Voice & Swallowing Disorders

Dysphagia
Laryngeal Papillomatosis
Spasmodic Dysphonia
Vocal Cord Paralysis

Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time, you should see an otolaryngologist—head and neck surgeon.

What is dysphagia?

People with dysphagia have difficulty swallowing and may also experience pain while swallowing. Some people may be completely unable to swallow or may have trouble swallowing liquids, foods, or saliva. Eating then becomes a challenge. Often, dysphagia makes it difficult to take in enough calories and fluids to nourish the body.

How do we swallow?

Swallowing is a complex process. Some 50 pairs of muscles and many nerves work to move food from the mouth to the stomach. This happens in three stages. First, the tongue moves the food around in the mouth for chewing. Chewing makes the food the right size to swallow and helps mix the food with saliva. Saliva softens and moistens the food to make swallowing easier. During this first stage, the tongue collects the prepared food or liquid, making it ready for swallowing.

The second stage begins when the tongue pushes the food or liquid to the back of the mouth, which triggers a swallowing reflex that passes the food through the pharynx (the canal that connects the mouth with the esophagus). During this stage, the larynx (voice box) closes tightly and breathing stops to prevent food or liquid from entering the lungs.

The third stage begins when food or liquid enters the esophagus, the canal that carries food and liquid to the stomach. This passage through the esophagus usually occurs in about 3 seconds, depending on the texture or consistency of the food.

How does dysphagia occur?

Dysphagia occurs when there is a problem with any part of the swallowing process. Weak tongue or cheek muscles may make it hard to move food around in the mouth for chewing. Food pieces that are too large for swallowing may enter the throat and block the passage of air.

Other problems include not being able to start the swallowing reflex (a stimulus that allows food and liquids to move safely through the pharynx) because of a stroke or other nervous system disorder. People with these kinds of problems are unable to begin the muscle movements that allow food to move from the mouth to the stomach. Another difficulty can occur when weak throat muscles cannot move all of the food toward the stomach. Bits of food can fall or be pulled into the windpipe (trachea), which may result in lung infection.

What are some problems caused by dysphagia?

Dysphagia can be serious. Someone who cannot swallow well may not be able to eat enough of the right foods to stay healthy or maintain an ideal weight.

Sometimes, when foods or liquids enter the windpipe of a person who has dysphagia, coughing or throat clearing cannot remove it. Food or liquid that stays in the windpipe may enter the lungs and create a chance for harmful bacteria to grow. A serious infection (aspiration pneumonia) can result.

Swallowing disorders may also include the development of a pocket outside the esophagus caused by weakness in the esophageal wall. This abnormal pocket traps some food being swallowed. While lying down or sleeping, a person with this problem may draw undigested food into the pharynx. The esophagus may be too narrow, causing food to stick. This food may prevent other food or even liquids from entering the stomach.

What causes dysphagia?

Dysphagia has many causes. Any condition that weakens or damages the muscles and nerves used for swallowing may cause dysphagia. For example, people with diseases of the nervous system, such as cerebral palsy or Parkinson's disease, often have problems swallowing. Additionally, stroke or head injury may affect the coordination of the swallowing muscles or limit sensation in the mouth and throat. An infection or irritation can cause narrowing of the esophagus. People born with abnormalities of the swallowing mechanism may not be able to swallow normally. Infants who are born with a hole in the roof of the mouth (cleft palate) are unable to suck properly, which complicates nursing and drinking from a regular baby bottle.

In addition, cancer of the head, neck, or esophagus may cause swallowing problems. Sometimes the treatment for these types of cancers can cause dysphagia. Injuries of the head, neck, and chest may also create swallowing problems.

How is dysphagia treated?

There are different treatments for various types of dysphagia. First, doctors and speech-language pathologists who test for and treat swallowing disorders use a variety of tests that allow them to look at the parts of the swallowing mechanism. One test, called a fiber optic laryngoscopy, allows the doctor to look down the throat with a lighted tube. Other tests, including video fluoroscopy, which takes videotapes of a patient swallowing, and ultrasound, which produces images of internal body organs, can painlessly take pictures of various stages of swallowing.

Once the cause of the dysphagia is found, surgery or medication may help. If treating the cause of the dysphagia does not help, the doctor may have the patient see a speech-language pathologist who is trained in testing and treating swallowing disorders. The speech-language pathologist will test the person's ability to eat and drink and may teach the person new ways to swallow.

Treatment may involve muscle exercises to strengthen weak facial muscles or to improve coordination. For others, treatment may involve learning to eat in a special way. For example, some people may have to eat with their head turned to one side or looking straight ahead. Preparing food in a certain way or avoiding certain foods may help other people. For instance, those who cannot swallow liquids may need to add special thickeners to their drinks. Other people may have to avoid hot or cold foods or drinks.

For some, however, consuming foods and liquids by mouth may no longer be possible. These individuals must use other methods to nourish their bodies. Usually this involves a feeding system, such as a feeding tube, that bypasses the part of the swallowing mechanism that is not working normally.

Laryngeal Papillomatosis

Laryngeal papillomatosis is a disease consisting of tumors that grow inside the larynx (voice box), vocal cords, or the air passages leading from the nose into the lungs (respiratory tract). It is a rare disease caused by the human papilloma virus (HPV). Although scientists are uncertain how people are infected with HPV, they have identified more than 60 types of HPVs. Tumors caused by HPVs, called papillomas, are often associated with two specific types of the virus (HPV 6 and HPV 11). They may vary in size and grow very quickly. Eventually, these tumors may block the airway passage and cause difficulty breathing.

Laryngeal papillomatosis affects infants and small children as well as adults. Between 60 and 80 percent of cases occur in children, usually before the age of three. Because the tumors grow quickly, young children with the disease may find it difficult to breathe when sleeping, or they may experience difficulty swallowing. Adults with laryngeal papillomatosis may experience hoarseness, chronic coughing, or breathing problems.

There are several tests to diagnose laryngeal papillomatosis. Two routine tests are indirect and direct laryngoscopy. An indirect laryngoscopy is done in an office by a speech-language pathologist or by a doctor. To examine the larynx for tumors, the doctor places a small mirror in the back of the throat and angles the mirror down towards the larynx. A direct laryngoscopy is performed in the operating room under general anesthesia.

This procedure is usually used with children or adults during lengthy examinations to minimize discomfort. It involves looking directly at the larynx. Direct laryngoscopy allows the doctor to view the vocal folds and other parts of the larynx under high magnification and samples of unusual tissue lesions that may be in the larynx or other parts of the throat.

Treatment

Many forms of treatment have been used to remove laryngeal papillomas such as surgery, chemotherapy, or antibiotic therapy. Currently, traditional surgical removal of the tumors and another technique, carbon dioxide laser surgery, are both used. Carbon dioxide laser surgery uses intense laser light as the surgical tool.

Once they have been removed, these tumors have a tendency to return unpredictably. It is not uncommon for patients to require repeat surgery. With some patients, surgery may be required every few weeks in order to keep the breathing passage open, while others may require surgery only once a year. In the most extreme cases where tumor growth is aggressive, a tracheotomy may be performed. A tracheotomy is a surgical procedure where an incision is made in the front of the patient's neck and a breathing tube (trach tube) is inserted through a hole, called a stoma, into the trachea (windpipe). Rather than breathing through the nose and mouth, the patient will now breathe through the trach tube. Although the trach tube keeps the breathing passage open, doctors try to remove it as soon as it is feasible. However, there may be some patients who may be required to keep a trach tube indefinitely in order to keep the breathing passage open. In addition, because the trach tube re-routes all or some of the exhaled air away from the vocal cords, the patient may find it difficult to speak. With the help of a voice specialist or speech-language pathologist the patient learns how to reuse the voice.

What is Spasmodic Dysphonia?

Spasmodic dysphonia (or laryngeal dystonia) is a voice disorder caused by involuntary movements of one or more muscles of the larynx or voice box. Individuals who have spasmodic dysphonia may have occasional difficulty saying a word or two or they may experience sufficient difficulty to interfere with communication. Spasmodic dysphonia causes the voice to break or to have a tight, strained or strangled quality. There are three different types of spasmodic dysphonia.

What are the types of spasmodic dysphonia?

The three types of spasmodic dysphonia are adductor spasmodic dysphonia, abductor spasmodic dysphonia and mixed spasmodic dysphonia

What are the features of spasmodic dysphonia?

In adductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal folds (or vocal cords) to slam together and stiffen. These spasms make it difficult for the vocal folds to vibrate and produce voice. Words are often cut off or difficult to start because of the muscle spasms. Therefore, speech may be choppy and sound similar to stuttering. The voice of an individual with adductor spasmodic dysphonia is commonly described as strained or strangled and full of effort. Surprisingly, the spasms are usually absent while whispering, laughing, singing, speaking at a high pitch or speaking while breathing in. Stress, however, often makes the muscle spasms more severe.

In abductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal folds to open. The vocal folds can not vibrate when they are open. The open position of the vocal folds also allows air to escape from the lungs during speech. As a result, the voices of these individuals often sound weak, quiet and breathy or whispery. As with adductor spasmodic dysphonia, the spasms are often absent during activities such as laughing or singing.

Mixed spasmodic dysphonia involves muscles that open the vocal folds as well as muscles that close the vocal folds and therefore has features of both adductor and abductor spasmodic dysphonia.

What causes spasmodic dysphonia?

The cause of spasmodic dysphonia is unknown. Because the voice can sound normal or near normal at times, spasmodic dysphonia was once thought to be psychogenic, that is, originating in the affected person¹s mind rather than from a physical cause. While psychogenic forms of spasmodic dysphonia exist, research has revealed increasing evidence that most cases of spasmodic dysphonia are in fact neurogenic or having to do with the nervous system (brain and nerves). Spasmodic dysphonia may co-occur with other movement disorders such as blepharospasm (excessive eye blinking and involuntary forced eye closure), tardive dyskinesia (involuntary and repetitious movement of muscles of the face, body, arms and legs), oromandibular dystonia (involuntary movements of the jaw muscles, lips and tongue), torticollis (involuntary movements of the neck muscles), or tremor (rhythmic, quivering muscle movements).

In some cases, spasmodic dysphonia may run in families and is thought to be inherited. Research has identified a possible gene on chromosome 9 that may contribute to the spasmodic dysphonia that is common to certain families. In some individuals the voice symptoms begin following an upper respiratory infection, injury to the larynx, a long period of voice use, or stress.

What treatment is available for spasmodic dysphonia?

There is presently no cure for spasmodic dysphonia. Current treatments only help reduce the symptoms of this voice disorder. Voice therapy may reduce some symptoms, especially in mild cases. An operation that cuts one of the nerves of the vocal folds (the recurrent laryngeal nerve) has improved the voice of many for several months to several years but the improvement is often temporary. Others may benefit from psychological counseling to help them to accept and live with their voice problem. Still others may benefit from job counseling that will help them select a line of work more compatible with their speaking limitations.

Currently the most promising treatment for reducing the symptoms of spasmodic dysphonia is injections of very small amounts of botulinum toxin (botox) directly into the affected muscles of the larynx. Botulinum toxin is produced by the Clostridium botulinum bacteria. This is the bacterium that occurs in improperly canned foods and honey. The toxin weakens muscles by blocking the nerve impulse to the muscle. The botox injections generally improve the voice for a period of three to four months after which the voice symptoms gradually return. Reinjections are necessary to maintain a good speaking voice. Initial side effects that usually subside after a few days to a few weeks may include a temporary weak, breathy voice or occasional swallowing difficulties. Botox may relieve the symptoms of both adductor and abductor spasmodic dysphonia.

What is Vocal Cord Paralysis?

Vocal cord paralysis is a voice disorder that occurs when one or both of the vocal cords (or vocal folds) do not open or close properly. Vocal cord paralysis is a common disorder, and symptoms can range from mild to life threatening.

The vocal cords are two elastic bands of muscle tissue located in the larynx (voice box) directly above the trachea (windpipe). The vocal cords produce voice when air held in the lungs is released and passed through the closed vocal cords, causing them to vibrate. When a person is not speaking, the vocal cords remain apart to allow the person to breathe.

Someone who has vocal cord paralysis often has difficulty swallowing and coughing because food or liquids slip into the trachea and lungs. This happens because the paralyzed cord or cords remain open, leaving the airway passage and the lungs unprotected.

What causes vocal cord paralysis?

Vocal cord paralysis may be caused by head trauma, a neurologic insult such as a stroke, a neck injury, lung or thyroid cancer, a tumor pressing on a nerve, or a viral infection. In older people, vocal cord paralysis is a common problem affecting voice production. People with certain neurologic conditions, such as multiple sclerosis or Parkinson's disease, or people who have had a stroke may experience vocal cord paralysis. In many cases, however, the cause is unknown.

What are the symptoms?

People who have vocal cord paralysis experience abnormal voice changes, changes in voice quality, and discomfort from vocal straining. For example, if only one vocal cord is damaged, the voice is usually hoarse or breathy. Changes in voice quality, such as loss of volume or pitch, may also be noticeable. Damage to both vocal cords, although rare, usually causes people to have difficulty breathing because the air passage to the trachea is blocked.

How is vocal cord paralysis diagnosed?

Vocal cord paralysis is usually diagnosed by an otolaryngologist-a doctor who specializes in ear, nose, and throat disorders. Noting the symptoms the patient has experienced, the otolaryngologist will ask how and when the voice problems started in order to help determine their cause. Next, the otolaryngologist listens carefully to the patient's voice to identify breathiness or harshness. Then, using an endoscope--a tube with a light at the end--the otolaryngologist looks directly into the throat at the vocal cords. A speech-language pathologist may also use an acoustic spectrograph, an instrument that measures voice frequency and clarity, to study the patient's voice and document its strengths and weaknesses.

How is vocal cord paralysis treated?

There are several methods for treating vocal cord paralysis, among them surgery and voice therapy. In some cases, the voice returns without treatment during the first year after damage. For that reason, doctors often delay corrective surgery for at least a year to be sure the voice does not recover spontaneously. During this time, the suggested treatment is usually voice therapy, which may involve exercises to strengthen the vocal cords or improve breath control during speech. Sometimes, a speech-language pathologist must teach patients to talk in different ways. For instance, the therapist might suggest that the patient speak more slowly or consciously open the mouth wider when speaking.

Surgery involves adding bulk to the paralyzed vocal cord or changing its position. To add bulk, an otolaryngologist injects a substance, commonly Teflon, into the paralyzed cord. Other substances currently used are collagen, a structural protein; silicone, a synthetic material; and body fat. The added bulk reduces the space between the vocal cords so the nonparalyzed cord can make closer contact with the paralyzed cord and thus improve the voice.

Sometimes an operation that permanently shifts a paralyzed cord closer to the center of the airway may improve the voice. Again, this operation allows the nonparalyzed cord to make better contact with the paralyzed cord. Adding bulk to the vocal cord or shifting its position can improve both voice and swallowing. After these operations, patients may also undergo voice therapy, which often helps to fine-tune the voice.

Treating people who have two paralyzed vocal cords may involve performing a surgical procedure called a tracheotomy to help breathing. In a tracheotomy, an incision is made in the front of the patient's neck and a breathing tube (tracheotomy tube) is inserted through a hole, called a stoma, into the trachea. Rather than breathing through the nose and mouth, the patient now breathes through the tube. Following surgery, the patient may need therapy with a speech-language pathologist to learn how to care for the breathing tube properly and how to reuse the voice.