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Voice Problems
(Laryngeal Problems)
Laryngitis
Spasmodic Dyphonia
Polyps
Cysts & Nodes
Contact Granuloma/Contact Ulcer
Laryngeal Cancer
The Aging Larynx
LARYNGITIS
Laryngitis, or inflammation of the larynx, is probably
the most common disorder affecting the larynx and voice.
This inflammation may be of primary origin or secondary
to other disorders. Laryngitis can be acute (short-term)
or chronic (long-term).
Symptoms:
The classic symptoms of laryngitis are hoarseness and
loss of voice. Occasionally, laryngitis may cause pain
in the laryngeal area during swallowing or speaking.
Causes:
Laryngitis can have many causes. Acute laryngitis frequently
accompanies viral or bacterial upper respiratory tract
infections. Chronic laryngitis can have a number of
causes. Among the most common are misuse or overuse
of the voice and chronic irritation by smoke, dust,
or other airborne irritants. Reflux of acid from the
stomach is another frequent cause of laryngeal inflammation.
Laryngitis can be secondary to a more serious condition
such as benign or malignant growths. Therefore, if hoarseness
lasts longer than two weeks, or is accompanied by a
lump in the neck or blood-tinged sputum, medical attention
should be sought.
Treatment:
Acute laryngitis is treated with resting the voice as
much as possible, increasing intake of decaffeinated
fluids (particularly water), and using a humidifier.
If a bacterial infection is the suspected cause, antibiotics
may be prescribed. Chronic laryngitis is treated differently,
depending on the cause. As mentioned above, if symptoms
persist for longer than two weeks or if common treatments
are ineffective, seek medical advice.
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SPASMODIC
DYPHONIA
Spasmodic
Dysphonia (SD) is one of a group of neurologic disorders
called dystonias. A dystonia is a movement disorder
characterized by inappropriate contraction of muscle
groups. With SD, the intrinsic laryngeal muscles are
involved. There are two primary types of SD. The most
common type is adductor SD. This occurs when the muscles
which close the vocal folds (thyroarytenoids and lateral
cricoarytenoids) contract with excess force. Abductor
SD involves the muscles which open the vocal folds(posterior
cricoarytenoids). A "mixed" form involving
both the abductor and adductor muscles also exists.
Symptoms:
The symptoms of SD depend on which form is present.
The adductor type produces a strained or strangled voice
quality. Abductor SD usually produces a breathy and
effortful voice. Both types cause abrupt breaks in phonation
and decreased intelligibility. Voice is often worse
on the telephone or when the speaker is under stress.
Some voice production can be normal, such as laughing,
coughing, and singing.
Causes:
The precise cause of SD is unknown and may involve multiple
factors. It does appear to be a neurological (not psychiatric)
disorder, similar to other focal dystonias.
Treatment:
Currently, the most effective treatment for SD is injection
of botulinum toxin - type A (Botox). Botox is injected
into the laryngeal muscles via the neck (just under
the adam's apple) using EMG guidance or transorally
using a special needle that curves over the tongue.
Botox interferes with the transmission of the electrical
impulses which result in the inappropriate contraction
of the laryngeal muscles and prevents the spasms associated
with SD. Botox treats the symptoms of SD, but it does
not cure the disorder.
The
effects of Botox injections are usually apparent within
24 hours and last for four to six months. Risks and
discomfort during the procedure are minimal. After an
injection for adductor SD, patients may experience a
weak, breathy voice and mild difficulty swallowing for
one to two weeks. Voice therapy is used in conjunction
with Botox injections to maximize voice capabilities
during the breathy period, minimize the dysfunction
as the spasms return, and lengthen the time between
injections.
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POLYPS
Polyps
are benign lesions that occur unilaterally and usually
develop at the junction of the anterior and middle third
of the vocal fold edge. They may appear as pedunculated
(attached by a slim stalk) or sessile (closely adhering
to the mucosa). A variant of these types is the hemorrhagic
polyp, which has the appearance of a blood-filled blister
on the vocal fold surface.
Symptoms:
Typical symptoms of polyps include hoarseness, breathiness,
or vocal roughness. These signs are commonly accompanied
by the sensation of something in the throat.
Causes:
Polyps are thought to result from vocal abuse and misuse.
They are often associated with a single traumatic event
(such as yelling at a sports event), but can be the
result of prolonged vocal abuse.
Treatment:
Polyps are usually surgically removed under general
anesthesia. Following removal, limited voice use is
recommended for a minimum of two weeks. Voice therapy
is also commonly implemented to facilitate healing and
minimize the potential for recurrence.
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CYSTS
AND NODES
Vocal
fold nodules and cysts are benign (non-cancerous) growths
which can affect people of all ages. While their symptoms
are similar, treatment usually differs. Cysts and nodules
also differ in their location on the vocal fold. Nodules
are most often bilateral and are found at the junction
of the anterior and middle third of the free edge of
the vocal folds. Cysts are usually unilateral and can
occur anywhere on the fold. When the cyst is at the
free edge, it is common for a reactive nodule to form
at the same location on the other fold.
Symptoms:
The most common symptom of nodules and cysts is hoarseness.
Voice production is often effortful. Occasionally, a
growth will become large enough to cause pain.
Causes:
Nodules typically occur as a result of voice misuse
or overuse, which causes irritation and inflammation
of the vocal fold mucosa. With continued misuse, the
tissue becomes fibrotic and hardened. Cysts, on the
other hand, are usually the result of a blocked mucous
gland within the fold. As mucous accumulates behind
the blockage, the tissue expands and a cyst is produced.
There appears to be a voice misuse component to the
formation of cysts, especially when they occur in the
same location as nodules. Some cysts occur at the time
of birth and may present with symptoms years later.
Treatment:
Vocal nodules are generally treated with voice therapy.
The patient is taught voice production techniques to
decrease the contact force between the nodules. Voice
therapy also teaches the patient to avoid behaviors
which might cause or aggravate the nodules. Some medical
conditions (such as allergies and laryngo-pharyngeal
reflux) can maintain the presence of the nodules and
require treatment. In some instances, surgery is necessary
to remove the nodules. In these cases, pre- and post-
operative voice therapy is also used. Cysts are treated
primarily by surgical removal. Voice therapy is often
useful to decrease associated swelling and improve voice
quality. Therapy is also used to treat any reactive
nodules.
Although
recurrence is a concern, treatment for both nodules
and cysts is usually successful and normal voice function
returns.
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CONTACT
GRANULOMA/CONTACT ULCER
Contact
granulomas or contact ulcers are formed as a result
of injury to the delicate tissues of the larynx. In
response to this trauma, the mucosa of the vocal folds
either ulcerates, forming a contact ulcer, or produces
heaped-up accumulation of tissue, a contact granuloma.
These lesions usually appear as a build-up of pinkish-white
tissue near the arytenoid cartilages at the rear of
the larynx.
Contact
granulomas occur almost exclusively in males over the
age of 20. They are common in professional voice users
such as lawyers, ministers, business executives, and
physicians.
Symptoms:
The primary symptom of a contact granuloma is the sensation
of a foreign body in the throat. Constant and vigorous
throat-clearing is often present and, less often, hoarseness
or a husky-sounding voice. Pain, usually described as
sharp and stabbing, may also be present and may radiate
toward the ear.
Causes: Contact granulomas are commonly caused and maintained
by a combination of laryngopharyngeal reflux, voice
misuse, and excessive throat-clearing or coughing. These
activities cause the vocal folds to "slap"
together forcefully, traumatizing the mucosa. Granulomas
can also be caused by direct trauma to the vocal folds,
for instance as a result of intubation.
Treatment:
Inhaled steroids and an antireflux regimen are generally
the initial treatment. Adjunctive voice therapy is commonly
used to teach the patient to avoid those behaviors which
may injure the vocal folds. Surgery to remove these
types of lesions is usually undertaken as a last resort
because recurrence is common.
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LARYNGEAL
CANCER
Like
all cancers, laryngeal cancer is the result of uncontrolled
division by the body's cells. As these cells divide
and accumulate, a mass develops. Unlike benign growths,
however, cancer can invade healthy tissue and spread
to other parts of the body. This process is called metastasis,
and it is the reason why it is important to identify
cancers early.
Symptoms:
The symptoms of laryngeal cancer depend largely upon
the size and location of the tumor. Hoarseness or other
changes in vocal quality are oftentimes the first symptoms.
Large tumors may interfere with the airway and cause
difficulty breathing or noisy breathing. Tumors can
also cause difficulty swallowing. Other symptoms may
include throat or ear pain, lumps in the neck or throat,
blood in the sputum, or a persistent cough.
Causes:
The exact cause of carcinogenesis is unknown, but the
risk factors are well established. Cancer of the larynx
usually occurs in patients over the age of 55, and is
four times more likely to occur in men than in women.
It is also more prevalent in the African-American population
than in the Caucasian population. Smoking, especially
in combination with heavy alcohol consumption, also
increases the risk of cancer. Exposure to carcinogens
in one's environment (e.g. asbestos) is also associated
with laryngeal cancer.
Treatment:
The treatment for cancer of the larynx depends on the
size and stage of the tumor, as well as the age, health,
and opinions of the patient. Treatment usually involves
radiation therapy, surgery, or a combination of the
two.
In
radiation therapy, high-energy rays are directed at
a tumor and the surrounding tissue to stop the cancer
and prevent its spread. Radiation therapy usually lasts
five days a week for five to six weeks. At the end of
this period, the tumor bed often receives an additional
"boost" of radiation.
For larger tumors, or if radiation therapy has failed,
surgery may be indicated. A partial laryngectomy may
be performed, in which only a portion of the larynx
is removed. This is the preferred treatment because
it often preserves the voice. If a tumor is widely invasive,
however, a total laryngectomy may need to be performed
in which the entire larynx is removed. At the same time,
a tracheostoma is created which brings the upper end
of the trachea to open onto the surface of the neck.
Because a total laryngectomy includes removal of the
vocal folds, normal voice is precluded. However, alternate
speech techniques are possible. If a surgeon suspects
that cancer may have metastasized to nearby tissue,
a radical neck dissection may also be performed to remove
the lymph nodes and surrounding tissues in the neck.
For
a patient with a total laryngectomy, several options
are available to restore speech function.
Electrolarynx:
A battery-operated device is placed on the neck when
one wishes to speak. It produces high-frequency vibrations
which are manipulated by the mouth and tongue to produce
speech. The technique is usually easy to learn, but
speech is mechanical and monotone.
Esophageal
Speech: This is a technique in which air
is injected into the esophagus by the tongue and then
regurgitated. As the air passes back through the mouth,
it is manipulated to form speech. While this technique
produces more natural-sounding speech, it may be more
difficult to learn.
Tracheoesophageal
(TE) Puncture: A puncture is made (during
the laryngectomy or shortly thereafter) between the
esophagus and the trachea, and a small silicone prosthesis
inserted. When the patient wishes to speak, their finger
is placed over the opening to the tracheostoma and air
is diverted through the prosthesis into the esophagus
and out the mouth. As in esophageal speech, the exiting
air is manipulated by the mouth and tongue to produce
speech. This procedure is usually very successful and
produces relatively natural-sounding speech.
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THE
AGING LARYNX
The
larynx, like any other part of the body, changes as
we grow older. Many of these alterations are not noticeable;
however, some of the changes can affect the quality
and sound of the voice. The framework cartilages of
the larynx ossify (turn to bone, which is less flexible)
and the cartilages responsible for vocal fold movement
become less mobile. There is often thinning of the elastin
fibers in the vocal folds, thickening or fibrosis of
the collagen fibers, and atrophy of the vocalis muscle.
These changes interact with fatty cells replacing mucous
secretors, causing a decrease in the elasticity of the
vocal folds. As we age, changes to the brain and spinal
cord can affect neurological control of the laryngeal
muscles. The net effect is a glottal gap during voice
production, decrease in fine control of the vocal folds,
and vocal fold stiffness.
Perceptually,
voice can become breathy, rough, hoarse, and quiet as
we age. The pitch of the of the voice tends to lower
for women and rise for men. With videostroboscopy, we
can see aperiodic vibration, a glottic gap, and decrease
in the vibratory parameters of amplitude of vibration
and mucosal wave.
A
program of voice therapy exercises is often beneficial
in maintaining or restoring periodic vibration and improving
voice quality and projection. If the glottic gap is
large, there are surgical procedures available to improve
vocal fold closure.
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