Diseases of the vocal folds (vocal cords) of the larynx are characterised by hoarseness, strained speech and a voice that cannot take much strain, which is a significant limitation in everyday life. In addition to inflammatory diseases, hyperfunctional voice disorders caused by cramping of the throat muscles, benign and malignant tumours and neurological diseases such as vocal fold paralysis or so-called spasmodic dysphonia, psychogenic factors are possible causes. In order to make a diagnosis and plan treatment, a video laryngostroboscopic examination of the vocal folds (dynamic laryngeal examination) is first carried out on an awake patient in the Phoniatrics and Paediatric Audiology department to assess the anatomical and functional condition of the vocal folds during voice production (phonation). This allows conclusions to be drawn about vocal fold closure and harmonic vocal fold vibrations that are impaired by vocal fold disorders.
Without initially recognisable changes to the vocal folds, patients with hyperfunctional voice disorders, i.e. with excessive muscle tension of the vocal folds during voice production (or an unnatural speaking and breathing technique), develop a clear effort to speak with hoarseness even in the early stages of the disease. The stroboscopic vibration behaviour of the vocal folds is restricted or irregular due to muscle tension.Conservative voice therapy with a focus on reducing harmful vocal overload is achieved through various procedures (e.g. speaking and breathing techniques, vocal hygiene). The prognosis is favourable with voice therapy measures. Asa result of an untreated hyperfunctional voice disorder, vocal fold nodules ("screaming or singing nodules") can develop
Organic voice disorders are caused by an increase in the mass of the vocal folds (e.g. in vocal fold polyps or cysts) with irregular fine vibration behaviour or incomplete vocal fold closure (e.g. in vocal fold paralysis). They are treated with phonosurgery (link to phonosurgery). A malignant tumour of the vocal folds also causes hoarseness. Treatment of vocal fold carcinoma and its precursors is carried out by the oncologists at the ENT Core Clinic in accordance with treatment guidelines.
Voice disorders are rarely an expression of a psychological stress situation or somatisation disorder. In addition to voice diagnostics, these patients usually undergo a psychological assessment by our clinical psychologist in order to initiate targeted psychotherapy. Voice therapy alone is not promising in such cases.
Voice-improving operations on the larynx (phonosurgery)
These patients can be helped with the help of phonosurgery, i.e. laryngeal surgery aimed at improving voice quality. Depending on the indication or disease, phonosurgical operations can be performed endoscopically, i.e. from the inside via the oral cavity/pharynx.
Under general anaesthetic, the larynx is adjusted with a laryngoscope and viewed magnified with a surgical microscope (direct microlaryngoscopy, MLS) (Figure 1). Microsurgical instruments can then be used to perform targeted treatment on the vocal folds. MLS is usually used to remove vocal fold polyps (Figure 2), vocal fold cysts (Figure 3), pure oedema (Figure 4), cry nodules, papillomas and leukoplakia (Figure 5). Laser surgery is also used if necessary.
If spasmodic dysphonia is present, treatment is carried out by injecting botulinum toxin (BOTOX) directly into the vocal cord muscle. If hoarseness occurs because the vocal folds do not shoot completely during vocalisation due to vocal fold paralysis (Figure 6a), the paralysed vocal fold must be shifted towards the middle (medialisation, vocal fold relining). This is done by injecting e.g. autologous fat, hyaluronic acid or calcium hydroxyapatite (Figure 6b). In the case of larger gaps, an operation must be performed "from the outside" with a skin incision in the neck. With the help of this so-called thyroplasty, the paralysed vocal fold is permanently moved to the centre using an (autologous) implant.
The voice-improving procedures are offered under general anaesthetic and, in special cases, also under local anaesthetic.
The causes of voice disorders can lie in a wide variety of areas, which requires an interdisciplinary approach to diagnosis and treatment [1].
In order to intensify clinical and scientific collaboration between the various disciplines involved in the care of voice patients, the Executive Board of the Ulm University Hospital decided to establish the "Ulm Voice Centre, SZU" at the beginning of 2019. The SZU is a joint unit run by the Department of Otorhinolaryngology, Head and Neck Surgery, the Section of Phoniatrics and Paediatric Audiology, the Department of Internal Medicine I, the Department of Neurology and the Department of Psychosomatic Medicine and Psychotherapy. It works closely with the Academy for Health Professions at Ulm University Hospital (Department of Speech Therapy).
Prof. Dr R. Reiter from the Department of Phoniatrics and Paediatric Audiology is a member of the Executive Board of the SZU.
The initial presentation of patients with voice complaints is still planned in the Section for Phoniatrics and Paediatric Audiology or in the Clinic for Ear, Nose and Throat Medicine. Speech therapy can be offered, for example, at the Academy for Health Professions at Ulm University Hospital (Department of Speech Therapy; homepage: https://www.akademie.uniklinik-ulm.de/ausbildung/logopaedie/logo-therapie.html)(contact Ms Ronja Traschütz, 0731/500 68255, ronja.traschuetz@akademie.uniklinik-ulm.de).
Prof Dr Reiter
(Speaker of the SZU)
[1] Reiter R, Hoffmann TK, Pickhard A, Brosch S. Hoarseness-causes and treatments. Dtsch Arztebl Int. 2015 May 8;112(19):329-37
