Q&A: Ms Ekpemi Irune

Epkemi 001 crop.jpg

The ear, nose and throat, head and neck, and thyroid surgeon at The London Clinic’s Head and Neck Rapid Diagnostic Clinic on treating dysphonia, a common but little-understood voice symptom

Interview: Viel Richardson
Portrait: Christopher L Proctor

What is dysphonia?
The voice is produced by the larynx, sometimes called the voice-box, and dysphonia is an overarching term used to describe abnormality in how the voice sounds. It is a symptom rather than a diagnosis: it could be a functional dysphonia caused by how the person is using their voice, a structural abnormality like a growth on the voice box, a temporary infection, or a more serious disease.

What kind of changes to the voice does it encapsulate?
The voice becoming gruff or sounding hoarse, suddenly becoming significantly lower in register, or rapidly losing power and becoming weaker than usual. What should raise alarm bells are unexpected changes in your voice that are not resolved after three to six weeks—that is when you should be going to see your GP, who will probably refer you to a head and neck surgeon to investigate further.

Where is the larynx and how does it work?
It sits about half way down the neck. It is a tubular structure surrounded by muscles. The vocal cords, the real instrument in the voice box, are fine, slim structures reminiscent of the weft you get on a violin or cello bow. Air coming up from the chest passes through two vocal cords, causing the fibres to vibrate. The sound this vibration generates is modulated and refined using the mouth and tongue to create speech.

What causes dysphonia?
It can occur for many reasons. If you have had a cold, cough or sore throat and have been run down, the symptoms are likely to be due to a viral or bacterial infection—with a bit of time, good hydration and perhaps some over-the-counter medication to help with the symptoms, the voice should return to normal. It can also be caused by laryngitis—a very specific condition where the vocal cords in the throat become swollen, often associated with a sore throat—or gastric reflux, where acid comes up from the stomach into the throat. Another problem can be overuse of the voice or not using the voice properly—for example, if you have been at a party or event and have been using your voice exuberantly, you may tire out your larynx, which will take time to recover. The voice box works through the synchronised movement of a group of muscles, and if that synchronisation is out of balance through poor use or fatigue, that can alter the voice. Dysphonia can also be a sign that a vocal cord has become paralysed. Most seriously, it can be one of the first symptoms of throat cancer.

Can you expand on vocal cord paralysis?
This is when a vocal cord loses the ability to move. There are a number of reasons this can occur, but the crucial thing is that once a vocal cord is paralysed it’s unlikely to recover. That means we have to implement procedures to augment the vocal cord. Your vocal cords need to meet in the mid-line like two hands clapping to work properly. But if one is paralysed, the other can’t move across enough to reach it. What we can do is inject the paralysed vocal cord with a substance that makes it get larger, occupying enough space so the healthy cord can meet it. It is a very effective treatment.

Can there be congenital issues with the larynx?
The major one is congenital laryngeal atresia, where the larynx does not open during development, so you are effectively born without a voice box. There is also congenital subglottic stenosis—a narrowing of the lower part of the airway. This reduces the amount of air flowing through the voice box, so the patient cannot generate much sound.

Is there anything you can do for an underdeveloped larynx?
If someone has a narrowing of the lower airway, surgical reconstruction can help. A specialist can make a little window in the narrowed section and replace that with a bit of rib cartilage. What you are doing is restoring the natural airflow to create a voice. If the procedure takes place when the child is still young, the cartilage grows with them, making an excellent repair. But it is not just about the voice—when the child is very young it can be about helping them with breathing difficulties. If the voice box or vocal cords have not developed at all, we are not in a situation where voice box transplants are possible. In patients that have undergone surgical removal of their voice box, also known as a laryngectomy, we can undertake a procedure known as surgical voice restoration.

What does that involve?
The technique is based on the fact that the sounds that the larynx generates are refined into speech mainly by the mouth and tongue. What we do is create a small hole between the back of the airway and the oesophagus. That allows air to flow directly into the upper oesophagus and the mouth. By moving the tongue, sound can be generated. It is a different quality of voice, but the interesting thing is in patients where the larynx has had to be removed, they still sound like themselves after the procedure. That is because the structures they used to refine their original voice are still the same, bringing the same qualities to the new voice.

The other thing we can do is develop an oesophageal voice. This uses something like the burping process to produce air movement. Patients can be taught how to control that action to produce speech. It’s a lot more refined than it might at first sound and for the group of people where you have to remove the larynx and for whom the small puncture is not possible, this is a way of giving them back the ability to speak.

Why would you remove the larynx?
This can be necessary if we are treating throat cancer. A big part of treating cancer is survivorship, which is about getting the patient to see life after their cancer treatment. Giving the patient the ability to speak after the treatment is hugely beneficial psychologically. The state of mind is so important when it comes to the completeness of a patient’s recovery.

We often hear about singers suffering from vocal cord nodules. What are they?
These are little pea-like structures that grow on the vocal cords. They tend to grow in areas where maximum sound is generated, altering the ability to create a pure voice, and that can be extremely serious for professional singers.

What can you do to help?
Well-developed nodules need to be surgically removed, preferably with a laser. One real issue is that nodules can return after being removed and each procedure to remove them is associated with the risk of scarring. This is reduced greatly by technique, technology and teamwork—an experienced surgeon using a laser, working alongside speech therapists. If you need multiple procedures, it could lead to you having long-term problems with the voice.

What happens when a patient first comes in?
That depends on the nature of the problem. However, the most important thing is to be able to get a really good view of your voice box. We have a very high quality ENT endoscopic stack in The London Clinic, which allows us to have a good look using very high resolution imagery.

So, visual inspection is a key part of diagnosis?
Absolutely. We have access to other techniques like biopsies, but dysphonic patients often have structural or functional, problems and being able to inspect the area in detail is crucial. For example, there is a technique called stroboscopy. For this, you use a specially equipped endoscope to film the vocal cords in action. You can record the airwaves moving along the fibres of the vocal cords and then watch individual waves in slow motion as they travel. We can also use a fine flexible endoscope to examine the rest of the larynx and its surrounding structures, such as the mouth and throat, while checking that the muscles necessary for voicing are working in harmony. These are just two techniques that are hugely helpful both in diagnosis and management of voice problems.

It seems that dealing with dysphonia can be complex.
Absolutely, dealing with the voice is a multi-disciplinary activity. At The London Clinic’s Head and Neck Rapid Diagnostic Clinic, we work with excellent speech therapists and clinical nurse specialists as well as a team of ENT consultants.

What can people do to avoid voice problems?
Lifestyle choices can have a real impact on voice health: things like keeping hydrated and managing your lifestyle to reduce gastric reflux. You should have your last meal two to three hours before going to bed so that the stomach empties of acid. Of course, smoking cessation and reducing or cutting out alcohol are very helpful.

Learning to use the voice well is also very important. If you sing professionally, you should see a speech therapist. They are phenomenal at teaching people to really understand how their voice works. They can teach you how to look after your voice so you can get the very best out of it over the long term. Anyone who uses their voice a lot, such as teachers and actors, can benefit from this.

What should we do if we think we have dysphonia?
If you are having a problem, it is very important not to just power through. You need to rest the voice—true ‘voice rest’, meaning not speaking at all. Whispering actually puts a greater strain on the vocal cords than normal speech. If you have to say something, speak at a normal vocal level and be as brief as possible. In most cases, with the right care it will resolve itself, but if it has not after six weeks you should go to your GP or come to the Head and Neck Rapid Diagnostic Clinic to get it investigated.