Mariano Rivera - Vocal Cord Problems

http://tracking.si.com/2011/11/23/mariano-rivera-may-need-require-vocal-cord-scraping/


I am sharing this blog post from SI.com regarding Yankee star Mariano Rivera. While it sounds sexy, the term "scraping" is extremely inaccurate to describe the delicate process of surgery on the vocal folds. Phonomicrosurgery, the term we use to describe highly magnified and precise surgery of the vocal folds, is inaccurately described by this sports blogger. But we will have to excuse the blogger, because after all he is a sports writer rather than a medical one.

Singer Adele’s vocal cord surgery in Boston called a ‘success’

Singer Adele’s vocal cord surgery in Boston called a ‘success’

My fellowship mentor, Steven Zeitels, has been in the news this week after operating on the British singer Adele. She reportedly suffered a vocal hemorrhage from a benign vocal fold polyp.

Right Vocal Cord Paralysis

Granular Cell Tumor of the Larynx

Left Vocal Fold Granular Cell Tumor

Pictured is a left vocal fold granular cell tumor.  When this patient presented, the left vocal fold lesion was suspected to be either a mucoid cyst or polyp.  But during surgery it became obvious that the lesion was infiltrative and adherent to the underlying lamina propria, unlike a cyst or polyp.  This patient happened to be a professional singer, and underwent successful surgery to remove the lesion while preserving the voice.   The lesion was biopsied and then ablated with very narrow margins using the pulsed KTP laser.

Laryngeal Chondrosarcoma

Low Grade Cricoid Chondrosarcoma

Pictured in the photo is a low grade chondrosarcoma of the cricoid cartilage.  Chondrosarcomas generally behave like benign tumors, with slow local expansion but without distal spread or tissue invasion.  In the photo, you can see blunting of the posterior commisure, due to an expansive lesion of the posterior cricoid.

Voice and Swallowing Disorder Podcast

Please check out my Podcast, discussing voice and swallowing disorders.

http://www.healthradio.net/component/mtree/Health-Radio-Shows/Hoag-Hospital/Voice-and-Swallowing-Disorders-43197/details

Office-Based KTP Laser Treatment Laryngeal Dysplasia - Clip 1

Laryngologist - Serving Orange County, San Diego, Los Angeles, San Bernadino, Riverside, California

What is a laryngologist?  A laryngologist is an otolaryngologist (ear nose and throat doctor) specializing in diseases of the voice box and the airway.  Most laryngologists have completed an addional fellowship in voice disorders and laryngeal surgery beyond the usual training requirements for an otolaryngologist.   There are laryngologists in most major metropolitan areas throughout the United States and throughout the world.

Many laryngologists work out of a voice center, which is a facility containing specialized equipment and personel for the treatment of voice disorders.  The team often includes a speech and language pathologist specializing in voice, and sometimes a voice coach.     

Laryngeal Laser Surgery - An Unsedated, Office Procedure for Laryngeal Dysplasia

Pulsed angiolytic lasers (KTP, PDL) give us the ability to treat pre-cancerous growths of the vocal folds and larynx in a minimally invasive fashion.  Without sedation, and with the assistance of state-of-the art video laryngoscopes, we can remove small growths without any sedation.  Anesthesia is given topically, and the procedures are well tolerated by the majority of individuals.  Above are pre and post photos of a patient with recurrent right vocal cord dysplasia (pre-cancerous growth). 

Pulsed-KTP Laser Applications in Head and Neck Surgery

Angiolytic lasers target blood vessels, and preferentially treat vascular tissue while preserving surrounding less vascular tissue.  This characteristic allows treatment of a variety of ear, nose, and throat disorders with favorable results compared with non-selective lasers.  Examples of angiolytic lasers used in the head and neck include the KTP, Nd-Yag, and pulsed dye laser. 

Common applications include treatment of laryngeal papillomatosis (recurrent respiratory papillomatosis), inferior turbinate hypertrophy, vocal cord pre-cancer and cancer, vascular malformations, telangiectasias of the skin, nose, and vocal cords, and nosebleeds.

Functional Dysphonia

http://abcnews.go.com/WNT/video/voice-massage-mother-voice-back-functional-dysphonia-vocal-chord-13616978?tab=9482930&section=1206853&playlist=1363340

This is a great story from ABC News about functional dysphonia.  Unfortunately, this disorder can go undiagnosed for weeks or months.  Amazingly it can be cured in as little as 10 minutes.  A variety of related problems can trigger functional dysphonia, including psychological stressors, respiratory infections, physical trauma, intubation for surgery, and acid reflux.   Treatment consists of speech therapy, and can also involve treatment of related disorders such as psychopathology, acid reflux, or respiratory infections.

Vocal Cord Paralysis - Paralyzed Vocal Cord - Vocal Cord Immobility

 Image 1 - Maximal Closure Prior to Injection

 Image 2 - Concave, immobile left vocal cord, pre-injection (right side of screen)

 Image 3 - Injection needle seen in left vocal cord

Image 4 - Convex left vocal cord, post-injection

Vocal Cord Paralysis, Vocal Cord Paresis, Vocal Cord Immobility
To produce a normal voice, the vocal cords must be able to approximate one another completely.  Air from the lungs is then able to oscillate, or vibrate the vocal cords.  Vocal cord immobility arises from a number of different causes, but the end result is an inability of the vocal cords to come together completely.  When one vocal cord is immobile, there is often a breathy, rough vocal quality.  Common causes of vocal cord immobility include thyroid surgery, chest surgery, intubation, cancer in the neck or chest, and viral infections.  Important in the workup of vocal cord paralysis, paresis, and immobility is finding the cause of the disorder. 

Paresis implies a partial immobility of the vocal cord.  There may be sluggish or partial motion, and some times lack of normal tone of the affected vocal cord.  Paralysis implies complete immobility.  The degree of immobility does not necessarily relate to the degree of tone of the affected vocal cords.  Some completely immobile vocal cords develop good tone, while some partially immobile vocal cords have flaccidity.

Treatment for vocal cord paralysis and paresis depends on the degree of disability for the patient.  If the voice sounds normal, and if there is no difficulty swallowing, there is no need for intervention.  When the voice is breathy and weak, intervention is indicated.  Treatement options include injection laryngoplasty (seen in the photo above), medialization laryngoplasty (thyroplasty), and speech therapy.

Injection laryngoplasty can be performed in the office or in the operating room.  I perform the vast majority of my procedures in the office.  Some patients have anxiety associated with the procedure, and in some cases a severe gag reflex, making office-based injection challenging.  Thyroplasty is always performed under anesthesia, usually conscious sedation without a breathing tube.  The patient is able to speak throughout the procedure, so that the voice can be optimized and the size of the implant properly tailored. 

In the photos above, a patient is undergoing transoral injection laryngoplasty with a temporary filler material for vocal cord paralysis arising after thyroidectomy.  Because we expect that the nerve may recover spontaneously, we use a material known to last 2-3 months.  If need be we can repeat the procedure while we await neurologic recovery.   

Vocal Cord Cyst (Vocal Fold Cyst)

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This are photographs of a left vocal cord cyst (seen on the right side of the pictures).  This was an interesting case in that the patient recently suffered a stroke, and her hoarseness seemed to come on around the same time as the stroke.  She had been referred for voice therapy at our Center, and given her irregular and diplophonic vocal quality the speech pathologist suspected that there may be a vocal fold lesion.

Videostroboscopy of the larynx revealed a mucoid cyst in the left vocal cord, impairing the vibration of the left vocal cord.  Treatment for this type of lesion is surgery, and the cyst is removed intact from the vocal cord while preserving the surrounding tissue.  Given her recent stroke, the patient decided not to have surgery but to live with her voice for now.

Cysts are benign growths, arising either from mucus glands or from trapped skin within the vocal cord.  They are not cancerous, although rarely cancerous lesions can take on a cystic appearance within the vocal cord.  The primary symptom of a cyst is hoarseness.

Vocal Cord Cancer

This is a photograph of a left vocal cord cancer.  With almost all cases of glottic cancer (vocal cord cancer), the presenting symptom is hoarseness.  Most patients have been hoarse for months or even longer prior to seeing an otolaryngologist.  Risk factors include cigarette smoke, and in some patients acid reflux.

As you can see in the picture, there is an ulcerated, irregular appearance of the left vocal cord (right side of the screen).  Diagnosis is confirmed by biopsying the vocal cord.  Treatment depends on the preference and experience of the diagnosing physician.  In general, small lesions of the vocal cord can be treated with minimally invasive surgery, preserving an excellent voice.  Access to a skilled surgeon who frequently performs this type of surgery will vary based on geography.  Surgery can be performed by different means, either open or endoscopic.  Endoscopic surgery using a laser is the most common for small tumors. 

For larger lesions, radiation therapy can sometimes by preferable.  For early vocal cord cancer, chemotherapy does not have a role, but it may for larger or disseminated lesions.

The Diane Rehm Show - Voice Disorders

http://thedianerehmshow.org/audio-player?nid=14076

Here is a great piece from the Diane Rehm discussing voice disorders, featuring my friend and colleague Dr. Nazaneen Grant.  Topics discussed include spasmodic dysphonia, vocal cord paralysis, vocal cord dysfunction (VCD), stroke and voice disorders, and others.  Please give it a listen!

Fungus Balls (Mycetoma)

Fungus balls are common causes of sinus disease.  In this photograph, a dental implant was improperly placed within the lumen of the maxillary sinus.  Typically, a bone graft procedure or "sinus lift" is done prior to the dental implant in order to prevent this type of complication.  In this case, bone grafting was not done, and the sinus was seeded with aspergillus, a type of fungus, from the mouth.  Over many years a collection of fungus developed in the sinus, along with a bacterial superinfection.

Treatment included endoscopic sinus surgery to remove the fungus infection, and to allow the sinuses to drain properly.  In addition, the dental implant will most likely need to be removed and then revised.  In addition, on the right side (left side of the photograph) the maxillary sinus has what appears to be an early fungal infection around another dental implant.

Osteophytes and Difficulty Swallowing

Did you know that bony changes of the spine are a common cause of dysphagia (difficulty swallowing)?  They can occur at one or more levels in the spine, usually above or at the level of the voice box.  Osteophytes occur due to degenerative changes of the spine, and sometimes as part of a disorder called diffuse idiopathic skeletal hyperostosis.  Treatment depends on the severity of symptoms, and can range from observation (most cases) to surgery to remove the bony growths. 

In this photo, the osteophyte between the vertebrae of C4 and C5 severely narrows the throat just above the voice box, leading to trouble swallowing food and pills.

Osteophytes can be diagnosed with laryngoscopy, an outpatient office-based procedure without sedation, and confirmed using an xray of the spine or a CT scan of the cervical spine.

Tracheal Stenosis

Narrowing of the trachea (windpipe) with scar tissue is referred to as tracheal stenosis.  Tracheal stenosis can occur due to prolonged intubation, tracheotomy, trauma, or due to caustic injury or burn.  The length and site of tracheal stenosis can vary depending on the cause and on the individual case.  Some times it extends proximally to involve the larynx, and is referred to as laryngotracheal stenosis.  Treatment of tracheal stenosis depends on the length of narrowing, the degree of narrowing, and on the involvement of the larynx.  For isolated narrowing of the trachea, treatment options include dilatation with cold instruments, laser, or balloon, and tracheal resection with anastamosis.  Dilatation is generally useful as a temporizing measure or for treatment of short segments of stenosis, while resection is more effective for definitive treatment of stenosis.  Other options such as tracheal stents also exist.

Here is an example of an acquired tracheal stenosis after tracheotomy

Office-Based Laser Surgery For Papilloma (Throat Warts)- What You Need to Know ------- Orange County, Los Angeles, San Diego, Inland Empire Laryngeal Surgeon

Today I saw a patient who self-referred for office-based laser surgery using the pulsed KTP laser. He has had 3 prior surgeries greater than 10 years ago, and he was told that he was an extremely difficult surgical exposure. When I examined his larynx, he had a tremendous amount of papilloma filling the entire airway and involving both vocal folds and the area in between (the anterior commisure).


This patient obviously has a challenging surgical problem; an extensive quantity of papilloma, and challenging anatomy making endoscopy difficult. This is a good case to highlight some key points:


1) The ideal candidate for pulsed KTP laser or pulsed dye laser treatment in the office has a mild to moderate quantity of papillomatous disease. If disease is too extensive, treatment in the office can still be performed, but it can be slow and tedious, and may require more than one session to remove all of the disease.


2) A large quantity of disease in the anterior commisure is problematic in the office. In the operating room, a special instrument (vocal cord spreader) can be used to separate the vocal folds and direct treatment toward only one vocal fold. This prevents "webbing", or scarring of the vocal cords together. In the office we have no such device, and treatment of bulky disease in the anterior commisure should be approached with caution.


3) The ideal candidate should have a mild to moderate gag reflex. A severe gag reflex can preclude treatment in the office.


And how did I approach this case? Despite his difficult surgical exposure in the past, I was confident that I could adequately expose his larynx. Therefore, I recommended his first treatment in the operating room, and subsequent treatments in the office to handle recurrent disease. He will be asked to follow-up regularly in order to treat him before his disease becomes out of control in the future.

Homeless Man with the Golden Voice

If you haven't heard this man's voice and his story you should check it out. 

http://content.usatoday.com/communities/gameon/post/2011/01/homeless-man-with-golden-pipes-to-voice-nfl-films/1