Different Voice Disorders

With the expertise of the doctors and the availability of the most advanced diagnostic tools, Yeson Voice Center is able to meticulously define these different voice disorders.

VOCAL FOLD PARALYSIS

The vocal folds of the larynx are the major source of sound in speech.  This is controlled by cranial nerve 10, the vagus nerve.  The muscles of the larynx and vocal folds move together naturally to produce sounds , for breathing, and to prevent food from entering the trachea.  These are innervated by the recurrent laryngeal nerve and superior laryngeal nerve, both from the vagus nerve.

The vocal folds are brought together by the action of the laryngeal nerves.  The air pressure builds up beneath the larynx, generating a sound through the rhythmic opening and closing of the vocal folds.  However, when the nerves are paralyzed, the vocal folds do not open or close properly, leaving the airway passage and lungs unprotected.  This causes hoarseness and coughing because of food that can get to the trachea.

This condition is called Vocal Fold Paralysis, it can be unilateral wherein one side is paralyzed, or bilateral wherein both the vocal folds are paralyzed.

Aside from laryngeal nerve paralysis causing the abnormal movement of the vocal folds, there are still many other causes of this condition that should be carefully examined.  These are laryngeal mass, arytenoid dislocation secondary to trauma, damage to joints, congenital malformation, inflammation, infection, and scarred vocal fold.

It is important to examine the severity of the vocal fold paralysis, whether it can still recover and the time of recovery.  There are different procedures that can be done to evaluate the paralysis according to its most likely cause.  Brain computed tomography and brain Magnetic resonance imaging are performed to examine brain disorder, brain tumors, disorder of the central nervous system and the peripheral nervous system.  Cervical computed tomography to identify neck tumors and disorders in the blood vessels and nerves.  Thyroid function test and ultrasonography can also be done.  Laryngoscopy and laryngeal stroboscopy are done to identify congenital disorders, inflammatory diseases and other functional disorders.

The treatment for vocal fold paralysis started since 1911 by Dr. Wilhelm Brunings when he treated vocal fold paralysis by injecting paraffin to the muscle.  This treatment is used only mainly until 1970s because of its side effect, the formation of granuloma.  In 1915,  Dr. Erwin Payr then developed the method of operating the thyroid cartilage.  From then on, there was no systematic theory until 1950.  In 1974,  Dr. Isshiki established thyroplasty which became common.  Arytenoid adduction was then performed to 12 patients by Dr. Slavit and Dr. Maragos in 1992.

In 1977, the method of partially resecting the omohyoid muscle which is connected to the hypoglossal nerve branch and implanting it to the vocal fold muscle was attempted by Dr. Tucker.  This is also the method of replacing the paralyzed nerve in the vocal fold with another nerve.  However, it is not commonly used because it requires too much time for the vocal fold to recover its function.

Later in 1984, Dr. Ford attempted the method of injecting collaged into the vocal folds.  In 1991, Dr. Mikaelin introduced the method of using fat transplantation.

Today, the newest operative method used is the Percutaneous EMG Guided Injection Laryngoplasty.  This is developed and presented at the national and international conferences by Dr. Hyung Tae Kim, the chairman of Yeson Voice Center.  This method involves the injection of artecoll to the vocal cord ligament layer using electromyogram.

VOCAL DYSPHONIA

VOCAL NODULE

Vocal fold nodules are caused by strenuous or abusive voice practices especially those who use their voice in their profession.  This usually occurs bilaterally and often symmetrically.

Continuous hoarseness and fatigue are the main symptoms of vocal fold nodules.  Nodules do not cause pain or difficulty when swallowing food.  The nodules usually appear in the center of the vocal fold, the area that receives the most pressure when the folds come together and vibrate.  Vocal fold nodules do not grow over a certain size and thus do not cause breathing difficulties.

In this case, it is important to receive voice therapy that focuses on eliminating voice abuse and teaching the proper use of voice.  Nodules usually resolve with voice therapy itself.  When therapy fails, surgical treatments are then necessary.  Surgeries include Microlaryngeal Surgery and CO2 laser.  Currently, endoscopic microfracture surgery and pulsed dye laser are performed.  Postoperative voice rest is very important.

VOCAL POLYP

Like vocal nodules, a vocal polyp is caused by voice abuse.  It may be caused by a temporary damage or an upper respiratory tract infection.  Seen more commonly in adults than in children.  They can be sessile or pedunculated, edematous or angiomatous.

Vocal polyps can cause hoarseness, and the symptoms may vary depending on the size and its location.  In some cases, the symptoms occur broadly and severely, and disseminated polyps may result in breathing difficulties.

This lesion requires microlaryngeal surgery and pulsed dye laser to be removed.  When the cause is voice abuse, voice therapy should also be done.

VOCAL CYST

Vocal cyst is a mass made up of collection of mucus that is surrounded by a membrane.  It is found underneath the mucosa, within the superficial lamina propia, the layer that is important for normal voice production.

Cysts generally cause painless hoarseness.  The hoarseness results from irregularities in the vocal fold closure and vibration.  In some cases, the voice change may be accompanied by sensation of a foreign body at the level of the vocal folds, or feeling of wanting to clear the throat or cough.

Cysts are most commonly removed by microlaryngeal surgery and pulsed dye laser at the same time.  It is very important to remove the root completely to prevent any recurrence.

GRANULOMATOUS LARYNGITIS

Intubation granuloma is caused after a laryngeal surgery, bronchoscopy or an endotracheal intubation.  It is usually found at the back of the vocal fold over the part of cartilage.  At the beginning, the granuloma becomes larger in size but it later on regresses in size.  In many cases, the granuloma occurs bilaterally, and hoarseness is not severe.  This is more commonly found in females.

Vocal rest and steroids can improve the condition.  While the granuloma is growing, antibiotics can be of help.  If the granuloma does not improve after these, a mocrolaryngeal surgery or steroid injection after an incision using CO2 laser may be necessary.  The recently developed pulsed dye laser surgery can also remove the granuloma under local anesthesia.

REINKE”S EDEMA

Reinke’s edema is caused by chronic voice abuse and vocal damage.  This is also related to smoking.  The main symptom of this lesion is hoarseness.  Biopsy of the vocal fold is used to help in the diagnosis.  Reinke’s edema causes the vocal folds to swell giving them a sac like appearance.

Conservative treatment involves removing the source of irritant in the larynx, vocal treatments, and smoking cessation.  Surgeries include microlaryngeal surgery or CO@ laser which removes the sumbucosal edema to help restore the normal vocal fold tissue.

SULCUS VOCALIS

Sulcus vocalis is thinning or absence of a tissue covering the vocal cord required for vibration to produce sound.  This can produce a harsh, reedy hoarseness.  People with sulcus vocalis frequently exert unusual effort to produce voice, and to find it more difficult to be heard over a background noise.

Microlaryngeal surgery can be done to incise the sulcus vocalis.  Other options are injection laryngoplasty and recently, the pulsed dye laser surgery brings great outcome to patients.

LARYNGEAL PAPILLOMA

Laryngeal papillomas are benign epithelial tumors caused by infection with Human Papilloma Virus (HPV) type 6 and 11.  The disease is more commonly found in children that may have contracted it through vaginal childbirth from a mother with HPV.

In adults, symptoms are hoarseness, or strained or breathy voice.  Size and location of tumor dictate the change in the voice.  Breathing difficulties may occur but are usually seen in children.

In infants and small children, the symptoms of papilloma include weak cry, trouble swallowing, noisy breathing, and chronic cough.  Noisy breathing may be a stridor, which can sound like a whistle or a snore, and is a sign that the laryngeal and tracheal parts of the airway are narrowing.

Yeson Voice Center has implemented the Photo Genica SV PDL from Cynosure Inc. US.  This is used to perform laryngeal surgery without general anesthesia.  This pulsed dye laser selects and solidifies only blood vessels at vocal band and does not damage the healthy tissue.  It only selects and destroys abnormal tissues.

LARYNGOPHARYNGEAL REFLUX

Laryngopharyngeal reflux (LPR) is the inflammation of the larynx or pharynx caused by stomach acid or food backing up into the esophagus.  Symptoms are chronic hoarseness, frequent or dry cough, sensation of lump in the throat, and difficulty and pain swallowing food.

General treatments for LPR are diet modification to reduce reflux, medications to restrain stomach acid, and surgery to prevent reflux.

SPASMODIC DYSPHONIA

Spasmodic dysphonia is a voice disorder caused by the excessive tension in the laryngeal muscles.  They have breaking voice and face difficulty to start and continue communication.  Spasmodic dysphonia is often classified according to the age when the symptoms develop.  When symptoms develop before age 20, it is called infant type.  If symptoms develop after age of 20, it is called an adult type.

Many doctors thought that mental problems were the cause of spasmodic dysphonia because symptoms would get better when taking alcohol and tranquilizers, and get worse when being stressed or talking on the phone.

In the 1980’s, researches of the cranial nerve brought the thought that the cause of spasmodic dysphonia was the abnormal spasm of the laryngeal muscles due to the inharmonic function with the basal ganglia where the integration of the central nerves take place.  However, Dr. Ludlow, from National Institute of Neurologic Disorder (NINDS) of National Institute of Health (NIH), proved that the cause of spasmodic dysphonia is the abnormal nerve system in the nucleus tractus solitaries, so patients lose control of their vocal fold muscle which makes it hard to talk and breaks off sounds.

Spasmodic dysphonia is classified according to the symptoms and characteristics.  Adductor type accounts for approximately 80%.  It can be glottis, supraglottic, dystonia tremor or an adductor type with tremor.  This is the most common type and involves spasm of the muscles that close the vocal folds.  Glottis type reacts better than supraglottic type to Botox.  Abnormal involuntary co-contraction of the vocalis muscle complex, resulting in inappropriate adduction of the vocal fold exhibiting strained-strangled voice quality with abrupt initiation and termination, resulting in short breaks in phonation.

The abductor type accounts for 4%.   This is an action-induced inappropriate co-contraction of the posterior cricoarytenoid muscles resulting in  inappropriate abduction of the vocal fold.  This type exhibits effortful voice quality with abrupt termination resulting in aphonic whispered segments of speech.

Other types are of mixed type for 11% and respiratory dysphonia for approximately 2% or now known as paradoxical vocal fold motion..

For the examination of patients with spasmodic dysphonia, first, one will receive an acoustic vocal test.  Then a test will be performed to measure the muscular spasm of vocal cord when speaking, and examine excessive spasm or tremor of the laryngeal muscle using a laryngoscope.  Next is to measure the basic vocal frequency with acoustic tests and observe the vocal waveform through spectrogram.  Then an electroglottography and measure of resistance of aerodynamic test are done.  Laryngeal stroboscopy examines the movement of the larynx, and the laryngeal electromyography helps find the abnormal movements of the larynx and the vocal fold muscle.  High speed vocal fold filming system helps find the exact location of spasm.

There are 3 types of treatment for spasmodic dysphonia.  Medical treatment uses anticholine drugs, tranquilizer, baclofen, and dopamine antagonist.  However, these has serious side effects and are only used in serious myotonic disorders.  Surgical treatment includes hemilaryngectomy, thyroid chondroplasty, laser vocalis muscle cordotomy, and nerve stimulator transplantation.  All surgical methods do not cure completely, and it may relapse with few months or few years.  The third treatment option is injection of botulinum toxin (Botox) which is currently the most effective treatment.  However, this is a temporary treatment which improves the voice for a period of 3-6 months.  This requires continuous injections to maintain good speaking voice.

Few years ago, treatment involves injecting only certain muscles on the vocal fold or in one side of the vocal fold.  But there was no study on the effect on the cerebrum and the other side of the vocal fold tries to match the balance and creates spasm on the other side.  Hence, this treatment might make the vocal fold worse due to the side effect.

The treatment now has changed to multiple laryngeal muscle injections with Botox.  It normalizes the voice by injecting small amounts of Botox to the abnormal laryngeal muscles.  This extends the period of having a good voice and minimized the term of hoarseness after Botox injection, helping the normalization of voice by cranial reflex rehabilitation.

FUNCTIONAL DYSPHONIA

Functional dysphonia is the abnormal use of voice despite normal anatomy and function of the vocal folds and the larynx which produce the voice, and pharynx and mouth which produce resonance.  This can be related to abuse or misuse of voice or habituation of compensatory techniques developed from condition of the larynx.

This is often classified into 5 types.  The conversion aphonia, habitual hoarseness, inappropriate falsetto, vocal misuse/abuse syndrome, postoperative dysphonia, and relapsing aphonia.

Mutational falsetto under a normal laryngeal system causes the voice to be high pitched weak and thin like a voice of a female.  The voice is easily fatigues.  The voice tone stays high, monopitched and high pith songs can’t be sung.

It can be classified into 2 different factors.  Functional factors are caused by psychological problems like young males of pubertal age who fail to accept their adult role or suffer emotional stress from changes.  Organic factors are caused by abnormality in the vocal membrane like contractions or scars in the mucosal membrane of underdevelopment of the larynx.

When functional dysphonia is caused by functional factors, the vocal folds appear normal on laryngoscopy and stroboscopy.  The outer laryngeal muscles are excessively used to make a sound and the larynx elevates.  In organic factors, there are abnormalities in the mucous membranes or underdevelopment of the larynx and vocal folds.