How Does Cervical Spine Surgery Potentially Cause Voice and Swallow Problems? [video]

It is not unusual for an ENT surgeon to see patients with swallowing and voice difficulties after cervical spine surgery. In particular, the ACDF surgery (Anterior Cervical Discectomy and Fusion).

The key to understanding these issues is to first understand the anatomy involved.

The cervical spine is located in the back of the neck. In front of this spine is the esophagus (swallowing tube) and voicebox.

As such, when a spine surgeon goes through the FRONT of the neck in order to perform cervical spine surgery located in the BACK of the neck, (s)he has to move the esophagus and voicebox over to the side.

A plate is than fixated to the spine to fuse the cervical vertebral bodies.

Because of such manipulation of the esophagus and voicebox, it is not uncommon for a patient to complain of hoarseness and difficulty swallowing after surgery.

Fortunately, such problems usually dissipate with time, but not always.

Watch the video describing ACDF and how it can affect voice and swallow.

Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

The Vocal Problems of Professional Singers

The Washington Post on May 20, 2011 published a great article on the travails of opera singers regarding their vocal cords and the stresses placed on them (the singers and their vocal cords).

The opera singer (as well as any other professional singer) are the Olympic athletes of the voice.  As such, peak performance is mandatory in order to sustain a successful career. Just as an Olympic sprinter measures their success in milliseconds... the professional singer is judged by the most minute inflections, variances, irregularities of their voice. Never mind the back-biting and gossip.

99.9% is not good enough in this cut-throat world when anything less than 100% perfection is considered failure.

As such, the demands placed on the vocal cords are tremendous and rather than pulled hamstrings of a world-class sprinter, vocal cord swelling let alone nodules or muscle tension dysphonia can cut a career short.

Push the voice too hard... and they can get damaged, especially when vocal technique gets sacrificed to perform pieces beyond appropriate range (and even ability). Even professional opera singers have vocal instructors and coaches... a point I regularly make with amateur singers with injured vocal cords when they argue against the necessity of voice therapy and singing lessons ("I already know how to sing!").

Read the Washington Post story here.

I did want to point out that there was one error in the story...

Near the end of the story, it is stated that Giuseppe Filanoti had thyroid surgery. Although this can affect the voice, it is NOT vocal cord surgery as reported.