1. Current Diagnosis and Treatment of Voice Disorders
Internal Medicine Grand Rounds:
February 28th, 2007
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

3. 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)

4. Laryngeal Anatomy

5. Laryngeal Anatomy

7. 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

8. 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

9. Evaluation of Hoarseness
History is paramount
Projection - tired, breathy and low volume
Quality - ”hoarse”, “gruff”, “raspy”
Range - high, middle and low

10. 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

11. Evaluation of Hoarseness
Endoscopic exam –
mirror, flexible endoscope, rigid endoscope
Digital archiving essential for documentation

12. 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.

13. 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

14. Normal Stroboscopy

15. Neuromuscular Disorders
Vocal cord paralysis
Vocal cord paresis
Cricoarytenoid joint dysmobility
Presbylaryngis (aging larynx)
Muscle Tension Dysphonia (Hyperfunction)

16. 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

17. Vocal Cord Paresis

18. Vocal Cord Paralysis 2

21. Medialization Thyroplasty

22. Adduction Arytenopexy

23. 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.

26. Medialization Thyroplasty

27. 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

31. 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”

34. Epithelial Diseases Papilloma Premalignancy (Vocal cord dysplasia)

35. 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!!!

38. 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!!!

41. 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

43. Subepithelial Diseases
Vocal cord nodules
Vocal cord polyps
Vocal cord cysts
Reinke’s edema
Vocal cord sulcus
Vocal cord scar

44. 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

45. Vocal Cord Nodules 1

46. Vocal Cord Nodules 2

49. 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

56. 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

59. 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

63. 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!!!

66. 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

69. Vocal Cord Inflammatory Diseases
Reflux Laryngopharyngitis (LPR)
Arytenoid Granuloma

72. 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

75. Summary Wide variety of disorders
An abnormal voice means there’s something wrong
All voice disorders are treatable
Most are curable
Let your history and ears guide you
RAPIDLY DEVELOPING FIELD

76. THANK YOU !!!