1. Voice Disorders: Recognition and Treatment
J. Michael King, MD
SUMMIT OFFICE PARK
403 Summit Blvd
Suite 204
Broomfield, CO 80021
JEFFERSON OFFICE PARK
1030 Johnson Road
Suite 350
Golden, CO 80401

2. GOALS Teach, Entertain and Dazzle
Discuss the role of Physician & SLP in treating voice disorders
Convince you that Voice is the most interesting and rewarding subspecialty you could possibly choose

3. Endoscopy
Prepare the patient

4. Vocal Fold Vibration
Not possible to see vocal fold vibration in real time without high speed video
Vocal fold Frequency
Male normative data = Hz
Female normative data = Hz
Stroboscopy allows for the illusion of vocal fold vibration

5. Stroboscopy

6. Vocal Fold Vibration

7. Vocal Fold Vibration/Strobe (Normal Flexible Scope)

8. Normal Strobe (Rigid Scope)

9. Strobe While Singing

10. What exam do I need to use?
Flexible scope?
Greater variety of phonatory tasks to evaluate vocal fold behavior during connected speech.
Rigid scope?
Higher resolution of images to evaluate presence of pathology and vibratory correlates.
Both?
Ideally, most patients would benefit from both
Rigid if you Suspect:
Lump or Bump
Scar
LPR
VF edema
Flexible if you Suspect:
Neurologic disease
VF paralysis / paresis
PVFMD
Severe MTD

11. The Laryngeal Exam and the SLP
Benefits of viewing the videostroboscopy
Collaboration with laryngologist
Treatment planning
Prognostic indicators
Response to unloading trials
Correlation of voice quality to anatomy
Voice quality does not correlate to specific laryngeal anatomy
Laryngeal anatomy does not correlate to a specific voice quality ( 11

12. Assessment Questionnaires: VHI, GCI, RSI, VRQOL Perceptual evaluation
Voice Quality
Vocal Health & Use
Resonance
Appearance / Posture
Vocal behaviors
Breathing patterns
Signs of musculoskeletal tension
Patient’s interactions
Therapeutic Probes

13. Vocal Health and Use Amount and types of vocal demand
Yelling, loud talking, telephone use, professional voice user?
Variation in vocal disorder?
AM vs. PM; good days vs. bad; fluctuation minute-by-minute
Vocal fatigue
Difficulty speaking over noise
Other triggers of voice problems?
Odors, temperature
Hydration
Common LPR triggers
Antihistamines? Steroid inhalers for asthma?

14. INDIRECT VOICE THERAPY
Educate about the laryngeal mechanism
Vocal wellness/hygiene
Reflux education
Decrease phonotrauma
Environmental modifications
Amplification
Decrease compensations
Articulatory precision
Stimulable for vocal change?

15. DIRECT (hands-on) VOICE THERAPY
To increase overall efficiency of the system
Improve the coordination of respiration, phonation, resonance, and articulation in a way that will transfer to conversational speech
Lessac-Madsen Resonant Voice **
Stretch / Flow Phonation **
Vocal Function Exercises **
Confidential Voice
Circumlaryngeal Techniquies / Reposturing **
Respiratory Retraining
Lee Silverman Voice Treatment
Accent Method
Biofeedback
Articulatory precision
Facilitating Techniques **
Etc.

16. Good Candidates… Motivation
How severe does patient rate their overall problem?
None
Mild
Mild-to-moderate
Moderate
Moderate-to-severe
Severe
How motivated is the patient to make change happen?
Anatomical limitations?

17. Neurogenic Voice Disorders

18. Vocal Fold Paralysis/Paresis
Cause:
Damage to branches of the Vagus Nerve
Superior Laryngeal Nerve
Recurrent Laryngeal Nerve
Iatrogenic (surgical complications)
Malignancy (lung, thyroid, skull base)
Idiopathic (unknown cause)

19. Vocal Fold Paralysis/Paresis
Otolaryngologist
Laryngoplasty
Augmentation
Airway management
Speech Pathologist
Reducing compensation
Muscle retraining and resonant voice training to maximize voice production
Vocal function exercises
VFE: strengthen and balance the laryngeal musculature and create a balance among airflow, laryngeal muscle effort and tone placement. Series of 4 exercies: 6-8 weeks

20. Vocal Fold Paralysis (Anterior Cervical Fusion)

21. Vocal Fold Paralysis: Injection Augmentation

22. Two weeks after In-Office Collagen Injection Augmentation

23. Vocal Fold Paralysis (Mediastinal Adenocarcinoma)
Nine months after diagnosis
One month after Collagen injection

24. Idiopathic TVF Paralysis (Post-Viral URI)

25. Bilateral TVF Paralysis

26. Vocal Fold Paresis

27. TVF Paresis

28. Spasmodic Dysphonia Cause: Symptoms:
Unknown
Neurological Disorder affecting fluency of speech
Focal dystonia; task specific
Symptoms:
“Strained-strangled” speech (ADductor Type)
“Weak/breathy” speech (ABductor Type)
Voice breaks
May have tremor in addition to SD
Key: MTD should be considered in differential diagnosis and ruled out before entering the patient into treatment

29. Spasmodic Dysphonia
Adductor SD

30. Spasmodic Dysphonia
Pre-Injection of Botox After Botox Injection

31. Spasmodic Dysphonia Otolaryngologist Speech Pathologist BOTOX
TA muscle
PCA muscle
Surgical approach
Denervation surgery
Speech Pathologist
Very limited as sole treatment method
Serves to frustrate
Patient education and expectations to BOTOX treatment
Useful when MTD component present – differential diagnosis
Maximize airflow during phonation

32. Essential Voice Tremor
Cause:
Age related disease of involuntary movement
Voice is affected in some 25-30% of patients
Symptoms:
Rhythmic pattern to vocal tremor
Rhythmic oscillatory motion of both vocal folds; present during quiet breathing in addition to phonation
Key: usually affects the pharyngeal, palatal, and extrinsic laryngeal muscles in addition to intrinsic laryngeal muscles

33. Additional Neurogenic Problems
Benign Essential Tremor

34. Essential Tremor Otolaryngologist Speech Pathologist Pharmacotherapy
Limited effectiveness with voice tremor
BOTOX
TA muscle
IA muscle
Extralaryngeal muscles
Speech Pathologist
Patient education
Management of BOTOX effects as needed
Voice
Swallowing

35. Vocal Fold Atrophy (bowing)
Cause:
Normal aging – presbylarynx
Muscular Dystrophy / ALS
Parkinson’s
Other
Key: Dysphagia + Atrophy could be neurologic

36. Vocal Fold Atrophy (bowing)

37. Vocal Fold Atrophy (bowing)
Otolaryngologist
Injection augmentation
Laryngoplasty
Speech Pathologist
Reducing compensation (secondary MTD)
Vocal function exercises
Swallowing management as needed

38. TVF Atrophy (Presbyphonia)

39. ? Disease

40. Parkinson’s Disease Otolaryngologist Speech Pathologist
Injection Augmentation
(Caution…)
Speech Pathologist
Lee Silverman Voice Therapy
Swallowing Tx

41. Non-Surgical Vocal Fold Pathology

42. Poor Vocal Hygiene Cause: “Dirty” Larynx Reflux Dehydration
LPR – Laryngopharyngeal Reflux
Diet
Dehydration
H2O intake
Caffeine Intake
Smoking / second hand smoke
Vocal demand
Misuse
Overuse
Allergies/Nasal congestion

43. Laryngopharyngeal Reflux
Infraglottic Edema
Laryngeal Pachydermia

44. Poor Vocal Hygiene Otolaryngologist Speech Pathologist Mucinex
Lifestyle Changes
Diet
Caffeine
Alcohol/Tobacco
Acid Suppression
PPI (Nexium)
H2 blocker (Zantac)
Nasal Steroid
Corticosteroid (prednisone)
Speech Pathologist
Behavioral Modification
Identify
Reprogram
Maintain
Counseling
Problem solving
Goal setting
Accountability
Amplification
Voice use modification
Training as needed to meet vocal demands

45. Laryngeal Candidiasis
Cause:
Fungal infection
At Risk
Use of steroid inhalers

46. Laryngeal Candidiasis

47. Laryngeal Candidiasis
Speech Pathologist
Muscle retraining as needed
Otolaryngologist
Antifungal Medication

48. Muscle Tension Dysphonia
Cause:
Strain/Tension
Need to close “the valve”
Primary vs Secondary (compensatory) disorder
Self-aware of mild voice changes / discomfort
Secondary gain
Monetary
Social
Findings:
Normal vocal folds
“Supraglottic Squeeze”
Most often secondary to underlying disorder; can occur in isolation.

49. Muscle Tension Dysphonia
Otolaryngologist
Treatment for:
Inflammatory
LPR
Allergies
Speech Pathologist
Muscle retraining
Relaxation
Manipulation
Behavior analysis & modification
Flow phonation
Management of irritable larynx / hypersensitive larynx if present

50. Muscle Tension Dysphonia

51. Muscle Tension Dysphonia (refractory to SLP)

52. Paradoxical VF Mobility (Vocal Cord Dysfunction)

53. Paradoxical VF Dysfunction
Otolaryngologist
Treatment for:
Inflammatory
LPR
Allergies
Speech Pathologist
Muscle retraining
Relaxation
Manipulation
Behavior analysis & modification
Breathing Exercises
Management of irritable larynx / hypersensitive larynx if present

54. Vocal Nodules Cause: Symptoms: husky, breathy, harsh voice At Risk:
“Excessive” Vocal Fold Contact
Symptoms: husky, breathy, harsh voice
At Risk:
Boys 3x greater risk between 5-10 years
Adult women
Former cheerleaders
High demand voice users
Untrained singers
Outgoing, loud talkers with aggressive glottal attacks

55. Vocal Nodules
Pre-treatment
Post-treatment

56. Vocal Nodules Otolaryngologist Speech Pathologist LPR treatment
Allergy Treatment
Speech Pathologist
Patient education
Vocal hygiene
Behavioral analysis & modification
Voice use & conservation strategies
Muscle retraining during voice production
Body and self awareness
Amplification
Defer to singing coach

57. TVF Nodules (Abuse & Overuse)

58. Laryngitis

59. Laryngitis Otolaryngologist Speech Pathologist
Rule out other pathology
Steroids
Hydration
Voice rest
+/- Antibiotics (Usually Viral)
Speech Pathologist
Supportive Care

60. Vocal Fold Hemorrhage

61. Vocal Trauma (hemorrhage)
Etiology
Vocal abuse (screaming/yelling)
Chronic cough
Symptoms
Acute hoarseness
Risks
Permanent scarring
Treatment
Supportive Care
Voice Rest
Consider Steroids (prednisone)

62. What’s the Disorder?

63. Surgical Vocal Fold Pathology

65. Vocal Process Granuloma
Cause:
Break in mucosa at the vocal process
At Risk
Intubation
Severe Cough
Chronic Aggressive Throat Clearing
Followed by:
LPR – inflammation ensues

66. Vocal Process Granuloma

67. KTP Laser Ablation of VP Granuloma

68. Vocal Process Granuloma (severe airway obstruction)

69. Vocal Process Granuloma
Otolaryngologist
Acid Suppression
PPI
Steroids
BOTOX for failures
KTP laser
Speech Pathologist
Vocal hygiene
Diet
Medication compliance
Throat clearing
Behavioral analysis & modification
Aggressive voice onset

70. Vocal Fold Polyp Cause: At Risk: Symptoms:
Vocal Abuse/hemorrhage
At Risk:
Prolonged intermittent, excessive/abusive behavior
Symptoms:
abrupt onset hoarseness
Most Common Benign Laryngeal Lesion
AKA:
When large and pedunculated: generally termed polyps.
When sessile and small: may be called polyps, nodules (if bilateral & symmetrical) or pseudocysts

72. Vocal Fold Polyp Otolaryngologist Speech Pathologist Surgery
Primary treatment
Microflap Excision
“cold” techniques
NO LASER!
Speech Pathologist
Patient education
Vocal hygiene
Behavioral analysis & modification
Voice use & conservation strategies
Muscle retraining to improve efficiency during voice production
Facilitate patient’s return to voice use after surgery (if required)

73. Vocal Fold Polyp Microflap Excision

74. TVF Hemorrhagic Polyp
Pre-Op
One Month post-excision

75. Vocal Fold Cyst Cause: Symptoms: Key Congenital
Voice abuse/misuse (epithelial trapping)
Blocked mucus gland
Symptoms:
Similar to VF nodules
Possible diplophonia especially in upper frequency
Severe impairment at specific frequency
Hoarse, pressed phonation with larger cysts
Key
Loss of mucosal wave

76. Vocal Fold Cyst

77. TVF Cyst
Pre-op
After Microflap Excision

78. Vocal Fold Cyst Otolaryngologist Speech Pathologist Surgery
Microflap Excision
Speech Pathologist
Behavioral voice analysis & modification
Muscle Retraining for optimal voice production
Facilitate patient’s return to voice use after surgery

79. Laryngeal Papilloma (Recurrent Respiratory Papilloma)
Cause:
Human Papilloma Virus (HPV)
Children – birth canal?
Adults – latent activation
Treatment:
Multiple Recurrences and surgical procedures
Debridement in OR
Laser ablations in OR or in-office procedures (KTP)

80. Laryngeal Papilloma

81. Adult-Onset RRP

82. RRP Treatment: KTP Laser

83. RRP after KTP (twice)

84. Laryngeal Papilloma Otolaryngologist Speech Pathologist Surgery
Microdebrider
Microflap
KTP
Anti-Viral injections
Cidofovir
Speech Pathologist
Amplification

85. Polypoid Corditis (Reinke’s Edema)
Cause:
Smoking (97%)
GERD
Voice Abuse
Symptoms: increasing hoarseness, females addressed “sir” on phone
Often recognized in elderly women smokers

86. Patty Bouvier’s Edema

87. Polypoid Corditis (Reinke’s Edema)

88. Polypoid Corditis (Reinke’s Edema)
Otolaryngologist
Stop smoking
Acid Suppression
Surgery
Microflap excision
KTP Laser
Speech Pathologist
Counseling
Vocal hygiene

89. Laryngeal Masses Benign Lesions Malignant Lesions Laryngoceles
Sacular Cysts
Mucous Cysts
Papilloma
Malignant Lesions
Carcinoma (cancer)
Sarcoma
Neurogenic Tumors

90. Supraglottic Oncocytic Cyst
Pre-Op
3 Weeks Post-Op

91. Leukoplakia Cause: Key Smoking Reflux
An early form of the spectrum of laryngeal dysplasia

92. Leukoplakia

93. Dysplasia (Mild, Moderate, Severe)

94. Carcinoma (Cancer) of Vocal Fold
Cause:
Smoking
Alcohol use

95. Carcinoma (Cancer)

96. Post-laser cordectomy
Early Stage Carcinoma
At Diagnosis
Post-laser cordectomy

97. Late Stage Carcinoma
At Diagnosis
Post-XRT treatment

98. Laryngeal Carcinoma Otolaryngologist Speech Pathologist
Surgery (early)
Radiation therapy (early or late)
Chemotherapy (late)
Laryngectomy
(very late, failed treatment)
Speech Pathologist
Amplification
Post-laryngectomy Voice Restoration
Post-laryngectomy swallowing assessment

99. Summary Variety of Pathology Surgical & Non-surgical Treatment options
Collaboration between SLP & ENT
Highly rewarding & privilege to treat

100. And Finally…. Anyone interested in spending time with me is welcome!
Hands-on workshops?
Summit Office Park
403 Summit Blvd, Suite 204
Broomfield, CO 80021
PeakENTandvoicecenter.com