The Institute for Voice Disorders

Specializing in advance care for voice and swallowing disorders.

  V O I C E   D I S O R D E R S  

The voice is a wonderfully complex phenomena produced by the activator (the lungs), the generator or vibraters (the larynx which houses the vocal folds also known as the vocal cords) and the resonating chambers (the throat, mouth, nasal cavity and other structures above the folds (figure 1).  Voice is produced when the vocal fold come together and air then flows by them.  (Figure 2) This causes the lining of the vocal folds (the mucosa) to vibrate with undulating waves.  The microscopic view of the mucosa is seen in Figure 3.  The mucosa is seen in parts 1 and 2 as the longer arrow and darker layer.  The shorter arrows point to the vocalis muscle and vocal ligament.  The space between the ligament and mucosa is a loose layer filled with a gelatinous material that allows the mucosal waveforms to develop.  Most pathology arises in the mucosa or in the loose layer underneath.  Surgically, it is important to minimize scarring from the mucosa to the vocal ligament. Changes in the voice are almost always indicative of a medical problem; patients experiencing hoarseness, clearing, a lump sensation in throat, coughing,phlegm, vocal fatigue, decreased range, breathiness, strain, pain with singing or talking, loss of loudness, difficulty breathing, throat tightness, throat trauma, difficulty with the passagio, or other voice changes should see a physician to determine the cause.

Click on an image to enlarge.

Figure 1

Figure 2

Figure 3

Figure 4

The Comprehensive Voice Evaluation (CVE) at Alpha Surgical Group involves a detailed analysis of the voice and the larynx.  First, the patient will be asked to fill out a complete medical and voice history.  A voice handicap questionaire will also be complete to aid in quantifying the severity of the problem and the effectiveness of treatment.  Then the history will be taken in more detail by the doctor.  Next, the doctor will listen to the speaking voice and, if needed the singing voice.  After that, a general ear, nose and throat exam will be done.  After that, the patient will go to the laryngeal lab where the larynx will be examened with the flexible or rigid scope, or usually both.  Videostroboscopy is a technique where the mucosal waves forms are slowed down to look for more subtle mucosal defects.

Disorders of the throat, or pharynx, and voice box, or larynx, can take many forms, including:

  • Cancers and Tumors : Either benign or malignant abnormal growth in the larynx. Capable of spreading to other parts of the body, but highly curable if diagnosed early. Many laryngeal cancers can be treated with endoscopic and laser surgery which can yield a high cure rate while preserving the voice and leaving no external scars.

  • Gastroesophageal Reflux (GERD) and Laryngopharyngeal Reflux (LPRD ): Backflow of stomach acid into the esophagus which can cause hoarseness, swallowing problems, and pain. Many times LPRD is not diagnosed because the patient is not experiencing heartburn.  GERD is very common.  For patients with GERD and also LPRD, studies show that heartburn is an unlikely symptom.  Physiologic studies show that the esophageal emptying time is more rapid in GERD patients who also have LPRD.  This means that in LPRD patients, the acid stays in the esophagus for a shorter time and, therefore, causes much less  (if any) heartburn.  The diagnosis can be made on visual inspection of the larynx with hallmark features of pachyderma larynges (thickening of the back part of the larynx next to the esophageal opening), arytenoid (the laryngeal joints) redness, and other findings Figure .  The work-up involves a CVE, and possible radiographic imaging, high-resolution mammometry, and/or esophagoscopy.  Treatment is with proper medication and, most importly, dietary modifications.  Call our office and we will gladly fax, mail or email you these dietary instructions.

  • Cyst : a mass on the vocal cord, often caused by blocked mucous glands as a result of irritation. Also, repeated trauma can be associated with the development of cysts.  Cysts are often confused with polyps, and nodules.  Stroboscopy has been very helpful with making a diagnosis.

  • Polyp : a clearly defined mass on the vocal cord often caused by heavy voice use.

  • Nodules : Symmetric masses occurring on both vocal cords, a common complaint among singers.

  • Papilloma : Warty growth of the larynx caused by a virus, often transmitted through person-to-person contact.

  • Granuloma : Benign growth on the vocal cord resulting from irritation or trauma.

  • Laryngitis : Inflammation of the vocal cords. It has many causes including acid reflux, smoke inhalation, or a virus.

  • Tremor : Involuntary muscle movement of the larynx and vocal cords, causing quavering or interruption of voice.

  • Aging Voice : Weakening of the vocal cord muscle and/or stiffening of vocal tissues as a result of old age. May cause roughness of voice and loss of projection.

  • Hemorrhage : Bleeding of the vocal cord as a result of heavy voice use or vocal trauma. Often causes a quick onset of hoarseness caused by one particular event of vocal stress.

  • Sulcus Vocalis : Thinning or absence of a vocal cord tissue called the superficial lamina propria, which is required to properly produce sound. Causes reedy hoarseness, and may be caused by a developmental disorder or by hemorrhage or cyst.

  • Vocal Fold Scar : Damage to vocal cord tissues that decreases their pliability, often a result of surgery. Causes hoarseness.

  • Reinke's Edema: Swelling of vocal cord tissues as a result of smoking. Causes a gravelly, low-pitched voice.

  • Vocal Cord Paralysis : Loss of movement in the muscles that control one or both vocal cords, often as a result of nerve damage. Causes breathy or hoarse voice.

  • Subglottic Stenosis : Narrowing of area below vocal cords, either congenital or caused by placement of breathing tube during surgery. May cause shortness of breath and hoarseness.

  • Tracheal Stenosis : Narrowing of trachea, similar to subglottic stenosis; may also be caused by a tumor.

  • Spasmodic Dysphonia : Neurologic disease causing involuntary vocal cord movements, resulting in strained or breathy breaks in speech.

The treatment of voice disorders is almost always a team approach.  The coordination of the laryngologist (an ear, nose, and throat doctor who has significant voice experience), speech pathologist, and singing teacher is critical.  Often the radiologist, gastroenterologist, allergist and other medical personnel are required.  Strict voice rest is rarely needed.  Vocal conservatism is often encouraged.  Medical therapy, both homeopathic and allopathic is instituted almost always before any surgery will be contemplated.  Surgery is reserved for refractory cases.  The use of microflaps, mucosal-sparing surgery, endoscopic laryngeal surgery, implants, medialization, laryngeal framework surgery and endoscopic laser tumor resection all all important modalities for superior surgical outcomes.

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 S W A L L O W I N G   D I S O R D E R S  

Patients with dysphagia will be asked about the exact sensations they feel when swallowing; how quickly the problem appeared and how long it has been occurring; whether they are taking any medications that could cause these side effects; what other symptoms they are experiencing, if any; and whether there is a family history of such problems. If a physical exam is not enough to make a diagnosis, other tests may be ordered such as X-rays of the upper GI tract and brain, endoscopy of the esophagus and stomach, or blood sampling. Treatment and recovery depend on the underlying condition.

  C A U S E S   O F   S W A L L O W I N G   D I S O R D E R S  

There are many possible causes for a person to have difficulty or pain when swallowing food or liquid. Common causes include:

  • Conditions that narrow the esophagus - Infection, esophageal strictures caused by scarring; gastroesophageal reflux disease (heartburn); tumors or cancers.
  • Conditions that compress the esophagus from the outside- Goiter (enlarged thyroid gland); tumors, cancers or other abnormalities of the throat, larynx, spine, and neck.
  • Muscle Dysfunction- Autoimmune or nerve disorders; nerve or brain damage such as ALS or stroke. Acid reflux can cause muscle dysfunction as well.
  • Zenker's Diverticulum- Outpouching of the weakened areas of the esophagus which leads to difficulty swallowing and regurgitation.

Patients with swallowing disorders undergo either a video swallow study or a fiberoptic endoscopic evaluation of swallowing (FEES) to assess the disorder before patients have such innovative procedures as endoscopic treatment of Zenker's diverticulum.

Voice and swallowing disorders are very complex and require a close relationship between the patient and physician. Careful analysis of the problem is required to devise the appropriate medical or surgical treatment plan. Our doctors utilize the latest technological advances to treat their patients.

 P R O F E S S I O N A L   V O I C E   C A R E  

Professional Voice Care involves the medical and surgical treatment of voice disorder for individuals who use there voice for a living.  This includes obviously singers, actors and celebrity voices.  However, attorneys, sales people, teachers, announcers, clergy,  and many other professions fall into this category.  The questions for such patients will be more detailed.  For example, we need to know if a singer has any upcoming performances and if there problem is in all or only part of their singing registers.  The style of singing (rock, jazz, opera, classical, cantorial, etc) is very crucial.  The type of acting performance or where and how the voice will be used will also be assessed.  The psychologic aspects are more important with professional voice users.  Voice disorders can be catostrophic on a performers career.  Coordination becomes a bigger issue in that working with managers, producers, directors, etc. is important.  Speech therapists that are experts in voice disorders need to be used.  Most laryngologists are well known to members of NATS (National Association of Teachers of Singing).

Our doctors are tied in with the Professional Voice community.  They have been quoted in Back Stage West, Music Biz Advice, Los Angeles Times, the text book Mother Nature, LA Weekly, Beverly Hills Today and featured on MTV News, ABC 7, CBS 2, and other media outlets.  They have given over 200 lectures and presentations.  The have included the course "Care of the Professional Voice" at the American Academy of Otolaryngology annual meeting for 10 years, presentations at NATS meetings, USC School of music, The Voice Symposium in Philadelphia, The Pacific Voice Conference, The International Voice Symposium (Scotland), and many other prestigious locations.

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David M. Alessi, MD, FACS  

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