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CASE September 2021

A. is an 11-year-old girl and takes solfège and drama lessons. She was registered on the advice of the class teacher and the music school. A. regularly suffers from hoarseness and is sometimes completely aphone. She also experiences a sore throat. Singing is no longer possible. These complaints already started at the age of three years and increase with voice strain and fatigue. A. perceives the hoarseness and sore throat as a serious problem (VAS scale 6/7) and is willing to do something about her voice (VAS scale 6/7). She rates her speech activity quite high (VAS scale 5/7) and also talks quite loudly (VAS scale 5/7). Self-reports show that the voice causes significant impairment (p-VHI 45/92) with the physical aspects predominating (Functional 12/28, Emotional 10/28, Physical 23/36). The use of the voice is strongly deviating and this is objectified in a deviating DSI (0.92) and a deviating AVQI (4.03).

 

The laryngostroboscopic examination shows the following images.

You can listen to the sound fragment below. 

CASUS 9 - 1 aanvang bij fonatie .jpg

At phonation

CASUS 9 - 0 aanvang bij expiratie.jpg

At expiration

Answer

Diagnosis: The laryngoscopic examination shows a cyst on the left vocal fold. With stroboscopy we see a disturbed wave pattern.

The GRBAS score at baseline was G3 R1 B2 A0 S2.

Therapy: The treatment consists of surgical removal of this vocal cord cyst with additional speech therapy for voice therapy. Two weeks after surgery, laryngostroboscopy shows a slightly swollen left vocal fold, with still suboptimal closure and a suppressed wave pattern. Consequently, postoperatively we note a slightly decreased DSI value (0.51) and slightly increased AVQI (4.54).

CASUS 9 - 5 postop fonatie kopregister.jpg

At phonation (post-op)

CASUS 9 - 3 postop fonatie.jpg

At expiration (post-op)

Speech therapy was started. After 5 months we see beautiful intact vocal folds and a symmetrical wave pattern on stroboscopy. This translates into improved voting capabilities (DSI 1.89) and improved voice quality (AVQI 3.05), with a GRBAS score of G1R1B1A0S1.

 

Fourteen months after the operation, the last check-up takes place. A. and her parents are satisfied. The voice continues to sound good (G1R0B1A0S0) and this is objectified in good vocal possibilities (DSI 2.63) and a still slightly different voice quality (AVQI 3.29). The speech therapist confirms that A. knows the vocal hygiene measures and voting techniques correctly, although transfer to the daily life remains a challenge. The speech therapy guidance was then completed.

Points of attention: In case of hoarseness from a young age, one should be aware of abnormalities as a result of a possible congenital defect. In this case, the cause is an epidermoid cyst, formed by keratin-producing cells located beneath the vocal cord lining. This explains the typical clinical picture of a white swelling. Such cysts can also form secondarily after voice overload. They usually occur in 'overdoers' (speech activity and loudness >4). The vocal ability test is characterized by vocal roughness and diplophonia is often present. The treatment always consists of a combination of surgery and speech therapy. In surgery, the entire lesion should be removed with attention to sparing the surrounding tissue to avoid scarring and rigidity. Usually both laser and micro-instruments are used for this. Incomplete excision can lead to recurrence. Speech therapy is important to prevent recurrence of strain-related vocal cord injuries.

If you want to submit a case yourself in the future, you can send it to stemkliniek@azdelta.be.

CASUS 9 - 7 controle fonatie.jpg

With phonation (check after 5 months)

CASUS 9 - 9 controle fonatie.jpg

At expiration (check after 5 months)

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