Current Diagnosis and Treatment of Voice Disorders

Seth H. Dailey, MDAssistant Professor

University of Wisconsin Hospital and Clinics

University of Wisconsin School of Medicine

Internal Medicine Grand Rounds:

February 28th, 2007

Cartilaginous skeleton

Intrinsic Musculature

• Abductors• Adductors• Tensors

Intrinsic Musculature

Innervation

Abduction

Adduction

Tension

Vocal Fold Anatomy

Laryngeal Anatomy

• Three surrounding structures- pharynx, trachea and esophagus

• Three levels - supraglottis, glottis and subglottis

• Three fixed structures - hyoid, thyroid and cricoid

• Three mobile structures -epiglottis, false vocal cords and true vocal cords (folds)

Laryngeal Anatomy

Laryngeal Anatomy

Mucosal wave/Phase delay

Body-Cover Theory

• Changes to mucosal wave– Stiffness– tension

Mucosal wave

• Velocity increases– Increased airflow– Increased subglottic pressure

Laryngeal Physiology

• Three main functions - airway, swallowing and voice

• Three criteria for voice- generator, vibrator resonator

• Three components for high quality glottic voice - closure, pliability and symmetry

Indirect mirror examination

• Advantages– Quick– Inexpensive– Little equipment

• Disadvantages– Gag– Anatomic features– nonphysiologic

Flexible laryngoscopy

• Advantages– Well tolerated– Complete examination– Video documentation

• Disadvantages– More time– Expensive

Rigid laryngoscopy

• Advantages– Best images– Magnification– Video documentation

• Disadvantages– Expensive– Nonphysiologic– Gag– Anatomic features

Common disorders affect the “magic three”

• Closure - neuromuscular, joint, vocal fold• Pliability - “golden layer” - mass, scar • Symmetry - tension and viscoelasticity

• VOICE DISORDERS ARISE FROM A COMBINATION OF THESE ELEMENTS

Differential Diagnosis of Hoarseness

• Vocal quality- determined by: – distance between vocal cords, – tenseness of the cords – how rapid cords vibrate

• Hoarseness is caused by –

Differential Diagnosis of HoarsenessTypes of voice

• Breathy- vocal cords do not approximate so air escapes.

• Raspy- harsh voice. Cord thickening due to edema or inflammation. Voice is low in pitch and poor quality

Differential Diagnosis of HoarsenessTypes of voice

• Muffled voice- painful dysphagia and dyspnea

• Shaky- high pitch or low soft. – Elderly – debilitated

Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis

• Laryngeal mucous membrane infection, usually viral (adenovirus/ influenza, RSV, coxsackie, rhinovirus)

• Also can be due to trauma to throat, vocal abuse, toxic exposure, GI complications, smoking, allergy

Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis

• Hoarseness• Cough• Sore throat• Fever• Vesicles on soft palate• Lymphadenopathy

Differential Diagnosis of HoarsenessAcute Hoarseness/Acute Laryngitis

• Diagnostics: Laryngoscopy if suspect mass, infection, vocal cord dysfunction

• Management: Voice rest, smoking/alcohol cessation, hydration

Evaluation of Hoarseness

• History is paramount• Projection - tired, breathy and low volume• Quality - ”hoarse”, “gruff”, “raspy”• Range - high, middle and low

Evaluation of Hoarseness

• Physical Exam• Speaking voice• Range profile• Fundamental Frequency – F0• Maximum Phonation Time• Standard Reading Passages• Singing if appropriate – local, regional, bodywide• Voice Lab – Acoustics and Aerodynamics

Evaluation of Hoarseness

• Endoscopic exam – • mirror, flexible endoscope, rigid endoscope• Digital archiving essential for

documentation

Evaluation of Hoarseness

• Studies• CT scan – evaluation of course of RLN• EMG – Is there an nerve to muscle problem?• Double pH probe – What is the severity of

Laryngopharyngeal reflux (LPR)?• Microlaryngoscopy – some lesions missed in the

office.

Evaluation of Hoarseness

• Studies – the future….• Aerodynamics and acoustics – Chaos theory and

mathematical modeling• Vocal cord motion – gross arytenoid motion being

evaluated endoscopically• Vocal cord pliability – endoscopic rheometers and

vocal fold oscillators• Ocular Coherence Tomography/Ultrasound

Normal Stroboscopy

Neuromuscular Disorders

• Vocal cord paralysis • Vocal cord paresis• Cricoarytenoid joint dysmobility• Presbylaryngis (aging larynx)• Muscle Tension Dysphonia (Hyperfunction)

Vocal Cord Paralysis

• Thoracic, thyroid surgery, “Bell’s” palsy of the larynx

• Closure and symmetry • Swallowing and voice• Static Repair - Watch and wait, temporary

procedure, permanent procedure (Laryngoplasty).

• Dynamic repair Nerve Muscle Transosition

Vocal Cord Paresis

Vocal Cord Paralysis 2

Videostroboscopy

Radiographic studies

• MRI• CT

Laryngeal EMG

• Myopathy – normal frequency of firing but decreased amplitude

• Neuropathy – decreased frequency but occasional normal amplitudes

• Polyphasic reinnervation potentials indicate some loss of function but reinnervation has begun

Laryngeal EMG

Differential

• Congenital • Inflammatory• Neoplastic• Traumatic• Neurologic• Endocrine• Iatrogenic• Local factors

Vocal Cysts

Vocal Nodules

• Usually bilateral • Voice rest and speech therapy for 6 months• Surgical removal

Vocal cord granulomas

• LPR• Intubation• Treat medically

Glottal Incompetence

• A “Leaky Valve” pure and simple• Loss of total vocal fold volume• Loss of pliable layer from use and scar• Most often a function of age• Temporary Injectables – fat and collagen • Permanent – Gore-tex, silastic etc.

Cricoarytenoid Joint Dysmobility

• Intubation, rheumatoid, osteoarthritis• Limit range of movement• Can’t open or close• Voice and airway• Medical therapy if appropriate• Surgery - move or remove arytenoid

Hyperfunction – a.k.a. MTD

• Overactivity of supraglottal musculature• Compresses and alters the airstream• Often normal glottic function• Inciting events can be ANYTHING• Voice therapy is used to get the voice

“back on track”

Epithelial Diseases

• Papilloma• Premalignancy (Vocal cord dysplasia)• Malignancy

Vocal Cord Papilloma

• Most common benign tumor of vcs• Pediatric and adult forms• Voice and airway• Surgery - mechanical or laser debulking• Anti-virals in children• High risk of permanent dysphonia• 585nm Pulsed Dye Laser – Treatment can now be

done in the office!!!

Vocal Cord Keratosis with Atypia

• Smoking and alcohol• Repetitive chemical insult to vocal folds• Dysplasia into cancer• Closure, pliability and symmetry• Radiation therapy - not recommended• Phonomicrosurgery• Pulsed Dye Laser - Treatment can now be done in

the office!!!

Vocal Cord Cancer

• Smoking and Drinking are synergistic• U.S. - 2/3 glottic, Europe 2/3 supraglottic• Hoarseness• Closure pliability and symmetry• Voice and airway• Radiation • Ultra-narrow margin surgery• Endoscopic approach for early cancers –

increasing evidence for late cancer also

Subepithelial Diseases

• Vocal cord nodules• Vocal cord polyps• Vocal cord cysts• Reinke’s edema• Vocal cord sulcus• Vocal cord scar

Vocal Cord Nodules

• Vocal overuse• Repetitive microtrauma to mid vocal folds• Closure and pliability• Reduce demands• Voice therapy• Surgery – Surgeons much less likely than

previously to operate unless firm

Vocal Cord Nodules 1

Vocal Cord Nodules 2

Vocal Cord Polyp

• Vocal overuse• Repetitive microtrauma to mid vocal folds• Closure and pliability• Reduce demands• Voice therapy• Surgery – Instrumentation and even

robotics being applied to improve precision and safety

Vocal Fold Cyst

• Congenital anomaly• Uni or bilateral• Mucus or keratin• Closure, pliability and symmetry • Voice only affected• Surgery - excise, but not likely to have a

normal voice

Reinke’s Edema

• Benign enlargement and alteration of golden layer

• Adult female smokers• Closure, pliability and symmetry • Voice and airway• Surgery - cytoreduction of SLP• Return almost to normal

Vocal Fold Scar

• Forms at the junction of epithelium and golden layer (SLP)

• Decreases the pliability of the membrane• Decreases the closure and therefore the

efficiency• Fatigue and projection problems are

common• LOSS OF UPPER REGISTER!!!

Vocal Cord Sulcus

• Developmental loss of SLP • Decreased pliability• Loss of cycle-to-cycle closure• Management with surgery is best hope• Slicing technique• Fat implantation• Medialization Thyroplasty

Vocal Cord Inflammatory Diseases

• Reflux Laryngopharyngitis (LPR)• Arytenoid Granuloma

Arytenoid Granuloma

• Cartilaginous vocal cord mass• Exposed cartilage and acid reflux?• Supraglottic modulation of air• Voice and airway• Surgery - rarely indicated• Voice therapy, LPR, inhaled steroids,

BOTOX

Vocal Cysts

Vocal Nodules

• Usually bilateral • Voice rest and speech therapy for 6 months• Surgical removal

Vocal cord granulomas

• LPR• Intubation• Treat medically

Vocal Cord Paralysis

• Lesion at nuclear level – cadaveric• Lesion above nodose ganglion – abducted• Lesion below nodose ganglion - paramedian

Vocal Cord Paralysis

• Superior laryngeal nerve – subtle voice changes with decreased pitch range, tilting of the larynx with a rotation of the glottis

Vocal Cord Paralysis

• Children– Neurologic– Traumatic– Idiopathic

• Adults– Iatrogenic– Traumatic– Neoplastic– Idiopathic– neurologic

THANK YOU !!!

Rule of Thumb• Any patient with hoarseness of two weeks

duration or longer must undergo visualization of the vocal cords