which tend to grow back no matter how completely they are removed. Patients may require multiple procedures, no matter how complete the excision.

There are many different techniques for removal of Papillomas, none of which has been proven to be superior. In removing Papillomas, it is essential to cause minimal damage to surrounding structures in order to prevent scarring that may lead to hoarseness or breathing difficulties. For patients with recurrent disease, the risks of surgery must be carefully weighed against the benefits of repeat excision of the Papillomas. For those who require frequent surgeries because of aggressive disease, investigational therapy may be considered.

Overall, patients with milder forms of Laryngeal Papillomas do well and eventually the disease goes into remission. The rare patients with severe disease may need lifelong frequent therapy.

Symptoms:

Polyps may produce a variety of symptoms, depending on their size and location. The main symptom is painless hoarseness. The presence of Polyps disturbs the normal vibration and closure of the vocal folds, resulting in hoarseness. Other symptoms may include the frequent need to clear the throat, coughing and trouble swallowing. Larger lesions can obstruct the larynx, resulting in difficulty breathing.

Treatment:

Treatment of Polyps varies and is dictated by the cause of the Polyp, as well as its size and location. For smaller Polyps, voice rest often reduces the hoarseness due to reduction of surrounding swelling, but does not address the root of the problem.

Voice therapy is almost always recommended in order to make the patient aware of the type of voice use that has led to the problem, and to find strategies to limit the irritation.

Small Polyps caused by smoking may be treated with smoking cessation alone.

Large Polyps often require surgical excision. Micro-laryngoscopy is the most precise means of operating on the vocal folds. All surgery is done under general anesthesia via a laryngoscope, an instrument inserted through the mouth to view the larynx directly. There are no skin incisions. A microscope is used for magnification of the field of surgery and micro-instruments are utilized. Great care must be taken to preserve the overlying mucosa in order to minimize the chance of scarring. Following surgery, medication and/or voice therapy is often prescribed to eliminate the vocal fold irritation and misuse that led to development of the Polyp.

Symptoms:

Common symptoms may include:

• Hoarseness or scratchy voice
• Chronic (ongoing) cough
• A frequent need to clear the throat A "lump in the throat" sensation A "choking" sensation Sore throat or irritation A mistaken perception of post-nasal drip or allergy Excessive, thick phlegm
• Problems while swallowing
• Sour/bitter/acidic taste in mouth (Especially in morning)
• Heartburn after eating
• Singing: Difficulty with high notes Voice fatigue Laryngospasm: (a sudden involuntary closure of the vocal folds that makes it impossible to breathe for a few seconds)

Treatment:

There are a number of tests to diagnose acid Reflux, and a number of effective ways to treat the condition. Anti-Reflux medications are often prescribed, but optimal treatment also involves some simple lifestyle and dietary changes as outlined below.

1. Stress: Take significant steps to reduce stress. Make time in your schedule to engage in activities that lower your stress level. Even moderate stress can dramatically increase the amount of Reflux.
2. Foods: You should pay close attention to how your system reacts to various foods. Each person will discover which foods cause an increase in Reflux. The following foods have been shown to cause Reflux in many people. It may be necessary to avoid or minimize some of the following foods to reduce Reflux:
   • Citrus fruits and juices (orange juice, grapefruit juice, cranberry juice, etc.)
   • Fried/fatty foods
   • Spicy and acidic foods (Mexican food, Tomatoes, etc.)
   • Sodas and/or carbonated beverages
   • Caffeinated beverages and chocolate
   • Alcoholic beverages
   • Onions
   • Peppermints
3. Mealtime: Controlling when and how much you eat is also very important in reducing Reflux.
   • - Eat sensibly (moderate amount of food)
   • Eat meals several hours before bedtime or lying down
   • Avoid bedtime snacks
   • Do not exercise after eating
4. . Habits: Other than eating habits, there are several additional things you can do to help control acid Reflux.
   • Try to maintain a healthy body weight. Being overweight can increase Reflux.
   • Elevate the head of your bed 4-6 inches with books, bricks or a block of wood to achieve a 10 degree slant.
   • Avoid tight belts and other restrictive clothing, especially around your waist.
   • Limit the intake of aspirin and ibuprofen.
5. IF YOU SMOKE, STOP!! Smoking dramatically increases Reflux and harms your body in many other ways.

Symptoms:

Reinke's Edema causes a lowering in the pitch of the voice. This change in voice is often more noticeable in women. Occasionally, the swelling can be significant and can obstruct the larynx, resulting in difficulty breathing.

Treatment:

Tobacco cessation is the best way to treat Reinke's Edema and mild forms of the disease are often reversed with tobacco cessation.

More advanced cases may require surgery to reduce the redundant vocal fold tissue. Micro-laryngoscopy is the most precise means of operating on the vocal folds. All surgery is done under general anesthesia via a laryngoscope, an instrument inserted through the mouth to view the larynx directly. There are no skin incisions. A microscope is used for magnification of the field of surgery and micro-instruments are utilized. Great care must be taken to avoid excessive tissue removal and to preserve an adequate amount of mucosa in order to minimize the chance of scarring. Following surgery, continued tobacco cessation is required to help reduce the risk of recurrence.

Symptoms:

Spasmodic Dysphonia patients have a "jerky" or "tremulous" quality to their voice and their voice often sounds strained. The voice changes are task specific and typically occur during just one type of vocal activity. For example, a patient with Spasmodic Dysphonia may only experience the symptoms when speaking, not when singing or laughing. The symptoms are often exacerbated with anxiety.

Treatment:

There is no cure for Spasmodic Dysphonia; the goal of treatment is to reduce the symptoms. Botulinum toxin (Botox) injections into the vocal folds, through the skin of the neck, reduce the involuntary movement of the vocal folds by partially weakening them. By doing this, the abnormal contraction can be effectively prevented. The effects typically last several months and therefore, patients require lifelong injections to reduce the symptoms. The frequency of injections, as well as the dose given each time, varies for each patient. Voice therapy offers little relief, since the vocal fold motion is involuntary.

Symptoms:

Sulcus Vocalis causes painless hoarseness and change in the pitch of the voice. The voice is often very harsh sounding and patients require increased effort to talk. Sulcus Vocalis is a lifelong condition that onsets in adolescence.

Treatment:

Since an appropriate replacement for the missing outer layer of the vocal fold has not been identified, there is not a universally accepted method of treatment for Sulcus Vocalis.

The best treatment option for Sulcus Vocalis is debated by physicians. Some physicians recommend excision of the sulcus with advancement of the adjacent normal tissues to cover the gap left by the removal. Unfortunately, this technique often results in scarring that increases the level of hoarseness. Other physicians prefer to fill the divot by injection with fat from elsewhere in the body or collagen. With this technique, the results are not always consistent.

Symptoms:

Patients with Vocal Fold Tremor are unable to keep their voice steady. The sound of the voice has a rhythmic wobble, quavering or shake. The voice changes are not task specific and are always present with any type of vocalization. It is common for patients with Voice Tremor to adopt whispering as a standard mode of speaking, since it masks the symptoms.

Treatment:

There is no cure for Vocal Fold Tremor; the goal of treatment is to reduce the symptoms. In addition, there is not a universally accepted treatment method for Vocal Fold Tremor. Although medications have been very beneficial in treating Benign Essential Tremors involving other parts of the body, they have not proved as successful in Vocal Fold Tremor patients.

In severe cases, Botulinum toxin (Botox) injection into the vocal folds, through the skin of the neck, reduce the involuntary movement of the vocal folds by partially weakening them. By doing this, the abnormal contraction can be reduced, making speaking easier. The effects typically last several months and therefore, patients require lifelong injections to reduce the symptoms. The frequency of injections, as well as the dose given each time, varies for each patient. Voice therapy offers little relief, since the vocal fold motion is involuntary.

Symptoms:

The most common symptom of Vocal Cord Paralysis is hoarseness. Vocal fatigue and aspiration (coughing when swallowing liquids due to penetration in to the windpipe (trachea)) are also commonly seen. Noisy breathing and breathing difficulties are seen with bilateral paralysis. The symptoms vary depending on how severely the patient is affected and how well they are able to compensate for the problem.

Treatment:

Treatment of Vocal Fold Paralysis depends on the cause and whether the paralysis is unilateral or bilateral. On occasion, the nerve does heal itself and regain function. It is therefore recommended to schedule any type of corrective surgery six months following the paralysis in order to give the vocal folds time to heal themselves.

Voice therapy and medications are not usually beneficial in reversing the paralysis. However, if the source of the nerve irritation and resultant paralysis is thought to be secondary to inflammation, steroids may be prescribed in order to reduce inflammation. Voice therapy helps to achieve a stronger voice by strengthening the other muscles in the larynx that are not paralyzed.

In most cases of unilateral Vocal Fold Paralysis, the voice can be restored to a near-normal conversational voice. Treatment is aimed at repositioning the immobile vocal fold closer to the midline (vocal fold medialization). This is accomplished by injecting the vocal fold with a filling agent (such as collagen) or by placing a block of artificial material into the larynx, adjacent to the paralyzed vocal fold, via an external approach through the neck (medialization laryngoplasty).

If bilateral vocal fold paralysis restricts breathing ability, a tracheotomy may be necessary to help accommodate breathing.

Symptoms:

Vocal Fold Scars result in painless hoarseness. The extent of hoarseness depends on the size of the scar. Voice fatigue and an increase effort to talk are also seen.

Treatment:

When performing vocal fold surgery for other pathologies, it is essential to take every measure to minimize the risk of scar formation before and after surgery. This includes voice therapy to eliminate harmful vocal habits, controlling acid reflux and avoiding smoking. During surgery, every effort must be made to preserve normal tissue and to avoid trauma to surrounding tissue that is unaffected by the lesion being operated on. In addition, voice rest after vocal fold surgery helps to reduce scar formation.

Voice therapy is the most effective first step in treating existing Vocal Fold Scars. If the scar is fresh, it often improves with voice therapy. Surgical intervention for scars carries a high risk, and may make the scar, and voice, worse. Surgery must therefore be considered very carefully and only performed for patients who have failed all other options