[Dysphagia] question about voice

[LiWalsh at serha.ca (Walsh, Linda (R1SE))]

Jonathan,
My first thought was RLN palsy post-thyroid resection but this should be
obvious on scoping.  SLN palsy can also cause breathiness post-thyroid
surgery if there is loss of tone in the vocal fold, but pts typically
don't have swallowing problems.  SLN damage is sometimes hard to detect
on scoping.  A change in voice +/- dysphagia due to laryngeal nerve
damage should be noticed right after surgery but I have seen pts who do
not notice anything until the effects of advancing age combine with the
laryngeal nerve palsy.
My second thought was GE reflux which can variably affect voice and/or
swallowing, if this has not been ruled out already.
Linda
 

Message: 1
Date: Thu, 21 Sep 2006 11:28:26 -0700 (PDT)
From: Jonathan Bennett <ajbennett05@yahoo.com>
Subject: [Dysphagia] question about voice
To: dysphagia@b9.com
Message-ID: <20060921182826.88345.qmail@web39515.mail.mud.yahoo.com>
Content-Type: text/plain; charset=iso-8859-1

I know this is a little off topic, but I thought you all would have some
good suggestions.  Sorry for the length:
   
  I have a patient that recently came in referred to me by the ENT for a
voice eval.  He is an 81-year old man that came in with c/o dysphonia
and decreased vocal intensity.  He was recently at the ENT, who scoped
him.  The results of the scope were unremarkable. After numerous visits,
the ENT was unable to state what the problem was and told him "not to
worry about it". Medical history included, a 4-way bypass, h/o prostate
cancer with resection, and h/o thyroid cancer with resection.  Patient
with NO KNOWN h/o stroke, neurological disease, or respiratory problems.
Patient and wife state that voice comes and goes.  He can go for weeks
at a time and voice will be fine, then all of a sudden he has a bad
stretch.  Results of my evaluation showed (I have limited access to
computerized diagnostics unfortunately): s/z ratio of 4.0, unable to
phonate /ah/ on command...very breathy, frequent breaks in phonation
during during conversation to me, and decreased pitch range. 
 Phonation time of /ah/ increased to 5 seconds when pushing or pulling
on chair.  He came back to me today, which is 3 weeks later (due to some
insurance issues), and his voice was much stronger during conversation.
Still breathy, but able to phonate /ah/ for 13 seconds when given to
direction for abdominal breathing.  Voice was still not completely
normal, but a marked changed from initial evaluation.  The wife says
that this is what happens...gets better, then worse again.   Oh, patient
also c/o dysphagia with food feeling "stuck" in throat.  A MBS was done
on the patient about a month ago and no major structural problems seen.
No aspiration seen on the video, no reflux, Zenker's, etc.  Pyriform
sinus and vallecular retention WAS seen though. According to the wife
there is no pattern to when the dysphagia comes and goes and says it
does not come and go at the same time the dysphonia does.  Also, they
stated none of this started at the same time as any of his surgeries.
   
  I'm not quite sure where next to go.  The ENT doesn't seem to think
there is anything wrong.  I know that Thyroid meds cause some issues
with the muscles, but I don't know why it would come and go so
frequently then.  ANY advice would be appreciate.
   
  Thank you
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