Disorders
The following pages
discuss the symptoms, etiology, and treatment for some of the more common
laryngeal disorders. Note: The information contained in these pages is
for educational purposes only. It should not be construed as individualized
diagnostic and treatment advice.
Select a disorder Topic
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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View a stroboscopic exam of the patient
above after Botox treatment. Note the improved voice quality and the more normal adduction of the
vocal folds during phonation.
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VOCAL FOLD MOTION IMPAIRMENT
The vocal folds, because of their position in the airway, play a vital
role in speech, swallowing, and breathing. In order to perform these
functions normally, the laryngeal muscles must be able to abduct (open)
and adduct (close) the folds.
Vocal fold motion impairment is of two major types: unilateral (more
common) and bilateral. These types differ in their seriousness, symptoms,
and treatment.
Symptoms: Patients with unilateral paralysis may exhibit a weak and "breathy" voice,
and speaking may require considerable effort. Because the vocal folds
are unable to close completely during swallowing, patients may also experience
coughing and choking while eating or drinking. Patients with bilateral
paralysis may experience these symptoms, but the possibility of a compromised
airway is a more serious threat. The muscles which normally abduct the
folds and provide for a patent airway are unable to function. Thus, the
folds may remain adducted in the airway and block normal respiration.
Causes: The most common cause of vocal fold motion impairment is injury
to the recurrent laryngeal nerve, the nerve responsible for controlling
the intrinsic muscles of the larynx. This may be due to trauma, surgery,
viral infection, a tumor pressing on the recurrent laryngeal nerve, or
other causes. Occasionally, injury or diseases of the brain, including
stroke, result in impaired motion.
Mechanical obstruction can also result in vocal fold motion impairment.
The arytenoid cartilages can become "locked" and restrict movement.
Scar tissue may also accumulate and inhibit vocal fold movement.
Treatment: A combination of surgery and voice therapy is used to treat
unilateral motion impairment:
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View
a stroboscopic exam of unilateral or bilateral vocal fold motion impairment
(QuickTime format, file size approximately 1 MB).
In the patient with unilateral
impairment, notice how the left vocal fold (on the right of the image) fails
to move in unison with the right fold. Also note the hoarseness and loss
of voice quality. In the patient with bilateral vocal fold motion impairment,
notice how the vocal folds remain adducted at the midline and movement is
minimal. This can lead to airway compromise and restriction of breathing.
Medialization thyroplasty is a surgical procedure in which a small incision
is made in the skin near the larynx and a small piece of thyroid cartilage
removed. A small block, usually made of silicone or hydroxylapatite, is secured
in the cartilage. This block acts as a shim which pushes the vocal fold medially,
helping to improve vocal fold closure. This procedure is relatively quick and
painless and is usually performed under local anesthesia.
The images to the left depict the medialization thyroplasty procedure. The
image on the left shows the placement of the shim in the thyroid cartilage.
The coronal image on the right demonstrates how this shim, when correctly placed,
can help push a motion-impaired vocal fold medially.
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The
second treatment for unilateral vocal fold motion impairment involves the
injection of small amounts of materials directly into the vocal fold. Again,
the goal is to push to fold medially and restore function. This technique,
while effective, is limited by the difficulty of controlling the placement
and volume of the injected material.
Several different substances are commonly used for injection:
Autologous Fat: Fat has the advantage of being well-tolerated by the body.
Because it is taken from the patient, the chances of rejection or infection
are small. Additionally, fat provides good vibratory characteristics within
the vocal fold. Fat, however, may be resorbed by the body and the procedure
may need to be repeated to achieve the desired result.
Gelfoam: Gelfoam is a starch-like material which is quickly absorbed by the
body. It is used to provide temporary improvement in patients with laryngeal
paralysis.
Collagen: Collagen is most often used in the correction of small defects of
the vocal fold. It offers good vibratory characteristics, and like hydroxylapatite,
it is bioactive. This bioactivity can stimulate fibroblasts to remodel and
can result in repair of the defect. Collagen's main limitation is that it is
resorbed in an unpredictable fashion.
Teflon: Teflon lasts longer in the body than fat or gelfoam and is usually
used to permanently repair vocal fold defects. When injected, teflon causes
an inflammatory granulomatous reaction which, if severe enough, can lead to
a "stiff" vocal fold which adversely affects voice quality.
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View a stroboscopic exam of the unilateral vocal fold patient above after treatment by medialization thyroplasty. Note how the patient's voice quality has been greatly improved by this procedure.
Voice therapy is useful when the vocal folds can almost close. Therapy techniques are designed to improve voice quality, increase loudness, and lessen the feeling of running out of air when talking. Therapy is often used to "fine-tune" the voice after surgery, with goals of decreasing any residual "gravelly" quality and vocal fatigue.
Several options exist for the treatment of bilateral vocal fold motion impairment. All of these treatments seek to improve breathing. They have different effects on the balance between breathing, voice quality, and airway protection during swallowing. The tracheostomy is considered the "gold standard" for bilateral vocal fold motion impairment.
It is a commonly performed procedure where an opening between the neck (below the level of the vocal folds) and the trachea is created surgically. A transverse cordotomy is another option and involves removing a small portion of the vocal fold from one or both sides.
Newer procedures for dealing with bilateral vocal fold motion impairment have recently emerged. One of these, a posterior cricoid split, involves splitting the cricoid cartilage and inserting a cartilage graft. This allows for a larger glottal opening and can help to relieve the symptoms of vocal fold motion impairment. An even newer technique, laryngeal pacing, involves the implantation of a small device which causes coordinated abduction of the vocal folds during respiration.
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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.
The image below is a magnified intraoperative view of a vocal fold polyp (yellow arrow).
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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.
The image below is a laryngoscopic view of vocal fold nodules (yellow arrows).
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CONTACT GRANULOMA/CONTACT ULSER
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.
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.
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The images below show laryngoscopic views of laryngeal tumors (yellow arrows).
The image on top is of a large supraglottic tumor.
The epiglottis is completely
obscured, and the vocal folds are barely visible below the mass. The image
on the bottom is of a laryngeal tumor of the left vocal fold.
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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View a stroboscopic exam of an
older patient's larynx. Note
the bowing of the vocal folds and the glottal gap during phonation.
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