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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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 either with medications or surgery. Examples of hypo-nasal speech causes include:

• Adenoid Hypertrophy (Very Common)
• Turbinate Hypertrophy (Common)
• Significant Deviated Septum (Uncommon)
• Nasal Polyps (Uncommon)
• Allergies (Common)
• Infection (upper respiratory illness and/or bacterial infections) (Common)
• Rarely, genetic conditions like cystic fibrosis and immotile ciliary syndrome
• Rarely, anatomic conditions such as choanal atresia
• Rarely, a sino-nasal tumor

HYPER-nasal speech itself has several different flavors, but the key concept is the presence of an opening between the mouth and nose when it should be sealed shut during speech. Normally, complete closure should occur with certain sounds like /s/, /sh/, /b/, and /p/. Such sounds are called plosives and sibilants. This link provides a cartoon animation of how each sound in the English language is produced from an anatomical standpoint.

Now what are some of the causes of HYPER-nasal speech? Causes can be divided broadly into either anatomic and functional variants.

Anatomic HYPER-nasal speech include:

• Cleft Palate
• Palate Fistula
• Submucus Cleft

Functional HYPER-nasal speech include:

• Velopharyngeal insufficiency without anatomic cause. Velopharyngeal insufficiency or VPI occurs when the soft palate does not seal against the back of the mouth during appropriate speech sounds.
• Poor articulation (person is not correctly pronouncing words)

Treatment of HYPER-nasal speech may include speech therapy and surgery depending on the cause.

Given the subtleties involved in differentiating the different causes of nasal speech, workup typically involves not only just looking in the nose or mouth, but also performing a nasal endoscopic examination.

Below is a video showing a young child undergoing just such an endoscopic exam. Here are some other videos containing audio of abnormal endoscopic exams.

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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 feeding in newborns. Infants do not breastfeed by using suction, rather the tongue works as pump to mechanically pull milk into the mouth. If the tongue cannot extend past the alveolar ridge (gum line) it makes it difficult to breast feed. This is the one urgent reason for a fix of this condition. Later on, ankyloglossia can affect how far the tongue can protrude from the mouth making things like licking an ice cream cone more difficult.

Another effect of severe tongue tie is on articulation of speech. To see how this can effect someone’s ability to enunciate words, try putting the tip of the tongue against the top of the lower teeth and holding it there while saying the alphabet. Not so easy to do, but possible.

There are many methods for freeing the tongue. The simplest is to simply cut the frenulum in infancy. Snipping the frenulum with Castro-Viejo scissors is my preferred method. If done before a newborn is 6 weeks old, it can be done in the office without local anesthesia. Some parents are quite concerned about what their baby will experience, but as long as they are less than 6 weeks, the frenulum does not have any significant blood supply and no significant nerve supply so it’s not dissimilar to cutting finger nails. Babies don’t like it, but you know it’s not a painful experience. Typically babies will cry for about 10-30 seconds if at all and there’s usually 1-2 drops of blood. I prefer to take kids older than 6 weeks to the OR, unless they are much older in which case we can numb the frenulum in the clinic similar to what’s done for dental work. Some doctors do this for all patients. I find that the numbing shot hurts more than the actual release in the newborns, however.

Another method involves removing the entire frenulum. Sometimes lasers are used for either method. I don’t use lasers because it provides no better result than scissors, takes longer, and there is a slightly higher risk of complications. Sometimes, we use advanced plastic surgery techniques in older children or kids who have had a recurrence of the frenulum after a release. This more often requires a trip to the OR, but in coooperative patients can be done in the clinic under local anesthetic.

Two main complications are possible with this procedure. First, as mentioned above, is re-tethering of the tongue. A scar band can form and replace the frenulum causing the same symptoms. Often the scar band is thicker than the original frenulum and requires more advanced techniques to resolve. The other risk is to the salivary gland ducts that have their openings at the base of the frenulum. Many young kids become aware of these ducts because they are responsible for the ability to “gleek”. If you’re not familiar with this term, present long before fans of the show, Glee, were around, you can watch a video about how to do it, but I have to warn you that for some it may not be something they want to watch. If these ducts are damaged from the procedure, pain, swelling, and infection can occur in the salivary glands beneath your jaw bone (submandibular glands). This can become a significant problem even requiring removal of the gland(s). Fortunately, this is extremely rare and I’ve never seen a case of it caused by this procedure.

If you’re concerned about the possibility of ankyloglossia, have it evaluated. It’s a fairly straight forward problem which is easy to identify and quite easy to fix in most cases.

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