Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to “callous” formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more “impatient” for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a “local injection” to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a “partial” vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:

Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

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.

Thyroidectomy (Thyroid Surgery) Risks

Thyroid removal (either total or only one side) is a common surgery performed by general surgeons as well as ENTs for thyroid cancer or masses suspicious for cancer.

Though I no longer perform this surgery, I often get asked for my opinion regarding this surgery. Rationale for why surgery should be done or not, I leave to others as it would literally take a textbook, especially given the controversy regarding when to observe and when to surgically remove. Back when I WAS performing thyroidectomy, I should state my bias was towards removal… and belief that a needle biopsy is not 100% accurate. Indeed, in certain situations, a needle biopsy (FNA) is at best no better than flip of a coin whether cancer is present (it is wrong 50% of the time!).

In any case, there are several risks involved when this surgery is performed. Other than the typical risks common to all surgeries like infection and the ho-hum bleeding, there are several unique risks specific to thyroid surgery. Let’s go over each one:

Windpipe
Given the thyroid is located over the windpipe, the surgeon may accidentally (or deliberately if thyroid cancer is invading the windpipe’s wall) enter into the airway. Why may this be a problem? Well, it may cause air to leak into the neck causing it to suddenly swell up and potentially lead to a pneumothorax (collapsed lung) if severe enough. The scary thing is that it could potentially occur days after the surgery though if it is going to happen, it usually occurs within hours after surgery.

Bleeding
Bleeding is ALWAYS a risk of surgery causing a hematoma to form. What makes this particular complication especially concerning is that it often occurs DAYS after surgery. Even more worrisome is that it could lead to death as the hematoma formation can cause significant swelling with resulting airway compression (remember that the thyroid is located over the windpipe). This particular complication unfortunately occurs not uncommonly… and often leads the patient to obtain emergency care in the local ER by a local surgeon to drain/remove the hematoma and stop the bleeding even if the surgery was done by surgeon located an hour or more away. A tracheostomy (a hole in the neck to the windpipe) may need to be performed at this time as well.

Recurrent Laryngeal Nerve Damage
The nerve that allows you to talk is called the recurrent laryngeal nerve. This nerve is RIGHT NEXT to your thyroid gland. As such, it can be damaged or cut resulting in a very breathy sounding voice. Oftentimes, it is temporary. Rarely, BOTH nerves can get cut if undergoing total thyroidectomy causing stridor or airway problems mandating a tracheostomy.

In the event that a patient suffers a vocal cord paralysis from recurrent laryngeal nerve damage, it can be corrected surgically resulting in an almost normal sounding voice. If BOTH vocal cords are paralyzed… well… breathing and talking will be a problem and options are quite limited if this unfortunate complication occurs.

Superior Laryngeal Nerve Damage
With this type of nerve damage, you can talk just fine… but you lose your upper range and falsetto.

Parathyroid Gland Loss

The parathyroid glands are located behind the thyroid gland in the 4 corners as depicted by the golden nuggets seen in the diagram to the right. These glands are very important regulating the calcium levels in the blood. In the devastating event that all 4 parathyroid glands get damaged or removed (as might occur during total or completion thyroidectomy), the patient loses the ability to maintain calcium levels in the blood resulting in cardiac and neurologic problems that could lead to death if not immediately addressed. Even if the parathyroid glands are preserved, if the blood supply to the 4 glands get cut off or damaged by the thyroid surgery, blood calcium levels may deteriorate.

Summary

Thyroid surgery has risks and should be performed by a well-qualified surgeon. However, keep in mind that the best person to take care of you should you experience any surgical complication is the surgeon who actually did the surgery (one of many factors to take into consideration when considering having the surgery done far from home).

References:
Mediastinal emphysema and pneumothorax following thyroidectomy. The Journal of Clinical Endocrinology Vol. 9, No. 10 987-998 doi:10.1210/jcem-9-10-987

Complications of Thyroid Surgery. EMedicine

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

Dr. Chang Mentioned in Newspaper Regarding Spasmodic Dysphonia

The Culpeper Star Exponent released a story on Sept 27, 2010 regarding an individual suffering from ABductor spasmodic dysphonia. This voice disorder is characterized by voice breaks while talking making it very difficult to talk as well as to be understood.

This individual has been treated with botox injections by Dr. Chang who was mentioned in the article:

“Taylor has one of the rarest forms of the disorder and therefore the hardest to treat. Nonetheless, she seeks treatment every four months through Dr. Christopher Chang, an ear, nose and throat specialist based in Warrenton. He is a leading expert in vocal chord treatments, and Taylor is happy he’s located so close by.”

Read the story here.

Age Influences Botox Response in Patients with Spasmodic Dysphonia

Dr. Chang recently published a book chapter discussing how age influences response to botox injections in patients suffering from spasmodic dysphonia.

Introduction
Spasmodic dysphonia is a dystonia (muscle spasms) involving the muscles of the voicebox resulting in involuntary attacks of a strangled sounding voice. Treatment is botox injection to the involved muscles resulting in a decrease of such spasms thereby resulting in a more smooth-sounding voice.

Unfortunately, there are side effects with botox injections to the voicebox including aspiration, dysphagia, breathy voice, etc for a short period of time prior to the good voice. Typically, one week of side effects results in about 3 months of a good voice.

Research into this area typically has been to try and maximize the duration of a good voice while decreasing the duration of side effects.

A prior paper published by Dr. Chang tried to establish what the correct dose is to maximize a good voice and minimize side effects.

This book chapter tries to determine if age influences botox response.

Age and Botox Responses
What was found is a positive correlation between age and duration of normal voice and duration of side effects after botox injection. Age did not appear to play a role in the severity of side effects experienced by patients. However, the number of BTX-A injections received by a given patient was negatively correlated with duration of normal voice and side effects to a degree greater than age.

What does this mean?

Age must be taken into consideration when deciding on what dose of botox to inject since as a patient becomes older, one may see a slow increase in not only duration of normal voice, but also duration of side effects reported. Stated another way, for a given dose, the duration of side effects is larger for an older patient compared with a younger one. However, as the cumulative number of injections a patient receives increases over time, the duration of normal voice and side effects would be expected to decrease slowly.

Reference:
Age as a Factor in Responses to Botulinum Toxin Injection in Adductor Spasmodic Dysphonia Patients pp. 101-112