Beatboxing Protective of the Vocal Cords?

Beatboxing is a popular vocal percussion technique that incorporates use of the entire vocal tract. Recently, research by Dr. Steven Simms (who I had the pleasure of working with briefly when we were both at Yale University in the 1990s) suggested that beatboxing techniques may actually protect against vocal cord injury.

Unlike singing where most of the sustained energy is directed at the vocal cord level, beatboxing makes extensive use of the entire vocal tract, especially the muscles of the throat.

Although more research is needed, it is not inconceivable that beatboxing techniques may potentially be helpful to patients who have suffered from vocal cord injury. The question is what techniques specifically and how it can be incorporated into voice therapy sessions. Furthermore, such vocal techniques may be more "acceptable" to teenagers who may scoff at more traditional strategies.

Check out this fiberoptic laryngoscopy video of a beatboxing artist.

Reference:
Functional Endoscopic Analysis of Beatbox Performers. Journal of Voice. Published Online 12/23/13. PII: S0892-1997(13)00243-9 doi:10.1016/j.jvoice.2013.11.007

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Lawsuit Alleges Transcranial Magnetic Stimulation Paralyzed Patient's Face

University of Iowa Hospitals and Clinics is being sued by a patient who underwent an experimental transcranial magnetic stimulation (TMS) therapy which allegedly caused a facial paralysis which was than negligently treated. The trial is scheduled for Oct 13, 2013. [link]

Briefly, the patient in 2008 underwent experimental TMS to treat constipation and incontinence. TMS is a noninvasive method to cause depolarization or hyperpolarization in the neurons of the brain using pulses of electromagnetic induction through the scalp. Researchers were hoping to learn more about the nerve connections between the brain and the rectum and how biofeedback training may affect them.

Unfortunately, the patient contended that the treatment gave her a severe headache and by the next day, a facial paralysis. She went to the emergency room and was given an anti-viral antibiotic to take, but no steroids.

Her facial paralysis worsened and she ultimately underwent facial nerve decompression surgery 12 days later which helped with her taste loss, but not her facial paralysis.

The lawsuit contends that:
1) The patient was not informed of the risks of TMS as it relates to facial paralysis
2) Steroids should have been prescribed and the patient immediately referred for nerve decompression surgery

Does TMS carry a risk of facial paralysis?

I honestly do not know much about TMS, but I can certainly state that I've never heard of TMS causing or carrying a risk of facial paralysis. In fact, TMS is used to evaluate facial paralysis by being able to assess the integrity of the facial nerve as well as predict its potential for regeneration after injury [link].

Hypothetically, could TMS cause cranial nerve injury and swelling leading to facial paralysis??? I suppose so, but will defer to people more knowledgeable than I to answer this question.

The timing is certainly suspicious in this case with paralysis occurring within 24 hours of TMS.

But if it can, it certainly is worth a published case report.

Even more importantly, patients who are currently undergoing TMS to evaluate their facial paralysis now need to be warned of the risk that the TMS test itself may make their facial paralysis even worse!!!

What about steroids?

Although some may consider medical management of facial paralysis still controversial, I personally feel that steroids SHOULD have been immediately prescribed without any anti-virals.

The current preponderance of evidence is that anti-virals make absolutely no difference in the treatment of facial paralysis... even when the facial paralysis is due to a virus [link].  I personally do not prescribe anti-virals for patients with facial paralysis regardless of etiology.

What about steroids? Moderate quality evidence show that steroids were significantly more likely than anti-virals to produce complete recovery [link #1; link #2]. I always prescribe steroids to treat facial paralysis.

What about facial nerve decompression surgery?

Now surgical decompression of the facial nerve can be considered controversial. Decompression entails removing part of the skull, moving the brain to one side slightly, and removing all bone covering the facial nerve.

The theory being that if the facial nerve is swollen as it courses through the skull from the brain to the face, strangulation followed by nerve death occurs. To use an analogy, if a finger starts to swell from trauma, a ring being worn may prevent blood flow and eventually cause strangulation of the finger. Treatment to reestablish finger blood flow is to cut the ring off. Facial nerve decompression is akin to cutting a ring off to save a swollen finger.

Typically, surgical decompression of the facial nerve is pursued when facial paralysis occurs in the context of physical head trauma (ie, car accident). In the absence of preceding physical trauma, it would be the rare surgeon who would recommend surgical facial nerve decompression.

Obviously, the main question related to this lawsuit is whether nerve swelling occurred due to the TMS therapy necessitating surgical decompression. Presumably, an MRI scan was performed showing a highly inflamed and swollen facial nerve as well as significant nerve degeneration on ENoG testing. Supporting evidence (not mentioned in media reports) would be if profound hearing loss also occurred. Why? Because the facial nerve and hearing nerve both go through the same boney canal.

Malpractice?

TMS is not known to cause facial paralysis. As such, in a normal situation, this particular risk would not be expected to be included in the consent (as it has not been previously described). However, given this therapy was provided in the context of an experimental research protocol, the consent process is much more rigorous with much higher standards. With such higher standards, should risks never before seen be also included in the consent, especially if TMS has been performed many times for other purposes??? I don't know...

Certainly, my feeling as an ENT specialist is that steroids should have been given and not an anti-viral medication. Whether ENT specialist standards should apply to emergency room staff is harder to say.

Without more information, negligence as it pertains to delayed surgical facial nerve decompression is also hard to say.

Ultimately, we shall see what the court decides.


Source:
Lawsuit alleges Iowa doctors left patient's face paralyzed. Associated Press 8/13/13

References:
Transcranial magnetic therapy. Wikipedia

Electrical and transcranial magnetic stimulation of the facial nerve: diagnostic relevance in acute isolated facial nerve palsy. Eur Neurol. 2012;68(5):304-9. doi: 10.1159/000341624.

Antiviral therapy for Ramsay Hunt syndrome (herpes zoster oticus with facial palsy) in adults. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006851. doi: 10.1002/14651858.CD006851.pub2.

Antiviral treatment for Bell's palsy (idiopathic facial paralysis). Cochrane Database Syst Rev. 2009 Oct 7;(4):CD001869. doi: 10.1002/14651858.CD001869.pub4.

Do either corticosteroids or antiviral agents reduce the risk of long-term facial paresis in patients with new-onset Bell's palsy? J Emerg Med. 2010 May;38(4):518-23. doi: 10.1016/j.jemermed.2009.08.016. Epub 2009 Oct 21.

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Men with Deeper Voices are More Successful

© Dreamstime Agency | Dreamstime Stock Photos

A Duke University study has found that men with deeper voices not only are more successful, but also make significantly more money. How much more money? $187,000 per year more than men with higher-pitched voices.

How much deeper does the voice need to be to make a difference? Apparently 22.1 hertz which is approximately 1/6 the difference between the pitch of James Earl Jones (low-pitch) and Mike Tyson (high-pitch).

Other research (see below) have found that a deeper voice also makes a candidate more likely to win, are more desirable to women, mate more frequently, and father more children.

How can a man with a relatively higher-pitched voice achieve a natural-sounding deeper voice? The first and perhaps best way to accomplish this is through voice therapy. Think of it like singing where a person learns to achieve a greater vocal range through intensive instruction... but in this case, focusing on the lower range.

Of course, there are surgical interventions that may also be helpful should voice therapy be unsuccessful including:

1) Vocal cord bulking through injection
2) Cricothyroid muscle dennervation through botox or lysis
3) Thyroid cartilage framework surgery (Isshiki Thyroplasty Type 3)

I should point out that surgical intervention is NOT recommended as a first step and usually does not achieve the profound improvement that most men desire... in other words, there is no simple, quick, and easy way to deepen the voice.

References:
Voice pitch and the labor market success of male chief executive officers. http://dx.doi.org/10.1016/j.evolhumbehav.2013.03.001, How to Cite or Link Using DOI

"Sounds like a winner: Voice pitch influences perception of leadership capacity," Proc Biol Sci. 2012 Jul 7;279(1738):2698-704. doi: 10.1098/rspb.2012.0311. Epub 2012 Mar 14.

Preferences for very low and very high voice pitch in humans. PLoS One. 2012;7(3):e32719. doi: 10.1371/journal.pone.0032719. Epub 2012 Mar 5.

Sources: 
Voters 'like low-pitched voices'. BBC 11/14/11

Your Voice Could Be Costing You Hundreds Of Thousands Of Dollars, Study Shows. Forbes 4/18/13

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Dr. Chang Quoted in the Wall Street Journal

The Wall Street Journal on 3/15/13 published a story on how voice therapy and vocal surgery can dramatically improve a person's vocal quality... seemingly taking years away from how you sound.

In this story, Dr. Chang was quoted a few times and even included a patient he has treated successfully with voice surgery to restore his voice.

In regards to how aging can create muscle atrophy and bowing resulting in:

"It creates a breathy, raspy voice," says Christopher Y. Chang, an otolaryngologist at Fauquier Ear, Nose & Throat Consultants in Warrenton, Va.

Later in the WSJ article, surgical intervention is discussed and introduced Mr. James Driver, a Warrenton, VA jewelry repair storeowner who Dr. Chang treated:

"In the procedure, called injection augmentation of the vocal folds, a doctor threads an endoscope through the patient's nose or mouth into the throat, then injects a tiny amount of collagen, fat, hyaluronic acid or a gel filler into the vocal cords to plump them up. The substances usually last three to six months. If the procedure works, a doctor may recommend inserting silicon or Gore-Tex implants to fatten the cords permanently.

In 2011, James Driver was felled by an episode of temporary paralysis that left one of his vocal cords frozen. The 57-year-old owner of a Virginia jewelry-repair business worked with a therapist and did throat exercises on his own, but he could only manage a whisper. "You had to be right next to him with your ear to his mouth" to hear him, says his wife, Erin.

The couple sought out Dr. Chang, who recommended an injection. The day after the procedure, Mr. Driver was speaking at near regular volume. A year later, he's still going strong, though he hears his own voice as being slightly raspier than it used to be. "It made a huge difference," Mrs. Driver says."

 Read the full article here.

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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!

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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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New Video on Treatment of Hyper-Nasal Speech by Injection

Our office has created a new video that we have uploaded that shows how hyper-nasal speech can be corrected via injection of filler agents under endoscopic guidance.

Keep in mind that this procedure ONLY works with small velopharyngeal insufficiency.

Hyper-nasal speech occurs when there is too much nasal airflow during speech as opposed to hypo-nasal speech (ie, nasal obstruction) which occurs when there is little or no nasal airflow during speech. In either case, the voice sounds "nasal".

Check out the video here.

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Nasal Sounding Speech

There are actually TWO different flavors of nasal sounding speech.

HYPO-nasal speech is due to reduced or no nasal airflow and HYPER-nasal speech due to too much nasal airflow.

HYPO-nasal speech is by far the most common cause of nasal-sounding speech. It is similar to how a person would sound if they pinched their nose shut while talking. As such, ANY anatomic nasal obstruction would by definition lead to such hypo-nasal speech. Treatment, obviously, is to remove this anatomic nasal obstruction whatever it may be either with medications or surgery. Examples of hypo-nasal speech causes include:

• Adenoid Hypertrophy (Very Common)
• Turbinate Hypertrophy (Common)
• Significant Deviated Septum (Uncommon)
• Nasal Polyps (Uncommon)
• Allergies (Common)
• Infection (upper respiratory illness and/or bacterial infections) (Common)
• Rarely, genetic conditions like cystic fibrosis and immotile ciliary syndrome
• Rarely, anatomic conditions such as choanal atresia
• Rarely, a sino-nasal tumor
  

HYPER-nasal speech itself has several different flavors, but the key concept is the presence of an opening between the mouth and nose when it should be sealed shut during speech. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Now what are some of the causes of HYPER-nasal speech? Causes can be divided broadly into either anatomic and functional variants.

Anatomic HYPER-nasal speech include:

• Cleft Palate
• Palate Fistula
• Submucus Cleft

Functional HYPER-nasal speech include:

• Velopharyngeal insufficiency without anatomic cause. Velopharyngeal insufficiency or VPI occurs when the soft palate does not seal against the back of the mouth during appropriate speech sounds.
• Poor articulation (person is not correctly pronouncing words)

Treatment of HYPER-nasal speech may include speech therapy and surgery depending on the cause.

Given the subtleties involved in differentiating the different causes of nasal speech, workup typically involves not only just looking in the nose or mouth, but also performing a nasal endoscopic examination.

Below is a video showing a young child undergoing just such an endoscopic exam. Here are some other videos containing audio of abnormal endoscopic exams.

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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

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Celebrity Chef Grant Achatz With Stage 4 Tongue Cancer

Chicago news recently published a story about their very own celebrity chef Grant Achatz who suffered from Stage 4B squamous cell carcinoma of the tongue.

Grant Achatz, chef and co-owner of Alinea/Next/Aviary, approached multiple physicians throughout the country who essentially told him the oral cancer was terminal. In the end, he underwent treatment at University of Chicago successfully, though he certainly is not out of the woods yet.

There are several approaches in the treatment of tongue cancer, especially one as advanced as Mr. Achatz's, each with its own advantages and disadvantages.

In one approach is surgery first to remove all visible disease followed by radiation and chemotherapy to get rid of microscopic tumor cells. Surgery is huge... it entails removal of most of the tongue, involved jawbone, and removal of lymph nodes in the neck (neck dissection). Given how much tissue is removed, reconstruction of the defect is typically performed using bone, skin, and muscle typically taken from the arm (radial forearm free flap). Given how massive the surgery is, a tracheostomy as well as stomach feeding tube is placed. Hospitalization is typically 1-2 weeks long.

An alternative approach is surgery second. Radiation and chemotherapy is done first to shrink the tumor. Once this course is completed, surgery is performed to remove residual disease. The amount of surgery depends on the degree of residual cancer that is left. This course of action is what Mr. Achatz chose to pursue.

Regardless of what step is pursued, there are lots of side effects from cancer treatment including:

• loss/alteration in taste and smell
• dry mouth
• difficulty with swallowing
• stiff neck
• poor teeth (often they get removed prior to cancer treatment)
• leathery skin

Unfortunately, cancer being cancer, risk of recurrence is VERY high especially for stage 4 tongue cancer no matter how well the initial response appears to be. Regularly monitoring over the next 5 years is absolutely essential starting with an exam every 2-3 months for the first two years as that's when the risk of cancer recurrence is highest.

Source:

Celebrated chef gives back. WGN 3/22/12

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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!

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New Webpage on Vocal Cord Cysts and Vocal Cord Polyps

We have uploaded a new webpage describing what vocal cord cysts and vocal cord polyps are as well as how they are treated.

Vocal cord cysts are masses below the vocal cord lining whereas vocal cord polyps are masses involving the vocal cord lining.

Read more here!

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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.

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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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