5 questions about vocal cord surgery

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on March 08, 2012 at 12:00 AM
McGinn,Johnathn QAVOCAL.JPGView full sizeDr. McGinn

NAME: Dr. Johnathan D. McGinn
TITLE: Associate professor of otolaryngology — head and neck surgery
COMPANY: Penn State Milton S. Hershey Medical Center

Q: Many singers — including Adele and Keith Urban — have had to take a temporary break because of vocal cord polyps. Can you explain what causes such polyps?

A: When we speak or sing, many factors come together to generate the sound. Our lungs provide the power, our vocal cords (or “folds”) provide the sound, and the rest of our throat and mouth modify that sound into what others hear. The vocal cords are small muscles covered by a very specialized and mobile lining, which allows for vibration in a controlled manner. All of these components must be working well to create a normal voice. The differences in those who can carry a tune and professional singers, involves many factors of inherited good anatomy, hard-work and training, and in-born talent.

In the case of vocal professionals, the vocal cords are what experience the most strain when speaking or singing. Professional singers are truly “vocal athletes” and push themselves beyond what most people do. In doing that, the vocal cords may experience damage. While not privy to their specific medical information, my understanding is that both Adele and Keith Urban experienced vocal cord hemorrhages, or bleeding. This is like a bruise on the vocal cord occurring as a result of voice overuse or misuse. It is considered by most laryngologists as a voice emergency, treated with voice rest. If not, further damage may be done, including polyp formation or even permanent scarring and voice problems. The problem for professional singers is that a lot of pressure for them to perform exists, and many “sing through” a problem. This may be especially true for young performers, such as Adele, trying to make their way in a tough profession. We have all heard the phrase “the show must go on.”

A vocal cord polyp is a specific area of the vocal cord, which is swollen, and may look similar to a small growth. This affects how the vocal cord vibrates, and thus the voice quality. Other vocal cord problems may include generalized vocal cord swelling, vocal cord nodules, cysts, papilloma and even cancer.

Q: What are the symptoms of a polyp, and how are they diagnosed?

A: Vocal cord polyps cause a voice change. Most people would describe it as hoarseness or a change in the quality of their voice. In voice professionals, it may be more subtle — a change in the level of effort needed to sing, a change in their vocal range, voice fatiguing, prolonged hoarseness after performing or simply a change in overall voice quality. In anyone experiencing a voice change lasting longer than three weeks, it is recommended that they see an otolaryngologist (also referred to as an ear, nose and throat doctor).

Diagnosis is made through a detailed view of the vocal cords, which requires special instrumentation not available to a general physician. A painless in-office examination is done through an endoscope placed via the mouth or nose. This laryngoscopy can provide the specialist with information to guide them in diagnosis and treatment. A videostroboscopy is a more detailed examination of the larynx done in the same fashion, and is available at some voice specialists. This exam provides greater details on the vocal cord functioning and may detect more subtle problems.

Q: How is a polyp repaired? Is surgery always required?

A: The first important step in treating the polyp is a change in behavior. As voice misuse is a common cause, the behavior that contributed must be stopped. For voice professionals, this can be very difficult, as it requires canceling performances, as Adele had to do for her 2011 tour. For others this may involve avoidance of yelling, loud speaking, reduced time speaking per day, or even using microphones during their voice activities. This voice misuse may not be obvious to the patient, and therefore speech and language pathologists (particularly those with training and expertise in voice professionals) may be used to aid the patient in recognizing these behaviors and changing them.

It is also important to treat any underlying medical issues that can contribute to the vocal cords being inflamed. When inflamed, the vocal cords are more vulnerable to developing a polyp. These irritants can even cause the polyps under normal voice use situations. The best example of this is smoking. Smoking takes a large toll on the vocal cords. Other medical conditions such as allergy, acid reflux, chronic sinus conditions, hypothyroidism, asthma inhaler use and any bleeding problems may need to be addressed. Many factors influence the need for surgery, but polyps not improved sufficiently with the above treatments may benefit from microscopic laryngeal surgery.

Q: Are there risks involved with treating a polyp? Can it change someone’s voice?

A: Every surgery carries with it some risks. The surgery for vocal cord polyps is done under general anesthesia, with the surgeon working through the mouth to access the vocal cords. A microscope is used to obtain a very detailed view of the vocal cords. Very fine surgical instruments, and sometimes other tools such as lasers, are then used to delicately remove the polyp. Most vocal cord polyps are only a few millimeters in size, so this is very precise surgery. Temporary complete voice rest is usually recommended after surgery to avoid mild trauma occurring with voice use. For professional singers, this may involve complete rest for a week or more, followed by significant restrictions of how they use their voice for months afterward. They will need to work with a voice coach in rehabilitating their voice after surgery, similar to an athlete working with a trainer or physical therapist after orthopedic surgery.

If proper healing does not occur, the area of the surgery may be stiff compared to the rest of the vocal fold. This can create permanent voice changes. Many readers may be familiar with the problems experienced by performer Julie Andrews after vocal cord surgery in 1997, which essentially ended her singing career. While most would still feel she has a beautiful voice, it was not of the same quality and range as before surgery. Fortunately this is quite rare, and most patients have near complete recovery of their voice.

Q: Do polyps only affect singers, or can other people get them, too?

A: Vocal problems, like polyps, are not restricted to singers. While singers require peak performance of their voice, other voice professionals, such as teachers, lawyers, clergy, salespeople and receptionists, are also at higher risk for many vocal cord problems. However, anyone can get a polyp if the wrong combination of vocal cord inflammation and voice use occurs.

If someone experiences hoarseness, voice rest is the best initial treatment. If the person is a smoker, stopping the use of tobacco is important. If simple things like voice rest, tobacco avoidance, good hydration and avoidance of medications that cause dry mouth, do not improve the voice after three weeks, then referral to an otolaryngologist should be considered.

Interview conducted via email by The Patriot-News staff.