Problems that require surgery.
- Spasmodic Dysphonia: Botulinum Toxin Treatment is the choice of
treatment of persons suffering from Spasmodic Dysphonia. Botulinum toxin (Botox)
is a neurological poison which weakens muscle by interfering with nerve impulses
which normally initiate muscle contraction. Prepared as a purified protein, it
is now used as a medicine to treat conditions which result from excessive,
involuntary contraction of muscles. This injection is done in the office,
while the patient is awake. A small needle is inserted through the neck at
the appropriate location and directed up towards the vocal cords. The
entire procedure takes about 15 minutes, and the patient is free to leave when
it is completed. The benefits usually last around 3 months then gradually
wear off at which time the treatment may be repeated. There are no known serious
long-term adverse effects of the treatments. (Botox Injections are not
considered to be surgery. I chose to place this information on the
"surgery" page since I don't have a page devoted specifically to in-office
procedures and treatments.)
- Vocal Cord Paralysis/Paresis: The decision to have surgery depends on several things. Speech therapy is almost always suggested before surgery. Speech therapy is often successful in helping this problem. Even a small
improvement is often enough to satisfy the demands of a normal voice user. The success of therapy will depend on the nature and
position of the paralyzed vocal fold as well as the vocal demands of the patient. If the paralysis is causing breathing or swallowing problems, then surgery will likely be required much earlier.
There are two main surgical procedures that are used to to treat vocal fold paralysis/paresis:
(a) Vocal Fold Injection: This injection process is also called vocal fold augmentation. It involves the injection of certain materials into one or both of the vocal cords. This injection makes the vocal cords bulkier, or fatter, thus improving closure when speaking. Thus, it pushes the paralyzed fold to the middle so that when the normal fold closes there is no gap. It also enhances vocal fold vibration. The materials commonly used are fat, gelfoam, collagen (Cymetra), and calcium hydroxylapatite (CaHA). Your doctor will decide if this is the right option for your condition. Some injections can be performed with local anesthesia, but most doctors seem to prefer putting the patient to sleep with anesthesia. Scroll down to the bottom of this page to see a detailed list of these injection materials.
(b) Medialization Laryngoplasty: The involves the implanting of a small device into the vocal fold in order to optimize its position so as to improve closure during speaking. Laryngoplasty usually requires a skin incision in the neck. The size and location of this incision depends on the type and extent of laryngoplasty being performed. A variety of implantable materials are available for laryngoplasty, including silicone, Gore-Tex™, and a substance called calcium hydroxylapatite. None has a clear advantage over another, but there are various considerations in implant selection. The advisability of repositioning certain cartilages (known as arytenoid adduction) and variations in technique are also debated among laryngologists. Both of these issues may be discussed with your surgeon.
If you undergo medialization laryngoplasty, your doctor will likely require that you stay overnight for observation. Why? Because the larynx typically swells somewhat after this type of surgery. This observation is usually necessary so as to monitor breathing. Breathing difficulties are rare with this procedure, but they can be very dangerous. Therefore, every precaution is taken to make sure this situation does not develop.
The main difficulty of the operation lies in obtaining the best voice results. A less than desired voice result motivates some patients to have this procedure repeated or revised. - Nodules or Polyps: As with so many other vocal problems, aggressive
speech therapy is usually the first suggestion. However if this produces no
result, then surgery is a likely alternative.
This procedure is quite simple. The patient is put to sleep with anesthesia. The tools are passed through the mouth and into the larynx for surgery. A surgical scope camera is used to guarantee precision. The nodules can simply be removed during this procedure, and it only takes a few minutes. After the surgery, the patient will usually need strict vocal rest for several days, perhaps a week. Speech therapy is needed to identify the vocal behavior that caused the nodules so as to prevent them from appearing again. - Injection Materials: There are a number of substances that can
be used for the Vocal Cord Injection surgery described above. Each have
pros and cons, and your voice surgeon will suggest the best material to use in
your particular case. Below are the most common materials used for these
injections:
(a) Autologous Fat: Fat has the advantage of being well-tolerated by the body. Since it is taken from the patient, the chances of rejection or infection are minimal. Fat also provides good vibratory characteristics within the vocal fold. The down side of using fat are the fact that it may be resorbed by the body and the procedure may need to be repeated to achieve the optimal result.
(b) Gelfoam: Gelfoam is a starch-like substance that is quickly absorbed by the body. Therefore, this material is used to provide temporary improvement in patients with laryngeal paralysis.
(c) Collagen: Collagen is most often used in the correction of small defects of the vocal fold. It offers good vibratory characteristics, and like hydroxylapatite, it is bioactive. This bioactivity can stimulate fibroblasts to remodel and can result in repair of the defect. Collagen's main limitation is that it is resorbed in an unpredictable fashion.
(d) Teflon: Teflon lasts longer in the body than fat or gelfoam and is usually used to permanently repair vocal fold defects. When Teflon is used, there is some risk of a foreign body reaction, which could cause the voice to deteriorate years in the future.
(e) Calcium Hydroxylapatite (CaHA): CaHA is a major component of the mineral constituent for both bone and teeth. This material has been used in the past as a biomedical implant in dental, orthopedic, and head and neck bony reconstruction. Somewhat recently, CaHA has been suggested as a vocal fold augmentation material for the treatment of glottal insufficiency. Radiesse, manufactured by BioForm Medical, Inc., is FDA approved for use in vocal fold augmentation. Since CaHA is a somewhat new product, there are many questions as to the results that can be achieved long term with Radiesse. Time and experience will help answer those questions.
** Please Note: Vocal fold injections can be accomplished in more than one way. My doctor required that I be put to sleep with general anesthesia during the procedure. Other doctors have different opinions concerning this . Dr. James P. Thomas, M.D., author of the website voicedoctor.net, seems to have had excellent success in performing this procedure in the office, while the patient is awake. According to his comments on his website, he prefers this method so that the patient can be assessed during the procedure, and a more accurate judgment can be made as to how much material to inject. His website give tons of information about these procedures and what to expect before, during, and after the injection. He even has videos that you can watch of these procedures being performed. Visit his website by clicking on the link above.
What are the risks of surgery? With all surgery, there are risks. For vocal cord injection, the risks are (a) underinjection of material - optimal vocal fold closure is not achieved and voice is hoarse, breathy, and/or fatigued, (b) allergic reaction to materials used for injection, (c) overinjection of substance - results in strained voice and possibly breathing problems, (d) injection substance only provides temporary benefit.
The risks of medialization laryngoplasty are: (a) an airway obstruction and/or swelling, which may result in breathing difficulties, (b) undercorrection or overcorrection, which produces similar problems similar to those described above in points a and c, (c) graft migration in which the implant does not stay in the place where the surgeon put it, (d) implant extrusion - the implant is rejected and pushed outwards.