Vocal Fold Surgery

Vocal Fold Surgery: Step by Step Guide on What You Need to Know

Vocal fold surgery is a specialized medical procedure aimed at correcting issues within the vocal cords, also known as vocal folds, located in the larynx (voice box). These delicate structures play a crucial role in sound production by vibrating as air passes through them during expiration, allowing us to speak, sing, and express ourselves vocally. When the vocal folds are damaged or develop any form of abnormal growths, it can lead to voice problems that might require surgical intervention.

This guide provides an in-depth look at vocal fold surgery, including when it is needed, the types of surgery available, the risks and benefits, preparation, recovery, and what patients can expect before, during, and after the procedure.

Understanding the Need for Vocal Fold Surgery

Vocal fold surgery is typically considered when non-invasive treatments, such as voice therapy or medications, are not sufficient to resolve vocal issues. It’s important to understand the common conditions that might necessitate vocal fold surgery:

Vocal Fold Nodules

Vocal fold nodules, often referred to as "singer's nodules” or “teacher’s nodules”, are benign, callous-like growths on the vocal cords. They usually form as a result of chronic vocal strain, which can occur in individuals who use their voice intensively over a long period of time, such as singers, teachers, and public speakers. Nodules can cause hoarseness and a breathy voice. Nodules are always two in number, and are present on both vocal folds. They have a typical appereance on both vocal folds which makes them easy to be diagnosed during an examinaiton. The main treatment is usually voice therapy. Most of the vocal nodules benefit from voice therapy and no further treatment is needed. However, if they persist despite voice therapy, surgical removal may be recommended.

Vocal Fold Polyps

Polyps are soft, fluid-filled lesions that can develop on one or both vocal folds. They are typically caused by acute vocal trauma, such as yelling or severe coughing. Unlike nodules, polyps can be in many different forms. Single or multiple, small or bigger, white or red. Some very early polyps that are small in size may heal very well with voice therapy. But, contrary to vocal fold nodules the main and most common treatment for vocal fold polyps is vocal fold surgery. If a polyp is large or persistent for a long period of time, it may require surgical removal.

Vocal Fold Cysts

Cysts are small, sac-like structures filled with fluid or semi-solid material that can form within the vocal folds. These can interfere with the normal vibration of the vocal cords, leading to a raspy or hoarse voice. Surgery is often the preferred treatment to remove vocal fold cysts, as they are less likely to respond to non-surgical interventions.

Reinke's Edema

Reinke's edema is a condition where the vocal folds swell due to fluid accumulation over a long period of time, often as a result of chronic irritation from smoking or vocal abuse. This condition can cause a deep, hoarse voice. While lifestyle changes such as quitting smoking are essential, surgery is needed to remove the excess fluid and restore normal vocal fold microstructure to provide normal function.

Vocal Fold Paralysis

Vocal fold paralysis occurs when one or both vocal cords are unable to move properly. This can result from nerve damage due to surgery, a viral infection, or a neurological disorder. Vocal fold paralysis can cause a weak, breathy voice and difficulties with swallowing. Surgical options like vocal fold injection or medialization thyroplasty may be necessary to improve vocal function.

Laryngeal Papillomatosis

Laryngeal papillomatosis is a rare condition caused by the human papillomavirus (HPV), leading to the growth of wart-like lesions on the vocal cords. These growths may be just on the vocal folds and affect voice quality or may be distributed even to the whole airway to lead to airway obstruction. Surgical removal of the lesions is often required, and because the condition can recur, multiple surgeries are usually necessary over time.

Laryngeal Cancer

Laryngeal cancer can affect the vocal folds, leading to significant voice changes, pain, and difficulty swallowing. Surgery to remove the cancerous tissue is often part of the treatment plan, which may include partial or total removal of the vocal folds or sometimes a larger part of the larynx (laryngectomy), according to which areas are invaded by the tumor.

Types of Vocal Fold Surgery

The type of vocal fold surgery performed depends on the specific condition affecting the vocal cords. The most common surgical procedures used to treat vocal fold disorders include but are not limited to:

Microlaryngeal Surgery (Phonomicrosugery)

Microlaryngeal surgery is a minimally invasive procedure designed to remove small lesions, such as nodules, polyps, or cysts, from the vocal folds. The surgery is performed using a microscope and specialized microinstruments, allowing the surgeon to operate with precision while minimizing damage to surrounding tissues.

Procedure Overview:

Anesthesia: The patient is typically placed under general anesthesia.

Laryngoscopy: The patient is positioned at the operating table to provide a view of the vocal folds to be directly seen via mouth. No incisions are made externally to the neck. A laryngoscope, a thin, rigid steel tube with light, is inserted through the mouth to provide access to the vocal folds.

Microscopic Surgery: The surgeon uses an operating microscope to magnify the vocal folds, to touch, rotate, move and examine the pathology in detail and to carefully remove the lesion using microinstruments. The microinstruments used are called cold instruments like scissors or knives, different types of lasers and cautery to control the possible bleeding at the area being operated. While cold instruments may be used for many types of vocal fold pathologies, lasers are especially useful for pathologies with increased blood supply like papillomatosis, vocal fold polyp, vocal fold ectasias and vocal fold cancer.

Duration: The procedure usually takes around 60 minutes.

Recovery: Most patients can go home the same day. Voice rest is typically recommended for a few days to allow the vocal folds to heal. Full recovery of the voice may take several weeks, depending on the extent of the surgery and adherence to postoperative care.

Vocal Fold Injection

Vocal fold injection is a procedure used to treat vocal fold paralysis or atrophy, where the vocal cords lose their bulk and fail to close properly during speech. The procedure involves injecting a filler material, such as fat, hyaluronic acid or calcium hydroxyapatite, into the vocal fold to improve its volume and bring it closer to the midline, enhancing vocal fold closure.

Procedure Overview:

Anesthesia: The procedure can be performed under local or general anesthesia.

Injection: A special needle is used to inject the filler material directly into the vocal fold. The needle passes through the nose or mouth or through the skin according to the plan of the surgeon.

Duration: The procedure is relatively quick, often taking less than 30 minutes.

Recovery: Most patients can resume normal activities the same day if performed under local anesthesia or the next day if performed under general anesthesia.

Voice Improvement: Voice improvement is often noticeable immediately, though the full effect may take a few days.

Longevity: The results of the injection may last from several months to a few years, depending on the material used and the patient’s vocal demands.

Medialization Thyroplasty

Medialization thyroplasty is a surgical procedure used to treat vocal fold paralysis by repositioning the paralyzed vocal fold closer to the midline. This allows the unaffected vocal fold to make better contact during speech, improving voice quality. The procedure involves placing an implant inside the larynx to push the paralyzed vocal fold into the desired position.

Procedure Overview:

Anesthesia: The patient is placed under local or general anesthesia.

Incision: A small incision is made on a natural crease in the neck to access the larynx.

Implant Placement: The surgeon creates a small window in the thyroid cartilage and inserts an implant to reposition the vocal fold.

Duration: The procedure usually takes 60 to 90 minutes.

Recovery: Patients may stay in the hospital for observation overnight.

Voice Rest: Voice rest is recommended for a few days.

Full Recovery: Full voice improvement may take several weeks as the tissues heal and the patient adapts to the changes.

Preparing for Vocal Fold Surgery

Proper preparation is essential for a successful outcome in vocal fold surgery. Patients should be well-informed and follow their surgeon’s instructions closely. Here’s what to expect:

Preoperative Evaluation

Before surgery, a comprehensive evaluation is conducted to assess your overall health and the specific condition of your vocal folds. This evaluation usually includes:

Laryngoscopy: A procedure to visualize the vocal folds by a flexible or rigid endoscope and to confirm the diagnosis.

Imaging Studies: Such as CT or MRI scans, if necessary, to evaluate the extent of the condition. This is usullay only needed for malignant lesions of the vocal folds like vocla fold cancer. It’s not necessary for benign conditions like polyps, cysts or nodules.

Voice Assessment: Your doctor may conduct a voice assessment to document and evaluate vocal function and discuss postoperative expectations.

Preoperative Instructions

Your surgeon will give you specific instructions to follow in the days leading up to your surgery. These instructions may include:

Medication Adjustments: You may need to stop taking certain medications, such as blood thinners, before surgery to reduce the risk of bleeding.

Fasting: You will likely be instructed not to eat or drink anything after midnight on the day of your surgery.

Voice Rest: In some cases, you may be advised to limit your voice use before surgery to minimize strain on the vocal folds.

Recovery After Vocal Fold Surgery

Recovery is a critical phase following vocal fold surgery. Adhering to postoperative care guidelines is essential for a successful outcome and to ensure the best possible restoration of vocal function. Here’s what you can expect during recovery:

Immediate Postoperative Care

After the surgery, you will be monitored in a recovery area until you are fully awake. You may experience some discomfort, such as a sore throat or mild pain around your jaws and neck, which can easily be managed with pain medication prescribed by your doctor.

Voice Rest

Voice rest is crucial after vocal fold surgery. You will likely be instructed to avoid speaking, whispering, or any vocal activity for a specified period, typically ranging from a few days to a week, depending on the surgery performed. This period of silence allows the vocal folds to heal without additional strain.

Gradual Reintroduction of Voice Use

After the initial voice rest period, you will gradually reintroduce vocal activity. A speech-language pathologist will guide you through vocal exercises designed to gently strengthen your voice without causing harm to the healing tissues. It is important to follow these exercises carefully to avoid setbacks.

Follow-Up Appointments

Regular follow-up appointments with your surgeon and speech-language pathologist are essential to monitor your progress. These appointments will allow your voice team to assess your healing and make any necessary adjustments to your treatment plan.

Long-Term Care and Voice Therapy

Depending on the type of surgery and the underlying condition, long-term voice therapy may be recommended. Voice therapy involves exercises and techniques designed to improve vocal function, prevent strain, and maintain vocal health. Patients who have undergone more extensive surgeries, such as laryngectomy, will require more intensive rehabilitation and may need to learn new methods of communication.

The Benefits of Vocal Fold Surgery

Vocal fold surgery significantly improves voice quality, allowing individuals to communicate effectively and confidently. The benefits of vocal fold surgery include:

Improved Voice Quality: By removing lesions or correcting structural issues, vocal fold surgery can restore a clearer, stronger voice.

Enhanced Communication: For individuals who rely on their voice for professional purposes, such as singers, teachers, and public speakers, surgery can be life-changing, enabling them to perform their duties without strain or discomfort.

Increased Confidence: A healthy, functioning voice can greatly enhance self-esteem and confidence in social and professional settings.

Symptom Relief: Vocal fold surgery can alleviate symptoms such as hoarseness, breathiness, and difficulty swallowing, improving overall quality of life.

Take Home Messages

Vocal fold surgery is a specialized procedure that offers significant benefits for individuals suffering from vocal fold disorders. Whether addressing benign lesions like nodules or polyps, treating vocal fold paralysis, or removing cancerous tissues, these surgical interventions play a crucial role in restoring and preserving vocal health.

For patients, understanding the need for surgery, the types of procedures available, and what to expect during recovery is essential for making informed decisions and achieving the best possible outcomes. At the International Voice Clinic, our team of experienced voice specialists is dedicated to providing personalized care, utilizing the latest state-of-art techniques in vocal fold surgery to help patients regain their voice and improve their quality of life.

If you or a loved one are experiencing voice issues, we encourage you to seek a consultation with Professor Doctor Haldun OGUZ. Early intervention and appropriate treatment are key to maintaining vocal health and preventing further complications.

This comprehensive guide on vocal fold surgery is intended to educate patients and their families about the importance of vocal health, the surgical options available, and the journey towards recovery. At the International Voice Clinic, we are committed to delivering the highest standard of care, ensuring that every patient receives the treatment they need to restore their voice and their life.