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Talking About Voices: Dr. Friedman on New Treatments

Monday, April 16, 2018 8:48 AM

As we've reached World Voice Day, we take a look forward at how much progress has been made in treating vocal cord conditions. Dr. Aaron Friedman, Director of the NorthShore Voice Center and Laryngeal Surgeon, provides insights below as to how he's seen the field change and how his team has kept in the forefront of vocal surgery.

 

What are some common voice issues that you diagnose?
Voice problems can be due to structural problems of the vocal cords, which are sometimes related to significant voice use (eg vocal cord nodules, vocal cord polyps, vocal cord cysts and/or vocal cord scarring). Other structural problems of the vocal cords include recurrent respiratory papillomatosis (RRP), dysplasia (pre-cancer) or, less commonly, cancer. Sometimes, hoarseness arises from weakness or paralysis of one or both vocal cords or other neurologic diseases. Other common sources for voice problems include infections or problems with abnormal function of the muscles within and around the voice box. Finally, voice issues sometimes arise from sources outside of the voice box: medication side effects, laryngopharyngeal reflux and/or medical conditions which affect air flow to the larynx (voice box).

What are the current challenges of performing surgery on the vocal cords?
The vocal cords are considered “high value” tissue, and they do not easily recover their function if surgery on them is imprecise. An eternal challenge of operating on the vocal cords is balancing surgical removal of whatever lesion or disease is being treated but maximally preserving surrounding healthy vocal cord tissue.

Another challenge of operating on vocal cords in a minimally invasive way (e.g. through the mouth under general anesthesia) is that surgery is performed through a straight metal tube (a laryngoscope) which does not bend. Some patients have head and neck anatomy or previous surgeries (e.g. cervical spine fusion) which make visualizing the vocal cords through direct line of sight (direct laryngoscopy) challenging or more rarely, impossible. NorthShore is one a few hospital systems in the country currently exploring using a new flexible robot to perform vocal cord surgery without this straight line limitation (see below question).

Can you tell us about the Voice Center’s latest ways of treating growths on the vocal cords?
Certain tumors (both benign and malignant) have an increased blood supply associated with them. Our Voice Center frequently uses a specialized type of laser, the KTP laser. This technology selectively targets the blood supply of certain tumors to the exclusion of surrounding non-tumorous tissues. When used by a surgeon who is experienced with this technology, the KTP laser can help to treat certain vocal cord growths in a way that minimizes damage to the surrounding normal tissues. This can lead to reduced bleeding during surgery, less vocal cord scaring and potentially improved voice outcomes.

How has the KTP laser changed the surgical process?
The KTP laser has improved the surgical precision and correspondingly some of the surgical voice outcomes laryngeal diseases like vocal cord cancer and vocal cord dysplasia (pre-cancer). Additionally, because this laser is delivered through a flexible fiber and is relatively portable, it has allowed certain chronic, recurrent vocal cord problems (like recurrent respiratory papillomatosis (RRP) and vocal cord dysplasia) to be treated in the operating room initially but subsequently managed in the office through a flexible scope, without the need for general anesthesia.

How has vocal cord surgery developed over the past few years?
As alluded to in a previous answer, NorthShore is one of a few centers in the country exploring use of a new flexible robot to perform laryngeal and specifically vocal cord surgery. This exciting technology allows a laryngeal surgeon to see around corners and removes the straight line of sight limitation that previously existed. This is particularly relevant for patients with previous “difficult laryngeal exposure.” New instrumentation is currently being developed to be used in concert with this robot, and ultimately the way that we perform laryngeal surgery in the future may be changed as a result.

Is there any research or new technology in the works aimed at treating vocal cord conditions?
In addition to the above work, the NorthShore Voice Center is currently the only other site in the nation to partner with Massachusetts General Hospital (a teaching hospital of Harvard University) in a clinical trial to treat severe cases of an incurable, chronic condition called recurrent respiratory papillomatosis (RRP) using an intravenous drug rather than repeated surgeries. RRP often affects the larynx and specifically the vocal cords, leading to chronic hoarseness. Surgery can improve the voice but the disease commonly recurs, along with the hoarseness. For RRP patients with more extensive disease (eg disease that spreads below the vocal cords, into the windpipe and lungs), surgery is generally less effective at controlling the disease. The drug being tested in this clinical trial is an immunotherapy medication which invigorates the body’s immune system to target the human papilloma virus which causes RRP. This may ultimately change how severe cases of RRP are managed.

If someone encounters issues with their vocal cords, who should they contact?
In general, if a person has problems with his or her voice, they should see an otolaryngologist (ENT doctor) to visualize the vocal cords if their symptoms have persisted for more than 2 weeks and are not improving.

Any tips for how to monitor the health of the vocal cords on a regular basis?
Avoiding voice overuse (e.g. yelling or talking for extended periods without a vocal break) and hydrating adequately (so that the vocal cords have the proper viscosity secretions to allow them to vibrate efficiently) are always good practices. If others around you notice a change in your voice and if that change is persistent, it may represent a problem that requires further investigation by a medical professional. If you are a singer or (other professional voice user), your ability to sing “high and light” is another good basic test of vocal function; an acute change of your baseline capacity may indicate a need for medical attention.