Broomfield • Brighton • Golden

Colorado Voice Clinic

Denver Voice Doctor

Voice Issues & Problems | Broomfield • Golden • Brighton • Colorado

Dr. King has undergone additional training in laryngology, a subspecialty field of ENT focusing on voice and airway disorders. Dr. King is uniquely trained in microsurgery of the larynx and is one of only a few fellowship trained laryngologists in the Mountain States area.

Peak ENT offers minimally invasive office-based laser surgery and other procedures of the throat. Dysphonia is a term to describe hoarseness or any change in voice quality. This is a very common symptom affecting about 1/3 of the population at some point in their lives, most often as a result of an upper respiratory infection that resolves in 7-10 days. Hoarseness that persists longer than 3-4 weeks may indicate a more serious problem and warrant scheduling an appointment for further evaluation.

Some of the symptoms we treat include:

Voice Disorder
Airway Disorders
Esophageal & Swallowing Disorders
Vocal Cord Dysfunction (VCD)
Laryngitis
Spasmodic Dysphonia
Vocal Cord Paralysis

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Our Voice Department

Voice Disorders

Having Vocal Disorders? We have answers.

Vocal disorders commonly present with a gravelly and hoarse voice. The cause can be a spectrum of disorders and pathologies ranging from benign respiratory infections to pervasive forms of laryngeal cancer. Peak ENT specializes in the early diagnosis and effective treatment of all presenting disorders.

Voice Disorders: Wide Range of Pathologies Can Result in Laryngeal (voice box) Disorders.

Patients typically present “hoarseness,” which is a general term that describes an abnormal sounding voice. There are many causes of hoarseness ranging from benign diseases of the larynx to more concerning malignant cancers.

Common causes of hoarseness include:

Viral upper respiratory infections (URI)
Vocal overuse or misuse (yelling, screaming, excessive talking)
Benign vocal cord masses (nodules, cysts, polyps)
Benign and malignant tumors (papilloma, granulomas and cancers)
Acid reflux
Smoking
Head and neck cancer (throat cancer)
Neurological conditions (Parkinson’s, Stroke)
Post-surgical nerve injury (from intubation, thyroid surgery, spine surgery or heart surgery)

When should you seek help for hoarseness lasting 3-4 weeks or longer?

Smokers or alcohol abusers (due to increased risk of throat cancers)
You are not otherwise sick with a cold or flu
Coughing up blood
Difficulty swallowing or painful swallowing
You feel a lump in your neck (enlarged lymph node)
Hoarseness associated with difficulty breathing
You are a vocal performer (singer, teacher, public speaker) and it affects your job

NORMAL LARYNX

This video shows an example of normal vocal cords seen on a videostrobe.

Airway Disorders

Airway disorders include abnormalities that affect the anatomy of the upper airway (throat and trachea). Patients present with difficulty breathing that may be gradual or sudden. Causes of airway obstruction include swelling from infections, inflammatory diseases, benign or malignant tumors, or scar tissue that narrows the breathing passage.

Specific treatments are aimed at the underlying cause and may include medications and/or surgical intervention. Our physicians perform in-office endoscopy with specialized scopes to make the diagnosis quickly and safely.

Lasers

Lasers are frequently used to treat airway disorders. Peak ENT physicians have extensive training in the use of a variety of laser types to treat laryngeal and tracheal lesions. Advanced technology has made possible minimally invasive techniques that are sometimes carried out under local anesthesia (without sedation) in the Summit Office in Broomfield. Dr. King is the only ENT surgeon in the state of Colorado performing these procedures.

Subglottic Stenosis

The subglottis is the upper trachea just below the vocal cords. Subglottic stenosis (narrowing) can result from infections, autoimmune diseases, severe reflux disease, or trauma. In some cases no cause can be identified (idiopathic). When the narrowing significantly impairs breathing, laser surgery and dilation of the narrowed segment can often achieve a normal tracheal airway diameter.

Esophageal & Swallowing Disorders

Esophageal and swallowing disorders (Dysphagia) can manifest at any age for a variety of reasons. Working in conjunction with swallowing therapists, Peak ENT can help diagnose common problems that prevent patients from swallowing normally.

Transnasal Esophagoscopy

Transnasal Esophagoscopy (TNE): Peak ENT’s digital endoscopy suite in Broomfield allows in-office and non-sedated esophagoscopy. Traditionally, gastroenterologists perform similar upper-GI endoscopies (Esophagogastroduodenoscopy or EGD) under sedative anesthesia that require close monitoring and extended recovery time. Otolaryngologists with special training now perform this procedure in the office with minimal discomfort. TNE has proven useful for diagnosing esophageal disorders such as strictures (narrowing), infectious/inflammatory diseases and abnormal premalignant or malignant lesions at the gastro-esophageal junction (Barrett’s Esophagus and carcinomas).

Esophageal Cancer

Esophageal Cancer has the fastest growing rate of all cancers in the United States and is the seventh leading cause of cancer deaths worldwide. In addition to problems swallowing, many of the early symptoms of esophageal cancer include chronic cough, hoarseness, and globus (sensation that something is stuck in the throat). Long-standing untreated or undiagnosed gastroesophageal reflux (GERD) and laryngopharyngeal reflux (LPR) are considered significant risk factors for developing cancer of the esophagus. Patients with these symptoms should undergo an esophagoscopy and/or barium swallow study for further evaluation and screening.

Laryngeal Cancer

Laryngeal cancer is the result of squamous cell carcinoma forming in the larynx tissue (voice box). While this cancer represents only 2-5% of all malignant cancers, its effects on swallowing and the voice are devastating. Though other forms of cancer are steadily decreasing, this specific type of cancer is increasing. The most common indication of this cancer is change or hoarseness of the voice.

Throat cancer can affect different areas. In this video, the cancer is eroding the left vocal cord entirely, causing a very hoarse voice and left vocal cord paralysis.

Other Symptoms Include

Constant coughing
Throat & Ear pain
Difficulty swallowing
Breathing difficulty
Mass or lump in the neck
Weight loss

Common Causes Include

Alcohol and tobacco use
Genetics
Viral factors
Prolonged exposure to toxins/fumes
Nutritional deficiencies

While these symptoms are often indicative of more mild conditions such as viruses, it is important to be vigilant regarding this cancer as early diagnosis is crucial. Early detection greatly increases the success rate of treatment. When caught early, this cancer is readily curable. Peak ENT provides in office biopsy lesions to identify this type of cancer directly. Utilizing the most effective and current endoscopic equipment, Dr. King represents the top of the field in treating laryngeal carcinomas.

This video shows a smaller cancer starting on the patient’s right vocal cord. She has a hoarse voice, but the cancer is confined to the edge of the vocal cord and there is no paralysis of the cord on that side.

Laryngeal Dysplasia (Pre-Cancer)

Laryngeal Dysplasia is the term for precancerous white or red patches on the vocal cord. While they are non-malignant, they can transition into malignant cancer if left untreated. Peak ENT offers in office laser procedures which treat laryngeal dysplasia on site.

This gentleman was found to have a white plaque (Leukoplakia) on his right vocal fold. A biopsy confirmed it was a high-grade, severe pre-cancerous lesion called dysplasia. This was successfully treated with a KTP Laser to prevent progression to cancer.

This is the same gentleman with the right vocal fold high-grade dysplasia undergoing an in-office KTP Laser procedure. The laser fiber is visible as it ablates the abnormal tissue. This patient is awake in the office with only local anesthesia.

Laryngeal Granulomas

Laryngeal granulomas are vascular lesions that occur on the back of the larynx. They are typically in response to trauma including extreme coughing, severe esophageal reflux, or laryngeal intubation. Symptoms often include vocal fatigue, hoarseness, pain and can cause chronic irritation if left untreated. While surgery has been offered as a treatment, the use of KTP lasers has been proven as a less invasive and more efficient treatment method. Peak ENT offers this precise and modern treatment option for patients suffering from laryngeal granulomas.

This gentleman presented with difficulty singing and intermittent breathing problems. This video is an example of a large left vocal process granuloma. The left vocal fold is also red from excessive coughing, resulting in hemorrhaging (bleeding) under the surface of the cord.

This is the same patient with the granuloma undergoing a KTP Laser ablation procedure in the office. You can see the laser fiber ablating the mass. This procedure was done in the office with the patient awake without sedation or general anesthesia.

This is the same patient after receiving two KTP Laser procedures in the office with only local anesthesia. You can see the granuloma is now very small compared to before treatment. The patient no longer has any voice concerns, and his breathing difficulties have been resolved.

Laryngitis

The larynx (“voice box”) is the upper portion of the windpipe (trachea) located in the middle of the neck around the Adam’s apple. The larynx is where sound/voice is created by the vocal cords. The larynx is also responsible for controlling airflow in and out of the lungs while preventing food and liquids from entering the lungs. Laryngitis is an inflammation of the larynx characterized by hoarseness, cough, difficulty in breathing and sometimes a sore throat. Viral infections are more common than bacterial. Non-infectious causes that have similar symptoms including acid reflux, chronic post-nasal drip from sinus and allergy problems, vocal cord masses (nodules, cysts or polyps), or nerve injury to the vocal cords (vocal cord paralysis).

Laryngitis from viral infections usually resolves by itself within one to two weeks with the help of voice rest and staying well hydrated. Because there are many possible causes of hoarseness, persistent symptoms should prompt further evaluation with your doctor. Dr. King specializes in diseases of the larynx and has specialized equipment that can help determine the root cause.

This patient has hoarseness due to a viral infection around the vocal folds resulting in swelling and poor vibration.

Laryngopharyngeal Reflux

Laryngopharyngeal Reflux (LPR) is detected through symptoms including a chronic cough, the feeling something is lodged in the throat, hoarseness, post nasal drip, the need to clear one’s throat, irritation or redness of the voice box etc. Though similar to GERD, the necessary symptoms of acid reflux, indigestion and regurgitation does not present with LPR, separating it from this condition. If left untreated, both GERD and LPR may increase the risk factor for Esophageal Cancer.

This video is an example of the vocal cords affected by acid reflux. Patients with this type of reflux usually have hoarseness, excessive throat-clearing and a sensation like something is stuck in their throat. The acid causes subtle damage around the voice box.

Spasmodic Dysphonia

Spasmodic Dysphonia (or laryngeal dystonia) is a vocal disorder characterized by involuntary spasms, contractions or movements of the muscles in the larynx region. It is classified as a neurological disorder known as a focal dystonia. The defining attribute of this disorder is its effects on the muscles, causing involuntary movement in a localized region. Spasmodic Dysphonia may also affect the muscles of the eye, face, jaw, tongue and neck. Symptoms present gradually, and while there is currently no definitive cure, Botox injection to the larynx proves extremely effective in negating symptoms. Visit www.dysphonia.org to learn more.

Recurrent Respiratory Papillomstosis

Recurrent Respiratory Papillomatosis (or PRR) is a disease in which tumors begin to grow in the air passages of the respiratory tract. While this often includes the nose and mouth, the larynx (voice box) is the most problematic location. Tumors tend to be recurring and grow rapidly. The cause is linked to two types of human papilloma virus: HPV 6 and HPV 11. Children and young adults are most commonly affected; however adults may experience this disease as well. While the presentation of this disease is rare (approximately 4.3% of all individuals exposed) possible transformation into squamous cell carcinoma is a risk factor. Hoarseness is the most common symptom, however coughing, difficulty breathing while lying down and difficulty swallowing may also be present.

Visit www.rrpwebsite.orgto learn more.

Vocal cord papilloma (RRP) is caused by the Human Papilloma Virus (HPV). In this video, it is mostly involving the patient’s entire right vocal cord. Vibration on that side is severely affected which results in a hoarse voice.

This video shows how the KTP Laser is used to treat (ablate) the papilloma. This procedure was done in the office with the patient awake. After two treatments, the papilloma was imperceptible!

This video shows the same patient after two KTP Laser procedures in the office. The papilloma has been completely ablated and his voice is back to normal.

Presbyphonia

As the vocal cords and supporting muscles age, they experience structural changes resulting in hoarseness, change in pitch, breathiness, and vocal strain. Symptoms begin occurring at approximately 60-70 years of age. This disorder can make articulation and vocal projection strenuous. It is important to rule out other causes with a laryngeal scope exam since these could also be signs of a vocal cord paralysis. Presbyphonia can often be treated through voice therapy or in some cases a surgery to enhance (augment) the laryngeal muscles.

This video shows an example of bowed vocal folds that results from aging atrophy of the vocal cord muscles. This results in a hoarse, weak, breathy quality voice.

Vocal Cord Polyps, Cysts, and Nodules

Vocal cord polyps, cysts, and nodules present as lesions on the vocal cord. They are noncancerous growths of varying size and structure. Their major symptom is vocal hoarseness, typically caused by vocal trauma or overuse.

Nodules

Nodules are common vocal cord lesions that typically result from vocal overuse or misuse. By definition they are bilateral, meaning they occur on both vocal cords directly opposite each other. Therefore, nodules are always plural. Nodules are like “calluses” that result from chronic abnormal friction between the cords. Over time these raised “bumps” on the cords affect how well the vocal cords can vibrate during phonation. Nodules result in the cords incompletely closing during phonation so patients’ voices often sound airy or breathy and pitch breaks are common. Singers may notice their upper register is erratic or absent.

Vocal cord nodules can occur in all age groups affecting both men and women. They appear more commonly in young boys before puberty, but beginning during the teenage years, nodules are far more common in women. Persons most affected or susceptible to develop nodules talk a lot or have vocally demanding jobs.

Like many voice disorders, nodules are best diagnosed by an experienced ENT who can perform a laryngoscopy or stroboscopy to directly look at the vocal cords. This is a simple and painless in-office procedure. Of note, it’s worth mentioning that many vocal cord masses are incorrectly labeled as “nodules.” It’s important to be evaluated by experienced ENTs who understand vocal lesions to make the correct diagnosis and ensure nodules are not mistaken for other common problems like cysts or polyps that are distinctly different.

Recommended treatment of vocal nodules is typically voice therapy and rarely requires surgery. Voice therapists help identify the underlying behavioral problems that created the nodules in the first place. By modifying how one uses their voice and creating healthy vocal habits, nodules usually resolve on their own.

- Caused by repetitive overuse of the voice
- Often referred to as “singer’s nodules”
- Most common in women between the ages of 20 and 50 years
- Appear as calluses under a microscope
- Can affect both men and women

Vocal misuse or overuse can result in vocal cord nodules or small bumps on each side of the vocal cords. Nodules don’t allow the cords to fully come together and vibrate normally. Patients with nodules have voice cracks or pitch breaks when talking or singing.

Polyps

- Caused by misuse/overuse of the voice
- Appear as red blisters of varying shape and size
- Can affect one or both vocal cords
- Generally larger than nodules
- Is often caused by vocal cord abuse such as shouting, singing, and excessive talking
- May also be attributed to smoking, allergies, sinusitis, and in rare cases hypothyroidism

This patient has hoarseness due to a polyp on his left vocal cord. You can see how it impairs vibration while he is talking.

The same patient seen a few weeks after the left vocal cord polyp was surgically removed. Normal vibration of the cords has been restored and his voice is back to normal.

Cysts

- Fluid filled sac with a semi solid center
- Present as mucus retention cysts or sebaceous cysts
- Less common than nodules or polyps
- Result of injury to the vocal cord

This patient has hoarseness due to a left vocal fold mass under the surface of the cord. You can see it affects the vibration and closure of the vocal folds when she is talking. The mass is a benign cyst.

This video shows the same patient a few weeks after surgical microflap excision of the left vocal fold cyst. Normal vocal fold closure and vibration have been restored, and her voice is back to normal.

Dr. King is a lead surgeon in endoscopic microsurgical procedures to correct and remove vocal cord lesions. Working in conjunction with a team of vocal therapists, Peak ENT leads the field in comprehensive and effective vocal cord care.

Vocal Cord Dysfunction – VCD

Vocal Cord Dysfunction (VCD) or paradoxical vocal fold movement (PVFM) is an abnormal closure of the vocal cords, usually on inhalation. It has been frequently mistaken for asthma. Individuals, however, can have either just VCD or a combination of asthma and VCD. It was first described by physicians at National Jewish Hospital.

Common symptoms include:
Struggle reaction with inhalation, shortness of breath, chest or throat tightness, intermittent hoarseness, numbness or tingling in hands, feet or around the mouth during a breathing episode, chronic cough or wheezing.

Evaluation:
Individuals should be examined by a laryngologist to determine the correct diagnosis.

Treatment:
Usually only 3-5 therapy sessions in addition to home practice exercises are needed to learn a technique which prevents abnormal vocal cord closure. Many individuals with VCD who have been previously misdiagnosed as having asthma are able to stop using asthma medications upon recommendation of their doctor and after a course of speech therapy.

Dr. King (laryngologist) and Dr. Artigliere (speech-voice pathologist) at Peak ENT are available to help diagnose and treat VCD.

The link below was written by a runner with VCD for runners and other athletes and includes comments from Dr. Artigliere.

Runners World Injury Prevention Recovery

Vocal Cord Paralysis

Vocal cord paralysis is diagnosed and treated at Peak ENT with non-surgical and surgical methods. Specialized in-office equipment and fellowship training makes the Voice Center at Peak ENT unique and sought after by professional and non-professional individuals relying on their vocal abilities.

The video below shows a patient (not the one above) with left vocal cord paralysis that resulted from a lung cancer. In this case the recurrent laryngeal nerve that is responsible for vocal cord movement is affected by the cancer.

Vocal cord paralysis can range from vocal cord weakness to total loss of movement and use. This debilitating condition makes communication extremely difficult for the sufferer. Causes include:

Stroke
Tumors
Neck or chest injury
Neurological conditions such as Parkinson’s
Injury to the vocal cords sustained during surgery due to nerve damage in the neck or chest region
Viral Infections including Epstein-Barr, Lyme Disease, and herpes virus

Vocal cord paralysis can be highly detrimental to verbal communication. Surgical and non-surgical treatment options are provided by Peak ENTs team of highly trained specialists. We utilize the utmost degree of modern medicine’s capability to restore patient’s quality of life.

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J. Michael King, MD

Voice Specialist