Friday, October 29, 2010

Radiation Therapy and Hoarseness

Radiation therapy cures cancer in many cases, but is a gift that keeps on giving.  The changes seen in the picture above are representative of your typical larynx after radiotherapy.  The blood vessels become disordered with vascular ectasias, seen on the middle portion of both vocal cords.  The surface appears dry, and invariable there is some degree of loss of softness of the vocal cords leading to a deeper or more hoarse vocal quality.  Hoarseness after radiation therapy should be evaluated.  In some cases, there is another concurrent problem (vocal cord polyp, vocal cord paralysis, and others).  If no other problem is identified treatment consists of voice therapy and hydration.  Once the softness of the vocal cords is lost we have no way of restoring it at this time.

Laryngeal Sarcoidosis

Sarcoidosis is a disorder of granulomatous inflammation of the lungs, chest, liver, skin, eyes, nose, and nervous system.  It can also involve the larynx, typically the supraglottis (above the vocal cords).  Diagnosis of laryngeal sarcoidosis is made with a biopsy.  Treatment is directed at control of the airway, systemic steroids and immunosuppressive medications, and occasionally surgery for relief of obstruction.

Radiation for Throat Cancer - Side Effects

Throat cancer is a very challanging diagnosis for the patient and for the doctor.  Depending on the site and stage of cancer, treatment can consist of surgery, radiation, chemotherapy, and any combination of the three treatments.   All treatments have pros and cons, and this post will focus on some of the cons of radiation therapy. 

As you can see in the picture above, radiation leads to loss of mucus glands within the throat, leading to a condition known as "laryngitis sicca", or dry larynx.  The throat becomes highly susceptible to stasis of secretions, crusting, and inflammation.  The sensation of the larynx and throat also becomes compromised, probably through loss of small blood vessels feeding the nerves of the throat.  Therefore, these mucus crusts are easily aspirated into the airway, leading to pneumonia.  Many years after radiation therapy it is not uncommon for the patient to decompensate and need a feeding tube for nutrition.  In many cases the patient may have done well for 5, 10, or even 15 years after treatment. 

In the patient above's case, he had throat cancer treated 15 years prior with radiation therapy.  He was swallowing and doing well until he underwent abdominal surgery and remained intubated for 5 hours.  Following surgery he began aspirating on foods and liquids, and he developed recurrent aspiration pneumonias.  Ultimately he required placement of a feeding tube, underwent intensive swallowing therapy, but never regained the ability to swallow. 

Unfortunately, this is not an isolated case.  I have at least 10 patients in my practice suffering from sequelae of radiation therapy and most cases started at least 5 years after treatment.  Most patients are unaware of the long-term consequences of treatment.  Given these devastating effects, every option should be presented to the patient and surgery should be strongly considered in cases of resectable and non-disfiguring disease.

Thursday, October 28, 2010

Zenker's Diverticulum

A Zenker's diverticulum is an acquired pouch in the lower throat, forming just above the opening to the esophagus. The pouch forms at the site of an anatomic weakness, and is associated with failed relaxation of the upper esophageal sphincter. This can be attributed to acid reflux or neurologic dysfunction.

Zenker's diverticuli have varied presentations, but typically cause difficulty swallowing, regurgitation of food and liquids, and cough. Pills and solid foods become more difficult to swallow, and bad breath (halitosis) is common.

Diagnosis can be made a number of different ways. Physical examination of the neck may reveal a compressable mass in very large diverticuli, which makes a gurgling noise with compression. Laryngoscopy often reveals pooling of mucus in the lower throat, and regurgitation can often be observed. Barium esophagram is most commonly used to make the diagnosis and assess the size of the diverticulum. Other modalities such as CT and MRI are less commonly used but will also confirm the presence of a diverticulum

Treatment is based on symptoms and the size of the diverticulum. For pouches less than 1 cm in size options include observation, cricopharyngeal myotomy (surgically relaxing the upper esophageal sphincter), or Botox injection into the upper esophageal sphincter. For larger diverticuli surgical diverticulostomy or diverticulectomy is indicated. Minimally invasive approaches using a stapler, laser, or Harmonic scalpel can be performed safely and with little morbidity. Open surgical approaches are also an option, and are favored for very large diverticuli.

There is a less than 1% chance of cancer within the Zenker's pouch, and the pouch should be carefully inspected during surgery to rule out a neoplasm.

Tuesday, October 26, 2010

Autoimmune Disease and Laryngitis

Systemic lupus erythematosus, rheumatoid arthritis, Crohn's disease, Wegener's granulomatosis, and other autoimmune disease can manifest with disease in the larynx. The throat manifestations of autoimmune disease are variable, but can include chronic redness, swelling, and ulceration of the vocal cords (chronic laryngitis), "bamboo" nodules (mid-vocal cord swelling), and in the case of Wegener's granulomatosis narrowing below the vocal cords (subglottic stenosis). In general disease will improve and worsen along with systemic disease. Because autoimmune disease can be controlled rather than cured relapse of vocal cord disease is not uncommon.

When prolonged laryngitis exists without explanation, it is useful to consider autoimmune disease and proceed with the appropriate blood tests and consider referral to a rheumatologist.

Irvine California Voice and Swallowing Disorder Specialist

We are pleased to announce the opening of a new office in Irvine, California, providing the same high quality and state-of-the-art care for patients with voice, swallowing, and breathing disorders. Conveniently located adjacent to Hoag Hospital Irvine, our office can accomodate patients with same day appointments. Our address is: 16300 Sand Canyon Avenue, Suite 201, Irvine CA 92618. To schedule an appointment, please call 949-727-1816.

Our primary office remains in Newport Beach at the Hoag Voice and Swallowing Center.

Thursday, October 7, 2010

Orange County Ear Nose and Throat Podcasts: Voice and Swallowing Disorders

Please check out our new podcasts featured on where Dr. Feinberg discusses voice and swallowing disorders! On the top tab, look for "on demand shows and podcasts" and open the "Hoag Hospital" channel. Or you can plug these links into your browser: