VOICE ASSIGNMENT

SUBMITTED TO: DR.SADHANA RELEKAR

SUBMITTED BY : RUTWESH KADAM

TOPIC COVERED:
1. Medical and surgical procedures in the treatment of benign vocal fold lesions.
2. pharmaceutical effects on voice.
3. phono surgery: re- innervation techniques.
Medical and surgical
procedures in the
treatment of benign
vocal fold lesions.
It depends upon the site of lesion, extent of lesion, pres ence or absence of nodal and distant metastases. Treat ment
consists of:
1. Radiotherapy
2. Surgery
(a) Conservation laryngeal surgery (b) Total laryngectomy
3. Combined therapy. Surgery with pre- or postoperative radiotherapy
4. Endoscopic resection with CO2 laser
5. Organ preservation
1. RADIOTHERAPY: Curative radiotherapy is reserved for early lesions which neither impair cord mobility nor
invade cartilage or cervical nodes. Cancer of the vocal cord without impairment of its mobility gives a 90% cure rate
after irradiation and has the advantage of preservation of voice. Superficial exophytic lesions, especially of the tip of
epiglottis, and aryepiglottic folds give 70-90% cure rate. Radiotherapy does not give good results in lesions with
fixed cords, subglottic extension, cartilage invasion and nodal metastases. These lesions require surgery.
2. SURGERY:

(a) Conservation laryngeal surgery.:Earlier total laryngectomy was done for most of the laryngeal cancers
and the pa tient was left with no voice and a permanent tracheos tome. Lately, there has been a trend for
conservation la ryngeal surgery which can preserve voice and also avoids a permanent tracheal opening.
However, few cases would be suitable for this type of surgery and they should be carefully selected.
Conservation surgery includes:
(i) Excision of vocal cord after splitting the (cordectomy via laryngofissure). larynx
(ii) Excision of vocal cord and anterior commissure region (partial frontolateral laryngectomy).
(iii) Excision of supraglottis, i.e. epiglottis, aryepi glottic folds, false cords and ventricle-a sort of
transverse section of larynx above the vocal cords (partial horizontal laryngectomy).
b) Total laryngectomy: The entire larynx including the hyoid bone, pre-epiglottic space, strap muscles and one or
more rings of trachea are removed. Pharyngeal wall is repaired and lower tracheal stump sutured to the skin for
breathing Laryngectomy may be combined with block dissection for nodal metastasis.
Total laryngectomy is indicated in the following conditions:
1. T3 lesions (i.e. with cord fixed)
2. All T4 lesions
3. Invasion of thyroid or cricoid cartilage
4. Bilateral arytenoid cartilage involvement
5. Lesions of posterior commissure
6. Failure after radiotherapy or conservation surgery
7. Transglottic cancers, i.e. tumours involving supra glottis and glottis across the ventricle, causing fixation
of the vocal cord. It is contraindicated in patients with distant metastasis.

3. COMBINED THERAPY:Surgical ablation may be com bined with pre- or postoperative radiation to
decrease the incidence of recurrence. Preoperative radiation may also render fixed nodes resectable.
4. ENDOSCOPIC RESECTION WITH CO₂ LASER:
Carcinoma of the mobile membranous vocal cord is tradition ally treated with radiotherapy. Now such lesions can be precisely
excised with CO2 laser under microscope with the same good results. Laser excision has the ad vantages of lower cost, lower
duration of treatment and morbidity.
Similar T, lesions of the supra- or infrahyoid epiglottis with or without neck nodes have been treated with CO2 laser. Cervical
nodes in such cases are managed surgically with appropriate neck dissection..
Endoscopic CO2 laser is getting popular at some centres where facilities of CO2 laser and expertise are available.

5. ORGAN PRESERVATION:
To avoid total laryngectomy in stage III and IV, trials were conducted for laryngeal preservation. They showed that induction
chemothera py followed by radiotherapy or concurrent chemoradia tion showed better locoregional control of disease than
laryngectomy with postoperative radiotherapy. It also had the advantage of preservation of laryngeal function. However
concurrent chemoradiation causes more toxic ity and proper selection of cases should be made. Such studies of organ
 EFFECTS OF
MEDICATIONS ON
VOICE.
Could Your
Medication
Be Affecting
 Some medications including prescription, over-the-counter, and herbal supplements can affect the function of your
voice. If your doctor prescribes a medication that adversely affects your voice, make sure the benefit of taking the
medicine outweighs the problems with your voice.
Most medications affect the voice by drying out the protective mucosal layer covering the vocal cords. Vocal cords
must be well-lubricated to operate properly; if the mucosa becomes dry, speech will be more difficult. This is why
hydration is an important component of vocal health.
Medications can also affect the voice by thinning blood in the body, which makes bruising or hemorrhaging of the
vocal cord more likely if trauma occurs, and by causing fluid retention (edema), which enlarges the vocal cords.

Medications from the following groups can adversely affect the voice:
Muscle relaxants
Diuretics
Antihypertensives (blood pressure medication)
Antihistamines (allergy medications)
Anticholinergics (asthma medications) High-dose Vitamin C (greater than five grams per day)
 Other medications and associated conditions that may affect
the voice include:
Antidepressants
Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a
cough or excessive throat clearing in as many as 10 percent of patients. Coughing or excessive
throat clearing can contribute to vocal cord lesions.
• Oral contraceptives may cause fluid retention (edema) in the vocal cords because they contain
estrogen.
• Estrogen replacement therapy post menopause may have a variable effect.
• An inadequate level of thyroid replacement medication in patients with hypothyroidism.
 Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp
formation in response to trauma.
PHONO
SURGERY:
REINNERVATIO
N
TECHNIQUES.
The term phonosurgery (PS) refers to any operation designed primarily for the improvement or restoration of voice. It is
defined by the intended operative goal, which pertains to quality of life rather than its preservation, and informed consent
needs to account for this emphasis.
Phonosurgery includes:
1.Phonomicrosurgery:microsurgery of the vocal folds done through an endoscope
2.Laryngoplastic phonosurgery:open-neck surgery that restructures the cartilaginous framework of the larynx and the soft
tissues,
3.Laryngeal injection: injection into the larynx of medications as well as synthetic and organic biologic substances,
4.Reinnervation:restoration of the nerve supply of the larynx
Phono surgery reinnervation include any of a number of surgical procedures intended to restore neural connections to the
larynx, which have usually been lost from some type of trauma
The nerve function(s) to be restored may be those of the recurrent laryngeal nerve or its subdivisions, those of the superior
laryngeal nerve, or both, and they may be motor or sensory. Several different donor nerves are available and have been
described. The technique used may be direct end-to-end anastomosis (neurorrhaphy), direct implantation of a nerve ending into
a muscle, the nerve-muscle pedicle technique, or muscle-nerve-muscle methods. These nerves and techniques may be
combined in many ways. A number of new techniques have been reported in animal studies
1. Combination Technique:
In cases where there is incomplete closure of the posterior glottis, a simultaneous arytenoid adduction procedure at the time of
reinnervation is followed.

2. Unilateral Reinnervation in Children:

In the paediatric population, reinnervation offers several advantages over the alternatives of injection medialisation or framework
surgery. It provides a permanent result without disruption of the growing larynx. It is well recognised that the patient should be
awake and able to vocalise on command to achieve the best voice outcome with thyroplasty. As this is not possible in children,
reinnervation under general anaesthetic is favourable.

3. Superior Laryngeal Nerve Injury

Paralysis of the cricothyroid muscle may occur due to damage of the main trunk of the vagus or SLN or due to damage of the
external branch of the SLN only as this branch supplies the muscle. The clinical consequence is mild dysphonia, poor pitch
control and loss of the higher register. Before considering surgery, it is important to await the results of speech therapy and
spontaneous recovery. The traditional surgical approach is a cricothyroid approximation but this increases the tension in the vocal
cords at all times and risks feminisation of a male voice and loss of the low register. Reinnervation is a viable alternative that has
been used with some success.
THANK
YOU