CASE July 2022
F. is a 75-year-old man who presents to the voice clinic with complaints of complete loss of voice. He is a retired carpenter. Sir would have had a somewhat hoarse voice for a long time, but the complaints have clearly increased since heart surgery under anesthesia 1 month ago. Mister can no longer speak normally, there is total aphonia. Voice quality does not vary during the day, unless after voice stress. There are no throat complaints (VHI-T 0/40), nor swallowing difficulty. F. has average speech activity (3/7) and loudness (4/7). He does not perform any additional voting activities. F. stopped smoking 8 years ago.
Self-reports show that the voice causes a number of limitations in daily life (VHI 37/120), with the functional aspects predominating (functional 18/40, physical 13/40, emotional 6/40). Mister experiences the voice complaints as a serious problem (6/7) and is motivated to solve this problem (6/7). The objective voice analysis shows a DSI of -7.56 and an AVQI of 7.0.
The laryngostroboscopic examination shows the following:
Phonation shows clear supraglottic contraction.
On inspiration:
note the collapsed mass of the thyroarytenoid muscle.
What is your GRBAS score?
What do you think the diagnosis would be?
What would your treatment proposal be?
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Diagnosis:
Laryngostroboscopy shows pronounced atony of the thyroarytenoid muscle bilaterally. The vocal cords adduct insufficiently. The patient compensates with hypertonic vocalization and supraglottis contraction. Perceptually, we rate the voice as G3R3B3A3S3.
Therapy:
The vocal cords are mediated in an outpatient setting under local anesthesia by injection of hyaluronic acid.
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Positioning needle in protective sheath
Extend needle
Injection
View of the vocal cords, immediately after the injection, on inspiration
Stroboscopic examination shows during the controla month laternicely filled vocal cords, with bilaterally increased tone in the m. vocalis and good glottal closure. F is satisfied. Perceptually we hear G1R0B0A0S1. The voice has improved a lot (7/7). F. finds the voice problem no longer serious or disturbing (2/7) and has no more complaints. Self-report shows that the voice no longer causes limitations in daily life (VHI 0/120).
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The laryngostroboscopic examination now shows the following:
When checkedafter six monthswe still see complete adduction of the vocal folds. The wave pattern is present. Supraglottis contraction is still observed in the falsetto register. F. no longer experiences voice problems (severity 1/7) and is very satisfied with the result of the medialization. His voice sounds like before. Perceptually we hear G1R0B1A0S1. This results in a DSI score of 0.82 and an AVQI score of 4.01. Self-report shows that the voice no longer causes limitations in daily life (VHI 0/120).
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The laryngostroboscopic examination now shows the following:
Points of attention:
Weak vocalization due to atony of the true vocal cords is often a disabling complaint for patients. The absence of the glottal closure entails a feeling of shortness of breath and fatigue. The voice sounds weak and there is a risk of aspiration. These patients, often elderly, can be helped very well with medialization of the vocal cords. This procedure can be performed outpatient at the consultation using a flexible layngoscope as described in this case. The procedure takes half an hour. Hyaluronic acid is used as a product, of which slow resorption occurs after an average of one year. Since patients can talk more easily and use their voice more, the tone and muscle mass of the vocal cords can increase so that in some cases a good result can be maintained in the longer term. If there is a recurrence of the complaints in the long term, a new injection can be considered.
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If you want to submit a case yourself in the future, you can send it to stemkliniek@azdelta.be.
At phonation (1 month post-op)
On inspiration (1 month post-op)
At phonation (6 months post-op)
On inspiration (6 months post-op)