Monday, April 25, 2011

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.   

Friday, April 22, 2011

Vocal Cord Cyst (Vocal Fold Cyst)


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.

Wednesday, April 20, 2011

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.

Tuesday, April 19, 2011

The Diane Rehm Show - Voice Disorders

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.