Clinic for Voice Swallowing and Airway Disorders
Welcome to Indiana University
Clinic for Voice, Swallowing, and Airway Disorders
Department of Otolaryngology- Head and Neck Surgery
The study of voice, swallowing and airway disorders is referred to a laryngology, a subspecialty of otolaryngology (the study of ear, nose, and throat disorders). Indiana University now has a clinic that specializes in laryngologic disorders such as hoarseness, swallowing problems, airway narrowing (subglottic or tracheal stenosis), and chronic cough. Dr. Stacey Halum, the director of the new clinic, works together with board-certified speech language pathologists to meet patients' laryngology needs. Dr. Halum is a board-certified otolaryngologist who completed a laryngology fellowship at Wake Forest University, and she is currently the only fellowship-trained laryngologist practicing in the state of Indiana.
The following material is a general educational tool for patients and their families. It is not recommended that patients self-diagnose or self-treat on the basis of this information, and we recommend any person with these disorders be evaluated by a laryngologist.
How does normal speech production occur?
Under normal conditions, air from the lungs is sent through the vocal folds (voice box) to generate the "power" for voice. The vocal folds come together as the rush of air passes between them, and this produces rapid vibration of the vocal folds resulting in the sound of the human voice. The vibration of the vocal folds is what causes the pitch or "frequency" of the human voice. Adult female voices are much higher pitched than males because female vocal folds generally vibrate faster (180-240 times per second) than those of males (80-130 times per second). After the air passes through the vocal folds to make voice, it continues up through the throat (pharynx) which adds additional quality to the sound of the voice, and then it comes out of the mouth. The mouth is the site where the voice is formed into words- this act of forming sounds and words is called articulation. Hoarseness, or dysphonia, is an abnormality of the voice. This is generally caused by problems with the vocal folds themselves, but occasionally lung or airway problems can also contribute to hoarseness, since strong airflow is needed to produce voice.
How are articulation disorders different than voice disorders?
Disorders that impair the normal pronunciation of words are generally considered articulation disorders, while disorders that cause a hoarse or strained voice are called voice disorders. Examples of two common articulation disorders are Velopharyngeal Insufficiency (VPI) and Stuttering.
Velopharyngeal Insufficiency (VPI)
While forming sounds or words is generally related to the mouth (lips, teeth, tongue), sounds are also highly affected by the airflow through the nose. The soft palate (back portion of the roof of the mouth) is generally responsible for allowing or blocking airflow escape through the nose during sound production. For example, air is allowed to travel up through the nose to create "mmm" and "nnn" sounds, but airflow to the nose needs to be blocked to create sounds like "pa" and "ba". In a condition called "velopharyngeal insufficiency" (VPI), the palate does not bock airflow escape out of the nose, making pronunciation of certain sounds difficult. With severe VPI, patients may even regurgitate liquids out of the nose upon attempted swallowing. There are a variety of treatments for VPI including prosthetics, surgery, and speech therapy.
Stuttering involves repetitive sounds that interrupt the normal flow of speech. It is a disorder of articulation, rather than actual voicing. Speech therapy is currently the best treatment available for stuttering, but certain centers have ongoing trials for medical interventions.
What are examples of voice disorders?
Voice disorders can have a wide number of etiologies. Some disorders affect the fluency of speech, which prevent people from having continuity of their words or sentences. Examples of disorders that affect fluency include spasmodic dysphonia (SD) and muscle tension dysphonia (MTD). SD and MTD can both present similarly, with a strained-sounding voice with episodic voice breaks. These breaks interrupt words, making speech sound irregular. Examples of voice disorders that make the voice sound hoarse include vocal fold paresis or paralysis, benign or malignant (cancerous) vocal fold growths, and laryngopharyngeal reflux (LPR).
Spasmodic Dysphonia and Tremor
Spasmodic dysphonia (SD) is a voice disorder that affects voice fluency. Patients generally have interrupted, strained sounding speech. Patients also complain that speaking requires extra effort, and they feel fatigued after prolonged voice use/speaking. SD is a neurologic disorder, and therefore does not tend to respond well to speech therapy alone. While SD is a neurologic disorder and not a psychiatric/psychological problem, it does tend to be aggrevated by stressors and stressful situations, such as talking on the phone or in front of groups. SD has several subtypes.
Adductor (Ad) SD
The most common SD subtype is Adductor (Ad) SD. These patients notice breaks in the voice primarily when saying vowels. On examination, their vocal folds are 'squeezing' together inappropriately in the middle of words, interrupting the normal flow of speech. This subtype of spasmodic dysphonia responds extremely well to botulinum toxin (Botox ) injection, with over 90% of patients attaining improved fluency. These injections are given every three to six months, depending on the patient response.
Abductor (Ab) SD
Abductor (Ab) SD is another subtype of SD that, like Ad SD, is characterized by voice breaks. Unlike Ad SD, however, Ab SD involves breaks with our shortly after consonants rather than vowels. On examination, the vocal folds pull apart suddenly in the middle of words, producing breathy sounding breaks. Ab SD is much more rare than Ad SD. While botulinum toxin injections are also the standard of care for Ab SD, it tends to have a much poorer response than Ad SD.
Many patients with SD also have a coexistent voice tremor. Tremor can be present with or without SD. Unlike SD, which produces irregular voice breaks, tremor tends to produce more regularly spaced breaks, that can occur with both consonants and vowels. On examination the vocal folds are continuously 'twitching' open and closed, and this tremulous movement causes interruptions in normal voicing. Unfortunately, tremor tends to be extremely difficult to treat, with a poor response to standard botulinum toxin injections, although IU Clinic for Voice, Swallowing, and Airway disorders, we are now doing variations in the standard botulinum toxin injections, and have had very encouraging results.
Muscle Tension Dysphonia (MTD)
Muscle tension dysphonia (MTD) is a voice disorder caused by excessive 'squeezing' or tension of the voice box with speaking. Often vocal fold weakness (partial or complete paralysis) will result in MTD, because straining or squeezing is necessary to bring the vocal folds for adequate closure and voice. These patients will often complain of fatigue and discomfort with prolonged voice use, and extra-effort required to speak. Most patients with MTD alone will respond very well to speech therapy. If patients have MTD because of underlying vocal fold weakness (see vocal fold paresis or paralysis), then they may need a procedure done to help them get adequate vocal fold closure. This usually involves an injection or placement of an implant to add bulk to the vocal fold for better laryngeal (voice box) closure.
Vocal Fold Paresis or Paralysis
If one of the vocal folds does not move normally, as in the case of partial (paresis) or complete vocal fold paralysis, the vocal folds will not be able to come together, and air will simply pass through them with little to no vibration. This results in a very breathy sounding voice, and patients often feel very short of breath with talking because the persistent gap between the vocal folds is like a "leaky valve," allowing rapid air escape. If the vocal fold is partially paralyzed, it is called a vocal fold paresis. If it is completely immobile, it is called paralysis. The causes of vocal fold paresis or paralysis can vary widely, with endotracheal intubation, surgery, tumors, and trauma being some of the most common known causes. In many cases the cause is unknown. The procedures to correct this involve insertion or injection of material that pushes the paralyzed vocal fold to the midline, so it can meet the normal vocal fold, and the vocal folds will again be able to vibrate and produce voice. If vocal fold injection is performed, it can be done in the clinic or in the operating room (see figure). If an implant is inserted, this procedure is called a medialization laryngoplasty, and it is done in the operating room, using local anesthesia and sedation.
Benign Vocal Fold Growths
Benign growths on the vocal folds most commonly result in a hoarse voice, which may range from rough to breathy. Patients often feel fatigued with prolonged voice use, and require extra-effort to speak. There are many different types of benign vocal fold growths, with some being self-limited, and primarily localized to the vocal folds. Examples of these include vocal fold granulomas, nodules, cysts, and polyps (see pictures below). Other growths can extend well beyond the voice box and produce airway obstruction and other problems. An example of this is recurrent respiratory papillomatosis (RRP) (see pictures below). When diagnosing vocal fold growths, the top priority needs to exclude malignancy or cancer. This is generally done with a biopsy, either in clinic or in the operating room. Benign vocal fold growths are generally treated with surgical excision. While this can be done in the operating room, new technology is now allowing us to treat many of these growths in clinic (see Pulsed Dye Laser). Patients tolerate this extremely well, and do not need to miss time of work or have the risks of general anesthesia, as would be needed with traditional surgery.
Malignant (Cancerous) Vocal Fold Growths
The most common malignant vocal fold growth is called squamous cell carcinoma. Presenting symptoms often include hoarseness and increased effort with speaking, with throat pain, ear pain, swallowing problems, and weight loss often being present as the cancer progresses. Patients often, but not always, have a history of heavy smoking and/or alcohol use. The diagnosis of cancer is made by obtaining a biopsy (tissue sample) of the growth. While this traditionally was done in the operating room, new technologies now permit us to do this in clinic with many patients. Treatment of squamous cell carcinoma of the vocal folds generally involves radiation or surgery when the cancer is limited to the true vocal folds alone. Surgery, radiation and/or chemotherapy in various combinations may be necessary when the cancer is more advanced.
ARE THERE OPTIONS TO TRADITIONAL SURGERY FOR VOICE DISORDERS?
At Indiana University, we are rapidly advancing treatment options for our patients with voice and swallowing disorders. For example, we have the latest technology including transnasal esophagoscopy (TNE) and the pulsed dye laser (PDL) that allow us biopsy and treat many vocal fold growths in the clinic, avoiding traditional surgery. Thus, our patients can drive themselves home the same day and avoid taking day(s) off work, as would be required with traditional surgery. They also avoid the risks of general anesthesia, with excellent outcomes and virtually no complications.
LASER SURGERY IN A CLINIC SETTING
At Indiana University, many benign vocal fold growths can now be treated with a special laser surgery in a clinic setting. This allows our patients to drive themselves home the same day and avoid taking day(s) off work, as would be required with traditional surgery. They also avoid the risks of general anesthesia, with excellent outcomes and virtually no complications. The laser used at Indiana University is called the pulsed dye laser (PDL). After the patients nose and throat are well numbed, the laser is passed through a special transnasal endoscope to just above the vocal fold growth. Multiple pulses of laser energy are applied to the growth and the procedure is then completed, usually taking less than 10 minutes of actual laser time. Patients generally have little to no pain, and can go back to work and resume normal activities immediately after the procedure. The PDL has also been used to successfully treat papillomas, granulomas, polyps, and dysplasia of the vocal folds. The PDL is an ideal laser for clinic use because it does not penetrate deeply (only approximately 2mm) and does not significantly damage normal epithelium, so it produces much less scarring than other lasers, such as the CO2 laser. It is also selectively absorbed by blood vessels, so there are no problems with bleeding. In fact, it can be used after office-based biopsies to control bleeding, if necessary. Finally, it is highly effective for treating many benign vocal fold growths, with small growths often requiring just one treatment.
TransNasal Esophagoscopy (TNE)
TNE is a new technique that allows us to examine the esophagus in the office. The TNE is a very thin endoscope that can be passed easily along the floor of the nose, and then advanced down the esophagus for a complete examination. Because so many patients have acid reflux disease and because the incidence of esophageal adenocarconima (linked to acid reflux) is rapidly rising, clinic based esophageal screening tools like TNE are especially important. The alternative to TNE is esophagoscopy done under deep sedation or general anesthesia. In both cases the sedation or anesthesia required to perform the procedure generally requires that the patient lose a day from work. With TNE, only topical anesthesia is required so that patient may return to work shortly after the procedure is completed. They also avoid the risks of general anesthesia. The TNE scope can also be used for other procedures such as obtaining biopsies (tissue samples) of growths involving the throat (pharynx), voice box (larynx), or esophagus.