Учебники / Voice Disorders and Their Management Freeman 2000

notch on the free border of the vocal fold. These thick bridges are fortunately uncommon, their surgical treatment being particularly difficult. An attempt is made to reduce the thickness of the bridge by removing the mucosa from the underside of the bridge while leaving the band and the overlying mucosa intact. The epidermoid pocket underneath the bridge is then dissected out and removed, thus allowing the band and remaining overlying mucosa to be replaced against the vocal ligament.

Unilateral recurrent laryngeal nerve paralysis

Indications for surgery. Surgical treatment of unilateral recurrent laryngeal nerve paralysis is appropriate where speech therapy rehabilitation alone has produced insufficient improvement, and inspection shows that the vocal fold remains atrophic and inadequately medialized or has remained in the intermediate position. Stroboscopic examination is essential in order to assess the vocal importance of any misalignment of the folds, atrophic change in vocal fold bulk, and the degree of failure of glottal closure, and is thus the single most important examination for assessing suitability for surgery. We normally wait for a year after the onset of the paralysis before injecting a paretic fold.

The operation. The aim of intrafold injection, be it with Teflon or with collagen, is to expand the paralysed fold in order to bring the free border back towards the midline without interfering with the vocal fold cover’s capacity to generate waves.

Teflon paste is injected with a needle having a double-angle offset near the tip, and which is fitted to a pistol with a notched plunger. The needle has a wide diameter and should be inserted deeply and lateral to the vocalis muscle, which will then be displaced from within by the Teflon.

It is essential to avoid two things:

•superficial or submucosal injection;

•injection of too much paste.

Generally, injection into an anterior and a posterior site is adequate, although Teflon paste cannot be spread in the area adjacent to the arytenoid; hence there is always a persistent posterior interarytenoid gap.

Phonagel (GAX collagen), after many initial problems, is now freely available and offers several advantages over Teflon:

•it is highly biocompatible;

•the suspension is much more fluid than Teflon paste, which allows the use of a much finer needle for injection and can thus be spread much more easily within the fold, usually from a single posterior injection site.

In either case massaging the fold with the end of the sucker or some other suitable instrument produces a much more even spread of the paste throughout the length of the fold, making the free border as straight as possible.

Postoperative follow-up and results. Postoperative benefits are immediately apparent. There is no point in the patient’s remaining silent for a period and we advise them to start speaking again the day after operation. Following the repositioning of the fold, the voice is stronger and frequently rather lower in pitch. Dyspnoea while speaking diminishes and may disappear completely, coughing becomes more forceful, and episodes of overspill/inhalation of liquids cease.

Laryngeal examination shows a somewhat over-inflated fold initially, which will retain a rather inflamed appearance for several weeks. There is an obvious improvement in glottal closure.

Speech therapy sessions should be started again so that the patient learns how to use his or her new voice. A few patients may find the initial experience of a new voice quite disorientating.

In the majority of cases anatomical and functional improvement is maintained in the long term. After collagen injection, the fold seems to appear progressively more normal, rather as if the collagen were being evenly distributed throughout the substance of the interior of the fold; the stroboscopic vibration meanwhile reappears in a reasonably satisfactory manner. In a few cases following either Teflon or collagen injection the vocal result is not stable and a further topping-up injection is necessary.

A final note about Teflon. There is a risk of occasional serious secondary complications due to a granulomatous inflammatory reaction in the vocal fold. This may present as a pseudotumour of the fold – sometimes years after the original injection (seven years in one of our cases).

Special problems

Iatrogenic scars

Under the general heading ‘scars of the vocal folds’ we include:

•notches in the vocal folds;

•adhesions between folds;

between a fold and ventricular band;

•fibrous scars;

•stiffening of the fold following use of the laser.

Indications for surgical revision must be carefully assessed. It is not always easy to say whether a poor result from previous surgery is due to scarring or vocal dysfunction.

Laryngeal examination may sometimes show clear evidence of a notch in the fold producing air escape and an explanation of the veiled quality of the voice. In contrast, sometimes the anatomical appearance shows little abnormality, and only stroboscopy will produce evidence of localized or even very extensive scarring of the fold.

Revision surgery may be suggested when a prolonged trial of speech therapy has been manifestly unhelpful, and if the patient is sufficiently motivated and has been fully forewarned about the hazards and limitations of this type of repeat procedure.

The operative technique that we use most commonly is derived from the technique used to elevate mucosa off a stretch mark. Where there is a notch or area of fold rigidity, one always finds that the mucosal scar and the surface of the vocal ligament are intimately stuck together. Using the technique described above, we try to mobilize the mucosa in order to restore some flexibility to this rigid area: intrafold injection of hydrocortisone suspension, superior cordotomy, meticulous dissection, and elevation of the mucosa in an attempt to find a plane of cleavage between mucosa and vocal ligament.

The results are difficult to schematize because they depend on both the initial lesion and the extent and difficulty of the revision surgery. However, postoperative examinations have shown us that after this ‘mucosal freeing’, the vocal fold does regain a degree of suppleness, which is demonstrable by improved stroboscopic vibration patterns and better glottic closure. At the same time there is an undeniable improvement in voicing which continues pari passu with postoperative speech therapy.

Microsurgery in children

Until very recently, phonosurgery in children was only undertaken with the greatest reluctance. In addition to the usual constraints, there are other relative contraindications to surgery in children: the small size of the immature larynx, the virtual impossibility of insisting on a period of postoperative silence, and above all, the habitual vocally abusive speech patterns of children presenting with lesions amenable to surgery. Nonetheless, several factors are causing us to turn to surgery as a treatment option with increasing frequency. Appropriate surgical and anaesthetic procedure is now well characterized, congenital lesions (cysts) are being discovered with increasing frequency when previous indirect examination had suggested that the lesions were simple vocal nodules, and speech therapy may fail to improve the voices of even the most

co-operative children. The final decision to opt for surgery is often made on the basis of the length of the history of dysphonia, which may suggest that the lesion is congenital, and the degree of handicap caused by the dysphonia, for instance in children studying music. Full preoperative preparation of both the child and the family is absolutely essential.

The operation itself is no different from the adult procedure, and generally one is struck by the ease and quality of the exposure in a child’s larynx. The optimum age for surgery is between 9 and 11 years old.

The outcome following surgery is straightforward and depends to a great extent on family support and speech therapy. The final result depends largely on the type of lesion that was removed. It is excellent following nodule excision and rather slower after removal of a cyst. The aim of postoperative speech therapy is to maintain this improvement, and therapy should be continued over several months to prevent the child’s returning to vocally abusive patterns. Nodules recur more frequently than in adults and are the direct result of continuing vocal abuse.

Microsurgery for singers

Lesions found on the vocal folds of singers are perfectly amenable to microsurgical treatment, provided that the operator is particularly cautious and meticulous in avoiding leaving a scar, no matter how small, which could be catastrophic for the singing voice. The lesions found in singers on whom we have operated are not solely varieties of nodule; there are also a significant number of epidermoid cysts and sulci. We thus conclude that small congenital anomalies of the larynx may be entirely compatible with a good quality singing voice, but that the passage of time may lead to a secondary ‘decompensation’.

When faced with any singer who presents with chronic vocal difficulties, it is thus obligatory to perform a full laryngeal assessment using optical magnification and stroboscopy, which may suggest the presence of a cyst or a sulcus, before blaming the problem on poor technique. In a few cases where the diagnosis remains uncertain, it may be necessary to inspect or explore the folds at microlaryngoscopy. One should be aware at all times that any laryngeal microsurgery poses particular problems for the professional singer:

•the anxiety of the patients that they may lose the tool with which they make their living;

•the difficulty of coping with a lengthy interruption in their professional singing career; in our experience, that interruption should not be less than three months;

•delicate postoperative adjustments in vocal technique require the help of a therapist with personal knowledge of singing problems.

Conclusion

Within the realm of phonosurgery, we feel that collaboration between phoniatrician and surgeon is absolutely indispensable. Such a collaboration is highly instructive to both parties, who as a result are able to make increasingly accurate diagnoses as well as adapting and refining surgical techniques required to improve vocal function. Improved microsurgical technique has drastically altered the prognosis for a large number of benign laryngeal lesions: nonetheless preand postoperative speech therapy remain an essential adjunct to the surgery.

number of problems that often occur where dysphonics are routinely treated in outpatient clinics. These advantages depend on the increased amount of time given to each patient, continuity of care and the variety of approaches that can be applied to the diagnosis and management of patients in a multidisciplinary setting.

Continuity of care

It is comparatively rare for voice clinics in the UK to be run by several different consultants. Usually, one consultant within an ENT team takes an interest in voice and takes on the voice clinic. Similarly, there is rarely more than one speech and language therapist specialized in voice who takes responsibility for the clinic, although others may sometimes be involved in the patient’s treatment or attend on a training basis. If the clinic team includes singing teachers, osteopaths, or psychotherapists they also tend to be regular members of the clinic, particularly as few are prepared to give up a session of private work for very little or no financial reward.

Patients usually report a strong preference for seeing the same staff at each clinic visit. They build up good relationships with the team and feel at ease to discuss their problems. This allows the team a much better overall picture of the patient, within the context of their general health, work and social life. As a result, causative factors that are often considered to be peripheral by the patient can be spotted early and the appropriate treatment provided.

Continuity of care enables clinicians to develop a ‘clinical memory’ of patients with difficult vocal problems, including the usual appearance of their vocal folds. Fine differences of appearance which herald change are then more likely to be noted; this can be particularly helpful where the clinic has no Mavigraph to print downloaded pictures from video and the clinician is reliant on a drawing or verbal description of the larynx.

The importance of team decisions

In most ENT clinics, the surgeon sees dysphonic patients as a routine part of the outpatient caseload. Neither the time nor the equipment is available for detailed case histories or analysis of vocal function. Pathology may be diagnosed accurately, but the management decision lies in the hands of the surgeon who may offer surgery, speech therapy, review or discharge. Each surgeon’s criteria for making these decisions can be different and, with pressure on the National Health Service, many patients who could have responded well to voice therapy techniques, advice, vocal hygiene or counselling may not be referred for voice therapy. Sometimes, of course,

reassurance is all that is needed and the patient gradually recovers. Unfortunately, others fail to resolve and finally re-present to the surgeon at a later date with visible pathology as a result of the continuing vocal misuse. If the surgeon decides to operate, patients may have their surgery, be reviewed and discharged with the original causative factors still present in their voice production.

Contributory medical factors

Medical problems that may be either causative or contributory to dysphonia are often not addressed in a general ENT clinic because of the shortage of time available for each patient and because the mental set of both patient and clinician is restricted to the ENT symptoms. Much depends on the patient providing unfiltered information about their health, in a way that their medical problems can be identified by the surgeon, and referred on for appropriate assessment. Patients do not necessarily realize that their indigestion, whiplash injuries, chest troubles, medications, or emotional difficulties can be related to the voice or swallowing problems they are experiencing.

Much has been written about these concomitant medical factors in recent years, so that many surgeons do now ask the relevant questions. Even so, concomitant medical conditions may still be missed because patients fail to recognize their symptoms from the questions they are asked. A common example can be found in patients who fail to relate their night cough, dry, tetchy, irritable throat and morning hoarseness to the heartburn that the surgeon inquires about.

Recognizing and treating the common concomitant medical problems is important. Patients with these problems often fail to respond to vocal techniques until their medical problems have been resolved, with the risk that they will lose faith in voice therapy and leave their ENT follow-up appointments unattended. Their unrecognized medical problems and poor voice production may then create or mask developing pathology or produce relapse at a later date.

Inappropriate referrals for speech therapy

Adequate equipment for detailed examination and analysis of vocal function is essential (see equipment section, pp. 327–32). All too often in the past, patients have been labelled ‘neurotic’ and subjected to long courses of inappropriate voice therapy or psychotherapy because the equipment used to examine them has been inadequate for assessing vocal function.

Hard, fibrous nodules, vocal fold sulci, intra-cordal cysts and advanced cases of Reinke oedema are not amenable to conventional voice therapy.

However, cases like these are still being referred to voice therapy and it may take several sessions of frustration on behalf of patient and therapist before the referral is queried. In the past, patients like these may have been responsible for some surgeons feeling that speech therapy was ineffectual for the treatment of dysphonia. Lack of faith in a treatment soon communicates itself to the patients, who then fail to keep their therapy appointments. In the past, audit has shown that quite a high proportion of patients referred to speech therapists fail to keep their initial appointment (Donnelly and Kellow, 1989). Inappropriately referred patients who do take up the option of voice therapy may soon become discouraged by their lack of progress and will sometimes fail to return for ENT reassessment. This jeopardizes any chance of the correct diagnosis being reached and the necessary surgery provided.

The aetiology of vocal dysfunction is multifactorial and complex and even with the appropriate level of equipment, microscopic or occult lesions may take several examinations and a variety of phonatory assessment tasks to identify. For example, if the patient has insufficient airflow, mucosal waves cannot be efficiently driven and it is therefore impossible to exclude the possibility of an occult lesion (such as a sulcus or intracordal cyst) affecting phonation. These patients will need short-term voice therapy to develop sufficient airflow before any previously hidden lesions can be identified at reassessment. Where patients understand the need for voice therapy, compliance is greatly increased. In some clinics patients are asked to leave the room while the team members discuss the management plan. However, a multidisciplinary voice clinic setting can be used effectively to encourage patients to take responsibility for their treatment and they generally respond extremely well when included in the team discussion and management decisions.

Disadvantages of voice clinics

There is no doubt that voice clinics are expensive in terms of equipment and personnel. Videostrobolaryngoscopy is a basic requirement these days and involves a big capital outlay. Balanced against this is the decrease in the number of operations required simply to exclude pathology and the decrease in the number of clinic appointments necessary for each patient.

Voice clinics are efficient in terms of reducing the number of clinic appointments patients require (Harris et al., 1986). However, patients do need to be seen for longer periods, especially initially. An average initial appointment is 30 minutes and an average follow up is 10–15 minutes depending on the outcome of treatment.

Personnel are expensive. The ENT surgeon and voice therapist form the basic core of necessary personnel but where possible, other practitioners, either on a regular basis or for specially selected patient groups (such as performers), are extremely valuable additions. At Queen Mary’s Hospital voice clinic in Sidcup, the regular team seeing patients in the voice clinic each week includes an osteopath and a singing advisor. Fortuitously, the osteopath is also a qualified psychotherapist, which has proved invaluable on many occasions. Patients who are seen from outside the district as extra contractual referrals (ECR) help to fund both the personnel and maintenance of the equipment, but funding for voice clinics has always been a problem and may become increasingly difficult within the National Health Service in the future.

The financial constraints imposed by (and on) the British National Health Service produce conditions that are specific to the UK. For a good overview of the North American experience the book by Deborah Koschkee and Linda Rammage, Voice Care in the Medical Setting (1997), is recommended.

Personnel

The laryngologist

In the UK, the laryngologist provides a thorough examination of each patient’s ENT systems, with particular attention to the structure and function of the larynx. In other European countries this role would fall to the phoniatrician, a consultant specializing in communication disorders. The examination these days requires videostroboscopy to exclude structural defects that cannot be detected with a laryngeal mirror, as already discussed. The clinic team can then replay the recording in slow motion so that they can observe and discuss the patient’s voice production patterns. The recording can then be used to provide an explanation of the problem for the patient.

The laryngologist will also be closely involved in taking the clinical history, in order to diagnose concomitant medical problems. This ensures that the patient receives any appropriate investigations which may be requested, either in clinic or by returning the patient to the GP, who will then take over and arrange appropriate investigation or medication.

The speech and language therapist

The speech and language therapist should always be present at the examination, and actively involved in the history taking and diagnosis of vocal function. Together with the laryngologist, the speech and language