Welcome to module five. This is the last module in this online course, and our purpose here is to talk about medical and surgical interventions for patients with voice disorders. Our objectives for this lecture are to allow you to determine when it's appropriate to use behavioral, medical, and/or surgical intervention in our patients. To understand the principles of medical and surgical intervention for voice complaints, and to understand contemporary surgical principles for the removal of benign laryngeal lesions caused by vocal trauma. We mentioned in module four that a combined approach between a laryngologist and a speech language pathologist is ideal. Very briefly, voice therapy techniques can be divided into indirect voice therapy and direct voice therapy. In indirect voice therapy, we tell the patients to use less voice, to use amplification, to speak more softly. The point is, indirect voice therapy asks the patient to stop doing something. We can give them some positive measures. We can say drink more water, sleep well, use a good exercise routine, eat well, avoid dusty costumes in your theater production, often these things though are not within their control. Direct voice therapy is directed at teaching them how to use their voice efficiently. This is difficult probably because we're asking for change, or asking them to use a relaxed laryngeal posture, not a tense laryngeal posture. We're asking them to use airflow and to breathe efficiently. And we're asking them to use efficient resonance patterns. This takes time to develop but the interested patient can develop these techniques relatively rapidly, particularly, if they have a good idea on how their voice should feel. So, in terms of laryngeal relaxation, we've assessed through palpation where their areas of laryngeal tension are, we can have them directly massage those areas. We can teach them how to massage those areas so their larynx can relax. We can massage the thyrohyoid area, the area above that, or the base of tongue. We can use stretching exercises with the goal being to relax and stretch the larynx to allow easy phonation through efficient airflow. And the concept of stretch and flow phonation then, we want the patient to reduce laryngeal tension, increase airflow so that when their vocal folds are vibrating, there is a cushion of air between the vocal folds to minimize the impact of vocal fold vibration. After the patient achieves efficient laryngeal relaxation and air flow, voice therapy techniques can be advanced to include resonant voice therapy. The goals here are to maximize oral nasal resonance. To allow the patient, or to have the patient feel their voice in the front of their face, behind their teeth, or in the top of their mouth, we want them to minimize the impact of vocal fold vibration. So, by having a relaxed laryngeal posture with efficient air flow then, the patients can produce efficient resonance and feel a constant vibration energy or buzz source in the front of their face. When is surgery necessary? In my opinion, surgery is only necessary when the patient has maximized their vocal improvements behaviorally and is still dissatisfied with their voice because the voice and the lesions which create the problem continue to interfere with the patient's ability to meet their vocal demands. This means they have a compromised quality, they have a decreased vocal range or an increased sense of vocal effort or fatigue. If we're concerned about malignant change, precancerous or cancers change, then surgery is necessary. But today, with our high resolution images, this concern can often be evaluated in our clinic with excellent or a high quality laryngeal examination. So I have a patient, they have a vocal fold lesion, and I've sent them to speech language pathology, and they've worked diligently for three or four sessions, and they come back and they're no better. The question you need to ask here is, are they no better because they did what the speech language pathologist asked them to do and they were able to do it or do they just not get it? How do you know? Well, this patient who just doesn't get it, has a reduced sense of kinesthetic awareness. You ask them where they feel voice, and they pause and they say, I don't really know. You repeat the examination and you say, go up in pitch, and they go down in pitch. And/or you say, speak louder, and they automatically speak at a higher pitch. And then you ask them, what did you do last night? Oh, I went to a concert. Yes, I'm hoarse today, but I really didn't think about that until you asked me about it. So, they have difficulty in self-monitoring. So what do you do? Well, you modify their vocal demand. You go back to that indirect voice therapy. You tell them no more frequently. So you can give them more vocal choices. You can talk to them about variations in volume, about minimizing techniques such as loud yelling or growling or screaming, if they're on the stage. But the point is, if they're having difficulty with self monitoring, they still may not get it. And that's okay. Some patients just will never get it. And it's not our fault if they can't get it. And by working as a team with a speech language pathologist and laryngologist, we can help build each other's confidence to make certain we're doing the best we possibly can for our patients. But just because there is a persistent lesion, it doesn't mean the patient should go to surgery. In fact, I often think that's a contra indication to surgery because we know these lesions are caused by ongoing trauma. And many of them have ongoing trauma for the reason and as the reason they persist. If we do decide to go to surgery, what are our principles for surgical intervention? I'm going to say this one more time. Only after voice therapy failed to improve their speech mechanism enough to produce adequate vocal improvement. When we do surgery, it should be directed at the primary site of the lesion, and we should spare the normal surrounding structures such as the normal epithelium and the normal lamina propria. And we remember what these are from the earlier modules. When I was trained, we often used something called a stripping approach. We would not suspend the patient, we would expose the larynx with a monocular laryngoscope, a little pipe that allows us to stretch the throat open so we can get down to the larynx, and monocular means we could only look at the larynx with one eye. We would then take a pair of forceps specifically called strippers, grab the lesion and pull it off from the vocal fold. Some of my earlier mentors would always say to me, Mark, I don't understand why some patients get good voice after this procedure and others don't. That is one of the reasons I wanted to go into laryngology. I trained with my mentor who used surgical precision, high magnification, and spend hours removing only the involved tissue. We named these techniques microflap excision techniques. And you can see here, in the cartoon on the right side of the slide, how we can examine the larynx as seen in figure A. Make a small incision represented by that dotted line, that white dotted line, and then dissect around the lesion that you see in section B, and place the flap of mucosa that's not involved. The superficial lamina propria and the epithelium back down to allow the body to fill in. So, our goal of the microflap techniques are really to use precision with high magnification to remove only the involved tissue. Before I operate on patients, I always discuss with them an informed consent. I talk to them about risk of loss of the public speaking voice. Remember, many of the times we've gotten the patient to an improved voice, they may or may not be able to continue using their voice for their communication needs whether that be raising children, working as an administrative assistant or speaking on the six o'clock news. So, if they're still continuing those demands prior to doing surgery, we do need to tell them that there is a small risk that after surgery their voice could be lost. And their public speaking voice may not be as good. If they're a singer, in a same way we have to talk to them about loss of the singing voice. I always go on to talk to my patients about airway obstruction requiring a temporary airway tracheotomy, and I tell them that this is as likely as being hit by a car walking across the street. The point is, we are operating on their airways and we need to have respect for that. And lastly, I do tell them about death from it. Finally, the patients need to understand that vocal fold healing occurs over a three to six month process. And so, they need to be on their game using their voice as efficiently as possible for that entire three to six months. It's critical that they do this. And this is why voice therapy intervention, pre-operatively, is so critical as well. We know from studies and cancer rehabilitation that after we excise a cancer, the voice does take six months to heal. So, similarly, if we excise a nodule, or polyp, or cyst, it's going to take a similar period to heal. Every surgeon needs to develop a set of instruments that they feel comfortable operating with. This slide has 90% of the instruments I use on a routine basis to do the types of surgery you're going to see. We have, on the upper left, a very small knife with a blade about two millimeters in length. In the middle on the upper slide, we have a small dissector very similar to a gimmick that would be used in ear surgery, that's a total of a millimeter and a half in length, that we can use to dissect within the vocal fold superficial layer of the lamina propria. We have scissors on the bottom left, curved right and left, and I also use the up-curved scissors. We have multiple suctions that we use to suction bladder secretions from the field, and then tiny grasping forceps on the right, just large enough to hold only the lesion we're removing. I mentioned the microflap techniques as a type of technique that requires high magnification and then uses dissection to achieve laryngeal precision, rather than just stripping, rather than just grabbing or removing the lesion. Instead, we make an incision on or near the lesion. If we make the incision on the top portion of the vocal fold and lateral to the lesion, we call it a lateral microflap because that's where the incision is made. If we make the incision on the inside surface of the vocal fold, on the medial surface of the vocal fold, just at the side of the lesion, that's called a medial microflap. We've seen laryngeal stroboscopy. On laryngeal stroboscopy pre-operatively, if the mucosal vibratory patterns are absent, we're more likely to do a lateral microflap. And if the vibratory parameters are present, we're more likely to do a medial microflap. The reason for that is oftentimes, the vibratory parameters are absent because the lesion is binding the cover to the body. If we make an incision directly at the site of the lesion in that instant, it's instance, it's going to be very difficult for us to identify the normal planes. If the vibratory parameters are intact then, we find that we can identify normal planes even if we make the incision just at the lesion or medially. Similarly, if it's a very large lesion within discrete borders, we're more likely to start our incision in an area of normal laryngeal skin rather than right over the lesion. The best way though to determine this, while stroboscopy can give us a clue, the best way to determine this is by palpating the health of the mucosa during our direct laryngoscopy. If we can place our forceps, or our instruments, or our suctions on the skin, the involved skin, and pull it off of the vocal ligament, we can then do a medial microflap. So, the last point on that slide is if we try to do this in the OR and the lesion is adherent to the vocal ligament, then we're better off starting our incision and our dissection in an area that's relatively normal. We see here a lateral microflap. The incision is made on the dorsolateral surface of the vocal fold, and then dissection occurs around the lesion so that we can place the flap of preserved superficial lamina propria and epithelium back into position to cover the defect. If the lesion is separating from the vocal fold as you can see here on this diagram, we can make an incision at the junction of the lesion to the relatively normal tissue. We can then dissect around the lesion and create small flaps of tissue to help fill in this defect once the lesion is removed. The real advantage of the microflap techniques though are that they allow you to remove lesions like these without creating a raw vocal fold that has to heal by contracture. We all know that when we get a brush burn, we have a big raw spot and we can see and actually feel it tightening up and contracting in. That's okay if it's the skin of the elbow or of the knee. But if it's the skin of the vocal fold and it tightens up or contracts in, then vibration is impaired, then voice is impaired. So, in the '70s and '80s, many of us would have been taught just to grab a lesion like this and strip it from the vocal fold. Even if we used a laser to cut it off we'd be left with a raw surface on the vocal fold from the very top of the vocal fold to the very bottom of the vocal fold. Similarly, lesions like this, if we strip them off or just cut them off with a laser, we'd be left with a big raw surface. By using a dissection technique with high precision then, we can remove the lesion under the normal epithelium and superficial lamina propria and redrape the flaps into position, so that we have a minimal raw surface, so that there's minimal contraction, so that healing occurs primarily without scar contracture. Now it's time to begin voice therapy. And I have the patient do one complete week of voice rest. After their one week or six days of complete voice rest in our clinic, they go on three weeks of modified voice use. So they incrementally increase the amount of talking they do each day so that they don't develop vocal fatigue. And then singing is usually introduced at four to weeks or so after surgery. Voice therapy regimen should be weekly for the first month. After that, it's every two to three weeks for the next two to three months, and then we continue as needed. This voice therapy regimen though is always customized to the patient. In summary of module five, voice therapy can be divided into indirect and direct techniques. These need to be individualized for the patient. Non-neoplastic lesions nodules, and polyps, and cysts, may regress significantly with voice therapy. Surgery for these benign nodules, polyps, and cysts is only indicated after attempts at voice therapy, lead to a stable voice, but fail to allow the patient to achieve satisfactory voice quality. If the patients voice is not stable after voice therapy, you need to question the patient's ability to be compliant with the voice therapy recommendations. Just because the lesion is there it's not a reason to automatically take the patient to surgery. If the patient non-compliant before surgery, they will likely be non-compliant with your recommendations after surgery. While you may get a better voice for a time, the voice problem is likely to recur. I believe also that surgery for these benign diseases is facilitated by high surgical magnification which allows us to enhance precision. These micro dissection techniques should be used to remove only the involved vocal fold tissue and to spare the normal surrounding tissue. Voice therapy is helpful post-operatively for three to six months to facilitate efficient vocal production techniques, which will likely result in improved healing. In summary of our entire online course, I'd like to make a few comments. First, benign non-neoplastic laryngeal disease is a response to injury, to vocal trauma, not trauma from a car accident, but trauma from excessive voice production and inefficient voice production techniques. These lesions arise in the superficial layer of the lamina propria. Treatment is directed at the elimination of the source of this injury, which is the vocal trauma, again, the trauma produced by the way the patient produces voice. Surgical intervention is improved by understanding laryngeal histology, physiology, and pathophysiology, or disease states. So, what the larynx is made up of; it's anatomy, it's skin, and cellular structure, the way it functions and vibrates and then how it can function and vibrate in diseased states. I think that our knowledge of this is critical to us being good voice care clinicians. Surgical therapy is a last resort option. Microflap approaches allow maximal preservation of uninvolved tissue. We have the medial and lateral techniques, which are simply name for where the incision is placed on the vocal fold. With awareness and knowledge of the patients voice use patterns and vocal demands, changes and vocal techniques can be made to maximize voice without surgical intervention. And when surgery is necessary, it's desirable for patients to have made, pre-operatively, the voice use changes required to maintain future vocal health. I'd like to thank you all for your attention to this online course. It's been a privilege to present this to you. Thank you.
