Voice Problems

Difficulties with the voice can arise from numerous problems and the causes can be many. As ENT surgeons we are uniquely placed in assessing voice problems as we are able to directly visualise the vocal cords, which are responsible for producing a clear voice. A short lesson in anatomy may be useful.

Anatomy of Voice Production

To produce a clear voice a person needs a) lungs to provide the air or ballast to allow speech, b) a larynx with functioning vocal cords and c) normal anatomy of the mouth and upper throat, to help in clear articulation. A problem with any of these areas can lead to voice problems or hoarseness.

The Larynx (voice box) is a complicated 3 dimensional sound box composed of cartilage, ligaments and many fine muscles. As can be seen from the illustration below, the 2 vocal cords are made up of ligament and muscle and are controlled by a number of other muscles to allow movement. The muscles rely on the recurrent laryngeal nerves to work, and if these nerves are damaged the vocal cord will not move, resulting in a hoarse breathy voice. The thin delicate lining of the vocal cords is vital in allowing vibration and celar voice production. Many voice problems are due to abnormalities in this lining (see below)

div style=" padding:10px">

Causes of Hoarseness

Singers Nodules

This is a condition that professional voice users dread. It is actually not that common, however, it does occur in people who overuse or abuse their voice. This can be professional singers, however, more often it occurs in the enthusiastic karaoke singer or somebody who simply shouts a lot. The diagnosis is usually obvious on examniation of the larynx and as can be seen below the nodules are bilateral and form at the junction between the front third and posterior 2/3 of the vocal cord.

Treatment is usually not surgical! All patients should be initially referred for an intensive course of speech therapy, and only if this fails or if the nodule is unilateral or looks suspicious, should the nodules be resected. If a patient needs surgery then the surgeon should very carefully excise,under magnification using a microscope and delicate instruments, an extremely small area of the vocal cord. Stripping of the cord has no place in managing this condition and will lead to permanent voice problems as the delicate mucosa is lost and the scar that reforms can not vibrate properly.

Reinkes Oedema

This is a condition seen almost exclusively in smokers who overuse their voice. As can be seen from below, the vocal cords change from clean whit cords to floppy swollen bags of fluid. The treatment is to stop smoking and speech therapy may help. Surgery is indicated for extensive examples or ones that dont respond to stopping smoking. Once again stripping of the cords is not the answer, rather, the surgeon should cut the mucosa and remove excess fluid and then excise a limited strip of mucosa reserving as much as possible

Laryngeal Polyps

Laryngeal polyps differ from nodules and reinkes oedema in being one sided only. This often means that treatment is surgical, for 2 reasons: firstly to ensure that this is a benign lesion and secondly speech therapy is less effective

Vocal Cord Palsy

If one side of the larynx is not functioning then this is called a vocal cord palsy. There are many reasons for this happening. They include trauma from surgery eg thyroid or spinal surgery of the neck, lung surgery etc, lung cancer which has invaded the recurrent laryngeal nerve, viral illnesses, you can also be born with this. Finally in a cerain proportion of patients no cause is ever found. The diagnosis is made by a flexible nasendoscpy and all patients should have a minimum of a chest Xray, but ideally if no obvious cause is found should have a CT of their neck and upper chest. Patients complain of a weak, breathy voice that fatigues and may experince fodd and drink going the wrong way. This is because the weakened cord moves to the side allowing air to escape as the other cord cannot compensate. Treatment depends on the cause, but if there is potential for the nerve to recover then most procedures should be deferred for 6-12 months. If no recovery is expected then immediate surgery can be undertaken to place an implant into the larynx to push the cord towards the midline. Other procedures include injecting collagen or other materials directly into the cord to cause the same effect.
The picture below shows that the normal cord can move from the side toward the midline, however, the weaker cord (large arrow) is shorter, more bowed, and cannot come properly to the midline.

Below is a diagram of a cross section of a larynx with the plastic implant S shown pushing the cord towards the midline