DIAGNOSIS AND TREATMENT OF VOICE DISEASES

Although different ways of communicating have emerged with modern life, I still think that our most important communication tool is our voice.

Whether we are a child, a young person or an adult in an active working life, our need for our voice never decreases at any time in our lives. We need to use our voice effectively while conveying our needs, wishes, feelings and thoughts to others. People working in some professions, on the other hand, are deprived of doing a significant part of their work as they want if they do not have a voice. This group, called “sound professionals”, actually includes many more professions than expected. Teachers, lawyers, doctors, voice and stage artists, communication center ( call center)employees, bank employees, lecturers, clerks, television and radio programmers, religious officials, marketers and many other professions can be included in this group.

How can voice disorders be prevented?

Voice disorders can be prevented before they occur, thanks to voice hygiene and voice therapy programs specially prepared for the individual’s voice needs. Hygiene and therapy methods to be applied in case of any voice disturbance will contribute significantly to the earlier and more successful outcome of the treatment.

What is the cause of voice discomfort, voice disorder, voice disease, hoarseness?

As in other organs of our body, many different causes can lead to similar symptoms. For example, hoarseness may be the first symptom of more manageable causes such as a short-term cold, allergy or reflux, or serious problems such as vocal fold (vocal cord) paralysis or vocal fold cancer.

How to diagnose voice disorders correctly?

Accurate diagnosis in voice disorders can be achieved by using objective (subjective) and subjective (objective) approaches together. The state of the individual’s voice is evaluated according to the perception of both himself and the clinician. When necessary, standardized sound recordings are taken, and comparable numerical data are obtained through the method called acoustic analysis from these recordings. In addition to a full ear, nose, throat and head and neck examination of the patient, a whole body examination is performed when necessary. Both rigid (rigid) and flexible (bendable) telescopes can be used to visualize vocal folds and other related structures. Since the vocal folds vibrate an average of 100-140 times per second in adult males and 200-240 times in females during vocalization, special instruments are needed to see these structures. The light technology that provides this is called stroboscopy. Sound examination under a stroboscopic light source (videolaryngostroboscopy) is the gold standard for diagnosis. In this way, many information that cannot be obtained with simple examination methods can be accessed and an accurate diagnosis can be made.

What are the most common diseases that cause voice disorders?

Voice disorders can be classified into two main groups as organic and functional causes. Organic causes are disorders that we can list some examples of such as nodules, polyps, cysts, grooves (sulcus), white and red spots, granulomas, reflux, paralysis and cancer in the vocal folds. Functional causes refer to situations in which a visual problem is not detected in vocal folds and otorhinolaryngological examination, but a problem with the use of the individual’s related structures is determined.

How are voice disorders treated?

Treatment of voice disorders is determined by the cause of the discomfort. Voice therapy, medical (medical) therapy, and surgical therapy are the three main treatment modalities.

What is sound therapy?

Voice therapy is a treatment method that can be used in all voice problems. While it is used as the sole treatment method in some voice disorders, it can be used as a support before and after medical or surgical treatment in others. Although very useful, there is no unique voice therapy method for any voice pathology. On the contrary, the sound therapy method, intensity and duration chosen for each patient should be different from each other according to the needs of the patient. Ideally, the cause of the patient’s voice problem should be determined before starting voice therapy. For this purpose, it is necessary to perform an objective voice analysis and evaluate the vocal cords with videoingostroboscopy.

The findings should be evaluated with the patient and the team that will play an active role in voice therapy, and if the patient is a voice professional, with other people who are interested in their voice, and therapy goals should be determined.

In recent years, the increase in information about the larynx (larynx, dagger) has also increased the interest in the physiology, disorders and treatment of voice and voice disorders. In this way, significant progress has been made in the objective evaluation of the voice and the visualization of the vocal cords. Thus, much faster and more accurate diagnoses are obtained and the treatment process can be started as soon as possible. Since the time constraints of both health professionals dealing with voice disorders and voice professionals who make a living with their voices increase with each passing day, today’s voice therapy protocols are planned as approximately 6-10 sessions. While the objectives of each sound therapy method are different, there are some general objectives that are universal to all sound therapy techniques. These are important for both pre- and post-surgical voice therapy, and voice therapy to be used as a sole treatment:

Patient education: Patient education is the first step for all treatment protocols. Every patient should be aware of how the voice is produced and how their problem is causing distress in their voice. The patient should understand the logic of voice therapy, the technique to be used and the goals of the therapy. It will be difficult for the patient to adapt to the treatment program if the treatment approach is not in the mind of the patient, or if the person administering the therapy is not determined or does not provide adequate explanations.

Sound hygiene: In addition to the sound hygiene rules that should be applied in general, specific attention should be paid to each patient and the issues to be done/not done accordingly should be determined. For example, adequate fluid intake and, if necessary, humidification of the environment are important for all voice users. Having information about personal sound usage habits, knowing the environment where sound is used intensively and the noise characteristics in the environment, and examining other environmental factors will enable the acquisition of healthier sound habits. Not smoking, reducing general stress, knowing the drugs used and their effects on body fluids are also important requirements.

Fixing excessive sound use behavior: It is important to enable individuals with hoarseness to speak in a lower voice, to prevent loud speech, and to prevent habitual or frequently repeated throat clearing. The total use of sound during the day should be reduced. Loud laughing, crying, and coughing are also voice-damaging behaviors. All these rules can be used for individuals with voice problems, except for patients with neurologic causes or hypofunctional hoarseness.

Agreed goals and expectations:The individual with a voice problem and the person who will give the voice therapy should be in agreement that there is a problem with the voice, something needs to be done about it, the path to be followed and the intended goals.

Being able to notice changes in the patient’s voice: If the patient cannot notice or feel the changes in his voice that occur with sound therapy, voice therapy cannot be beneficial. This is a situation that we do not encounter frequently in audio professionals, but we encounter a lot, especially in the elderly population and individuals with neurological problems.

Is it possible to treat voice sickness only with voice therapy?

Yes, some voice disorders can only be treated with voice therapy methods. Among these, functional voice disorders, voice problems due to some neurological and psychiatric diseases and most vocal fold nodules can be given as examples.

Are surgical methods successful in the treatment of voice disorders?

Yes, surgical methods can be successful up to 100% in the treatment of many voice disorders. These include vocal fold polyps, vocal fold cysts, granuloma, papilloma, and many different causes such as cancer.

What is the role of medical/medical/drug therapy in the treatment of voice disorders?

It is possible to obtain successful results with drug treatment in many different voice diseases, especially laryngitis (infection and inflammation of the vocal folds and different parts of the larynx) and laryngopharyngeal reflux (backflow of stomach contents to the level of vocal folds).

To whom should a person who has a voice disorder or a problem with his voice contact?

An individual with a voice problem should consult an otolaryngologist who specializes in voice disorders.

I wish you a healthy voice.

  • 332 male, 28 female patients
  • Age range 18-78 (average 48)
  • Symptoms: Hoarseness 91%, foreign body sensation 9%; duration 1-36 months
  • 60 cases bilaterally, 29 cases located anterior commissure
  • Conservative treatment (phonation restriction, oral anti-inflammatory agents, oral antacids, and budenoside) was applied to 21 cases, with monthly follow-up until the lesion disappeared.
  • 339 patients were treated surgically; Submucosal cordectomy for leukokeratosis located opposite the main lesion, mucosal slicing and scanning for leukokeratosis with type II and III sulcus, partial subligamental or transmuscular cordectomy for leukokeratosis without a known cause. Follow-up was done monthly in the first year and bimonthly in the second year.

The lesions were divided into 4 groups according to their history, video image and microscopic morphology:

Type I – inflammatory leukoplakia (#21, 6%): Bilateral, white membrane-like appearance, 2 weeks to 2 months history; With URTI, excessive coughing, excessive alcohol use, excessive use of voice, sudden onset and marked hoarseness. With approximately 2 months of conservative treatment, the symptoms improve significantly.

Type II – frictional polyp (#76, 21%): Characterized by unilateral, limited, local mucosal thickening in the cord opposite the polyp.

Type III – sulcus vocalis (#68, 19%): With type II or III sulcus vocalis located in the same direction. There are clefts of varying depth and length on this vocal fold, and the base of the lesions arises from the bottom of the cleft as verrucous, angular, or curved.

Type IV – simple leukokeratosis (#195, 54%): May be limited to the mucosa or extend to the submucosa. Like the patch, it can be verrucous or papillary. It may be limited or involve the entire cord.

All of the cases with type I lesions healed conservatively within 2 months.

Submucosal resection was performed in type II lesions, and mucosal slicing treatment was applied in type III lesions. Subligamental cordectomy was performed in 162 and transmuscular cordectomy in 33 of type IV lesions. Surgery was performed again in 31 cases 3-12 months later. The cure rate with a single surgery is 91%. The incidence of cancer in all cases (22/360) was 6.1%; 6.5% in cases with surgery (22/339); 0% in type I-III lesions, 11% in type IV lesions (22/195).

After the surgery of type II and III lesions, mucosal congestion lasting up to one month and pseudomembranous material lasting up to two months were observed. It took approximately 2 months for the mucosal wave movement to return to its best state. It may take up to 6 months for type IV lesions to take their final form.

When the pathological specimens were evaluated according to the WHO classification of intraepithelial vocal cord lesions, after the first surgery, 20% of cases had simple hyperplasia, 42% had mild dysplasia, 29% had moderate dysplasia, 7% had severe dysplasia, and 3% had carcinoma in situ determined. More than half (13/22) of the cases with severe dysplasia were diagnosed with squamous cell carcinoma after the second surgery.

Ma LJ, Wang J, Xiao Y, Ye JY, Xu W, Yang QW. Clinical classification and treatment of leukokeratosis of the vocal cords. Chin Med J (Engl). 2013 Sep;126(18):3523-7. PubMed PMID: 24034102.

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