Orange County Ear Nose and Throat Doctor Voice and Swallowing Blog

Our office has moved!

2012-01-23T21:57:00.000-08:00

We are excited to announce the relocation of our practice effective January 26, 2012! Our new office is located at 180 Newport Center Drive, Suite 158, Newport Beach, CA. For appointments, please call (949)266-1630.

Mariano Rivera - Vocal Cord Problems

2011-11-30T23:06:00.000-08:00

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’

2011-11-10T21:55:00.000-08:00

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

2011-10-20T10:03:00.000-07:00

Granular Cell Tumor of the Larynx

2011-10-17T23:52:00.000-07:00

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

2011-10-17T23:45:00.000-07:00

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

2011-10-17T23:20:00.000-07:00

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

2011-10-13T23:50:00.000-07:00

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

2011-07-31T22:14:00.000-07:00

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

2011-05-19T22:44:00.000-07:00

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

2011-05-17T22:59:00.000-07:00

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

2011-05-16T22:11:00.000-07:00

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

2011-04-25T14:27:00.000-07:00

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)

2011-04-22T14:16:00.000-07:00

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

2011-04-20T18:11:00.000-07:00

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

2011-04-19T23:09:00.000-07:00

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)

2011-04-19T10:52:00.000-07:00

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

2011-03-28T17:15:00.000-07:00

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

2011-01-21T13:57:00.000-08:00

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

2011-01-10T23:59:00.000-08:00

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

2011-01-06T21:15:00.000-08:00

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

Killian-Jamieson Diverticulum - Irvine, Orange, Newport Beach, Tustin, Los Angeles, Santa Ana, Long Beach, San Diego, Huntington Beach, Riverside, San Bernandino

2010-12-16T20:36:00.000-08:00

Difficulty swallowing is a common complaint. When food sticks in the lower throat, coughing or choking occurs with meals, and there are symptoms of regurgitation of food matter after meals, the diagnosis of a pharyngeal or esophageal diverticulum should be considered. If you experience these symptoms, you should seek the care of an otolaryngologist or a gastroenterologist, and a barium esophagram should be obtained. This consists of swallowing contrast material, which outlines the contour of the swallowing tube.

The most common type of pharyngeal diverticulum is the Zenker's diverticulum, which occurs in the lower throat starting just above the upper esophageal sphincter. A less common type is the Killian-Jamieson diverticulum, taking off just below the upper esophageal sphincter. These are less commonly symptomatic, but can also present with the same symptoms as a Zenker's diverticulum.

Treatment consists of surgery if the pouch is symptomatic. Minimally invasive surgery is preferred, including endoscopic procedures. In some cases (smaller pouches, restricted mouth opening or neck extension) surgery through the neck is preferable.

Roger Daltrey and Voice Disorders

2010-12-02T22:26:00.000-08:00

There was an interesting story tonight on KCAL 9 in Los Angeles. It was about Roger Daltrey, who underwent laryngeal surgery just before last years super bowl. The surgery happened to be performed by my fellowship mentor, Steven Zeitels, at the Massachusetts General Center for Voice Rehabilitation and Laryngeal Surgery. The story also featured Julie Andrews and Steven Tyler, and brought attention to the challenge of treating patients with vocal fold scar, and promising research attempting to heal scarred vocal folds. Please check out these links.

http://www.youtube.com/watch?v=2RKE55UIhDw&feature=related

http://losangeles.cbslocal.com/2010/12/02/the-who-frontman-opens-up-about-almost-losing-his-voice/

http://losangeles.cbslocal.com/2010/12/02/who-better-more-on-roger-daltreys-return-to-good-voice-part-2/

Our Blog Has Moved!

2010-11-09T20:50:00.000-08:00

I am excited to announce that the newportvoiceblog has moved to my website, and has relocated to blog.newportvoiceandswallow.com

We will continue to provide educational tools regarding diseases affecting the voice, swallowing, and airway.

Radiation Therapy and Hoarseness

2010-10-29T13:35:00.000-07:00

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

2010-10-29T12:30:00.000-07:00

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

2010-10-29T10:28:00.000-07:00

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.

Zenker's Diverticulum

2010-10-28T16:52:00.000-07:00

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.

Autoimmune Disease and Laryngitis

2010-10-26T22:33:00.000-07:00

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

2010-10-26T22:15:00.000-07:00

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.

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

2010-10-07T15:33:00.000-07:00

Please check out our new podcasts featured on www.healthradio.net 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:

http://www.healthradio.net/hr_on_demand/?play_id=43198

http://www.healthradio.net/hr_on_demand/?play_id=43197

Fungal Laryngitis

2010-07-21T00:30:00.000-07:00

Fungus is not a normal finding on the vocal folds but can occur in a number of settings. Perhaps the most common is in the patient treated with inhaled steroids for asthma or airway inflammation. Other patients susceptible to fungus include those on antibiotics and those with immune supression. Symptoms on presentation include hoarseness and rarely discomfort.

Typical physical findings include white, cheesy exudates on the vocal cords. Underlying rednesss and inflammation of the vocal tissue often occurs. Occasionally the exudate can mimic vocal cord keratosis with dysplasia or cancer.

Treatment includes systemic antifungal medications and/or removal of the causative factor leading to the infection (antibiotics, inhaled steroids).

Laryngospasm

2010-06-27T21:58:00.000-07:00

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

2010-06-19T19:15:00.000-07:00

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?

2010-06-09T22:43:00.000-07:00

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

2010-06-09T12:09:00.000-07:00

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

2010-06-08T23:56:00.001-07:00

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?

2010-06-08T23:08:00.000-07:00

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

2010-06-08T22:49:00.000-07:00

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

2010-06-07T16:20:00.000-07:00

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.

Swallowing Disorders

2010-05-25T10:35:00.001-07:00

I wide range of disorders impair our ability to swallow. Please check out this episode of the American Health Journal.

http://www.youtube.com/watch?v=3dYki_E2zZw

Aging and Voice Disoders

2010-05-25T10:27:00.000-07:00

As we age, our voices tend to deteriorate, and can lead to a decline in our quality of life.

Please enjoy this video on again and voice disorders.

http://www.youtube.com/watch?v=kLk2ua447Ck

Facebook

2010-05-25T10:20:00.000-07:00

Please join Dr. Feinberg and Newport Voice and Swallowing on Facebook.

http://www.facebook.com/pages/Newport-Beach-CA/Newport-Voice-and-Swallowing/129192363758935?v=app_2309869772&ref=ts#!/pages/Newport-Beach-CA/Newport-Voice-and-Swallowing/129192363758935?v=wall&ref=ts&ajaxpipe=1&__a=7

Swollen Glands

2010-05-25T10:13:00.000-07:00

Have you ever wondered why your glands become swollen?

http://www.youtube.com/watch?v=IO2FMD18ZYQ

Smoking and the Voice

2010-05-12T23:17:00.000-07:00

Do you smoke?

Suprisingly, I see few patients in my practice that are smokers. This is fortunate, as more than 90% of laryngeal cancers occur in smokers. Unfortunately, the tissue damage from smoking persists for decades after quitting. Some patients develop smoking-related cancers many years after quitting.

In addition to cancer, smoke causes inflammation and swelling, polyp formation, and precancerous changes of the vocal cords.

We know very little about the effects of marijuana smoke on the vocal cords, though I suspect it is equally dangerous as cigarette smoke.

2010-05-12T23:05:00.000-07:00

What is a laryngocele?

A laryngocele is an air filled mass of the larynx, connecting to the lumen of the larynx through the ventricle. The ventricle is the space above the vocal cords and below the false vocal cords. The anterior part of the ventricle, called the saccule, can become enlarged and filled with air and/or mucus.

Laryngoceles can be confined within the voice box (internal laryngocele) or may extend beyond the larynx into the neck (external laryngocele) through the thyrohyoid membrane.

The image to the left is an example of an external laryngopyelocele. The mass (green arrow) is extending outside of the larynx into the neck. Laryngoceles can be associated with cancer of the larynx, and with certain occupations associated with blowing. These include horn players and glass blowers.

Treatment consists of surgery, either externally (through the neck) or endoscopically (through the mouth).

Vocal Health

2010-05-12T22:30:00.000-07:00

Welcome to the Newport Voice and Swallowing Blog. On a regular basis, I hope to post on vocal health, voice and swallowing disorders, and new scientific advances in the area of laryngology, bronchoesophagology, and otolaryngology. Please feel free to leave comments and questions.

My practice is located in Newport Beach, California. I am the Director of the Hoag Voice and Swallowing Center and specialize in Otolaryngology - Head and Neck Surgery, with a special interest in voice and swallowing disorders, laryngeal cancer, and airway surgery.

Please visit my website at http://www.newportvoiceandswallow.com/