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

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John Mayer Undergoes Second Vocal Cord Surgery

On August 27, 2012, media reported that grammy-award winning singer John Mayer underwent vocal cord surgery for a 2nd time in an attempt to permanently remove a recurrent vocal cord granuloma.

Fans know that in September 2011, John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

On Oct 20, 2011, he underwent surgery for the first time to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma had recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

Well, it seems that whatever intervention pursued since March 2012 did not work completely given the repeat surgery.

Given this is his second surgery for the same problem, I suspect that not only was the granuloma removed, but perhaps steroid was injected into the wound bed to try and prevent the tissue growth that may lead to granuloma reformation as well as application of mitomycin C, a chemotherapy agent. Post-procedure treatment with PDL or KTP laser may also be pursued to ablate any proliferative blood vessels that my encourage granuloma formation. Botox may even have been injected to partially paralyze his ability to bring the vocal cords together to prevent phono-trauma to the site.

Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

That means strict voice rest.

Indeed, John Mayer stated (or wrote) after his most recent surgery:

"Silent for the next few months, no singing for probably six, but all signs point to this being the last step in getting to perform again."

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential with medications.

Surgical removal of the granuloma may have looked something like this video...

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:
Surgery silences singer John Mayer for a spell. CNN 9/1/12

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Singulair May Help Cure Mild Sleep Apnea in Children

Singulair (generic montelukast as of Aug 2012) is a medication often prescribed for asthma as well as allergies and works by blocking the leukotriene receptor. This mechanism is different than that found in common allergy medications like claritin and benadryl which work by blocking the histamine receptor (anti-histamine).

Singulair has also incidentally been found to possibly help reduce the size of tonsils and adenoids. Given this beneficial affect, singulair may be a helpful intervention in those kids with mild obstructive sleep apnea or nasal obstruction due to adenoid hypertrophy avoid surgical intervention (tonsillectomy and adenoidectomy).

The most recent research published in Sept 2012 suggests that singulair may lessen symptoms in children with non-severe apnea and potentially allow them to skip the surgery.

In the study, 46 children with non-severe sleep apnea received singulair or a placebo for 12 weeks. The kids who received the drug showed improvements in their sleep apnea, their sleep-related symptoms, and the size of their adenoids compared to the placebo group. There were no side effects seen among kids who took the study drug.

Beyond singulair, steroid nasal sprays have also been found helpful to reduce adenoid size.

Singulair can be given from the age of 1 year old.

References:
Leukotriene modifier therapy for mild sleep-disordered breathing in children. Am J Respir Crit Care Med. 2005 Aug 1;172(3):364-70. Epub 2005 May 5.

Leukotriene pathways and in vitro adenotonsillar cell proliferation in children with obstructive sleep apnea. Chest. 2009 May;135(5):1142-9. Epub 2008 Dec 31.

The role of mometasone furoate aqueous nasal spray in the treatment of adenoidal hypertrophy in the pediatric age group: preliminary results of a prospective, randomized study. Pediatrics. 2007 Jun;119(6):e1392-7. Epub 2007 May 28.

Intranasal corticosteroids for nasal airway obstruction in children with moderate to severe adenoidal hypertrophy. Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006286.

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FDA Approves New "Dry" Steroid Nasal Spray

On March 26, 2012, the FDA approved of a new type of steroid nasal spray in the treatment of nasal allergies that puffs powder into the nose rather than a liquid. Liquid formulations such as nasonex, flonase, veramyst, nasacort, and rhinocort has been until now the only delivery medium of administration.

This new spray made by Teva Pharmaceuticals is called QNASL which puffs a steroid beclomethasone dipropionate. For those who know pharmaceuticals, it is the same active ingredient as (liquid) beconase nasal spray.

Just like the other nasal sprays, administration is 2 puffs (sprays) in each nares daily.

This spray does pretty much the same thing (and has similar side effects) as the other established nasal sprays. However, QNASL may be better tolerated in those patients who HATE the drip down the back of the nose after liquid nasal spray use.

Drug should be available for prescription starting in April 2012.

Source:
Teva Announces FDA Approval of QNASLTM (beclomethasone dipropionate), a New Nonaqueous Nasal Aerosol, for the Treatment of Allergic Rhinitis. Teva Pharma 3/26/12

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Singer John Mayer Has Recurrence of Vocal Cord Granuloma

In September 2011, grammy-award winning singer John Mayer announced the cancellation of a number of concerts as well as an album due to the development of a vocal cord granuloma of his voicebox. Read a blog article about this.

On Oct 20, 2011, he underwent surgery to remove the granuloma and was on strict voice rest for several weeks with plans to resume live singing in the first quarter of 2012.

Unfortunately, on March 9, 2012, it was found that his vocal cord granuloma has recurred in the same location. In a statement he publicly released:

"Because of this, I have no choice but to take an indefinite break from live performing. Though there will be a day when all of this will be behind me, it will sideline me for a longer period of time than I care to have you count down."

 Is this unusual that his vocal cord granuloma recurred?

Unfortunately, it is not...

Vocal cord granulomas are benign masses that commonly are due to repetitive mild vocal trauma resulting in exuberant growth of a specific region of the voicebox lining. An imprecise analogy of what a granuloma is would be a keloid of the skin. Unfortunately, such repetitive mild vocal trauma includes talking/singing, hence the high risk of recurrence. The key to treatment is to allow the granuloma site to heal COMPLETELY prior to any further phonotrauma (ie, talking/singing).

Strict voice rest as well as voice therapy helps as it eliminates the repetitive phonotrauma that promotes regrowth. Reflux control is also essential. However, it is not unusual that steroid injections to the granuloma site as well as even botox injection to partially and temporarily paralyze the vocal cord may need to be pursued for complete resolution. Laser and mitomycin C application has also been found to be helpful.

Surgical removal of the granuloma may have looked something like this video...

To summarize, the steps followed when a granuloma-like mass is discovered on exam is as follows:

1) Trial restricted voice use and reflux medications. Voice therapy also strongly recommended. Strict voice rest is preferred if possible.

2) If no improvement after a period of time, surgical excision to ensure it truly is a granuloma and not cancer or some other pathology

3) Follow-up with steroid injections to the granuloma site. Watch video below.

4) Botox injection can be considered which chemically prevents complete vocal cord adduction preventing the repetitive trauma to the granuloma site.

5) Re-excision may be required at which time mitomycin C application can be tried.

Read more about voicebox granulomas.

Source:

John Mayer's Granuloma Returns, Singer Taking "Indefinite Break From Live Perfoming". E Online 3/9/12

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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.

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