Let's show a clinical case presentation here. This patient is a 43-year-old female who works as a police detective on a Major Case Squad. She has a history of chronic voice problems that have gotten worse slowly over the last year. It's important to know that she has a long history of voice problems, and that two years prior to her seeing me, she had a lesion removed from her left vocal fold and then steroids injected into the mucosa of her right vocal fold. She felt that her voice was better for about a year, and prior to seeing me, her voice had been deteriorating. Her primary vocal complaints were fatigue everyday by noon. She described herself as a loud talker who needed to talk over background noise in the squad room, and she felt that as though she always needed to clear her throat. And that was made worse by voice use. She was told this was heartburn or gastroesophageal reflux disease and had been placed on a proton pump inhibitor and some dietary restrictions. This really had no effect on her need to clear her throat. And she denied symptoms of classic heartburn or indigestion. This patient initially was treated with speech therapy for her speaking voice. She used indirect and then again direct voice therapy methods, but her voice didn't improve. Let me show you her examination. We'll start by listening to her voice. The blue spot is on the key again. Keep going. How hard did he hit me? Did he hit him? Keep going. We were away a year ago. Her voice is breathy and a little bit rough. But it's not anything that we would stare at in the grocery store line. We can see her preoperative video, and you see that her left vocal cord, which was operated on two years ago, is vibrating fairly well through a series of pitches. Her right vocal fold, however, has this area in the middle of it that doesn't vibrate well at all. In fact, the entire middle of the right vocal fold moves like a brick. What are her complaints? Vocal fatigue and loss of volume, inability to be heard over background noise. What determines voice volume, how well the vocal folds shot and how rapidly they shot? Her right vocal fold is stiff, not vibrating well. Her larynx isn't shutting rapidly and isn't closing completely. She's tried voice therapy and hasn't made enough gains. At this point, it's time to try surgical intervention. We take the patient to the operating room, and we put them to sleep. We use something called a laryngoscope to stretch open their mouth so we can peer directly down at their larynx. We can then use a zero-degree telescope or a plain telescope through that laryngoscope to get a close up view of the larynx and take some nice pictures. We can use an angled telescope and in this instance, we use a 70-degree telescope to be able to assess how the lesion appears on the vocal folds. So in the operative setup, this is their right vocal fold, and you can see from the straight on or zero-degree view that she has a bump on that right vocal fold that corresponds to the area of whiteness or stiffness that we saw on stroboscopy. With the angled telescope, we can see how much of that bump involves the entire medial surface of the vocal fold from the top to the bottom. In the olden days, we would have just grabbed this with a pair of forceps and stripped it off of there and not done anything to alleviate this portion of the lesion or the cyst that's on her vocal fold that's really the problem that's stopping vibration. So what do we do? Do we want to go to surgery or not? Well, she's failed our preoperative voice therapy, and she still has voice complaints. She seems vocally aware. Once we're there, now what are we going to do? Are we going to excise this lesion? Are we going to dissect it with a microflap technique? Or are we just going to use a laser to vaporize it and everything around it? So our signs here, what are we going to do? Are we going to do a medial microflap or a lateral microflap? We're going to do a dissection, and we're going to start the dissection where the mucosa is relatively normal so we can identify our normal planes. Here's our surgical intervention. Right now, we're using a three French suction to palpate the skin of the vocal fold and healthy skin, this is her left vocal fold, should pick up freely. Even her left vocal fold which vibrated nicely doesn't pick up freely. The top surface of her vocal fold where the cyst is doesn't pick up at all. The only thing that picks up a little bit is when you put your suction directly on the obvious portion of the lesion or a small polyp that's extending out. When you're over the cyst, there's really an old change. So I could start my incision way out here and then dissect, but I'd still have to excise this polyp like portion of the lesion. So in order to create only one incision because this was free, I made the decision to make the incision along the inside surface of the vocal fold. The risk here is that I'm not going to be able to get all the way around this cyst. After I make my incision, I use up cutting scissors, small up cutting scissors to be certain the incision is long enough and made to the right depth. I put one blade of the scissors in the incision and then the other blade out and I cut. Now, I'm concerned about this cyst area here. So I'm going to take my small dissector and I'm going to try to dissect this mucosa that's not involved with a cyst free. And I'm finding that it's very stuck. I started behind the lesion, which was relatively normal, and I'm going up to where the lesion is, and I can't get over it. You see how you can see my dissecting instrument through the flap of tissue. Now, I'm in front of the lesion and I've created two tunnels, and I'm going to try to join these. And when I join them, you can see the cyst like lesion underneath. So now I can separate all of this uninvolved mucosa. Now, I have to separate my cyst from my underlying vocal ligament. So once again, I go in front of the lesion, where it's relatively soft. And I work from front to back or from back to front. Now, I have to separate the lesion from as much of this overlying lamina propria, superficial lamina proprian mucosa as possible. I've still got to make sure I'm totally elevated from my vocal ligament. So I'm using a small suction here to hold my pocket open. And now, I'm dissecting once again the polyp portion of the cyst lesion from the underlying cyst, and all of the cyst tissue is up in the flap, and I've just got to remove this falling polyp. I'm now working with two instruments and a small instrument. I'm grabbing the polyp like changes and I'm going to gently dissect them free from the flap to preserve as much as possible, pulling them out from underneath. And I'm creating more separation again as thin as possible. Now, you can see that I've got the polyp separated here from the mucosa, from the epithelium over the top. And I'm going to remove these changes with sharp dissection at this point, so that I trim my flap so that it all fits back together. Here's my upper flap. And I'm stretching out my lower flap with my suction and I'm going to fill this pocket with a little Kenalog, a little steroid injection 40 milligrams per ml. I'm not really injecting it into the vocal fold. I'm just placing it within my dissection pocket. Here's what we see. Here is actually our preoperative pictures on the top side of the slide here; the zero-degree, the straight on view and the 70-degree or angled view here on the right. And then postoperatively, you can see our straight on or zero-degree view showing that the polyp is gone, and the whole appearance of the cyst is gone as well. And here's our angle view showing our incision right here, where a little bit of that Kenalog is leaking out. In a close up view, here's our postoperative pictures, our zero-degree, straight on view showing less fullness in this vocal fold and our 70-degree or angled view. 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 weeks or so after surgery. Voice therapy regimen should be weekly for the first month. This really depends on how much voice therapy they've done before surgery. Oftentimes, they can get by with only two visits in that 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. Here's our patient after six days of complete voice rest. Who won the game? Who won the game? Who won the game? Who won the game? You're somewhere in between. Yeah. Who won the game? Who won the game? Now, she hasn't spoken for a week so her voice was somewhat static or weak. And we're helping her reestablish airflow. We can see that the vocal fold on the right where our dissection was, is beginning to heal and it's vibrating at least as well as it was preoperative. There's some minor irregularities along the inside surface, but she's looking fairly well. Here she is at one month after surgery. How hard did he hit him? We were away a year ago. We eat eggs every Easter. Mama will make lemon muffins. Peter will keep at the peak. You can see here how the vocal folds are beginning to heal. The right vocal fold is beginning to heal nicely. Vibration is actually improved from where it was preoperatively. The lesion on the top surface of the right vocal fold is gone. And the entire vocal fold through a range of pitches is working as one unit for her. It's still slightly stiffer than the non-operated left vocal fold, but it's better than it was preoperatively. This is the current state of where this patient is and her continued improvement now depends on her ability to maintain the changes she made in her voice use patterns before surgery.
