Speaking up to Save a Voice: New Surgery Creates a Vocal Platform
Jerry Young had had a routine endoscopy and assumed that the hoarseness that appeared in his voice was an after-effect of that exam. "If it doesn't go away in a couple of weeks, make an appointment with an ENT," his doctor told him. It didn't and Young went to see an ear, nose and throat physician, who thought the redness on Young's left vocal cord was caused by a virus.
Young was not convinced. He had been retired from his job as an engineer and yet his information-seeking mindset continued. His research made him suspect that cancer was the cause. A friend of his wife, under treatment for cancer at Stanford Hospital & Clinics, recommended he see a physician there.
His redness was cancer, a squamous cell carcinoma. It was small, at a very early stage. Radiation offered as much as a 90 percent chance of removing the cancer, so Young went through that treatment. But the cancer remained and Edward J. Damrose, MD, director of the Stanford Voice and Swallowing Center, became Young's doctor.
I had no idea that voice sparing was an option. I had no idea Dr. Damrose was one of the few in the U.S. with the ability and skill to do this surgery.
In the midst of his fear about the cancer, Young prepared himself for the worst. He didn't think about what surgery might bring; he just wanted the cancer out. "Both my mother and brother died young, of pancreatic cancer. I knew mine was neither as aggressive or lethal as theirs, but having any kind of cancer was not something I wanted," he said.
More than sound
He did trust Damrose's knowledge. "I had a lot of confidence in Dr. Damrose, in him as a person and his ability to make good decisions," Young said.
What Damrose did was a surgery that saved Young's ability to speak without any kind of mechanical equipment inserted in his neck, preserving his dignity and freedom of expression. In a surgery done only at a few medical centers in the U.S., Damrose removed the part of Young's larynx where the cancer lay. Then he closed the gap by connecting the two main supports of the larynx, the cricoid cartilage and the hyoid bone. Instead of air vibrating through the muscular vocal cords, it vibrates with the help of cartilage, allowing a human voice instead of a robotic one to say the words that form Young's life. The procedure is called a supracricoid laryngectomy with cricohyoidoepiglottopexy. Young's surgery was one of just a dozen times in the last year that Damrose, one of the nation's few experts in the procedure, performed at Stanford Hospital & Clinics.
The voice is, of course, as distinctly identifying as a person's face. Perhaps even more than the face, the voice is a nuanced audio track of every possible emotion. From the interplay of the vocal folds, muscles, cartilages, nerves, tongue, mouth, palate and lungs comes the ability to form words that resonate and emerge as audible communication.
The ability to speak can be altered by a number of changes in that set of voice-enabling components, including loss of muscle mass, decreased saliva and vocal cord atrophy or paralysis. And, surgery for cancer.
Cancer of the larynx is the most commonly diagnosed head and neck cancer. Between 10,000 and 12,000 new cases emerge each year in the United States. But it is the least common cause of hoarseness. Its symptoms also include difficulty swallowing, coughing up blood, sore throat and trouble breathing.
Any surgery in these tight quarters must be done precisely. "One millimeter too far one way," Damrose said, "and you've cut out an important nerve needed to speak. Too far the other way and you've left cancer behind, or your patient will never swallow again."
- Vocal cords are two bands of smooth muscle located in the larynx, sometimes call the voice box
- The larynx is located at the top of the trachea, or windpipe
- Sound is created as air from the lungs vibrates the vocal cords
Protecting your vocal health
- Drink plenty of water, for its moisturizing effect
- Don't smoke. Smoking raises the risk of cancer and vocal cord polyps. Alcohol consumption by smokers also increases risk. As many as 90 percent of head and neck cancers are related to use of these substances.
- Keep your voice below the yelling and screaming level, which strains the vocal cords.
- Symptoms can include persistent hoarseness, difficult or painful swallowing, ongoing sore throat, difficulty breathing, pain in the ear, lump in the neck.
Common vocal cord conditions
- Laryngitis: an inflammation that can be caused by infection, overuse of the voice, inhaled irritants or gastrointestinal reflux
- Nodules: small, benign and callous-like growths
- Polyps: soft, benign and blister-like growths
- Vocal cord hemorrhage, paralysis or weakness
When to see your doctor
- If you have hoarseness or a change in voice that lasts for more than two weeks
That precision, he said, is even more of a challenge because "you are cutting through thick and muscular tissue," he said. If a patient has had radiation, that treatment can distort and swell the structures' appearance, adding another level of difficulty.
Once you look at what you've got, it becomes very intuitive as to why it works and works so well. I'd like to see it more routinely offered, to preserve more larynxes.
"I had no idea that voice sparing was an option," Young said. "Dr. Damrose just said, 'We'll go in and take this thing out.' He didn't want to get my hopes up, I think, so he didn't get into specifics. It was months later that he asked if I wanted to know the specifics. I had no idea that he was one of the few in the U.S. with the ability and skill to do this surgery."
The traditional approach has been to remove the entire larynx, following failed chemotherapy or radiation. It's a relatively quick surgery—about four hours, compared to the seven hours Damrose needed for Young's partial laryngectomy. The impact is hugely different. With a total removal of the larynx, speaking is possible only with external help. The most common involves a prosthesis that fits into a hole in the throat; some work when pressure is applied, others can function hands-free. For others, speaking requires an electronic device pressed against the throat to amplify vocal sounds. Sometimes, some of the nerves to the tongue can be affected, damaging the ability to swallow and taste.
The psychological trauma, Young said, is immense. He saw it first when he went to a meeting of a laryngectomy support group and found himself the only person without a prosthesis. "None of the people there had ever even heard about the surgery I'd had."
Developed in the 1950s and popularized by French surgeons, the surgery Damrose performed on Young was not done in the US until the 1990s. Damrose describes the approach as elegant. "It was hard to visualize why it should work," he said, "but once you look at what you've got, it becomes very intuitive as to why it works and works so well."
I realize how lucky I am, lucky that the cancer was found early and lucky to have found Dr. Damrose.
Yet its frequency remains low. The most recent data shows that in patients who fail radiation, up to 50 percent may be candidates for the voice-preserving partial laryngectomy.
Damrose trained with that physician and with the physician who did the first U.S. surgery. Now, he is training others. "I'd like to see this more routinely offered, to preserve more larynxes. It's an operation that has a high degree of success and predictable results. It's worthwhile trying."
Young is an example of someone whose cancer was caught early, "otherwise a healthy, vibrant, vital guy who can now look forward to years of quality voicing," Damrose said.
Several months went by before Young knew what his voice would sound like. After four months, he could make himself understood. He has a new vocal reality, a new normalcy, he calls it, with delightful wit. "My wife loves that I can't yell at her anymore," he said. And its deep tone, with a roughed edge, has won some admirers. "Lots of women say it's very sexy," Young said, with a bit of a blush.
He still loves to do woodworking projects, to cook and to travel, but he has added another mission to his life—letting others know about the voice-sparing surgery he had. "I want to spread the word," he said. Every month he returns to Stanford for a meeting of the local chapter of SPOHNC, Support for People with Oral and Head and Neck Cancer.
"I could sit around and feel sorry for myself because I don't have a normal voice," Young said, "but I realize how lucky I am, lucky that the cancer was found early and lucky to have found Dr. Damrose."
By Sara Wykes
About Stanford Hospital & Clinics
Stanford Hospital & Clinics, located in Palo Alto, California with multiple facilities throughout the region, is internationally renowned for leading edge and coordinated care in cancer, neurosciences, cardiovascular medicine, surgery, organ transplant, medicine specialties and primary care. Stanford Hospital & Clinics is part of Stanford Medicine, which includes Lucile Packard Children's Hospital Stanford and the Stanford University School of Medicine. Throughout its history, Stanford has been at the forefront of discovery and innovation, as researchers and clinicians work together to improve health, alleviate suffering, and translate medical breakthroughs into better ways to deliver patient care. Stanford Hospital & Clinics: Healing humanity through science and compassion, one patient at a time. For more information, visit: StanfordHospital.org.