Posts tagged #ENT

Advice Post-Slice: Voice Recommendations After Surgery

How much voice rest is necessary after surgery to the vocal folds? When I had voice surgery 10 years ago, I was instructed to rest my voice strictly for 1 week. No talking, singing, throat clearing, grunting, you get the picture. It was unclear, however, how I was to get back to singing normally again. So what do I tell patients? It varies depending on the extensiveness of the laryngeal surgery, but I pull my recommendations from studies.

The Rat Pack

Leydon et al 2014 describes how forty rats, (I know they're not people,  but I'm sure the experimenters formed relationships with their little buddies for the duration of the trial) had the mucosal layer of the vocal folds removed. (That's the top layer.)  Then the rats' larynges were examined between 3-90 days at 5 different times. 

This image is pulled from Springer online: Operative Techniques in Laryngology

This image is pulled from Springer online: Operative Techniques in Laryngology

 

Researchers found that a vocal fold tissue structure regenerated quickly (like, within 5 days) with intercellular junctions and multi layered epithelium (the tissue on the very outside of the vocal folds that receives the biggest impact during vibration). 

However, atypical permeability of this layer of the TVF's was seen up to 5 weeks after surgery. This means that if you have vocal surgery, you should be sure to keep tabs on your vocal use for many weeks following surgery, as there is a very elevated risk for further damage as your body continues to rebuild where the surgeon worked. Intact structure does not necessarily mean you can demand vocal use you were using before surgery.

Scarring Woes

Scarring is frequently seen after surgery and results in issues with phonation. So obviously we want to minimize scarring. We can't exactly massage the vocal folds to soften this scar tissue, but perhaps gentle vocal exercises that stretch and contract the tissues, as well as utilize resonant voice can help

Another study by Branski et al from 2006 really looks at how a vocal fold wound heals, including inflammation and swelling, as well as scarring. Again, we're talking our animal friends' vocal folds. Scarring develops when there is an increased inflammatory response following an injury. The study discusses differences in lesions to the vocal folds, including nodules, polyps and cysts. Particularly interesting to me, was the suggestion that a cyst, especially one at the midpoint of the vocal fold, might be due to injury associated with impact stress. (Which further convinces me that my vocal fold cyst from years ago was likely a product of a poorly coached belting role I performed during High School.)

Lesions and Surgery

The Branski article suggests that vocal fold lesions are probably the body's way of healing a wound, much in the way a scar results from a cut. Applicable to many of my patients is the discussion of chemical vocal fold injury from LPR, and that 50% of patients with voice disorders also have LPR or GERD, or both. We must also consider the effect of reflux on the healing process after surgery.

So, how long should a person realistically expect to be on complete vocal rest after surgery? For 2 weeks-5 weeks post injury, epithelium remains permeable and impacted by the wound healing process. I say impacted and not weakened, because epithelialization (restoring structural integrity) occurs rapidly between 3-5 days after injury.  Complete rest during this rapid healing time with a very strict ease back into phonation over 2-5 weeks appears to win here. 

We're still learning so many things about how this delicate tissue heals itself, we can only recommend based on the information we have now. Every patient heals differently, and the degree of surgical manipulation will vary case to case. 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

Resources:

Leydon, Ciara, Imaizumi, mitsuyoshi, Yang, David, Thibeault, Susan L., & Fried, Marvin P. Structural and functional vocal fold epithelial integrity following injury. Laryngoscope 2014, Dec. 124 (12) 2764-2769

Branski, Ryan C, Verdolini, Katherine, Sandulache, Vlad, Rosen, Clark A., & Hebda, Patricia. Vocal fold wound healing: A review for clinicians, Journal of Voice, 2006 Vol 20, No 3, pp 432-442

 

Textbook Hyperfunction or Something Else: When Can Hoarseness be ALS?

When a patient comes to you with complaints of hoarseness, the first thing you do is probably perform your evaluation. Check. You make sure the patient has been seen by an ENT, and then you perform a videostroboscopy. You'll most likely follow with a behavioral voice evaluation and/or a laryngeal function study. You have an idea in your head of what the diagnosis might be before the patient even steps in the room. Case history can lead you in the right direction,  but sometimes it is important to be aware of all possible causes of symptoms, even the very rare. You patient comes in:

1. The voice is strained, pressed and sounds strangled. Hoarseness is present, as well as a mild hypernasal quality and vocal fry.

2.  The patient has a low pitch, it's lower than normal for gender and age.

3. Voice onset for vowels is difficult, and the patient speaks softer than normal.

Initially, you think there is a strong possibility that the patient has Muscle Tension Dysphonia because of the strain. You want to make sure and rule out Adductor Spasmodic Dysphonia, however. You have your patient count from 80-89 to listen for laryngeal spasms. Your videostroboscopy reveals some vestibular fold hyperfunction paired with hypoadduction of the true vocal folds. Your patient is also complaining of some mild dysphagia.

You're still uncertain of what your diagnosis is. There are just some missing pieces. Something is just not adding up. How can you explain the low pitch and low intensity? It might be MTD, but what if it is something else...

Amytrophic Lateral Sclerosis (ALS) has been all over social media lately with the viral Ice Bucket Challenges. It usually presents with extremity weakness, atrophy, and decreased muscle tone. Sometimes, however, it begins with voice quality changes before anything else. A person can develop a voice that sounds strained, strangled, harsh or breathy. The voice might waver with tremor or have unsteady pitch. A patient might also have some hypernasality to boot. A certain kind of ALS onset, called bulbar (affecting the lower motor neurons), can be the culprit. It affects the lower motor neurons in the brain stem, and your videostroboscopy might show some hypoadduction. A patient with this bulbar onset might show signs of mild dysphagia and dysarthria early on, and quite possibly have hyperfunction of false vocal folds and ventricular compression to compensate for that hypofunction.

So how do you determine if it is ALS? ALS has a very rapid onset time, and within months you start to see the degenerative progression in multiple areas. One case study (to be taken with a grain of salt) showed that after 4 months, with the usual treatment for vocal fold atrophy/bowing, there was no improvement. Dysphagia worsened as well as the dysarthria. So, time might be a deciding factor here.

Knowing that ALS is a possible cause for hyperfunction and hypofunction in the larynx is something to hold in your back pocket. It will not happen often as a diagnosis, but it is worth being aware of. Just treat the symptoms you see, and if your patient's condition gets progressively worse despite intervention, there's a good chance you might be dealing with a progressive neurological disease. You should always refer back to the neurologist if you suspect this component.

But with what type of treatment can help you with this differential diagnosis? For bowing or atrophy of the TVF's, you might find success with Lee Silverman Voice Treatment (LSVT) as it has helped improve individuals suffering from age related bowing or Parkinson's disease. You might try to improve the hyperfunction by trying Lessac-Madsen Resonant Voice Therapy (LMRVT) or Casper-Stone Confidential Flow Therapy (CS-CFT) or a variation of Stone & Casteel's Stretch-and-Flow. With whatever is appropriate for your patient, pay close attention to whether there is benefit, or whether quality worsens despite your best efforts.

 

-ATVC

 

References: Watts, Christopher R, and Martine Vanryckeghem. “Laryngeal Dysfunction in Amyotrophic Lateral Sclerosis: a Review and Case Report.” BMC Ear, Nose, and Throat Disorders 1 (2001): 1. PMC. Web. 10 Jan. 2015.

 

Kristie Knickerbocker, MS, CCC-SLP, is a speech-language pathologist and singing voice specialist in Fort Worth, Texas. She rehabilitates voice and swallowing at her private practice, a tempo Voice Center, and lectures on vocal health to area choirs and students. She also owns and runs a mobile videostroboscopy and FEES company, Voice Diagnostix. She is an affiliate of ASHA Special Interest Group 3, Voice and Voice Disorders, and a member of the National Association of Teachers of Singing and the Pan-American Vocology Association. Knickerbocker blogs on her website at  www.atempovoicecenter.com. She has developed a line of kid and adult-friendly therapy materials specifically for voice on TPT or her website. Follow her on Pinterest, on Twitter and Instagram or like her on Facebook.

2 Resources and some Deep Voices

2 Resources and some Deep Voices

by atempovoicecenter atempovoicecenter on 05/29/14

 

Hello all!

I am feverishly writing up reports tonight, but wanted to stop and talk about some great new resources I have uncovered. The first is a website run by Dr. James P. Thomas, an ENT Laryngologist with an interest in voice and some savvy computer skills. It is full of videos that are very informative and are easy to follow for any SLP or potential patient with a voice disorder. Enjoy!

I have also reached out to the Fort Worth Transgender Community to let them know a tempo Voice Center is a resource they can take advantage of. Voice therapy for transgender individuals can be a daunting task, and sometimes it is the first step of a person's journey. Receiving voice therapy for my vocal cyst really opened my eyes to how nervous one can be when seeing a speech therapist for the first time.

On a fun and science-related note, I found this video of some adults (still young at heart) and their experience with Sulfur Hexafluoride gas. This gas, also known as SH6, is very dense. It is heavier than oxygen, so when inhaled, it slows the speed of sound and resonates lower frequencies than regular air. It causes a perceivable drop in pitch. Please do not try this at home, it is dangerous.