Humans have two vocal folds shaped like a “V” at the inlet of the breathing pipe that open and let air through to the lungs for us to breathe and close and vibrate allowing us to talk or phonate. When the movement of one vocal fold, or worse both, is affected, a large gap between the two allows air leak from the wind pipe resulting in a breathy or absent voice.

In Tanyas case the reason in all probability is a viral infection, more common in the monsoons. There is however no reason for alarm as paralysis of the vocal folds occurs in a very small percentage of individuals. Recovery usually does take place but may take from 6months to 18 months. Tanya has been advised a period of speech therapy, akin to physiotherapy, but for the voice muscles. If her voice does not come back with this therapy then a surgery called “thyroplasty” shall be performed where an implant is placed in the voice box to push the immobile vocal fold and close off the gap between the folds with an immediate return of the voice! The results of the surgery are very gratifying for both the patient and the surgeon as the entire surgery is done with the patient awake so as to “tailor make” the voice to the satisfaction of both.

It is essential to rule out cancer or tuberculosis, both of which are common in the Indian population, by doing a CT scan.  Mangesh, a 7 year old boy who had a breathy voice since 6 months was detected with large tuberculous lymph nodes in the chest pressing on the nerve supplying the vocal fold. Following medical treatment for tuberculosis his voice is improving.

Occasionally patients may develop vocal fold weakness following thyroid, heart, spine or food pipe surgery.

One of the commonest causes of a voice change however is acute infection i.e. Laryngitis which settles with voice rest and medicines. Vocal nodules, also known as teachers, singers or screamers nodules are seen more commonly in professional voice users and people who abuse their voice.

It is advisable to visit an ENT specialist for a voice change persisting for over 3-4 weeks.

Not all cases of an immobile vocal fold however are due to infection, tumour or surgery.

The most recent patient I had the occasion of performing Thyroplasty surgery on had come to me with a complete loss of voice following an accidental fall on his bedpost injuring his neck. A CT Scan showed a fracture with fixation of one of the vocal folds. Since he was a call center employee, he lost his job promptly and was desperate for his “voice”. Happily for this patient, following his surgery, he is today with a job and a voice to go with it!

Dr Nupur Kapoor Nerurkar
M.S. (ENT)
Laryngologist and Voice Surgeon
Bombay Hospital and Medical Research Center

One unit of this poison is lethal for mice and generally 3,500 units are lethal for humans. However in the correct dose this poison has many benefits. This toxin creates a weakness in the muscle into which it is injected and this effect lasts for a variable period of 2 to 9 months.

The question that comes to mind – Why would we want to create muscle weakness?

Well, many reasons really. Lets start with one of the most popular – prevention of wrinkles! Facial muscles where wrinkles are developing  are injected with botulinum so as to cause a localized weakness of that area which then cannot wrinkle and  appears smooth (and at times expressionless!)

When I was doing my Laryngology training in America I was amazed to see hoards of very pretty and wrinkle free 20 something girls line up for a shot of left-over botulinum. On my very naïve inquiry I was told that the injection was being taken to prevent the future possibility of a wrinkle!So anyway, the toxin was “left-over” from being used for a debilitating voice disorder called as “spasmodic dysphonia”. In this uncommon voice disorder the patients vocal muscles contract too much giving rise to a strained voice. The toxin is injected into the straining vocal muscle under EMG control so as to weaken and relax it. Interestingly the voice in this disorder tends to get better while singing, whispering or after a few drinks! One of my patients came to me 2 months after his first injection of botulinum saying he had a problem. Since his voice was sounding good I wondered what it was.Well, as it turns out his friends were aware of the fact that his voice improved with alcohol and now they were ribbing him about being constantly under the influence of alcohol!

Botulinum has helped in the rehabilitation of children and adults suffering from dystonia’s in which large muscle groups become rigid such as cerebral palsy and cervical dystonia. Hemi facial spasms, blepharospasm , migraine, severe underarm sweating and strabismus are other indications for its use.

Side effects can include pain at the injection site, flu-like symptoms, headache,upset stomach,allergic reactions. You should not use Botox if you are pregnant or breast feeding.

Botulinum is expensive, not currently made indigenously, not covered by insurance companies, and so for many the treatment can prove to be prohibitively expensive. Matters do not improve on telling the patient that every 6 months or so a repeat shot is needed.

One way out to reduce costs is pooling of resources by doctors and clubbing together patients who need the toxin. Basically working as a TEAM –Together Everyone Achieves More!

Our voice is like our signature – unique and characteristic to each individual.

 What are the causes of voice disorders?

 The commonest cause of dysphonia (change in voice) is viral or bacterial infection of the voice-box (larynx) that is referred to as laryngitis. Dysphonia caused by laryngitis should settle in 2 weeks. A change in voice that does improve within 2 weeks needs to be seen by an ENT surgeon, preferably at a voice clinic.

A voice clinic has facilities to see the vocal folds on the monitor using a rigid telescope and showing this image to the patient helps in patient compliance towards the treatment.

 A large percentage of voice disorders in tertiary hospitals are due to unilateral vocal fold paralysis. This can be attributed to a large number of referrals, cancer surgery for the thyroid, food pipe or trachea, Cardiovascular Thoracic surgery, Trauma, congenital paralysis and Strokes. Tuberculosis remains an important cause of vocal fold paralysis. A vocal fold paralysis is labeled idiopathic only when a CTscan of the base skull to upper mediastinum is unremarkable.

Vocal fold polyps, nodules and cysts are formed as a result of vocal abuse (talking too much) and vocal misuse (talking with a wrong technique).One wrong technique of talking is using the false vocal folds to talk rather than the true vocal folds. This is called ventricular phonation.

With age, like muscles everywhere in our body, the vocalis muscle also atrophies resulting in bowed vocal folds with a gap between them.Hypothyroidism, laryngopharyngeal reflux and smoking (especially in women) may cause vocal fold oedema referred to as Reinkes oedema.

Due to the widespread use of chewing and inhaled tobacco in India, laryngeal cancer remains an important cause of dysphonia.Human Papilloma Virus can cause multiple papillomas in the larynx that often is a cause of dysphonia in children.

Spasmodic dysphonia is a laryngeal dystonia and the patient has a voice with spasms that often is mistaken to be psychogenic. A neurologist’s examination is vital to rule out causes such as Parkinsonism, myasthenia, ALS etc

 An absence of the sub-epithelial layer of the vocal fold creates a gutter called sulcus vocalis.

Voice Clinic

Laryngology is today an important subspecialty in ENT. A voice clinic is run by a laryngologist and a speech language pathologist but also involves teamwork with the gastroenterologist, psychiatrist and neurologist. It is the aim of “The Association of Phonosurgeons of India” to have voice clinic in every city of India.

Stroboscopy

Stroboscopy is an important diagnostic tool in the armamentarium of the laryngologist. Using a bright, flashing strobe light the vocal fold vibration is seen and recorded in a slow motion allowing the diagnosis of very early laryngeal lesions such as early glottic cancer. Stroboscopy also allows differentiation between various laryngeal lesions.

Laryngeal EMG is performed by introducing a Teflon coated needle into the specific laryngeal muscle to check its response to phonation or breathing. This helps in diagnosing vocal fold paralysis and its prognosis. Laryngeal EMG is primarily used in the injection of Botulinum Toxin into the larynx in cases of spasmodic dysphonia. The toxin weakens the spasms of the voice but needs to be re-injected every 6 months.

Management of Voice Disorders

 Medication is warranted in laryngitis and laryngopharyngeal reflux.Voice therapy is the first line of management for vocal fold nodules, early polyps, ventricular phonation, bowed vocal fold and vocal fold paralysis.However, if voice therapy fails to improve the voice, Phonosurgery is recommended.

 A type 1 thyroplasty surgery medializes the paralyzed vocal fold using Silastic, titanium or Gore-Tex giving excellent postoperative voice.

Microflap endoscopic surgery is performed for excision of polyps, nodules and cysts.

Early laryngeal malignancies can be tackled with CO2 laser endoscopic excision obviating the need for tracheostomy and decreasing morbidity to a large extent.

 Gone are the days when a patient had to “just live with problem”. A better understanding of the anatomy of the vocal folds, physiology of phonation and improved instrumentation has resulted in optimizing the treatment of vocal fold disorders.