Disorders of voice

Dr. Humra shamimJNMCH ,AMU,ALIGARH

• Human speech requires coordinated interaction of the mouth, pharynx, larynx, lungs, diaphragm, and abdominal and neck muscles.

• The three fundamental components in the process are phonation, resonance, and articulation:

1. Phonation is the generation of sound by vibration of the vocal folds,

2. Resonance is the induction of vibration in the rest of the vocal tract to modulate laryngeal output, and

3. Articulation is the shaping of the voice into words.

Laryngeal mucosa develops from the endoderm of the cephalic part of foregut. Laryngeal cartilages and muscles develop from the mesenchyme of the fourth

and fifth branchial arches.Development of other structures is as follows:

STRUCTURE DERIVED FROM

Epiglottis Hypobranchial Eminence

Upper part of thyroid cartilage, Lower part of thyroid cartilage, Cricoid cartilage, Corniculate cartilage,

Cuneiform cartilage,

Intrinsic muscles of larynx

4th Arch

Upper part of body of hyoid bone, Lesser cornua of hyoid bone,

Stylohyoid ligament6th arch

Lower part of body of hyoid bone and greater cornua 2nd arch

EMBRYOLOGY

The laryngo-tracheal groove appears as a vertical slit on the floor of the primitive foregut. The laryngo-tracheal diverticulum develops from this groove and rapidly gets separated from the foregut by the formation of the tracheoesophageal septum.

The ventral portion develops into

the larynx and the lower respiratory tracts.

Development of the tracheobronchialdiverticulum and oesophagus. (a) Laryngotracheal groove appears in the ventral aspect of the foregut. (b) The edges ofthe groove close in to form the oesophagotracheal septum. 1,foregut; 2, laryngotracheal groove; 3, oesophagotrachealseptum; 4, trachea; 5, lung bud; 6, stomach

• The human larynx is composed of three single and three paired cartilages held together with ligaments,membranes and intrinsic muscles of the larynx.

• This unique arrangement allows movements and variations of shape and volume of the supraglottic vocal tract

• This is essential for regulation of the acoustic characteristics of human voice

• The thyroid, cricoid and paired arytenoid cartilages are the most important structures of the larynx in relation to the vocal function

• Thyroid cartilage is formed from two rectangular laminae fused at the midline. The angle between these two laminae is 90degree in males and 120degree in females, resulting in variation of the anteroposterior length of the laryngeal cavity.

• Vocal folds are, therefore, longer in males (17.5 mm–25 mm). Female vocal fold length is approximately 12.5 mm–17.5 mm.

Anatomy • The larynx consists of

four basic components: A cartilaginous

skeleton Membranes and

ligaments Intrinsic and

extrinsic muscles Mucosal lining

• The cartilaginous skeleton is comprised of : Single Cartilages:

Thyroid Cricoid Epiglottis

Paired Cartilages: Arytenoid Corniculate Cuneiform

• Laryynx two laminae, which meet in the midline and form a prominent angle, called laryngeal prominence (Adam’s apple) and the superior thyroid notch at the rostral margin.

• The posterior border of each lamina forms superior & inferior cornu (horns)

• Outer surface of each lamina shows an oblique line which gives attachment to thyrohyoid, sternothyroid & inferior constrictor of the pharynx

• The superior border gives attachment to the thyrohyoid membrane

Cricoid Cartilage• Lies below the thyroid cartilage

Forms a complete ring• Has a narrow anterior arch & a

broad posterior lamina• Has an articular facet on its:

• Lateral surface for articulation with inferior cornu of the thyroid cartilage (hinge like synovial joints that create a “bucket handle” structure )

• Upper border for articulation with base of arytenoid cartilage (shallow ball-and-socket joints )

Arytenoid Cartilages• Small, pyramidal in shape• Situated at the back of the larynxHas: • A base articulating with the upper border

of the cricoid cartilage• An apex supporting the corniculate

cartilage• A vocal process projecting forward, gives

attachment to the vocal ligament• A muscular process projecting laterally,

gives attachment to muscles

Corniculate Cartilages • Small nodules• Articulate with the apices

of arytenoid cartilagesCuneiform Cartilages• Small rod shaped, placed in

each aryepiglottic fold, producing a small elevation

• Do not articulate with any other cartilage

• CO

CO

Epiglottis• Leaf shaped, situated behind the root

of the tongue• Connected:

In front to the body of hyoid bone by the hyoepiglottic ligament

By its stalk to the back of thyroid cartilage by the thyroepiglottic ligament

• Upper edge is free.• Laterally gives attachment to

aryepiglottic fold• Anteriorly mucosa is reflected onto the

tongue forming three glossoepiglottic folds & valleculae

INTRINSIC MUSCLES OF THE LARYNXAbductor• The posterior crico-arytenoid (PCA)

muscle,pulls the muscular process of the arytenoid posteriorly and caudally .The structure of the cricoarytenoid joint prevents the entire arytenoid from being pulled along this vector. Instead, the arytenoid rotates, which displaces the vocal process upward and laterally and thereby abducts the vocal fold

• Segmental compartmentalization within muscles increases the possibilities for fine control. The human PCA muscle is divided into two compartments supplied by separate nerve branches; they differ in fiber type and insert on opposite sides of the muscular process .

• The human thyroarytenoid muscle is also compartmentalized, and it has long been regarded to have a separate medial compartment, the vocalis.

Adductors• The adductor muscles include

the lateral cricoarytenoi(LCA), inter-arytenoid (IA) and thyroarytenoid (TA).

• Vocal folds need to be in the adducted position, allowing intimate contact of the contralateral mucosal surfaces to initiate the rise in subglottic pressure in part of the vibratory cycle of phonation.

• In contrast to other intrinsic laryngeal muscles, the cricothyroid muscle does not insert on the arytenoid cartilage and therefore has no direct action on arytenoid motion.

• Instead, the cricothyroid muscle connects the anterior edges of the thyroid and cricoid cartilages. Contraction of this muscle pulls the two cartilages closer together, which increases the distance between the anterior commissure and the cricoid.

• The result is a stretching of the vocal fold and an increase in its length and tension .Vocal folds insert on the anterior commissure, contraction of either cricothyroid muscle affects both ipsilateral and contralateral vocal folds.

• Contraction of both right and left cricothyroid muscles results in maximal anterior traction

EXTRINSIC MUSCLES OF THE LARYNX

The sternohyoid, thyrohyoid, and omohyoid muscles are innervated by the ansa cervicalis and exert caudal traction on the larynx.

This action, as well as downward traction on the trachea during inspiration, causes abduction of the vocal folds.

Muscles that exert a cephalad force include the geniohyoid, anterior belly of the digastric, mylohyoid, and stylohyoid muscles. In patients with hyperfunctional dysphonia, excess activity can usually be palpated in the extrinsic laryngeal muscles.

Vocal fold• The vocal fold is a trilaminar musculomembranous structure

that extends from the vocal process of the arytenoid cartilage to the anterior commissure, where it meets its counterpart and is anchored into the lamina of the thyroid cartilage by the ligament of Broyle.

• Vocal folds are made up of five distinct layers; the rigidity of the tissue increases with its depth.

• The anterior two-thirds of the vocal fold contributes mainly to phonatory function, while the posterior one-third contributes to respiratory function.

SURFACE MUCOSA• The mucosal lining is approximately 0.05 to 0.1 mm in thickness and is

composed of nonkeratinizing squamous epithelium. • This layer of tissue can tolerate a minimal degree of stretching.A transition

layer between the surface mucosa and the lamina propria is described as the basement membrane zone.

• It has two subdivisions:lamina lucida and lamina densa. These layers are held together by collagen IV and fibronectin.

• Anchoring fibres, composed of collagen VII, bind the lamina densa to the superficial layer of lamina propria (SLLP). There is a significantly high concentration of these fibres in the middle third of the vocal folds, thus providing increased integrity and tensile strength to this layer.

LAMINA PROPRIA

• The lamina propria is composed of three histologically and somewhat functionally distinct layers of tissues. It is made up of extracellular matrix (ECM). Collagen, elastin, fibronectin, fibromodulin,decorin and hyaluronic acid variably constitute the body of the ECM.

Superficial layer of lamina propria• The SLLP is a very thin (0.5 mm)

elastin-rich layer with sparse collagen fibres embedded in mucopolysaccharideand mucoprotein matrix. The SLLP also contains macrophages, decorin, fibronectin and myofibrils with high healing potential. This layer is also described as Reinke’s space. This is a highly deformable, isotropic and resilient layer with innate structural integrity to support the generation of mucosal waves.

Intermediate layer of lamina propria

The intermediate layer of lamina propria (ILLP) is characterized by the highest concentration of strongly hydrophilic glycose amino glycan (GAG) molecules.

There is also an abundance of elastin fibres along with the presence of fibronectin and fibromodulin. A predominance of elastin fibre at the anterior and posterior parts of the vocal ligament may have a function in dissipation of any tension.

Deep layer of lamina propria

• This layer is predominantly made of longitudinally arranged collagen fibres. There is also fibroblast, elastin, hyaluronic acid and fibronectin in the ECM.

MUSCULAR LAYER

• Fibres of the vocalis muscle form the body of the vocal fold and add bulk and rigidity to it. The fibres nearest to the vocal ligament are densely innervated of slow-twitch type while the fibres at the muscularis part are of fast-twitch type in function

• The length, mass, tension and volume of the vocal folds will determine the fundamental physical characteristics of the voice. The resonance of the voice is determined by the resonating chambers of the SGVT and their natural resonance frequency.

• Loudness of the voice increases with any increase in the amplitude of vibration,while the pitch of the voice increases with an increase in the frequency of vocal fold vibrations.

Physiology of larynx• Swallowing (deglutition) During swallowing, the primary function of the larynx is to prevent

food and liquid entering the airway. This is achieved by means of the sphincteric action of the aryepiglottic folds and the true and false vocal folds which occurs simultaneously with elevation of the larynx.

• Coughing Coughing is the process by which material is expelled from the airway.

It is preceded by rapid inspiration, followed by forceful closure of both the vocal and vestibular folds. Air pressure is then built up below the adducted folds as the diaphragm ascends spasmodically until the folds separate explosively and mucus or foreign material is expelled.

• Effort closure During any form of exertion involving use of the arms, the vocal folds are

firmly adducted preventing expulsion of air and collapse of the chest walls, thus providing a fixed origin for the arm and shoulder muscles. This fact is clinically important in that those who have undergone laryngectomy or who have paralysis of one or both vocal folds, for example, may have difficulty with weightbearing activities because of their inability to close the glottis effectively. Trauma to the vocal fold mucosa can occur or be aggravated by forceful, prolonged vocal fold adduction during some types of physical training, such as working with weights.

Effort closure of the larynx also occurs during childbirth and defaecation as the abdominal contents are compressed by the abdominal muscles in order to achieve expulsion

The biomechanics of phonation• INITIATION OF VOICE Immediately before phonation, the vocal folds rapidly abduct to

allow the intake of air. This is termed this the ‘prephonatory inspiratory phase’. Subsequently,the vocal folds are adducted by the contraction of the lateral cricoarytenoid muscles. The vocal note is generated by pulmonic air (air from the lungs) as it is exhaled between the adducted vocal folds.

The vocal folds working together, therefore, constitute a vibrator which is activated by the excitor, the exhaled air.

The production of the vocal note at this point is the result of the repeated vibratory movement of the vocal folds, known as vocal fold oscillation.

• The vocal folds, in common with all vibrators, have a degree of inertia which has to be overcome in order for phonation to occur. The amount of air pressure required to begin voicing is known as the ‘phonation threshold pressure’.

THE VIBRATORY CYCLE

• Each vibratory cycle of the vocal folds consists of three phases:

• Adduction• Aerodynamic separation • Recoil

• Vocal fold gets blown upwards by increasing subglottic pressure

• Undulating wave moves on the medial margin from the lower part to upper part.

• After the width of the glottis reaches the maximum, subglottic air pressure reduces and elastic recoil of vocal folds draw them towards midline. Closure occurs from below upwards

• The lower lip of vocal folds close first followed by the upper

• Glottis closes completely when the upper lip of both vocal folds come together.

• This phase lasts till the subglottic pressure overcomes the glottic closure

• The “body-cover” concept of phonation is that vibration of the mucosa does not correspond directly to that of the rest of the vocal fold. Instead, the “body” of the vocal fold is relatively static, whereas the wave is propagated in the mucosal “cover.”

• This mucosal wave begins on the inferomedial aspect of the vocal fold and moves rostrally

• Normal phonation requires that five conditions be satisfied;

1.Adequate breath support 2. Approximation of vocal folds 3. Favorable vibratory properties 4. Favorable vocal fold shape 5. Control of length and tension

• The frequency of vibrations varies among adult males (100–120 Hz), adult females (180–220 Hz) and children (250–300 Hz).

• At puberty, in boys, the bulk of the TA muscle increases significantly under the action of testosterone.

• Increase in the bulk of the vocal fold brings about the lowering of the fundamental frequency, adding more bass to the voice.

• In girls the vocal pitch drops as well, thus adding more maturity to the voice of a women.

DISORDERS OF VOICE

• A disordered voice can be defined as one that has one or more of the following characteristics:

• it is not audible, clear or stable in a wide range of acoustic settings;

• it is not appropriate for the gender and age of the speaker;

• it is not capable of fulfilling its linguistic and paralinguistic functions;

• it fatigues easily;• it is associated with discomfort and pain on phonation.

• Voice disorders are often multifactorial in aetiology and to complicate matters patients may develop compensatory vocal behaviours in order to be able to communicate effectively. This may mask the true underlying or primary disorder, for example muscle tension imbalance secondaryto extraoesophageal (laryngopharyngeal) reflux

• More often than not patients will have more than one condition contributing to their voice disorder. For example, a patient with vocal fold nodules may well have a degree of muscle tension imbalance and extraoesophagealreflux.

Pathological Processes Causing Voice Problems

• There are four main pathological processes that can contribute to the voice becoming disordered

• It is essential that the presence or absence of these four processes is checked for systematically, particularly as voice disorders tend to be multifactorial .

• This also reduces the chances of overlooking pathologies

• Each pathological process can affect any part of the three essential elements of voice production, that is, breath control, vocal fold vibration, and resonance. This is determined by careful history and examination, occasional specialist assessments, and probe therapy or empirical treatment.

• By looking for evidence for each of the four etiologic factors individually, target the treatment more precisely.

PATIENT ASSESSMENT

The patient should be assessed in a voice clinic where a voice therapist and a laryngologist are present.

The laryngologist’s role in the initial assessment of the patient is to formulate a diagnosis or differential diagnosis, exclude serious underlying causes, determine the impact of the condition on the quality of life and provide information about treatment options and prognosis.

History

• Nature & chronicity• Exacerbating / releiving factors• Life style / dietary / hydration issues• Medical conditions / trt effects• Pts voice use / voice requirements• Impact on quality of life• Pts expectations

complaints• Voice quality changes - (hoarseness, roughness and breathiness)• Inappropriate pitch - age and sex• Poor voice control (break in pitch)• Inability to raise voice to be heard in noisy environment• Difficulty in singing• Voice tiring• Throat related symptoms• Reduced ability to communicate• Difficulties in using voice at different times of the day• Emotional effects due to voice changes

Examination

• Oral cavity• Oropharynx• Nasal cavity• Lower cranial nerves• Cervical adenopathy• Signs of increased muscle tension• Laryngeal position• Breathing pattern

Direct laryngoscopy

• Small view• Brief duration of

visibility• Mucosal wave cannot

be appreciated (100 cycles / sec. Retina can perceive only 5 cycles / sec)

Stroboscopy

A stroboscopic light source brightly illuminates the vocal folds across multiple vibratory cycles, and a series of images are captured that highlight the vocal folds at successive phases of the cycle.

When the images are presented to the viewer at the proper rate, the vocal folds appear to be moving and create smooth cycles of the vocal folds separating and returning to midline.

• Perceptual judgements of the stroboscopic images can include:

1. Symmetry, or the degree to which the two vocal folds provide mirror images of each other

2. Periodicity, or the regularity of apparent successive cycles of vocal fold vibration

3. Amplitude, or the extent of horizontal excursion of the vocal folds

4. Presence of stiffness or adynamic (nonvibratory)segments on the vocal fold

5. Pattern of closure.

• It is the extent of vocal fold movement in the horizontal plane

• Usually it is one half of the width of the visible part of the vocal fold

• Amplitude decreases when the pitch increases• Amplitude increases with increasing loudness

of phonation

Amplitude of vibration

Decreased vocal fold vibration amplitude

• Vocal fold stiffness• Reduced subglottic pressure• Sulcus vocalis increases stiffness of the vocal

folds• Tight glottic closure - Hyperfunctional

dysphonia

Increased amplitude of vocal fold vibration

• Reinke's odemea - There is a consious increase of subglottic pressure in these patients to move the increasingly bulky cord

• Decreased laryngeal muscular tone - vocal fold paralysis (appears like flag fluttering in the wind)

Mucosal wave

• This is a normal wavy motion of vocal fold mucosa travelling both in vertical and horizontal planes

• Normally it travels across in the vertical plane of the vocal folds and then rolls laterally across atleast 50% of the width of the visible part of vocal fold

• It is affected by the mucosa and the underlying muscle layers

• Normally it decreases with rising pitch of phonation• It increases with increasing loudness of phonation

Decreased mucosal wave - causes

• Increased stiffness due to mucosal changes - Polyp, sulcus vocalis and vocal fold dysplasia

• Increased muscle tension leading to tight glottic closure (Hyperfunctional dysphonia; it leaves a long closed phase)

• Decreased muscle tone causes weak glottic closure pattern (Hypofunctional dysphonia with long open and short closed phase)

Mucosal wave absence

• Stroboscopic fixation (synonym)• Malignant neoplasm• Vocal fold scarring• Recurrent laryngeal nerve paralysis

Increased mucosal wave

• Reinke's oedem This is due to elevated subglottic pressure

VIDEOKYMOGRAPHY

• Videokymography analyzes the high-speed images of oscillation at one specific horizontal position on the vocal fold. It produces a spatiotemporal image of the vibration of the medial edge of the vocal fold in that area and plots this along the vertical axis against time.

• Asymmetry of vibration or pathologic changes are particularly well seen with this technique.The endoscope must be perpendicular to the fold, and for true comparison exactly the same segment must be used, which does provide some technical challenges

NARROW BAND IMAGING

• Narrow band imaging (NBI) is a technique for imaging the mucosal surfaces with selected portions of the light spectrum – usually blue (400 nm) or green (540 nm). Haemoglobin will preferentially absorb these, so that early cancers with increased vasculature give a dark signal when viewed with NBI techniques. Early studies suggest that it may also have a role in early detection of laryngeal cancer and in guidance regarding the limits and location of biopsies

LARYNGOGRAPHY

• Laryngography is a quantitative assessment of laryngeal function. The electrolaryngograph consists of two electrodes placed on either side of the thyroid cartilage at the level of the vocal cords.

• A high-frequency current (3 MHz) is applied between the electrodes. The change in conductance correlates to the change in contact area between thevocal folds during vibration.

• This gives an assessment of the laryngeal component of voice and is not affected by any change in the vocal tract (resonance) that is present when using a microphone to analyze the voice at the mouth.

ELECTROMYOGRAPHY

• Electromyography (EMG) measures electrical activity of muscle. This gives a visual signal of electrical activity and is usually coupled to a speaker to produce an audible output. There are three different types of electrical potential: spontaneous,insertional and volitional

• Differentiating laryngeal paralysis from mechanical fixation• Diagnosing neurological diseases such as myasthenia gravis

and amyotrophic lateral sclerosis, and distinguishing between upper and lower motor neuron conditions

• Estimating the degree and prognosis (recovery) of paralysis/paresis

Specific voice disorders

The most common voice disorders are:• Muscle tension dysphonia;• Laryngitis/muscle tension dysphonia secondary to poor

vocal hygiene, dietary and lifestyle issues;• Extraoesophageal reflux• Vocal fold nodules• Vocal fold polyps• Vocal fold cyst• Vocal fold palsy and paresis• Arytenoid granulomas.

Less frequently seen conditions include:

• Sulci and mucosal bridges;• Spasmodic dysphonia;• Papillomatosis;• Microvascular lesions;• laryngeal trauma, including post-surgical causes;• Other neuromuscular causes hyperkeratosis,

dysplasia and carcinoma;• Endocrine causes;• amyloid;

Functional voice disorders• Muscle tension dysphonia (MTD) is the most common type

of functional voice disorder. It is described in patients with significant vocal demand living in stressful situations.

• Increased and sustained tension of the laryngeal muscles leads to abnormal laryngeal movement during phonation with consequent dysphonia.

• The primary form is seen predominantly in females (up to 40 %)

• Primary MTD is diagnosed in absence of any organic pathology of the vocal fold, or psychiatric or neurological pathology

• Secondary MTD has an established association with underlying organic pathology.

• It still remains undecided whether MTD is the cause or the effect in the secondary variety

MTD classification

• MTD Type 1: Hypertonic state of the posterior crico-arytenoid muscle causing posterior open chink and laryngeal isometric contraction

• MTD Type 2: Supraglottic contraction with adducted ventricular folds

• MTD Type 3: Anterior-posterior contraction with approximation of the epiglottis with the arytenoids; posterior migration or placement of the tongue base

• MTD Type 4: Extreme anterior-posterior contraction;supraglottic squeeze. Difficult to view the entire larynx with the flexible endoscope positioned in the mid-oropharyngeal level.

• The underlying factors predisposing and/or perpetuating MTD can be psychological conditions,misuse/abuse of the voice, organic pathology (local/systemic) or changes (aging) where vocal compensationis needed.

• Respiratory infections associated with prolonged frequent coughing, deafness,chronic snoring and laryngopharyngeal reflux(LPR) may also predispose an individual to MTD.

Management of MTD• Voice therapy :This is the mainstay of treatment for muscle

tension dysphonia (MTD) 1. vocal exercises with the aim of targetting and strengthening

specific muscle groups and improving glottal closure and efficiency;

2. increasing awareness of and reducing excessive tension in the muscles around the larynx, neck and shoulders;

3. advice on posture and improving breathing during speech;4. laryngeal massage;5. general relaxation exercises and stress management;6. psychological counselling

• Hyperfunctional disorders include dystonia, myoclonus, essential tremor, stuttering, and muscle tension dysphonia

• Hypofunctional disorders include focal disorders, such as vocal fold paresis and paralysis, Parkinson disease, multiple sclerosis, neuromuscular junction disorders, poliomyelitis, myopathies

SPASMODIC DYSPHONIA

• Spasmodic dysphonia (SD) is a neuropathology of focal dystonia affecting muscle groups of the larynx supplied by the RLN.

• The central pathology is thought to be at the basal ganglia of the midbrain and its connections. The incidence is 1 in 50 000–100 000. Adductor spasmodic dysphonia (ADSD)is the most common variety and is characterized by strained and strangulated voice. Symptoms of ADSD are more intensified during voiced reading (reading the Rainbow Passage).

• Abductors spasmodic dysphonia (ABSD) constitutes approximately 15 per cent of laryngeal dystonia. Combined varieties of SDs are very rare. SD may present with generalized dystonia. Public speaking, speaking to a stranger and telephone conversations are knownto trigger symptoms of SD.

VOICE THERAPY FOR DYSPHONIA

• The voice therapy technique used varies based on patient strengths and needs and clinician strengths and training.

• No gold standard technique or “recipe” for voice therapy works for all patients and clinicians, even within a diagnosis, and patients respond to different types and levels of feedback and instruction.

Vocal hygiene, lifestyle and dietary advice

The areas covered may include:1. The links between lifestyle, phonatory and nonphonatory vocal activities and

stress on voice disorders;2. The potentially traumatic effects to the vocal folds of‘vocally abusive behaviours’,

such as talking or singing too loudly, talking too fast, shouting, throat clearing and harsh coughing;

3. Communicating without raising or straining the voice, for example using a whistle in the school playground or using amplification devices where practical

4. The importance of adequate hydration for vocal fold function, i.e. by drinking water, use of steam inhalations and avoiding excessive amounts of drinks containing caffeine, i.e. coffee, tea and colas;

5. Smoking cessation, reducing alcohol and social drug consumption (particularly spirits, cannabis andcocaine)

6. Avoiding exposure to fumes, dust and dry air;7. Avoiding eating late at night, large or fatty meals.

INFLAMMATORY DISORDERS

LARYNGITIS• This is a common short-lasting acute inflammation of the

laryngeal mucosa of multifactorial aetiology. • Upper respiratory tract infections, viral infections, physical

and chemical injury (coughing, voice misuse,smoking, alcohol abuse) and sometimes bacterial infection can cause laryngitis.

• Most patients will recover spontaneously. Voice rest, rehydration and inhalation of steam (without any additive) are effective in resolution of acute laryngitis, when toxic causes are avoided.

• When symptoms continue beyond 3 weeks, it is then considered to be chronic laryngitis. Laryngopharyngeal reflux, smoking, heavy alcohol ingestion, severe snoring and inhalers for asthma (if not administered correctly with precautions) may frequently predispose individuals to recurrent and chronic laryngitis

• Dietary and lifestyle strategies are most effective in the management of this category of laryngitis, along with voice therapy.

• Some rare systemic diseases (Wegener’s granuloma, sarcoidosis, rheumatoid arthritis) may be associated with chronic inflammation of the laryngeal mucosa and present with hoarse voice and/or variable intensity of respiratory distress

SPECIFIC INFLAMMATORY CONDITIONS

Arytenoid granuloma Arytenoid granulomas are benign

inflammatory lesions that arise from the medial surface of the arytenoid Cartilages and in particular the vocal processes. Other terms for them include:

• contact ulcer or granuloma;• vocal process granuloma;• intubation granuloma;• contact pachydermia;• peptic granuloma.

These consist of a proliferation of granulation tissue with epithelial hyperplasia.

They result from injury to the thin mucoperichondrium over the vocal processes from mechanical trauma, either following intubation or repeated high velocity impact of the vocal processes against each other from throat clearing, coughing or talking in a habitually low pitched, creaky, hyperfunctional manner.

Men tend to develop granulomas secondary to hyperfunction, while women develop them more commonly as a result of intubation.

Extraoesophageal reflux is an important aetiological factor either contributing to the symptoms leading to the mechanical trauma or preventing healing of the damaged mucosa.

• Presentation with a change in the voice and/or vocal fatigue, a constant tickling sensation, discomfort or pain localized to the posterosuperior aspect of the larynx which is worse on phonation, coughing and throat clearing , radiation to the ear. In addition, there may be symptoms associated with extraoesophageal reflux, including choking episodes and, in severe cases, stridor.

• These symptoms may come on insidiously, after intubation, an infection or a period of stress.

• They may be unilateral or bilateral and range from a nodular, diffuse thickening over the vocal process to large pedunculated, exophytic masses obscuring the posterior glottis

Treatment include reducing the effects of laryngeal irritants, i.e. stopping smoking,improving vocal hygiene, treating any respiratory tract infections, allergies

and extraoesophageal reflux. Voice therapy ,raising awareness of and reducing hyperfunctional and vocally abusive behaviour

and psychological counselling where necessary. Surgery when used in isolation, does not usually cure arytenoid granulomas as there is a high rate

of recurrence. It is useful in• confirming the diagnosis histologically, • excluding a carcinoma • in debulking large lesions. There is no good evidence in support of use of antibiotics steroids in general. • Botulinum toxin injections into the thyroarytenoid muscle is useful in resistant cases The vocal fold paresis created by the action of the Botulinum toxin allows for forced voice rest

with adequate time for healing over the vocal process.

Recurrent respiratory papillomatosis

• Human papilloma virus (HPV) types 6 and 11 are the frequently identified pathogens.

• Endoscopic removal of papillomas with a microdebrider is the preferred surgical option.

• Recalcitrant cases need concomitant local treatment with Mitomycin or cidofovir or α-interferon.

• Hemoangiolytic lasers such as 585-nm pulse dye laser and potassium titanyl phosphate (KTP) laser are especially useful in the management of this vascular lesion.

• recurrence is rampant due to the presence of the virus in the neighboring normal tissue

Structural or neoplastic lesions

Vocal fold polyps• A true vocal polyp is a benign

swelling of greater than 3mm that arises from the free edge of the vocal fold .It is usually solitary, but can occasionally affect both vocal cords.

• Most common structural abnormality that cause hoarseness and they affect men more than women.They are most frequently seen in smokers

• Polyps can shrink spontaneously or even be coughed up.• Voice therapy may provide the patient with coping

strategies, preventative advice and may help ease symptoms, but is unlikely to result in resolution of the polyp. Any concomitant inflammatory conditions should be treated.

• Most polyps need removal under a general anaesthetic.The aim is to restore the smooth edge of the vocal cord allowing them to close fully and vibrate normally.

Vocal fold nodules• Vocal fold nodules are manifestations of

repetitive trauma due to misuse of the voice with overactive intrinsic muscle action. These nodules are a frequent cause of hoarseness in children who are naturally excitable and vocal.

• When seen in singers,the condition is called ‘singer’s nodules’.

• Vocal nodules are bilateral, small swellings (less than 3mm in diameter) that develop on the free edge of the vocal fold at approximately the midmembranous portion.In singers, they may be smaller, more pointed and white in colour reflecting a more superficial response to trauma. They are of variable size and are characterized histologically by thickening of the epithelium with a variable degree of underlying inflammation

• Mainstay of treatment for persistent vocal nodules is voice therapy

• Significant number of nodules recur if surgery is performed without voice therapy either pre- or postoperatively.

• The centre of the nodule is held with grasping forceps and pulled medially towards the opposite cord.Microscissors are then used to cut the mucosa close to its base, thus preserving normal mucosa, keeping a straight vibratory edge and preventing secondary notching. Theopposite nodule can then be removed in a similar fashion, taking care not to damage the mucosa of the anterior commissure.

• Postoperative voice rest for 48 hours is recommended and correct technique of voice productionis essential to prevent recurrence.

MUCOSAL INFLAMMATORY PATHOLOGY (EXUDATIVE

PATHOLOGY) Cysts• Cysts are usually associated with

laryngitis, vocal trauma or laryngopharyngeal reflux.

• The two distinct varieties are epidermoid cysts, which are pearly in appearance and found buried in submucosa, and greyish-yellow .Ductal mucus retention cysts, which are often found under the free edge of the focal fold in its middle third.

• Histologically, epidermoid cysts show keratinized stratified squamous epithelium, while retention cysts show columnar epithelium

• A mucus retention cyst is thought to arise from a blocked minor salivary gland, possibly secondary to phonotrauma or inflammation.

• It is lined by cuboidal or low columnar epithelium and can be associated with oedema and fibrosis in Reinke’s space.It is usually unilateral and is found on the free edge of the vocal fold or can arise in the ventricular fold (false cord).

• Patients with vocal fold cysts should be given a trial of voice therapy, particularly when symptoms are relatively mild. Many will require surgery but this must be done precisely preserving the overlying mucosa as much as possible. It is important to avoid leaving part of the wall behind which will result in a recurrence or causing localized scarring and poor voice results

• Postoperative voice therapy helps patients to restore vocal function and improvement may continue for up to nine months.

• Complete sharp dissection of the cyst with microlaryngoscopy instruments or with the laser is the treatment of choice.

Polypoid degenerations (Reinke’s oedema)• Reinke’s oedema is a term used to describe

the vocal folds when they become chronically and irreversibly swollen

• Reinke’s oedema is often bilateral at presentation but can be a unilateral finding.

• Most commonly found in smokers, polyploidal degeneration of the vocal fold can also be found in presence of severe laryngopharyngeal reflux.

• Hypothyroidism may be found as a concomitant feature

• Increased bulk of the vocal cord causes masculinization of the voice, producing predominantly bass notes like the thicker cords in the guitar.

• Lateral cordotomy (mucosa-sparing approach) with the removal of viscous fluid from Reinke’s space is effective in restoring voice function. If the precipitating noxious agent (smoking in most cases) for oedema is not removed, recurrence is almost inevitable.

GRADING

Surgical treatment should be considered when:• Leukoplakia is present and a histological

diagnosis is required;• Gross Reinke’s oedema is present causing

choking episodes or airway compromise;• Pitch elevation of the voice is the main

requirement of treatment.

The principles of surgery for Reinke’s oedema include:• Reducing the bulk of the mucosa (mass per unitlength) of the vocal

fold• Obtaining a straight mucosal edge, i.e. avoidingleaving small deposits

of the myxoematous material behind;• Avoiding damage to and exposure of the underlying ligament,

thereby reducing the chances of scarring and web formation.• ‘Reduction glottoplasties’ can be performed with phonosurgical

instruments or new generation of microspot lasers. The myxoematous material from the superficial lamina propria layer is aspirated, removed with forceps or vaporized and the epithelial edges apposed following excision of redundant mucosa as necessary.

Sulcus vocalis• A congenital absence or idiopathic loss of lamina propria

results in a sulcus vocalis . Most sulci are congenital and run through the entire length of the membranous vocal fold, referred to as linear vergeture

• It has been classified into three types depending on the depth of the sulcus and its shape.

• Type I is superficial and is not associated with any voice abnormality.

• Types IIa and IIb cause moderate and severe dysphonia, respectively.

• Management is challenging. A small epithelial cordotomy with elevation of epithelium over the sulcus with fat implantation is preferred .This is followed by a long course of voice therapy with the patient counseled regarding postoperative voice improvement expected at 6 to 8 weeks

NEUROMUSCULAR CAUSESUNILATERAL VOCAL CORD PARALYSIS• Malignancy (20 to 40%)• Surgical trauma (22 to 44%) • Nonsurgical trauma (9 to 10%)• Neurological causes (2 to 3%)• Inflammatory and infectious causes (2 to 3%)

• BILATERAL VOCAL CORD PARALYSIS• Iatrogenic (57%), ( thyroidectomy, pneumonectomy, and posterior fossa surgery)• Trauma( postintubation or whiplash injury.) • Neurological 21%( encephalitis, syringobulbia, multiple sclerosis, and progressive bulbar

palsy) • Malignancies.• Infections (thyroiditis, syphilis, and viral diseases)• IDIOPATHIC

Management of VFP

IDIOPATHIC VOCAL FOLD PARALYSIS

• Twenty to forty per cent of patients with idiopathic vocal fold paralysis show spontaneous recovery.

It might take up to 12 months to show signs of

recovery; some patients get partial recovery with an acceptable quality of voice

MANAGEMENT OF BILATERAL VFP

The basic aims of management are as follows: • Achieve a safe and stable airway. • Preserve speech and voice quality. • Allow safe swallowing without aspiration

Tracheostomy is done in management of most patients with bilateral VFP Vocal Fold Lateralization • There are several techniques to widen the glottal opening. • Surgical intervention is performed about a year following the paralysis to permit

any spontaneous reinnervation to occur.1. Arytenoidectomy: This entails removing part or whole of the arytenoid cartilage

and may be done endoscopically with the laser or microsurgically or externally via a lateral neck approach (Woodman procedure).

2. Arytenoidopexy: involves displacement of vocal fold and arytenoid by means of suture passed around the vocal process of the arytenoid and secured laterally. This procedure has a relatively high failure rate.

3. Cordectomy: This consists of carbon dioxide laser (or cold steel) removal of a C-shaped wedge from posterior edge of one true vocal fold (posterior partial cordectomy) with or without additional removal of part of the false fold and arytenoidectomy.

JOINT PATHOLOGY

• Cricothyroid joint and crico-arytenoid joint involvement by trauma or systemic disease may present with the symptom of dysphonia. Intubation trauma can dislocate the crico-arytenoid joint causing immobility of the vocal fold and resultant marked hoarse voice.

• Closed reduction is the most effective treatment in this situation.

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