Most of us take speaking and singing for granted. A healthy voice is critical for good communication and is often the source our livelihood and happiness. But many people struggle with their voice. Some can only speak at a very low volume; others are chronically hoarse or breathy.
The problem for many of these folks is one of anatomy: Each of us has two vocal cords, which open during breathing and close during swallowing and voice production. During vocalization, the vocal cords come together and vibrate very fast (from 100 to 1,000 times per second) to produce sound.
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But in some people, one or both of the vocal cords may develop lesions such as polyps, nodules or granulomas, or one of the vocal cords may stop working. And sometimes as we age, one or both of the vocal cords thins and loses its tautness, making it difficult to speak (a condition known as presbylaryngis). When the two vocal cords can’t come together or produce fluid motion, vocalization problems result. In severe cases, patients may have trouble swallowing and run the risk of aspirating.
Traditionally, vocal cord procedures (removal of lesions or injection of filler materials into the vocal cords) have been performed under general anesthesia. But today, thanks to advances in technology, we’re often able to perform the procedure right in the doctor’s office with the patient fully awake. By avoiding general anesthesia, we dramatically cut down on the recovery time for patients. And the cost is significantly less: about one-tenth the cost of doing surgery in the hospital under full anesthesia.
For example, consider the treatment of vocal cord paralysis (where one vocal cord stops working) or aging of the voice box, where we inject a variety of materials into the vocal cords to act as a temporary filler. By restoring bulk, these vocal cord injections (which can be repeated) restore patients with the ability to vocalize and sing.
When performed in the doctor’s office, this is a two-doctor procedure. One doctor inserts a tiny camera (about 1 mm thick) through the patient’s nose and works it down to the vocal cords as the other doctor goes in through the neck with a needle to inject the bulking material into the vocal cord(s) under direct visualization from the camera. The whole procedure only takes about 10 to 15 minutes and it’s a dynamic process: The patient is able to use his or her voice immediately. If we find that the voice still isn’t strong enough, we can immediately inject more filler until the patient is satisfied.
Some fillers (like Restylane) are effective for four to six months, while others (such as Cymetra) will provide relief for 6 to 12 months. For patients with a temporary vocal cord problem, this is often all they need to bridge them over until their vocal cord regains function. For those with an aging larynx or permanent paralysis, who might be considering more permanent implants (done under anesthesia), the temporary in-office injections can provide confidence the procedure will work and allow them to know what their voice will sound like.
These techniques also have benefit for patients with lesions on their vocal cords, such as papilloma or polyps. We’re now able to use the same instruments, threaded through the nose, to take a biopsy right in the doctor’s office while the patient is awake, rather than subject the patient to surgery in the hospital under anesthesia. In some cases, we also thread a laser through the camera, which enables us to laser off the lesion while the patient is awake, producing good voice outcomes. There’s minimal pain and the patient can go home immediately afterward.
[See: What Your Doctors Wish You Knew.]
Salivary Stones
It’s not only people with vocalization problems who can benefit from the advent of in-office procedures. We are similarly using small cameras and instrumentation in patients with salivary stones. Salivary stones can develop in people young and old and are similar to kidney stones. When they form in the salivary glands and become lodged in an individual’s saliva ducts, theses stones block the production of saliva and can be quite painful. Some patients develop so much swelling in their salivary glands that they can’t open their mouths to eat. Sometimes salivary stones lead to abscess and infection.
Often, we can use a course of antibiotics and warm compresses to pass the salivary stone. But sometimes that doesn’t work. In those cases, up until about five or 10 years ago, our only option was to perform surgery under full anesthesia to remove the entire salivary gland.
Now, we’re able to take an endoscopic approach. With the help of a minimally invasive technique known as sialoendoscopy, we can thread a tiny camera through the patient’s mouth and into the salivary ducts and project the image onto a monitor. Once we find the stone, we can remove it, using instrumentation that is part of the camera. These tools allow us to remove the stone with minimal pain. Like the vocal cord injection procedure, this can be done while the patient is awake on an outpatient basis, allowing us to avoid the risks (and costs) of general anesthesia in the hospital. Patients make a quick recovery and can return home — often even to work — the same day.
Not every otolaryngologist is equipped to offer these head and neck procedures in the office using this technology. For that reason, and given the myriad benefits, it’s important for patients with vocal cord lesions, paralysis or salivary stones to ask the right questions to find the specialist who will serve their needs best. With the help of these minimally invasive techniques, alongside the expertise of a surgeon knowledgeable in vocal cord and salivary stone procedures, patients can receive excellent and efficient care without much disruption to their daily lives.
[See: 10 Questions Doctors Wish Their Patients Would Ask.]
Nitinkumar J. Patel, MD is a board-certified head and neck surgeon with the Mid-Atlantic Permanente Medical Group, who specializes in voice disorders/vocal surgery and salivary gland surgery. He sees patients at the Kaiser Permanente Mid-Atlantic States Medical Center in Tysons Corner and Falls Church, Virginia. He graduated valedictorian from the George Washington University School of Medicine and completed his otolaryngology-head and neck surgery residency at George Washington University School of Medicine.
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The Future of Otolaryngology: Office-Based Vocal Cord and Salivary Stone Surgery originally appeared on usnews.com
