Cancers and other conditions that develop in the voicebox, or larynx, may not be commonplace, but they do present unique challenges related to preserving a patient's voice. Laryngeal surgery is generally recommended for laryngeal cancer, which affects the aerodigestive tract. This tract includes the upper digestive and respiratory organs, such as the mouth, vocal cords, nose, throat, and windpipe. Aerodigestive-related conditions usually appear as a sore throat, or difficulty speaking, swallowing, or breathing. Some aerodigestive illnesses can be treated with medicine, while others require surgery.
Who should have laryngeal surgery?
People who have benign aerodigestive tract lesions such as polyps, nodules, and cysts can sometimes be removed by surgery. Vocal professionals such as singers, teachers, public speakers, and sales people tend to have high incidence of these lesions, says Nwanmegha Young, MD, director of the Yale Medicine Speech and Swallow Surgery Program.
Swallowing issues have many causes, including Zenker’s Diverticulum and cricopharyngeal achalasia. Dr. Young performs endoscopic laser surgery in these cases. This is minimally invasive, leaves no scar and patients go home the same day.
Some disorders can be more difficult to diagnose. “Subglottic stenosis, which causes a narrowing of the airway below the vocal cords, is often mistaken for other disorders such as asthma or bronchitis,” Dr. Young says. “Neurological diseases are also underdiagnosed or misdiagnosed. For example, spasmodic dysphonia constricts the voice muscles in the larynx, causing spasms and choppy voice breaks. When this is misdiagnosed as stuttering, people get sent to a psychologist.”
How are laryngeal disorders diagnosed?
Evaluation usually uses a team-based approach. Patients generally meet with an otolaryngologist and a speech pathologist for a comprehensive evaluation. These evaluations may also include pulmonary, neurology, and GI specialists.
An assessment includes a comprehensive history and physical exam to check for issues such as nerve compression or thyroid gland problems, as well as a laryngeal examination to look at the patient’s larynx and throat. One of the most common diagnostic tests is a direct laryngoscopy. For this procedure, the doctor inserts a thin, flexible fiberscope through the nose or mouth into the throat.
“A direct laryngoscopy with a fiberscope is the best way to image the larynx itself,” Dr. Young says. “Whereas, a stroboscopy, a specific type of laryngoscopy that uses strobe light, is the best method to image the vocal fold function.”
Both procedures can be performed in the office with local anesthesia.
Depending on the patient’s symptoms, others tests may be needed. These might include a reflux test, X-ray, biopsy, or additional endoscopic examination such as functional endoscopic evaluation of swallowing (FEES). In some cases, the doctor may order a laryngeal electromyography, a diagnostic procedure that uses an extremely fine needle to test the strength of the vocal nerves.
What surgical procedures are available for laryngeal disorders?
The three most common surgical procedures for all types of voice and swallowing procedures are:
Laser surgery of the vocal cord. Also called microlaryngoscopy or laryngeal microsurgery, this minimally invasive surgery uses special lasers to treat diseases of the vocal cord, including benign lesions, cancer of the vocal cord, and tumors. Laser surgery is performed in an operating room under general anesthesia and usually lasts 60 to 90 minutes, depending on the case. Patients generally go home the same day. “The vocal cords produce sound and are responsible for character of the voice, so there are many techniques we use to remove the disease, but we always try to maintain or restore the voice,” Dr. Young says.
Laryngeal framework surgery. This surgical technique modifies the cartilage where the muscles attach to the vocal cords, to help vocal cords close better or have more tension. The result is that the vocal folds vibrate and create better sound for speaking and singing. Laryngeal framework surgery is used to treat patients with vocal cord paralysis or laryngeal stenosis, to restore the original shape of their larynx. It also can be used to treat people who have had cancer, surgery that caused nerve damage or a trauma to the larynx. The surgery is performed with local anesthesia, so that the doctor can talk with the patient, get his or her feedback and make adjustments to correct the voice. “Laryngeal framework surgery is very effective,” Dr. Young says. “About 90 percent of people benefit from restored function of their voice.”
Vocal cord injections. Injections of collagen and other gel fillers are used to temporarily treat conditions such as vocal cord paralysis or muscle weakness. This treatment improves voice or swallowing function. Medicine is also sometimes injected. For example, Botulinum toxinis is used to treat spasmodic dysphonia (laryngeal dystonia). Injections are typically done in the office, with local anesthesia. The doctor injects the material into the vocal fold directly through the skin in neck.
“Injections are a temporary solution,” Dr. Young says. “For people with paralyzed vocal cords, including older people, sometimes we’ll try an injection first before framework surgery. Most people who get an injection are hoping that their body will recover on its own and they won’t need the framework surgery. Sometimes it does.”
Laser endoscopic cricopharyngeal myotomy. Cricopharyngeal muscle is the cause of dysphagia in Zenker’s and Cricopharyngeal dysphagia. The myotomy is performed without an incision and is an outpatient procedure.
What are the risks related to laryngeal surgery?
Surgery for laryngeal disorders is considered very safe, and the risk depends on the procedure. With framework surgery and implants, such as a thyroplasty, there can be complications related to surgery and general anesthesia, such as bleeding or infection. According to Dr. Young, the biggest risk with phonosurgery is scarring: “One of the complicated things about surgery on the larynx is that if it scars, it will change the character of the voice,” he says. “So the surgery has to be very delicate.”
“Our team is really trained to minimize trauma to the vocal chords and to preserve or restore the voice," Dr. Young says. "We apply a lot of specific surgical techniques. Using lasers really minimizes the risk.”
What makes Yale Medicine’s approach unique?
Yale Medicine’s Speech and Swallow Program offers specialized medical, rehabilitative, and surgical options for diagnosing and treating voice, airway and swallowing disorders. The program’s multidisciplinary team provides coordinated, comprehensive care for adults and children of all ages.
“We can offer a lot of procedures in the office without the need to go to the operating room,” Dr. Young says, and thatadded convenience really helps patients. “If you just need a 15 minute procedure, like a vocal injection,” he says, “you can drive yourself to and from the appointment, without having to spend hours in pre-op and recovery time.”
The program’s team approach and its unique technology are other huge advantages, Dr. Young says. “We’re all working together, sharing resources and information, and I think that leads to more effective care and better outcomes.”