VINY

Voice disorders (hoarseness, laryngitis, and dysphonia) are common and they are usually treatable. We at VINY have specialized in the medical and surgical aspects of voice rehabilitation for more than 25 years.

Who Gets Voice Disorders and Why?
 

A voice disorder may prevent a professional singer from performing or a business person from effectively managing his or her affairs, or it may prohibit simple, daily, verbal communication between elderly spouses. A person’s vocal quality may influence the type of work that person does, and conversely, the type of work a person does may influence the importance of avoiding voice difficulties and the degree of professional impairment that may result from a voice problem. Voice disorders are ubiquitous, and many have severe social, psychological, professional, and economic consequences.
 

Prevalence of Voice Disorders
 

In the United States, voice disorders affect approximately 25 million people, and yet there are less than 80,000 patient visits annually to a voice specialist. For this population, voice disorders are not just a mere annoyance. And, the professional and economic impacts of voice disorders will continue to increase as the United States’ economy continues to shift from manufacturing to a service and information base. As a result, by 2010, the portion of the population that relies on its voice for their profession will grow five times faster than those who do not need their voices for their work. Approximately 1%-2% of the American population has a voice disorder and the prevalence of voice disorders is higher than other well-known diseases.

Prevalence of Some Well-Known Diseases

Additionally, as many as 30%-50% of the American population has reflux disease, a condition caused by the backflow of stomach contents into the esophagus and/or throat. Reflux is one of the most commonly under-diagnosed and under-treated causes of voice problems; and, it is an important focus of contemporary laryngology. Until relatively recently, many voice disorder patients went untreated, but today, with advances in diagnosis and treatment, that has changed.
 

Levels of Vocal Usage

The success of treating patients with voice disorders depends to a great extent upon accurate diagnosis and identification of the vocal needs of each patient within the context of the patient’s professional and social needs and obligations. The same voice disorder may have profoundly different impact on two different patients depending on their professions. There are four levels of vocal usage, based upon a hierarchy of vocal use, performance, and need:

Level I: Elite Vocal Performer
A person for whom even a slight aberration of voice may have dreadful consequences. Most singers and actors are in this group; the opera singer is the quintessential level I performer.

 

Level II: Professional Voice Use
A person for whom a moderate vocal problem might prevent adequate job performance. This group includes most broadcasters, actors, clergy, teachers, etc.

 

Level III: Non-Vocal Professional
A person for whom a severe vocal problem would prevent adequate job performance. This group includes lawyers, physicians, businessmen, business women, etc.

 

Level IV: Non-Vocal Non-Professional
A person for whom vocal quality is not a prerequisite for adequate job performance. This group includes many clerks, laborers, and so forth. Although persons in this group may suffer very significant social liability from a voice disorder, they are not prevented from doing their work.

Professional vocalists, especially singers, are the first to seek medical attention if something happens that adversely affects the voice. When a voice disorder strikes a well-known vocalist, it may prevent an adequate performance or even force cancellation of performances. Obviously, concert promoters, support staff, and the public are impacted. Thus, a voice problem can have profoundly adverse financial and professional implications for the singer’s career, and may damage the singer’s reputation as well.

Most commonly, the voice problems of vocal performers are acute “emergencies” caused by upper respiratory infection such as a cold, reflux; or they may be environmental or stress-related.

Other professional voice users (levels II and III) may suffer similar emergencies; however, more commonly, the voice problems in these groups are chronic. For non-vocal non-professionals, the type of voice problems may be similar, but level IV patients usually do not seek medical attention until the problem is chronic. However, any level patient may be just as severely affected from a social and a psychological point of view as any other patient.

Multiple Causes of Voice Disorders
 

In most cases, voice disorders are multifactorial (that is they have more than one cause.) It’s almost as though several things need to go wrong before voice decompensation occurs; see “vocal decompensation.” The most common problems that affect the voice and larynx are:

• Laryngopharyngeal reflux (the backflow stomach contents into the throat) that may be completely silent occurring without heartburn or digestive symptoms

• Vocal fold weakness (partial paralysis, effects of aging, or Bell’s palsy of the throat)

• Vocal misuse abuse and overuse syndromes

• Lesions (growths) occurring on the vocal folds

The table below shows the results of a study done on 200 voice disorder patients by Dr. Jamie Koufman. It can be seen that approximately 70% of patients have laryngopharyngeal reflux and 50% have vocal vocal fold weakness or some other neurological problem that affects the voice while 1 out of 5 (20%) have a vocal fold growth of some kind, and 90% have abnormal laryngeal biomechanics (meaning they are having to use compensatory mechanisms such as extra work, to achieve vocal fold closure. The table below shows the distribution.
 

Results of the Voice Disorders Etiology (Causes) Study

The Voice Institute of New York prides itself on providing precision diagnostics. These include videostroboscopy, laryngeal electromyography, acoustical measurement, and reflux testing. Once accurately diagnosed, most voice disorders can be corrected.

Contact VINY for an appointment 
Dr. Koufman's Curriculum vitae

STATE-OF-THE-ART DIAGNOSTIC TESTING
 

The success of treating patients with voice disorders depends to a great extent upon accurate diagnosis. To get successful outcomes, it is necessary to diagnose and treat each of the underlying problems. All of the testing done at the Voice Institute of New York is state of the art. Furthermore, we have extensive experience with most of the important testing methods.
 

Videostroboscopy

Videostroboscopy is a quick and painless examination of the larynx and throat. It is performed by the doctor spraying the nose with a numbing medicine and then placing a small flexible soft fiberoptic instrument through the nose to view the throat. This procedure allows for a magnified view of the vocal folds, for assessment of vocal fold vibrations, for a subsequent video-analysis, and for photography. At VINY, all videostroboscopy examinations are digitally archived.

Laryngeal Electromyography
 

Laryngeal electromyography (LEMG) is a term that almost defines itself. The larynx is the voice box, electro means electrical, myo means muscle, and ography means measurement. Thus, this test is performed by inserting a fine needle like an acupuncture needle into the voice box and measuring the electrical potentials of the muscles. While this test can be uncomfortable, it lasts only about a few minutes and it is not associated with any complications.

LEMG provides essential information about the neuromuscular status of the larynx that no other test can provide. Dr. Jamie Koufman, the Institute’s director, has been performing LEMG on a daily basis since 1987, “I make more clinical decisions based upon laryngeal electromyography than almost any other test.”

Reflux Testing (See also the Reflux-Testing Information Page)
 

Reflux refers to the back flow of gastric (stomach) contents into the esophagus or throat. Laryngopharyngeal reflux (LPR) is very common in voice disorder patients and it can be “silent”, that is, it can occur without heartburn or digestive symptoms. Reflux testing actually has several elements: esophageal manometry, ambulatory 24-hour pH testing, and transnasal esophagoscopy.

Manometry
 

Manometry is a way of measuring swallowing pressures and effectiveness of the entire swallow mechanism, including the upper and lower esophageal sphincters. (The upper esophageal sphincter is supposed to prevent reflux into the larynx and pharynx; whereas, the lower esophageal sphincter is supposed to prevent reflux into the esophagus.) In actuality, everyone has some reflux some of the time. This test determines whether or not the valves and the swallowing mechanism itself are healthy or defective.

pH Monitoring

pH monitoring is a method of testing in the esophagus and throat for acid reflux. This test is performed overnight. A small flexible tube in placed in the nose and enters the throat and esophagus where it measures acidity and backflow in both the esophagus and the laryngeal areas. This test is the state-of-the-art and it is profoundly important in many voice disorder patients.

Transnasal Esophagoscopy
 

We are able to evaluate the esophagus in the office without any intravenous sedation or anesthesia. The small flexible instrument that is used to examine the larynx can be inserted into the esophagus just behind the voice box and provide a spectacular quick and comfortable examination. This technique obviates more complex time-consuming, expensive, and unpleasant procedures.
 

Acoustical Analysis and Voice Therapy
 

The VINY acoustical analysis (voice) laboratory employs a full battery of diagnostic tools, including spectral analysis (like the finger prints of the voice) that can distinguish spasmodic dysphonia (SD) from other conditions such as muscle tension dysphonia. This technology is also an important adjunct in the diagnosis and treatment of vocal fold weakness due to paresis (partial paralysis), paralysis atrophy, and/or aging. In addition, voice therapy is the cornerstone of treatment for many voice conditions. It can help strengthen the voice, including the dynamic and pitch-ranges. A trial of therapy is often an important element of the diagnostic voice evaluation.

Swallowing Evaluation and Therapy
 

Endoscopic Swallowing Evaluation. The use of a small flexible endoscope, introduced through the nose, provides a quick well-tolerated, safe, and effective method of evaluating swallowing; and, it replaces older, more expensive, and unpleasant methods.

SURGICAL AND NON-SURGICAL TREATMENTS OFFERED AT VINY
 

There are treatments available at the Voice Institute that are available almost no where else. The cornerstone of voice rehabilitation surgery is “laryngoplastic phonosurgery” that refers to plastic surgery of the larynx to alter the voice. This type of surgery was introduced in the United States by Dr. Jamie Koufman in 1983, and she has done much to evolve this voice technology since that time.

Voice Rehabilitation Surgery (Laryngeal Framework Surgery, Laryngoplastic Phonosurgery, Isshiki Thyroplasty)
 

The most important applications of laryngoplastic phonosurgery are for rehabilitation of vocal cord paralysis or partial paralysis. (Partial paralysis of the vocal folds is common and is often diagnosed as vocal fold weakness or bowing.) Vocal fold bowing is one of the most common causes of vocal nodules and polyps. At VINY we strive to fix the lesions on the vocal folds, as well as the underlying cause.

Bilateral Medialization Laryngoplasty (BML)
 

The most common of the procedures is called “bilateral medialization laryngoplasty” (BML). BML is performed under local anesthesia in the operating room and allows straightening or strengthening of crooked or bowed vocal folds to alleviate hoarseness, vocal fatigue and other voice symptoms. This procedure does require an overnight stay in the hospital; nevertheless, BML provides tremendous benefit and voice imporvement for the majority of patients with weak vocal folds from Bell’s palsy of the larynx, prior intubation injuries, prior surgical intervention, cancer, viral neuropathy, or simply the aging process itself. After cancer surgery, laryngeal injury, or chronic illness, the voice may become weak due to vocal fold damage and scarring. In many cases, the voice can be restored by rebuilding part of the vocal folds or larynx.

Rare Laryngeal Diseases
 

We at VINY have extensive experience with rare laryngeal disorders, including amyloid, sarcoid, lupus, rheumatoid arthritis, fungal infections, relapsing polychondritis, laryngeal chondrosarcoma, and spasmodic dysphonia (SD).

Office-Based Laryngeal Laser Surgery
 

Office-based laryngeal laser surgery is new and safe and profoundly effective. It generally is preferred by patients to traditional surgical methods; see the article Unsedated, office-based, laryngeal laser surgery: Review of 444 cases using three wavelengths. Office-based surgery has many advantages, including:

• No intravenous sedation or other medication is needed

• Patients require no postoperative recovery

• Only anesthesia needed is topical (spray) with a topical anesthetic

• Biopsies can be obtained for histology

• Actual operating time is reduced (in most cases to under 15 minutes)

• Many procedures are actually technically easier and safer in the office than in the operating room

• There are tremendous time and cost savings for the patient

Among the most exciting applications are for laryngeal polyps and papillomas. At this point, with confidence, we can state that these in-office laser technologies with new lasers provide superior results to any other method in many cases.

The real great advance of in-office un-sedated laser surgery is there is no risk of general anesthetic complications, it’s less invasive, there are no large rigid metal endoscopes, and so there are fewer complications such as airway problems, dental injuries, or sore tongue. In terms of patient satisfaction 90% of patients who have had in-office, as well as in the operating room procedures, prefer the in-office procedure. Patient satisfaction is increased because of improved comfort, safety, and outcomes, easy recovery, and no significant loss of time from work or family.

Care of the Professional Voice
 

Care of the professional voice itself is an art and not a science. In addition to the medical problems that can affect the voice of us all, there are specific occupational hazards and unique problems that vocal professionals experience. These include allergies, exposure to environmental pollutants, ambient noise problems, inadequate amplification, training and inappropriate tessitura issues, over-scheduling, hormonal influences, and psychological, stress-related problems.

Vocal professionals need medical care that is appropriately customized, timely, and that doesn’t compromise the long-term outcomes. In addition, singers especially need enough time with their physicians to understand and participate in their own treatment. At VINY, we don’t have to rush to get to the next patient, and treatment is comprehensive.