http://www.nyee.

edu/patient-care/otolaryngology/voice-swallowing/therapy/exercises

Medialisation thyroplasty:

This technique is used to close the glottic gaps commonly seen in sulcus vocalis. This
procedure cannot be performed endoscopically. This is an external procedure which
uses different medialising implants like silastic, Gore-tex or hydroxyapatite
blocks. Sometimes strap muscles can also be used is autogenous graft is
preferred. Goretex is the preferred material to medialise the vocal fold. This material
not only reduces the glottic gap it also maintains the normal pliability of the vocal
folds. The surgical procedure will be detailed elsewhere.

Collagen injection:
Collagen can be injected into the vocal fold thereby causing medialisation of the injected
vocal fold. This procedure can be preformed through an endoscopic approach. This
injection can be performed under out patient settings. This injection closes the glottic
gap causing an improvement in the quality of voice. The only problem with this method
is that collagen has been known to be absorbed by tissues. No long term study is
available to study the long term effects of this injection. Large gaps cannot be treated
by this method.

Cold redrape: This procedure is performed under microlaryngeal approach. It involves

a longitudinal epithelial cordotomy with release of the sulcus from its depth followed by
simple redraping of the epithelium. The major advantage of this procedure is that
implants need not be used and is a fairly simple procedure to perform. The release of
the tethered tissue helps to close the glottic chink somewhat better. One major word of
caution is that the healing process of the epithelial cover is not under our control,
ultimately the operated area may heal with fibrosis reducing the pliability of the vocal
fold whereby worsening the condition. Surgery must hence be performed with utmost
caution with minimal trauma to the covering mucosa.

Laser undermining with redraping: CO2 laser is used lto perform the cordotomy. It
has the advantage of excellent hemostasis with minimal trauma to the surrounding
tissues. Steroids are injected at the time of redraping and fibrin glue is applied to the
epithelium to facilitate reapproximation and tissue healing of the epithelial cover.

Slicing technique of Pontes and Behlau: This technique utilises the principles of scar
contracture repair. The scar bands are interrupted with medial advancem ent of vocal
fold cover. In this procedure cuts of varying lengths are made in the coronal plane of
the vocal fold to release the longitudinal scar band. This procedure is reserved for cases
of severe deformities where less aggressive surgical management may not suffice.

Fat injection: Glottic insufficiencies can be corrected by injecting fat into the
paraglottic space. This can be achieved via a laryngofissure approach.
An inflammation in the voice box or larynx causes hoarseness in the voice and in some cases
the complete loss of the voice-as the larynx is the organ affected, the condition is known as
laryngitis. Commonly occurring with other upper respiratory tract infections, the condition
known as laryngitis has symptoms such as soreness and scratchiness in the throat of the
affected individual, and affected patients usually also develop signs of a fever. A dry and
barking type of cough typically accompanies the sounds produced in the throats of people
with laryngitis. Several days may pass before full vocal recovery is restored in individuals
who have entirely lost their voice. The condition known as croup is probably involved if the
cough and hoarseness brings about any difficulty in breathing. The condition known as croup
is especially common in many children; the more severe forms of this disorder can be
alarming to a parent as an affected child gasps for air in a desperate manner. Breathing
normally is rendered more difficult by the persistent presence of anxiety and fear in the child.
Individuals affected by vocal hoarseness that does not disappear within a week must seek
professional help, this is suggested as the presence of a tumor or an enlargement of the
thyroid gland can bring about similar symptoms.

Infections of the throat or the sinuses are often followed by cases of the acute form of
laryngitis-which itself is brought on by the usual causative organisms and factors as the
common cold and pathogens like the bacteria and many types of viruses. Recurring
hoarseness and chronic cases of laryngitis can also be caused by the overuse of the voice, as
stressing out the vocal chords creates a predisposition for developing laryngitis. It is
important not to strain the vocal chords repeatedly by speaking or shouting for long periods
of time, great stress is also placed on the vocal chords if a person yells excessively, or if an
individual takes part in long sessions of singing or lecturing. The larynx is also predisposed to
many types of infections by smoking heavily, similar effects can be induced by inhaling other
irritating toxins-inhaling polluted air and cigarette smoke are important factors in the
development of laryngitis. The cause of hoarseness in the voice can sometimes be due to
anxiety and other psychological factors. Cases of laryngitis have also known to have occurred
as result or as a form of hangover symptom, caused by the consumption of high amounts of
drinks containing alcohol.

Supplements and herbs

The use of supplemental zinc lozenges can alleviate the symptoms of a sore throat and this
compound will help support and mobilize an effective immune system response to pathogens
in the throat. Viruses and bacteria that have invaded the throat can also be dealt with using
throat sprays which contain the seed extracts of the grapefruit-this herbal extract will help
eliminate all pathogens accumulating in the throat. The antibiotic properties of the grapefruits
must be used effectively and this herbal extract is also available in the form of a liquid herbal
extract or if preferred it can also be taken in the form of herbal tablets.

Immune system functioning can be boosted and restored through the use of high doses of the
vitamin C, similar in dosage strengths to those used during the treatment of other infections,
this vitamin must be taken to doses that the bowel can tolerate at any one time without
adverse symptoms. The effectiveness of the vitamin C supplements can be enhanced by the
use of plant based natural substances called the bioflavonoids, indeed, these two substances
must be taken together by the patient for optimal treatment from the illness, and both of these
substances also ensure that the immune system functions properly. To soothe and heal the
irritated mucus membranes and to support the action of the immune system, supplements of
the vitamin A are also strongly recommended for all patients suffering from laryngitis.

Since antibiotics are used during the treatment period, there is a loss of intestinal friendly
bacteria, this loss can be replaced by supplements of the Lactobacillus acidophilus bacterium
as the normal intestinal bacteria complement is vital to maintain health in the body. This
particular supplement will help prevent the onset of further illness, and such supplements of
these friendly bacteria must be taken when taking any antibiotics to treat throat problems.
While the Lactobacillus acidophilus occurs naturally in all natural brands of yogurt, the
capsule forms are stronger and more effective and should preferably be used during the
treatment of laryngitis. As a preventative measure, all of the supplements given here can be
used at lower dosages on a regular basis by all patients with laryngitis.

The following herbs and herbal combinations can help in the purification of the blood, they
will fight back infection from different pathogens and they will also help in bringing some
alleviation from different forms of allergies induced by the laryngitis in the affected
individual.

For the elimination of all the infective germs and the pathogens in the body, regularly gargle
using an herbal sage tea once every hour or if this is not possible at least thrice every day. An
effective herbal alternative that can be used in the herbal gargle water is the common garlic.
The odorless garlic capsules may be preferred by some individuals; these capsules have the
same potency of raw garlic and can be used by those who cannot deal with the smell of raw
garlic. Dosage of this herb can be three garlic capsules taken every day at regular intervals.
The antiseptic actions of the tea tree oil can also be utilized in the treatment of a throat
problem. Gargle using warm water to which five drops of the tea tree oil has been added for
maximum relief from the symptoms of a throat infection. Use different herbs as infusions in
gargling water some herbs that can be used include a tbsp. each of the tincture of the lemon
balm along with some brandy. To treat coughs and persistent hoarseness in the throat drink
herbal teas made from a combination of herbs to which some non-pasteurized honey has been
added, these herbs include some Echinacea herbal extract, the ginger, the garlic, the sage, the
goldenseal, the licorice and the slippery elm in equal measures. To disinfect and soothe the
throat as well as to heal and soothe the inflammation resulting from laryngitis, steam
inhalations of the wild thyme, the sage, the lavender or some oak bark can be employed.
Steam inhalations of the oak bark are particularly effective, the bark has antiseptic properties,
it also has a natural anti-inflammatory ability, it functions as a pain-relieving analgesic and its
astringent properties are also very potent. Respiratory organs are disinfected by steam
inhalations made from the wild thyme. If there is a fever present in the patient, a drop of
sweat inducing oils of the eucalyptus or the peppermint can be added to bring about
perspiration and relief from the fever.

Aromatherapy
Commonly used essential oils for laryngitis:

Benzoin
Cajuput
Myrrh

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Homeopathy
The following homeopathic remedies can be used in hourly dosages at 6c,12c or 30c
potencies, the initial strength of the dose can be progressively reduced as the intensity of the
symptoms decrease. Depending on the physical response given by the patient, during
treatment of chronic laryngitis cases, a single dose daily will be sufficient for several days or
weeks at a time to bring relief from the many symptoms. Sometimes immediate improvement
may be noticed after taking just a single dose of a homeopathic remedy, before you take
another dose wait and see how long the effects from the initial dose lasts. The response of
different people to the any given homeopathic remedy is likely to be different from how
everyone else responds to the same remedy - for this reason, all treatments must be carried
out on individual basis.

Aconite
Aconite is to be used in the homeopathic treatment of patients suffering from a sudden
onset of hoarseness in the voice and other problems related to laryngitis. There is a husky,
crowing or squeaky quality to the voice of the affected person. This type of loss of voice
comes about due to sudden fright, because of sudden shock, and after being chilled by dry
and cold winds out of doors. Physical symptoms include the presence of a persistent fever
and the development of a hollow, croupy cough along with the drying of the windpipe.
Symptoms experienced by the affected individual can also include dryness and a sensation
of burning heat in the throat. The psychological symptoms can include persistent
restlessness and a fearful emotional state at all times. The condition of the patient can
greatly worsen during the nighttime, the condition can also be aggravated by touching, and
the person feels worse when breathing in, exposure to cold air and talking can also
aggravate the symptoms. The presence of one or more of these symptoms requires the
immediate use of Aconitum as a homeopathic remedy in the treatment of the laryngitis.
Argentum nitricum
Argentum nitricum is to be used in the homeopathic treatment of patients afflicted by a
chronic hoarseness in the voice, this remedy can also be used in the treatment of patients
with a loss of voice, and the remedy also treats the form of laryngitis experienced by many
singers. The condition causes a cough whenever the person sings in a high note. Physical
symptoms which are apparent include soreness in the larynx and along the pit of the throat.
The individuals airways in the throat have a coating of very thick mucus. When the person is
swallowing there is a sensation of some splinter stuck in the larynx and the windpipes. The
physical symptoms experienced by the patient also include a sensation of hair like tickling
along the inner throat. Physical symptoms also include the presence of choking sensations,
as if some food has lodged itself in the upper throat after a meal. Psychological symptoms
include helplessness and a feeling of being numb and paralyzed. Physical symptoms like a
burning or drying sensation in the throat is also present at most times of the day and night.
The condition of the patient can worsen after midnight, the condition of the patient is also
aggravated by fear and anticipation of events, and anxiety can worsen the symptoms, the
consumption of sugar, staying in a warm room can all worsen the condition of the patient.
The condition of the patient improves when he or she stays out of doors exposed to the cool
air. The presence of one or more of these symptoms requires the immediate use of
Argentum nitricum as a homeopathic remedy in the treatment of the laryngitis.
Causticum
Causticum is to be used in the homeopathic treatment of patients afflicted by a case of
chronic laryngitis and other related throat problems. Physical symptoms include the
presence of a soreness and rawness in the throat, the throat may also have a burning and
dry sensation most of the time. Further physical symptoms in the patient include a
tenderness in the larynx and all along the throat. Physical symptoms felt by the patient
include a hoarse, hollow, husky and cracking voice. The person may also have a very weak
voice, and this could be because of paralysis setting in on the vocal chords. Physical
symptoms also include the accumulation of mucus in the throat, this collected mucus may
be very hard to expel and the patient may be hawking or choking at most times, the affected
individual will also complain of a sense of being constricted slowly around the throat. The
patient may feel a lot of pressure in the area of the larynx when blowing the nose or when
exhaling with force. The symptoms may also include a sensation of some foreign body stuck
in the throat. The condition of the patient can greatly worsen when exposed to dry and cold
weather, when the person inspires he or she may feel a lot of discomfort, symptoms also
 worsen with a lot of coughing after midnight which disturbs sleep, the condition of the
patient is also aggravated when he or she is speaking, or when he or she strains the voice.
The presence of one or more of these symptoms requires the immediate use of Causticum
as a homeopathic remedy in the treatment of the laryngitis.
Kali bich.
Kali bich. is to be used in the homeopathic treatment of patients with laryngitis
accompanied by a chronic hoarseness of voice, the remedy can also be used to deal with
individuals who have experienced a total loss of voice, and the remedy can also be used to
treat hoarseness in the voice which tends to worsen towards the evening. Physical
symptoms commonly experienced by the patient include a tickling and persistent sensation
in the throat, this causes the patient to hawk and cough a lot, and the patient may also need
to clear the throat a lot of times. Physical symptoms may also include the presence of a dry
and constricting sensation in the throat. Symptoms include soreness and rawness in the
larynx, and the persistent burning sensation radiates from the throat up into the nostrils
causing a lot of discomfort to the affected person. A persistent and rattling cough is also
often seen in most patients. The patient also suffers from the accumulation of a tough, and
stringy type of mucus that is very hard to expel from the nose. Symptoms may resemble the
condition known as the croup. The condition of the patient can greatly worsen when the
person is out in cold and damp conditions, sudden changes in the weather can also
aggravate the condition, the condition of the patient is also worsened by excessive use of
the voice, such as speaking or laughing for too long, and a persistent coughing after midnight
worsens the symptoms disturbing sleep. The presence of one or more of these symptoms
requires the immediate use of Kali bich. as a homeopathic remedy in the treatment of the
laryngitis.
Phosphorus
Phosphorus is to be used in the homeopathic treatment of patients who have a persistent
hoarseness in the voice, patients afflicted with a sudden loss of voice can also be treated
using this homeopathic remedy. Physical symptoms evident in the patient include the
presence of a sore and raw sensation, along with a burning sensation in the larynx which
causes a tickling cough to appear. The trachea is also affected by too much talking, which
will cause the appearance of a sudden intense stitching pain in the tracheal region. The
patient may complain of a feeling of being constricted in the region around the neck.
Symptoms also include the giving off of thick mucus as an expectorate. Sharp pains in the
throat can also come about because of associated conditions of cough or croup
accompanying the throat problem. The condition of the patient can greatly worsen when
any cold air enters the throat, too much talking and laughter can also aggravate the
condition of the patient, the patient hates being touched, and the condition worsens
steadily after midnight and is at its worst in the evenings. Symptoms are also aggravated by
eating warm things and lying on the left side of the body for prolonged periods of time, the
condition of the patient is also worsened by sudden changes in the weather. The condition
of the patient can greatly improve when eating cold food items. The presence of one or
more of these symptoms requires the immediate use of Phosphorus as a homeopathic
remedy in the treatment of the laryngitis.
Spongia tosta
Spongia tosta is to be used in the homeopathic treatment of patients afflicted by acute and
chronic laryngitis and other related throat conditions. Physical symptoms apparent in the
patient can include a persistent hoarseness in the voice, along with a sore and burning
sensation in the larynx. There is also a persistent tickling sensation present in the larynx and
along the throat. There is a sensation of a plug or a nail stuck somewhere in the throat. The
patient also complains of a great deal of dryness in the throat. The person is often hawking
constantly due to excessive mucus. There is a sensation of constriction around the larynx,
 this sensation can greatly worsen during midnight and also during sleep along with
suffocative sensations and feelings of anxiety accompanied by other psychological
symptoms. Symptoms also include a persistent barking cough at the beginning or during the
onset of croup. The condition of the patient can greatly worsen when the patient is touched
and some pressure is applied to the throat, too much talking or swallowing a lot of things
can also worsen the symptoms, eating sweets and being exposed to dry and cold wind also
aggravated the condition. The condition of the patient improves when the patient eats
warm food or warm drinks, sitting and lying with the head held low can also improve the
condition of the patient, eating a little at a time reduces the stress on the throat and
improves the condition of the patient. The presence of one or more of these symptoms
requires the immediate use of Spongia tosta in the homeopathic treatment of the patient.

Additional things you may do

The use of topical treatment methods such as using hot wraps around the neck will heal and
help relieve the worst symptoms of the condition in an indirect way. To make a hot wrap,
carefully soak a cotton cloth in some heated apple cider vinegar and wrap this cloth around
the neck when the symptoms are particularly intense. Topical treatments that can also be used
include some raw and crushed, heated leaves of cabbage, apply this around the neck along the
area of greatest discomfort. A salve made from the arnica can also be applied directly on the
neck. Use a dry towel to always keep the neck wrap or compress covered. Another great
topical treatment can be made by boiling two lbs. of small potatoes with the skins on. The
boiled potatoes can then be mashed and the mashed paste can be spread on a cotton cloth, this
can then be placed while it is still hot, directly on the throat along the affected area. A woolen
shawl can also be used to cover the affected area on the neck. Gargle your throat using a
solution of concentrated whey once every hour or if this is not possible at least thrice every
day so as to rid the throat of germs and harmful pathogens. The antiseptic property of the
liquid whey can greatly aid in the elimination of germs and other pathogens. Laryngitis can
be soothed and healed using steam inhalations on a regular basis. If the air within your room
is too dry, use a humidifier in the bedroom to increase the moisture content in the room - this
is very good for dryness in the throat.

Usual dosage
Grapefruit seed extract, three capsules thrice a day.
Vitamin A, 25,000 IU. Should be avoided during pregnancy.
Vitamin C, with bioflavonoids, 1,000 mg every few hours to bowel tolerance.
Zinc lozenges, with 3 mg of copper, 25 mg, every few hours.
Acidophilus combination supplement, three capsules or one tsp.

Other beneficial herbs

Throat:- There is a tendency to favor the growth of warts and in the throat there are little wart-like
growths; polypoid growths in the throat and about the genitals and anus hence its great use in
sycotic constitutions. "Feels as if he had a stick in the throat when swallowing." . At once you will
see its close relation to Hepar. In inflammatory conditions of the throat with ulceration. In Argentum
nitricum he wants to be in a cold room, wants cold air, and to swallow cold things. In Hepar he wants
warm things to drink, a warm clothing, warm room , and cannot put even his hand out of bed or his
throat will begin paining him. Things, you see, just oposite, but they both have "sticks" in the
throat. In dry chronic catarrh Alumina and Natrum muriaticum have "sticks" in the throat; but the in
red throat with tumefaction and pain these two remedies gives no relief, the former two are better.
Nitric acid, hepar and Argentum nitricum are the most striking remedies for the fish-bone sensation.
Many remedies have sticking in the throat, but these are the most prominent. We know how
Argentum nitricum has been used for ulceration in the throat, and here it comes in as one of the mot
useful remedies in congestion of the throat of long standing. Catarrhs with loss of voice. Warty
growths, condyulomata, etc. Loss of voice, tumefaction of the mucous membrane round about the
vocal cords and paresis of the vocal cords. Condylomata on the vocal cords.

Disclaimer: Results are not guaranteed*** and may vary from person to person***.

I had planned to see a concert the other day (its always

exciting when you can sit back and relax with friends at a show). Unfortunately, it was
canceled at the last minute because the singer came down with laryngitis and lost his voice. I
was certainly disappointed that the performance got canceled, but I was also concerned for
the singer.

Laryngitis is any singer or public speakers worst nightmare. In fact, it is a pretty

uncomfortable illness for anyone who uses their voice on a daily basis. It is a condition where
your voice box (larynx) and vocal cords become irritated or inflamed. In most cases, acute
laryngitis is caused from viral infections, such as the common cold or flu. The overuse of
your voice from cheering or singing can also lead to laryngitis. In rare cases, the bacterial
infection diphtheria may be the cause of acute laryngitis.

How Do You Cure Laryngitis?

Treatment for acute laryngitis is fairly simple: avoid using your voice as much as possible
and consume lots of water and everything should be back to normal within a couple of weeks.
Laryngitis may also be a sign from your body to cut back on smoking or drinking alcohol,
since both cause irritation in the voice box.

However, chronic laryngitis may form from constant exposure to irritants such as allergens,
toxic fumes, caffeine, cigarette smoking, or asthma inhalers. It is best to avoid these
substances. Other causes of chronic laryngitis include acid reflux or gastroesophageal disease
(GERD), chronic coughing and sinusitis, and viral infections like mumps or measles.

Ad

The Homeopathic Laryngitis Cure

Im a huge fan of homeopathic remedies. For example, the most beneficial homeopathic
remedy for overexerted vocal cords is argentum nitricum, which is prepared from watered
down silver nitrate. The remedy is also recommended when laryngitis is connected with stage
fright and anxiety. Argentum nitricum is also effective for other throat conditions such as
chronic hoarseness and loss of voice.
When a singer belts out a high note and it causes coughing, argentum nitricum is very
effective. Argentum nitricum is a great remedy for a person who feels thick mucus in the
airways or a splinter in the larynx when they swallow. They may also choke and food may
lodge in the upper throat. They may feel like they are paralyzed with dry and burning skin.
Warmth is known to make laryngitis worse with these people, while cool air actually makes
the condition better.

To treat acute laryngitis, it is best reduce the dosages of argentum nitricum when your
symptoms decrease. Take a potency of 6c, 12c, or 30c every hour. One dose daily for a long
period of time is usually recommended for chronic laryngitis.

Other Natural Remedies for Laryngitis

Homeopathic remedies are typically recommended for a person based on particular
symptoms. For laryngitis, a homeopath may also prescribe aconitumespecially from
sudden symptoms. Homeopathic phosphorus is a common remedy for bronchitis, coughs, and
laryngitis. Kali bichromicum is also considered the most effective remedy for sinuses, but can
also be used for laryngitis and other throat conditions. Other common homeopathic remedies
for laryngitis include spongia tosta, causticum, arsenicum album, ammonium carbonicum, or
ambra grisea.

Antibacterial foods that can provide relief for laryngitis include apple cider vinegar, ginger,
onions, garlic, lemon juice, honey, and warm salt water. Slippery elm and eucalyptus oil are
also known to provide natural treatment for laryngitis. It is also best to avoid foods that cause
acid reflux such as coffee, fried foods, or anything spicy.

Remember, when you still cant speak for more than two weeks, seek advice from a doctor or
a natural health practitioner.

Sources for Todays Article:

Hershoff, A., N.D., Homeopathic Remedies: A Quick and Easy Guide to Common Disorders an

mucous membrane round about the vocal cords Medical Therapy

Anatomic change in the vocal fold (eg, sulcus vocalis) is difficult to treat medically. Any
intercurrent medical conditions affecting the voice (eg, reflux laryngitis, allergic rhinitis) are
evaluated and treated. Prior to considering surgical therapy, all known sources of mechanical
trauma are maximally reduced to determine reversibility and hopefully prevent a
postoperative recurrence. This is accomplished in part by medical and speech therapy to
reduce vocal trauma through improved phonatory technique and vocal hygiene.

The primary goal of speech therapy is to improve vocal efficiency. The method most
commonly employed is direct speech therapy, which is covered in the Medscape Reference
article Voice Therapy. When voice therapy is combined with external measures (eg,
amplification) and behavioral alterations (eg, scheduling vocal rest periods), vocal fatigue
may dissipate.

Surgery is reserved for unresolving lesions that have resulted in persistent troublesome
dysphonia.
Surgical Therapy
Patients with sulcus vocalis may complain of vocal insufficiency, loss of quality, or both.
When low volume and loss of projection are major complaints, medialization of the scarred
vocal fold may significantly improve vocal performance while decreasing effort and fatigue.
[4]

Medialization alone may not significantly impact vocal quality. An attempt to reconstitute the
lamina propria may be considered for patients who have adequate volume but poor vocal
quality. [5]

Current opinion holds that placing a biocompatible material between the vocal ligament and
cover or within the layers of the lamina propria could compensate for lost tissue and restore
sliding movement of the mucosal cover. This additional layer also may prevent fibroblast
migration from deeper layers and further scar formation. A thick scar band associated with
the sulcus may be removed through a microflap approach. However, this maneuver carries
the risk of further fold thinning. The ideal implant material assumes the function of the
intermediate layer of the lamina propria, which is composed of elastin, hyaluronic acid, and
fibromodulin. Implant material is placed to augment the infraglottics and free edge of the
vocal fold. Phonation threshold pressure (ie, amount of pressure required to initiate voice) is
decreased by improved closure, increased fold thickness, and lower viscous damping (ie,
tissue inertia). Therefore, the ideal implant has low viscosity and resorption and is injectable.

Injectable collagen gained interest early because of its ability to soften scar tissue when used
in the face. Bovine collagen has a comparatively high resorption rate and a moderate risk of
local immune reaction. Autologous collagen has good short-term results, but information
about long-term survival is limited. In addition, skin must be harvested at a separate sitting
for autologous collagen extraction, and processing is relatively lengthy and expensive. When
normal lamina propria reproduction is the goal of implantation, fat is the available material
most similar in viscosity (4 pascal seconds [Pa-s]) to the lamina propria. In contrast, collagen
has a much higher viscosity (10 Pa-s).

Autologous fat probably is the best augmentation material currently in widespread use. [6]
More forgiving placement of autologous fat within the larger muscle bed is possible, and
longevity has improved through development of viable adipocytes. Archer and Banks
demonstrated maintenance of viable adipocytes and bulk for up to 1 year in an animal model.

Fat may be implanted into the vocal fold through an endoscopic approach but may also be
implanted through a surgically created window in the thyroid cartilage, or "minithyrotomy."
[7]
Paniello (2008) reported good results in 2 patients treated specifically for sulcus vocalis
with this approach. [8]

Injectable hyaluronic acid may also have an application in the treatment of patients with
sulcus vocalis. Because hyaluronic acid makes up the gel-like space of the superficial lamina
propria, replacing it has long been considered the holy grail of therapy for vocal scarring.
Although the usefulness of hyaluronic acid is unknown, early reports suggest that
maintaining sufficient volume of material in the desired location is problematic. Studies into
the use of this material are ongoing.
A study by Hwang et al suggested that pulsed dye lasers can effectively be used to treat
sulcus vocalis. Each treatment in the study, which involved 25 patients with the condition,
consisted of 60-100 laser pulses (0.75 Joules per pulse) on each vocal fold. The procedures
appeared to decrease vocal fold stiffness, improve mucosal wave properties, and reduce
dysphonia. Moreover, in most patients, improvement was demonstrated in several
postoperative voice analysis indices. [9]

The aforementioned study by Lee et al, which indicated that epithelial pathology plays an
important part in sulcus vocalis, suggested that surgical treatment should involve the removal
of pathologic epithelium, as a means of treating inflammation. [3]

Preoperative Details
Surgical candidates must be willing to postpone speaking and singing engagements for at
least 3 months postoperatively. Patients presenting with dysphonia are evaluated by indirect
laryngoscopy (as seen in the image below) and videostroboscopy (as seen in the image
below), with particular attention to vocal fold mobility; glottic closure; and the presence,
amplitude, and symmetry of the mucosal wave.

Sulcus under normal light indirect

laryngoscopy: Note the very subtle appearance.
View Media Gallery
 Sulcus under stroboscopy: Note
the defect in the vibratory surface caused by the sulcus.
View Media Gallery

Diagnostic laryngoscopy may be necessary prior to invasive procedures aimed at altering

laryngeal anatomy in order to have a more complete understanding of vocal fold pathology
and potential for surgical treatment. Specifically, the ability of the surgeon to adequately
expose the larynx may affect the surgical approach chosen. The area of vocal scarring may be
more closely estimated by palpation. Some surgeons employ a diagnostic infusion of saline
under the mucosa to assess the feasibility of injecting or implanting biocompatible material.

Intraoperative Details
Bring the microscope into position after the larynx is adequately exposed. Remove obvious
scar tissue and bands of fibrosis whenever possible, preferably through a microflap approach.
Endoscopic or transcutaneous injection is the most convenient method of implant delivery,
but anecdotal reports suggest that sufficient bulk cannot be obtained through injection alone;
passage through a needle barrel is too traumatic to the adipocytes; and the implants may
extrude out of the injection site. On the other hand, implanted fat tends to migrate superiorly
in the pocket. The authors' current technique is to harvest fat via a large 8-mm liposuction
cannula and inject it into the thyroarytenoid muscle with a Breunig syringe. Anecdotal reports
support rinsing harvested fat in insulin to support adipocyte cell membrane stabilization. A
moderate decrease in volume in the early postoperative period should be expected. Therefore,
overcorrect the vocal fold at the time of surgery.

Postoperative Details
Patients are placed on strict voice rest for 2 weeks following microflap surgery. Patients with
more extensive dissections may be placed on a short course of corticosteroids. All patients
receive antibiotics for 7 days and a mild narcotic for pain relief. Patients with symptoms or
findings of laryngopharyngeal reflux are medically treated with a proton pump-inhibiting
agent.

Follow-up
Patients are re-examined at 2, 4, 8, and 12 weeks postoperatively. At the 2-week
postoperative visit, videostroboscopy is performed, and the patient resumes therapy with the
speech pathologist. Gradual return to voice use over the first few weeks is recommended,
increasing by 5-minute intervals twice daily. Singers may begin work with the vocal
pedagogue at 1 month but are cautioned to back off if they feel any discomfort or strain. Most
patients can expect to see 90% of the functional surgical result at about 3 months.

Complications
Surgical complications are related to laryngoscopy, vocal cord incision, and implantation of
material for medialization. Complications of laryngoscopy include damage to or avulsion of
teeth; oral mucosal laceration; and pressure damage to the tongue, including numbness or
altered taste. Any vocal fold incision can result in further scar formation with recurrence of
the sulcus.

Outcome and Prognosis

In 2 studies, microsurgical techniques were used on 30 patients with pathologic sulcus. Voice
improvement was reported in the majority of subjects using objective measures. Using fat
implantation methods, Sataloff et al described voice improvement and limited return of
mucosal wave. [10] Most patients can expect significant voice improvement from either
technique, but results are not equal to premorbid conditions in most cases. Additionally,
insufficient data exists on the longevity of improvement.

Future and Controversies

Future injectable materials may more closely simulate composition of the intermediate layer
and hyaluronic acid, but consistent placement and long-term positional stability remain
difficult. Certainly, the best way to treat scarring is to prevent it. Improperly performed or
timed surgical intervention can result in irreversible dysfunction and dysphonia. Conservative
treatment should be exhausted before surgical intervention is considered, which should be
based on the modern concept of vocal fold microanatomy and histology. Use of microflap
techniques avoids a raw mucosal surface that heals by secondary intention and may result in a
sulcus.

Overview
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