The power of voice therapy. (Laryngoscopic Clinic).

We have periodically treated a 32-year-old professional jazz and blues singer who maintains a busy performance and teaching schedule. During her first visit with us, she complained of intermittent hoarseness, pitch breaks, decreased singing range, vocal fatigue, and breathiness. She had also been treated for gastroesophageal reflux laryngitis with a proton-pump inhibitor, and at the time of her most recent visit, she was taking an [H.sub.2] blocker for her reflux symptoms. She had experienced multiple episodes of vocal fold hemorrhage in the past, which we treated with voice rest. She had had many years of professional voice training, but she had not taken any lessons during the previous 6 months.

On examination, the patient was moderately breathy and hoarse, and she experienced occasional episodes of diplophonia, especially at the higher frequencies. On videostroboscopy, we noted a moderate degree of supraglottic hyperfunction. The patient also exhibited reduced longitudinal tension on the right, which was suggestive of a superior laryngeal nerve paresis. This finding was confirmed by laryngeal electromyography. We also noted a mild erythema of the arytenoids, cobblestoning of the posterior glottic mucosa, and a large mass on the right true vocal fold (figure 1). The mass appeared to be fairly firm, at least partially fluid-filled, and sessile. It was diagnosed as a posthemorrhagic cyst. A reactive swelling with a central crater was also seen at the contact point on the left vocal fold. These masses prevented closure of the vocal folds anteriorly and posteriorly. Varicosities were noted bilaterally on the true vocal folds.

In light of the size and chronicity of these masses and particularly the patient's history of recurrent hemorrhage, we recommended microdirect laryngoscopy with excision of at least the right mass and excision of the varicose vessels to help prevent future hemorrhage. Because the patient had moderate hyperfunction, we asked her to work with a speech-language pathologist and singing specialist for several sessions before she made any final decision regarding surgery. We had hoped that this therapy would improve her vocal mechanics and reduce the size of at least the reactive left mass.

The patient initially decided to undergo surgery, but the operation was delayed for several months because of scheduling conflicts. In the meantime, she continued to participate in aggressive voice therapy. In fact, 5 months following her initial examination, her voice had improved substantially. After extensive counseling regarding the potential risks and benefits of surgery, she elected to continue voice therapy and nonsurgical management. Follow-up videostroboscopy performed 9 months following the initial evaluation showed persistent bilateral masses in the striking zones that interfered with complete glottic closure (figure 2). Persistent varices were also noted bilaterally. Nonetheless, the patient was happy with the quality and range of her voice, and she continued performing frequently without difficulty. She was counseled on measures to help minimize the risks of recurrent hemorrhage.

From the Department of Otolaryngology, Graduate Hospital, Philadelphia, and the Department of Otolaryngology, Thomas Jefferson University, Philadelphia