CINCINNATI, OH ( Ivanhoe Newswire) - Imagine not being able to speak above a whisper. For one woman, it was a reality for 35 years, but now she regained her voice with help from jet engines.
Picking up the phone or placing an order is something Jan Christian hasn't been able to do for decades. At just 17, a car accident robbed her of her voice. Jan's throat hit the dashboard, crushing her larynx. After that, she barely spoke above a whisper
"I sounded like the girl in the Exorcist," Jan Christian, told Ivanhoe.
"She was completely what you call euphonic. She was talking like that [whispers] and you don't know if that's something you can fix or not," Sid Khosla, M.D., an assistant professor at UC department of otolaryngology-head and neck surgery and director at UC Health professional voice center at the University Hospital Cincinnati, explained.
Normal vocal cords come together and vibrate to produce sound, but in Jan's case, the cords were so severely crushed, they couldn't join together. To rebuild them, Doctor Sid Khosla took what he knew about throat cancer patients and coupled it with his research on jet engines and flow patterns.
"The flow has these things called vertices which are areas of rotational motion," Dr. Khosla said. "And from aerospace, from jet engines we know that the vertices can cause sound."
Those principles enabled doctor Khosla to build new cords with lining from Jan's cheek and a laser to stiffen them so they could come together and vibrate.
While still not perfect, words can't describe how thankful Jan is to have her voice back.
"I broke down in tears cause I never thought there was a possibility," Jan said.
A possibility 35 years in the making. Jan's now working with a speech therapist to get her voice even stronger. Doctor Khosla has performed the first of several surgeries similar to Jan's on a 16-year-old girl whose throat was crushed when a 750 pound basketball hoop fell on her.
THE WORKS OF THE VOCAL CORDS: What is the human voice made of? Very simply- the muscles of the larynx, air, space and the articulators (tongue, teeth, palate, lips). These components interact with each other to produce your unique vocal sound. Voice is produced by vibration of the vocal folds. The vocal folds are a pair of pliable shelves of tissue that stretch across the top of the trachea. They are enclosed within the thyroid cartilage, which is the hard structure that forms the mass in the neck known as the Adam's apple. The vocal folds, together with the muscles and cartilages that support them, are known as the larynx. (Source: Voicemedicine.com)
BACKGROUND: The larynx, also known as the voice box, is located in the neck and plays a crucial role in speech and breathing. It has three important functions including; control of the airflow during breathing, protection of the airway, and production of sound for speech. Larynx injuries account for only 1 in every 22,900 emergency room visits each year. Although rare, larynx injuries can result in serious problems including impairment of voice production and difficulty breathing. (Sources: www.evmsent.org, www.utmb.edu)
INJURIES: Symptoms of larynx injuries include difficulty breathing, difficulty speaking, difficulty swallowing, and hoarseness. (Source: www.utmb.edu). Although injury to the laryngeal nerves is uncommon it can occur from car accidents, neck or chest surgery complications, breathing tube complications, viral infections that affect the nerves, and tumors in the neck or upper chest. (Source: www.health.nytimes.com)
TREATMENT: Treatments for larynx injuries vary depending on the cause of the injury. In some cases, no surgery may be needed and the nerve may recover on its own. In the case that surgery is needed, doctors attempt to change the position of the paralyzed vocal cord to improve the voice. This can be done with; arytenoid adduction (stitches to move the vocal cord toward the middle of the airway), injections of collagen, or gel foam. Jet engines have provided insight into the flow patterns of the human voice and have helped give some patients their voices back. Vortices may help explain why individual voices are different and can have a different richness and quality to their sound. According to Doctor Sid Khosla, when surgery is required to treat voice disorders, it's primarily done on the vocal cord. He also says, knowing there are additional sources that affect sound may open up a whole new way for us to treat voice disorders (Source: health.nytimes.com, UC Health News)
Khosla Assistant Professor at University of Cincinatti and Director of
Voice and Swallowing Center talks about helping one woman get her voice
What was your impression when you first saw her come in?
Dr. Sid Khosla: She came in for another reason actually and I heard her voice and I was thinking to myself can I do anything with this voice and as she told the story it was just pretty impressive. What had happened is that she had had this accident and her stepfather had kept her at home for several days after the accident thinking that he could help her and she didn't need any other care, and given that her larynx was pretty much crushed and almost separated it's amazing that she went through this and finally when she was almost dead she went to the hospital. So the first thing was just her story that her stepfather would do this and then second thing is what does her voicebox look like so she was what we call completely aphonic (?) she was talking like that (mimiced in whisper voice) and you don't know if that's something you can fix or not so I was just listening to her story and was pretty amazing that it happened, and so I'm also wondering what it looks like.
When a normal person talks what mechanizm has to happen and what was she missing that she couldn't?
Dr. Sid Khosla: Dr. Sid Khosla: The vocal cords are connected in the front and they move in the back and when the vocal folds vibrate, they produce the source of sound which is then modified by her tongue or whatever, so the vocal folds vibrating don't make an interesting sound but they make the sound source and then its modified. Without the sound source you don't get any voice or vibrations, you don't get any what we call voiced speech so – mimiced whisper – so it sounds like that, and how you get that sound source is the vocal folds when we breathe they go apart and when we talk they come together and then air going through the vocal folds is what causes a vibration. We're learning the mechanizms of that vibration actually in my lab which has a NIH funded project and so we're learning what actually makes these cords vibrate and what you can do to get vibration. We used some of those concepts on her to help her get a sound source. In her case there were a couple of things wrong-one was, the vocal folds connect in front so when they come together they're straight but her cartilage was actually blunted so instead of coming together her vocal cords were like this (demo) so there was a big space between them, like a tapezoid, and secondly, when we got in there we realized that her vocal cords themselves were pretty minimal or just bands of scar, so even if they came close together they couldn't vibrate because they didn't have a loose layer to vibrate.
So the damage didn't occur so much from the car accident as it did from…
Dr. Sid Khosla: No I did think if came from the car accident, it was a classic she wasn't wearing her seat belt, she crushed her larynx against the steering wheel, those types of accidents don't happen as much anymore with seatbelts, her larynx was crushed against the steering wheel.
Garbled question…stuffed that down her throat
Dr. Sid Khosla: Yeah, no…he stuffed an NG tube down her…and several things happened, so when they repaired it they did a great job in terms of they were able to get an airway, she didn't need a trach long term but the cartilage instead of being a sharp angle such that the cords come together in front, it was blunted like this, the cartilage itself was severely destroyed so there was a large gap in front between the cords
So how does this case compare with other cases that you've had in the past?
Dr. Sid Khosla: We've done about 5 that have been complete crush injuries where everything is gone and thats what hers were like, we use some concepts from our lab plus some concepts from conservation laryngeal surgery which is where you would take part of the larynx out due to cancer then re-construct whats remaining in various ways. We don't do that much anymore because there's been better techniques to treat the cancer, but I use a lot of what we learned from cancer surgery to re-construct fairly traumatized larynges. The ones that have nothing remaining-she didn't have the normal cartilage, she didn't have the vocal folds – those things were gone so those cases we've had 5 – 10. We've gotten "a" voice in almost all of them.
So what can she expect from this I know she has somewhat of a voice but it still sounds a bit strained.
Dr. Sid Khosla: It's very strained, for people that you have to reconstruct the entire vocal fold and put them in position and get some movement, the best that we go for a least right now, is that they can be understood over the phone, that they can talk in a somewhat of a noisy envirnoment like a restaurant, that they can order through the drive-thru and so that their family can understand them in sort of a large family situation with some noise in the background. Before she could not talk and be understood over the phone very well unless the person knew her because it was only a whisper at best, she could not order through the drive-thru she could not talk in a noise environment-the person who was listening would have to be like our distance apart – more than that; so it gave her the ability to function much more socially, to be understood in a noisyenvironment, to be really understood is the main problem here and being loud enough so you can project and be heard over noise and be understood. As opposed to our professional voice patients or even most of our patients with milder disease where you expect excellent voice quality, in this case we were going for anything that produces sound that could be understood.
Do you think that she'll be able to make even more improvements or is this something that is sort of unchartered?
Dr. Sid Khosla: They are unchartered and there's definitely some things we can do and try to improve, there's problems with the vibrating source and there's things we can try to improve it, we've talked about that. Her voice definitely gets better when she does her voice excersices so there's some of that, it's going to improve but I think without further surgery it's going to reach its limit at some point. It's loud enough to be understood in an environment but its not that loud, its not as loud as your voice could go and it also comes and goes and is raspy to a degree that your voice isn't. To get it at a total normal level may be impossible or we may have to do further surgery and also different therapy's are involved here to treat vocal cord scarring of which she's going to have some of. With different materials are coming out all the time and different experiments are coming to re-grow parts of the vocal folds so as that therapy improves we might be able to give her something much better.
Is this true that you used some of your research that you're doing with jet engines? In order to rebuild?
Dr. Sid Kholsa: Yes. What we do is study the flow patterns that are between the vocal cords because the flow has these things called vortices which are areas of rotational motion and from aerospace, from jet engines we know that the vorices can cause sound and that's something called aero-acoustics – aero meaning the flow, acoustics meaning sound; there's also aero-elastisity where the flow actually causes flutter kind of like a flag waving in the wind. In the case of jets you don't want either of those, you don't want flutter where the wing is going like that (demo) and you don't want the noise. In the case of the larynx you actually want them and we've shown that those vorticies help. In our lab we learned that those areas of rotational motion are important to get loudness which is the main thing we're trying to go for and important to get some vibration, and one thing that we've learned in our lab too is that the vocal cords have height and if you make the bottom part stiffer than the upper part then that will help in the loudness we think – it's a theory that we have some evidence for in our lab, so that's what I did with her, we originally made these big things that would become vocal cords and we did that by opening up her neck and reconstructing her entire voice box. Then we go later and we laser little pieces that make them look more cords. Now in the process of trying to make the bottom part stiffer I did that but I also gave her a web or a connection between these cords, but what happens is that these cords come together and the web is at the bottom which definitely gives it a very stiff edge and much stiffer obviously we don't want the web but the bottom part is stiffer and the top part is what actually vibrates, we can see vibration on what we call a strobe exam where we can see the vibrations. Now until we created a stiff part at the bottom of the cords she didn't have much voice at all and it was certainly not loud enough to be understood so giving her a louder voice meant that she didn't have to put that much effort.The idea that a louder voice can be caused by making the bottom edge stiffer came from our lab – and this project is funded by the National Institute for Deafness and Other Communication Disorders, one of the instututes of the NIH or National Institute of Health. Stiffening the inferior edge has also helped improve loudness on other patients with signficant laryngeal reconstructioon. A lot of the techniques came from old fashioned cancer surgery but the trick in her to making her actually get a loud enough voice came from our lab. Then she used speech therapy also because the whole system is stiff, so voice therapy helped make it all flexible.
So you were able to use what you knew from cancer patients, jet engines and the voice lab all come together to give her a voice.
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