Part V Vocal Health, Voice Therapy and Surgery

What about voice therapy?

Voice therapy is generally provided under the supervision of a certified, licensed, speech-language pathologist (SLP). An SLP usually has a master's degree or Ph.D. and is a trained health professional. However, an individual's training may or may not include skills in the management of voice disorders. SLPs care for many other problems such as swallowing therapy following strokes. Hence, it is important to find an SLP with special interests, training, and expertise in voice problems.

Therapy generally begins with procedures to analyze the voice problem. The analysis process includes subjective assessment by the SLP, as the patient speaks and performs a variety of vocal tasks. Objective voice analysis is also extremely helpful and is available in more sophisticated centers. The process uses a variety of instruments to measure, quantify and analyze various aspects of the voice-producing system. The information obtained from voice therapy can be extremely helpful when designing voice therapy that accomplishes the desired goals optimally and quickly. 

Voice therapy is really a form of physical therapy for the voice. It usually involves exercises that help a person eliminate abusive vocal habits, relax unnecessarily tense muscles, and learn to use the voice efficiently and effectively. Patients need to practice between therapy sessions in order to achieve the desired results. Therapy generally results in an improvement in vocal quality, ease, and endurance. In some cases, it may also produce resolution (cure) of structural abnormalities such as nodules. 

What should be considered when voice surgery is contemplated?

Surgery can cure many voice problems, but it may also result in complications that worsen the voice. Scar tissue occurs in response to trauma, including surgery. If scar tissue replaces the normal anatomic layers, the vocal fold becomes stiff and a-dynamic (non-vibrating). This results in asymmetric, irregular vibration with air turbulence that we hear as hoarseness, and/or incomplete vocal fold closure allowing air escape which makes the voice sound breathy. Such a vocal fold may look normal on traditional examination but will be seen as abnormal under stroboscopic light. Conveniently, most benign pathology (nodules, polyps, cysts, etc.) is superficial. Consequently, surgical techniques have been developed to permit the removal of lesions from the epithelium or superficial layer of the lamina propria without disruption of the intermediate or deeper layers in most cases. All of these delicate microsurgical techniques are now commonly referred to as phonosurgery, although the term was originally introduced by Dr. Hans Von Leden in referring to operations designed to alter vocal quality or pitch.

Most voice surgery is performed through the mouth after placement of a metal tube called an operating laryngoscope, utilizing a microscope, and is called endoscopic (or internal) laryngeal surgery. Surgical treatment of laryngeal abnormalities can be performed using microscopic scissors and other instruments, or lasers. Lesions involving the vibratory margin are still removed most safely using traditional instruments and magnification through an operating microscope. Such lesions include nodules, polyps, and cysts that have not responded to voice therapy. Current techniques allow the surgeon to remove virtually nothing but the diseased tissue. Such a traumatic surgery may not even require post-operative voice rest, and rapid healing with good voice quality usually follows. Although lasers are "high tech," they are not always the best choice for laryngeal surgery -- at least not the lasers currently utilized.

The potential problem with the carbon dioxide (CO₂) laser in standard surgical use is the associated heat which may damage surrounding tissues. At the power densities required for surgical ablation and the laser beam spot diameters generally used, there is a heat halo around the beam. When used on the vocal fold edge, the heat may be sufficient to provoke scarring. This produces an a-dynamic segment on the vocal fold and hoarseness. The CO₂ laser is, however, extremely useful for selected lesions such as varicosities that lead to vocal fold hemorrhages, vaporization of blood vessels that supply laryngeal polyps, papillomas (lesions caused by the wart virus), and selected cancers. 

When surgery is indicated for vocal fold lesions, it should be limited as strictly as possible to the area of abnormality. Virtually no place exists for "vocal cord stripping" in patients with voice problems. Even when there is good reason to suspect malignancy, more precise surgery can and should be performed in most cases. 

A detailed discussion of laryngeal surgery is beyond the scope of this publication. However, a few points are worthy of special emphasis. Surgery for vocal nodules should be avoided whenever possible and should almost never be performed without an adequate trial of expert voice therapy, including patient compliance with therapeutic suggestions. In most cases, a minimum of 6 to 12 weeks of observation should be allowed while the patient is using therapeutically modified voice techniques under the supervision of a certified speech-language pathologist and possibly a singing teacher. Proper voice use rather than voice rest (silence) is correct therapy. The surgeon should not perform surgery prematurely for vocal nodules under pressure from the patient for a "quick cure" and early return to voice performance. Permanent destruction of voice quality is a very real complication. Even after expert surgery, voice quality may be diminished by submucosal scarring. This situation produces a hoarse voice with vocal folds that appear normal on routine indirect (mirror) examination, although under stroboscopic light the a-dynamic segment is obvious. No reliable cure exists for this complication.

There are also other potential complications of voice surgery. Although they are uncommon or rare, they may be seen occasionally even if the surgeon and patient do everything right. They include the following (among others): 1) swelling with airway obstruction requiring tracheotomy; 2) chipping or fracture of a tooth by the laryngoscope; 3) bleeding; 4) infection; 5) recurrence of the problem (or a new mass such as a cyst or granuloma) requiring additional therapy (medications, voice therapy and/or surgery); 6) injury to the larynx, such as arytenoid dislocation; and others.

New techniques of external laryngeal surgery to modify the laryngeal skeleton have become extremely useful in treating vocal fold paralysis, a common consequence of viral infection, surgery, and cancer. Until recently, vocal fold paralysis was most often managed by endoscopic injection of Teflon into the tissues beside the paralyzed vocal fold. This pushed the paralyzed side toward the midline, allowing the normal vocal fold to meet it, thus permitting glottic closure and improving the voice. Although Teflon is relatively inert, granulomatous reactions to the foreign body are not uncommon, and stiffness of the vocal fold edge frequently impairs voice quality. Teflon infiltrated into tissues is hard to remove if the results are unsatisfactory. Teflon injection has been largely replaced by fat injection or thyroplasty. Thyroplasty is a technique in which a window is cut in the laryngeal skeleton, and a piece of the thyroid cartilage is depressed inward and held in place with a silicone block. This pushes the vocal fold toward the midline fairly reversibly, without injecting a foreign body into the tissues. We have also introduced an injection technique similar to Teflon, which uses the patient's own fat, harvested from the abdomen. This eliminates the disadvantages of Teflon, but it may have other problems such as resorption of the fat in some cases. Fat may also be used to improve vocal fold scar in selected cases.

Can surgery change the pitch of a voice?      

Surgery of the laryngeal skeleton can also be used to modify vocal pitch. Although such operations are done infrequently, they are valuable in certain circumstances. By closing the space between the cricoid and thyroid cartilages (an extreme version of cricothyroid muscle function), the vocal folds can be lengthened and tensed, and the voice raised. By cutting out vertical sections of the thyroid cartilage, the vocal folds can be shortened and their tension decreased, lowering the pitch. While these techniques are not sufficiently predictable for elective use in singers or other professional voice users, they are valuable in treating selected voice abnormalities and in altering vocal pitch in patients who have undergone transsexual surgery.

What can be done about a voice that is worse after surgery?

Too often, the laryngologist is confronted with a desperate patient whose voice has been "ruined" by vocal fold surgery, recurrent or superior laryngeal nerve paralysis, trauma, or some other tragedy. Occasionally, the cause is as simple as a recently dislocated arytenoid that can be reduced. However, if the problem is an a-dynamic segment, decreased bulk of one vocal fold after "stripping," bowing caused by superior laryngeal nerve paralysis, or some other serious complication in a mobile vocal fold, great conservatism should be exercised. Voice therapy is nearly always helpful in optimizing compensatory strategies and minimizing fatigue, but it usually will not restore the normalcy of the patient's voice. None of the available surgical procedures for these conditions is consistently effective. If surgery is considered at all, the procedure and prognosis should be explained to the patient realistically and pessimistically. It must be understood that the chances of returning the voice to excellent quality are slim and that it may be made worse. Zyderm Collagen [Xomed] injection and fat injection are currently the most common approaches in these difficult cases. However, a great deal more research will be needed to determine the efficacy of the treatments currently available for vocal fold scarring and to establish the treatment of choice. 

How can the voice be kept healthy?

Preventive medicine is always the best medicine. The more people understand their voices, the more they will appreciate their importance and delicacy. Education helps us understand how to protect the voice, train and develop it to handle our individual vocal demands, and keep it healthy. Even a little bit of expert voice training can make a big difference. Avoidance of abuses, especially smoke, is paramount. If voice problems occur expert medical care should be sought promptly. Interdisciplinary collaboration among laryngologists, speech-language pathologists, singing teachers, acting teachers, many other professionals, and especially voice users themselves has revolutionized voice care since the early 1980s. Technological advances, scientific revelations, and new medical techniques inspired by an interest in professional opera singers have brought a new level of expertise and concern to the medical profession and improved dramatically the level of care available for any patient with voice dysfunction.

How can a "normal" voice be made better? 

Voice building is possible, productive, and extremely gratifying. Speaking and singing are athletic. They involve muscle strength, endurance, and coordination. Like any other athletic endeavor, voice use is enhanced by training that includes exercises designed to enhance strength and coordination throughout the vocal tract. Speaking is so natural that the importance of training is not always obvious. However, running is just as natural. Yet, most people recognize that, no matter how well a person runs, he or she will run better and faster under the tutelage of a good track coach. The coach will also provide instruction on strengthening, warm-up, and cool-down exercises that prevent injury. Voice training works the same way.

Voice building starts with physical development. Once vocal health has been assured by medical examination, training is usually guided by a voice trainer (with schooling in theater and acting voice techniques), a singing teacher, or a speech-language pathologist. In the author's setting, all three specialists are involved under the guidance of a laryngologist, and additional voice team members are utilized, as well, including a psychologist or psychiatrist (for stress-management), pulmonologist, neurologist, and others. Initially, training focuses on the development of physical strength, endurance, and coordination. This is accomplished not only through vocal exercises but also through medically supervised bodily exercise that improves aerobic conditioning and strength in the support system. Singing skills are developed (even in people with virtually no singing talent at all) and used to enhance speech quality, variability, projection, and stamina. For most people, marked voice improvement occurs quickly. For those with particularly challenging vocal needs, voice building also includes training and coordinating body language with vocal messages, organizing presentations, managing adversarial situations (interviews, court appearances, etc.), television performance techniques, and other skills that make the difference between a good professional voice user and a great one. 

The process of voice building is valuable not just for premiere professional voice users. Virtually all of us depend upon our voices to convey our personalities and ideas. The right subliminal vocal messages can be as important in selling a product or getting a job as they are in winning a presidential election. The initial stages of voice building are no more complex than the initial stages of learning to play tennis or golf, and their potential value is unlimited. A strong, confident, well-modulated voice quietly commands attention, convinces, and conveys a message of health, strength, youth, and credibility.