Etiology
The history is the significant element. The voice disorder should arise in close temporal proximity to the injury. External neck trauma would be acquired from something like an auto accident or perhaps a gunshot. They type of trauma will direct the exam. The other typical trauma seen in a voice clinic is from intubation injuries, either because of traumatic insertion, too large a tube or because of prolonged intubation. Other cofactors such as reflux may add to the injury.
Diagnosis
History
Change in voice after an accident or after an intubation
Character of an trauma patient
Vocal capabilities
- General
- Traumatic injuries can cause widening or narrowing of the glottic opening. This may cause a change in voice or a change in breathing. The usual injury in some way limits vocal fold mobility and consequently the capabilities will be representative of an air wasting voice or a normal voice but a restricted airway.
- Reading voice
- variable depending on the injury
- Pitch range
- variable depending on the injury
Singing
- variable depending on the injury
Yelling voice
- variable depending on the injury
Laryngeal Exam
- Videolaryngeal exam
- Rigid and flexible exams are usually complementary
- It is important to completely topically anesthetize the larynx. An injury may be visible on rigid scope exam but usually some features of the injury will be hidden. The flexible endoscope may be brought adjacent to the anesthetic vocal folds and the actual motion of the arytenoids observed even if the apex of the arytenoids are hooding over the posterior commissure. The topical anesthesia helps prevent coughing from interfering with the exam. Intubation injuries almost always affect the posterior commissure with scarring. Additionally, intubation injuries may be subglottic so the flexible scope needs to be passed through the glottis. Besides visualizing the subglottis, the airway reserve can be assessed by how much additional respiratory restriction the endoscope adds. If there are two narrow areas a comparison of airway restriction with and without the endoscope through each narrowing may be performed.
- other potential findings
- Hemorrhage
- Laceration
- Ulceration
- Synechia
- Mobility limitation
- Edema
- Stroboscopy - helpful if the injury involves the true vocal folds
- Radiologic Exam
- CT scan
- If the mechanism or degree of injury points to a potential fracture of the laryngeal cartilages, this is a necessary exam.
Treatment
Medical
Steroids, antibiotics, antireflux agents may play a role. Watchful waiting may also be appropriate.
Behavioral
- Speech Therapy probably has limited usefulness
- Feedback to the appropriate caregiver if the injury was iatrogenic can prevent further occurrences.
Surgical
Depends on the degree and type of injury - these are some possibilities
- arytenoid dislocation - reduction if acute injury
- thyroid cartilage fracture - surgical plating
- cricothyroid separation or thyroepiglottic separation - immediate surgical repair
- Fixed vocal folds - cordotomy or arytenoidectomy
- Webbing/ synechia - lysis
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