The voice is a fundamental part of human communication, and problems with voice can cause a variety of issues with how a person is perceived by others, and how she perceives herself. Below is a list of the types of voice disorders Dr. Rosow sees and treats:
Vocal Fold Paralysis
Vocal fold paralysis is the name of a condition when one of our two vocal folds is immobile. Ordinarily, the vocal folds come apart to let air into the lungs and come together tightly when we speak, cough, or swallow. If one vocal fold is not working correctly, an individual can typically experience a very weak and breathy voice, as well as difficulty swallowing liquids. This is caused by the paralyzed vocal fold allowing too much air to pass through while talking or swallowing, much like a leaky valve. Our team will diagnose this by visualizing the vocal fold movement using an endoscope, either through the nose or mouth. There are many different causes of vocal fold paralysis including neck or chest surgery, recent intubation with a breathing tube, trauma, stroke, cancer (brain, lung, or thyroid), or a viral infection. In some cases, however, the cause is unknown (idiopathic). Unless clearly related to a cause such as surgery or trauma, a CT or MRI may serve to rule out a tumor causing the paralysis.
Treatment for vocal fold paralysis has evolved over the years and ranges from surgical intervention to voice therapy. Timeframes for intervention have also advanced with patients being treated earlier than in the past. For example, Dr. Rosow treats most patients with an in-office procedure that takes less than 15 minutes. Under local anesthetic, an inert filler material is injected through a fine needle to bulk up and push over the paralyzed vocal fold. This allows the mobile vocal fold to meet the paralyzed one more easily and with much less effort when speaking. Patient tolerance is good with only mild discomfort. Results are usually instantaneous and, depending on which material is injected, last anywhere from 2-3 months to 1 year. Over time, the material is generally reabsorbed, but many patients can experience longer lasting improvement. For those who do not, open surgical procedures under local anesthesia offer excellent voice outcomes that are permanent in nature.
Vocal Fold Nodules
Our vocal folds strike each other over 100 times per second when we are speaking, and this repeated trauma can lead to a build-up of thickened callus on the surface. These calluses are referred to as nodules, even though there may not be anything “nodular” about them. This benign condition is commonly seen in people who use their voices heavily: singers, teachers, lawyers, and public speakers are at risk, but so is anyone who talks excessively! Treatment consists of improving vocal hygiene, voice therapy, and for severe cases, surgery.
Vocal Fold Cysts
A cyst is simply a small, closed-off structure that may either be filled with fluid or with solid material. These benign lesions can occur below the surface of the vocal fold and have a significant impact on the normal vibration and sound production. While voice therapy can sometimes be helpful in patients with small cysts, most will eventually require surgery to see long-term voice improvement.
Vocal Fold Polyps
Vocal fold polyps are benign growths that generally occur in response to a broken blood vessel. The body attempts to heal the broken vessel by forming a layer of tissue that then grows into a polyp. These can disturb the quality of the voice by preventing the vocal folds from closing and vibrating appropriately. Depending on the size of the lesion, either voice therapy or surgery will usually result in permanent voice improvement.
Recurrent Respiratory Papillomatosis (RRP)
This relatively rare condition, which affects both children and adults, causes the development of numerous wart-like growths on the vocal folds and sometimes, the rest of the larynx as well. While it is technically a benign (non-cancerous) condition, it has a frustrating tendency to recur, even after numerous surgeries that seem to eradicate it. People are often very bothered by the negative impact RRP has on their voice.
Initial treatment for this condition usually requires surgery under general anesthesia, but most patients can usually transition to an office-based treatment paradigm. This involves treatment with a laser designed specifically to target blood vessels, which abundantly overgrow in RRP. During treatment, the nose and throat are given topical anesthesia, and a flexible camera used to visualize areas of disease. A laser fiber is guided through the camera and used to painlessly treat areas of papilloma. This technique is more convenient for patients and allows improved control over their disease with fewer trips to the operating room.
Transgender Voice Modification
When a patient's voice does not match their gender, it can lead to mis-gendering and negatively affect quality of life. For female-to-male (FTM) transgender patients, this can usually be managed with testosterone supplementation, but there is no equivalent for male-to-female transgender people. Typically, we can work on voice modification therapy to help feminize the voice -- not only in pitch, but in tone, inflection, expressiveness, and numerous other attributes that are typically viewed as more feminine. When therapy alone does not allow a patient to achieve their desired voice, surgery can be used to shorten the length of the vocal folds, increasing the pitch.
Spasmodic Dysphonia and Essential Voice Tremor
Spasmodic dysphonia (SD) is a neurologic voice disorder known as a dystonia. In this condition, the muscles of the vocal folds go into spasm, which prevents air from naturally and easily flowing through. This results in a tight and strained voice, which is a particularly frustrating and debilitating problem as it impacts individuals’ ability to communicate naturally. Currently, no cure is available but botulinum toxin (Botox®) has been demonstrated to help control the spasms and free patients’ voices. In addition to SD, we also treat patients with vocal tremor. This is a similar condition to SD but typically strikes individuals later in life and may be accompanied by tremors in other body parts like the hands or head.
Laryngopharyngeal reflux (LPR)
LPR can be referred to as “silent reflux” because most patients DO NOT HAVE HEARTBURN. LPR is common, but less well known than gastroesophageal or reflux disease.
Phlegm (typically worse in the morning), throat clearing, and sore throat are the typical symptoms. However other symptoms can be hoarseness, irritation/discomfort, cough, or a feeling of a lump (something stuck) in the throat. Reflux is a backflow of stomach acid into your throat and voice box. This is usually prevented by a muscle valve (lower esophageal sphincter) at the entrance of the stomach. But if it is not functioning well you may develop these symptoms. The valve is very weak if there is a hiatal hernia, but also there are many common foods/drinks that unfortunately relax this valve. Weakening of this valve is also a common occurrence with the aging process. Treatment is based on two key components: diet and lifestyle changes and medications.
Vocal Fold Leukoplakia and Dysplasia
These conditions usually present as white plaques on the vocal folds and can result in hoarseness, although people may experience no voice disturbance. They can often recur, even after multiple surgical treatments, but dysplasia (also known as “pre-cancer”) can be dangerous if left untreated, as it sometimes has the potential to transform into cancer. Fortunately, these disorders can often be treated with in-office laser procedures once a surgical biopsy has been done to confirm the diagnosis and rule out cancer.
Vocal Fold Cancer (Laryngeal Cancer)
Cancer of the vocal folds affects approximately 12,000 people per year in the United States. It tends to occur more frequently in smokers as well as people who consume alcohol. It can often present as hoarseness that may worsen over time. Depending on the size of the cancer, there may also be difficulty swallowing, difficulty breathing, or coughing up blood. Prompt diagnosis of this condition is extremely important, as early-stage cancers have very high cure and survival rates when treated appropriately with surgery or radiation.
For most early stage cancers of the vocal folds (Stages 1 and 2), laser surgery can be an extremely effective way to cure the cancer, preserve voice, and avoid prolonged courses of radiation.