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1 A Laryngologist s Approach to Voice Presentation at the Nebraska Speech- Language-Hearing Association Fall Convention Thursday, September 27, :45-16:45 Christopher M. Bingcang, MD Assistant Professor of Otolaryngology-Head & Neck Surgery University of Nebraska Medical Center Sunshine Act Disclosure I have no disclosures to report I will discuss the use of Botox as off-label use I will not discuss any commercial products Learning Objectives Understand Voice disorders and how to assess Understand the purpose of a stroboscopic evaluation Review selected pathology 1

2 Vocal Tract Resonator Oral Cavity Pharynx Sinonasal Tract Vibrator Larynx Air Pressure System Lungs and surrounding musculature and chest walls Adduction and Abduction ADduction Abduction (1 muscle only!!!) Anatomy: Innervation larynx 2

3 The Body Cover concept of vocal cords Body: TA muscle and ligament Cover Epithelium and superficial lamina propria (SLP) SLP vibrates in a Mucosal Wave The Body Cover concept of vocal cords Body: TA muscle and ligament Cover Epithelium and superficial lamina propria (SLP) SLP vibrates in a Mucosal Wave EVALUATION OF HOARSENESS History Examination Testing Pre-surgical assessment 3

4 HISTORY Chronicity Severity Impact on social and professional life Drugs Abuse, dehydration, inhaled steroids Neuro Speaking or singing Singer s History Formal training Current voice coach or teacher Range Voice type Singing style/genre Medical History GERD Asthma Allergies Smoking history (and other drugs) 4

5 EXAMINATION General head & neck exam Perceptual analysis of voice Quality, loudness, pitch GRBAS Stridor Body Habitus Neurologic evaluation GRBAS Used in conjunction with CAPE-V sentences Scored 0-3 Grade Roughness Breathiness Asthenia Strain Evaluation of Hoarseness: TESTING Laryngoscopy Stroboscopy High Speed laryngoscopy Aerodynamics and Acoustics Laryngeal EMG Radiology CT neck- if paralysis, look for RLN mass 5

6 Transnasal (flexible) Transoral (rigid) Laryngoscopy Routes Flexible Transnasal Laryngoscopy Soft Palate Swallow, and say kitty cat Base of Tongue say /ee/ and /ah/ Pharynx note pooling of secretions Larynx Breathing, including sniffing Phonating Coughing Laryngeal Videostroboscopy (LVS) Purpose- assess vibratory properties of the vocal folds 6

7 Mucosal Wave - Stroboscopic evaluation of larynx slows the movements to allow analysis of the organized mucosal wave Stroboscopy- OF ME! Other Adjunct Testing Acoustic analysis (jitter, shimmer, harmonic tonoise ratio) Aerodynamic assessment (mean phonatory time, phonatory and respiratory airflow ) Laryngeal EMG (LEMG) 7

8 Laryngeal EMG (LEMG) Useful for Diagnosis of vocal fold palsy Directing Botox injections into target muscles i.e. spasmodic dysphonia Blitzer A, Crumley RL, Dailey SH, et al. Recommendations of the Neurolaryngology Study Group on laryngeal electromyography. Otol head neck surg. 2009;140(6): Select Voice Pathologies 1) Muscle Tension Dysphonia 2) Spasmodic Dysphoina 3) Parkinson Hypophonia 4) Unilateral Vocal Cord Paralysis 5) Laryngopharyngeal Reflux 6) Vocal Nodules 7) Vocal Polyps 8) Vocal Cysts 9) Vocal Cord Cancer Muscle Tension Dysphonia Palpation of larynx- spastic/tight thyrohyoid space. Odynophonia TREATMENT Voice therapy is gold standard Botox injections if refractory to voice therapy 8

9 Spasmodic Dysphonia (SD) A focal dystonia of the larynx Task specific Characterized perceptually by instability Strained / strangled voice Intermittent voice breaks Voice therapy generally not helpful Botox injections standard of care Blitzer A, Crumley RL, Dailey SH, et al. Recommendations of the Neurolaryngology Study Group on laryngeal electromyography. Otol head neck surg. 2009;140(6): Botox From Clostridium botulinum NOT FDA approved for larynx Works approximately 3 months Used for spasmodic dysphonia Can decrease amplitude of tremor Parkinson Hypophonia VOICE and ARTICULATION may both be significantly affected leading to poor comprehension Voice often quiet because of Poor diaphragm recruitment Vocal fold atrophy 9

10 Treatment for Parkinson Hypophonia Lee Silverman Voice Therapy Increased vocal effort and loudness Individuals monitor their own vocal output Improved articulation May also improve swallowing and facial expression VOCAL CORD PARALYSIS Breathy quality Decreased loudness Sometimes increased pitch Diplophonia Low Maximum phonatory time Take multiple breaths to finish sentences. Frequent causes of vocal cord paralysis Trauma Surgery Neck Surgery (ENT, Vascular, Neuro) Chest Surgery (Cardiothoracic) Virus Intubation injury 10

11 Unilateral Vocal Cord Paralysis- Findings on Laryngoscopy Forward tilted arytenoid Loss of movement Loss of muscle tone Bowing of the vocal fold Aynehchi BB, McCoul ED, Sundaram K. Systematic review of laryngeal reinnervation techniques. Otolaryngology--head and neck surgery. 2010;143(6): Treat UVFP Early? Vocal Paralysis Treatment Options Observation/Voice Therapy Injection laryngoplasty Thyroplasty Reinnervation 11

12 Injection Laryngoplasty Temporary solution Injectable fillers with different durations of action, routes of administration, safety profile and cost Does NOT fix pharyngeal muscular or sensory dysfunction! Peroral VF injection for Paresis From U Iowa H&N Wiki Courtesy of Dr. Seth Dailey Thyroplasty 12

13 Laryngopharyngeal Reflux (LPR) Hoarseness Globus Dysphagia Chronic cough Throat clearing Pain Cricoid Otalgia Diagnosis based on history LPR Treatment Aggressive acid suppression with proton pump inhibitor Extended therapy 6-8+ wk before improvements Lifestyle modification Dietary changes Head of bed elevation Avoid eating before bed Voice therapy can be helpful for hygeine Some recent thoughts about diagnosis of LPR with Laryngoscopy 13

14 Benign Vocal Fold Lesions Almost always traumatic, irritative, or overuse/abuse Vocal nodules Polyps Cysts Scars Surgery usually performed with microsurgical technique Vocal Nodules Rough voice with vocal fatigue Vocal abuse Singers Inability to sing high notes Talking voice may NOT be affected Midpoint of membranous segment Often symmetric and bilateral Vocal Nodules- Treatment Hydration Management of allergies, GERD, and LPR Responds well to Voice Tx Surgery seldom needed 14

15 Vocal Polyp Sudden onset of hoarseness after extreme voice use, with persistent rough, raspy quality Unilateral polyp, dark and filled with blood Vocal Polyp- Treatment Stop any anticoagulant/antiplatelet meds Voice therapy successful for small polyps Surgery is usually needed Can be cut or laser applied Vocal Fold Cysts Cysts may rupture and progress to sulcus Hx Mucus retention cyst: Often no voice abuse/risk factors Epidermoid inclusion cyst: Similar risk factors to vocal fold nodules (voice overuse, etc) Sx Epidermoid cysts cause greater hoarseness than what would be expected, mucus retention cysts cause less 15

16 Vocal Cord Cysts- Treatment Generally require surgery Voice therapy sometimes helpful if h/o vocal abuse Laryngeal Cancer Laryngeal Cancer MANDATORY laryngeal examination if hoarseness > 3 weeks 16

17 Summary Voice evaluation involves through history taking Speech language pathology evaluation and treatment is essential for nearly all voice disorders Questions? 17