Treatment Options for Voice Conditions

Treatment options for voice disorders

The Cleveland Clinic voice Center is a center of excellence within the Head & neck institute that is dedicated to the treatment of voice disorders, particularly those of the professional voice user. Through a team approach, voice Center specialists tailor voice disorder treatment plans to their patients needs. ear, nose and throat specialists, speech pathologists and voice teachers provide primary services in conjunction with other medical specialists. The voice Center coordinates care of its patients with Cleveland Clinics Center for Performance Medicine, Arts and Medicine institute and Wellness institute. This guide provides an overview of the services and voice disorder treatment options offered through the voice Center.

Cleveland Clinics ear, nose and throat program is ranked no. 8 in the nation, according to U.S.News & World Report.

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About voice disorders

Symptoms of a voice disorder can include hoarseness, roughness of the voice, discomfort when talking or singing, and loss of singing control. The cause of these symptoms cannot be determined without the evaluation of a voice disorder specialist.

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Types of voice disorders

Cancer of the larynx The inner walls of the larynx (voice box) are lined with cells called squamous cells. Almost all laryngeal cancers begin in these squamous cells. If not caught early, laryngeal cancer can spread (metastasize) to nearby lymph nodes in the neck. If caught early, laryngeal cancer is very treatable. Functional dysphonia is a condition in which the voice becomes very hoarse in the absence of vocal fold or laryngeal pathology (disease). Hoarseness is a general term that describes abnormal voice changes. When hoarse, the voice may sound breathy, raspy, strained or inconsistent, or there may be changes in volume, clarity or pitch of the voice. Laryngitis is an inflammation of the true vocal folds or larynx in general (voice box) that causes hoarseness or the complete loss of voice. Laryngopharyngeal reflux disease is caused by the regurgitation of stomach acid up into the throat. This reflux can cause inflammation and swelling in the throat or in the larynx (voice box) and can cause hoarseness, a sense of a lump in the throat (also known as globus sensation), a sense of mucous sticking or a need to frequently clear the throat. Laryngeal stenosis is a narrowing of the airway typically caused by prior trauma to the vocal folds, joints that move the vocal folds, or the airway immediately below the vocal folds. Common causes of stenosis include trauma from intubation, prolonged placement of an endotracheal tube, or the placement of an endotracheal tube that is too large for the airway. Stenosis is also seen in patients with chronic autoimmune diseases such as Wegeners Granulomatosis and rheumatoid arthritis. Muscle tension dysphonia is a condition in which there is an imbalance of muscle tone in the muscles related to voice, causing hoarseness and vocal fatigue. Polypoid Corditis, also known as Reinkes edema, is chronic swelling of the vocal folds due to cigarette smoking. This typically causes hoarseness and will recur following surgery if the patient continues to use tobacco.

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Types of voice disorders Continued

vocal fold lesions or masses are noncancerous (benign), abnormal growths within or along the vocal fold that impair normal vocal fold vibration and cause hoarseness. These lesions include nodules, polyps or cysts. They are treated by voice therapy, surgery, and sometimes both. vocal fold paralysis is the immobility of one or both vocal folds, causing problems with either hoarseness or breathing. This requires a formal diagnostic workup. Short- and long-term voice rehabilitation typically involves surgery, voice therapy or both. vocal fold scarring results from damage to or gradual loss of the pliable layer of the vocal folds. This can occur as a result of damage from repetitive trauma from poor vocal hygiene, vocal abuse, intubation injury, congenital vocal fold lesions, surgery or aging.

Professional voice disorders Many people who use their voices for a living, including singers, teachers, coaches, clergy, salespersons and other public speakers, may experience temporary or more long-lasting problems with their voices. These problems may be experienced as increased vocal fatigue, decreased volume, decreased vocal clarity or discomfort after speaking or performing. Persistence of such symptoms should prompt a visit to a voice specialist. recurrent respiratory papillomatosis is a disease in which papillomas or wart-like lesions grow along the surfaces of the larynx or vocal folds or, occasionally, along the respiratory tract leading from the trachea into the lungs. The papillomas, which are caused by the human papilloma virus, are typically a chronic problem characterized by irregular recurrence patterns. This causes hoarseness, but can occasionally cause breathing problems if the papillomas involve the lower airways. Laryngeal papillomatosis can affect adults, children and infants. This disease typically requires repeated procedures to remove the papillomas. There is no cure for this disease at this time. Spasmodic dysphonia is a localized muscle disorder of the larynx that causes the voice to have a spastic strained or breathy quality. Swallowing disorders Dysphagia, or difficulty while swallowing, can be caused by a number of possible conditions including cancer, surgery or radiation for cancer, laryngopharyngeal reflux, degenerative neurologic conditions, strokes and esophageal motility problems. A multidisciplinary approach involving speech pathologists, otolaryngologists (ear, nose and throat doctors), gastrointestinal specialists, and neurologists is often required for appropriate diagnosis and treatment. vocal fold dysfunction is a condition characterized by episodes of shortness of breath, caused by inappropriate movement of the vocal folds, resulting in a functional upper airway obstruction. Breathing and laryngeal-control therapy are very effective treatments for this condition.

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voice Center Services

our full range of voice care services and state-of-the-art facilities help us to provide optimal care for voices in need. We treat major problems and minor disorders and offer personal consultations and comprehensive evaluations to stop potential problems before they start.

voice evaluation
To evaluate voice issues, Voice Center specialists utilize state-of-the-art technology to assess laryngeal biomechanics and vocal fold oscillation. Cleveland Clinic Voice Center staff members perform physical exams and specialized tests on each patient to determine the nature and extent of their voice disorders. These tests include voice recording and analysis, high-resolution video analysis via a flexible or rigid endoscope, and videostroboscopy (a procedure in which the oscillation and pliability of the vocal folds is evaluated). Formal airway evaluation also can be performed. The endoscopes visualize the vocal folds or airway via the nose or mouth and are generally well tolerated.

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office-based procedures offer patients immediate benefits and allow voice specialists to evaluate the effectiveness of the treatment as it is being done: Botulinum toxin (BoToX) injections are used for the temporary treatment of spasmodic dysphonia, typically improving the quality of the voice for a period of time that ranges between three and four months. The procedure is simple and has had predictably good results, with most patients experiencing a return to normal or near normal voice. vocal fold injection for the short-term treatment of vocal fold paralysis, paresis, or age-related vocal fold bowing. Laser surgery for the treatment of vocal fold lesions including laryngeal papillomatosis, vascular lesions and laryngeal dysplasia. It is common for patients to initially undergo surgical treatment in the operating room for these conditions and then transition to office-based management. Surgical therapy includes procedures to remove be-

Treatment options
Most voice problems can be managed successfully without surgery through behavioral change and medical care. If surgery is necessary, specialized techniques that limit harm to laryngeal tissues and strive to preserve the pliable, layered microstructure of the vocal folds, are employed by our surgeons. The Voice Center offers the following treatment options for various voice disorders: voice therapy - the use of vocal and physical exercises, along with behavioral changes, to treat voice disorders and improve vocal health. Laryngeal manipulation - a technique for manually repositioning the larynx to reduce irregular muscle tenion and improve voice quality. Medical therapy may sometimes be used to treat laryngitis, acid reflux or post-nasal drainage from allergies or infection that causes laryngeal irritation.

nign, pre-malignant and malignant masses or lesions as well as temporary or more permanent procedures to rehabilitate vocal cord paralysis. vocal fold medialization procedures to rehabilitate unilateral vocal fold paralysis are typically done under local anesthesia with light sedation. vocal fold injection and microsurgery of the vocal folds are performed through a specialized scope with microsurgical instruments. Some surgical procedures will use laser technology. Some vocal fold surgeries will require a period of complete voice rest. Surgery is typically outpatient or requires a brief stay in the hospital. Postoperative discomfort is typically brief but patients may experience a sore throat, hoarseness, temporary numbness of the tongue, or brief alteration in taste. Each surgical plan is individualized to the patients medical and vocal situation.

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Care of the Professional and Performing voice

The Cleveland Clinic Voice Center, one of only a handful of complete, dedicated voice treatment centers in the country, specializes in helping voice professionals perform better, prolong their careers and preserve their voice health. A laryngologist (a sub-specialized ear, nose and throat doctor) and a speech-language pathologist conduct evaluations to determine the cause of the voice problem. The examination includes a formal history and voice recording as well as a complete head and neck examination and appropriate general medical examinations, depending on the patients overall health history. A direct evaluation of the vocal folds usually is performed via videostroboscopy. The voice team uses the information gathered to diagnose the problem and to guide treatment. The patients voice teacher or personal doctor may be included in the treatment planning. There may be times in which the professional voice user needs to be evaluated at the theater or studio. The voice team can give the performer images or videos of his or her vocal folds to be used to evaluate response to treatment and to have available should treatment be needed in other centers.

216.4 45.TA LK
or 800.223.2273, ext. 58255

voice Center Specialists

Tom Abelson, Md

richard Freeman, Md

Call 216.445. TALK or 800.223.2273, ext. 58255, to make an appointment with experts in the voice Center.

Paul Bryson, Md

douglas Hicks, Phd

Michael S. Benninger, Md

Claudio Milstein, Phd

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216.4 45.TA LK
or 800.223.2273, ext. 58255