Current Diagnosis and Treatment of Voice Disorders Seth H. Dailey, MD Assistant Professor University of Wisconsin Hospital and Clinics University of Wisconsin School of Medicine Internal Medicine Grand Rounds: February 28 th, 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

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 Hoarseness Types 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 Hoarseness Types of voice Muffled voice- painful dysphagia and dyspnea Shaky- high pitch or low soft. –Elderly –debilitated

Differential Diagnosis of Hoarseness Acute 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 Hoarseness Acute Hoarseness/Acute Laryngitis Hoarseness Cough Sore throat Fever Vesicles on soft palate Lymphadenopathy

Differential Diagnosis of Hoarseness Acute 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

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