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What are Voice Disorders?
Up to 10% of the adult population in the UK are affected by voice disorders.
The “voice” sound originates from your voice box (or larynx) and is altered as it passes through the throat, mouth, lips and sometimes the nose. The larynx is the passage into the lungs and contains two vocal cords that part during breathing. When the vocal cords gently come together whilst breathing out, they vibrate making a noise. It is this vibration that generates the sound of your voice. Everyone’s voice is different but when there is a change in the quality of voice, the term hoarseness is often used, the medical term is dysphonia.
What are the causes of Voice Disorders?
Dysphonia usually occurs because of either a change in the shape of the surface of the vocal cords or in the way they move. The closure of the vocal cords is affected, altering the vibration and ultimately voice. The change in voice may be associated with other symptoms such as cough or swallowing difficulties.
Hoarseness that lasts for more than a few days often causes worry, affecting quality of life and many people’s ability to work. This is especially true for people who rely on their voice for their professions: singers, actors, broadcasters, telephonists and teachers for example.
Although there are numerous causes for dysphonia, most are self-limiting and harmless.
- Swelling from the effects of infection, allergy, smoking and other irritants including voice overuse/ misuse. Small blood vessels within the cords may burst as a result of these causes.
- Reflux of gastric acid and other stomach contents onto the larynx is an important irritant that should be controlled. Nasal discharge from patients suffering with nose and sinus conditions may “drip” onto the larynx and should also be treated if present.
- A range of other voice box problems such as vocal cord nodules (singers’ nodules), polyps, cysts, scarring and granulations may cause hoarseness.
- Non-cancerous but potentially life-threatening causes include conditions affecting the nerve supply to the voice muscles such as brain and nerve disorders including strokes or other paralysing conditions. Injury to the larynx may affect the nerve(s) that move the vocal folds, or damage the muscles or framework that allow their movement. These injuries and other conditions may additionally narrow the voice box and breathing tube (trachea).
- One of the most important conditions to exclude is a cancerous growth in the larynx or in the mouth, throat and upper gullet.
It is important that you seek an urgent consultation with a Laryngologist or Head and Neck surgeon if your hoarseness:
- Has lasted for more than 2-weeks; especially if you smoke or consume large quantities of alcohol
- Is associated with noisy breathing or you are finding it difficult to breath.
- There is prolonged pain in the throat, especially if it’s on one side of the neck with ear pain or if it is painful to swallow.
- Is associated with a persisting neck lump, bloodstained phlegm.upon coughing or unexplained weight loss,
- Is associated with difficulty with swallowing or if food/ fluid seems to go down the wrong way into the windpipe and lungs when swallowing (aspiration). Aspiration usually triggers a strong bout of coughing and spluttering just after eating or drinking.
How are Voice Disorders diagnosed at OneWelbeck?
We are a group of highly experienced, internationally recognised ENT surgeons who have busy practices dedicated to managing the full breadth of benign and malignant conditions of the throat, voice box (larynx), windpipe (trachea) and swallowing apparatus.
We have significant experience in managing patients with high vocal demands in their profession such as singers, actors and broadcasters and work very closely with experienced speech therapists, professional voice coaches and singing teachers.
It is critically important to have a detailed clinical assessment from an ENT surgeon experienced in laryngology as many voice conditions may be subtle and often overlooked or misdiagnosed.
As part of the history, you may be asked to fill out validated questionnaires related to voice and swallowing. This will help us assess the severity of your symptoms and provide us with a baseline against which to compare improvement from any recommended treatment or therapeutic intervention.
An important component of the assessment is adequate visualisation of the vocal cords during speaking and breathing. At OneWelbeck, we utilise state of the art flexible endoscopes (or cameras) which have a high-definition camera attached to their end (“chip on tip” cameras) providing an unparalleled 4K high-definition magnified view. This fine flexible camera is placed through the nose and guided directly over the larynx and swallowing apparatus.
An important component of endoscopy is video assisted stroboscopy. This enables a super slow-motion assessment of the way the vocal cord surfaces vibrate against each other. Without this, minute and subtle changes on the surface of the vocal cords will be missed; examples include small scars or deep otherwise hidden cysts.
Every hoarse patient will have a stroboscopic assessment of their vocal cords.
If swallowing is affected, then the flexible endoscope may be used to perform a detailed swallow assessment of the passage of food and fluid through the larynx and throat. This specialist examination is called flexible endoscopic evaluation of swallow (FEES). This will be video recorded to document the effectiveness of swallow. FEES can be used to provide you with feedback to help improve swallow function with the assistance of a speech swallow therapist.
If necessary, further information about the swallow may be obtained from a dynamic X-ray study which records the swallowing of radio-dense dye through the swallowing apparatus including the gullet (video swallow or modified barium swallow).
Other tests will be dictated by symptoms and may include a dedicated high-resolution CT scan of the larynx, neck and chest and an MRI scan.
What treatment is available?
Whilst the specific underlying condition will dictate how your voice condition will be managed, there are some important underlying principles of management common to all. Optimal treatment of a voice disorder follows a three-pronged approach.
Following the initial assessment, many conditions may be managed successfully by prescription and over the counter medicines that are designed to reduce infection, inflammation and exacerbating conditions such as gastroesophageal reflux and post nasal drip (from nasal and sinus conditions).
The surgical team offering laryngological treatment at OneWelbeck have over 60 years of experience between them. This critical expertise ensures the delicate structures that comprise the larynx are respected, in order to be able to cleanly and precisely remove the diseased section, with minimal injury to surrounding healthy tissue. Inappropriate surgical treatment risks worsening the voice post-operatively through the formation of potentially irreversible scarring.
The exact surgical procedure will be tailored to the particular condition, but common to most is a short general anaesthetic, suspension laryngoscopy and in most cases ventilation without the need for a tube. This gives the surgeon unimpeded, two-handed access to the voice box structures without the need for any external incisions.
Our group are skilled in the use of fine dissecting instruments and lasers to cleanly excise pathological lesions. We have equipped our theatre with a wide array of microsurgical instruments and the latest lasers including carbon dioxide and KTP laser technology to help facilitate clean dissection.
Other treatments we offer may include fine suture techniques, injection of steroid, biological filler, or botulinum toxin (botox). Some of the injectable treatments may able to be performed under local anaesthetic, providing immediate real time feedback of their efficacy.
Behavioural modification including dedicated speech and swallow therapy
This is a very important component in the restoration of a voice disorder and should be performed in conjunction with any medical or surgical treatment. Patients suffering from hoarseness often develop abnormal or compensatory vocalising behaviours and tension in the muscles that surround the larynx. This dysfunction may persist and indeed exacerbate the hoarseness even after the trigger has gone.
There are specific and tailored laryngeal physiotherapy protocols that will help “unload” these dysfunctional muscle patterns. The Speech therapists that we work with have enormous experience in managing all aspects of voice and swallow rehabilitation.
All patients will be instructed and guided on favourable vocal hygiene measures.
Get in touch
To speak with a specialist about Voice Disorders, contact our team today.
We are available from Monday to Friday: 8am – 8pm.