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
Cartilaginous skeleton
Intrinsic Musculature
• Abductors
• Adductors
• Tensors
Intrinsic Musculature
Innervation
Abduction
Adduction
Tension
Vocal Fold Anatomy
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)
Laryngeal Anatomy
Laryngeal Anatomy
Mucosal wave/Phase delay
Body-Cover Theory
• Changes to mucosal wave
– Stiffness
– tension
Mucosal wave
• Velocity increases
– Increased airflow
– Increased subglottic pressure
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
Indirect mirror examination
• Advantages
– Quick
– Inexpensive
– Little equipment
• Disadvantages
– Gag
– Anatomic features
– nonphysiologic
Flexible laryngoscopy
• Advantages
– Well tolerated
– Complete examination
– Video documentation
• Disadvantages
– More time
– Expensive
Rigid laryngoscopy
• Advantages
– Best images
– Magnification
– Video documentation
• Disadvantages
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Expensive
Nonphysiologic
Gag
Anatomic features
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
Differential Diagnosis of
Hoarseness
• Vocal quality- determined by:
– distance between vocal cords,
– tenseness of the cords
– how rapid cords vibrate
• Hoarseness is caused by
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Differential Diagnosis of Hoarseness
Types of voice
• Breathy- vocal cords do not approximate so
air escapes.
• Raspy- harsh voice. Cord thickening due to
edema or inflammation. Voice is low in
pitch and poor quality
Differential Diagnosis of Hoarseness
Types of voice
• Muffled voice- painful dysphagia and
dyspnea
• Shaky- high pitch or low soft.
– Elderly
– debilitated
Differential Diagnosis of Hoarseness
Acute Hoarseness/Acute Laryngitis
• Laryngeal mucous membrane infection,
usually viral (adenovirus/ influenza, RSV,
coxsackie, rhinovirus)
• Also can be due to trauma to throat, vocal
abuse, toxic exposure, GI complications,
smoking, allergy
Differential Diagnosis of Hoarseness
Acute Hoarseness/Acute Laryngitis
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Hoarseness
Cough
Sore throat
Fever
Vesicles on soft palate
Lymphadenopathy
Differential Diagnosis of Hoarseness
Acute Hoarseness/Acute Laryngitis
• Diagnostics: Laryngoscopy if suspect mass,
infection, vocal cord dysfunction
• Management: Voice rest, smoking/alcohol
cessation, hydration
Evaluation of Hoarseness
• History is paramount
• Projection - tired, breathy and low volume
• Quality - ”hoarse”, “gruff”, “raspy”
• Range - high, middle and low
Evaluation of Hoarseness
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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
Evaluation of Hoarseness
• Endoscopic exam –
• mirror, flexible endoscope, rigid endoscope
• Digital archiving essential for
documentation
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.
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
Normal Stroboscopy
Neuromuscular Disorders
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Vocal cord paralysis
Vocal cord paresis
Cricoarytenoid joint dysmobility
Presbylaryngis (aging larynx)
Muscle Tension Dysphonia (Hyperfunction)
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
Vocal Cord Paresis
Vocal Cord Paralysis 2
Videostroboscopy
Radiographic studies
• MRI
• CT
Laryngeal EMG
• Myopathy – normal frequency of firing but
decreased amplitude
• Neuropathy – decreased frequency but
occasional normal amplitudes
• Polyphasic reinnervation potentials indicate
some loss of function but reinnervation has
begun
Laryngeal EMG
Differential
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Congenital
Inflammatory
Neoplastic
Traumatic
Neurologic
Endocrine
Iatrogenic
Local factors
Vocal Cysts
Vocal Nodules
• Usually bilateral
• Voice rest and speech therapy for 6 months
• Surgical removal
Vocal cord granulomas
• LPR
• Intubation
• Treat medically
Glottal Incompetence
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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.
Cricoarytenoid Joint Dysmobility
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Intubation, rheumatoid, osteoarthritis
Limit range of movement
Can’t open or close
Voice and airway
Medical therapy if appropriate
Surgery - move or remove arytenoid
Hyperfunction – a.k.a. MTD
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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”
Epithelial Diseases
• Papilloma
• Premalignancy (Vocal cord dysplasia)
• Malignancy
Vocal Cord
Papilloma
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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!!!
Vocal Cord
Keratosis with Atypia
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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!!!
Vocal Cord Cancer
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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
Subepithelial Diseases
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Vocal cord nodules
Vocal cord polyps
Vocal cord cysts
Reinke’s edema
Vocal cord sulcus
Vocal cord scar
Vocal Cord
Nodules
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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
Vocal Cord Nodules 1
Vocal Cord Nodules 2
Vocal Cord
Polyp
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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
Vocal Fold Cyst
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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
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
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!!!
Vocal Cord Sulcus
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Developmental loss of SLP
Decreased pliability
Loss of cycle-to-cycle closure
Management with surgery is best hope
Slicing technique
Fat implantation
Medialization Thyroplasty
Vocal Cord Inflammatory
Diseases
• Reflux Laryngopharyngitis (LPR)
• Arytenoid Granuloma
Arytenoid Granuloma
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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
Vocal Cysts
Vocal Nodules
• Usually bilateral
• Voice rest and speech therapy for 6 months
• Surgical removal
Vocal cord granulomas
• LPR
• Intubation
• Treat medically
Vocal Cord Paralysis
• Lesion at nuclear level – cadaveric
• Lesion above nodose ganglion – abducted
• Lesion below nodose ganglion - paramedian
Vocal Cord Paralysis
• Superior laryngeal nerve – subtle voice
changes with decreased pitch range, tilting
of the larynx with a rotation of the glottis
Vocal Cord Paralysis
• Children
– Neurologic
– Traumatic
– Idiopathic
• Adults
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Iatrogenic
Traumatic
Neoplastic
Idiopathic
neurologic
THANK YOU !!!
Rule of Thumb
• Any patient with hoarseness of two weeks
duration or longer must undergo visualization of
the vocal cords