| Patient
Services
Voice disorders treated/procedures performed
at or through Bastian Voice Institute
Benign vocal
fold lesions
Common lesions affect the mucosa or surface covering
of the vocal folds. The basic list includes vocal nodules,
various kinds of polyps, capillary ectasia, epidermoid cyst,
mucus retention cyst, glottic sulcus, mucosal bridge, granuloma,
scarring, and keratosis. Some of these lesions will resolve
with time and medical and/or behavioral (speech pathology)
treatment measures – or they will improve to the point
that the continuing limitations to voice associated with them
reduce to an acceptable level. Yet others are chronic and
not reversible via behavioral or medical measures. Examples
of this latter category include cysts, capillary ectasia,
glottic sulcus, and some polyps and recalcitrant nodules.
In these instances, vocal fold microsurgery may become an
option.
Vocal fold microsurgery
A considerable part of the workload at Bastian Voice
Institute centers on vocal fold microsurgery. Microsurgery
is done either for diagnostic reasons or, much more commonly,
to try to improve the quality of the voice, when medical and
behavioral (speech therapy) modalities are either inappropriate
or have already been tried but have failed to rehabilitate
the voice to a level acceptable to the patient. Combined physician
experience with vocal fold microsurgery comprises a conservatively-estimated
4000 cases to date. Common lesions addressed via microlaryngoscopy
include otherwise irreversible nodules, polyps, vocal fold
cysts, glottic sulcus, capillary ectasia, vocal fold scarring,
as well as benign and malignant tumors. Noteworthy subsets
of the BVI experience include:
- Vocal fold microsurgery in singers
– an estimated 600 cases to date.
- Vocal fold carcinoma. This includes
individuals who were recommended for radiotherapy or a much
larger operation elsewhere, but who instead were treated
successfully via laser excision, almost always on a day-surgery,
outpatient basis.
- Individuals referred by other otolaryngologists
because of extremely difficult anatomy that prevented visualization
of the vocal folds in the operating room.
- Rare lesions such as amyloidosis, granular
cell tumors, neuroendocrine carcinoma, post-radiation sarcoma,
and scarring disorders.
- Laryngeal papillomatosis, aka Recurrent
Respiratory Papillomatosis (RRP), with an adult-only experience
numbering approximately 140 patients.
Vocal fold microsurgery in singers
When Dr. Bastian finished residency, vocal fold microsurgery
in singers was discouraged, and often condemned, by the community
of voice clinicians. At some initial risk to his reputation,
Dr. Bastian was arguably the first in the United States to
consistently and publicly affirm the safety and voice-restoring
potential of expertly performed vocal fold microsurgery in
this group. As always, Dr. Bastian teaches that this kind
of surgery is to be done only for otherwise-irreversible lesions.
Furthermore, it must be performed to an exacting standard
in order to achieve good results.
“It is easy for the uninitiated to
ruin the voice during vocal fold microsurgery,” Dr.
Bastian says. “But excellent, voice-restoring results
can also be routine for experienced, technically proficient,
and perfectionistic surgeons attempting to improve and often
restore the voice completely using techniques that are extremely
low risk.”
The combined BVI caseload of surgery in
singers numbers approximately 600 to date. This caseload includes
not only avocational singers but also a significant number
of regionally, nationally, and internationally known performers.
Professional
voice disorders
More often than not, the difficulties encountered by
professional voice users resolve or at least improve to an
acceptable level through a combination of medical, speech
therapy, and “life strategy” maneuvers. At BVI,
we offer comprehensive assessment and treatment of medical,
functional, neurological, and structural disorders affecting
professional voice users.
Recurrent respiratory papillomatosis
(RRP)
RRP is caused by the human papilloma virus. In infected
individuals, this virus resides chronically in the surface
tissue or mucosa of the larynx and may induce proliferation
of mucosa (surface tissue) into either low-profile velvety
or elevated wart-like lesions called papillomas. These lesions
can occur on the vocal folds, in areas above the vocal folds,
and even in the subglottis and trachea. Lifetime experience
of BVI physicians comprises approximately 140 adult-only patients.
The standard of care for this condition
remains periodic vocal fold microsurgery to remove papillomas
meticulously but with care to avoid injury to underlying vocal
fold structures. BVI physicians have extensive experience
with adjuvant treatments, including interferon; the so-called
“cabbage pill” (indole 3-carbinol, or its active
metabolite marketed as DIM); and most recently, cidofovir.
In recent years, we have used cidofovir along with surgery
with what seems to be in some cases remarkable clinical success.
Thus far, approximately 30 adult patients
have been treated with cidofovir. After meticulous but conservative
removal of visible lesions in the operating room, the base
is injected with cidofovir. Otherwise, we inject in the videoendoscopy
procedure room of BVI under topical anesthesia and occasional
sedation, rather than in the operating room under general
anesthesia. Some lesions appear to regress with injection
only, and to thus do not require a trip to the operating room;
BVI physicians have just begun to offer, along with a few
other physicians in the nation, office-based laser treatment
for papillomas of the larynx.
Spasmodic dysphonia
(laryngeal dystonia)
The combined experience of Bastian Voice Institute
physicians comprises approximately 1300 patients with this
rare neurological disorder. This patient population continues
to be multi-state and regional, but began with a national
draw in 1989, when very few physicians were treating this
condition.
Noteworthy subsets within this population
include:
- Those whose spasmodic dysphonia is
atypical and has therefore been overlooked or misdiagnosed
prior to evaluation at Bastian Voice Institute.
- Individuals who have had difficulty
achieving consistent results with Botox therapy elsewhere.
- Individuals with abductory spasmodic
dysphonia, the injections for which are inherently technically
challenging as compared with adductory spasmodic dysphonia.
- Persons with respiratory involvement
causing involuntary breath holding or noisy inspiratory
sounds as the sole manifestation of laryngeal dystonia,
or along with voice manifestations (spasmodic dysphonia).
At BVI, we continue to believe that the
mainstay of treatment is Botox therapy. While various surgical
approaches to laryngeal dystonia should be a continuing option,
the permanence, mild unpredictability of surgical results,
and potentially evolving nature of any individual’s
dystonia manifestations lead us to believe that surgery options
should be considered only if optimized Botox therapy results
are disappointing. Botox injections are offered weekly at
BVI.
Larynx cancer
Dr. Bastian received extensive training in the science
and art of larynx cancer surgery under the internationally
famous Dr. Joseph Ogura at Washington University in St. Louis.
Dr. Richardson received similar training under Dr. George
Adams at the University of Minnesota in Minneapolis. Building
on that foundation, both physicians have utilized innovative
conservation operations for larynx cancer. They have also
removed many tumors endoscopically, as inspired by a case
Dr. Bastian witnessed as performed by Dr. Wolfgang Steiner,
then of Erlangen, now of Gottingen, Germany, in 1983. Using
these techniques, surgery can often be a part of patient treatment
in a way that preserves voice, swallowing, and breathing function
and yet includes what has traditionally been considered the
“strong arm” of cancer treatment in this site.
Larynx cancer is a particular interest
of both Dr. Bastian and Dr. Richardson, who continue to believe
that a true surgical opinion from an individual well-versed
in both open conservation and endoscopic laser surgery is
critical to the decision-making process and can often provide
a very appealing and less morbid option to consider alongside
radiation and chemotherapy.
Of special note is Dr. Bastian’s
work showing (1) that for early vocal fold cancer, laser excision
can provide equal cure rate and voice quality when compared
with more traditional radiotherapy and (2) that definitive
yet narrow margin excision can be an excellent strategy to
“downsize” the size of defects left after cancer
extirpation, thereby diminishing voice and swallowing impact,
yet with good cure rates.
Vocal fold paralysis
Vocal fold paralysis and/or paresis (weakness) may
be idiopathic (meaning the cause is unknown), presumed to
be due to a viral injury after upper respiratory infection;
or it may be the result of thyroid, esophageal, lung, heart,
or aorta surgery or tumors. Persons with vocal fold paralysis
may experience a weak, air-wasting kind of hoarseness. They
are unable to compete with background noise; they may also
cough on liquids; have a weakened cough; and experience generalized
fatigue when they talk for any extended period of time. Particularly
when the paralysis seems spontaneous and unexplained, the
main diagnostic issue, after application of the integrative
diagnostic model, is to use radiography –typically a
CT scan – to visualize the path of the nerve that goes
to the affected vocal fold, to be sure that there is not some
sort of growth pressing on the nerve, or other treatable cause
of the paralysis.
Treatment for vocal fold paralysis depends
entirely on the severity of vocal limitations, the time since
onset of the paralysis, the potential for spontaneous recovery
of the paralysis, and patient preference. In some cases this
may mean voice building; in others, a temporary paste-consistency
implant that is injected into the vocal fold to fatten and
firm it up for some weeks or months while we await recovery
of nerve function.
When the paralysis is known to be permanent,
a permanent implant is placed either by injection at BVI,
or during an outpatient surgical procedure using silastic,
gore-tex, or titanium. BVI physicians manage an estimated
60-plus patients per year with this relatively uncommon problem.
About 40 undergo a permanent rehabilitative outpatient surgical
procedure called medialization laryngoplasty.
Scarring of
larynx, subglottis, or trachea
A subset of patients who have experienced external
trauma, inhalation of noxious chemicals, long-term endotracheal
tube intubation, or tracheotomy develop a narrowing or scarring
between the vocal folds, and/or in the area just below the
vocal folds called the subglottis, and/or in the trachea (windpipe).
When they arrive at Bastian Voice Institute, such patients
may be experiencing some degree of exercise intolerance or
noisy breathing. In other cases, they are tracheotomy dependent.
Occasionally a straightforward dilation (stretching) procedure
is all that is required to solve the problem; in other instances,
reconstructive surgery is necessary to restore or at least
improve breathing function. Simple dilation may be done on
an outpatient basis during a brief general anesthetic. Larger
reconstructions are done at Advocate Good Samaritan Hospital
and typically require a hospital stay of two to five days.
Nonorganic voice
disorders
After an upper respiratory infection that never seemed
to go away or perhaps because of life stress, some individuals
develop a voice disorder that persists in spite of an entirely
normal structural and neurological examination. In this case,
the ongoing problem is not based in the mechanism of the larynx
but instead in the abnormal use of that mechanism. Sometimes
such individuals go for weeks, months, or even years with
a distinctly abnormal voice of this sort. BVI physicians see
a large patient population of such individuals from a wide
area. BVI clinicians’ ability to address the voice’s
“skill and will” capabilities and limitations
are key to establishing this diagnosis. Sometimes within the
first consultation, and almost always by the end of a couple
of sessions of voice therapy with our speech pathologist,
virtually all such patients, assuming appropriate motivation,
revert to normal voice on a stable basis.
Vocal fold granuloma
Most often, this lesion is the result of an endotracheal
tube (breathing tube) that was placed for surgery or for respiratory
support during a critical illness. In contrast to many physicians
elsewhere, BVI physicians believe that these lesions rarely
need removal in order to establish a diagnosis; visual criteria
for this, along with continued observation, are generally
sufficient. Asymptomatic lesions are observed at intervals
to confirm resolution. Symptomatic lesions may be injected
with steroid medication in the “chair” in the
videoendoscopy procedure room. More recently, laser treatment
in this same room may be useful. Only occasionally do we go
to the operating room – for instance, when a lesion
becomes pedunculated (attached by a stalk) but does not seem
to want to spontaneously detach in spite of waiting many months.
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