Laryngology seminar
94-08-17
R3 戴安修
Medical treatment for dysphonia
● Dysphonia: Voice quality change; decrease of dynamic range, frequency, intensity;
decrease of vocal tolerance; increase phonation effort.
Irregularities and noises
● Mechanic causes of dysphonia
Random movement of mucus (viscosity; uneven surface)
Turbulence in the air steam
Asymmetry in the movement between vocal folds
Increase vocal fold viscosity
Non-linear motion of vocal folds
Poor neuromuscular-mechanic coupling
●
Preventing further damage
Facilitating regeneration
Improve voice quality
●
The ideal management is vocal rest (Punt, 1983)
● Laryngeal syringe with a fine and properly curved pipe (Punt 1968); Gargles may
be somewhat soothing or moistening but do not reach further than the anterior fauces.
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Empirical used medicaments
 mucus water content and evenness;  mucus viscosity;  Cover stiffness
Mucolytic
Decongestants: Ephedrine: vaso-constrictor and may possibly reduce slight cordal
oedema.
Carboxamide, Urea: Topical urea is a potent hydrating agent in the skin. This is
mediated by its hygroscopic properties and its ability to cause configurational change
in proteins in the stratum corneum.
It acts as a mucolytic and helps to clear sticky mucus from the pharynx and larynx. A
salt-spoonful to 50 ml of a watery solution.
Transamin (Tranexamic acid): Synthetic aminocaproic acid. It produces an
antifibrinolytic effect by competitively inhibiting the activation of plasminogen to
plamin as a lysine substitute, Preventing of bleeding after surgery or trauma,
prevention of spontaneous or postoperative corneal oedema, treatment of
angioneurotic oedema.
The clinical use of tranexamic acid in acute inflammation of the upper respiratory
tract [Italian, Giornale di Clinica Medica. 1979];
Punt: in cases where a singer suffers from hyperaemic cords and even cordal
haemorrhage, if she has to sing just before or in the first few days of menstruation.
Myotonine chloride: parasympathomimetic drug, actions through its stimulant action
on muscarinic cholinergic receptors, increase secretion, (cardiovascular effects
minimal) taken before performance is often useful in stimulating lubrication in
performers who suffer from the dreaded dry throat at these times.
Lubrication: Rapidly vibrating cords are protected by an adequate supply of thin
mucus, especially that secreted by glands in the ventricles just above the cords.
Stimulation of these glands by KI and Myotonine may be very effective.
KI: dryness of throat or recurrent compulsion to clear the throat of sticky mucus.
 Mucosal irritation
Cough syrup (Polymucosaccarides, block irritation)
Diphenhydramine: Ethanolamine class antihistamine  predominantly as a
competitive but reversible inhibitor of histamine at the H1 receptor sites. Action at H1
2
sites include contraction of bronchial, intestinal, and vascular smooth muscle.
Additional sedative, anticholinergic and local anaesthetic properties.
● 0.5% in water, mild vaso-constrictive and gently analgesic action. Most valued
local application by Punt, bitterness, the patient experience a slightly burning
sensation, then a feeling of lump, and after a few minutes a comfortable clear larynx
and a gruff speaking voice may then rise toward its normal pitch.
Topical anesthetics (release mucosa irritation): Xylocaine: only used in moderation,
valuable in relieving pain from mouth ulcers, or by swallowing if there is upper
esophageal pain resulting from a fish bone which has passed on.
 It should not preferably be used within half-an-hour or so before performing or the
voice may go out of control.
 Mucosa tension;  Tremer
Anti-tussive; Muscle relaxants; Minor tranquilizer; Beta-blockers
Cortico-steroids: May be very valuable in damage to muscles, Reinke’s space and
the cordal epithelium. Systemic prescribed. Never give them to young female as
virilization and loss of high tones may result.
Avoid Anabolic hormone; steroid inhaler; ACEI (mucosa irritation  muscle tension
 tight )
Mandel’s solution: Iodine (elemental iodine used as topical broad spectrum
antiseptics and disinfectant sanitizers; Absorption of iodine across damanged skin and
mucous membrane is extensive; May be used for the treatment of infected
inflammatory lesions of the mouth and pharynx caused by bacterial or monilial
infection); KI; phenols (denature protein and precipitation): menthol; glycerin
Protagol: silver protein, Denature protein and precipitation
● Treatment for vocal abuse and overuse
Vocal nodule, acute haemorrhagic, very quiet talking for a week (no whispering, as
this may do further harm by muscle strain), steroids, local vasoconstrictors to the
larynx may be most valuable.
If menstruation is a likely factor, transamin may be valuable to prevent recurrence
at the next menstrual period.
 Some of the nodules do not subside  remove
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Chronic non-infective laryngitis: Cords which are grossly hyperaemic and
roughened are productive of an unpleasant hoarse voice of limited range.
 Vasoconstrictors locally and long-acting steroids.
 Reduction of the causative abuses.
 Operation can worsen the voice.
Reinke’s oedema: (severe cases polypoid corditis) In gross vocal-abuses, workmen
who shout above noisy machinery, and heavy smoking.
 Lesser degrees are freguently seen in singers and actors.
 Swelling, usually anterior, may be slight and careful observation is necessary.
 Lack of quality, and power in the voice.
 Vaso-constrictor sprays may be useful before performance.
Contact ulcer and pachydermia: Commoner in who imagines that the forceful,
low-pitched by loud, mode of voice production improved his image.
 Typically swelling over the arytenoid vocal area on one cord, which has struck
against the opposing area of the other cord, denuding the perichondrium and
producing an ulcer by a ‘hammer on anvil’ action.
 Pachydermia  gross keratotic thickening of the epithelium covering the posterior
ends of the cords.
 Treatment of these-condition is unsatisfactory unless the patient can change his
habitual speech-pattern.
Regurgitation of acid from the stomach may produce laryngitis seen as hyperaemic
aryepiglottic folds. Simple anti-acids and gastric sedatives may be sufficet but a
consultant physician may be necessary.
Lubrication
● A speaking or singing voice may fail when there is nothing wrong with the
structure of the pharynx or larynx, but only a defect in the essential lubrication of the
mechanism and especially of the vocal fold.
● Conditions result in lubrication defects:
Emotional factors
Nose and sinus conditions
Excessive smoking and drinking,
Medicaments (antihistamines which inhibit mucous and salivary secretion)
Poor air-conditioning.
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Tracheo-bronchial secretions may enter the larynx from below and impede
lubrication.
● Jets of mucus squirted onto the cords by the ventricular glands.
 This natural lubricant should be adequate in quality and thin in consisitency.
 The patient will often complained of too much mucus, when actually the trouble is
that there is too little mucus and it is too thick.
 Even if more obvious trouble, such as vocal nodules or other vocal abuse damage
is evident, improving lubrication may greatly help.
Systemic medications
Iodide compound for two weeks stimulates mucous glands;
Tracheo-bronchial secretions cause trouble they may be thinned by given ‘Bisolvan’
two tables tid for a week.
Very dry mouth may be moistened by stimulating salivary and mucous glands with
myotonine taken about an hour before performing.
Local treatments: delivered to the larynx to wash out sticky mucus.
 0.5% Benadryl.
 Urea: mucolytic.
 3% alcohol and 6% glycerin in normal saline
Peanuts are hazardous as the oil may inflame the larynx if it comes nearby.
REFERENCES
Punt N A. Laryngology applied to singers and actors. The journal of laryngology and
otology, 1983, supplement No 6.
Dolley C. Therapeutic drugs. Churchill livingstone 1991.
Laryngology and phoniatric course 2005.
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