Benign Vocal Fold Lesions
Benign vocal fold lesions are growths on the vocal folds that are non-cancerous and non-malignant. These lesions include nodules, polyps, cysts, ulcers, and granulomas. Some lesions can be associated with dilated blood vessels (ectasias) and/or a vocal fold hemorrhage. Vocal fold injury can also result in scarring or an area of stiffening on the vocal folds. Frequently, lesions and scarring are caused by how an individual is producing their voice (e.g., pushing, straining, yelling), however some may be present from birth or the result of medical and surgical interventions.
Lesions of this nature may be accompanied by a change in voice quality, increased vocal effort, vocal fatigue, decreased pitch range, pitch instability, or throat pain with voice use or even at rest. Changes can affect the speaking and/or singing voice. Symptoms may have an acute or gradual onset, and be chronic or waxing and waning in nature and warrant a comprehensive voice evaluation by a laryngologist and voice trained speech pathologist (SLP).
Workup for benign vocal fold lesions is completed during a joint visit with the MD and SLP to determine the nature and cause of the lesions, and an appropriate course of treatment. Evaluation workup will include a: comprehensive history intake during which voice quality and patterns of tension are assessed; acoustic and aerodynamic measurements of voice; a complete head and neck exam including assessment of vocal fold vibration during laryngeal videostroboscopy using high-definition, state of the art visualization equipment; and stimulability testing to assess ability to make vocal changes to address complaints and promote healing of the vocal folds.
Since many benign lesions develop and are exacerbated from inefficient voice use patterns, changing voice use patterns through voice therapy/behavioral intervention is frequently the first line of treatment. Integration of voice therapy techniques in day-to-day voice use can result in improvement of symptoms and vocal fold healing. Voice therapy may include vocal hygiene education, laryngeal massage and myofascial release, and voice efficiency exercises. Pending on the nature of the lesion, other forms of intervention may be required by one the UCSF Voice and Swallowing Center’s fellowship trained laryngologists. These will be discussed with the team and may include medical management or surgical excision. The patient, MD and SLP will work together to develop an individualized treatment plan.
Early Laryngeal Cancer
At the UCSF Voice and Swallowing Center, we treat early laryngeal cancer patients or patient with precancerous (dysplastic) laryngeal lesions in a holistic, interdisciplinary framework. In our clinic, physicians work alongside speech-language pathologists (SLP) in order to provide the best care possible. Our goal is to eradicate the disease, while maintaining function and quality of life. We believe that patients benefit immensely from working with our close-knit team of physicians, voice SLP specialists, and swallow SLP specialists throughout their entire course of treatment and recovery.
Patients often present with complaints of hoarseness, more effortful voice production, or vocal fatigue. They may experience difficulty swallowing or a cough. While early laryngeal cancers typically do not significantly restrict the patient’s airway, there maybe the sensation of a change in breathing.
A comprehensive head and neck examination is performed at every office visit. This will include a laryngoscopy (endoscopic examination of the larynx) and/or laryngostroboscopy to evaluate the vibratory properties of the vocal folds. In order to determine the diagnosis, a tissue must be obtained and sent to the pathologist. Typically, this involves an evaluation under anesthesia in the operating room and biopsy of the abnormal tissue. Our laryngologists and SLPs participate in the Multidisciplinary Head and Neck Oncology Tumor Board meeting, where the patients’ cases and treatment options are discussed.
Early stage laryngeal cancer responds very well to treatment. The treatment options are surgical resection or radiation therapy. The survival rates are equally good for both options. Chemotherapy is not a standard treatment option for early larynx cancer. The decision of whether to undergo surgery or radiation is usually made after a long discussion with the patient weighing expected side effects of the treatments based on the location and size of the tumor and individual preferences.
- Endoscopic surgical resection: Minimally invasive surgery performed under the operating microscope, usually with a CO2 laser, to resect the disease. Patients typically go home the same day as surgery.
- Radiation therapy: Patients may undergo radiation either at UCSF or at a facility closer to home. The course of therapy is usually 5-6 weeks.
Laryngopharyngeal Reflux (LPR), also known as “silent reflux”, is when stomach contents flow up into the throat causing irritation of the laryngeal (voice box) structures. This can occur due to incomplete closure of the lower esophageal sphincter, which connects esophagus (food tube) to the stomach.
Unlike gastroesophageal reflux disease (GERD) where patients experience active heartburn, indigestion, and reflux into the mouth, patients symptoms can be more subtle manifesting as voice change - typically in the morning or soon after meals, sore throat, sensation of a lump in the throat, and/or excessive mucous.
This disease is diagnosed with laryngoscopy during a clinical visit where the laryngologist looks for edema (swelling) and erythema (redness) of the laryngeal structures. Based on the findings, the doctor may recommend additional gastrointestinal (GI) testing (e.g., pH probe or manometry).
LPR is typically treated with behavioral modifications (i.e., reducing foods and behaviors that trigger reflux), medications to reduce or eliminate the acidity of the stomach, and in extreme cases, surgery to tighten the lower esophageal sphincter.
Muscle Tension Dysphonia
Muscle Tension Dysphonia (MTD) is a voice disorder that occurs when the muscles of the neck, throat, tongue, and/or larynx are overly activated during voice use. This creates an imbalance in the vocal mechanism that can lead to voice changes and/or throat discomfort.
Over activation of the above-mentioned muscles is inefficient and can lead to increased strain on the vocal folds during vibration. Muscle tension patterns can lead to vocal quality changes, reduced vocal range, vocal fatigue, increased vocal effort, throat irritation, globus sensation (a lump in the throat), chronic cough/throat clearing, and/or the development of vocal swelling or even benign vocal fold lesions. MTD is often diagnosed with other vocal fold injuries as people may change their muscle tension patterns in order to compensate for the changes in the larynx. It is also common for habitual MTD to cause benign vocal fold lesions.
MTD is diagnosed by a laryngologist and voice trained speech pathologist (SLP). The evaluation will include a: comprehensive history intake during which voice quality and patterns of tension are assessed; acoustic and aerodynamic measurements of voice; a complete head and neck exam including assessment of vocal fold vibration during laryngeal videostroboscopy using high-definition, state of the art visualization equipment; and stimulability testing to assess ability to make vocal changes to address complaints.
The gold standard to treat MTD is voice therapy. The SLP works with the patient to build awareness and reduce of tension in neck and laryngeal muscles, re-balance the coordination of breathing and voice, and optimize resonance (where the energy of voice is felt).
Neurological Voice Disorders
Parkinson’s Disease (PD) is a neurologic disease, which affects the whole body. This disease is caused by a loss of nerve cells in a specific area of the brain controlling movement. As the disease progresses, the coordination of movement becomes less controlled.
These include difficulty with balance and walking, bradykinesia (slowness of movement), tremor, difficulty with fine motor movement, cognitive impairments, and flat facial affect (masked facial appearance).
Speech, Voice, and Swallowing symptoms
These can include low volume and difficulty projecting the voice, inaccurate articulation (‘mumbling’), increased rate of speech, monotone voice, difficulty with swallowing, and drooling.
The diagnosis of PD is made by a neurologist who is an active ongoing member of the patient’s care team. When seen at the UCSF Voice and Swallowing Center (VSC), a comprehensive voice and swallowing evaluation by the laryngologist and speech-language pathologist will be completed. Evaluation will include a: thorough history intake during which voice quality and speech patterns are assessed; complete head and neck exam including assessment of laryngeal function and vocal fold vibration; and flexible endoscopic evaluation of swallowing (FEES). Depending on swallowing complaints, the laryngologist may also order a videoflouroscopic evaluation of swallowing (VFSS) a specialized x-ray swallow test.
Patients with PD can benefit from both voice and swallowing therapy. Because of the nature of the disease process, patients may benefit from more intensive voice therapy with a focus on loud, clear speech. One approach is Lee Silverman Voice Therapy (LSVT) which all of the VSC clinicians are certified to administer.
Spasmodic Dysphonia (SD) is a focal dystonia that is present in the larynx. The dystonia is neurologic in nature and results in aberrant signals being sent to the laryngeal musculature to spasm during voice production. There are two sub-types of SD. Adductor Spasmodic Dysphonia (ADSD) is when the vocal folds close together too tightly during voiced sounds and Abductor Spasmodic Dysphonia is when the vocal folds spasm open during voiceless sounds.
A person may experience the voice cutting out on certain words or sounds, feelings of increased vocal effort, or a change in overall vocal quality. People with spasmodic dysphonia may note a variation in vocal ease and quality depending on the situation. Talking on the phone may be more difficult, while speaking or singing in a high pitch or whispering may be easier.
Evaluation is completed by a laryngologist (an otolaryngologist who specializes in voice) and a voice trained speech pathologist. A comprehensive head and neck exam is completed. The patient will be asked to perform a series of vocal tasks and a voice recording and larygostroboscopy will be completed to aid in identfiying the appropriate diagnosis. A referall to neurology is often made to identify other possible contributing factors.
The ‘gold standard’ for treatment of spasmodic dysphonia, at this time, is injection of Botulinum Toxin (Botox). Botox is injected through the neck into the primary muscles that are spasming. For ADSD this is typically the thyroarytenoid or vocal fold muscle while for ABSD this is the posterior criciarytenoid, the muscle responsible to opening the vocal folds. The starting dosage is typically small and the physician and speech pathologist work closely with the patient to determine the best dosage and frequency of injection.
Other treatment options include voice therapy and surgical intervention. Voice therapy helps with management of spasmodic dysphonia through behavioral techiqnues in isolation or in conjunction with Botox treatments. The goals are to maximize vocal effeicieny and minimize effort in the presence of the disorder. Surgical options can also be considered however are typcailly not the first line of treatment. The options may include denervaton-reinnervation of the adductor branch of the recurrent laryngeal nerve (the nerve the helps close the vocal fold) or a laryngael nerve avulsion. These options can be discussed with the laryngologist to identify candidacy.
Vocal Tremor is a neurologic disorder in which there is an essential, action induced tremor in the vocal folds or other laryngeal/pharyngeal structures observed during voicing. Vocal tremor can happen in isolation or is seen in conjunction with spasmodic dysphonia.
Symptoms may include a change in the sound of the voice, vocal shakiness, increased effort or vocal fatigue with extended talking, and/or cutting out. Cutting out is rhythmic in nature and not related to certain sounds as it is with spasmodic dysphonia.
A comprehensive evaluation is completed by a laryngologist (an otolaryngologist who specializes in voice) and voice trained speech pathologist. This will include a head and neck examination, voice recording and laryngeal examination including laryngoscopy and videostroboscopy. The patient will be asked to perform a series of vocal taks to elicit voice characteristsic that may aid in identfiying the appropraite diagnosis. A referal to neurology is often made to rule out other contributing fators.
Vocal tremor can be managed with medical treatment and/or behavioral intervention. Oral medications can help reduce the tremor. Some people with vocal tremor may be candidates for injection of botulinum toxin. Voice therapy can also be of benefit to teach management strategies, reduce strain and maximize voice use in the presence of the tremor.
Anyone that makes a living using his or her voice is considered a professional voice user. Professional voice users have unique needs and expectations for their voice. Because of this, we practice interdisciplinary voice care. The voice care team includes fellowship-trained laryngologists and speech pathologists, with specialized voice and singing training, who work side by side to evaluate patients and develop a comprehensive plan of care. We have particular expertise in managing professional and semi-professional voice users - from amateur choristers and teachers to nationally known vocalists and lecturers.
Professional voice users may experience voice changes that the typical speaker may accept as normal variations in voice. Small changes can lead to big impact when expectations for voice quality and vocal demand are high. Symptoms may include changes in voice quality, increased vocal effort, vocal fatigue, decreased pitch range, pitch instability, difficulty at a certain note or in a specific pitch range, and/or throat discomfort or pain with voice use. These complaints may wax and wane or be more persistent in nature and warrant a comprehensive evaluation.
The evaluation will completed by a laryngologist and voice trained speech pathologist (SLP) to determine the nature and cause of the voice changes. Evaluation will include a: comprehensive history intake during which voice quality and patterns of tension are assessed; acoustic and aerodynamic measurements of voice; a complete head and neck exam including assessment of vocal fold vibration during laryngeal videostroboscopy using high-definition, state of the art visualization equipment; and stimulability testing to assess ability to make vocal changes to address complaints and promote resolution. An individualized treatment plan will be developed with the patient, physician and speech pathologist that takes into consideration the special requirements of the professional voice user.
The course of treatment depends in the diagnosis, symptoms, and level of vocal demand/requirements of the patient. Behavioral intervention is often the first line of treatment for professionals with voice complaints. Voice therapy would focus on vocal hygiene, tension reduction and management techniques, and vocal exercises to practice independently and apply in all voice use. The voice therapy program will be patient specific and based on physiologic and voice science principles to maximize voice use, speaking and singing, and promote vocal fold healing.
Medical intervention and/or surgical intervention may be required based on the diagnosis and complaints. Medical intervention may include medications to address allergy or laryngopharyngeal reflux. Surgical intervention is typically considered only after behavioral modification has been maximized and gains in therapy have plateaued. There are specialized micro-surgical procedures to remove benign vocal fold lesions. The medical and behavioral team work closely before and after any surgery from voice rest through the rehabilitation process to help the professional voice user return to the highest level of function and meet their vocal demands.
Gender Affirming Voice Care
Much about voice and speech that identifies gender relates to word choice, phrase structure, and intonation patterns. People are often unaware of habitual communication patterns. These habitual patterns convey more about gender perception than vocal pitch or quality alone.
Voice and communication patterns that are incongruous with gender identity.
Evaluation is completed by a laryngologist (an otolaryngologist who specializes in voice) and voice trained speech pathologist. A comprehensive head and neck exam will be completed including a voice recording and larygostroboscopy. Larygostroboscopy is completed using a rigid or flexible telescope, that is insterted into the mouth or nose respctively, to evaluate how the vocal folds vibrate during voicing. The patient patient, physician, and speech pathologist work to identify areas to target to help reach voice and communication goals.
Typically, treatment beigns with voice therapy. Voice use patterns are addressed to maximize ease and efficiency of voice, in an accessible pitch range, that is more in line with one’s gender identity. Communication and speech patterns are also addressed. This may include word choice, phrase structure, articulation patterns and pragmatic (social) interaction.
Surgical voice modification is generally considered only after behavioral modification has been maximized. A Wendler’s Glottoplasty is a procedure to reduce the length and mass (weight) of the vibrating vocal folds leading to a higher pitched voice.A tracheal shave can also be compelted to reduce the size of the ‘adam’s apple’ and is not related to voice use. These can be discussed with the surgeon and voice care team.
Vocal Fold Motion Impairment
The vocal folds, housed in the larynx (voice box), act as a valve on top of the airway. Their primary function is to protect the airway and to create voice. The vocal folds open during inhalation and close during breath holding, cough, and voice production. Vocal fold motion can be impaired due to two causes – neurologic or mechanical (scar that limits vocal fold motion). Paralysis (absence of vocal fold motion) or paresis (partial impairment of vocal fold motion) are terms used when the cause of the vocal fold immobility is due to damage to its main nerve supply. In the larynx, the Recurrent Laryngeal nerve is the primary nerve supply to the majority of the laryngeal muscles. This nerve travels down from the brain and into the chest as part of the Vagus nerve before it branches off and turns upward towards the larynx. The nerve on the left side dips lower into the chest than the right side and is generally at a higher risk for injury. Paralysis of the vocal folds can be either one-sided (unilateral) or on both sides (bilateral). Unilateral vocal fold motion impairment often results in the inability to close the vocal folds fully, which may leads to changes in voice, breathing and swallowing.
Those with unilateral vocal fold motion impairment may be experience a breathy voice quality with decreased volume, increased vocal effort, and/or a sense of increased breathing effort or breathlessness when speaking or during activity.
In order to appropriately assess vocal fold motion, the laryngologist and voice trained SLP work together to obtain: a comprehensive history during which voice quality and voice use patterns are assessed; a complete head and neck exam including assessment of vocal fold motion and vibration during laryngeal videostroboscopy; acoustic and aerodynamic measurements of voice; stimulability testing to assess ability to make vocal changes.
Treatment for vocal fold motion impairment varies based on severity, symptoms, and onset. Voice therapy may be recommended to learn how to behaviorally manage the voice changes and maximize voice use in the presence of the impairment. Other treatment options include injection augmentation laryngoplasty (temporary vocal fold injection) or a Type 1 Thyroplasty, which is a more permanent procedure. Both procedures help to put the vocal fold into a better position for voice production while maintaining breathing function. All of these options will be based on interdisciplinary conversation between the patient, the physician, and the SLP to identify an individualized plan.