The Medical Consumer's Advocate

Voice change after strangulation injury:

Finding an appropriate specialist for voice problems

Q: I was injured as a result of strangulation over two years ago. My voice has been hoarse, my volume low, and I can no longer hit high-pitched notes. It is a strain to talk, and it affects me on a daily basis. I feel my ability to communicate has been severely hampered, and I am looking for a solution. Could you please give me some suggestions for possible rehabilitation, or even possibilities for surgery or a specialist I should consult?

 

A: Strangulation can injure the larynx (voice box) in many ways. The persistence of your symptoms suggests that you may have fractured your larynx. Even though the larynx is made up of cartilage, and not bone, you can still fracture cartilage. Since the vocal cords are anchored to the thyroid cartilage ("Adam’s apple"), the position of the vocal cords can be altered by a fracture of this cartilage. Your voice is probably the way it is because the cords are no longer in an appropriate position.

We take for granted the fact that our voices are clear, we can speak loudly when we want to, shout or scream, and "hit the high notes." This all depends on the ability of the two vocal cords to come together, forming a fairly tight pair: || . When we breathe, the cords are open, like a V, to permit the passage of air into the lungs. The cords are anchored to the thyroid cartilage at the point of the V. If the thyroid cartilage is fractured, the cords may lose their ability to fully close; the result is a hoarse or breathy voice, loss of volume, and loss of dynamic range (the ability to hit the high and low notes).

It isn’t all just a question of cartilage and cords, however; there are nerves and muscles involved, too. You may have sustained an injury to these structures, as well, and the result could be much the same as a thyroid cartilage fracture.

Many of these problems are surgically correctable, but you will have to find an ear, nose and throat surgeon (otolaryngologist) who is comfortable with such procedures. It is also possible that you could benefit from speech therapy. Full rehabilitation may even require the assistance of a speech therapist AND an otolaryngologist.

For starters, you need to be examined by an otolaryngologist who is competent in the diagnosis of such problems. Ask your primary care doc for a recommendation. If your doc is at a loss, you may be able to ask family or friends for the name of a good ENT (ear, nose and throat surgeon, AKA otolaryngologist). Regardless of whether you get a recommendation or hit the yellow pages, you need to ask the ENT whether he/she is "comfortable with laryngeal framework surgery for the treatment of voice problems." Call the receptionist and leave that message. Hopefully, this will ensure that you are seen by someone who can not only diagnose, but also treat you.

Even if you are told, "Sorry, there is nothing we can do; you will just have to live with it," do NOT take this for an answer. It may be true, but it may also be a cowardly way of saying, "Sorry, there is nothing I can do, so you will just have to live with it." Do not accept this answer unless it comes from a laryngologist.

A laryngologist is an otolaryngologist who has "super-specialized" in the treatment of laryngeal and voice disorders. These doctors have typically spent an extra year or two in training, in which they are focused entirely on laryngeal diseases and voice problems. You'll probably need to travel to the nearest large city (perhaps greater than 1 million population) to find a laryngologist.

Your state's medical board can help you find one– call the state capital (general information number) and ask for the phone number for the state medical board. Be very clear that you are looking for a laryngologist, not an otolaryngologist.

Here’s another way to track down a laryngologist: call your nearest medical school (your librarian can help you find this phone number.) Ask for the phone number of their otolaryngology department, and talk to the department’s secretary. This person will know if they have a laryngologist on staff; if not, he/she can probably ask one of the otolaryngology faculty members for the name and city of the nearest laryngologist.

Many ENTs are very competent in the diagnosis and treatment of your problem; hopefully, you will be spared the hassle!

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