A Family Doctor's Tale - VOCAL CORD POLYP

DOC I HAVE VOCAL CORD POLYP, NODULE AND CYST

Vocal polyp is a benign tumor with soft round body rising on a stalk from one of the vocal cords.

Vocal nodules are thickened area occurring on both vocal cords
and are also known as singer's nodules or callusese of the vocal cords.

Vocal cysts are swellings (containing fluid in a sac) found on the vocal cords.  

Vocal polyp,nodules and cysts can occur at any age.

The causes of vocal polyp and nodules are:

1.Vocal polyps and nodules are usually the result of chronic inflammation or repetitive trauma to the vocal cords such as frequent shouting or voice overuse.

2.reflux of acid from stomach to larynx

3.smoking irritates the vocal cors

4.cysts occur due to blockage of a mucous gland in the mucosa of  the vocal cords.

Symptoms of Vocal Cord Polyp, Nodule and Cyst:
1.Hoarse voice

2.breathless voice

3.low pitch husky voice

4.vocal faigue

5.inability to sing high pitched notes

6.increased effort to speak or sing

7.frequent throat clearing

Diagnosis of Vocal Cord Polyp, Nodule and Cyst:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords and confirm the presence of nodules, polyp or cysts

3.test for laryngopharyngeal reflux

4.Sensitive nose and sinusitis may be excluded with CT Scan of skull from nose to vocal box.

There can be complications of Vocal Cord Polyp, Nodule and Cyst such as:
1. bleeding (rare)

2. chronic hoarseness of voice

Treatment of Vocal Cord Polyp, Nodule and Cyst:
Medical:
1.antibiotics to treat infections

2.antihistamine to treat allergy

3.antacid to reduce acid reflux

4.voice rest

Most benign vocal cord growths will resolve with conservative medical treatment especially voice rest.

Surgery:
The only surgical treatment is phono-microsurgical removal of the Vocal polyp,nodules and cysts if the medications do not work or if there is suspicion of cancer.

Phono-microsurgery is surgery to the vocal cord using micro-surgical techniques and instruments and sometimes lasers.

This surgery can also be done to improve the voice or remove a growth for microscopic analysis.

If a lesion is found to be cancerous, further treatment may be required.

The prognosis of a Vocal Cord Polyp, Nodule and Cyst is usually excellent.

Recurrence at the same spot is rare but do occur due to regrowth of the blood vessel supplying the Polyp or nodule.

Prevention of Vocal Cord Polyp, Nodule and Cyst:
Avoid strenuous use of the vocal cords

Avoid smoking and alcohol

Avoid any irritants or allergies as much as possible

A Family Doctor's Tale - SNORING

DOC I HAVE SNORING

Snoring is the symptom of spectrum of problems including Sleep disorders such as Obstructive Sleep Apnea during which breathing is interrupted during sleep.

About 24 per cent of the local population are loud habitual snorers.

Causes of snoring:
The cause of snoring is due to the vibration or flapping of the tissues lining the upper respratory passages.

Snoring in most people are due to multiple factors each playing some part in the snoring process:
1.Inadequate muscle tone of the palate, tongue and pharynx leads to airway collapse during inspiration causing the walls of the airway to vibrate.

2.bulky tissue in the upper respiratory airway(adenoids and tonsillar hypertrophy, cysts and tumors)cause narrowing of the airway and result in snoring.

3.excessive soft palatial tissue or long uvula can also vibrate during breathing causing snoring.

4.a backward prolapsing tongue may fall backwards into the throat when sleeping on the back and contribute to snoring

5.anatomical abnormalities in the nose(deviated nasal septum, hypertrophied inferior turbinates) or congested nasal passages (allergies, sinusitis, nasal polyps) can cause poor nasal inflow and make the soft tissues of the palate and throat vibrate.

Systemic disorders:
1.Hypothyroidism -large tongue

2.Acromegaly - large tongue

3.heartburn resulting in congestion of the throat

4.Obesity - enlarged tongue or uvula

Symptoms:

1.snoring present in 20% of men and 5% of women at age 30-35 years.
At age 60 years or more, 60% of men and 40% of women snore habitually

2.unrefreshed sleep

3.daytime sleepiness

4.poor concentration

5.forgetfulness

6.morning headaches

7.dryness of mouth in the morning

8.irritabilty

9.depression

10.sexual dysfunction

Signs:

1.Enlarged nasal turbinates, polyps , and nasal blockage

2.Enlarged tonsils and adenoids

3.Long uvula

4.large protruding tongue


Diagnosis of Snoring is made:
1.Symptoms of snoring, nasal congestion and inadequate sleep

2.observation of airway obstruction during sleep

3.Sleep study using monitoring devices such as

a. electroencephalogram(EEG)

b electro-oculogram(EOG)

4.Electrocardiogram(ECG)

5.Blood oxygen studies

6.Nasal and oral airflow

7.Thoracic and abdominal movement

8.Snoring sounds

Complications:
1.higher risk of hypertension

2.cardiovascular disease

3.Congestive heart failure

4.cardia arrhythmias

5.cerebrovascular accidents

Treatment:
A.Non Surgical treatment:

1.Continuous Positive Airway Pressure(CPAP)
CPAP administered by mask through the nose is the single most effective least invasive treatment for Obstructive Sleep Apnea.
It can improve all the bad effects of OSA.

2.Oral appliances which pushes the mandible forward and prevent it from falling open during sleep

3.Nasal Congestion treatment:
Patients with nasal congestion and blockage should be treated with antihistamine and decongestant

4. Weight reduction:
Any obese patients should have at least 10% of his weight reduced over a 6 months period

B.Surgical Treatments:
1.Surgery on the upper pharyngeal airway(uvula and palate)

a.Radiofrequency reduction of the palate and uvula shrinks the tissues of these and is indicated in simple snorer or mild OSA.

b.Uvulopalatopharyngoplasty (UPPP) surgery includes uvulectomy, palatal releasing and shortening incisions.

2.Surgery of the Tongue base:
Radiofrequency reduction is done for mild cases.
Advancement of the tongue, hyoid suspension is done under general anesthesia. All these enlarge the posterior airway space.

3.Maxillomandibular Advancement:
This is the most effective surgical procedure for treatment of OSA.It causes enlargement of the pharyngeal and hypopharyngeal airway by physically expanding the skeletal framework.

Prognosis depends on the severity of the condition but is generally good.

Prevention:
1.Lose weight in obese individual with snoring

2.Healthy lifestyle with balanced diet and exercise.

3.Neck elevation to prevent obstruction of airways and heartburn

4.Sleep on the side rather than on the back.
Snoring is worse when sleeping on the back

A Family Doctor's Tale - MUSCLE TENSION DYSPHONIA

DOC I HAVE A MUSCLE TENSION DYSPHONIA

Muscle Tension Dysphonia is an excessive tightness or imbalnce of the muscles in and around the vocal box resulting in hoarseness and difficulty in using the voice.

The causes of Muscle Tension Dysphonia are:
1.Direct problem with the use of vocal technique

2.voice muscle habitual misuse

3.acid reflux from the stomach or laryngopharyngeal reflux

4.underlying inflammation of the vocal cord

5.growth on the vocal cord

6.neurological condition affecting the vocal cord

Symptoms  of Muscle Tension Dysphonia:
1.Hoarse voice

2.strained voice

3.pain or sore throat when talking

4.vocal fatigues easily

5.difficulty controlling pitch

Diagnosis of Muscle Tension Dysphonia:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords

3.videostroboscopy to view the vocal cords ( a thick endocscope with camera is passed down the nose to the vocal cords to examine its movements on video)

4.CT or MRI Scanning of skull from nose to vocal box to look for underlying causes.

5.evaluation of laryngopharyngeal reflux

There can be complications of Muscle Tension Dysphonia such as:
1.chronic hoarseness of voice

2.damage to the vocal cords

Treatment of Muscle Tension Dysphonia:
Medical:
1.Speech therapy
a.to improve voicing techniques
b.overcome bad vocal habits which strain on the voice
c.avoid unneccesary voice use to allow the voice muscles to relax and rest

2.medication to treat acid reflux

Surgery is usually not required.
The prognosis of Muscle Tension Dysphonia is usually fairly good .

Prevention of Muscle Tension Dysphonia:
1.It would be wise to hydrate the throat
2.warm up the voice before talking for long periods of time
3.use a microphone rather than shouting or using a loud voice to convey your message to a large crowd of people
4. Always rest the voice whenever possible

A Family Doctor's Tale - VOCAL PARALYSIS

DOC I HAVE A VOCAL PARALYSIS

Vocal paralysis is a paralysis of one or both of the vocal cords and results in inability to close the the vocal cords completely.

Vocal paralysis usually involve one of the vocal cords.

If the vocal cords do not close completely:
1.the voice becomes weak and hoarse

2.there may be choking on swallowing due to food or liquids going down the windpipe.

The causes of vocal paralysis are:
1.tumors pressing on the nerve that control vocal cord movement
Examples are cancers of the larynx, thyroid, nasopharynx or esophagus

2.injury of the nerve controlling vocal cord movement
a.during thyroid and chest surgery
b.following radiation treatment to the neck  
c.neck injury.

3.stroke or neurological condition affecting the movement of the vocal cords

Symptoms  of vocal paralysis:
1.Hoarse voice

2.breathless voice

3.low pitch husky voice

4.vocal fatigue

5.choking or coughing especially on drinking liquids

Diagnosis of vocal paralysis:
1.history of voice problem

2.nasoendoscopy through the nose down to vocal cord under local anesthesia to check on the vocal cords and confirm the presence of  paralysis

3.videostroboscopy to view the vocal cords

4.CT or MRI Scanning of skull from nose to vocal box to look for cause of paralysis.

5.Laryngeal electromyography which use a fine needle to measure function of the vocal cord muscle

There can be complications of vocal paralysis such as:
1.choking with effect to breathing difficulty

2.chronic hoarseness of voice

Treatment of vocal paralysis:
Sometimes the recovery occurs by itself and no action is needed.
This may take up to one year.
Medical:
1.Speech therapy

2.injection of collagen to increase the bulk of paralysed vocal cord may help

Surgery:
1.Surgical treatment (medialization thyroplasty)may be needed to permently shift the paralysed vocal cord to improve the voice.
This operation is done under local anesthetic.

Phono-microsurgery is surgery to the vocal cord using micro-surgical techniques and instruments and sometimes lasers.

2.Rarely if both vocal cords are affected by paralysis there may be difficulty in breathing or noisy breathing because of the narrowed airway at the vocal box.
A tracheostomy may be needed. This involves making an opening in the windpipe and putting a trachecstomy tube into the opening to help breathing.

3.A laser procedure may be done to widen the the airway.

The prognosis of vocal paralysis is usually fairly good except when cancer is involved.

Prevention of vocal paralysis:
surgery around the neck and throat region should done carefully to avoid cutting the nerve to the vocal cords.