Speech–language pathologists (SLPs) who evaluate and treat populations with voice disorders work collaboratively with other medical professionals as part of a voice care team. In most situations, the primary members of the voice care team will be the voice therapist and otolaryngologist. Additional members may include but are not be limited to neurologists, gastroenterologists, singing voice teachers, psychologists, pulmonologists, allergy specialists, and endocrinologists. Members of the team may be physically located near each other (e.g., in an otolaryngology private practice or medical center), in the same community, or sometimes spread across different cities and states. Regardless of team member locations, it is key that they communicate effectively and efficiently with each other to maximize care and management of the patient.
Otolaryngologists who specialize in laryngeal disorders affecting voice, swallowing, and airway are known in the United States as “laryngologists.” There is no formal degree or credential which certifies one as a laryngologist, although many complete a postresidency laryngology fellowship where they learn the specialty under the mentorship of an experienced physician (who will also be a laryngologist). Training guidelines for laryngology fellowships have been developed by the American Laryngological Association (ALA). According to the ALA, there were at least 23 laryngology fellowship programs participating in the National Resident Matching Program as of 2017. Other laryngology fellowship programs are also offered which do not participate in this program. Otolaryngologists who complete a fellowship are often referred to as a “Fellowship trained Laryngologist.” According to www.voicedoctor.net, as of the year 2017, there were a total of 212 laryngologists in the United States, and 368 practicing worldwide.
When one practices as a voice therapist, it is important that the “golden rule of voice therapy” is always considered. It is as follows: before developing and implementing a voice treatment program, a patient must be evaluated by an otolaryngologist for the determination of an existing medical diagnosis. This does not mean that the voice therapist must wait to conduct a voice evaluation—in fact, that information can be of great value to the otolaryngologist’s subsequent examination. However, although knowledge and skill domains of the voice therapist and otolaryngologist overlap, and both may perform laryngeal endoscopy, it is only the otolaryngologist who will determine the final medical diagnosis regarding organic disorders affecting the larynx. The otolaryngologist possesses advanced knowledge of systems and structures and are the only medical/health professional qualified to diagnose specific organic vocal fold impairments. These pathologies must be ruled in or out before initiating behavioral voice treatment.
7.3 The Otolaryngology Office Examination
In treatment-seeking populations, the clinical otolaryngologic exam is either the first or last stage of assessment prior to the initiation of treatment. When voice therapy is warranted, the patient might come to the voice therapist via otolaryngology referral, or it may be the voice therapist who refers to the physician before initiating treatment if that patient has not yet been evaluated by an otolaryngologist. The otolaryngology office examination will consist of a series of steps which facilitate the process of differential diagnosis. Typically, these steps will follow the order outlined below.
7.3.1 Patient Questionnaires
As with the voice evaluation performed by the voice therapist, the otolaryngologist may ask the patient to complete questionnaires or ratings of self-perception prior to the office examination. These indices will be used to evaluate self-perceived handicap, quality of life, and/or reflux-associated symptoms. Examples include the following:
Voice Handicap Index. 1
Singing Voice Handicap Index. 2
Voice Related Quality of Life. 3
Voice Symptom Scale. 4
Glottal Function Index. 5
Voice Activity and Participation Profile. 6
Reflux Symptom Index. 7
7.3.2 Patient History
After greeting in the office, the otolaryngologist will ask the patient a series of questions regarding domains of voice use and problem history. The questions presented to the patient are designed to elicit information which will elucidate (1) the patient’s perception (description) of the current voice difficulties; (2) the temporal (time) development of the current voice problem; (3) potential behavioral, medical, environmental, and psychological etiologies associated with the problem; and (d) the patient’s personality, motivation, occupational, and social activities which may contribute to the current problem and which may influence subsequent treatment decisions.
7.3.3 Physical Examination
The otolaryngologist will complete a general evaluation of systems and structures associated with the head and neck. The goal of the physical examination is to rule in or out conditions which may be causing the current voice problem(s), and to further characterize the nature of an existing problem. Among the domains assessed during this part of the clinical examination are
Otoscopic view of ears.
Oral and nasal cavity exam.
Palpation of nodes and glands within the neck.
Perceptual evaluation of voice quality and function.
7.3.4 Laryngeal Visualization
The penultimate step in the otolaryngology office examination is visual observation of laryngeal structure and function (laryngoscopy). There are three primary methods with which the otolaryngologist can visualize the larynx: (1) indirect mirror laryngoscopy, (2) direct laryngoscopy using a flexible fiberscope (nasoendoscope) routed through the nose, and (3) direct laryngoscopy using a rigid endoscope routed through the mouth. A majority of general otolaryngology practices will utilize a flexible endoscope routed through the nose to complete laryngeal visualization. In laryngology practices, the physician may use a standard flexible fiberscope, a distal chip nasoendoscope, or a rigid endoscope, all of which may be used with a steady light source or with stroboscopy for examination of vibratory dynamics. ▶ Fig. 7.1 shows the three tools (laryngeal mirror, flexible endoscope, and rigid endoscope) with which an otolaryngologist can visualize the larynx and vocal folds.
Fig. 7.1 Instrumentation used for laryngoscopy: (a) laryngeal mirror, (b) rigid endoscope, and (c) flexible endoscope.
(From Aronson A, Bless D. Clinical Voice Disorders. 4th ed. New York: Thieme Publishers, 2009.)
7.3.5 Debriefing, Diagnosis, and Referral Pathways
The office examination concludes with the otolaryngologist considering all the evidence collected from the procedures described earlier. The physician will describe to the patient which findings were suggestive of physiological impairment and indicate what options might be available to rehabilitate or improve those impairments. The collective evidence may lead to the determination of a medical diagnosis from which the appropriate treatment recommendations can be made. In some cases, the otolaryngologist will need more detailed information of internal structure as well as neurological and systemic function that requires referral to another medical professional or subsequent otolaryngologic procedure. Examples include
X-ray, computed tomography or computed axial tomography (CT or CAT), magnetic resonance imaging (MRI) scan: these examinations are completed to better visualize internal bony structures and spaces (X-ray), or soft tissues such as the brain, nerve pathways, and blood vessels (CT and MRI). These referrals are often made to rule out tumors or structural irregularities which cannot be visualized using laryngoscopy.
Gastroenterology examination: referral to the gastroenterologist is sometimes made when the otolaryngologist suspects laryngopharyngeal reflux. The current gold-standard assessment for reflux is 24-hour dual-channel pH monitoring. 8 In this examination, probes are placed above and below the upper esophageal sphincter. The probes are attached to a monitor which records the pH levels of the probes. The patient wears the monitor with probes in place for 24 hours, and the pH levels are recorded across this time frame.
Oncologist: when laryngeal cancer is diagnosed, the multidisciplinary medical management will typically include referral to an oncologist when recommended treatment will include irradiation and/or chemotherapy. Oncologists are medical doctors with specialty training in the prevention, diagnosis, and treatment of cancers. To practice as an oncologist, the educational requirements necessitate completion of a postresidency fellowship in oncology. The oncologist may remove large or complex head/neck tumors (these are referred to as “surgical oncologists”), they may administer chemotherapy (these are referred to as “medical oncologists”), or they may administer radiotherapy (these are referred to as “radiation oncologists”).
Allergist/Immunologist: the otolaryngologist may need to rule in or out allergic or immunologic conditions associated with the current voice problems. When this need exists, the physician may refer to an allergist (or allergist/immunologist). These medical professionals are physicians with specialty training in the form of a fellowship in allergy/immunology, and in the United States are certified by the American Board of Allergy and Immunology. The allergist/immunologist can conduct specialized testing to investigate the presence of allergic reactions to various substances, asthma, and immune system disorders.
Endocrinologist: referral to the endocrinologist might be needed when the otolaryngologist needs to rule out impairments to the endocrine system. The endocrine system controls hormone levels in the body, and the endocrinologist is the medical specialist who diagnoses diseases to this system. Of importance to the otolaryngologist is the status of the thyroid gland, as voice quality change such as hoarseness can be a clinical manifestation of a hypoactive thyroid. 9
Neurologist: the otolaryngologist can diagnose certain neurological disorders—among these include vocal fold paralysis, spasmodic dysphonia, and voice tremor. However, additional and more specific neurological information may be needed and in these cases assessment by a neurologist can be warranted. Voice disorders can be associated with degenerative or acute neurological disease processes, which the neurologist is specially trained to assess and diagnose.
Electromyographic testing: when vocal fold paralysis is suspected, the otolaryngologist may need to perform electromyography (EMG) to test the function of peripheral nerves innervating the laryngeal muscles. Fellowship-trained laryngologists may have the knowledge and skills to perform this procedure, otherwise the otolaryngologist can refer the patient to a neurologist. Laryngeal EMG can provide important information for the differential diagnosis of paresis/paralysis based on the electrical activity of laryngeal muscles (needles connected to electrical sensors are inserted into the muscles), and possibly provide information that can inform prognosis for recovery. However, it has been suggested that information obtained from laryngeal EMG is most useful within 6 months from problem onset, and assessments after that time frame may provide misleading information. 10
7.4 Surgical Management Options
Once an accurate medical diagnosis is established, the otolaryngologist will recommend the appropriate options for treatment. Ultimately, the patient is responsible for choosing the option that best meets their goals for health, function, and quality of life. Depending on the specific diagnosis, these options can include (1) temporal observation of the problem and subsequent follow-up appointment with the otolaryngologist, (2) referral to the voice therapist for further evaluation and behavioral treatment of the disordered voice, (3) pharmaceutical management, (4) surgical management, and/or (5) referral to another medical specialist. Kirtane et al have developed an algorithm (▶ Fig. 7.2) to assist the otolaryngologist in determining the appropriate course of referral when pathological tissue is detected during the examination. 8 A significant factor affecting the decision pathway in this model is the suspicion of laryngeal cancer. The algorithm leads to three possible pathways: (1) multidisciplinary management for confirmed malignancy, as described earlier; (2) observation, pharmaceutical and/or behavioral voice therapy with subsequent follow-up; or (3) surgery.
Fig. 7.2 Decision-making algorithm outlining the key steps in the management of vocal pathology.
(From Bhattacharyya A. Laryngology: Otorhinolaryngology—Head and Neck Surgery Series. 1st ed. New York: Thieme Publishers, 2014.)
Some diagnoses will most effectively be treated with surgical procedures. Surgeries performed by otolaryngologists for the purposes of sustaining, restoring, or improving vocal function are known collectively as phonosurgery. Phonosurgical procedures can be organized into three general categories: (1) phonomicrosurgery via microlaryngoscopy, (2) laryngeal framework surgery, and (3) office-based phonosurgery (OBP).
Phonomicrosurgery is performed in an operating room using a microscope to visualize the vocal folds and surrounding regions (microlaryngoscopy). An example of the operational setup is illustrated in ▶ Fig. 7.3. The primary purpose of phonomicrosurgery is to remove abnormal tissue. Abnormal tissue may be malignant or benign, and surgery will be chosen when there is a strong possibility for cure or improved vocal function upon removal of the tissue. Microlaryngoscopy provides a detailed, close-up view of the vocal folds, pathological tissue, and surrounding structures as demonstrated in ▶ Fig. 7.4. Once an otolaryngologist has visualized the vocal folds, they can remove pathological tissue using different surgical options, which include the following:
Fig. 7.3 Operation theatre setup for phonomicrosurgery.
(From Bhattacharyya A. Laryngology: Otorhinolaryngology—Head and Neck Surgery Series. 1st ed. New York: Thieme Publishers, 2014.)
Fig. 7.4 Example of laryngeal visualization during microlaryngoscopy. Here a subepithelial cyst is being removed.
(From Bhattacharyya A. Laryngology: Otorhinolaryngology—Head and Neck Surgery Series. 1st ed. New York: Thieme Publishers, 2014.)
Microflap dissection: epithelial microflaps are a preferred technique for removing submucosal (below the outer epithelium) vocal fold lesions. This option is used for lesions such as cysts, polypoid degeneration, scar, and sometimes polyps. 11, 12 Microflap procedures require microdissection of the epithelium to create a flap, which is then raised and moved laterally to expose the superficial layer of the lamina propria (SLLP). Lesions are then removed while maintaining as much integrity to the SLLP as possible, and the epithelial flap is then laid back in place to support the healing process. This technique preserves epithelium and minimizes disruption to the vocal fold cover to facilitate mucosal wave function after surgery.
Another type of microsurgical dissection has been used in selected cases of spasmodic dysphonia. Selective laryngeal adductor denervation–reinnervation surgery has been used to improve vocal function in patients with Adductor Spasmodic Dysphonia (ADSD). 13 This surgery dissects the adductor branches of the recurrent laryngeal nerve innervating the thyroarytenoid (TA) and lateral cricoarytenoid (LCA) muscles. These branches are severed and treated in a manner which prevents their resprouting toward their former muscle targets. 14 The distal axons of the recurrent laryngeal nerve which enter the TA muscle (the tips which are left after the remainder of the nerve has been dissected away) are then reanimated by connection to the sternohyoid branch of the ansa cervicalis nerve (formed by portions of spinal nerves C1–C3). 15
Mass resection with cold instruments: lesions which occur on the epithelial surface or superior to the SLLP may be resected using various microinstruments including scissors, forceps, and microdebriders. These devices are made of medical grade metals and are also referred to as “cold steel instruments.” This option is used for lesions such as vocal fold nodules, polyps, premalignant lesions, cancer, granulomas, vascular lesions, and papilloma. These lesions are literally cut off from the vocal fold surface, which results in an obligatory injury to the vocal fold epithelium. Surgeons attempt to spare as much epithelium and deeper tissue as possible, and may further trim the epithelium to create a smooth vocal fold vibratory edge. 16
Laser resection: Some surgeons prefer to use laser technology to remove abnormal tissues from the vocal folds and surrounding laryngeal regions. These have been used in place of cold instruments or as the primary choice for a wide variety of impairments, including premalignant lesions and vocal fold cancers, papilloma, vascular lesions, hemorrhagic polyps, cysts, nodules, polypoid degeneration, and granulomas. 10 While CO2-type lasers are the most commonly employed, other laser technologies are preferred by certain surgeons and include pulse dye lasers, yttrium aluminum garnet lasers, and potassium titanyl phosphate lasers. 10 Laser technology can be advantageous for lesion removal because the beams can be directed to small focal regions of tissue. They have also been preferred for removing vascular injuries and disrupting the vascular supply to papilloma. 17 Lasers produce heat, however, and the settings of the instrument must be monitored closely by the surgeon to prevent thermal injury to surrounding vocal fold regions.
Laryngeal framework surgery is designed to alter or improve vocal fold position, shape, and tension or to reconstruct the larynx. Another name for this type of phonosurgery is laryngoplasty. Laryngoplasty techniques manipulate the cartilaginous framework of the larynx to achieve targeted results. The laryngeal framework can be modified using various methods, which include (1) medialization laryngoplasty (ML) using implants, (2) arytenoid repositioning (arytenoid adduction or arytenopexy), or (2) cricothyroid repositioning (approximation or subluxation).
Laryngoplasty performed as an open procedure in the operating room (as opposed to injection laryngoplasty, described later) creates permanent changes to the laryngeal framework. Because the vagus nerve can spontaneously recover in many cases of vocal fold paresis/paralysis, it is recommended that many forms of laryngoplasty, and especially thyroplasty (see later), be delayed for at least 6 months post-onset, and possibly up to 1 year to allow for recovery to take place. As the patient is observed by the otolaryngologist over this time, behavioral voice therapy can be applied and has shown to be effective for rehabilitation of vocal function secondary to vocal fold paralysis, especially when the vocal fold is positioned closer to midline (as opposed to a more abducted position) and has some residual adductor movement.
Medialization laryngoplasty was first described by Isshiki et al in the 1970s as “thyroplasty,” and also goes by the name “medialization thyroplasty.” Isshiki et al originally described four types of thyroplasty techniques which require augmentation of the thyroid cartilage to achieve different results: (1) Type 1 thyroplasty, designed to medialize the vocal fold; (2) Type 2 thyroplasty, designed to lateralize the vocal fold; (3) Type 3 thyroplasty, designed to shorten and relax the vocal fold to lower fundamental frequency; and (4) Type 4 thyroplasty, designed to lengthen and tense the vocal fold to increase fundamental frequency. 18 Type 1, the most commonly employed thyroplasty technique, is used to correct glottal insufficiency secondary to vocal fold paralysis, presbylaryngis, and in some cases of bowing secondary to Parkinson’s disease. 19, 20
ML (Type 1 thyroplasty) has evolved over time such that various materials can be used to medialize one or both immobile vocal folds. The procedure is performed in the operating room and requires the creation of a rectangular window in the thyroid cartilage at the level of the vocal fold (▶ Fig. 7.5 and ▶ Fig. 7.6). The window is marked and cut out using various instruments. Silicone or Silastic blocs can be placed through the window to press against the paralyzed vocal fold, pushing it toward midline (▶ Fig. 7.7). Sutures hold the implant in place, and the healing process will further secure the implant within the cartilaginous framework.
Fig. 7.5 (a,b) Landmarks of the thyroid cartilage showing location of the window within the thyroid cartilage created for medialization laryngoplasty (Type 1 thyroplasty).
(From Fried M, Tan M. Clinical Laryngology. 1st ed. New York: Thieme Publishers, 2014.)
Fig. 7.6 Thyroplasty window excised from the left thyroid lamina.
(From Fried M, Tan M. Clinical Laryngology. 1st ed. New York: Thieme Publishers, 2014.)
Fig. 7.7 Example of a Silastic implant used for medialization laryngoplasty (Type 1 thyroplasty). This bloc can be customized to the patient.
(From Fried M, Tan M. Clinical Laryngology. 1st ed. New York: Thieme Publishers, 2014.)
The anesthesia level provided to the patient can be adjusted so that they are able to follow directions and vocalize on instruction from the surgeon. This allows for testing the effectiveness of the implant placement prior to completion of the surgical procedure. The silicone bloc can be modified during the operation to create a customized shape which will be most effective for the patient. Some otolaryngologists prefer to use materials other than silicone blocks, with one popular option being GORE-TEX. This is a flexible material manufactured by W. L. Gore & Associates (www.gore.com), which allows the surgeon to modify the location of the GORE-TEX ribbon within the excised window of the thyroid to produce desired outcomes.
Arytenoid repositioning techniques include arytenoid adduction and arytenopexy. Arytenoid adduction, when performed, is typically used in conjunction with ML to facilitate improved closure of the posterior glottis. The technique re-creates the physiological adduction properties of the LCA muscle, although it results in a fixed adducted vocal fold position. 10 The arytenoid is repositioned using monofilament sutures, which are routed through the muscular process and thyroid cartilage. Tension is applied to physically rotate the arytenoid such that the vocal process and vocal fold tissue moves medially, and the suture is fixed. 21
Arytenopexy is a procedure designed to improve upon the arytenoid adduction technique. The arytenopexy procedure is accomplished by the surgeon manually manipulating the arytenoid cartilage on the surface of the cricoarytenoid joint (e.g., it is dislocated from the joint). A unique suture technique routes monofilament through the cricoid cartilage and muscular process of the arytenoid, tension is added, and then the suture is fixed. The orientation of the arytenopexy suture is thought to not only improve posterior glottal closure but also increase the length of the paralyzed vocal fold, improve the horizontal plane of the paralyzed vocal fold so that it is better aligned with the opposite fold, and also improve the vertical orientation of the targeted arytenoid cartilage (e.g., it sits higher and in a more vertical position, as opposed to a prolapsed position). 22, 23 It is thought to accomplish this by re-creating the adductor action of the LCA, TA, and interarytenoid muscles in addition to the antagonistic abductor action of the posterior cricoarytenoid (PCA) muscle. 24
Cricothyroid repositioning is used to adjust the relationship of the cricoid and thyroid cartilage to the remaining framework of the larynx. One procedure, cricothyroid subluxation, can be utilized in conjunction with ML or be combined with ML and arytenopexy as a triple laryngoplastic procedure. 25 Cricothyroid subluxation is designed to add length and tension to the paralyzed vocal fold, restoring substantial range to the patient’s physiological frequency abilities. It is accomplished by the surgeon tying a suture to the inferior cornu of the thyroid cartilage on the affected side, routing the suture underneath and around the cricoid so that it returns to the inferior cornu, as illustrated in ▶ Fig. 7.8a,b. Tension is added which creates a traction on the thyroid and cricoid so that the distance between the anterior commissure of the thyroid and the vocal process of the arytenoid is increased. This has the effect of elongating and tensing the vocal fold, allowing for higher vibration frequencies. 25
Fig. 7.8 (a) Cricothyroid subluxation: a suture is first tied to the inferior cornu of the thyroid cartilage and the routed under and around the anterior rim of the cricoid cartilage. (b) Cricothyroid subluxation: the suture is routed back to the inferior cornu and the appropriate tension is added. This orientation increases the distance between the vocal process of the arytenoid and anterior commissure of the thyroid, resulting in increased length and tension of the vocal fold.
(From Dailey S, Verma S. Laryngeal Dissection and Surgery Guide. 1st ed. New York: Thieme Publishers, 2013.)
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