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By Joel A. Ernster, MD, FACS

Second only to our personal appearance, our voice is the most important way we present ourselves to the world. When it malfunctions, we lose our most reliable and basic communication tool. As Lord Byron pointed out, though, the voice can be used for more than just communication. It can be used to inspire and educate or it can be used to entice or tempt. Yet as Seneca presciently noted, the voice is really nothing more than “beaten air.” He may have been referring to the habits of the long-winded Roman senators, but his comments very well describe a rough understanding of vocal production.

Our understanding of the mechanics behind the production of voice has expanded dramatically over the past ten to twenty years. The physicians at Colorado Otolaryngology Associates have participated in expanding this new understanding of voice and the diseases which affect it. As a result, we are able to offer the latest in evaluations and treatments for those individuals afflicted with diseases affecting the voice.

Causes of Voice Disturbance

Diseases of the voice may be broadly categorized into structural problems (Table I) and neurologic problems (Table II). In order to make a diagnosis and to distinguish between these two, it takes a skilled ear and the latest in diagnostic tools. We have committed to having those tools available. These tools may include flexible fiberoptic laryngoscopy as well as rigid laryngoscopy with or without stroboscopic examination. We record these evaluations both to share with colleagues and to compare at future visits. We even provide copies for patients upon request.

Treatment

Once the diagnosis is made, we offer a treatment approach for the condition altering the voice. Occasionally that means working with a skilled speech therapist. We work with many regional speech therapists, each specializing in a specific area of voice or speech. Sometimes a neurologic evaluation is necessary, and we will work with neurologists in our region.

Finally, interventions might include more invasive procedures depending on the problem. Examples include:

1. Injection of botulinum toxin into the vocal folds for adductor spasmodic dysphonia. This technique is performed in the office using electromyographic guidance. The botulinum toxin is injected directly into the thyroarytenoid muscle, and as a result vocal quality can be dramatically improved for a three- to four-month period of time in most patients.
2. Medialization pro cedure for unilateral vocal cord paralysis. This procedure is used for patients who manifest breathy dysphonia on the basis of a weak or completely paralyzed vocal fold. The origin of the vocal fold paralysis may be iatrogenic, it may be idiopathic. Injection procedures as well as external medialization procedures using either Silastic or Gore-Tex are available and can be very effective in ameliorating the breathy dysphonia.
3. Lateralization procedure for bilateral vocal fold paralysis. This condition is rare and is quite debilitating. It is marked by a normal voice with marked inspiratory stridor. It can be the result of a number of medical conditions or the result of iatrogenic causes. A complete review of this condition and its treatment can be reviewed at www.emedicine.com/ent/topics348.htm. This is a review article on the treatment of bilateral vocal fold paralysis which I wrote and revise yearly.
4. Laser procedures for cancer or precancerous lesions of the vocal cords. German surgeons have determined that cancers at a number of different sites in the endolarynx can be surgically excised with oncologic resection using endoscopic techniques. In 2000 I went to Germany and spent time with one of these surgeons and have been able to offer this surgical option for many patients who would otherwise have undergone much larger surgical procedures.
5. Antiviral drug injections into the vocal folds for papilloma. Recurrent laryngeal papillomatosis remains a debilitating condition for both children and adults. Endoscopic surgical removal remains the mainstay of treatment. However, injecting antiviral drugs such as cidofovir can play an adjuvant role as well.
6. Phonosurgical treatments of benign laryngeal lesions. Instruments have been developed which create extremely minimal trauma to the vocal folds as surgical procedures are undertaken. This can result in preservation of normal structures and return to optimal vocal quality in a short period of time.
7. Application of Mitomycin-C after surgical procedures to reduce scar. This chemotherapeutic drug in high concentrations can be applied to open surfaces resulting in reduced fibroblast formation and thus less aggressive scar formation. This can be extremely helpful in stenotic airways or after excision of lesions which impact the airway.

We take particular interest in treating the professional voice. Included in this group are professional and recreational singers, ministers, teachers, salesmen, essentially anybody who uses their voice for employment or to participate in their avocation of singing or speaking to groups. Many times this requires a variety of medical treatments along with close co-treatment with a speech therapist or vocal coach.

Many times changes in voice occur as a result of behavior we have under our control. The National Center for Voice and Speech has compiled a comprehensive list of suggestions which may be viewed at www.ncvs.org.

We are very pleased to include a sophisticated approach to the evaluation and treatment of patients with voice disturbances for patients in the Colorado Springs region. We back our commitment to providing this care by obtaining the latest in training and equipment. Please let us know when we can return your patient’s voice to, as Lord Byron said, “an arrow for the heart.”