The Center for Laryngeal (Voice) and Esophageal Disorders
Lee M. Akst, MD, Director
Treatments and Procedures
Strobovideolaryngoscopy
Office laryngoscopy refers to using a camera to study the vocal cords. This
camera can either be a flexible camera passed through the nose or a rigid
camera passed through the mouth – once the camera reaches the back
of the mouth, it is held in place while it looks down at the vocal cords.
When a strobe light is attached to the camera, it can give a slow-motion
look at vocal cord motion and vibration to help study vocal cord pliability.
This examination is recorded as digital video so it can be saved and reviewed
following the examintation. Adding a strobe light and video recording to
laryngoscopy yields a “strobovideolaryngoscopy”. Strobovideolaryngoscopy
is an excellent technique for determing how vocal cord lesions affect the
voice and vocal dynamics.
Suspension Microlaryngoscopy
As compared to strobovideolaryngoscopy, which is performed in the office,
Suspension Microlaryngoscopy is performed in the operating
room. Laryngoscopy in the operating room refers to placing a laryngoscope,
or hollow metal cylinder, through the patient’s mouth to reach the
vocal cords. Special instruments are designed to hold this laryngoscope
in place, so that the surgeon can operate with both hands simultaneously
– this is the “suspension” part of suspension microlaryngoscopy.
The “micro” part comes into play when an operating microscope
is used to peer down the laryngoscope at the vocal cords. Use of this microscope
magnifies the vocal cords by as much as 10 times. As part of suspension
microlaryngoscopy, the surgeon can place instruments through the laryngoscope
to reach the vocal cords. Using these special tools, the surgeon can remove
vocal cord lesions, perform biopsies, and even inject substances into the
vocal cords.
You may read Dr. Akst’s handout concerning Suspension Microlaryngoscopy here.
Phonomicrosurgery
Phonomicrosurgery is a particular type of laryngeal surgery that is performed
under Suspension Laryngoscopy. When the surgery on the vocal cords is designed
to remove a benign lesion in order to improve a voice, it is termed “phonomicrosurgery.”
Phonomicrosurgery is most often performed on nodules, polyps, and cysts.
When done appropriately, phonomicrosurgery can be quite delicate and should
be performed only by specially trained laryngeal surgeons. Although phonomicrosurgery
is often performed on singers who have developed phonotrauma, it can also
help to restore the speaking voices of other professional voice users.
Laryngeal Framework Surgery
Laryngeal framework surgery is surgery that is performed through a neck
incision to help re-position paralyzed or weak vocal cords. For instance,
patients with permanent vocal cord paralysis can benefit from laryngeal
framework surgery to re-position their immobile vocal cord in the middle
of the voicebox, where the normal vocal cord can close against it completely.
Depending on the desired effect, there are different types of laryngeal
framework surgery. Medialization laryngoplasty inserts permanent Gore-Tex
strips into the lateral part of a vocal cord, either moving an immobile
vocal cord towards the middle or helping an atrophic vocal cord to become
larger. Adduction arytenopexy re-positions the cartilage which inserts on
the back of the vocal cord, and it can help close gaps in the back part
of the voicebox. Lastly, cricothyroid subluxation can help stretch a paralyzed
vocal cord in a way that helps the patient’s voice recover more of
its normal range. These 3 procedures (medialization laryngoplasty, adduction
arytenopexy, and cricothyroid subluxation) can all be performed at the same
time. Surgery is performed through a neck incision, and it is done under
sedation and local anesthesia so that the patient can speak to the surgeon
during the procedure. In this way, the voice can be “tuned”
during the operation.
You may read Dr. Akst’s handout concerning Laryngeal Framework Surgery here.
Vocal Cord Injection
Vocal cord injection is the procedure of injecting a substance into a vocal
cord to make it larger. If a vocal cord is paralyzed and immobile, the effect
of the vocal cord injection is to help move that cord towards
the middle of the voicebox. By moving a paralyzed vocal cord towards the
middle, the other (moving) vocal cord can contact it better, allowing for
improved voice, cough, and swallowing. The substance that is injected into
the paralyzed vocal cord can be either permanent or temporary – temporary
substances are chosen when it is unsure whether or not the vocal cord will
recover function. Vocal cord injection can be performed both in the office
under local anesthesia or in the operating room under general anesthesia.
Pulsed Laser Therapy
Pulsed laser therapy refers to the ability to deliver laser energy into
the vocal cord in very short (millisecond) pulses. This energy is targeted
specifically at the blood vessels within the vocal cord, and the pulse of
the energy delivery is so short that the blood vessels absorb all of the
energy before any of it can leak into the surrounding vocal cord tissue.
The overall effect of the pulsed laser therapy is to coagulate or collapse
the blood vessel without causing any scar tissue in the vocal cord. In this
way, the vocal cord remains pliable and voice quality can be preserved while
treating diseases that depend upon blood supply for growth. For instance,
recurrent respiratory papilloma (RRP) and early vocal cord pre-malignancies
can be treated well by using pulsed laser therapy. Because these diseases
might require repeated treatments over a long period of time, the ability
to treat them while minimizing damage to the vocal cords is very important
to preserve good voice.
Pulsed laser therapy use in vocal cords is an emerging and innovative technology
that is not available at all medical centers. It can be performed in both
the office and the operating room. Dr. Akst is pleased to be able to offer
this exciting new therapy to his patients.
Botox Injection
Botox (Botulinum Toxin Type A) is a chemical that can be injected into a
muscle in order to weaken it. For instance, cosmetic surgeons might inject
Botox into a patient’s forehead to lessen wrinkles by making a patient
less able to use forehead muscles. In the vocal cords, Botox can decrease
the ability of the vocal cords to squeeze strongly against one another,
or spasm. For this reason, Botox injection into the vocal cords is the treatment
of choice for Spasmodic Dysphonia. Botox vocal cord injection can be performed
in the office, and the effect of the Botox on improving spasmodic dysphonia
generally lasts for 2-3 months.
You may read Dr. Akst’s handout concerning Botox Injection here.
Transnasal Esophagoscopy
Transnasal esophagoscopy (TNE) is an office-based procedure in which a flexible
scope is passed through the nose and into the voicebox. The procedure is
performed under local anesthesia and only takes a few minutes. It is very
well tolerated by most patients. Transnasal esophagoscopy is often warranted
to look at the esophageal lining in patients with gastroesophageal or laryngopharyngeal
reflux disease. Transnasal esophagoscy is also a useful procedure in patients
with swallowing difficulty. The alternative to transnsasal esophagoscopy
in the office is a sedated esophagogastroduodonoscopy (EGD) by a gastroenterologist
in an endoscopy suite, a procedure which takes longer and has a longer recovery
period than transnasal esophagoscopy. For this reason, more and more patients
who need monitoring of their esophageal lining are choosing the expanding
new technique of transnasal esophagoscopy.
You may read Dr. Akst’s handout concerning Transnasal Esophagoscopy (TNE) here.
