Hoarseness
Hoarseness occurs with the deterioration of voice strength and quality as a result of the vocal cords failing to perform their functions for any reason. Voice disorder is not only related to the vocal cord. It is a condition that encompasses all kinds of voice changes, including hoarseness, related to the larynx and all extra-laryngeal structures. The word dysphonia defines hoarseness in its simplest form and voice disorder in a broader sense. For any type of hoarseness and voice disorder lasting longer than 2 weeks, a specialist doctor must be consulted. The specialist doctor, who will examine the patient's larynx and vocal cords, will make the definitive diagnosis of the disease causing the hoarseness.
There is an organ called the larynx located in the front part of the neck adjacent to the pharynx. The most important tasks of the larynx are to provide breathing, to protect the airway during the swallowing function, and to enable the production of voice. The larynx is a structure consisting of a single cricoid cartilage, a single thyroid cartilage, paired arytenoid cartilages, a single epiglottis cartilage, and small cartilage pairs. Its inner surface is entirely covered by an inner skin called the mucosa.
Coming to the vocal cords, as defined by specialist doctors, there are two vocal cords. The starting point of the vocal cords is the projections of the left and right arytenoid cartilages sitting on the back of the ring-shaped cricoid cartilage. They stretch forward tightly together face to face and adhere adjacently to the inner surface of the middle part of the thyroid cartilage. Contrary to what is thought, the vocal cord is not a thin string. It is a tense structure with layers. Sound is produced when the strong airflow that emerges while exhaling creates pressure below the vocal cords and forcefully passes through the space between them, causing the mucosa on the cord to undulate (vibrate). Meanwhile, the lungs act almost like a generator producing the airflow needed for voice production. The pure sound produced by the vocal cords is amplified in the pharynx, the upper part of the larynx, the nose, the mouth, and the paranasal sinuses as it travels outward from the vocal cords. In this way, the sound is shaped. This shaping is called resonance.
Causes of Hoarseness
The emergence of hoarseness can occur due to many reasons. Hoarseness, which we call dysphonia, can be based on different causes such as vocal misuse, reflux, smoking, faulty throat behaviors, acute infections of the larynx, non-tumoral and tumoral organic lesions, vocal cord paralyses, infectious and non-infectious chronic inflammatory diseases.
In every case of hoarseness, one of the factors is definitely dominant. However, this factor remaining as the sole cause of hoarseness is a situation seen in the initial stage of acute or chronic pathologies. Hoarseness is mostly the manifestation of a spiral created by one or more of the factors, sometimes many of them together. The diverse and contrasting functions of the larynx and vocal cords, their neighborhoods, and their being open to any external effect via the mouth-nose route form the basis of this negative interaction. If we discuss the causes of hoarseness separately;
- Faulty throat behaviors: It can be related to psychological reasons, habits, or formations like reflux. To give examples of faulty behaviors, factors such as throat clearing, recurrent ticklish coughs, giving a faulty position to the throat, and tensing the throat can be counted. Such behaviors can irritate the larynx and may take place as a secondary lesion over time. Faulty throat behaviors create a situation that triggers vocal misuse in addition to their own effects and findings.
- Vocal misuse: It can vary according to psychological reasons and bad habits. For example, it can be based on reasons such as speaking loudly, shouting, speaking in a different tone, forcing the larynx by tensing it, and similar reasons. The misuse of the voice in this way causes the faulty contraction syndrome of the larynx, which we call laryngeal muscle misuse, and the development of vocal cord nodule and vocal cord polyp lesions, which are called secondary lesions within a certain period. Vocal misuse such as shouting also causes acute acoustic traumas.
- Reflux: Reflux, which is the condition that most frequently affects the larynx in the field of ear, nose, and throat, stands out with its sensitive structure and its position adjacent to the esophagus. Reflux causes reflux laryngitis with its findings in the larynx and supports the formation of Reinke's edema with vocal cord granulation over time. Laryngopharyngeal reflux triggers vocal misuse and faulty throat behaviors in addition to its own formation.
- Smoking: It shows its harm directly through the damage to the laryngeal mucosa. As is known, the larynx is in a position open to external influences just like the lungs and the mouth. That is, it is at the top of the organs that smoking and polluted air can easily damage. Over time, smoking causes many negative conditions such as precancerous lesions, laryngitis, Reinke's edema, and cancer.
- Acute infections of the larynx: These infections cause inflammation and directly affect the larynx and vocal cords by forming acute laryngitis. However, apart from this, they can also play a role in triggering vocal misuse or faulty throat behaviors even after the infection heals.
- Organic lesions of the larynx: Laryngeal lesions characterized by harmful tissue formation or deterioration of the normal anatomical structure are seen in different and various ways. Also, there are differences in their formation mechanisms. It is possible to define the organic lesions of the larynx and vocal cords in 2 ways as tumoral and non-tumoral. Tumoral organic lesions of the larynx are carcinomas and similar malignant conditions or benign-featured conditions like papillomas. Tumoral organic lesions are explained under a separate heading, especially larynx cancer, etc. Non-tumoral organic lesions of the larynx are in a wide group ranging from vocal cord nodules to Reinke's edema. The organic reactions of the larynx can be tied to the vocal cord nodule similar to carcinomas, to the wrong way the voice is used as in smoking and vocal cord polyps, to an unknown reason as in intracordal cysts, to the vocal misuse-smoking-reflux combination as in Reinke's edema, and to faulty throat behaviors and reflux as in granulomas. In addition to being able to create their own direct effects and findings, all organic laryngeal lesions can also invite vocal misuse or faulty throat behaviors.
- Chronic inflammation-based diseases in the larynx: It covers vocal cord paralyses, traumas, and other serious factors that cause hoarseness. It can develop depending on infectious or non-infectious causes. The inflammation we call infectious chronic can be seen in conditions like tuberculosis, and non-infectious chronic inflammatory conditions can be seen in interactions like sarcoidosis. Laryngeal trauma and vocal cord paralysis are diseases that manifest themselves with their own specific diagnoses and findings. These conditions can occur spontaneously, or they can additionally lead to conditions such as faulty throat behaviors and vocal misuse over time.
Microlaryngosurgery - How is the Microscopic Vocal Cord Surgery Process?
Vocal cord surgery, which we call microlaryngosurgery, is a type of surgery performed under general anesthesia with microsurgical techniques and methods with the help of a microscope without making any incision on the skin. The operation to be applied is performed through thick and steel tubes extending from inside the mouth to the larynx. This surgery is performed not with an endoscope but more commonly with a device we call a surgical microscope, which has high magnification capability and allows the use of both hands. However, if needed, it can also be supported by an endoscope.
Special instruments have been designed for laryngeal microsurgery. With these long instruments, they are sent through the steel tubes up to the vocal cords. The destruction formed is intervened professionally under magnified image quality. Damaged tissues that have formed are cut and removed with sensitive and careful work. Or, if deemed appropriate, different surgical interventions can be applied. The tools used in the surgery will generally be classic tools like microsurgery scissor blades that are generally used in almost every operation. If needed, laser, electrocautery, and similar methods can also be added.
In this surgery, the technique varies according to the damage intervened. Vocal cord polyp, vocal cord nodule, vocal cord cyst, and vocal cord granulation are cut and removed from where they are placed with micro-scissors-micro-knives or lasers as a whole. In damages like Reinke's edema, vocal cord scar, and vocal cord sulcus, it is applied with more comprehensive and different interventions. While microsurgery techniques are applied in saccular cysts and laryngoceles, a combination to be applied together with open surgical techniques may also be in question.
Post-Operative Process of Microscopic Vocal Cord Surgery
To summarize the situation during and after vocal cord surgery; bleeding leaks will be controlled when the procedure is finished after the operation. Then, the steel tube and the instruments used in microsurgery will be removed. Patients need to stay under observation for a short period like 4-5 hours. After that, they can be discharged. The post-operative process will be comfortable for the patient. However, the doctor will request voice rest for 1 week. The reason for this is a precautionary measure in terms of accelerating healing and the success of the surgical intervention.
Triggering, primary, and paving factors will be determined in order to prevent the recurrence of the disease after the surgery period and to improve surgical results. With all these factors, the requirements of the situation will be explained to the patient. For example, quitting if smoking, staying away from environments with polluted air and cigarette smoke, avoiding vocal misuse, reflux treatment and precautions against reflux, speech therapy (in necessary cases), and paying attention against faulty throat behaviors will be requested.
In the process after vocal cord surgery, the recurrence of the disease will vary depending on the condition of the disease. At this point, the condition of the disease, eliminating the situation that triggers the formation of this disease, is important in terms of preventing this disease. Conditions we call vocal cord polyp and vocal cord nodule will change depending on vocal misuse. Vocal misuse must definitely be ended after surgery.
The condition we call vocal cord-arytenoid granuloma is tied to faulty throat behavior and reflux, except for development as a result of intubation, which can be seen as an exception. In the period following the surgery, ending harmful habits and treating reflux are necessary. The causes of intracordal cysts can be uncertain. For this reason, if an extra situation has not occurred, there will be no need to take an additional precaution. Cysts rarely re-form.
The edema we call Reinke's will vary depending on vocal misuse, smoking, and reflux. Therefore, after the surgical operation, conditions such as reflux treatment, quitting smoking if used, and vocal misuse should be ended. In all damaged conditions in the non-tumoral cord, whether the agent is small-scale or large-scale, usually vocal misuse and faulty throat behaviors trigger the situation together. Patients must definitely be warned by the doctor against such situations. Minimal or larger precautions to be applied in each damage are important in terms of the disease not repeating itself. On the other hand, vocal cord and vocal cord scar damages, regardless of what cause their formations are tied to, are resistant to treatment and may need to repeat the treatment depending on the melting of the filling materials.
Laryngocele damage and saccular cysts can exceptionally repeat themselves. Surgical intervention applied in non-tumoral organic damages is evaluated as a whole, taking into account factors such as risk, gain, and loss. As a result of this evaluation, if a need has arisen, it is aimed to increase the patient's quality of life by giving the patient minimal discomfort.
