UNDERSTANDING VOCAL PROBLEMS

Created for the7th c students

Taishan Medical University

Healthy Vocal Cords

Healthy vocal cords have smooth straight edges and are pearly white in color.

These pictures of normal, healthyvocal cords give another view of theirpearly-white color in contrast to thepinkish surrounding tissue.

BENIGN TUMOURS OF LARYNX NON NEOPLASTIC

Vocal nodules Vocal polyp Reinke’s oedema Contact ulcer Intubation granuloma Leukoplakia Amyloid tumours Laryngocele Ductal cysts Saccular cysts

NEOPLASTIC Squamous papilloma

Chondroma Haemangioma Granular cell tumours Glandular tumour Rhabdomyoma Lipoma fibroma

Vocal NodulesVocal nodules are non-cancerous growths that normally occur bilaterally. Nodes keep the cords from closing properly.

The most common symptom of nodes is hoarseness.

Vocal production will take effort and depending upon the size of the nodes, production may be painful.

Vocal fatigue on prolonged phonation , are other common symptoms.

Nodules usually occur because of vocal misuse or overuse. This causes vocal irritation and inflammation. With continued misuse, the tissue becomes fibrotic and hardened.

EARLY CASESNodes are treated with voice therapy that teaches techniques to reduce the vocal force on the cords as well as behaviors to avoid.

Educating people for proper use of voice

Certain medical conditions such as allergies and reflux may maintain the nodules.

LATE STAGE / LARGE NODESSurgery is required , excision with precision under operating microscope avoiding any trauma to the underlying vocal ligament.

PREVENTION Speech therapy and re-education in

voice production are essential to prevent their recurrence.

Polyps Polyps are

non-cancerous lesions.

They occur usually in males.

Polyps cause a hoarse, breathy voice that tires easily.

Feeling of “something in the throat”

Symptoms of Polyps

Causes of Polyps

Vocal abuse and misuse Often associated with a single traumatic event such as yelling at a sporting event.

TRETMENT

Surgical excision under operating microscope followed by speech therapy

REINKE’S OEDEMA Collection of oedema fluid in the subepithelial space

of Reinke. The most superficial layer of the lamina propria is

called Reinke's space and consists of a very loose material that allows the cover of the fold to vibrate over the more rigid deeper strucutres

 Fluid can occur in response to chronic inflammation. Fluid collection in the body is called edema, so this fluid build-up is called Reinke's edema.

Cause same – vocal abuse Alcohol & smoking

TREATMENT Vocal cord stripping, preserving

enough mucosa for epithelialisation. Only one cord operated 1 time . Patient re-education in production and

cessation of smoking are essential to prevent recurrence.

The photo to the left shows example of Reinke's edema. (The front of the vocal folds is at the top of the photo.)

This disorder is quite typical in heavy smokers, and can produce a low pitched voice.

It is not premaligant, though smokers certainly are at risk for developing laryngeal cancer (as well as heart disease, emphysema, lung cancer, and a variety of other problems.)

As the edema becomes more gelatinous, it may eventually turn into actual vocal fold polyps.

Reinke's edema can be treated surgically by making an incision in the lateral portion of the vocal folds and carefully removing the thick gelatinous fluid in Reinke's space.

If there is a lot of excess mucosa (the covering of the vocal fold), this excess mucosa can be trimmed.

The photo to the left shows a post-operative view of the folds of the above patient immediately after evacuation of the edema.

The goal in this surgery is to preserve the healthy lower layers of the vocal folds and to avoid excessive removal of vocal fold mucosa.

This view shows the same patient in the office about three weeks later.

This photo was taken through a flexible fiberoptic scope with a different light source, so the colors are slightly different.

The folds had already started to vibrate fairly well and the voice was significantly improved.

It usually takes 4-6 weeks for all the swelling from the surgery to resolve.

Vocal Fold Cysts

The image to the left shows a vocal fold cysts in a person who had significant hoarseness. This picture was taken with a stroboscopic light source through a flexible fiberoptic scope.

The vocal folds are therefore "frozen" in time at the point of closure.

Note that the folds cannot close completely due to the cyst.

This cyst was removed surgically and the voice returned to normal

This image shows a close up view of a larger cyst in a different individual. This photograph was taken at the time of surgery for removal of the cyst.

Notice that the left vocal fold is slightly thickened immediately opposite the cyst.

This thickening has developed in response to the cyst, and should resolve spontaneously after removal of the cyst.

The to the the left shows bilateral cysts on vocal folds that may have developed at the site of previous nodules.

The cyst on the right is more solid in appearance but did contain fluid.

The cyst on the left has a little dark red dot showing where there has been bleeding into the cyst.

Laryngistis sicca is caused by inadequate hydration. The protective mucus normally needed for the vocal cords becomes too thick and they cannot open or close properly.

Laryngitis Sicca

Acid Reflux Acid reflux affects singers

in that the stomach acid can flow past the esophagus into the throat.

Small amounts of reflux can cause considerable damage.

The left picture is damage from acid reflux. Notice how the vocal cords are mostly red instead of white.The right picture is the same vocal cords after successful treatment. Another result of acid reflux.

Grandulomas

Symptoms Hoarseness Bad/bitter taste in mouth

(especially in morning) Chronic (on-going) cough Asthma-like symptoms Frequent throat clearing

Referred ear pain Pain or sensation in throat Post-nasal drip Feeling of "lump" in throat Singing: Difficulty hitting

high notes Problems while swallowing

HemorrhageA vocal hemorrhage is actually a ruptured blood vessel on the true vocal cord, and bleeding into the tissues of the fold.It is a rare occurrence caused by aggressive use of the vocal cords (e.g. cheerleading)

Common Signs of Vocal Abuse Throat is tender to the touch after use. Voice is hoarse at the end of singing. Throat is very dry, with a noticeable

“tickle” that is persistent. Check dehydration.

Inability to produce your highest notes at pianissimo volume.

Persistent hoarseness or an inability to sing with a clear voice after 24-48 hours of vocal rest.

Chronic Laryngitis

Divided into:- Chroinc laryngitis without

hyperplasia( chronic hyperaemic laryngitis)

Chronic hypertrophic laryngitis ( chronic hyperplastic laryngitis)

CHRONIC LARYNGITIS

It is diffuse inflammatory condition symmetrically involving the whole larynx, i.e. true cords, ventricular bands, interarytenoid region and root of the epiglottis.

AETIOLOGY It may follow incompletely resolved acute simple laryngitis

or its recurrent attacks.

Presence of chronic infection in paranasal sinus, teeth and tonsils and the chest are important contributory causes.

Occupational factors, e.g. exposure to dust and fumes such as in miners, strokers, gold or iron smiths and workers in chemical industries.

Smoking and alcohol.

Persistent trauma of cough as in chronic lung diseases.

Clinical feature

Hoarseness

Constant hawking

Discomfort in the throat

Cough dry and irritating

On examination There is hyperaemia

of laryngeal structures.

Vocal cords appear dull red and rounded.

Flecks of viscid mucus are seen on the vocal cords and interarytenoid region.

Treatment for chronic laryngitis:

Same as acute laryngitis HOWEVER If symptoms last for longer than 2 weeks, seek medical

attention. Avoidance of irritating factors, e.g. smoking, alcohol,

or polluted enviromnment , dust and fumes Voice rest and speech therapy Steam inhalations expectorants

Chronic hypertrophic laryngitis

May be either a diffuse and symmetrical process or a localised one, the latter appearing like a tumour of the larynx.

Localised variety presents as dysphonia plica ventricularis, vocal nodules, vocal polyp, reinke’s oedema and contact ulcer.

Aetiology SAME AS BEFORE CLINICAL FEATURES

MOSTLY AFFECTS MALE (8:1) IN THE AGE GROUP OF 30-50 YEARS

HOARSENESS, CONSTANT DESIRE TO CLEAR THE THROAT DRY COUGH , TIREDNESS OF VOICE HAS BEEN USED FOR AN EXTENDED PERIOD OF TIME, ARE THE COMMON PRESENTING SYMPTOMS

On examination: Laryngeal mucosa , in general , is dusky red

and thickened. Vocal cords appear red and swollen. Their

edges lose sharp demarcation and appear rounded.

In later stages, cords become bulky and irregular giving nodular appearance.

Ventricular bands appear red and swollen and may be mistaken for prolapse or eversion of the ventricle.

Mobility of cords gets impaired due to oedema and infiltration , and later due to muscular atrophy or arthritis of the cricoarytenoid joint.

PBL A 3 year old child was referred to an ENT

specialist because of cough, difficulty of respiration and temperature 39.5 C of few hours duration.

The child was admitted to hospital for observation and medical treatment. 6 hours later, the physician decided an immediate tracheostomy.

After the surgery the child was relieved from the respiratory distress for 24 hours then he became dyspnic again.

The physician carried out a minor procedure that was necessary to relieve the child from the dyspnea.

Few days later the tracheostomy tube was removed and the child discharged from the hospital.

A 4 year old child was referred to an ENT specialist by a pediatrician because of repeated attacks of severe chest infection (three in number) during the last month that usually resolved by antibiotics, expectorants and mucolytics, but the last attack did not resolve.

On examination the lower right lobe of the lung showed no air entry and a lot of wheezes all over the chest by auscultation.

A chest x-ray revealed an opacified lower right lobe.

Temperature 38 C, pulse 120/min and respiration rate 35/min.

Ohh !! Guys it’s time for pneumonics

D/D OF ACUTE TONSILLITISMADI LoVe MAT

Quote: M-membranous tosillitis

A-agranulocytosisD-diphtheriaI-infectious mononucleosisL-ludwig's anginaV-vincent's anginaM-malignancyA-aphthous ulcerT-tonsillar cleft

D/D of membrane over the tonsilWe Mainly Discuss At Length About Membrane In Tonsil

Quote: We - Vincent's angina

Mainly - MalignancyDiscuss - DiptheriaAt - AgranulocytosisLength - LeukemiaAbout - Apthous ulcersMembrane - Membranous TonsillitisIn - Infectious mononucleosisTonsil - Traumatic ulcer

Little's area: Arteries  " LEGS " L - superior Labial artery E - anterior Ethmoidal artery G - Greater palatine artery S - Sphenopalatine artery

Voice box component"There are 3 Vs in your  Voice box" The structures as they appear in the

sagittal section are Vestibular fold Ventricle Vocal fold

Tonsils in ENT "PPL (people) have tonsils" Pharyngeal Palatine Lingual

Types of DNS (Deviated Nasal Septum)

 'SCAN your nose' S -shaped deformity C -shaped deformity Anterior dislocation Nasal spur