Evaluation and Treatment of Voice Problems


Evaluation and Treatment of Voice Problems


Table of Contents: Quick Links:

Care of the Professional Voice

What Happens at the Initial Visit?


What Can Go Wrong With the Voice?

Voice Therapy

Computerized Voice Analysis

Singing Voice Therapy

Surgical Procedures

Awake Laryngeal Procedures

Botulinum Toxin Injections



1. Care of the Professional Voice

It is a personal form of self-expression and communication.  Every person has a unique voice which is an integral part of their identity. Voice is an important part of our lives and never is this more evident than when it ceases to be reliable.  Professional performers are often keenly aware of changes in their voice quality, range, and level of effort to achieve their vocal demands, and will seek out professional help and advice when they experience these changes.  Others, however, may tend to ignore a change in voice quality until it becomes difficult or impossible for them to manage their daily activities, both socially and in the workplace.  This delay may be very costly, and in the least, may delay healing and return to normal function.  Early evaluation and management of voice problems yield the best chance of complete voice recovery.  Voice teams composed of a laryngologist and voice pathologist provide specialized care for the voice professional, and together with the patient, they create a program of healthy voice use to promote healing and healthy function.

When one considers the term “professional voice user,” one typically thinks of professional performers, such as professional singers or actors. However, numerous occupations depend on a healthy voice for effective communication, including but not limited to: teachers, sales professionals, clergy, telemarketers, receptionists, broadcasters, physicians, assembly line leaders, and many others.  In fact, it is difficult to think of many professions where the voice is not needed to work and communicate effectively.  By this definition, anyone who needs to rely on his or her voice to do their job effectively is a professional voice user.

The first line of defense in caring for the voice is the prevention of injury. Prevention includes training in healthy techniques for speech and singing, as well as a vocal hygiene program.  It also requires attention to and seeking care for voice changes. Those in vocally demanding occupations are most at risk and would benefit from education and training for healthy voice use to assure a long and healthy career.  Investment in training will likely pay dividends by preventing future vocal injuries and lost work days.

We at Lakeshore Professional Voice Center are dedicated to the care and rehabilitation of voice injuries and are trained to restore voice function for all people with voice concerns: those with average voice demands as well as high-demand, professional voice users who rely on his or her voice to be able to work.

What Happens at the Initial Visit?

At Lakeshore, we provide a multidisciplinary approach to patient care. This means a laryngologist and voice pathologist will work together to diagnose and treat patients in a collaborative fashion.

At your initial evaluation, you will meet with the voice team to discuss your problem.  The doctor will perform a full head and neck examination and evaluate the larynx (voice box). The vocal folds are visualized with flexible (through the nose) and rigid (through the mouth) strobovideolaryngoscopy to assess their structure, movement, and vibration.

The voice pathologist may record a patient’s voice and perform a computerized analysis of the voice sample. Additional tests assess the potential for voice therapy as a treatment modality for voice problems.

By the end of an evaluation, patients will understand the nature of their voice problem and the potential roles of voice therapy, pharmacology (medicine) and surgical intervention in the treatment of their voice problem. Additional workup may be recommended.


2. Videostroboscopy

Videostroboscopy is a sophisticated imaging technique that allows the clinician to evaluate the vibratory characteristics and structure of the vocal folds in the awake patient. A surface microphone is placed on the larynx to detect the frequency of vibration of the vocal folds. This sends a signal to a computer which triggers a stroboscope to flash at a rate slightly slower than the vibratory cycle of the vocal folds. As a result, the clinician is able to see the vibration of the vocal folds in slow-motion. The vocal fold is a multi-layered structure. Videostroboscopy provides a method to evaluate the structure and its vibratory properties in great detail so that the voice care team can make an accurate diagnosis and treatment plan. The examination is recorded and archived, so that it may be reviewed multiple times. Treatment can be followed closely. A complete analysis of a voice problem requires videostroboscopy.

Videostroboscopy may be performed through a flexible laryngoscope or rigid 70-degree telescope. The flexible laryngoscope is passed through the nose after topical anesthesia is applied. The telescope is passed about 2 inches into the mouth so that it can look down at the larynx. The telescope provides more magnification, and thus, is often more successful in evaluating small vocal fold lesions or vibratory abnormalities. The voice team at Lakeshore Professional Voice Center uses the most sophisticated stroboscopic equipment available today.

What Can Go Wrong With the Voice?

Vocal Fold Lesions - Lesions on the vocal folds will often present with a change in voice quality (hoarseness).  That is because they are likely to impair the vibration and closure of the vocal folds.  Many vocal fold lesions develop from trauma or insufficient use (misuse or abuse) of the voice. Other lesions may develop from a virus or other process.  Cancers can develop on the vocal folds and other parts of the larynx as well.  

Examples of Lesions in the Vocal Folds Include:

  • Nodules: Nodules are pinpoint, symmetrical calluses that form on the vocal folds due to repetitive vocal trauma (misuse and abuse).  Often this term is overused by physicians, and almost every mass on a vocal fold is called a “nodule”. However, this term should be reserved for small, symmetrical calluses that form on both vocal folds directly opposite from each other.  Also, by definition, nodules will go away with specialized voice therapy and proper use.
  • Hemorrhagic Polyps: Hemorrhagic polyps are formed by a “vocal accident”. This may be a scream at a football game, singing a note out of one’s normal vocal range, or from a violent cough.   A blood vessel ruptures and blood spreads throughout the vocal fold resulting in a vocal fold hemorrhage.  Over time, the hemorrhage may localize and a collection of blood accumulates into a polyp on the edge of the vocal fold.  If detected early, the polyp will look red because it will be filled with fresh blood. Over time, however, the redness may disappear and the polyp may appear translucent.  Small polyps can be treated with voice therapy, but often surgical intervention is required.
  • Cysts: Vocal fold cysts are like cysts in other parts of the body.  Essentially they are fluid-filled sacs surrounded by a capsule skin.  The fluid may be very thick or thin. They are often deep within the vocal fold, but may also occur on the edge.  It is not clear what exactly leads to vocal fold cysts.  Vocal trauma likely plays a role in many cases.  Although voice therapy is useful in the treatment of vocal fold cysts, microlaryngeal surgery is often warranted.  Meticulous dissection is required, particularly when the cyst is deep within the vocal fold.
  • Reinke's Edema, Reinke's Polyposis, Polypoid Degeneration, Smokers' Polyps: These terms are often used synonymously, but likely represent different severities of the same process.  The layer of the vocal fold just underneath the epithelium (skin) of the vocal fold is called “Reinke’s space”.  When it accumulates fluid, it is called Reinke’s edema.  This may result from chronic trauma or inflammation.  When this layer becomes more “jelly-like”, it is called polypoid degeneration.  As the jelly-like substance accumulates, the whole vocal fold becomes larger and heavier, resulting in a lower pitch to the voice.  This is called Reinke’s polyposis, or the development of “Smokers’ polyps”.  The name comes from the fact that this process is caused by smoking.  When this occurs in men, they are sometimes bothered by the raspiness of the voice.   When it occurs in women, they are bothered by the voice becoming more “manly”. If the polyps become very big, they can actually block the airway and cause significant breathing problems. Treatment involves smoking cessation and surgical intervention.  Often, these lesions can be treated very well with an awake pulsed KTP laser procedure. Classic microlaryngeal surgery is still required at times. 
  • Sulcus/Scar: These terms are often used interchangeably as well.  A sulcus is a groove in the vocal fold resulting from loss of the deeper tissue layers of the vocal fold.  There are different types of sulci depending on the depth of the groove.  A physiologic sulcus is a shallow groove that may not cause any voice problems at all.  A “sulcus vergeture” is a deeper groove and often does cause voice problems.  A “sulcus vocalis” or “type 3” sulcus is a deep pit in the vocal fold that often goes all the way to the vocal ligament or muscle.   This almost always causes significant hoarseness and is a very difficult problem to treat. Vocal fold scar results from loss of the pliable tissue layers of the vocal fold.  It may be more irregular in appearance than a sulcus, and not look like a discreet groove.  Both scar and sulcus result in impaired vibration, and often closure, of the vocal folds.  When severe, these can be very difficult to manage, as we do not have a way as of yet to dependably restore lost pliable tissue.  Voice therapy and, in some cases, surgery can be helpful, but the best way to treat scar is to prevent its formation.  This requires good vocal hygiene and paying and seeking attention to any change in vocal quality lasting longer than 2 weeks.  Voice therapy is often useful in preventing mature scar formation.  Sometimes injections of steroids into the vocal folds are also useful. There is some controversy as to how sulci form: some may result from a ruptured cyst, others may be congenital.  Vocal trauma likely plays a role in their development. Certainly, if one develops a polyp or other mass on one vocal fold, and it goes ignored, it may cause a sulcus on the other vocal fold by continually banging into it.  This can make it much more difficult to recover the voice completely. Vocal fold scar almost always results from vocal trauma. This can be the result of an ignored vocal fold hemorrhage or tear or persistent vocal abuse.  Even a bad coughing fit can result in scar if resulting persistent hoarseness is ignored.
  • Papilloma (Human Papilloma Virus): Papillomas are lesions resulting from infection involving the human papillomavirus (HPV). When it occurs within the larynx (voice box), it causes hoarseness and, in serious cases, airway obstruction. Treatment is surgical. Unfortunately, this is not a curable disease and recurrence is likely. There are some adjuvant treatments which may slow the rate of recurrence. These include injections of the vocal folds with cidofovir or Avastin. Papillomas are precancerous, although some subtypes present a higher risk than others. The goal of surgical treatment is to maintain the function of the larynx, primarily preserving the voice, and keeping the airway patent. This requires meticulous surgical technique. Often, these lesions also may be treated with awake pulsed KTP laser procedures performed without a general anesthetic, although microlaryngeal surgery might be warranted.
  • Cancer: Laryngeal cancer (cancer of the voice box) is most commonly caused by smoking. Reflux and human papillomavirus (HPV) can also lead to laryngeal cancer. When cancer affects the vocal folds themselves, this will cause hoarseness. If the hoarseness is not ignored, early diagnosis can be made. Dr. Rubin treats some early cancers of the vocal folds endoscopically (through the mouth), often avoiding radiation therapy. More advanced lesions are treated by one of Lakeshore Ear, Nose & Throat’s head and neck cancer specialists.
  • Aging Voice: Certain changes can occur to the vocal folds as we age. “Presbyphonia” is the term used to describe the aging voice. “Presbylaryngis” is the term given to the larynx which demonstrates changes from aging. Often the vocal folds become thin and more flaccid. Closing the vocal folds becomes more difficult, so the voice may become somewhat more breathy and weak. In addition, other changes can occur as we age including insufficient breath support which can also adversely affect the power of one’s voice. Presbylaryngis can be seen in people as young as 50 years old. One should NEVER attribute a change in vocal quality solely to age until all other possible reasons have been investigated and ruled out. Visualization of the vocal folds is mandatory to rule out cancer or other lesions of the vocal folds, vocal fold paralysis, or neurologic diseases. Presbyphonia is often successfully treated with specialized voice therapy. When voice therapy does not sufficiently return the patient their optimum voice, Dr. Rubin offers injection laryngoplasty to improve contact of the vocal folds, thereby improving vibration and voice quality.  The procedure involves an injection of the vocal folds with a filler material to “bulk up” the vocal folds.  This minimally invasive procedure can be performed with topical anesthetic, avoiding the potential risks of a general anesthetic. The filler material eventually resorbs or dissolves over time, and the procedure can be repeated, or a permanent procedure (thyroplasty) can be performed.
  • Vocal Fold Paralysis and Paresis: One or both vocal folds can become paralyzed, or immobile due to a variety of circumstances. The most common reasons for this include surgery on the neck (cervical spine surgery, thyroid surgery) and cancer.  Even cancer in the lung can cause a vocal fold paralysis because it may affect the nerve to the vocal fold which travels into the chest before turning upwards to enter the larynx (voice box). Another common cause of vocal fold paralysis is called “idiopathic vocal fold paralysis”. “Idiopathic” means that we do not know the cause. The most likely cause is a virus. Certain neurologic, rheumatologic, and cardiovascular diseases can also result in a paralyzed vocal fold.  Sometimes an immobile vocal fold results from injury to the joint that rotates the vocal fold. When one vocal fold is paralyzed this is called “unilateral vocal fold paralysis”. This typically, though not always, results in a very breathy voice because the vocal folds cannot close and air escapes during voicing. Patients may feel winded when they speak. When both vocal folds are paralyzed, the voice often is not as badly affected, because usually the vocal folds are paralyzed fairly close together. Unfortunately, breathing is often affected because the airway becomes narrow. Stridor, or voicing in inhalation may be heard when breathing. Treatment options for unilateral vocal fold paralysis include voice therapy, injection Laryngoplasty, and laryngeal framework surgery (thyroplasty and arytenoid adduction). If the paralysis occurred after a surgery, and the nerve was not severed, it is typical to wait for a year to allow for recovery of function before offering any permanent adjustments. Injection Laryngoplasty is a good, temporary solution to help in attaining a better voice while waiting for a nerve recovery. When a patient presents with a paralyzed vocal fold without a traditional cause (e.g., immediately following thyroid surgery), a CT scan of the neck and chest is ordered to rule out a malignancy. There are two nerves that supply movement to the vocal folds. The recurrent laryngeal nerve (RLN) is predominantly responsible for vocal fold opening and closing.  The superior laryngeal nerve (SLN) is primarily responsible for stretching the vocal fold which affects the ability to change pitch. When the SLN is injured, the voice may be affected more subtly. If it is injured on both sides, singers, in particular, will notice a dramatic reduction in vocal range. This can be a very difficult injury to treat. Lastly, nerves may be only partially injured resulting in a partial paralysis or “paresis.” This is a less severe injury, and treatment options are mostly the same as for a complete paralysis. Treatment of bilateral vocal fold paralysis requires improvement of the airway. In severe cases, a tracheostomy might be required. Additionally, procedures which increase the size of the airway at the level of the vocal folds can be performed through a scope in the mouth. The procedures include laser cordotomy and arytenoidectomy.
  • Spasmodic Dysphonia and Laryngeal Tremor: Dystonias are disorders of abnormal muscle contraction. “Writer’s cramp” may be the most well-known dystonia.  Focal dystonia of the larynx is termed spasmodic dysphonia (SD). There are several types: adductory, abductory, and mixed.  Adductory is characterized by abnormal spasms causing vocal fold closure. The voice sounds tightly pressed and strained. Abductory SD is characterized by abnormal spasms resulting in an opening of the vocal folds. Thus, the voice has numerous breathy breaks. Lastly, mixed dystonia has both adductory and abductory spasms. Laryngeal tremor results in a “shaky” quality to the voice. The most famous example of this was the voice of the marvelous actress, Katherine Hepburn. Laryngeal tremor may coexist with SD or be the only movement disorder. SD, and often laryngeal tremor, can be treated with botulinum toxin injections into the vocal folds. This minimally invasive procedure is performed by Dr. Rubin in the office setting. Voice therapy is often helpful as an adjunct measure, and in distinguishing spasmodic dysphonia from other disorders. Oral medications for tremor can be tried, but are often ineffective. Spasmodic dysphonia is sometimes confused with other neurologic diseases, and visa-versa. Appropriate diagnosis is crucial to ensure appropriate workup and treatment.
  • Change in Resonance: Anything affecting resonance cavities above the vocal folds can result in changes in resonance. Most people have experienced nasal congestion due to a cold or allergies at some point, and the subsequent changes in voice/resonance. Other reasons for having altered resonance can be reduced movement of the soft palate (after a stroke or neurological affection), polyps or growths in the nose or throat or in any area of the vocal tract. Changes in resonance may be addressed in voice therapy, although in some cases additional medical or surgical management might be necessary.


3. Voice Therapy

The American Speech-Language Hearing Association (ASHA) defines voice therapy as a program designed to reduce hoarseness through guided change in vocal behaviors and lifestyle changes. Voice therapy consists of a variety of tasks designed to eliminate harmful vocal behavior, shape healthy vocal behavior, and assist in healing after injury, or in preparation for and recovery from vocal fold surgery. Essentially, it is ‘physical therapy’ for the voice. Following a thorough voice evaluation, the voice pathologist, together with the patient, will develop a plan of care specific the patient’s voice demands. Sessions are typically approximately 30 minutes in length and occur once weekly for an average of 6-8 sessions. During these sessions, the voice pathologist will guide the patient in exercises that target rehabilitation of the voice. It is recommended that patients record sessions for use in daily home practice, using a smart phone’s voice recorder application, a digital voice recorder, iPod, or tape recorder. Each session will begin with a review of the previous week’s assignments and will build on these skills as they are acquired, applying them to conversation and other functional uses specific to the patient’s needs (e.g., presentations, classroom instructions, etc.) The therapy plan treats not only the patient’s particular voice disorder but provides a life-long maintenance program for healthy and efficient voice use.


4. Computerized Voice Analysis


Voice recordings are analyzed through the Computerized Speech Lab (CSL) and a full report describing the patient’s voice is generated.



These analyses are then compared with a database of normal measures. Using quantitative and qualitative measures, this information is used to establish “before” and “after” measures which are helpful setting treatment goals and to assess the patient’s progress. The voice laboratory is also equipped to perform specific voice tests which provide in-depth information regarding the underlying mechanisms of voice disorders.


View a Sample Report >


5. Singing Voice Therapy

What is a Voice Pathologist?

Speech pathologists treat a variety of communication and swallowing disorders (e.g., speech delay, articulation disorders, communication disorders, autism, brain injuries, dementia, head and neck cancer, swallowing issues, etc.), including voice. However, voice disorders make up a very small percentage (~8%) of the disorders they treat. A voice pathologist (also called a voice therapist) is a speech-language pathologist who has completed a clinical fellowship or independent study in voice disorders and rehabilitation, and who specializes exclusively in the treatment of voice and upper airway disorders.

What is a Singing Voice Specialist?

The Voice Foundation defines a singing voice specialist as a singing teacher who has special training equipping him or her to practice in a medical environment with patients who have sustained vocal injury. Most singing voice specialists have a degree in voice performance or pedagogy. Some have extensive performing and teaching experience but without a formal academic degree. Nearly all have professional performance experience, as well as extra training in laryngeal anatomy and physiology of phonation, training in the rehabilitation of injured voices, and other special education. Some voice pathologists have extensive experience with the singing voice, and thus, are also singing voice specialists.  Lakeshore is proud to have voice pathologists all experienced in treating the speaking and singing voice.

Singing Voice Therapy

Singing voice therapy is specialized therapy for the treatment of voice disorders in the singer. Typically, therapy is focused on the speaking voice and subsequently transitioned to the singing voice. The singing voice specialist will coordinate care with the patient’s singing teacher if he or she has one. Ultimately, the singer will return to private study once therapy is complete.


6. Surgical Procedures

Microlaryngeal Surgery

Surgery may be indicated for some vocal fold lesions. Because of the delicate architecture of the vocal folds, highly-skilled surgery is required to restore vibration to the vocal fold. Microlaryngeal surgery is performed through a scope that is placed in the mouth. It is performed under a high-powered microscope using delicate instruments to remove the lesion. General anesthetic is required. Postoperative voice therapy is necessary to assist in healing. Limits on voice use are typically placed to assist in healing after the procedure.

Some lesions are able to be treated with awake laser procedures performed under topical anesthetic, avoiding the risks and inconvenience of a general anesthetic.


1. Schedule a visit with the voice pathologist. When preparing for a surgery, you will meet with the voice pathologist at least one time before surgery. During this visit, the voice pathologist will evaluate and record your voice so that progress can be monitored. The voice pathologist will also review a postoperative voice rest protocol and a recovery plan for your voice and answer any further questions you may have regarding your surgery and recovery.
2. Schedule one-week postoperative visit with Dr. Rubin. Typically, one week after your surgery, you will see Dr. Rubin, who will go over pathology results and view and evaluate your vocal folds as they are healing. He will then give permission for you to start using your voice again*.
3. Schedule one-week postoperative visit with the voice pathologist. These two appointments (one week post op with Dr. Rubin and one week post-op with the voice pathologist) can often be made for the same day. Once Dr. Rubin has given you permission to use your voice, the voice pathologist will “break your silence” through a structured hierarchy of gentle exercises combined with specified periods of vocal rest. These exercises are designed to reduce inflammation and promote healing. You will also be taught to use a “confidential” or “breathy” voice to maintain gentle, low impact vibration in brief conversations (see Voice Rest Protocol). A therapy plan tailored to your needs will be discussed, which generally involves therapy appointments once a week for 6-8 sessions.
4. Make sure you have any prescriptions filled that Dr. Rubin has prescribed for you (e.g., reflux medication)
5. You may need medical clearance from your primary care doctor or other physicians. If this is the case, make appointments accordingly before the date of surgery.
6. Make sure you stop any blood thinners before the surgery.

Prepare for one week of complete voice rest following your surgery. You may use text-to-speech apps, paper and pen, dry erase board or Boogie Board to communicate, but you may not use your voice.


7. Awake Laryngeal Procedures

Numerous procedures on the vocal folds and larynx that traditionally have been performed under general anesthesia are now able to be performed on an awake patient with only topical (local) anesthesia. For those patients who do not feel they could tolerate being awake, a light sedation can be provided. In either case, patients can avoid the added risk and expense of general anesthesia. In addition, if no sedation is given, patients are able to drive themselves to and from the procedure, and return to daily activities more readily, as they do not have to wake up and feel the after-effects of general anesthesia. The development of these techniques has truly advanced the field of laryngology and care of the voice. These procedures are safe and well-tolerated. In fact, studies have shown that most patients would prefer to do these procedures awake, rather than while asleep.  Every patient is different. Dr. Rubin discusses all possible treatment options and determines if an awake laryngeal procedure is appropriate for you.

The most commonly performed awake laryngeal procedures include: injections into the vocal folds to assist in vocal fold closure and strengthen the voice; laser procedures for benign and precancerous laryngeal lesions; transnasal esophagoscopy, and small biopsies of laryngeal or esophageal lesions.  A brief description of each is given below.

Injection laryngoplasty is a procedure that is performed to improve the closure of the vocal folds. In general, this is most commonly performed for patients with a paralyzed vocal fold and for patients who have atrophy (thinning) of the vocal folds.

Vocal fold atrophy typically occurs with age (presbyopia). The procedure may be performed while the patient is under general anesthesia or with the patient awake with topical anesthetic. When performed awake, the patient’s nose is anesthetized with cotton pledgets soaked in anesthetic. Some topical anesthetic is also sprayed into the mouth to anesthetize the throat. Lastly, anesthetic is either dripped onto the vocal folds or injected into the trachea. A thin flexible laryngoscope (camera) is passed through the nose and held in place to visualize the larynx.  Dr. Rubin is then able to pass a needle through the skin and inject filler into one or both vocal folds.

Vocal fold atrophy is particularly common in the elderly (aging voice). Awake injection laryngoplasty is a wonderful technique to help the aging voice without putting the elderly patient at risk of general anesthesia.

Awake pulsed KTP laser ablation of laryngeal lesions can be performed using a fiber laser passed through a port in a flexible laryngoscope. The laryngoscope is passed through the nasal cavity after the appropriate anesthetic is applied (see above). This is particularly useful for recurrent lesions of the vocal fold, such as laryngeal papilloma (HPV) and dysplasia (precancerous changes). These lesions can recur very rapidly and have the potential to advance to cancer.  In the past, patients had to be put to sleep on numerous occasions to treat these lesions. Dr. Rubin uses the pulsed KTP laser to treat these lesions in the awake or lightly sedated patient. This laser targets blood vessels. In general, papilloma and dysplasia are highly vascularized so the laser targets these lesions while sparing the rest of the vocal fold. This minimizes trauma to the normal vocal fold tissue, resulting in excellent voice recovery. Abnormal blood vessels (ectasias and varices) which may cause voice changes or recurrent hemorrhages can also be cared for in this fashion. Other benign lesions such as hemorrhagic (traumatic) polyps and cysts may be treated this way, however, in general, hemorrhagic polyps and cysts are more precisely excised with microlaryngeal surgery.

Injection Laryngoplasty

Injection laryngoplasty is a temporary procedure to improve the closure of the vocal folds, usually due to vocal fold paralysis or the aging voice. It involves injecting a filler into the vocal fold to “plump it up” and help it make contact with the other vocal fold. Sometimes the procedure is done to help the patient with a paralyzed nerve while the nerve is regaining function. Other times it is used as a “trial” to see if additional vocal fold closure will help the voice. The procedure may be performed through a scope in the mouth with the patient under a general anesthetic (like microlaryngeal surgery) or with a topical anesthetic only as an awake laryngeal procedure.

Laryngeal Framework Surgery

Laryngeal framework surgery is designed to improve the function of the larynx when the vocal folds cannot close well. This is often seen in the case when one vocal fold is paralyzed (vocal fold paralysis) and in the aging voice. Voice therapy is often tried first. Sometimes, injection laryngoplasty will be tried prior to performing the permanent laryngeal framework surgery.

Thyroplasty is the most common framework surgery performed. This involves exposing the larynx with a small incision in the skin of the neck. A window is then drilled within the cartilage of the larynx. An implant is placed through the window and pushes the vocal fold toward the midline so that contact with the other vocal fold is improved. This results in a stronger voice and cough. It also helps with the “windedness” one might feel when he or she cannot close the vocal folds.

Arytenoid adduction is an additional procedure to help with vocal fold closure when a thyroplasty is not sufficient. This involves exposing the cartilage that rotates the vocal fold to close. A stitch is placed through it to mimic the natural action of the cartilage and rotate the vocal fold more to the midline.

Voice Rest Protocol

  • Week One: For the first week following your surgery, you are on Complete Voice Rest. This means no speaking, no singing, no whispering, no whistling, no humming, no throat clearing, no coughing, no heavy lifting, and nothing that presses the vocal folds together.
  • Week Two: After Dr. Rubin gives you permission to use your voice again, you are advised to perform gentle voice exercises approximately one minute every 15 minutes. Each week, you will add more exercises and one additional minute per every 15 minutes, so that by week 6 you will be speaking approximately 5 minutes per every 15 minutes, which is said to be the average amount of voice use for the average person. Your voice pathologist will go over this protocol with you in more detail at your preoperative therapy visit.


8. Botulinum Toxin Injections
(For treatment of spasmodic dysphonia, vocal tremor, chronic cough, and upper esophageal sphincter dysfunction)

Botulinum toxin injections to the muscles of the vocal folds is the gold standard treatment for spasmodic dysphonia.

  • It may also be used to treat laryngeal tremor and chronic cough.
  • Patients return for repeat injections every 3-6 months, depending on symptoms.

What to Expect for the First Injection

When referred for Botox, patients undergo a comprehensive evaluation of the voice. Patients may work with the voice pathologist to unload any compensatory muscle tension and to obtain baseline vocal function measures.

Patients are then scheduled to be seen in Botox clinic, during which the physician will inject muscles of the vocal folds with Botox.

To start, the physician numbs the skin of the neck with lidocaine. Electromyography is used to guide a needle to the appropriate muscle, which requires electrodes to be placed on the patient with cords that attach to the needle. The physician then injects one or both muscles of the voice box (larynx) with Botox.

What to Expect After an Injection

Within a few days, the patient’s voice becomes weak and breathy, but with less spasm or tremor. Ideally, this effect will last 1-2 weeks. As the voice returns, tremor/spasm/cough will ideally be reduced. This “good” effect ideally will last 3-6 months.

Botox dosing is not a perfect science, so it sometimes takes several injections to find the “optimum” dose. The way this is determined is by having patients track their voice quality after the injection. If the patient is breathy for too long, the physician may reduce the dose for the next injection. If the patient is not breathy for very long or if spasms return sooner than desired, the physician may increase the dose for the next injection.


Three days after your injection, patients are asked to leave a message on the Lakeshore answering machine so that the voice team may hear the effects of the injection (the patient’s voice should be breathy). To leave this message, call (586-779-7610 Ext. 174) and leave a few sentences stating your name, the date, and how your voice is doing. Please do not use this extension for any other reason, as these messages are NOT checked daily. If you need to contact someone in the office, call the front desk at 586-779-7610 or use the patient portal.


Two weeks after the first injection, patients return to the office for a videostroboscopy to evaluate the movement of the vocal folds. Patients typically only have to do this after the first injection.

When patients feel the symptoms return, they call the office, to schedule another Botox injection.

For repeat injections in Botox clinic, patients meet with the voice pathologist to discuss voice symptoms, so patients are encouraged to keep track of their voice and bring back the form they have filled out. This helps determine the need for changes in dosing, which patients then discuss with the physician, who then reinjects the muscles with Botox, and the process repeats.