How do Vocal Cord Cysts, Polyps, and Nodules Form?

There are MANY theories as to how vocal cord cysts, polyps, and nodules form. However, one theory that seems to make the most sense to me deals with how the vocal cord heals after a traumatic event (ie, screaming, yelling, coughing, etc).

With a cyst, the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the vocal cord lining. Vocal cord nodule for comparison’s sake is just callous thickening of the vocal cord lining that occurs over time.

To use human skin as an analogy…

A vocal cord cyst is like a sebaceous cyst that commonly occurs under the skin of the face or neck (a pimple, but no opening to the surface).

A vocal cord polyp is like a blister that forms on the hand if you shovel dirt too much.

A vocal cord nodule is like a callous that forms after prolonged repetitive skin trauma (like callous on the hands after shoveling dirt for years).

Read more about vocal cord cysts, polyps, and nodules!

New Webpage on Vocal Cord Cysts and Vocal Cord Polyps

We have uploaded a new webpage describing what vocal cord cysts and vocal cord polyps are as well as how they are treated.

Vocal cord cysts are masses below the vocal cord lining whereas vocal cord polyps are masses involving the vocal cord lining.

Read more here!

Respiratory Spasmodic Dysphonia

Respiratory spasmodic dysphonia is one of the most rare subtypes of a class of laryngeal dystonia collectively known as spasmodic dysphonia. It is also known more accurately as laryngeal adductor breathing dystonia or respiratory spasmodic dystonia or respiratory laryngeal dystonia.

Introduction

Spasmodic dysphonia is a type of dystonia in which there are involuntary muscle spasms or contractions of the muscles involved in voice production. This disorder is similar to the involuntary eyelid twitches of blepharospasm. Spasmodic dysphonia should not be, but is often confused with muscle tension dysphonia or tremor. There are 2 main types of spasmodic dysphonia: ABductor and ADductor. Other much more rare types include mixed and respiratory.

ADductor dysphonia is when the vocal cords comes together suddenly while talking resulting in voice stops and effortful speech. Often, the voice chokes off. Counting from 80 to 89 is harder than counting from 60 to 69. Stressful situations often exacerbate the condition. ABductor dysphonia is when the vocal cords suddenly moves apart while talking resulting in loss of voice (breathy). These patients find counting from 60 to 69 harder than counting from 80 to 89. ABductor dysphonia is not as common as ADductor dysphonia.Respiratory Spasmodic Dysphonia

Respiratory spasmodic dysphonia is when the vocal cords come together suddenly when inhaling. So the voice actually sounds quite normal… until the patient takes a breath in. During such inhalation, one can hear an audible choking sound.

A brief word about nomenclature. “Dysphonia” means hoarseness. As such, the term respiratory spasmodic dysphonia is not accurate. Rather, “dystonia” should be used instead which is defined as an abnormal muscle contraction.

Watch the video clip shown in this blog (same as this article, but video was not able to be uploaded here). In the first half of the video, listen to the audio of a patient suffering from respiratory spasmodic dystonia talking. The latter half is a video of the patient’s voicebox while vocalizing. Note that the vocal cords intermittently do not move apart when she is taking a breath in. Normally with breathing, the vocal cords should move apart to allow air to pass between the vocal cords.

Treatment

Treatment is the same as for ADductor spasmodic dysphonia. Botox is injected into the vocal cords which reduces the spasms when she takes a breath in.

Watch a video of botox being injected.

Click here to read more about spasmodic dysphonia.

Dr. Chang performs botox injections for this disorder every Friday afternoon.

What About a “Voice-Lift” with your Facelift?

I was informed about this interesting concept on ABC news…

With many aging baby boomers tapping into cosmetic surgery in order to look younger, some are taking it a step further to “sound” younger as well with a “voice lift”.

For some, it’s not right to look 10-20 years younger after a facelift but still sound like 70 years old.

A hoarse voice with aging is not unusual, but a surgical “voice-lift” is not necessarily the first step that should be taken.

First things first…

• Make sure the hoarseness is not due to something bad like vocal cord cancer. As a person ages, risk of cancer does increase especially if tobacco and alcohol use is present.

• Make sure there are no physical problems with the vocal cords like paralysis, polyp, cysts, reflux, etc.

Beyond that, vocal limitations often seen with the aging voice should first be addressed with voice therapy. Bowed vocal cords as well as compensatory muscle tension dysphonia are conditions often seen in this patient population causing a significant raspy voice and often respond quite well to voice therapy. Should voice therapy fail to resolve the vocal disquality, than surgical options can be considered.

What are the surgical options?

Just like a facial wrinkle may require a collagen injection to plump it up or a chin implant to address a receding chin, the vocal cord can also undergo collagen injections or receive an implant to plump it up and give it volume lost to aging which can lead to vocal problems.

Click here to read more about this procedure.

Click here to read the ABC new report.

The Vocal Problems of Professional Singers

The Washington Post on May 20, 2011 published a great article on the travails of opera singers regarding their vocal cords and the stresses placed on them (the singers and their vocal cords).

The opera singer (as well as any other professional singer) are the Olympic athletes of the voice.  As such, peak performance is mandatory in order to sustain a successful career. Just as an Olympic sprinter measures their success in milliseconds… the professional singer is judged by the most minute inflections, variances, irregularities of their voice. Never mind the back-biting and gossip.

99.9% is not good enough in this cut-throat world when anything less than 100% perfection is considered failure.

As such, the demands placed on the vocal cords are tremendous and rather than pulled hamstrings of a world-class sprinter, vocal cord swelling let alone nodules or muscle tension dysphonia can cut a career short.

Push the voice too hard… and they can get damaged, especially when vocal technique gets sacrificed to perform pieces beyond appropriate range (and even ability). Even professional opera singers have vocal instructors and coaches… a point I regularly make with amateur singers with injured vocal cords when they argue against the necessity of voice therapy and singing lessons (“I already know how to sing!”).

Read the Washington Post story here.

I did want to point out that there was one error in the story…

Near the end of the story, it is stated that Giuseppe Filanoti had thyroid surgery. Although this can affect the voice, it is NOT vocal cord surgery as reported.

Is Whispering Bad for Your Vocal Cords???

For most people, the answer is yes according to research publicized in a New York Times article on Feb 7, 2011.

In the mentioned study, out of a group of 100 patients, 69% exhibited increased supraglottic hyperfunction with whispered voice (ie, it was bad for the voice). 18% had no change and 13% had less severe hyperfunction.

As such, though whispering is not bad for everybody, it is for most people and as such, the safest thing to do if the vocal cords are damaged whether by infection or trauma is to rest your voice. If you have to talk, do not whisper, but rather talk in a soft voice.

The best way to think about injured vocal cords is to talk in an analogy. Laryngitis is like a badly sprained ankle. In this scenario, talking is like walking and screaming is like running. So just like you would rest the sprained ankle and not walk on it in order for it to recover as quickly as possible, you should refrain from talking in order for the laryngitis to recover as quickly as possible. Where does whispering fall in this analogy? Probably equivalent to running on a sprained ankle.

Read the NYT article here.

Read more about voice problems here.

Reference:
Laryngeal hyperfunction during whispering: reality or myth? J Voice. 2006 Mar;20(1):121-7.

“The Who” Roger Daltrey Underwent Vocal Cord Surgery

A story was published in December 2010 about Roger Daltrey’s experience with losing his voice and requiring vocal cord surgery literally 6 weeks before he was to sing at the Superbowl February 2010.

Fortunately, under the expert care of Dr. Zeitels at Massachusetts General Voice Center, he was successfully treated and recovered his voice in time to sing during the 2010 Superbowl half-time show in Miami.

Read the story here.

Simple Rubber Device Mimics Complex Birdsongs & Implications for Human Voice

A team of US researchers at Harvard has developed a simple rubber device composed of two pieces of rubber replicating the ‘vocal tract’ and a motor that replicates the action of a contracting muscle. With this device, the researchers have been able to EXACTLY mimic the birdsong of a variety of species including the bengalese finches and vireos.

Given complex birdsongs have been faithfully reproduced with such a rudimentary device as shown here, it does suggest that complex neurologically processes are NOT required. In reality, physics is all that is needed with just a little brain power.

You can listen to samples of birdsongs produced by the device here (halfway down the page).

If birdsongs can be replicated with such a simple device, just maybe, better vocal cord devices can be created for humans who have lost the ability to produce a clear voice.

Humans can lose the ability to talk/sing clearly due to cancer, papillomas, scarring, paralysis, etc. Although research on vocal cords is active, I’m not aware of any projects pursuing complete replacement with a biological equivalent of the rubber band. In fact… I’m not aware of any research project being pursued to create the biologic rubber band in the first place.

If you read any textbooks describing the vocal cords, it does seem mind-numbingly complex which perhaps explains why researchers have been discouraged from pursuing this line of inquiry.

But, if it can be done for birdsongs whose vocal cords are anatomically similar to humans, than theoretically, a simple rubber band device can also be created mimic-ing the human voice. This does sound like a fun high school science project the more I think about it.

Once that has been achieved, the physical characteristics of this rubber band can be broken down and than replicated by biochemists to create a biologic equivalent (or biologically inert) rubber band which can than be transplanted into a human with a damaged vocal cord.

Even to just more faithfully replicate a human voice would be a boom for those whose voiceboxes have been completely removed due to cancer (laryngectomy). Current replacement talking devices sound like a robot using state-of-the-art electrolarynx. Watch video below:

http://www.youtube.com/v/AYydnhu6NbU?fs=1&hl=en_US

Just a thought that I am sure is easier said than done.

Read the full article in the BBC here. Research paper on this topic to be published in near future.

Distributed Botox Injection for Spasmodic Dysphonia (Rather than Single Injection)

For many patients with spasmodic dysphonia, botox injections to the vocal cords are a regular right of passage every few months towards a clearer voice. Spasmodic dysphonia characterized by spastic or breathy voice breaks while talking causes much problems socially as well as misunderstandings.

For many physicians who perform botox injections for spasmodic dysphonia, a single injection is performed to either one or both vocal cords.

However a few and perhaps growing number of physicians are now using a more sophisticated method of injection where not only one, but multiple “mini”- injections are performed to the vocal cord during an injection.

Why would multiple injections be performed when one will do?

For that, I would like to take the reader to the world of cosmetic botox injections for facial wrinkles.

For the millions more sufferers of facial wrinkles, patients know that from the point of injection, there is a limited region of affect… typically no more than a dime to nickle area in size depending on the volume used. SO… in order to get rid of forehead wrinkles, 5 or more injections are required as shown here by the “x” marks.

The point is… in order for a great outcome in forehead wrinkles… multiple injections are performed. Not one single injection.

The same holds true for the vocal cord muscles. Rather than a single large injection to one spot in the vocal cord muscle, there is a growing belief that multiple “mini”-injections should be performed throughout the vocal cord muscle in order to produce a better outcome… a distributed injection. No specific research to prove this, but rather anecdotal.

Here is a video of botox being injected in a patient with spasmodic dysphonia.

http://www.youtube.com/v/fuPNM33ToR8?fs=1&hl=en_US&rel=0

What is Vocal Cord Stroboscopy?

Stroboscopy of the vocal cords is a special exam whereby a scope is introduced down into the throat where the vocal cords can be directly visualized. Using a special light, the vibration of the vocal cords can be examined and allows identification of subtle pathology that can contribute to a raspy voice.

The exam is recorded and can be played back at any speed to allow for careful analysis.

Here is a YouTube video our office has made showing how this exam is performed!

http://www.youtube.com/v/hfOZxJnY4c8?version=3