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Most often resulting from overuse or coexisting disease, conditions affecting the larynx are serious concerns for the performing artist. At Methodist’s Center for Performing Arts Medicine, our physicians are experts in the treatment of voice disorders including those described here.
Nodules are calluses on the vocal folds that occur with improper voice use or overuse. They are most common in children and females. They prevent the vocal folds from meeting in the midline and produce an hourglass-shaped deformity on the folds' closure, resulting in a raspy, breathy voice. Most times these will respond to appropriate speech therapy. Occasionally (20% of the time), these may persist after intensive speech therapy and will require meticulous microlaryngeal surgery.
Polyps are benign lesions of the larynx, usually located on the phonating margin (edge) of the vocal folds, that prevent the vocal folds from meeting in the midline. Polyps can interfere with voice production and may produce a hoarse, breathy voice that tires easily. These may respond to conservative medical therapy and intensive speech therapy. If the lesion fails to respond, meticulous microsurgery may be indicated. Laryngeal polyps occur most frequently in adult males. One of the cofactors in the cause of these lesions may be laryngeal reflux disease.
Laryngitis sicca is caused by inadequate hydration of the vocal folds. Thick, sticky mucus prevents the folds from vibrating in a fluid, uniform manner.
Vocal fold hemorrhage
Vocal fold hemorrhage is a very rare occurrence that usually is caused by aggressive or improper use of vocal folds (e.g. cheerleading). It is a result of rupture of a blood vessel on the true vocal fold, with bleeding into the tissues of the fold.
If cancerous lesions are detected early, they can be treated with either radiation or surgery, with a cure rate approaching 96%.
Impaired Vocal Fold Mobility, a condition where one or both of the vocal folds do not move appropriately, can be due to paralysis, paresis, scarring, or inflammation of the crico-arytenoid joint.
Vocal fold paralysis or paresis results from a lesion of the neural or muscular mechanism.
- Unilateral vocal fold paralysis can be caused by a variety of diseases or disorders that prevent movement in one vocal fold. When one weakened vocal fold does not move well enough to meet the other fold in the midline during speech, air leaks out too quickly. This causes the voice to sound breathy and weak, making it necessary for the speaker to take more frequent breaths during speech. After a full day of talking, someone with a weak vocal fold can feel exhausted due to frequent breathing, and can experience choking and coughing on food or liquids.
- Bilateral vocal fold paralysis: When both vocal folds have movement problems, the situation can be much more serious. With both vocal folds paralyzed in the midline position, the person has difficulty breathing and a tracheotomy may be necessary to establish an airway. If both folds are paralyzed near the midline, although the voice may be good the airway may be compromised. If both folds are paralyzed far apart, there may be no voice.
Vocal fold bowing can result from neural, muscular, traumatic, congenital, or functional causes, with or without vocal fold atrophy, and can result in vocal weakness.
Presbylaryngis is a condition that is caused by thinning of the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and therefore do not meet in the midline. As a result, the patient has a hoarse, weak, or breathy voice. This condition can be corrected by injection of fat or other material into both vocal folds to achieve better closure.
Laryngeal dystonia, or spasmodic dysphonia (SD), is a voice disorder caused by involuntary movements of one or more muscles of the larynx. There are two major types of spasmodic dysphonia: adductor and abductor, although most are a mixture of both types.
- Adductor SD, with spasms causing sporadic vocal fold closures, are identified by a strained, strangled voice.
- Abductor SD, with spasms causing sporadic (occasional) vocal fold closures, produces a voice with interruptions of air.
A class of conditions known as functional disorders of the larynx are the result of inappropriate movement of laryngeal muscles. These include:
- Muscle tension disorder: Excessive laryngeal muscle tension squeezes the vocal folds and surrounding muscles into a “fist” configuration, preventing air from moving through the vocal folds to enable normal vibration. The voice is reduced to a “squeaky” sound.
- Dysphonia plica ventricularis: A laryngeal function disorder caused by phonation of the ventricular folds (false folds) rather than the true vocal folds. When the ventricular folds are squeezed together, the resulting voice is harsh and strained. This can be a learned behavior, but may be the result of true vocal fold weakness.
- Paradoxical vocal fold dysfunction: Paradoxical vocal fold dysfunction is the result of the vocal folds coming together during inspiration, instead of normally opening to allow air to flow freely. This can alarm the patient and those nearby, as the patient is gasping for air. Frequently, these patients are seen in the emergency room and treated (incorrectly) for asthma. The typical symptom of this disorder is phonation during inspiration. The diagnosis can be suspected by the history and physical exam, and confirmed by examination of the larynx with a flexible fiberoptic laryngoscope during an attack. Laryngopharyngeal reflux can exacerbate the symptoms. Treatment may involve several specialties, especially Speech-Language Pathology.
Laryngopharyngeal Reflux Disease (LPRD)
The esophagus has two sphincters - bands of muscle fibers that close off the tube - to help keep the contents of the stomach where they belong. One sphincter is at the top of the esophagus (at the junction with the upper throat) and one is at the bottom of the esophagus (at the junction with the stomach). The term "reflux" means "a backward or return flow," and it usually refers to the backward flow of stomach contents and acids up through the sphincters and into the esophagus or throat. If the reflux makes it all the way up though the upper sphincter and into the back of the throat, it is called LPRD or Laryngopharyngeal Reflux Disease. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of reflux into this area can result in more damage.
Common symptoms of LPRD include hoarseness, cough, frequent throat clearing, pain or a "lump" in the throat, problems with swallowing and difficulty with singing high notes. In addition to a basic medical examination of symptoms, a method known as 24-hour Pharyngo-Esophageal pH monitoring can provide a definitive diagnosis of LPRD. This method involves the insertion of a tube through the patient's nose into the esophagus, where it provides information on the activity of the esophagus and associated sphincters during the patient's daily routine.
Some voice disorders can be easily treated with appropriate medication, voice rest, increased hydration, and vocal hygiene. Others may require surgical intervention and/or extensive speech therapy.
Laryngeal Dystonia (Spasmodic Dysphonia): Whether the spasms occur with the vocal folds open or closed, this neurological disorder improves with Botox® injections and supplemental speech therapy.
Incompetent Larynx: Treatment for incomplete vocal fold closure may involve specialized speech therapy and/or surgical management.
Benign Lesions: Treatment may include medication, voice rest, increased hydration, vocal hygiene, extensive speech therapy and/or surgical intervention.
Malignant Lesions: A biopsy will be performed on suspicious lesions, followed by recommendations for appropriate treatment.
Functional Disorders involve inappropriate laryngeal muscle movement, and often require extensive speech therapy.
Laryngopharyngeal Reflux Disease (LPRD) treatment normally involves a combination of dietary adjustments, behavioral and lifestyle modification (such as stress reduction techniques), and medications.