Glossary of Terms
Age-related voice changes
With normal aging, the voice changes. In men the pitch becomes higher, and in women the pitch drops. The volume and endurance of the voice decreases. Similar to the loss of muscle mass throughout the rest of the body, the muscles of the vocal folds also atrophy with age. This can cause thinning or “bowing” of the vocal folds decreasing the strength of closure of the vocal folds. Additionally, with age the mucus membranes become more dry and the cushioning layer over the muscles of the vocal folds thin. In general, maintaining overall body health can help improve voice health. Voice exercises under the direction of a speech language pathologist can help a person to regain strength of the voice. Procedures such as vocal fold injection augmentation and medialization thyroplasty can also help in refractory cases.
Amyotrophic Lateral Sclerosis (ALS) or Lou Gehrig’s disease is a debilitating progressive neurologic disease characterized by muscle weakness, atrophy, fasciculations, spasticity, difficulty articulating words, difficulty swallowing, and difficulty breathing. Patients sometimes present initially to the laryngologist with complaints of difficulty speaking or swallowing. While there is currently no cure for ALS, if a patient choses to use a ventilator to assist with breathing, Dr. Bergeron will perform a tracheostomy and help to manage the tracheostomy long-term.
Arytenoid repositioning surgery
Arytenoid repositioning surgery includes both arytenoid adduction and arytenopexy procedures. They are indicated for patients with a paralyzed vocal fold with a wide gap posteriorly (in the back of the voice box). This procedure is usually performed in conjunction with a thyroplasty or laryngeal reinnervation procedure.
Botox or Botulinum Toxin is a medication which when injected into a muscle weakens the muscle for usually a period of two to three months. In laryngology, Botox can be injected into the vocal folds to weaken the muscles of the larynx as a treatment for spasmodic dysphonia or laryngospasm. Botox injections to the vocal folds can also be used to chemically force a patient to rest his or her voice to allow certain lesions of the vocal folds to heal.
Cancer of the larynx
The most common type of laryngeal cancer is Squamous Cell Carcinoma. Risk factors for this type of cancer include smoking and drinking. Patients with laryngeal cancer may present with symptoms of hoarseness, pain, and even difficulty breathing. First the diagnosis of a cancer must be confirmed with a biopsy, then the cancer is staged with imaging, and recommendations are made for treatment.
A chest x-ray is an x-ray of the chest, lungs, heart, large arteries, ribs, and diaphragm.
Chronic cough can be a difficult entity to diagnose and treat. The source of the cough may be from above the voice box from sinus disease or postnasal drip. It may be from below the voice box from infection, inflammation or irritation in and around the lungs. It may be from acid reflux or other abnormalities in the esophagus. Lastly the cough may come from the infection, inflammation, irritation or dysfunction of the larynx. When all of these have been excluded the cause of the cough may be hypersensitivity of nerves to or from the larynx. Several medications have been recommended in the treatment of this disorder that calm the nerves and help to diminish the coughing.
Cricopharyngeal Dysfunction is a condition where the upper esophageal sphincter muscle does not appropriately relax to allow swallowed material to pass easily into the esophagus. Symptoms of cricopharyngeal dysfunction include a sensation of a lump in the throat, difficulty swallowing, feeling as if food gets stuck in the throat, and occasionally pain with swallowing. Temporary treatments of cricopharyngeal dysfunction include dilating or stretching the muscle or injecting botulinum toxin into the muscle. Long-term treatments include cutting the cricopharyngeal muscle either endoscopically or through an incision in the neck.
Cricotracheal resection is an open surgery to remove a portion of the cricoid and the trachea which is narrowed or stenosed. It is indicated for patients with narrowing of the airway below the vocal folds who have either failed more conservative treatments or no longer wish to pursue the required repeated treatments.
CT or MRI of neck and or chest
Computed tomography or CT uses X-rays while magnetic resonance imaging or MRI uses strong magnetic fields to create detailed images of the portion of the body scanned. During the test you will lie on a table which will then pass you through the CT or MRI scanner machine. For some studies you will have an IV placed and contrast material will be passed through the IV to allow better delineation of certain structures.
A vocal fold cyst is a membrane-bound sac which can be filled with mucus and is found underneath the surface of the vocal fold. A cyst can be very superficial or deeper into the vocal fold. Cysts often do not respond completely to voice therapy and can be removed with Phonomicrosurgery.
Dilation of airway stenosis
Some patients with subglottic or tracheal stenosis can be treated and managed well with dilation procedures to open the areas of narrowing. There are several different techniques available to dilate the airway including balloon dilation or rigid dilators with or without first cutting the scar with instruments or a laser. The technique chosen depends on the patient and the type of stenosis being treated. Depending on the cause of the stenosis, a patient may require multiple dilation procedures over time to keep the airway open.
Endoscopic cricopharyngeal myotomy
Cricopharyngeal myotomy is a procedure that cuts the main muscle of the upper esophageal sphincter. It is indicated when patients have a cricopharyngeus muscle that does not relax normally to allow food to pass with swallowing. An endoscopic cricopharyngeal myotomy is performed through a laryngoscope or a diverticuloscope passed through the patient’s mouth. Once exposed, the muscle is usually cut with a laser. Sometimes adequate exposure to perform the procedure endoscopically cannot be obtained, which may require the procedure to be performed instead through an incision in the neck.
Endoscopic Zenker’s diverticulotomy
A Zenker’s Diverticulum can be treated endoscopically through a diverticuloscope passed through the patient’s mouth. The diverticuloscope exposes the common wall between the diverticulum or pouch and the esophagus. This wall is then cut using either a stapling device or a laser. In cutting the common wall, we are also cutting the cricopharyngeus muscle, the main muscle of the upper esophageal sphincter which is theorized to be an underlying cause of developing a Zenker’s Diverticulum is cut to prevent recurrence of the diverticulum. In some patients adequate exposure cannot be obtained through the mouth, and the diverticulum must be treated with a transcervical approach with an incision in the neck.
Esophageal dilation is a procedure to enlarge the lumen of the esophagus. It is indicated when a patient has a narrowing of the esophagus from various causes. There are several different dilation techniques available and these techniques are individually tailored to the patient.
Esophageal Stenosis or stricture is an area of narrowing in the esophagus which can cause difficulty swallowing and even result in food or pills getting stuck in the esophagus. Esophageal stenosis or stricture is usually the result of scarring after an injury which causes inflammation. Examples of such injuries include radiation treatment, surgery, or chemical injury. Often times the area of narrowing can be treated with dilation procedures to improve symptoms.
An Esophagram is a study performed in radiology where the patient swallows barium, a type of contrast material easily seen on X-rays. Multiple X-rays are taken while the patient swallows to display the barium as it passes from mouth, through the throat, and through the esophagus to the stomach. Esophagrams are helpful in diagnosing disorders of the esophagus and pharynx which cause difficulty swallowing.
Flexible Endoscopic Evaluation of Swallowing
Flexible Endoscopic Evaluation of Swallowing (FEES) is a diagnostic study performed by either the laryngologist or speech language pathologist to assess swallowing. It is performed by visualizing the larynx and pharynx with a flexible laryngoscope passed through the nose while the patient swallows different consistencies of food or liquids.
A flexible laryngoscope is a very thin scope which passed through the nose to examine the pharynx and larynx.
Glottic stenosis is narrowing of the airway at the level of the vocal folds. It can cause hoarseness and difficulty breathing. Glottic stenosis is usually caused by scarring in the larynx from prolonged intubation, prior surgeries, infection, trauma or inhalational burn injury. Treatment of glottis stenosis depends on the cause, thickness or scar, area of scarring.
Laryngeal granulomas are benign and located on the posterior aspect (back end) of the vocal folds. They can be on one side or both sides of the larynx. Granulomas can cause severe throat pain and irritation of the throat, and even pain in the ear. They are associated with a history of intubation trauma, trauma from voice abuse or chronic cough, and acid reflux. Treatment of granulomas depends on the cause, size, and symptoms. Granulomas will very frequently come back if they are simply removed.
In-office laryngeal biopsy
For some patients with masses or lesions on the vocal folds who cannot undergo a direct laryngoscopy with general anesthesia in the operating room, biopsies can be performed in the clinic through a flexible laryngoscope. The patient’s throat is first anesthetized with topical numbing medicine. Then a flexible laryngoscope is passed through the patient’s nose to visualize the pharynx and larynx. Biopsy forceps are then passed through a working channel of the scope and biopsies are taken. The tissue is sent to the pathologists to obtain a diagnosis.
In-office steroid injections of some laryngeal lesions or scarring
Some lesions of the vocal folds or areas of scarring can be treated with steroid injections. This can be achieved with direct laryngoscopy with general anesthesia in the operating room or with local anesthesia in the office. In the office, the patient’s throat is first anesthetized with topical numbing medicine. Then a flexible laryngoscope is passed through the patient’s nose to visualize the pharynx and larynx. A needle is then either passed through a working channel of the laryngoscope or passed through the skin of the neck and used to inject steroids into the intended area.
In-office vocal fold injection augmentation
Vocal fold injection augmentation is used to treat glottic insufficiency due to vocal fold paralysis, paresis, bowing or atrophy related to aging of the vocal folds. The vocal fold is augmented by injecting filler directly into the vocal fold. This filler material plumps up the vocal fold to help close the glottic gap. This can be achieved with direct laryngoscopy with general anesthesia in the operating room or in the office. In the office, a flexible laryngoscope is passed through the patient’s nose to visualize the pharynx and larynx. A needle is then passed through the skin of the neck into the vocal fold, and the filler material is injected until the desired effect is achieved.
Laryngitis is defined as inflammation of the larynx, and it can cause a hoarse voice. Laryngitis can be can be acute (lasting less than 3 weeks) or chronic (lasting longer than 3 weeks). It can be caused by infections (viral, bacterial, or fungal) or noninfectious causes of inflammation (acid reflux, allergies, trauma, voice overuse or misuse, coughing, burn, or medications). The treatment of laryngitis depends on the underlying cause.
Laryngopharyngeal reflux (LPR), is the reflux of stomach contents to the throat which can then cause inflammation in the larynx and cause such symptoms as hoarseness, cough, globus sensation (feeling a lump in the throat), chronic throat clearing, and excess mucus or phlegm. LPR can be diagnosed by patient history, specific laryngoscopic exam findings, and by pH probe testing. Treatment of LPR is multifactorial involving both diet/lifestyle changes and medications.
Laryngoscopy is a procedure which obtains a view of the inside of the larynx.
Laryngotracheal reconstruction includes open surgical procedures to treat airway narrowing involving the vocal folds, subglottis and the upper trachea. The procedures are sometimes done in one stage and sometimes done in multiple stages. The procedure is always tailored to the specific needs of the patient.
Laser treatment of papillomas and other vocal fold lesions
An angiolytic laser such as the KTP laser can be used to treat certain disorders of the larynx such as papillomas, varices, polyps, and leukoplakia. This can be achieved with direct laryngoscopy with general anesthesia in the operating room or with local anesthesia through a working channel scope.
The term leukoplakia literally means “white patch.” A white patch on the larynx can be caused by infection, inflammation, pre-cancerous lesions, and early cancers. These lesions are treated in different ways depending on the underlying cause.
Medialization Thyroplasty or Isshiki Type I Thyroplasty is a procedure performed to improve voice in patients with glottic insufficiency. The insufficiency may be due to vocal fold paralysis, paresis, bowing or atrophy related to aging of the vocal folds. The procedure is done with the patient awake with twilight anesthesia and local anesthesia injected into the operative site (the neck). An incision is made in the center of the neck to expose the cartilages of the larynx. A hold is made in the thyroid cartilage of the larynx and a small brace or implant of either silicone or Gortex is placed through this hole to support and even move the affected vocal fold into a better position for speaking. We have the patient speak as we form the implant into the appropriate size and shape.
Modified Barium Swallow Study
A modified barium swallow study is ordered for patients with difficulty swallowing. It is performed by a speech language pathologist with radiology. The patient is given different consistencies of barium to swallow while several X-rays are taken during the swallow. This allows the radiologist and the speech language pathologist to assess swallowing abnormalities and the safety of eating and drinking.
Vocal fold nodules are referred to as “calluses” on the vocal folds. They are found on the mid-portion of the true vocal folds bilaterally. Nodules, also known as nodes or singer’s nodules, are usually the result of voice overuse, misuse, abuse, or excessive coughing. The initial treatment of vocal fold nodules is with voice therapy with or without voice rest.
Papillomas are benign, warty lesions caused by certain strains of the Human Papilloma Virus (HPV). They can occur anywhere in the mouth, nose, and throat. When they occur on the vocal folds they can cause hoarseness and even difficulty breathing. While the lesions are commonly removed surgically with many possible techniques, they frequently recur.
Paradoxical Vocal Fold Motion and Laryngospasm
Paradoxical Vocal Fold Motion (PVFM) occurs when the vocal folds paradoxically close instead of opening during inspiration. This results in difficulty breathing and even noisy breathing. It is often confused with asthma and may require pulmonary function testing to determine the diagnosis. Laryngospasm occurs when PVFM is so severe that the vocal folds close or spasm together entirely blocking off the airway. Laryngospasm, though quite frightening is temporary and will break. There are many potential triggers to PVFM/laryngospasm and they are thought to be related to laryngopharyngeal reflux (LPR). In addition to treating LPR if present, PVFM and laryngospasm are treated with breathing recovery exercises taught by a speech language pathologist.
Parkinson’s disease is a degenerative disorder of the central nervous system with symptoms such as tremor, rigidity and slowness of movement. Parkinson’s disease can also affect the voice. The most common voice change in Parkinson’s disease is hypophonia or reduced volume of speech. One treatment option for Parkinson’s hypophonia is specialized speech therapy with a technique called Lee Silverman Voice Treatment (LSVT) to help a person regain strength in the voice. Some patients with Parkinson’s disease develop weakness and bowing of both vocal folds. When this happens a person is left with a very breathy voice due to glottic insufficiency. If this is the cause of hoarseness treatment options may include vocal fold injection augmentation or medialization thyroplasty.
Phonomicrosurgery includes a variety of procedures with the goal of improving voice quality by precisely removing or treating benign lesions of the true vocal folds.
Vocal fold polyps can occur in many different shapes and sizes usually on one vocal fold. It is often the result of voice misuse or abuse. Some polyps can be treated with voice therapy, while some are best treated with Phonomicrosurgery to remove the lesion.
Radiation-related swallowing disorders
Patients who have undergone radiation treatment to the head and neck may develop difficulty swallowing from tissue changes caused by the radiation. These changes include dry mouth, scarring with narrowing of the throat, and scarring with weakness of the muscles used for swallowing. Narrowing of the throat is sometimes treated with surgery to open the throat while many of the other radiation-related causes of dysphagia are treated with swallowing therapy with a speech language pathologist.
Reinnervation of the paralyzed vocal fold
A paralyzed vocal fold does not move and is usually bowed and loose. Because of the bowing, even if the other vocal fold is able to come together and meet the paralyzed vocal fold the lack of tone or bulk prevents adequate vibration. Laryngeal reinnervation for vocal fold paralysis does not restore vocal fold motion; however, it can increase vocal fold tone and decrease bowing. If the vocal fold is in an appropriate position (usually with an arytenoid repositioning procedure) the improved tone from the reinnervation will improve the quality of the voice by decreasing the breathiness.
A rigid laryngoscope is a rigid telescope angled at 70 or 90 degree which is passed along the tongue to the back of the throat to look down at the larynx.
Spasmodic dysphonia, also called laryngeal dystonia, is a voice disorder characterized by involuntary spasms or movements in the muscles of the larynx, which causes the voice to break, and have a tight, strained, or strangled sound. It most often affects women, particularly between the ages of 30 and 50. The cause of spasmodic dysphonia is not known, but most cases are believed to be caused by a nervous system disorder and may occur with other movement disorders.
There are three main types of spasmodic dysphonia:
Adductor spasmodic dysphonia: Characterized by sudden involuntary spasms that cause the vocal cords to close and stiffen. The spasms interfere with vibration of the vocal cords and production of sound is difficult. Stress can make spasms more severe. Speech sounds are strained and full of effort. Spasms do not occur when whispering, laughing, singing, speaking at a high pitch, or speaking while breathing in.
Abductor spasmodic dysphonia: Characterized by sudden involuntary spasms that cause the vocal cords to open. Vibration cannot occur when cords are open so production of sound is difficult. Also, the open position allows air to escape during speech. Speech sounds are weak, quiet, and whispery. Spasms do not occur when laughing or singing.
Mixed spasmodic dysphonia: Characterized by symptoms of both adductor and abductor spasmodic dysphonia.
These 3 types can occur with or without tremor.
Spasmodic dysphonia treatment is be determined by your physician based on a patient’s age, overall health, medical history, extent of the disease, tolerance for specific medications, procedures, or therapies, expectations for the course of the disease, and opinion or preference. The goal of treatment is to reduce symptoms of the disorder. Periodic botulinum toxin injections to one or both vocal cords can often relieve symptoms.
More information and resources for Spasmodic Dysphonia can be found at the National Spasmodic Dysphonia Association website: http://www.dysphonia.org/
A stroke is the rapid loss of brain function due to loss of blood supply to a portion of the brain. The symptoms of a stroke depend on the area of the brain that is affected. If the area that controls the muscles of the throat, tongue or vocal folds area affected, a person may develop voice changes or difficulty swallowing after a stroke. If the cause of the voice change is dysarthria (difficulty articulating speech), a patient may be treated with speech therapy to help a person gain strength and coordination of the muscles of the tongue. If the voice change is from a paralyzed vocal fold, a patient may be given several options of treatment such as voice therapy, vocal fold injection augmentation, or medialization thyroplasty. Difficulty swallowing after a stroke may be from many different causes. It is important to first assess the safety of swallowing, discern the cause of the difficulty swallowing, and then initiate treatment which often involves swallow therapy.
Subglottic Stenosis is narrowing of the airway below the level of the vocal folds. It usually causes shortness of breath with noisy breathing. Causes of subglottic stenosis include intubation, external neck trauma, tracheostomy, chronic infection, and chronic inflammatory diseases such as Wegener’s Granulomatosis or Sarcoidosis. Some patients with subglottic stenosis have none of the above known causes and are categorized as idiopathic subglottic stenosis (which means subglottic stenosis of unknown cause). Treatment of subglottic stenosis includes dilation procedures, steroid injections, and resection procedures depending on the severity, type and location of the stenosis.
Supraglottic stenosis is narrowing of the airway above the level of the vocal folds. It can cause difficulty breathing and swallowing, and can occur as a result of radiation treatment to the head and neck. Supraglottic stenosis can sometimes be treated with surgery to help widen the area which is narrowed.
Swallow therapy can be used to treat many different causes of difficulty swallowing. It is conducted through sessions with a speech language pathologist teaching the patient techniques and exercises to improve swallowing.
Tracheal resection is an open surgery to remove a portion of the trachea which is narrowed or stenosed. It can be performed in patients who have isolated narrowing only involving the trachea. . It is indicated for patients with narrowing of the airway below the vocal folds who have either failed more conservative treatments or no longer wish to pursue the required repeated treatments.
Tracheal stenosis is narrowing of the airway in the trachea (wind pipe). It usually causes shortness of breath with noisy breathing. Causes of tracheal stenosis include intubation, prior tracheal surgery, tracheostomy, external tracheal trauma, chronic infection, and chronic inflammatory diseases. Tracheal stenosis may also be idiopathic, which means the cause is unknown. Treatment of tracheal stenosis includes steroid injections, dilation procedures and resection procedures depending on the severity, type and location of stenosis.
A tracheoesophageal puncture is one of the speaking options for patients following a total laryngectomy. A hole is surgically created between the trachea and the esophagus (tracheoesophageal puncture) within the laryngectomy stoma. A One-way speaking valve is placed in this small hole. This valve allows the patient to force air through the hole into the esophagus when the patient covers his or her laryngectomy stoma and breaths out. The air passing through the esophagus causes the walls of the pharynx to vibrate mimicking the vibration of vocal cords to create sound used for speech.
Transcervical cricopharyngeal myotomy
Cricopharyngeal myotomy is a procedure that cuts the main muscle of the upper esophageal sphincter. It is indicated when patients have a cricopharyngeus muscle that does not relax normally to allow food to pass with swallowing. A transcervical cricopharyngeal myotomy is performed through an incision in the neck (usually on the left side).
Transcervical treatment of Zenker’s diverticulum
A Zenker’s Diverticulum can be treated through an incision in the neck (usually on the left side). The diverticulum or pouch is usually removed (and rarely pexied or stitched up). Additionally the tight cricopharyngeus muscle, the main muscle of the upper esophageal sphincter which is theorized to be an underlying cause of developing a Zenker’s Diverticulum is cut to prevent recurrence of the diverticulum.
Esophagoscopy is a procedure where a scope is passed through the nose behind the larynx and into the esophagus to examine the entire length of the esophagus for masses, lesions or abnormalities. This can be used to assess for causes of difficulty swallowing. Transnasal esophagoscopy is performed in the office without any general anesthesia. After applying a topical anesthetic to the patient’s nose, the flexible esophagoscope is passed through the patient’s nose, through the pharynx and into the esophagus. It is passed all the way to the stomach and then withdrawn slowly, examining the entire length of the esophagus. If an abnormality is seen requiring a biopsy, the biopsy can be performed at that time with flexible biopsy forceps through a working channel of the flexible esophagoscope.
Varices or ectasias of the vocal folds are enlarged blood vessels on the surface of the vocal folds. They may cause problems if they rupture causing a vocal fold hemorrhage, or if they affect the ability of the vocal folds to vibrate normally.
Vocal fold hemorrhage
A vocal fold hemorrhage is blood that has leaked out of an injured blood vessel and into the true vocal fold. It is essentially a bruise within the vocal fold. It can be caused by vocal abuse and misuse especially in the setting of a varix (enlarged blood vessel) on the surface of the vocal fold. It is treated initially with voice rest and possible voice therapy. The underlying cause should also be treated to prevent recurrence.
Vocal fold paresis/paralysis
Normally the vocal folds move symmetrically, opening or separating with inspiration and closing or coming together with talking or coughing. These movements are controlled by the recurrent laryngeal nerve on each side of the larynx. Vocal fold paresis or paralysis is caused by damage or injury to the neurologic input to the larynx.
Unilateral: If one of the vocal folds does not move appropriately it can cause hoarseness with a breathy voice. This is when the vocal folds do not come all the way together to vibrate against each other resulting in a gap or space between the vocal folds. This space between the vocal folds can be closed through both temporary and permanent treatment options including vocal fold injection augmentation, medialization thyroplasty, laryngeal reinnervation, and arytenoid repositioning surgeries.
Bilateral: If both of the vocal folds do not move appropriately, a patient may have difficulty breathing from the vocal folds not being open enough, or hoarseness if the vocal folds are not close enough together. In some cases, patients require a tracheostomy to breath comfortably. While procedures can be done to both improve the voice or the airway in the setting of bilateral vocal fold paralysis, it is a balance between breathing and talking. If breathing improves, generally the voice worsens, and the risk of difficulty swallowing increases. If the voice improves, breathing may become more difficult.
Vocal fold scarring
Scarring of the vocal folds, often due to injury or trauma, causes thick and stiff tissue to replace the normal soft and pliable tissue of the vocal folds, which can disrupt the vibrations of the vocal folds. This disrupted vibration can cause hoarseness and difficulty maintaining a consistent voice.
Voice therapy can be used to treat many different vocal fold lesions and causes of hoarseness. It is conducted through sessions with a speech language pathologist who teaches the patient techniques and exercises to improve protect and improve the voice.
A Zenker’s Diverticulum is an outpouching of the in the throat just above an abnormally tight upper esophageal sphincter. Patients classically present with regurgitation of swallowed material from the pouch. They may also have generalized difficulty swallowing and even aspiration. Treatment options include endoscopic and open surgical treatment.