VOICE  | Conditions We Treat

What is Spasmodic Dysphonia/Laryngeal dystonia?
Spasmodic dysphonia, also called laryngeal dystonia, is a voice disorder. Spasmodic dysphonia is characterized by involuntary spasms or movements in the muscles of the larynx, which causes the voice to break, and have a tight, strained, or strangled sound.

What are the effects?
Difficulties that result from spasmodic dysphonia range from occasional problems with saying a word or two to complete inability to communicate.

Who does it affect?
Spasmodic dysphonia most often affects women, particularly between the ages of 30 and 50.

What is the cause?

• The exact cause of spasmodic dysphonia is not known. Most cases are believed to be caused by a nervous system disorder, and may occur with other movement disorders.
• Spasmodic dysphonia may be a genetic disorder, or may begin following an upper respiratory infection, injury to the larynx, a long period of voice use, or stress.

There are three types of spasmodic dysphonia.

• Adductor spasmodic dysphonia
  • Characterized by sudden involuntary spasms that cause the vocal cords to slam together and stiffen. The spasms interfere with vibration of the vocal cords and production of sound is difficult. Stress can make spasms more severe. Speech sounds are strained and full of effort. Spasms do not occur when whispering, laughing, singing, speaking at a high pitch, or speaking while breathing in.
• Abductor spasmodic dysphonia
  • Characterized by sudden involuntary spasms that cause the vocal cords to open. Vibration cannot occur when cords are open so production of sound is difficult. Also, the open position allows air to escape during speech. Speech sounds are weak, quiet, and whispery. Spasms do not occur when laughing or singing.
• Mixed spasmodic dysphonia
  • Characterized by symptoms of both adductor and abductor spasmodic dysphonia.

How is it diagnosed? What testing occurs?
In addition to a complete medical history and physical examination, examination of the vocal folds by fiberoptic nasolaryngoscopy may be performed. Patients are evaluated in a multidisciplinary manner by both a Speech Language Pathologist and a Laryngologist. Often you will be asked to read a paragraph and repeat some specific sentences. Always consult your physician for a diagnosis.

What treatment is available?
Specific treatment for spasmodic dysphonia will be determined by your physician based on:

• Your age, overall health, and medical history
• Extent of the disease 
• Your tolerance for specific medications, procedures, or therapies
• Expectations for the course of the disease
• Your opinion or preference
• The goal of treatment is to reduce symptoms of the disorder.
• Periodic botulinum toxin injections to one or both vocal cords can often relieve symptoms.
• Some patients will be a candidate for surgical therapy - selective laryngeal nerve adductor dennervation and reinnervation (SLAD-R). This involves cutting the nerves to the vocal cords that are responsible for spasm and inserting new nerves that can allow for a normal voice. Our team at the Ark-LA-Tex Center for Airway, Voice and Swallowing are the only practitioners to offer this surgery in the southeastern United States.

What is Reinke's Edema?
Also called polypoid chorditis, Reinke's Edema is a swelling of the entire layer of the superficial lamina propria (or Reinke’s layer), a structure crucial to normal voice function. 

Who is affected?
It occurs almost exclusively in smokers.

How is it diagnosed?
Reinke’s edema is not itself a precancerous lesion, but it is a sign that the vocal cords have been exposed to a damaging degree of smoking. The entire surface of the mouth, as well as the nose, throat and neck, should be carefully examined in people with Reinke’s edema to make sure no cancer or precancerous lesions have been overlooked.

Reinke’s edema causes a very characteristic gravelly, low-pitched voice. This is the result of swelling of the superficial lamina propria, which becomes boggy and vibrates less well as it gains in mass. Because the voice is low-pitched, Reinke’s edema is most noticeable in women. Often, it can be overlooked in men with a naturally deep voice for the same reason. Always consult your physician for a diagnosis.

What are the effects?
Sometimes, the swelling of Reinke’s edema can become large enough to impair breathing. Initially, this occurs only during strenuous activity, but may ultimately affect breathing at rest and contribute to sleep apnea, a disorder of breathing during sleep.

How is it treated?
It is essential to recognize that Reinke’s edema is evidence of severe damage from smoking. The initial step in the treatment of Reinke’s edema is to quit smoking. Early or mild cases of Reinke’s edema may improve with smoking cessation alone. Continued smoking makes recurrence likely following treatment, sometimes in a matter of weeks. For that reason, many laryngologists prefer that a patient stop smoking prior to operating on Reinke’s edema.

If Reinke’s edema fails to improve sufficiently following smoking cessation, microlaryngoscopic surgery is the main treatment option. Surgery for Reinke’s edema has unique difficulties, because the superficial lamina propria must be reduced - but not excessively, in order to preserve vibration of the vocal fold. Excessive reduction produces scar and hoarseness that is very difficult to correct. The more surgeries that have to be done, the greater the risk of scarring - hence the importance of stopping smoking before treatment. Surgery can usually improve the voice substantially and eliminate any breathing difficulty.

More information is available here: https://pubmed.ncbi.nlm.nih.gov/36000026/

Vocal nodules are benign (non-cancerous) growths on the vocal cords caused by vocal abuse.

Who is affected?
Vocal nodules are a frequent problem for professional singers, teachers, athletic coaches, preachers and fitness instructors. Occasionally, vocal fold nodules will develop in children.

How is it diagnosed?
The nodules are small and callous-like and usually grow in pairs (one on each cord). The nodules usually form on areas of the vocal cords that receive the most pressure when the cords come together and vibrate (similar to the formation of a callous). Voice nodules cause the voice to be hoarse, low, and breathy. Always consult your physician for a diagnosis.

How is it treated?
Treatment usually consists of voice rest and voice therapy

Laryngitis is inflammation of the vocal cords due to excessive voice use, infections, inhaled irritants and gastroesophageal reflux (GERD).

How is it diagnosed?
It is characterized by a raspy voice. Always consult your physician for a diagnosis.

Paralysis of the vocal cords may occur when one or both vocal cords or folds does not open or close properly. A common disorder, this condition can range from relatively mild to life threatening. 

What is the affect?
When one or both vocal cords are paralyzed, the open cord(s) allows food or liquids to slip into the trachea and lungs.

How is it diagnosed?
A person with vocal cord paralysis typically experiences a notable change in voice quality. A person may experience difficulty swallowing and coughing. Always consult your physician for a diagnosis.

How is it treated?
Treatment may include surgery and voice therapy. Sometimes, no treatment is necessary and a person recovers on his/her own.

When a person speaks, the sound of their voice, their gestures and speaking style help convey a sense of their gender. For transgender men and transgender women, specialized therapy and vocal cord surgery can help them communicate in a way that is more aligned with their gender identities.

How is it treated?
Adjusting the voice of a transgender person may involve therapy, medicine, surgery or a combination of these approaches.

• Speech therapy can help trans women and men use their voices and learn nonverbal communication to align with their identities and preferences.
• Medications or surgical procedures on the vocal cords may be used to raise or lower the voice in trans patients.

The Ark-LA-Tex Center for Airway, Voice and Swallowing is the only comprehensive voice center to offer transgender and gender-diverse voice care in the state of Louisiana.

Laryngeal papillomatosis is a rare disease caused by the human papillomavirus (HPV). More than 60 HPVs exist.

What is effected?
Laryngeal papillomatosis causes the growth of tumors inside the voice box, vocal cords, or the air passage from the nose to the lungs.

Who is affected?
Most laryngeal papillomas (tumors) occur in children before the age of three.

How is it diagnosed?
The tumors are usually quick growing and can vary in size, causing breathing and swallowing problems. Other symptoms may include coughing and hoarseness. Always consult your physician for a diagnosis.

How is it treated?
Treatment for laryngeal papillomas may include surgery to remove the tumors, laser ablation and injection of medication. Because the tumors tend to return, repeat surgery may be necessary. 

Leukoplakia and erythroplakia are thick patches on the vocal cords that may become cancer. Leukoplakia spots appear white, and erythroplakia are red. Leukoplakia and erythroplakia are lesions observed occasionally in the throat and on the vocal folds.

Who is affected?
The lesions are commonly seen in smokers, individuals exposed to toxic irritants, and patients with nutritional deficiencies - but they also occur in the absence of such factors.

What is the effect?
Leukoplakia and erythroplakia generally cause changes that can range from simple hoarseness to complete loss of voice. Symptoms typically evolve slowly.

How is it diagnosed?
Leukoplakia and erythroplakia are generally considered precancerous lesions, although their potential to turn into cancer cannot be assessed by their appearance. This risk is assessed by examining samples under a microscope for a characteristic of cells called dysplasia. Having dysplasia does not guarantee that cells are cancerous, but it places patients at a higher risk level than the general population for eventual cancer development. Even so, the majority of leukoplakia and erythroplakia lesions, including those with dysplasia, will never lead to cancer formation.

How is it treated?
Once leukoplakia and/or erythroplakia are identified, a biopsy and specialized examination of the specimen under a microscope are usually needed in order to determine whether the lesions harbor dysplasia. Subsequent management will depend on the location of the lesion and the nature of the biopsy findings. The options can include a combination of simple observation, laser treatments in the office, or surgical removal (microlaryngoscopy). Smoking cessation and avoidance of other irritants should always be part of the treatment strategy.

Treating leukoplakia surgically may sometimes be necessary to improve voice function when it affects the vocal folds, even in the absence of dysplasia or other concerning features on biopsy.

Clicking larynx syndrome, also known as hyoid bone syndrome is a type of faciocervical pain that is caused by degeneration and/or elongation of the stylohyoid ligament. A clicking is often hearing in the throat, usually during swallowing or neck movement, caused by the abnormal contact between the hyoid bone and the thyroid cartilage.

What is the effect?
Patients can experience clicking sensation, pain radiating to the ear, pain with speaking or yelling or singing, and pain with swallowing.

What is the cause?
The true cause of this condition is unknown but it can be related to previous neck trauma like strangulation or whiplash.

How is it diagnosed?
The workup for this condition includes a physical examination, CT scan and often times a modified barium swallow (MBSS). The CT scan is used to measure the distances between the hyoid bone and the surrounding bony structures.

How is it treated?
Treatment may include a series of steroid injections to the site of the clicking, physical therapy, or myofascial release therapy. For more severe cases it may include surgical resection of parts of the hyoid bone or thyroid cartilage.

Here at the Ark-LA-Tex Center for Voice, Airway and Swallowing we are one of a few centers familiar with this diagnosis and the possible treatments including surgical intervention.

More information on this rare condition can be found here: https://pubmed.ncbi.nlm.nih.gov/31050806/