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Current Diagnosis and Treatment of Voice Disorders

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Current Diagnosis and Treatment of Voice Disorders

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    1. 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

    3. 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)

    4. Laryngeal Anatomy

    5. Laryngeal Anatomy

    7. 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

    8. 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

    9. Evaluation of Hoarseness History is paramount Projection - tired, breathy and low volume Quality - ”hoarse”, “gruff”, “raspy” Range - high, middle and low

    10. Evaluation of Hoarseness 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

    11. Evaluation of Hoarseness Endoscopic exam – mirror, flexible endoscope, rigid endoscope Digital archiving essential for documentation

    12. 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.

    13. 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

    14. Normal Stroboscopy

    15. Neuromuscular Disorders Vocal cord paralysis Vocal cord paresis Cricoarytenoid joint dysmobility Presbylaryngis (aging larynx) Muscle Tension Dysphonia (Hyperfunction)

    16. 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

    17. Vocal Cord Paresis

    18. Vocal Cord Paralysis 2

    21. Medialization Thyroplasty

    22. Adduction Arytenopexy

    23. Glottal Incompetence 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.

    26. Medialization Thyroplasty

    27. Cricoarytenoid Joint Dysmobility Intubation, rheumatoid, osteoarthritis Limit range of movement Can’t open or close Voice and airway Medical therapy if appropriate Surgery - move or remove arytenoid

    31. Hyperfunction – a.k.a. MTD 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”

    34. Epithelial Diseases Papilloma Premalignancy (Vocal cord dysplasia) Malignancy

    35. Vocal Cord Papilloma 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!!!

    38. Vocal Cord Keratosis with Atypia 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!!!

    41. Vocal Cord Cancer 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

    43. Subepithelial Diseases Vocal cord nodules Vocal cord polyps Vocal cord cysts Reinke’s edema Vocal cord sulcus Vocal cord scar

    44. Vocal Cord Nodules 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

    45. Vocal Cord Nodules 1

    46. Vocal Cord Nodules 2

    49. Vocal Cord Polyp 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

    56. Vocal Fold Cyst 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

    59. 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

    63. 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!!!

    66. Vocal Cord Sulcus Developmental loss of SLP Decreased pliability Loss of cycle-to-cycle closure Management with surgery is best hope Slicing technique Fat implantation Medialization Thyroplasty

    69. Vocal Cord Inflammatory Diseases Reflux Laryngopharyngitis (LPR) Arytenoid Granuloma

    72. Arytenoid Granuloma 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

    75. Summary Wide variety of disorders An abnormal voice means there’s something wrong All voice disorders are treatable Most are curable Let your history and ears guide you RAPIDLY DEVELOPING FIELD

    76. THANK YOU !!!

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