Illnesses and injuries of the upper aero-digestive tract can affect people of all ages and walks of life. Disorders usually present with difficulty speaking, swallowing or breathing. While diagnosis can be challenging, many conditions can be treated with a combination of medicine and therapy. Others may require surgery.
“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,” says Nwanmegha Young, MD, director of the Yale Medicine Speech & Swallow Surgery Program.
Who should consider aero-digestive tract surgery?
Patients with benign upper aero-digestive tract lesions such as polyps, nodules and cysts can sometimes benefit from surgery. In the case of vocal fold paralysis, there are several surgical procedures that can provide a better voice.
Vocal professionals such as singers, teachers, public speakers, and sales people tend to have high incidence of these lesions, says says Dr. Young.
Swallowing issues have many causes, including esophageal diverticulum and cricopharyngeal achalasia.
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. This can be misdiagnosed as stuttering."
How are laryngeal disorders diagnosed?
Patients meet with a team of doctors for a comprehensive evaluation, which can include a comprehensive history and physical exam to check for issues such as nerve compression or thyroid gland problems and a laryngeal examination to look at the patient’s larynx and throat.
“A direct laryngoscopy with a fiberscope is the best way to image the larynx itself,” says Dr. Young. For this procedure, the doctor inserts a thin, flexible fiberscope through the nose or mouth and into the throat. This procedure is performed in the office with local anesthesia.
Depending on the patient’s symptoms, others tests may be needed. These may include a reflux test, X-rays, a biopsy (if cancer is suspected), or an additional endoscopic examination such as functional endoscopic evaluation of swallowing (FEES).
In some cases, the doctor may order a laryngeal electromyography (LEMG), a diagnostic procedure that uses an extremely fine needle to test the strength of the vocal nerves.
“There are a lot of options we can offer at Yale Medicine that may not be available other places, including advanced imaging techniques and in-office treatments, such as biopsies, that help us make a more accurate diagnosis,” Dr. Young says.
What surgical procedures does Yale Medicine offer for laryngeal disorders?
Yale Medicine offers surgical treatments for all types of voice and swallowing disorders. The three most common 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.
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.
This procedure 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. “About 90 percent of people benefit from restored function of their voice," says Dr. Young.
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.
For example, Botulinum toxinis is used to treat spasmodic dysphonia (laryngeal dystonia). Using 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?
While surgery for laryngeal disorders is considered very safe, each procedure has its risks. With framework surgery and implants, such as a thyroplasty, there can be complications related to surgery and general anesthesia, such as bleeding or infection.
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,” says Dr. Young. “So the surgery has to be very delicate.”
“Our team is trained to minimize trauma to the vocal chords and to preserve or restore the voice," he says. "Using lasers really minimizes the risk.”
What makes Yale Medicine’s approach to upper aero-digestive tract surgery unique?
Yale Medicine’s Speech & 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,” says Dr. Young. “With a 15 minute procedure, like a vocal injection, 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. “We’re all working together, sharing resources and information,” says Dr. Young. ”And I believe that leads to more effective care and better outcomes.”