Voice Amplification for Patients with a Weak Voice

There are certain voicebox conditions that naturally tends to a weak sounding voice. For some, the voice is weak all the time sounding breathy or just lacks projection. For others, the voice starts out OK, but than becomes weak after talking for some period of time. There are both pathological (ie, vocal cord paralysis) as well as functional (ie, muscle tension dysphonia) causes of a weak voice, but in the end, a patient just wants a better sounding voice one way or another. Although voice therapy i ...

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Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent irreversible hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

• Steroid injection to the vocal cord nodule(s) can possibly resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

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Coffee Reduces Risk of Death from Oral Cancer

In a prior blog, I mentioned that researchers found that regular coffee drinkers who drank more than four cups of coffee a day had a 39 percent decreased risk of two types of head and neck cancer: oral cavity and pharynx cancers. In the study published in the Journal of Cancer Epidemiology, Biomarkers & Prevention, they found however, that coffee did not decrease the risk of laryngeal cancer. Read a CNN report on this here. In a more recent study (Dec 2012), researchers have fo ...

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Embedded Earrings and Treatment

A few times a month, I have a patient, usually a young child, who presents with an earring that not only can not be removed, but is embedded within the earlobe (or ear) itself. There are two common scenarios that lead to this unfortunate situation: infection and fiddling. Infection is fairly straightforward. For whatever reason, the piercing gets infected and the earlobe skin starts to swell around and eventually even enveloping the earring itself. To prevent an embedded earring, immediately remove the earring!!! If you ...

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Is Patient Abandonment in the Operating Room Ever Justified?

I ask this question mainly because there WAS an ENT who WAS sued (and settled) for NOT abandoning his patient in the operating room. [link] Imagine this hypothetical scenario... You are an ENT surgeon in a rural community hospital performing a fairly difficult but elective sinus surgery on a 12 years old child with cystic fibrosis with extensive pan-sinus nasal polypoid disease. Given the extensive nasal polypoid disease, a fair amount of bleeding is occurring which was not unanticipated. Suddenly, you ...

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Taste Changes after Tonsillectomy

Very rarely, patients will complain of taste changes after tonsillectomy. Such taste changes (aka dysgeusia) is most often described as metallic though other taste variations or absences may be reported. Depending on what study you look at, this complaint occurs anywhere from 0.3% to as high as 9% of tonsillectomy cases. Dysgeusia after tonsillectomy is felt to be due to a number of different causes including: 1) medication side effect 2) injury to the lingual branch of the glossopharyngeal nerve 3) zinc deficienc ...

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Brooke Burke Has Thyroid Cancer

Brooke Burke, TV personality best known for winning the 7th season of Dancing with the Stars and later co-hosting the show starting in 2010 announced in a self-published video the fact that she has thyroid cancer and will soon be undergoing thyroid surgery. Apparently, on a routine physical exam, a thyroid nodule was appreciated in July 2012. This was biopsied (presumably via an ultrasound guided fine needle aspiration) and came back as "atypical". Given atypical findings, a diagnosis ...

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Breathing or Voice... You Can Only Have One...

Sounds like a choice taken out of a morbid horror movie... "You can ONLY have one... Your voice or your breath..." The victim than loses one or the other after making a choice getting either the tongue or head cut off with a knife. But patients with vocal cord paralysis on both sides are essentially faced with this very question. Normally, the vocal cords (TVC in picture below) found in the voicebox move to accommodate talking or breathing. When the vocal cords are apart, breathing occurs allowing air to pass unimpeded ...

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Nasal Sounding Speech

There are actually TWO different flavors of nasal sounding speech. HYPO-nasal speech is due to reduced or no nasal airflow and HYPER-nasal speech due to too much nasal airflow. HYPO-nasal speech is by far the most common cause of nasal-sounding speech. It is similar to how a person would sound if they pinched their nose shut while talking. As such, ANY anatomic nasal obstruction would by definition lead to such hypo-nasal speech. Treatment, obviously, is to remove this anatomic nasal obstruction whatever it may be ...

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Elbowed by Your Spouse While Sleeping? You May Have Sleep Apnea!

Canadian researchers have determined that if a patient answers in the affirmative to two questions: 1) Do you get elbowed/poked while sleeping for snoring? 2) Do you get elbowed/poked while sleeping for stopping breathing? There is a significant chance that the patient may have obstructive sleep apnea (OSA) with AHI score  more than 5. This quiz has been dubbed the "Elbow Test". Actual diagnosis for OSA is by sleep study. Should OSA be actually diagnosed on a sleep study, initial t ...

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"Mother's Kiss" to Remove Nasal Foreign Bodies

In 1965, a general practitioner Vladimir Ctibor described the "Mother's Kiss" technique of removing nasal foreign bodies in a child.

Essentially, a trusted adult (like a mother) places her mouth over the child's mouth as if to perform mouth-to-mouth resuscitation. While pinching off the unaffected nostril, the adult than blows gently into the child's mouth until resistance is felt caused by the child closing the glottis. At that moment, the adult gives a sharp explosive exhalation to deliver a strong puff of air that passes up into the nose and out the unblocked nostril. If successful, this air puff will also blow the foreign body out the nose as well.

If the adult blow's air when the child's glottis is open, air will just go into the lungs rather than up the nose.

Prior to the procedure, the child is informed that the mom will give the child a "big kiss," hence the name of this procedure.

Now... does this technique actually work?

According to one meta-analysis, it works about 59.9% of the time.

The way I consider it... it can't hurt to try before using instruments to manually remove the nasal foreign body. A "mother's kiss" is certainly a more comfortable and familiar approach for a child versus the alternative.

However, one warning point... the child should be calmly breathing during this procedure. If the child becomes hysterical during the procedure, the child might strongly inhale through the unblocked nostril and potentially suck the foreign body (if small enough) down into the lungs making an unlucky situation into a medical emergency.

Another point for those uninformed... do NOT use this procedure on ear foreign bodies. It will NOT work. The ear canal is a closed container with no inlet or outlet for any air pressure produced by a "Mother's Kiss." In fact, trying to perform this procedure on the ear may cause a ruptured eardrum and even permanent hearing loss.


Reference:
Removal of Foreign Bodies from the Nose. NEJM 1985; 312:725.

Efficacy and safety of of the "Mother's Kiss" technique: A systematic review of case reports and case series. CMAJ 2012. DOI:10.1503/cmaj.111864 (full length pdf)

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What do Earthquakes Have to do with Thyroid Masses?

I'm not sure what is going on within the Italian Court system, but in October 2012, the Italian Court convicted 7 scientists to jail terms for not accurately predicting the 2009 L'Aquila earthquake that ended up killing over 300 people. Also in October 2012, the Italian Supreme Court ruled that cell phones caused one man's brain tumor. Since when does the Court decide on matters of scientific validity? And even more importantly, what does this have to do with ENT??? I'm sure people here and there wil ...

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Cheerleading A Dangerous Sport from an ENT Perspective

The American Academy of Pediatrics (AAP) published its first policy statement regarding cheerleading due to the increasing rate of injuries found in this increasingly competitive sport. Who knew that although the overall risk of injury is lower than other sports, it has one of the highest rates of catastrophic injuries including closed-head injury, skull fractures, cervical spine injuries, paralysis, and even death. After all, cheerleaders do not wear protective gear and safety is utterly dependent on external factors ...

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Tinnitus: Top 12 Topics I Teach

by Dr. Richard Thrasher, III Tinnitus. It’s a subject I discuss at least 2-3x every time I hold a clinic. There’s a lot of misinformation out there. I’m going to break it down the way that I describe it for my patients in clinic. There is far more information out there that I’m not going to go into, but these are the bullet points I think most everyone with it should at least hear once. 1 – Tinnitus is common. If you took every person on the planet and individually put them in a soundproof booth with a complete absence of sound ...

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Broken Owen Wilsons. .errr. .uh. .Noses

by Dr. Richard Thrasher, III Probably the most famous crooked nose I know belongs to Owen Wilson. He wasn’t born that way. He broke it twice. Once in a fight with another kid at school and once playing football with buddies. Adam Foote was a great hockey player who spent much of his time with the Colorado Avalanche and has quite the crooked nose also from multiple fractures. The reason I bring up these two noses is because they are some of the more famous extremes of the results of unreduced nasal fractures of which I’m awar ...

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Tongue Tie–And Not the Kind Politicians Have

by Dr. Richard Thrasher Ankyloglossia, or tongue tie, is a very common congenital condition, meaning it’s something with which you’re born. This picture from Dr. Ghorayeb’s site shows a perfect example of a pretty dramatic one. Ankyloglossia is when the lingual frenulum (the band of tissue under your tongue which tethers it to the floor of your mouth) is either too short or extends too far to the tip of the tongue. It can then prevent normal tongue movement. While often not signficant, a severe tongue tie can impede breast fee ...

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Synthetic Vocal Cords [video]

Synthetic vocal cords being under development at MIT and Harvard... Very good video! What are some of the vocal cord problems that may benefit from such a synthetic gel? Vocal cord paralysis, vocal cord surgery to address polyps, cysts, nodules, granulomas, etc. As an FYI... the synthetic vocal cord gel portrayed in the video is still under development and not available for patient use yet... ...

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Video on Zenker's Diverticulum Surgery (Endoscopic Staple Diverticulostomy)

A new video describing Endoscopic Staple Diverticulostomy to treat Zenker's Diverticulum has been produced. For more information, click here. ...

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Devices That Help Fix Clogged Ears

Clogged ears due to eustachian tube dysfunction or fluid in the ears is one of the most common complaints seen in an ENT clinic. Beyond medications like steroids & nasal sprays or even surgery (ear tubes) to resolve this complaint, a fundamental physical maneuver the patient MUST also be doing is called "valsalva". Valsalva is the attempt to "pop" the ears by yawn, swallow, or attempting to gently blow air out the nose that is pinched shut. The yawn and swallow are passive maneu ...

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Azithromycin Increases Risk of Death Slightly... Well, So Does Tylenol and Ibuprofen

The media has made much fuss about a NEJM study suggesting a slight increased risk of death from taking azithromycin or z-pack. The more unhealthy you are, the higher the risk... no duh... (I would think the sicker you are, the greater the risk of death PERIOD... a sick person by definition is closer to death than a healthy person). How slight? Compared to amoxicillin, about 47 additional cardiovascular deaths per one million courses of therapy. Never mind the blatant biases found in the study nicely es ...

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