Voice is gaining increasing importance in the world today as a natural result of the growing numbers of professional voice users, be it a singer, teacher, politician , actor, disc jockey or a call center employee to name a few. Even in non professional voice users the importance of voice cannot be overemphasized – albeit this realization is often only on losing it!
Our voice is like our signature – unique and characteristic to each individual.
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.
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 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.
Dr Nupur Kapoor Nerurkar has received her medical training at Seth G.S. Medical College and K.E.M. Hospital where she received the first rank by the University of Mumbai. She has been a faculty member of L.T.M.M.College, which is a premier teaching institute in Mumbai, for 12 years. She received the Hargobind fellowship award and received her Laryngology training at Vanderbilt University, Mt.Sinai Medical Center and Massachusetts Eye and Ear Infirmary at U.S.A
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