Vocal Cord Tear Silences R&B Singer Frank Ocean

Image by Fred von Lohmann from Wikipedia

On July 25, 2013, R&B singer Frank Ocean was forced to cancel his entire Australian concert tour due to a small vocal cord tear.

After singing his opening night with a sore throat during which he reportedly sounded "noticeably off-key," he seeked medical attention and was informed of the unfortunate condition of his vocal cord. Listening to his voice on this YouTube video recorded during this fateful concert, his voice actually does not sound as bad as I would expect with a vocal cord tear. However, at time point 1:20, there was an obvious pitch break.

If a vocal cord tear was truly present, it must have been extremely small and not along the free edge because even with a small vocal cord tear located along the vibrating margin, the vocal quality would have been noticeably degraded throughout the vocal range. Why?


In order for the vocal cords to produce a clear voice, the vocal cords must come together and vibrate evenly. This vibration occurs on the vocal cord mucosa. ANYTHING that disrupts this mucosal vibration would result in a raspy voice including small bumps like a nodule or polyp, but also a vocal cord tear. Watch video of normal vocal cords in motion.

Small bumps typically cause problems in the voice only in the high range at quiet volumes because often the bump can vibrate along with the mucosa (just like a buoy on the ocean). As long as the vibration is unaffected, the voice comes out. As a bump gets bigger, a greater portion of the vocal range becomes affected.

A tear, however, depending on where it is located could affect the entire vocal range due to vibratory disruption as it moves to and around the tear (the tear acts like an anchored pillar in the ocean).

The only way to correct a tear is MANDATORY strict voice rest for several weeks. Further using the voice when injured like this may only "rip" the tear larger potentially causing a greater risk of scar formation and a permanent hoarse voice.

Strict voice rest means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the vocal cord tear preventing proper healing. I would even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking. The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Here's an example picture of a vocal cord tear on both vocal cords in a patient suffering from viral laryngitis who did not quit using her voice for a prolonged period of time.

WHY would a vocal cord tear appear in the first place? Usually from excessively traumatic vocal abuse (ie, strong cough, scream, yell, etc).

Source:
Frank Ocean Suffers Tear to Vocal Cord, Scraps Australian Mini-Tour. Billboard Biz 7/26/13

Read More

Google CEO Larry Page Suffers from Bilateral Vocal Cord Paralysis

Image by Marcin Mycielski from Wikipedia

Over the past year, there has been concern over the health of Google CEO Larry Page after missing a few important meetings and having a hoarse voice that is unusually soft and prolonged.

Apparently, it's because he suffers from bilateral vocal cord paralysis. [link]

He initially suffered from a unilateral vocal cord paralysis at the age of 14 years old. At that time, his left vocal cord became paralyzed after a viral URI. Beyond a viral infection of the nerve, no other specific cause was identified.

Than during the summer of 2012, he suffered another viral URI followed by the unfortunate paralysis of his opposite right side resulting in bilateral vocal cord paralysis. It is EXTREMELY rare that both vocal cords become paralyzed in this manner in the same individual.

With bilateral vocal cord paralysis, he now suffers from an even weaker voice along with reduced ability to exercise.

Now, why is that?

First, a basic anatomy lesson...

Briefly, the voicebox is composed of a right and left vocal cord that is attached on one end, much like a "V". When the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows one to breathe. When a person wants to sing/talk or say "eee," the vocal cords come together and vibrate very quickly creating the voice. The vocal cords and their movement can be visualized on fiberoptic laryngoscopy (watch movie of this exam).

A "paralyzed" vocal cord is when one or both of the vocal cords do not move resulting in voice changes as well as difficulty breathing easily. Specifically, when both vocal cords are paralyzed, the vocal cords do not come together as tightly resulting in a weaker than normal voice. At the same time, given the vocal cords are not able to move apart, there is a smaller than normal opening thru which to breath resulting in shortness of breath, especially with exercise. Here are two video examples of when both vocal cords are paralyzed. Compare this to a normal example. Note the difference in how wide the vocal cords move apart.

Why would the vocal cords both become paralyzed in the first place? The MOST common cause of bilateral vocal cord paralysis is surgery, especially thyroidectomy. Other less common causes include neck trauma, traumatic intubation, and cancer (especially lung or thyroid cancer). Regardless of cause, if the paralysis is permanent, the options are quite limited and require the sacrifice of either breathing or talking. You can't have both good breathing and a good voice. Please note that a patient may have bilateral vocal cord fixation and NOT paralysis which is treated completely differently.

Why can't you have both good breathing and a good voice when both vocal cords are paralyzed? Because in order to have a good voice, the vocal cords need to come tightly together... but given they are paralyzed, they will not come together to allow for a good strong voice.

In order to have good breathing, the vocal cords need to be widely apart... but given they are paralyzed, they will not be able to move apart to allow for good breathing. Which in essence means you can't have both good breathing and strong voice.

One or the other needs to be sacrificed... or a compromise of both is required resulting in so-so breathing and a so-so vocal quality... which seems to be the option Larry Page has gone with.

Well... there is ONE option in order to have good breathing and a good voice... and that's a tracheostomy with a one-way valve. The vocal cords could be fixated together to allow for good voice. To allow for good breathing, airway is achieved through the tracheostomy (hole in the neck that goes directly into the airway). A one-way valve is placed with the tracheostomy such that when breathing in, the valve opens up to allow air passage thru the tracheostomy, but when breathing out, the valve will close to force air up thru the vocal cords to allow for talking.

BUT, if tracheostomy is out-of-the-question.. than a patient with bilateral vocal cord paralysis is stuck with a compromise between the voice and breathing.

To explain this compromise of voice and breathing further, normally, when the vocal cords are both moving fine, the voice is at 100% and breathing is at 100%. However, with bilateral paralysis, the voice and breathing are now linked to each other and collectively can not exceed 100%. As such, a patient with new onset bilateral vocal cord paralysis may start with a 40% of normal vocal quality and 60% of normal breathing ability for a total of 100%. If a patient desires to improve the vocal quality from 40% to 100% (an improvement of 60%), then the breathing WILL correspondingly decrease 60% down to 0% (or vice-versa). The total percentage of vocal and breathing quality can never be more than 100%. If a patient wants the best possibly voice and breathing, than the compromise would be to increase the vocal quality 10% from 40% to 50%, but understanding that this 10% improvement in vocal quality WILL mean a corresponding 10% decrease in breathing ability from 60% to 50%. This 10% change means that in the end, the voice and breathing would both end up at 50% of normal.

Wondering what kind of workup is required as well as surgery to adjust the voice when both vocal cords are paralyzed? Click here to read more...

Source:
Larry Page Explains Why He Lost His Voice. Businessweek 5/14/13

Read More

What to Do and Care After Vocal Cord Surgery

When surgery is performed on the vocal cords, there are some very specific after-care that is required to allow for optimal healing. In order to understand the "why" such post-operative care is required, one must first understand how the vocal cords normally work. If you already know, just skip down to the bottom.

The vocal cords are arranged in the shape of a "V". When breathing, the vocal cords are open to allow air to pass through and down into the windpipe. When talking, the vocal cords come together and vibrate. Click here to watch a video.

When surgery is performed on the vocal cords, one is actually cutting into the actual organ that allows one to talk and make other noises.


As such, the care required after vocal cord surgery requires the elimination of any activity that may lead to damage to the surgery site and allow proper and safe healing.

I should mention that the following instructions are our opinion. Other laryngologists may have different after-care instructions.

Strict Voice Rest! 

This means absolutely no talking and whispering. Such activities cause the vocal cords to come together and "bang" against the surgery site. I even instruct patients to avoid even mouthing words as it causes the brain to "think" you are talking even if you are not. Essentially, the lips should always remain closed except when eating/drinking.

The analogy would be if you have surgery done on the heel of your foot, you should not walk or put any weight on the heel, otherwise risk improper healing.

Strict voice rest typically lasts for 1-2 weeks after surgery.

No Coughing or Throat-Clearing

Just as with talking, coughing and throat-clearing also causes the vocal cords to come together and should be avoided if at all possible. Narcotic strength cough-suppressants (ie, hycodan) are often prescribed to help suppress the urge to cough.

Take Reflux Medications

Reflux medications should be taken both before and after surgery to prevent any possibility of acid damage to the surgery site. Such medications should be taken EVEN IF you do not have any symptoms of acid reflux. I typically recommend patients to start such medications one week before surgery and to continue for as long as 3 months after surgery.

Voice Therapy

Voice therapy is recommended before surgery so that patients will understand what and how they are supposed to talk once cleared to do so after surgery. It's much easier to answer questions and practice proper talking technique before surgery rather than after surgery when you are on strict voice rest!

The rationale for voice therapy is to prevent continued phono-trauma to a freshly healing surgery site on the vocal cord. Often, if improper talking technique persists after surgery, the surgery site becomes damaged again or heals with abnormal scar tissue leading to the possibility of needing surgery again.

Voice therapy minimizes the likelihood of needing repeat vocal cord surgery in the future!

Restricted Voice Rest

Once the period of strict voice rest ends, the patient is slowly allowed to talk under voice therapy guidance. From this point forward over the next 4-6 months, the patient is under restricted voice rest.

Restricted voice rest is a fairly broad phrase, but essentially means to:

• NEVER abuse the voice (ie, yelling, screaming, loud talking, etc)
• Talk only when you must (ie, no social talking)

This period of restricted voice rest is important because it allows time for the new vocal cord tissue that has developed to not only heal, but also strengthen. Abusing the voice may tear the freshly healed surgery site which must be avoided at all costs!

Read More

Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent irreversible hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

• Steroid injection to the vocal cord nodule(s) can possibly resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

Read More

Congressman Putney with Vocal Cord Cancer

Media has reported that Congressman Lacey Putney, chairman of the powerful Appropriations Committee in the House of Delegates, has early stage vocal cord cancer.

He is currently undergoing radiation therapy which has a high chance of cure with relatively minimal side effects along with voice preservation.

My suspicion is that he is suffering from squamous cell carcinoma which is the most common type of vocal cord cancer. Though radiation therapy is a common form of treatment for this type of early stage cancer, surgical excision without the need for radiation is also possible. No chemotherapy is necessary for early stage vocal cord cancer.

Below is a picture of an early stage right vocal cord squamous cell carcinoma.

Compare to normal:

Source:
Putney undergoing treatment for throat cancer. WSLS10 8/15/12

Read More

Stem Cells Restore Toddler's Congenital Hearing Loss

In a potentially revolutionary treatment, a two years old toddler born deaf has had her hearing restored after receiving stem cells from her banked umbilical cord blood. (Reported in ABC News)

Madeline Connor at age 1 year old was completely deaf in the right ear and had severe hearing loss on the left. Normally hearing aids or cochlear implant would have been the only options.

However, in January 2012 at the age of 2 years old, Madeline underwent a "simple" experiment whereby stem cells were infused into her damaged inner ear. The stem cells were derived from umbilical cord blood that was banked at the time of her delivery at the Memorial Hermann-Texas Medical Center.

Over the next 6 months, there has been dramatic improvement in her hearing. She is also now talking for the first time.

Madeline also is not the only child who has undergone this revolutionary stem cell treatment. Apparently, there are ten other children who are being followed after undergoing similar stem cell infusion derived from banked cord blood.

It must be stressed that though Madeline's progress is quite amazing, it is still too early to say if this is a "bona fide" treatment for congenital hearing loss.

• Will the improvement continue and more importantly, last over years to decades?
• Will it work for other children?
• What is the expected hearing improvement with stem cell infusion?
• Will it treat ALL forms of nerve-damaged hearing loss?
• Does it have to be stem cells derived from cord blood or are stem cells derived from other sources possible (i.e., skin)?
• Can adults with non-congential hearing loss also benefit?

I eagerly await the outcome of this FDA approved trial which hopefully will be published at some point in the near future.

I also eagerly await the protocol used to obtain and infuse the stem cells. I suspect the infusion of stem cells is similar to that done when steroids are infused into the ear for sudden hearing loss as shown in this video below. However, this is just a guess of mine.

Source:

Cord Blood Stem Cells Restore Toddler's Hearing. ABC News 7/11/12

Read More

NY Yankees Mariano Rivera Undergoes Vocal Cord Surgery

NY Yankees pitcher Mariano Rivera may have a fabulous right arm, but his voice was not exactly golden. He apparently had vocal cord polyps that resulted in a progressively raspy voice. Read the NY Post article.

On Dec 2, 2011, he underwent surgery to get them removed and if he now sticks to an appropriate voice therapy program, his voice should essentially revert completely back to normal! Watch the video to see what vocal cord surgery looks like.

There are MANY theories as to how vocal cord polyps as well as other similar vocal abnormalities like cysts and nodules form. However, one theory that seems to make the most sense to me deals with how the vocal cord heals after a phono-traumatic event like screaming or yelling... something I'm sure Mr. Rivera routinely performs during baseball games.

To differentiate among the various benign vocal cord masses, consider a cyst which is formed when the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the vocal cord lining. Vocal cord nodule for comparison's sake is just callous thickening of the vocal cord lining that occurs over time.

To use human skin as an analogy...

A vocal cord cyst is like a sebaceous cyst that commonly occurs under the skin of the face or neck (a pimple, but no opening to the surface).

A vocal cord polyp is like a blister that forms on the hand if you shovel dirt too much.

A vocal cord nodule is like a callous that forms after prolonged repetitive skin trauma (like callous on the hands after shoveling dirt for years).

Read more about vocal cord cysts, polyps, and nodules!

Read More

Singer Keith Urban to Undergo Vocal Cord Surgery

The year 2011 so far seems to be the year for vocal cord surgery in singers... John Mayer, than Adele, and now Keith Urban.

On Nov 3, 2011, it was announced that country singer Keith Urban will be undergoing vocal cord surgery to remove a polyp from his vocal cords forcing him to cancel/postpone upcoming concerts. Read ABC News report here.

A vocal cord polyp would cause a mild rasp in the voice that is worse in the upper pitch range and soft voice. Onset delays and pitch breaks are common.

There are several theories as to why a vocal cord polyp may form on the vocal cord in the first place. My personal favorite theory is as follows. At some point, an acute traumatic event to the vocal cord occurred stemming from a yell, cough, excessive singing, or laryngitis. Depending on what happens next determines whether a polyp or cyst develops. With a cyst, the mucosal vocal cord lining breaks down and during the healing process a cyst develops due to entrapped cells meant for creating lining. A polyp, however, is in essence a blistering of the lining. Vocal cord nodule for comparison's sake is just callous thickening of the vocal cord lining.

Traditional standard of care management of a vocal cord polyp starts with voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). The main reason is that with voice therapy alone, it is not uncommon that the polyp may resolve to point where the vocal quality becomes acceptable and stable. However, more often, only mild improvement occurs with persistence of hoarseness. At this point, surgical excision is recommended. Watch video.

With a polyp, it is simply grabbed and removed at its base. Typically no sutures are used to close the incision after excision, mainly because sutures tend to promote scar formation that can adversely affect the voice. After surgery, STRICT voice rest is mandatory to allow the body to heal the surgical wound site. After about 1-2 weeks, the patient is allowed to start talking in small increments under the guidance of a voice therapist until complete healing has occurred in about 4 weeks. However, the vocal cord lining is "brand new" and careful voice use is recommended for at least 6 months (absolutely no screaming, yelling, or excessive voice use) which risks mucosal tearing and recurrence. Eventually, the patient may use their voice without restriction. Both for 1 week before and up to 3 months after surgery, reflux medications are recommended for reflux prophylaxis. Why? Because if there's ANY acid that washes over the surgical site from a reflux event, healing will not occur properly (imagine putting some acid drops into the eye after eye surgery). As a reminder, though vocal cord polyps can be removed with surgical excision, they can recur if underlying abusive voice behavior that led to the initial formation is not addressed.

Read more about vocal cord polyps here.

Read More

New Webpage on Vocal Cord Nodules

Our office has created a new webpage on the evaluation and management of vocal cord nodules.

Vocal cord nodules also known as Singer's nodules is a common cause of a painless raspy voice that mainly affects individuals who use their voice a lot. Such individuals include teachers, singers, cheerleaders, and people who simply just love to talk a lot.

Read more about this condition here and how to treat it!

Of note, the cartoon is by Dave Walker at We Blog Cartoons.

Read More

Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

Read More