Vocal Cord Nodule escaped from surgery

Dr.R.Gnanasambandam

Introduction

Vocal Cord nodules are very common ailment, which requires confidence in treatment.
Here Dr.R.Gnanasambandam presents one a simple case history on vocal cord nodule from
his case file.

A twenty-nine years old Lady, Personal Secretary to a Psychiatrist at Bangalore

consulted me for loss of voice since four months. Initially she had croupy cough with
hoarseness of voice. She tried some antibiotics but loss of voice was progressive. Ultimately
she was guided to a ENT specialist and suspected pathological vegetations. She was referred
to an endocopist. Laryngoscopy revealed vocal card nodule on the right side.

Her family members do not want take the risk of using a knife on her voice box.
Naturally Homoeopathy was the choice for them among the other alternative systems.

She presented the following details regarding her case history

l Pain and Hoarseness of throat < morning

Headache <stooping, Sun Exposure

Micturation-Burning and scalds during
Fair, tall, thin and well built.
Sweats on the forehead and Armpits, offensive and stains the clothes with yellow colour
Mental and intellectual state of mind is sad , can not cope up the ups and downs; very
sensitive, easily offended, hasty and highly impulsive
Her mother had warty growths around neck
 Father is a Diabetic and Hypertensive

She placed her investigation report on my table which was taken on 14-4-2000. It gave
the impression that
A small nodule is noted on the right vocal cord. Movements of the both cords are normal. A
small phonatory gap was seen Refer back wrapper

First prescription 22-4-2000

The physical and mental make up of the patient; side affinity and sphere of action ultimately
dragged my mind to think causticum as my choice of the remedy.I prepared high potency as
the state of the disease is chronic with low susceptibility.

Rx Causticum 1m 6 doses on empty stomach for six days

Followed with placebo for fifteen days.

Follow up 1 15-5-2000

Pain ++
Croupy cough

Rx Causticum 1m 6 doses on empty stomach for six days

Followed with placebo for fifteen days

Follow up 2 5-6-2000

Loss of Voice < after eating

Rx Causticum 1m 6 doses on empty stomach for six days

Followed with placebo for fifteen days.

Follow up 3 23-6-2000

Voice better
Headache on right side < grief

Rx Causticum 1m 6 doses on empty stomach for six days

Followed with placebo for fifteen days
 In between she skipped the treatment for sometime and again consulted with
moderated change in voice. After few months she came in with a smile and placed the report
on my table. The laringoscopy which was taken on 12-3-2001 gave the impression that

The previously noted small right nodule is hardly visible now. Both Cords are
mobile. Refer back wrapper
She was very happy and continued the same medication for three months and then
discontinued.

Conclusion

Causticum is a well-proved trio miasmatic polycrest drug and its clinical efficacy is
well proved in many pathological vegetations and neurological affections.

Dr.R.Gnanasambandam, M.D (hom)

#,6 Lloyds IInd Lane
Royapettah
Chennai -600 014
Ph : 044-28113300
EML:gnanas@vsnl.com
Prevention of vocal fold scarring with local
application of basic
fibroblast growth factor in rat model
Ryo
Suzuki,MD
; Shigeru
Hirano,MD,
PhD; Ichiro
Tateya,MD, PhD;
Yo
Kishimoto,MD,PhD;
Nao
Hiwatashi,MD;
Yoshitaka
Kawai,MD; Juichi
Ito,MD,PhD

ABSTRACT
C O N TA C T
Objectives:

The

Vocal

fold

requires

an ideal

viscoelasticity

for

rapid
mucosal

vibration

during

phonation.

Vocal

fold

scarring

is

intractable

state

with

histological

alteration

of lamina

propria.

It

occurs

as

consequence

of

inflammation

or injury

. We

have

shown

that

local

injection

of basic

fibroblast

growth

factor

(bFGF
) has

therapeutic

potential

for

vocal

fold

scarring.

The

current

study

aims

to clarify

the

preventive

capacity

of bFGF

against

scarring

by local

application

at the

same

time

of vocal

fold

injuring.

Methods

Sprague

-Dawley

rats

(n=

20)

were
anesthetized

and

bFGF

with

different

concentrations

(100

ng/

10

, 10 ng/

10

, 1 ng/

10

, 10

L of saline

only)

was

injected

in the

thyroarytenoid

muscle,

then

unilateral

vocal

fold

lamina

propria

was

stripped

until

the
thyroarytenoid

muscle

was

exposed

Histological

and

immunohistochemical

studies

were

performed

2 months

after

the

procedure.

Results:

Histological

examination

showed

that

hyaluronic

acid

was

significantly

increased

and

collagen

was

significantly

decreased

in bFGF

treated

group
at

100

ng/

10

compared

with

sham

treated

group.

Immunohistochemical

examination

showed

that

collagen

type
III

were

significantly

decreased

in bFGF

treated

group

at 100

ng/

10

L as

compared

with

sham

treated

group.

Conclusions
:

The

current

results

suggest

that

local

injection

of bFGF

at the

time

of injury

has

the

potential

to prevent

vocal

fold

scarring

. Preventive

injection

of bFGF

could

be applied

at phonomicrosurgery

to avoid

postoperative

scar

formation.

Vocal fold scarring is intractable state characterized by

the depositions of disorganized collagen and elastin

bundles and loss of hyaluronic acid in lamina

propria
.

Optimal treatment for vocal fold scarring has not been

established, so prevention of scarring is important.

Corticosteroid and

Mitomycin-

C are candidate agents

for preventing vocal fold scarring, but its efficacy

remains controversial.

The current study aims to clarify the preventive

capacity of

bFGF

against scarring by local application at

the same time of vocal fold injuring.

1.

Suehiro

A, Hirano S,

Kishimoto

Y et al. Treatment of acute vocal fold scar with local injection of

basic fibroblast growth factor: a canine study. Acta

Otolaryngol

. 2010; 130(7):844-

50.

2.

Hirano S, Mizuta M, Kaneko M et al. Regenerative Phonosurgical

Treatment for Vocal Fold Scar

and Sulcus With Basic Fibroblast Growth Factor. Laryngoscope 2013; 123:2749

-2755

3.

Ta t e y a

I, Ta t e y a

T, Sohn

JH, Bless DM. Therapeutic effect of basic fibroblast growth factor on

chronic vocal

fold scarring
in a rat model.

Clin

Exp

Otorhinolaryngol

, in press.

Ryo Suzuki, MD

Department of Otolaryngology, Head and

Neck

Surgery. Graduate

School of Medicine,

Kyoto University

Email: r_suzuki@ent.kuhp.kyoto

-u.ac.jp

Department

of Otolaryngology, Head and Neck Surgery, Graduate School of Medicine, Kyoto University, Kyoto,

Japan

To study the preventive effect of basic fibroblast growth factor against vocal fold scarring.

Current study suggests that local injection of bFGF

at the same time of injury has the
potential to prevent vocal fold scarring.

Preventive injection of
bFGF
could be applied at phonomicrosurgery
to avoid
postoperative scar formation.

I
Local application of
bFGF
against vocal fold
scarring is reported to be effective both in
acute and chronic phase.
Protective effect of
bFGF
against vocal fold
scarring has not been reported, so we tried
to confirm it in current study.
Histological and
immunohistochemical
studies showed therapeutic effect in
bFGF

treated group at 100 ng/10

l
compared with
sham
treated grou
Current study suggests that local injection of bFGF
at the same time of injury has the
potential to prevent vocal fold scarring.

Preventive injection of
bFGF
could be applied at phonomicrosurgery
to avoid
postoperative scar formati

Histological Effect of Basic Fibroblast Growth Factor on Chronic Vocal Fold

Scarring in a Rat Model

Ichiro Tateya1, Tomoko Tateya2,3, Jin-Ho Sohn4, Diane M. Bless5

1
Department of Otolaryngology-Head and Neck Surgery, Graduate School of Medicine,
Kyoto University, Kyoto, Japan
2
Institute for Virus Research, Kyoto University, Kyoto, Japan
3
The Hakubi Center, Kyoto University, Kyoto, Japan
4
Department of Otorhinolaryngology-Head and Neck Surgery, Kyungpook National
University School of Medicine, Daegu, Korea
5
Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison,
Madison, WI, USA

Corresponding author: Ichiro Tateya, Department of Otolaryngology-Head and Neck Surgery,

Graduate School of Medicine, Kyoto University, 54 Shogoin-Kawahara, Sakyo-ku, Kyoto 606-
8507, Japan
Tel: +81-75-751-3346, Fax: +81-75-751-7225, E-mail: tateya@ent.kuhp.kyoto-u.ac.jp

Received November 19, 2014 Revised December 23, 2014 Accepted January 14, 2015
Copyright 2016 by Korean Society of Otorhinolaryngology-Head and Neck Surgery
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and
reproduction in any medium, provided the original work is properly cited.

Abstract

Objectives

Vocal fold scarring is one of the most challenging laryngeal disorders to treat and there are currently
no consistently effective treatments available. Our previous studies have shown the therapeutic
potential of basic fibroblast growth factor (bFGF) for vocal fold scarring. However, the histological
effects of bFGF on scarred vocal fold have not been elucidated. The aim of this study was to examine
the histological effects of bFGF on chronic vocal fold scarring.

Methods

Sprague-Dawley rats were divided into phosphate buffered saline (sham) and bFGF groups.
Unilateral vocal fold stripping was performed and the drug was injected into the scarred vocal fold
for each group 2 months postoperatively. Injections were performed weekly for 4 weeks. Two
months after the last injection, larynges were harvested and histologically analyzed.

Results

A significant increase of hyaluronic acid was observed in the vocal fold of the bFGF group compared
with that of the sham group. However, there was no remarkable change in collagen expression nor
in vocal fold contraction.

Conclusion

Significant increase of hyaluronic acid by local bFGF injection was thought to contribute to the
therapeutic effects on chronic vocal fold scarring.
Keywords: Vocal Cords; Basic Fibroblast Growth Factor 2; Hyaluronic Acid; Collagen

Go to :

INTRODUCTION

The extracellular matrix (ECM) of the vocal fold lamina propria (LP) consists of a number of
important molecules that contribute to tissue characteristics during oscillation [1,2]. The ECM
consists of fibrous proteins and interstitial constituents. Collagen and elastin are 2 of the fibrous
proteins found in the vocal fold LP and contribute to tissue strength and flexibility. Hyaluronic acid
(HA) is a member of the glycosaminoglycan family and is abundant in the vocal fold LP. Several
studies have shown that HA contributes to the viscoelastic properties of the vocal fold cover and
influences tissue viscosity, playing an important role in proper vocal fold vibration [1,3].

Vocal fold scarring is the single greatest cause of poor voice following phonosurgery [4,5].
Pathophysiological studies of vocal fold scarring using animal models showed that scarred vocal folds
are characterized by increased/disorganized collagen [6-8] and decreased HA [7,8], which destroys
the viscoelastic property of the vocal fold [2,6]. The altered structure changes the biomechanical
properties of the vocal fold often resulting in a severe dysphonia that is difficult to treat surgically or
by behavioral modification. Many injectable materials such as bovine [9], autologous [10],
homologous collagen [11], or autologous fat [12] have been used for the treatment of vocal fold
scarring. However, the therapeutic effects of these materials on vocal fold scarring still have been
limited.

Vocal fold LP consists of ECM components and cells consisting mostly of fibroblasts, which produce
ECM components. It is reasonable to assume that an appropriate control of fibroblasts in terms of
ECM production may be necessary to digest the excessive collagen deposits, synthesize HA, and
restore the scarred vocal fold to normal [13]. Growth factor is a potent regulatory element that
affects fibroblasts and their functions. Basic fibroblast growth factor (bFGF) stimulates cell growth of
fibroblasts and modulates ECM synthesis [14,15]. In vitro study using rat vocal fold fibroblasts
suggested that bFGF stimulates HA production and suppresses the production of collagen [16] and in
vivo study using a rat model of chronic vocal fold scarring showed that local injection of bFGF
improved the phonatory function of scarred vocal folds [17]. Local bFGF injection has been applied
on vocal fold scar and sulcus in human cases and reported to improve some of phonatory
parameters [18]. Though there have been those reports that suggested the therapeutic effect of
bFGF on vocal fold scarring, histological effects of chronic vocal fold scarring treated by bFGF have
not been documented. The purpose of this study was to examine the therapeutic effects of bFGF on
chronic vocal fold scarring using a rat model.

Tateya et al. [7], clarified the characteristics of rat vocal fold scarring by examining the alteration of
key components in the ECM and showed that the tissue remodeling process in scarred vocal folds
slows down around 2 months after wounding. It suggested that chronic vocal fold scarring can be
obtained 2 months after vocal fold injury and therefore the scarring in vocal folds 2 months after
wounding was defined as chronic vocal fold scarring.

Go to :

MATERIALS AND METHODS

Rat videolaryngoscopic surgery

Eleven Sprague-Dawley male rats (400450 g in weight) were involved in the study. Rat vocal fold
stripping was performed as previously described [7,8]. In short, rats were anesthetized with an
intraperitoneal injection of ketamine (90 mg/kg; Animal Health, Fort Dodge, IA, USA) and xylazine (9
mg/kg; Phoenix, St. Joseph, MO, USA). Atropine sulfate (0.05 mg/kg; Phoenix) was injected
intraperitoneally to reduce the secretion of saliva and sputum in the laryngeal lumen. The animals
were placed on an operating platform in a near-vertical position [19,20]. A suspension
microlaryngoscope, fabricated from 1-mm diameter steel wire, was inserted though the mouth to
maintain the surgical field. Vocal folds were visualized using a 1.9-mm diameter telescope with an
angle of 25 degrees (Richard Wolf, Vernon Hills, IL, USA). Using a 25-G spinal needle (Tyco
Healthcare, Mansfield, MA, USA) and microforceps, unilateral vocal fold stripping was performed
until the thyroarytenoid muscle was exposed. The other side was kept intact and used as a control.
All rats recovered from the anesthesia.

bFGF injection into scarred vocal folds

Two months postoperatively, rats were randomly divided into sham group and bFGF group. Six rats
were sham and 5 rats were bFGF group. Ten microliters of phosphate buffered saline (PBS) or bFGF
(100 ng in 10 L of PBS, Sigma-Aldrich, St. Louis, MO, USA) were injected into the scarred vocal folds
of each group, respectively. Injections were performed weekly for 4 weeks using 27G Hamiltons
syringe (Hamilton, Reno, NV, USA) under the videolaryngoscope. We chose this procedure in order
to share the experimental protocol with our previous study [17], though less frequent injection
would be more practical for considering clinical application to human body.

Tissue preparation and histological confirmation of the injury

Two months after the last injection, the rats were humanely euthanized. The rats were anesthetized
with a mixture of ketamine (90 mg/kg) and xylazine (9 mg/kg) and Euthasol (0.22 mL/kg; Diamond
Animal Health Inc., Des Moines, IA, USA) was injected intracardially. Whole larynges were harvested,
soaked in embedding medium (O.C.T. compound, Tissue-Tek, Kyoto, Japan), frozen quickly with a
combination of acetone and dry ice, and kept in a deep freezer (80C). Ten-micron thick cryostat
coronal sections of the vocal folds were prepared, air-dried, and stored at 20C until use. Slices
were numbered from the posterior end to the anterior end of the membranous portion of vocal
folds. The slides, including the middle one third of the vocal folds, were used for histological analysis.

Staining method

Massons Trichrome staining (American Master Tech ScientificInc., Lodi, CA, USA) was used to detect
collagen. Alcian Blue staining (Newcomer Supply Inc., Middleton, WI, USA) and a hyaluronidase
digestion technique were used to detect HA, and HA was identified by comparing the sections
without digestion to those with digestion. For the hyaluronidase digestion procedure, 50 mg of
bovine testicular hyaluronidase (Sigma-Aldrich) was diluted in 100-mL PBS. Each section was
incubated in this solution for 1 hour at 37C. Next, the sections were stained with Alcian Blue (pH
2.5). HA was identified by comparing the sections with and without digestion.

The stained area of each scarred and control vocal fold in each slice was analyzed using an image
analysis system specifically developed for the quantification of histological images [7,8,13,21]. The
LP of each vocal fold was examined at original magnifications 20. Images were captured with a
Nikon Eclipse E600 microscope (Nikon, Melville, NY, USA) and a Pixcera color camera (model PVC C,
Los Gatos, CA, USA). Metamorph Image Analysis Software (Universal Imaging, West Chester, PA,
USA) measured the density of the stained regions from the LP. The ratio (%) of pixels in the stained
area relative to the total number of pixels in the LP was provided as an indicator of each molecules
density and regarded as the density of HA or collagen. To minimize measurement bias, all
measurements were carried out in a blinded fashion such that the examiner who analyzed the
images had no information of the groups to which the specimens belonged.

Two slices for each stain from each animal were prepared and measured, and the results were
averaged for each vocal fold. Ratios of HA and collagen in the scarred vocal folds compared to the
ratios in the contralateral control vocal folds were calculated, with the average stained ratio of
collagen and HA for each animal.

Contraction of the scarred vocal folds was measured as previously described [21]. In brief, the
thickness of the LP was determined by measuring the distance from the free edge of the vocal fold
down to the muscle layer at 10 microscopic power using Adobe Photoshop Image Analysis Software
7.0 (Adobe Systems Inc., San Jose, CA, USA). The measurements were performed on both normal
and treated sides, and the thickness of the treated LP was represented by the ratio of pixel size
measured on the treated side per that on the normal side. To minimize measurement bias, all
measurements were carried out in a blinded fashion. Statistical comparisons were performed
between sham and growth factor-treated groups using an unpaired t-test. A P-value <0.05 was
considered statistically significant.

Statistical analysis

The specimens of sham, bFGF, and HGF groups were used for statistical analysis. Mann-Whiney U-
test was used to calculate differences between treated and normal sides within each group, and
between sham and bFGF groups. Differences at P<0.05 were regarded as statistically significant.
Interjudge reliability was assessed using Spearman correlation. Five percent of these specimens
were selected at random and remeasured. Initial measures were significantly correlated with
repeated measures (image analysis; r=0.83).

Ethics

This study was performed in accordance with the PHS Policy on Humane Care and Use of Laboratory
Animals, the National Institutes of Health Guide for the Care and use of Laboratory Animals, and the
Animal Welfare Act (7 U.S.C. et seq.); the animal use protocol was approved by the Institutional
Animal Care and use Committee of University of Wisconsin-Madison.

Go to :

RESULTS

HA expression

Dense blue stain was found chiefly in the intermediate and deep layer of the LP of the normal vocal
folds (Fig. 1). The sham control treated with PBS injection showed less blue stain in the intermediate
and deep layer whereas bFGF-treated vocal folds revealed a dense blue stained area in the
intermediate and deep layer of the LP (Fig. 1). Because this blue stain in the LP was not observed in
the specimens treated with bovine testicular hyaluronidase, it was thought to be HA.

Fig. 1.
Representative samples of hyaluronic acid expression (blue) in
normal (A) and treated groups (B, C) stained by Alcian Blue
stain. The scale bar at the bottom of the figure indicates 50 m.
bFGF, basic fibroblast growth factor.

Statistical analysis showed less HA (P<0.01) in sham compared to the normal vocal folds whereas the
bFGF group showed no significant difference (Fig. 2). Vocal folds treated with bFGF had significantly
higher HA (P<0.01) than sham-treated vocal folds.
 Fig. 2.
The average ratio of hyaluronic acid (HA) seen with Alcian Blue
staining in the treated vocal fold compared to the ratio in the
contra lateral normal vocal fold. Sham groups showed a
significant lower HA level compared to the normal control
whereas basic fibroblast growth factor (bFGF) group showed no
significant difference. *Significant difference (P<0.01) from
normal control.

Collagen expression

Collagen was found mainly in the deep layer of the LP of the normal vocal folds (Fig. 3). In the sham
vocal folds, denser collagen was found in all layers of the scarred LP and the collagen deposition was
similar in bFGF-treated vocal folds (Fig. 3). There was a significant difference (P<0.01) between
normal and treated groups and no significant difference between sham and bFGF groups (Fig. 4).

Fig. 3.
Representative samples of collagen expression (blue) in normal
(A) and treated groups (B, C) stained by Trichrome stain. The
scale bar at the bottom of the figure indicates 50 m. bFGF,
basic fibroblast growth factor.

Fig. 4.
The average ratio of collagen seen with Trichrome staining in
the treated vocal fold compared to the ratio in the contra
lateral normal vocal fold. bFGF, basic fibroblast growth factor.

LP thickness

The thickness of the LP in every treated group was significantly thinner (P<0.01) than that of the
normal vocal folds, and there was no significant difference between sham and bFGF groups (Fig. 5).
 Fig. 5.
Thickness of lamina propria in treated groups compared to the
contralateral normal side. bFGF, basic fibroblast growth factor.

Go to :

DISCUSSION

In vitro study using fibroblasts from skin [22], gingiva [14], periodont [15], and vocal folds [16]
revealed that bFGF stimulates HA production and decreases collagen type I production. The present
in vivo study demonstrated the significant effects on HA increase and no remarkable effect on
reduction of collagen and contraction in bFGF treated chronic vocal fold scarring. Similar results have
been observed in a rat model of aged vocal folds and bFGF injection into aged vocal folds
significantly increased the HA but showed no effect on collagen [23].

We previously demonstrated that local injection of bFGF improved the phonatory function of rat
vocal folds suffering chronic scar [17]. Moreover, local bFGF injection into human vocal fold scar and
sulcus improved some of the phonatory parameters, and the dissection of scar tissue and the
implant of gelatin sponge with bFGF led to better phonatory function than local bFGF injection [18].
Considering these previous studies, HA increase in scarred vocal folds by local bFGF injection was
thought to cause therapeutic effect on phonatory function to some extent. It is also suggested that
regenerative surgical procedures such as the dissection of scar tissue and the implant of gelatin
sponge with bFGF are necessary to restore better phonatory function because local bFGF injection
cannot lessen collagen deposition and contraction.

Despite the significant effect on HA, bFGF showed no remarkable effect on reduction of collagen and
contraction on chronic vocal fold scarring, despites of the previous in vitro study; bFGF
downregulated procollagen I expression in fibroblasts from rat vocal folds [16]. Fibroblasts from
scarrd vocal folds may have different properties of producing ECM from those from normal vocal
folds. Our previous study showed that collagen types I and III are distributed in the vocal fold LP and
that collagen type III is dominant in chronic vocal fold scarring, probably due to the dominance of
collagen type III of normal vocal fold LP [7]. The dominance of collagen type III in the chronic vocal
fold scarring might result in the insufficient collagen reduction.

In conclusion, the present study confirmed that local bFGF injection led the desirable histological
change, HA increase, by using a rat model of chronic vocal fold scarring. It was thought to contribute
to the therapeutic effects on chronic vocal fold scarring.

Go to :
CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

Go to :

ACKNOWLEDGMENTS

This study was supported by the grant NIDCD RO1DC4428 from the National Institutes of Health, and
a grant from the Ministry of Health, Labour, and Welfare (Japan), and a grant from the Ministry of
Education, Culture, Sports, Science, and Technology (Japan). The authors thank Dr. Xinhong Lim, for
his help for the image analysis, and Ms. Jessica Tiede, Mrs. Maia N. Braden, and Ms. Bridget Ruth
Welbourne for their assistance in

Regenerative phonosurgical treatments for

vocal fold scar and sulcus with basic
fibroblast growth factor.
Hirano S1, Mizuta M, Kaneko M, Tateya I, Kanemaru S, Ito J.

Author information

Abstract

OBJECTIVES/HYPOTHESIS:

Vocal fold scar and sulcus are still challenges. Basic fibroblast growth factor (bFGF) has
proven to be effective to resolve scar tissue in animal models. This study reports the efficacy
of regenerative treatments using bFGF on vocal fold scar and sulcus in human cases.

STUDY DESIGN:

Retrospective chart review.

METHODS:

Fifteen cases (7 scar; 8 sulcus) were treated by either local injection of bFGF (n = 6) or
regenerative surgery using bFGF (n = 9). Injection regimen was to locally apply 10
micrograms of bFGF in 0.5 mL saline into each vocal fold under topical anesthesia
repeatedly (4 times with intervals of 1 week between each injection). The regenerative
surgical procedure consisted of the dissection of scar tissue and the implant of gelatin sponge
with bFGF. Follow-up periods ranged from 6 months to 24 months.
RESULTS:

Maximum Phonation Time (MPT); Voice Handicap Index (VHI)-10; and Grade, Roughness,
Breathiness, Asthenia, Strain (GRBAS) scale were assessed in both groups. The injection
group showed significant improvement on VHI-10 and GRBAS. The regenerative surgery
group showed significant improvement in all parameters. Jitter and shimmer were evaluated
in the surgery group, and the results indicated improvement in six and five cases of nine
cases, respectively. No major adverse effects were observed in both treatment groups.

CONCLUSIONS:

Regenerative treatments using bFGF has shown to be effective for improvement of vocal
function in scar and sulcus.

Copyright 2013 The American Laryngological, Rhinological and Otological Society, Inc.

KEYWORDS:

Vocal fold scar; basic fibroblast growth factor; regenerative medicine; sulcus

PMID:

23553343

DOI:

10.1002/lary.24092

A good voice comes from two major components: healthy vocal folds and proper voice use. It
is not uncommon for a singer or professional voice user to have vocal complaints but have
normal appearing vocal folds. In these instances, vocal technique is often the source of the
problem. Voice therapy is geared towards this part of the problem.

This applies to the speaking and singing voice. Because we use the same instrument to speak
and to sing, either task can injure the voice and make the other task more difficult. Often singers
are excellent technicians with their singing voice but speak incorrectly, thereby setting
themselves up to sing with a tired and misused instrument.

What is voice therapy?

Voice therapy is the practice of treating the voice non-surgically by emphasizing healthy voice
use. It is essentially physical therapy for the voice and is a highly effective method to reduce
the need for surgery. Therapy is also a critical component in optimizing surgical outcome by
minimizing vocal strain. However, voice therapy is only as effective as the skill of the therapist.

Voice therapy uses highly individualized exercises and techniques to:

Optimize the voice

Assist in pre-operative and post-operative voice use
Eliminate harmful vocal use habits
Strengthen and coordinate the vocal folds
 Educate about healthy voice use
Adjust behaviors or lifestyles that caused the voice injury

Who should have voice therapy?

Almost anyone who relies on their voice for their living can benefit from voice therapy. Even
without a distinct disease or injury, most people do not use their voices optimally to minimize
fatigue and maximize comfort.

Figure 2: Improper voice use can commonly lead to symptoms of a tired voice or even pain.

Voice therapy is especially critical in the treatment of voice disorders. Commonly,

vocal nodules can be completely eliminated with voice therapy alone. In more complex cases,
such as vocal polyps or cysts, voice therapy may be insufficient. In these situations, vocal
surgery may be necessary; however, surgery should never be the only treatment. Concurrent
voice therapy is critical to ensure an optimal outcome.

Who provides voice therapy?

Voice therapy is a highly-specialized form of general speech therapy, and is performed by a

licensed and certified speech-language pathologist (SLP). Speech pathologists undergo
specialized training to become voice therapists, ensuring they are skilled in helping the injured
voice.

It is often very difficult to find a skilled voice therapist, as general speech therapists are
permitted to do voice therapy. Often the only way to be sure the therapist is proficient in voice
therapy techniques is to find one through a laryngologist or in a laryngologists office.
At Osborne Head and Neck Institutes Division of Voice and Laryngology, healthy voice is
emphasized. This means having detailed analysis with distal
chip laryngoscopy and stroboscopy as well as complex voice analysis and voice therapy. If you
have any questions as to whether or not you could benefit from voice therapy, please contact
the Osborne Head and Neck Institute for a voice consultation.

To learn more about Amy Chapman or voice therapy,

visit: http://www.voicedoctorla.com. Article excerpt
MANY DIFFICULTIES CAN PREVENT SINGERS from reaching their fullest potential.
While certain obstacles are technique related, others are the result of medical pathology
impairing function with varying degrees of severity. Symptoms of anatomic problems range
from inability to maintain pitch effectively to diminished voice quality rendering singers
unable to perform professionally. One survey showed that more than half of young singers
reported vocal difficulties including hoarseness, fatigue, decreased range, and breathiness.1
While most singing teachers recognize the need for evaluation by a laryngologist, many
conditions escape early detection and diagnosis by traditional methods of vocal fold
evaluation. It is important to acknowledge that, although no underlying pathology may be
uncovered during an initial visit, more subtle pathology such as sulcus vocalis may be
causing singing difficulties otherwise ascribed to lack of discipline or even vocal senescence.

Sulcus vocalis refers to a long, thin groove running lengthwise along the vocal folds.2 Sulci
extend along the surface layer of the vocal folds, called epithelium, as an invagination toward
the underlying vocal ligament. True sulcus vocalis results from scarring of the surface
epithelium to the underlying vocal ligament as a result of loss or absence of the loose layer in
between, known as the superficial lamina propria.3 Sulci can be divided into three categories,
based on microscopic appearance.4 Type 1 sulcus vocalis, known as physiologic sulcus,
refers to a shallow groove in the vocal fold that doesn't alter physiologic movement, and,
therefore, generally doesn't result in dysphonia. Type 2, also known as sulcus vergeture, is
the result of partial loss or thinning of the superficial lamina propria, as opposed to type 3,
known as true sulcus vocalis, which represents a true invagination of the surface epithelium
down to the vocal ligament. Both types 2 and 3 sulci refer to higher grade, pathologic lesions
that may cause dysphonia.

The etiology of sulcus vocalis is controversial. Early thought focused on a congenital basis
for sulcus, favoring a developmental defect. Sulci also have been suggested to be due to a
ruptured epidermoid cyst within the vocal fold. These hypotheses have been supported by
findings of sulcus abnormalities and early dysphonia in children, the absence of recurrence
after resection (indicating that a continuing source isn't present),5 and familial tendencies.6
Others have argued for acquired causes such as phonotrauma, vascular lesions, and
postoperative scarring. Supporting evidence includes a low incidence of dysphonia in
childhood, with over two thirds occurring after 40 years,7 and findings of bilaterality and
higher rates of sulcus in patients with cancer or inflammatory laryngeal changes.8 The true
etiology remains undetermined and may involve any or all of these proposed causes.

Dysphonia generally ensues because of vocal fold stiffness leading to improper propagation
of the mucosal wave. Additionally, glottic incompetence, or the inability of the vocal folds to
close completely, leads to air leakage and decreased vocal efficiency. Patients
characteristically present with strained vocal quality (described as harsh or "reedy"), pain,
and/or fatigue. Most patients with symptomatic sulcus present with increased breathiness
and/or hoarseness. Also noted are decreased maximum phonation time, range, and sound
pressure levels.9 Patients typically find phonation more effortful with increased difficultly
being heard over background noise. These symptoms may correlate more with glottic
incompetence than with stiffness. Sometimes, an elevation in the pitch of the spoken voice
can accompany the disorder, leading some men to complain that they are mistaken for
women on the phone.

An otolaryngologist specializing in voice, known as a laryngologist, should evaluate voice

professionals with complaints suggestive of sulcus vocalis.

Best Homeopathic Medicines for Paralysis

By Dr. Vikas Sharma MD 90 Comments

What is Paralysis?
Paralysis is defined as loss of muscle function resulting in inability to move the affected part.
The cause behind paralysis does not lie in the muscles but in the nervous system. The main
causes of paralysis are stroke (poor blood flow to brain leading to cell death), trauma, nerve
injury, poliomyelitis, spina bifida, Parkinsons disease, Guillain-Barres syndrome, multiple
sclerosis and cerebral palsy. Paralysis can be localised or generalised. Localised paralysis
affects the face, eyelids, hands and vocal cords. Generalised paralysis includes monoplegia
(paralysis of one limb), hemiplegia (paralysis of an arm and leg on one side of the body),
paraplegia (paralysis of both lower limbs, the urinary bladder and rectum are also usually
involved) quadriplegia (paralysis of both arms and legs).

Advantage of Homeopathic Treatment

Homeopathy offers a wide range of Homeopathic medicines obtained from natural plant
sources to treat paralysis. The extent of recovery varies from person to person. The earlier the
Homeopathic medicines are started, the higher are the chances of a positive outcome.
Homeopathic medicines for paralysis are safe for long term use and have no associated
adverse side effects.

Recommended Homeopathic Medicines for Paralysis

The top recommended Homeopathic medicines for paralysis are Causticum, Plumbum Met,
Conium and Arnica. Causticum is one of the best Homeopathic medicines for paralysis of the
face, vocal cords, urinary bladder, eyelids and limbs. Paralysis following sudden exposure to
cold air also demands prescription of Homeopathic medicine Causticum. Plumbum Met is
one of the most effective Homeopathic medicines for paralysis of the limbs where the
condition is accompanied by emaciation. Homeopathic medicine Conium is known to
effectively treat ascending paralysis. The symptoms begin in the lower limbs and ascend
upwards. Arnica is rated among top grade Homeopathic medicines for paralysis following
stroke and spinal injuries.

Homeopathic Medicines for Paralysis

Causticum and Cadmium Sulph Top grade Homeopathic medicines for
paralysis of face (Bells palsy)

High grade Homeopathic medicines for paralysis of the face include Causticum and
Cadmium Sulph. Causticum is one of the best Homeopathic medicines for paralysis of face
on the right side. The symptoms worsen with opening the mouth. Paralysis from sudden
exposure to cold air or from suppressed skin eruptions also points towards use of Causticum.
Homeopathic medicine Cadmium Sulph is recommended for facial paralysis of left side. The
mouth gets distorted, with difficulty in swallowing and speaking in such cases.

Arnica, Phosphorus and Belladonna Effective Homeopathic medicines for

paralysis after stroke

A stroke is mainly a brain attack arising either from obstruction of blood supply to the brain
or rupture of blood vessels in the brain. Prominent Homeopathic medicines for paralysis after
stroke are Arnica, Phosphorus and Belladonna. All three medicines are equally effective in
treating paralysis resulting from a brain stroke. These medicines are natural and focus on
healing loss of muscle function after a stroke.

Conium, Plumbum Met and Picric Acid Best Homeopathic medicines for
paralysis of ascending type (Guillain-Barres syndrome)

Guillain-Barres syndrome is a disorder whereby the immune system attacks the nervous
system and causes weakness and tingling sensation in lower limbs which ascends to the upper
part of the body. Homeopathic medicines for ascending paralysis include Conium, Plumbum
Met and Picric Acid. These are the most effective medicines for treating ascending type
paralysis. Conium is selected when the complaint starts with weakness in legs and difficulty
in walking. This initial complaint is followed by the symptoms spreading upwards. Plumbum
is one of the most useful Homeopathic medicines for paralysis of ascending nature where
atrophy and emaciation accompany the loss of muscle function. Picric Acid is prescribed
when tired, weak heavy sensation begins in the legs and moves to the upper body parts.
Burning in the spine also appears predominantly in such cases where Picric Acid has shown
remarkable results as the best among Homeopathic medicines for paralysis of the ascending
type.

Arnica, Hypericum and Natrum Sulph Top Homeopathic medicines for

paralysis after spinal cord injury/trauma

On the list of Homeopathic medicines for paralysis from spinal cord injury, Arnica,
Hypericum and Natrum Sulph are majorly indicated. All three medicines are equally reliable
and can be considered as effective treatment options while dealing with cases of paralysis
from spinal cord injuries. These medicines, as all other Homeopathic medicines, are natural,
with no linked side effects.
Cocculus and Causticum Wonderful Homeopathic medicines for paralysis
that is localised

For localised paralysis of the vocal cords, Cocculus and Causticum are rated among the best
Homeopathic medicines. To deal with localised paralysis of upper eyelids, Physostigma,
Gelsemium and Causticum are considered the most effective among Homeopathic medicines
for paralysis that is localised. These medicines are the most prominently indicated and need
to be administered for quite a long time to get positive results.

Stannum and Lachesis Top rated Homeopathic medicines for paralysis of

one side (hemiplegia)

Stannum and Lachesis are remarkable Homeopathic medicines for paralysis of the left side.
On the other hand, significant Homeopathic medicines for paralysis of the right side are
Plumbum Met and Opium. The selection of medicines is based on the detailed case history of
the patient which is painstakingly recorded. The extent and time of recovery depends upon
various factors including duration of the disease, severity of the disease and how early the
treatment is started.

Picric Acid, Lathyrus and Causticum Best Homeopathic medicines for

paralysis of lower limbs (paraplegia)

Homeopathic medicines Picric Acid, Lathyrus and Causticum are the most reliable among
Homeopathic medicines for paralysis of the lower limbs, also called paraplegia. The person
who needs to be prescribed Picric Acid will have paralysed legs. The feet may appear cold.
Burning sensation in the spine is another prominent symptom. Lathyrus is indicated when
emaciation of lower limbs appears along with loss of function. The legs may appear bluish in
colour in such cases. Spastic paralysis of lower limbs also points towards use of Lathyrus as
the most effective among Homeopathic medicines for paralysis of lower limbs. Homeopathic
medicine Causticum is most helpful where the urinary bladder and rectum also get paralysed
along with the lower limbs.

Fill the Comment Form below -You can write about your problem To Dr. Sharma and
receive a reply on How Homeopathy can help in treating your illness.

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Patients From rest of the world and India call +91-9815299965
 on 2007-
Left Vocal Cord From Prags
10-04

Paresis- Causticum 1 replies

Can Causticum be taken for LEFT Vocal cord paresis after having taken Carbo
vegetabilis to nullify the effect of PHOSPHORUS? Can it cause any side effects
(because of Phosphorus taken earlier) even though Causticum is taken after
2-3 days of Carbo Vegetabilis 200? I have started having numbness and
stiffness at night in my right hand fingers after taking Causticum. I am a
diabetic patient and had Thyroid gland surgery quite a many years back. I am
also allergic to Disprin.

From on 2009-
Re: Left Vocal Cord Paresis- Causticum
backtoindia 12-06

Hi!

i saw you had no answers and i just posted a question on causticum as well.i
also have the left vocal cord paralysed and noone would help so i tried
causticum as well for three full weeks on a daily basis. now i find that i might
have taken it way too long....i do know that causticum can cause a problem if
you are diabetic....i found that online..so better to consult a doctor on the
matter and be careful with it in your case1 good luck! i hope things improve
for you!

To post a reply, you must first LOG ON or Register

Important
Information given in this forum is given by way of exchange of views only, and those views
are not necessarily those of ABC Homeopathy. It is not to be treated as a medical diagnosis
or prescription, and should not be used as a substitute for a consultation with a qualified
homeopath or physician. It is possible that advice given here may be dangerous, and you
should make your own checks that it is safe. If symptoms persist, seek professional medical
attention. Bear in mind that even minor symptoms can be a sign of a more serious underlying
condition, and a timely diagnosis by your doctor could save your life

Vocal Cord Paralysis:-Affordable Herbal

Treatment
By: ayurveda12 Posted Dec 15, 2012 General 6997 Views

(Updated Dec 17, 2012 10:56 AM)

The voice box is composed of a right and left vocal cord that is attached on one end. When
the vocal cords are apart, air moves in between the vocal cords into your windpipe that allows
one to breathe. A "paralyzed" vocal cord is when one of the vocal cords does not move
resulting in a gap between the vocal cords. This gap when attempting to talk results in air
escape which causes the "breathy" sounding voice.

Nowadays many treatments are available for vocal cord paralysis, but ayurvedic treatment
give the best result.

Vocal cord paralysis Herbal Treatment India

Vocal cord paralysis is a voice disorder that occurs when one or both of the vocal cords (or
vocal folds) do not open or close properly. Vocal cord paralysis is a common disorder, and
symptoms can range from mild to life threatening. The vocal cords are two elastic bands of
muscle tissue located in the larynx (voice box) directly above the trachea (windpipe). The
vocal cords produce voice when air held in the lungs is released and passed through the
closed vocal cords, causing them to vibrate. When a person is not speaking, the vocal cords
remain apart to allow the person to breathe. Someone who has vocal cord paralysis often has
difficulty swallowing and coughing because food or liquids slip into the trachea and lungs.
This happens because the paralyzed cord or cords remain open, leaving the airway passage
and the lungs unprotected.Vocal cord paralysis Herbal Treatment.

Symptoms

Raspy or hoarse tone of voice

Loss of voice or vocal fatigue could be a symptom of vocal cord paresis or vocal cord
paralysis

Itching, irritation or burning sensation in the throat

Sore throat causing pain or discomfort

Coughing up blood

Lump in your throat

Dry sensation in the throat

Dry cough

Treatment Objectives:

The objective of this treatment is to improve all sysmptoms, prevent and treat later
complications, correct imbalance, adjust the immune system and most importantly to boost
energy and strong body for better health and quality of life.

Herbs used for vocal cord problems includes:

Cortex Phellodendri
 Ramulus Taxilli

Rhizoma Anemarrhenae

Bombyx Batryticatus

Radix Rehmanniae Praeparata

Radix Achyranthis Bidentatae

Fructus Aurantii

Scolopendra

Cost of vocal cord paralysis treatment in Kerala is less than other states of India. Alternative
system of health and worlds most primitive science can create a world of goodness to the
mankind if adopted with faith and patience. Adopt a healthy life style, live happily.
To know more, Please visit: ayurveda-treatment-hospital.com

Call Dr. Sharma's Clinic - From United States and Canada call 703-659-0873. Patients From
rest of the world and India call +91-9815299965

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VOCAL CORD PARALYSIS

Posted by Dr.Sadhana Gaykar on March 13, 2010 at 4:45am
View Blog

Hello everyone,
This is a case of one of my very best friend, a Software Engineer
In Jan2009, he suddenly lost his voice
He ignored it for sometime, but later it worsen
By evening, he could not speak at all
Later there was problem to utter vowels
The Laryngeoscopy revelaed Left Vocal Palsy
He tried with the Speech therapist, but no improvement

As he searched on Internet, he said everywhere i got just one thing that Only and only Homoeopathy
can cure this condition

I was very happy that even the world knows that we can cure anything which was once termed
incureable
I took his case in brief
A Single dose of CALC-SULPH 200 is helping him till now
He can talk now properly
i can say its 40% improvement
Soon i will ask him to repeat his laryngeoscopy to see the actual change

I am happy i could help my friend...

Thank God that i m Homoeopath :)

Dear Everyone,
Thank u for the interest in my blog

Dr.MAS: let me answer ur query 1st

Causticum is a bold remedy
its just based on physical symptom

Dr.Jain & Debby:

In Dr.Rajan Sankaran he describes Calc-Sulph indicated for Indian males
In India there are lot of expectations from a male child
If he is unable to fulfill he goes into self contempt
This is the very state of my friend
His younger bro is M.Arch n his younger sis pursueing Medical
Both are very intelligent
My friend too was good in studies but was failing in one or 2 subjects every yr

Recently i.e. just before the complaint statred his younger bro got selected for a very high post at
the govt office
also his salary is higher than my friend
My friend is not jealous but he wish he too could have done the same to please his father
he is afraid of his father

This were few points i selected CALC SULPH 200

He is still on that single dose
Its 90% improvement
Very soon i will post the video of his laryngeoscopy (before & after)

Views: 4883

Like

1 member likes this

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Comment by Debby Bruck on November 12, 2009 at 2:09am

Wonderful. If your friend does not mind, we may be interested to know how you made this
selection?

Comment by Dr. MAS on November 12, 2009 at 10:10pm

Please read Causticum

Comment by Dr.Suresh Jain. on November 14, 2009 at 9:10am

Please let us know the basis of prescribing Cal-sulph-Dr.Suresh Jain

Comment by Dr.Sadhana Gaykar on March 13, 2010 at 4:34am

Dear Everyone,
Thank u for the interest in my blog

Dr.MAS: let me answer ur query 1st

Causticum is a bold remedy
its just based on physical symptom

Dr.Jain & Debby:

In Dr.Rajan Sankaran he describes Calc-Sulph indicated for Indian males
In India there are lot of expectations from a male child
If he is unable to fulfill he goes into self contempt
This is the very state of my friend
His younger bro is M.Arch n his younger sis pursueing Medical
Both are very intelligent
My friend too was good in studies but was failing in one or 2 subjects every yr

Recently i.e. just before the complaint statred his younger bro got selected for a very high
post at the govt office
also his salary is higher than my friend
My friend is not jealous but he wish he too could have done the same to please his father
he is afraid of his father

This were few points i selected CALC SULPH 200

He is still on that single dose
Comment by dr.sadathsait on March 13, 2010 at 8:05am

GREAT WORK.

Comment by Debby Bruck on March 14, 2010 at 2:06am

We can learn from you personal relationships and how remedies can help.

Comment by Nandini sharma on April 21, 2010 at 3:00am

Thats amazing n shows how little we know about our medicines.i would have thought of
calcarea on the basis of painless hoarseness but not calc sulph .do let us know the reason of
prescription

Comment by Dr.Sadhana Gaykar on April 22, 2010 at 3:46pm

Hi Nandini,
Calc cud have been the remedy, but his thermals is Hot

When we are sure of Calc element in our patient and his/her thermals is hot Calc-Sulph &
Calc Flour are best suited
I consider thermals as a pointer coz its a General which represents the constitution itself

Comment by Dr.Sadhana Gaykar on May 18, 2010 at 1:31am

hi gary,
right now he is better
thanks for ur suggestion,
i will definetly consider it when needed
:) thank u

Comment by Muhammad Nuruzzaman on May 19, 2011 at 2:47am

Dear Dr.S.Gaykar,

I have been suffering from left vocal cord paralysis for last 3 years & painless
hoarseness. I am chilly, timid, afraid, afraid of public appearance, profuse sweating
with little exertion except head, palms & feet are cold & sweating in winter, thirstless,
diarrhoea from sad news & fright, tongue is flabby, teeth indented, no thirst,
alternately constipation & diarrhoea.

I tried with caust, C.veg,merc sol,phosphorous,silicea, Argnt.nit, Lach, etc.

 It will be highly appreciated if you kindly suggest any remedy.

With thanks & regards.

Dr.Md.Nuruzzaman

Comment

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comments!

There are two homeopathic remedies that are especially well known to have an action on the vocal
cords and surrounding systems. The first is a remedy called Drosera and the second is Phosphorus. I
would start with the Phosphorus and if in 3-4 weeks there is not considerable improvement, I would
move to the Drosera.

Home Remedies For Lost Voice

December 30, 2010 1 Comment

What is Lost Voice?

The condition of Lost Voice is a throat problem that is mostly caused by inflammation of
voice box. Basically, when you speak, air is pushed through the lungs and causes vibration in
the vocal cords, thereby producing sound. However, during inflammation of tissues present in
the larynx, air is simply forced out of lungs and does not cause vibration, thereby resulting in
loss of voice.

Unless caused by the serious conditions like lung tumor, vocal cord paralysis or other such
conditions, the problem of having lost voice tends to be temporary in nature.

Therefore, you can follow a number of natural home remedies for Lost Voice home treatment
by using simple natural cures and precautionary measures. Voice therapy may also be needed
in certain cases.

Causes of Lost Voice

More often than not, the problem of temporary Lost Voice arises due to overuse of voice
caused by excessive talking, yelling, singing and other such activities leading to voice strain.

Upper respiratory tract infections like Common Cold, Pneumonia, Bronchitis, Chronic
Sinusitis, Chronic Asthma, Tonsilitis etc can also cause the same.

Mouth breathing, coughing, postnasal drip, use of Asthma inhalers causing yeast infection in
throat and dryness in throat because of certain medications increase the chances of
developing the problem.
Besides, conditions like Laryngitis, Acid Reflux and certain autoimmune diseases like
Relapsing Polychondritis, Sarcoidosis and so on can contribute in causing Lost Voice.

The problem can be induced by Emotional or Psychological Stress as well. Allergies and
exposure to vocal irritants may also lead to loss of voice. In case the condition does not heal
within two weeks then it is recommended to consult a doctor.

Symptoms of Lost Voice

Generally, Lost Voice does not mean complete loss of voice or else you would not be able to
generate sound even while coughing or clearing your throat. It refers to weak, coarse voice or
voice fatigue. Issues like sore throat, swollen lymph nodes, difficulty swallowing and feeling
of fullness in throat may also be present.

As Lost Voice can cause problems in communication, you would surely want to heal this
ailment as soon as possible. Given below are some highly beneficial Lost Voice home
remedies that are easy to follow. In addition, you will have to be patient. Remember the
famous German proverb, Speech is silver; silence is golden.

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Natural Home Remedies for Lost Voice

Resting your voice is a valuable home remedy to cure Lost Voice naturally. So, avoid
talking and even whispering. In fact, whispering tends to cause more strain in the vocal folds.
Moreover, restrain from clearing your throat repeatedly as it can cause throat irritation.

Drinking warm herbal teas like that of peppermint, Echinacea, chamomile, licorice root,
slippery elm bark, eucalyptus leaves, ginger, lemon, etc are highly beneficial in reducing
throat problems causing loss of voice. Do not forget to add honey to make these herbal cures
more effective.

Gargling with warm water mixed with half a teaspoon of salt is a highly beneficial natural
remedy for Lost Voice treatment at home. Follow this treatment three times in a day but do
not gargle too forcefully as can put more strain on the vocal cords.

Having a mixture prepared by adding half a teaspoon of fresh basil juice in a teaspoon of
honey serves as a good natural cure for Lost Voice. Follow this therapy about 3-4 times in a
day.

Inhaling steam and drinking plenty of water are the best natural home remedies for Lost
Voice caused by dry throat. This is useful in soothing the throat and vocal cords.

Sucking herbal lozenges and chewing gums are helpful in dealing with Lost Voice by
keeping the throat moistened. In addition, take hot showers and use humidifiers.

Take half a glass of warm water and add two teaspoons of apple cider vinegar in it. Drink
this solution to recover Lost Voice naturally. You can also add honey and lemon juice in the
solution.
 Drinking a cup of lukewarm milk mixed with some black pepper powder can help relieve
throat discomfort associated with Lost Voice. Simply having a cup of warm water mixed with
three teaspoons of honey, two teaspoons of sugar and two ounces of lemon juice is also
beneficial reducing the problem.

Specific breathing techniques and exercises are considered as excellent natural home
remedies for Lost Voice natural treatment. They also help a great deal in achieving control
over voice. When following this therapy, it is essential to relax the abdominal muscles first.

Aromatherapy and localized massage are also considered as valuable Lost Voice natural
remedies.

Diet for Lost Voice

Dietary measures like taking nutritious foods, drinking 8-10 glasses of water and including
lots of warm fluids in the diet are highly beneficial in relieving this problem. If you are not
used to drinking plenty of water then keep sipping it at regular intervals. You should also try
to include more garlic, black pepper and ginger in your diet to ease throat irritation.

In addition, avoid smoking and drinking alcohol, caffeinated and carbonated beverages as
they can aggravate the problem by drying the throat further. Follow the tips and natural home
remedies for Lost Voice for a few days and give rest to your vocal cords to get rid of this
problem in a natural way.

All Licensed Speech Language Pathologists are instructed about various vocal fold disorders
in their training as graduate students. I can't confirm that every class in voice disorders delves
heavily into one disorder over another, but in most cases vocal fold paralysis is covered at
least minimally in most curriculums. In saying that, when the student graduates they may
decide upon different employment settings and there are certain professionals and settings
that have more opportunities and experiences in with working with voice disordered patients.
Usually Speech Language Pathologists (SLPs) that work in clinics, hospitals or other out
patient rehabilitation units have more experience working with patients with paralyzed vocal
fold conditions. My suggestion is to seek out those facilities in your immediate area and
locate a professional who specializes in voice and voice related disorders.

In terms of exercises, my experiences have differed greatly depending on the patient and their
specific presenting symptoms. Not all paralysis cases look identical, some more severe, some
accompanied by muscle tension in the laryngeal musculature, some paralysis may affect both
vocal folds (bilateral VFP) and some may only affect one fold (unilateral VFP). Therefore, it
is important to seek an evaluation by a qualified SLP and ENT (ear nose and throat
physician) before attempting any of the listed activities.

In saying that, there are typical facilitating approaches that usually are attempted with VFP
cases. Some of these techniques were outlined in the website you listed, "Unilateral Vocal
Cord Paralysis and Dysphagia" (www.speechpathology.com/askexpert).

Often if a specific therapy technique is not working effectively the focus of therapy and the
activities change to suit the patient's needs and goals for therapy. Typically as a therapist the
goal would be to improve the overall vocal quality, loudness and maintain appropriate pitch
for the patient's age and gender. Usually decreased loudness is the primary concern for most
VFP patients. In order to increase loudness it is imperative to improve vocal fold closure and
thereby increase the pressure beneath the vocal folds (subglottal pressure). As you are aware
this is the main problem, the vocal folds are not coming together at midline in order to build
this pressure underneath. Typically, the initial routines are to improve this closure through
push/pull and other similar activities that attempt to have the healthy cord move more toward
midline and compensate for the immobile cord or to get the immobile cord moving again.

There are also surgical procedures that will physically move the affected cord to midline
(medialization techniques) to allow the "healthy" cord to not have to move as far over to get
to midline in order to contact the immobile cord. However, this is usually discussed after
therapy has not improved the condition. There are also surgical interventions that involve
"increasing the size" of the affected cord by injecting a substance such as collagen, Teflon or
Radinesse. This effectively makes the affected cord bigger and again eases the movement of
the "healthy" cord to make midline closure.

Now back to the exercises of push/pull. This exercise involves pushing or pulling up on a
chair or a wall with your hands and trying to forcefully close the vocal folds while
pushing/pulling up or out (depending on the activity). The theory is that when people lift
objects or push objects there folds naturally close to build pressure to gain force to complete
the action. The pulling or pushing usually is for about 1-2 seconds with repetitions of 8x per
activity. The therapist and the patient should always be careful that excess muscle strain
present in other laryngeal muscles is not occurring as this can impede the movement of the
folds and create more problems and ultimate worsen voice quality. It is a delicate balance
between strengthening one muscle group in the larynx and making sure tension does not
elevate in the surrounding muscles impeding easy voicing.

Other exercises that seem to create this balance are starting with a gentle massage of the
laryngeal musculature through manual circumlaryngeal massage (Aronson Technique). This
allows decreased muscle tension prior to starting voicing therapies. Also the Lee Silverman
Voice Treatment Program (Developed by Lori Ramig) has been used to improve loudness in
VFP cases. This approach has a series of exercises with the basic premise of talking "loud"
even if your goal is normal loudness. Essentially by attempting to speak louder you are
moving the vocal folds closer together thus there is the increased possibility of improved
closure and thus increased loudness levels. Other exercises in this approach include flexibility
drills (attempting to move from lowest to highest pitch on a glide at various frequencies on a
vowel /a/).

Another technique is digital manipulation of the larynx. Essentially the affected cord is
physically pushed over to the other mobile cord again to reduce the distance between the
immobile and mobile fold. The larynx is moved over with the hand and the hand is eventually
removed over time when the patient is used to the positioning of the larynx. Other elements
of successful therapies include improving overall patient awareness of respiratory support of
voice, appropriate hygiene and vocal care (water intake, etc), vocal fold and upper airway
anatomy. Progress in therapy should also be monitored constantly and manipulated to suit the
patient's goals in therapy. Facilitating approaches to improving vocal quality should
constantly be evaluated by the therapist and the patient.

Bridget A. Russell is an Associate Professor at the State University of New York Fredonia
and directs the Speech Production Laboratory in the Youngerman Centers for
Communicative Disorders at the University. She has published in the Journal of Speech,
Hearing and Language (JSHLR), Speech and Voice Review. She has presented over 70 peer
reviewed presentations at national and international conferences on voice and respiratory
disorders. Dr. Russell also has served as an editorial consultant for JSHLR, National Science
Foundation (NSF) and DelMar Publishing Group. Dr. Russell's research interests include
voice disorders in children and adults, professional voice, and respiratory disorders of
speech production.

y Glossary Terms

Vocal Fold Scar:

Abnormal scar tissue in the vibrating layer of the vocal fold that causes voice problems

Lamina Propria:
Vibrating component of the vocal folds that covers the vocal fold muscle or body; the lamina
propria is composed of three layers: superficial, intermediate, and deep lamina propria

Mucosal Wave:
Wave-like motion of the vibrating layer of the vocal fold as seen upon slow motion-like
viewing through stroboscopy

Stroboscopy:
Laryngoscopy with synchronized strobe light that provides a slow motion-like view of vocal
fold vibration (mucosal wave); stroboscopy is the key tool used to analyze vocal fold
vibration

Glossary

What are the treatment options for vocal fold scarring?

Currently, no treatment can eliminate formed scars or reverse scar formation. Rather,
interventions are aimed at preventing continued scarring and/or improving voice.

Prevention Is the Best Treatment

The best treatment for vocal fold scarring is, of course, prevention.

Healthy and appropriate voice use can effectively prevent vocal fold scar.

Excessive scarring from surgical treatment can be prevented by:

Using careful and precise laryngeal and phonomicrosurgical techniques (For more
information, see Prevention and Phonomicrosurgery.)
Ensuring full patient compliance with voice rest after surgery
Treating other associated medical conditions, such as laryngopharyngeal reflux, aggressively
especially during surgical recovery
Minimizing use of the CO2 lasers
Appropriately managing breathing tubes when a breathing tube is necessary

Key Information
Ongoing Research Important to Addressing Key Questions on Vocal Fold Scarring

Presently, no definitive treatment modalities for scarring exist. Different surgeons prefer
different treatment options. Ongoing research is focused on:

How scarring is produced specifically in the vocal folds

How best to improve voice function, if not remove scar
How best to prevent vocal fold scarring
Research Specific to Vocal Folds Necessary

An understanding of vocal fold scarring should not simply be deduced from findings
regarding scarring elsewhere on the body, since scarring in the vocal folds affects voice
function.

Non-Surgical Treatment Options for Vocal Fold Scarring

Other medical problems: The first line of intervention for vocal fold scarring should be to
treat any associated medical problems that could be compounding the voice disorder
associated with vocal fold scarring. The two most common such problems are allergic
conditions and laryngopharyngeal reflux disease.

Allergies: Allergies of the sinus and nasal regions can often have a detrimental effect on
voice quality and worsen voice symptoms associated with vocal fold scarring. This problem
can be successfully treated with a variety of options such as medication, allergy shots, and
avoidance of specific allergens.

Voice therapy: Voice therapy is another important preliminary (and sometimes the only)
step in the treatment of patients with vocal fold scarring. Voice therapy will not directly
change the nature of the vocal fold scar; however, it will assist the patient in compensating
for the voice problems. The body can develop poor singing/speaking adaptive behaviors
when scar tissue forms on the vocal folds. High quality voice therapy will address these
issues and teach alternative techniques to maximize voice efficiency and quality. Voice
therapy is especially helpful for patients with symptoms of vocal fatigue and instability of the
voice. Often, voice therapy is extremely helpful, but will not directly affect the actual quality
of the voice. (For more information, seeVoice Therapy.)

Singing voice therapy: Singing voice therapy is another technique often employed in the
early stages of treating patients with vocal fold scarring. Singing voice therapy involves using
a variety of singing exercises to optimize both spoken voice and singing voice production in
the face of some underlying vocal pathology such as vocal fold scarring.

Surgical Options for the Treatment of Vocal Fold Scarring

Multiple options exist for the surgical treatment of vocal fold scarring. The selection of a
surgical option depends upon the severity of the voice problem and the patients specific
symptoms and voice demands.

Removal of associated lesions: Patients with vocal fold scarring often have associated
lesions, such as cysts or polyps. These lesions should be removed via phonomicrosurgical
techniques. (For more information, see Phonomicrosurgery.)
 Augmentation of vocal fold closure: When vocal fold scarring causes poor or no vocal fold
closure during voice production, the voice is often extremely weak and breathy. A successful
surgical approach to this problem is called vocal fold augmentation. The procedure is aimed
at increasing the size or bulk of the vocal folds to improve vocal cord closure by medializing
or pushing each vocal fold toward each other (the midline). This enables the vocal folds to
close and subsequently vibrate better, despite still having scar tissue within the lamina
propria. This type of surgical augmentation of the vocal folds can be done either with fat
injection (lipoinjection) of the vocal folds or with bilateral thyroplasty.
Dealing with the scar: Surgical options for the direct problem of scar tissue within the all-
important lamina propria of the vocal fold are currently not proven and remain under
intense study. (For more information, see Frontiers.)

Treatment of vocal fold scarring is one of the most difficult areas of vocal fold surgery and
should be performed by surgeons with significant expertise and experience in this area.

Currently, what can patients reasonably expect from vocal fold scar treatment?

The success of treatment depends on the initial severity of the vocal fold scar, the nature of
the patients voice demands, and the patients response to a particular treatment technique.
There is no one single treatment option that works for all patients with vocal fold scars.
Thus, preventing vocal fold scarring and attempting all non-surgical treatment options prior
to surgery are crucial.
For severe vocal fold scarring, substantive improvement can be attained through treatment,
but generally there will not be a complete return to function, especially with regard to
singing. It is not known if one surgery treatment is superior to another.
For minor vocal fold scarring, non-surgical treatments (medications, voice therapy, and
singing voice therapy) will often allow the patient to resume all or almost all vocal function.
Vocal fold augmentation can also result in noticeable voice improvement.

Key Information

Opting Not to Treat Vocal Fold Scarring

According to current best practices, when the cause or causes of vocal fold scarring are
eliminated, no further voice problems will occur if an individual chooses not to have
treatment for vocal fold scar.

However, if the cause of the vocal fold scar is not eliminated, as when vocally abusive
activities such screaming, yelling, or singing in unhealthy fashion continue, then further vocal
fold scar or other voice problems will most likely develop, resulting in a further decline in
vocal function.

Advisory Note
Patient education material presented here does not substitute for medical consultation or
examination, nor is this material intended to provide advice on the medical treatment
appropriate to any specific circumstances.
Laryngeal steroid injection for vocal fold
scar.
Mortensen M1.

Author information

Abstract

PURPOSE OF REVIEW:

Vocal fold scar is generally caused by trauma or from iatrogenic causes such as intubation,
radiation therapy or phonomicrosurgery. Once a vocal fold scar has occurred it becomes a
difficult problem to treat. There are many different tools that otolaryngologists use for vocal
fold scar treatment. This study reviews the literature and discusses the usefulness of laryngeal
steroid injection for the treatment of vocal fold scar.

RECENT FINDINGS:

Steroid injection can be performed on an outpatient basis using a rigid laryngeal telescope or
with a flexible laryngoscope under topical anesthesia. This technique allows easy surgical
manipulation with a good visual field and an easy accurate approach to the lesion. The
literature is limited regarding the benefits of steroid injection for vocal fold scar.

SUMMARY:

Steroid injection of the scarred vocal fold using an office-based technique is one of the ways
that we can treat vocal fold scarring that may improve the patient's voice outcomes with
minimal side effects or complications.

Abstract

Although several treatments for sulcus vocalis have been reported, the condition continues to
be known as an extremely intractable vocal disorder even now. We report the good outcome
of a new treatment for sulcus vocalis. The operation was performed under intubated general
anesthesia. We aspireted abdominal fat using an 18-gauge needle and a 20 = cc disposal
syringe first. After collection of the fat, laryngomicrosurgery and laser vaporization of the
sulcus bilaterally was performed using a KTP laser. Then, the collected fat was injected into
the thyroarytenoid muscle bilaterally (about 1cc on each side). Seven patients underwent this
surgery. The voice, as evaluated auditorily, improved in all the cases and the maximum
phonation time increased in 6 of the 7 cases. We attribute the vocal improvement to the
formation of new free edges of the vocal folds after this surgery.

oice Therapy Techniques

The voice therapy program includes a technical skills component.
A few techniques most effectively target a specific type of voice disorder - for instance, the
Lee Silverman Voice Therapy approach is developed specifically for use with Parkinson's
patients, while confidential voice is used mainly for individuals who have an injury to the
vocal fold mucosa. In general, however, there is no single correct set of techniques for a
specific voice problem. This is because most voice problems are made up of more than one
feature and have more than one single cause. In addition, most techniques achieve improved
voice by targeting improved balance of all of the components of voice production; they just
use slightly different means of obtaining that balance. Different therapists have different
approaches, all with many commonalities. One technique may work best for one therapist or
patient, and another approach works best for others. Voice therapy is an interaction of the
therapist and the patient. Most (but not all) of these exercises begin by eliciting the correct
voice production technique using the most facilitating sounds and combinations of sounds.
Then, as the patient becomes able to produce voice in this optimal way, the technique is
carried over into words, phrases and sentences until integrated into conversational speech.

In alphabetical order, some of these techniques:

Accent Method
Confidential Voice
Digital Laryngeal Manipulation
Lee Silverman Voice Treatment (LSVT)
Resonant Voice
Vocal Function Exercises

Accent Method: This program uses rhythmic exercises to facilitate the coordination of
minimally-constricted vocal fold vibration with appropriate air pressure and air flow. The
Accent Method is a holistic approach that addresses pitch, loudness and timbre
simultaneously, rather than focusing separately upon each of these vocal parameters.
Rhythmic contraction of the muscles involved in breathing are coordinated with production
of increasingly complex utterances. The consonants in these utterances are used as accents
within the rhythm. Initially, rhythmic whole body movements are used to facilitate clear and
easy voice production. Rhythmic variation in pitch and loudness are incorporated to gain
increased vocal flexibility.

Confidential Voice: Confidential voice is designed as a temporary style of voice production

used to help facilitate mucosal repair. It is often used in acute (short-term) voice problems
and after surgery. It is part of a modified voice rest program and can be used as the only type
of voice production for one to two weeks, or as part of a longer-term program that alternates
periods of voice rest with more demanding voice use. Confidential voice is a light voice. It is
an easy, breathy, low airflow style of phonation. It is a softly-produced voice, and therefore
not functional for many communicative needs. Although the voice is soft, it is not a breathy
whisper. Low-effort is critical to the success of this style of phonation. However, low-effort
does not imply low pitch or low (pharyngeal) tone focus. Importantly, the normal pitch of the
voice is maintained, and even a slightly increased pitch contour (mildly "sing-song") is
encouraged to prevent "monotone", which can force the laryngeal muscles into a "locked-in",
inflexible setting that can be contrary to facilitating mucosal repair.

Digital Laryngeal Manipulation: Also called laryngeal massage, the focus of this technique
is to decrease excessive contraction of the muscles of the larynx (see muscle tension
dysphonia). This is achieved through pressing on selected areas of the neck (focal palpation),
circumlaryngeal massage, and manually repositioning the larynx. Using the thumb and
forefinger, moderate pressure is applied in small circles, from front to back, targeting selected
areas of the larynx and neck. Often, excessive muscle contraction causes the larynx to be
positioned too high in the neck, pulled up towards the base of tongue. Speaking in this
position for extended periods of time can cause neck discomfort and even focal pain or
tenderness.

Laryngeal massage will therefore often focus initially upon the contracted thyrohyoid space
(the area between the larynx and the hyoid bone) to release the excessive contraction and
allow the larynx to descend. Gentle manual repositioning of the larynx during phonation can
sometimes prevent habituated patterns of excessive contraction. Vocal exercises are
incorporated during the massage to facilitate clear and easy voice production without
excessive muscle contraction. The patient is then encouraged to focus upon auditory and
vibrotactile feedback to encourage maintenance of easy voice production in the absence of
manual manipulation.

Lee Silverman Voice Treatment (LSVT): This is an intensive program, with attendance
required four days/week for four consecutive weeks. The focus of LSVT is the use of "loud"
voice, emphasizing both the production and the habituation of loud voice. This program was
developed and has been tested mainly on patients with Parkinson's disease. However, many
clinicians have found it helpful with patients who have other types of diseases or voice
problems that cause problems with loudness level and/or clarity of articulation.

Resonant Voice: This approach focuses upon achieving a specific configuration of the vocal
folds and muscles immediately above the vocal folds (termed the epilaryngeal area) by
training the patient to respond to sensations of vibration in the face (similar to the "buzz" that
you would feel when humming). Resonant voice techniques aim to increase the power and
clarity of the voice while decreasing the vibratory forces that can contribute to mucosal
trauma. The goal is to create an optimal pressure balance between the lung pressure below
the vocal folds, the air pressure in the vocal tract above the glottis, and the vocal fold
resistance to the airflow. This technique is commonly used in cases of primary or
secondary muscle tension dysphonia in which the vocal folds are either squeezed together
with too much force, or held stiffly apart and prevented from contacting together or vibrating
fully. Resonant voice production may decrease the excessive or uncoordinated muscle
contractions, allows the vocal folds to vibrate more freely, and therefore improve vocal fold
contact and vocal quality.

Vocal Function Exercises: This approach is a three-component program of warm up, pitch
glides (high to low and low to high) and sustained vowel phonation at selected pitches. These
exercises are performed a specific number of times during the day. Like any type of exercise,
they can be done incorrectly or correctly. Producing them with a resonant voice (also called
"flow" mode of phonation) rather than excessive effort, is key to these exercises. These
exercises are based upon the hypothesis that their systematic practice will increase the bulk
and strength of the thyroarytenoid muscle (the body of the vocal folds) and improve
coordination of the multiple muscles of the larynx that must be co-activated for speech.

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