Laryngospasm

Laryngospasm is an involuntary closure of the vocal folds during respiration. Laryngospasm occurs in different settings:

Anesthesia-related laryngospasm occurs during emergence from general anesthesia, when the vocal cords can forcefully come together. This type of laryngospasm is treated with muscle relaxants and sometimes reintubation. Due to the drugs used during surgery, the patient most often does not remember experiencing laryngspasm after the event.

Sleep-related laryngospasm is an involuntary closure of the vocal folds occuring during sleep. The patient awakens with noisy breathing (stridor) and difficulty breathing. This can be quite scary, and can lead to fear of sleep and anxiety. Some patients experience symptoms during the day as well as at nighttime. There is often an associated cough which triggers laryngospasm. There is also a strong association with acid reflux, with acidification of the esophagus or larynx triggering the spasms. In addition, laryngospasm is associated with laryngeal nerve inflammation or damage (neuropathy.) A significant percentage of patients will demonstrate impaired movement of one of the vocal cords. Neuropathy increases the sensitivity of the vocal cords to saliva, mucus, or stomach acid.

Treatment for sleep-related laryngospasm is targeted at control of acid reflux, management of neuropathy, and cough supression. Reflux is managed through medication, dietary modification, and lifestyle changes (timing of meals, weight loss, stress management). In addition, relaxed breathing strategies can be helpful to the patient in order to shorten events of laryngospasm when they occur. Botox injection into the vocal cords (thyroarytenoid muscles) is helpful in many patients through an incompletely understood mechanism, as are drugs used to treat neuropathy including amitriptyline and gabapentin (Neurontin).

Pediatric Voice Disorders - More Common Than You Might Think

Does your child have a raspy voice?  Are they very outgoing and do they like to yell and scream?  If they get a cold, do they lose their voice completely?  Do they suffer from repeat bouts of laryngitis?

Children, like adults, are prone to developing inflammation of the vocal cords from overuse.  When overuse occurs over an extended period of time, callouses may form in the middle of the vocal cords.  These callouses are referred to as vocal nodules, or vocal nodes.  Vocal nodules prevent normal vibration of the vocal cords, lead to incomplete closure of the vocal edges, and create a raspy vocal quality.  In particular, the voice declines in higher pitch phonation.  Vocal nodules are not typically associated with pain. 

Diagnosis is made by an otolaryngologist (ear nose throat surgeon) or laryngologist (voice specialist) using laryngeal endoscopy, ideally with videostroboscopy.  This is a slow motion video of the vocal cords vibrating, and is available in voice centers and some pediatric voice clinics. 

Masquerading as vocal nodules are other disorders affecting the vocal cords, including vocal cord cysts, polyps, papillomas, and sulci.  Vocal cord cysts are congenital or acquired collections of mucus or skin under the surface of the vocal cord.  Diagnosis can be made either with laryngeal videostroboscopy or with direct laryngoscopy (examining the vocal cords with the patient asleep).  Polyps are similar to vocal nodules, but are larger collections of vibrovascular tissue on one rather than both vocal cords.  Papilloma is a disease affecting children exposed to human papilloma virus (HPV). 

Treatment of vocal nodules in children is generally conservative with voice therapy and avoidance of vocal abuse.  Vocal nodes or nodules tend to regress when the child adheres to proper vocal hygeine.  In rare cases patients may benefit from minimally invasive vocal cord surgery.  For vocal cord polyps, cysts, and papilloma, the treatment is primarily surgical. 

Voice Center - What does that mean?

A voice center is a medical facility dedicated to the care of patients with laryngeal disorders. These disorders can range from laryngeal cancer (vocal cord cancer or voice box cancer) to neurologic diseases such as Parkinson's disease, ALS, myesthenia gravis, vocal cord paralysis, etc. A voice center distinguishes itself from a traditional medical practice due to specialized personel and technology. Personal typically consists of a speech and language pathologist skilled in voice therapy, an otolaryngologist or laryngologist, and often a singing or acting voice specialist. As far as technology, the basic technologies typically consist of a videostroboscopy unit, rigid and flexible laryngoscopes, and voice analysis software. While difficult to define the advantages of a voice center vs. a traditional medical practice, the patients seem to benefit from a multidisciplinary approach to disease and improved coordination of care. It is much easier to track outcomes in a team approach, and to aim for quality improvement.

Swollen Glands

Swollen glands are a common clinical complaint. "Glands" are actually lymph nodes, which are present throughout the body. In the head and neck, there is a rich supply of lymphatics and lymph nodes, what are part of the immune system.

When lymph nodes become enlarged they can be painful or painless. Painful enlargement is a sign of infection or inflammation, while painless enlargement can be a sign of multiple processes. Examples include cancer, low grade infections, granulomatous diseases.

Lymph node enlargement for greater than 4 weeks should be assessed by a medical specialist. Often that specialist is an otolaryngologist, although primary care physicians are well trained to assess swollen glands.

Then picture on the left is of a patient with massive neck swelling on the right side (left side of the screen), and the diagnosis was made by performing an open neck biopsy. This was a lymphoma (a type of cancer affecting the lymph nodes).

Laryngeal Papillomatosis in Southern California, Los Angeles, Orange County, San Diego County

Laryngeal papillomatosis is a challenging disease affecting children and adults. Human papilloma virus causes growths of the vocal cords leading to hoarseness. In severe cases (especially in children) airway obstruction. The throat warts can be asymptomatic if they do not involve the vocal cords. Papilloma can affect the palate, nose, trachea, lungs, subglottis, epiglottic, and false vocal cords. Transmission occurs sexually, or in the case of juvenile papillomatosis from a mother infected with the virus. In rare cases, though, infants can become infected despite being delivered via C-section. This may be due to inocculation during labor prior to the decision to perform C-section.

Treatment is aimed at gentle removal of laryngeal papillomas, preserving the integrity of the vocal cords. Unfortunately, despite careful surgery, papillomatosis recurs at a variable rate. In children surgery needs to be performed as frequently as every few weeks. In adults the rate of recurrence can also be quite rapid.

Treatment modalities in surgery include the angiolytic lasers (pulsed KTP laser and pulsed dye laser), CO2 (Carbon Dioxide) laser, microdebrider (shaver), and cord instrument excision. Angiolytic lasers target the blood supply of the papillomas, which is more dense than the surrounding normal tissue. They act as "smart" lasers, avoiding thermal injury to uninvolved tissue. In the past 8 or 9 years, laser surgery for laryngeal papillomatosis has been performed in the office setting without sedation. For patients requiring surgery every few months this is a major convenience as far as ability to return immediately to work with no downtime.

Adjuvant treatments exist to modulate the rate of recurrence of papilloma. There are many options. Cidofovir is an antiviral drug that is injected into papilloma. It has been linked inconsistently to pre-cancerous changes in papilloma, though largely it appears to be safe. It also has the potential to cause scarring of the vocal cords and should be used cautiously on the vocal folds for this reason. Avastin is an anti-angiogenic drug preventing growth of the blood vessels feeding papilloma. Avastin has been injected for laryngeal papillomatosis for the past 2 years or so, and so far there has been only one report on its efficacy. There is an ongoing clinical trial looking at the drug and papilloma.

At Newport Voice and Swallowing both Cidofovir and Avastin are offered for laryngeal papillomatosis. We offer unsedated office-based laryngeal surgery for papilloma using the pulsed KTP laser, and at the present time we are the only center in Orange County offering the treatment.

Below is an interesting article about Avastin and recurrent respiratory papillomatosis.

http://abcnews.go.com/WN/story?id=7700000&page=1

Why is My Voice Hoarse After Intubation?

When a breathing tube is placed into the airway for surgery or mechanical ventilation due to severe illness there is a chance of temporary or permanant damage to the vocal cords. Injury leading to vocal cord dysfunction can occur from a variety of mechanisms.

The first group of injuries occur during the intubation procedure. During intubation, a breathing tube (endotracheal tube) is passed through the mouth, throat, and vocal cords, into the windpipe. The tube can traumatize the vocal cords during placement, leading to bruising or ulceration of the vocal cord, dislocation of the arytenoid cartilage (part of the vocal cord), or a combination of injuries. Bruising of the vocal cord is referred to as a vocal hemorrhage. In particular, patients with difficult to expose larynges or those intubated emergently are at a higher risk.

The next group of injuries includes damage from a breathing tube sitting in place in the larynx and upper windpipe. The risk of injury correlates with the duration of the intubation. The inflated cuff on the breathing tube can create a pressure injury to the trachea or subglottis, leading to ulceration, inflammation, and scarring. When scarring occurs it can lead to a narrowing of the airway. If this occurs below the vocal cords it is called subglottic stenosis or tracheal stenosis. If the injury occurs at the level of the vocal cords it is referred to as glottic stenosis. And above the vocal cords it is called supraglottic stenosis.

More common than airway stenosis is the formation of a laryngeal granuloma. A laryngeal granuloma is also referred to as a pyogenic granuloma, contact ulceration, or intubation granuloma. Granulomas are inflammatory growths caused by injury to the covering of the arytenoids by the breathing tube. They normally resolve over time, although they can be difficult to eradicate often due to concurrent acid reflux or voice abuse.

Another group of injuries after intubation includes vocal cord paralysis and vocal cord paresis. A paralysis can occur from pressure exerted by the breathing tube on the recurrent laryngeal nerve. This can occur in conjunction with arytenoid dislocation. Paralysis can resolve on its own or persist. Permanent weakness can develop with varying degrees of recovery. A partially recovered paralysis is referred to as a vocal cord paresis. Treatment of the paralyzed vocal cord depends on the mechanism of injury, duration of vocal cord paralysis, and the symptoms experienced by the patient.

Treatment options include vocal cord injection (injection laryngoplasty), vocal cord medialization laryngoplasty (thyroplasty, Isshiki type I thyroplasty). Injection of the vocal cords is easily performed in the office setting in the unsedated patient. Materials used to inject or augment the vocal cords include Restylane, Radiesse Voice, Radiesse Voice Gel, Juvederm, Collagen, Cymetra, Fat, Gelfoam, etc. Injections can be temporary, semipermanent, or permanent, depending on the material used.

If your voice is hoarse after an intubation, you should seek the care of an otolaryngologist or laryngologist. Laryngeal examination will be performed and the cause of your hoarseness can be addressed.

Orange County Spasmodic Dysphonia Doctor

Spasmodic dysphonia, or laryngeal dystonia, is a neurologic condition affecting the vocal cords. It can manifest as involuntary closure of the vocal cords during vowel sounds, or involuntary opening of the vocal cords during voiceless consonants. Symptoms can start as early as adolescence and are worse with stress and improved by relaxation, alcohol, and depressant drugs. In addition to the larynx and vocal cords, dystonia can affect muscle groups throughout the body. Examples include hand dystonia (writer's cramp), cervical dystonia (torticollis), and oromandibular dystonia (jaw and tongue).

Treatment of spasmodic dysphonia is targeted at relieving involuntary spasm, and the primary treatment at the present time is laryngeal Botox injection. The vocal cords are injected with minute doses of Botulinum toxin, slightly weakening the muscles. This leads to an improvement of the voice lasting an average of 3 months at a time. Injections are typically performed by otolaryngologists (ear, nose, and throat specialists) with interest in the voice, although some neurologists perform the procedure with the help of an otolaryngology physician.

Newport Voice and Swallowing, the medical practice of Steven Feinberg MD, performs laryngeal Botox injections using electromyography for proper injection placement. We also perform Botox injection for cervical and oromandibular dystonia.

Our Newport Beach office serves patients from Irvine, Orange, Tustin, Laguna Beach, Lake Forest, Long Beach, Seal Beach, Huntington Beach, Santa Ana, Anaheim, Brea, Fullerton, Yorba Linda, Costa Mesa, San Clemente, Mission Viejo, Yorba Linda, Dana Point, Aliso Viejo, San Diego, Los Angeles, Riverside, San Bernadino, Palm Springs, and throughout Southern California.


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Voice Specialist Serving Orange, San Diego, and Los Angeles Counties

As a voice specialist and ear nose throat surgeon serving all of Southern California, including Orange, San Diego, and Los Angeles Counties and the Inland Empire, much of my time is spent caring for patients from outside of the area.

In fact, San Diego including Del Mar, La Jolla, Encinitas, Carmel Valley, Poway, Fallbrook, Carlsbad, Oceanside, Rancho Bernardo, and Rancho Santa Fe is an underserved area with no laryngologists currently practicing in the area. Newport Beach is no more than a 90 minute drive from San Diego and we welcome patients with vocal cord polyps, vocal cord cysts, vocal nodules, swallowing problems, and glottic stenosis, subglottic stenosis, vocal cord paralysis, spasmodic dysphonia, laryngeal cancer, laryngeal papillomatosis, and related disorders from outside of the area.

In addition, patients from Beverly Hills, Long Beach, Downey, Whittier, Manhattan Beach, Redondo Beach, Torrance, Pasadena, San Pedro, Palos Verdes, the San Fernando Valley, Callabasas, Ventura County, Palm Springs, Hemet, Riverside, San Bernadino, Loma Linda, Redlands, Corona, Chino Hills, Burbank, Carson, El Monte, Glendale, Hawthorne, Lancaster, Malibu, Palmdale, Pomona, Santa Clarita, West Covina, Fullerton, Brea, Orange, Irvine, Tustin, Santa Ana, Costa Mesa, Fountain Valley, Huntington Beach, Laguna Beach, Dana Point, Laguna Niguel, Laguna Hills, Laguna Woods, San Clemente, Anaheim, Buena Park, La Habra, Yorba Linda, Los Alamitos, La Palma, Cypress, Seal Beach, Ladera Ranch, San Juan Capistrano, Mission Viejo, Lake Forest, Coto de Caza, Placentia, Buena Park, and Trabuco Canyon are served by our practice.