Advice Post-Slice: Voice Recommendations After Surgery

How much voice rest is necessary after surgery to the vocal folds? When I had voice surgery 10 years ago, I was instructed to rest my voice strictly for 1 week. No talking, singing, throat clearing, grunting, you get the picture. It was unclear, however, how I was to get back to singing normally again. So what do I tell patients? It varies depending on the extensiveness of the laryngeal surgery, but I pull my recommendations from studies.

The Rat Pack

Leydon et al 2014 describes how forty rats, (I know they're not people,  but I'm sure the experimenters formed relationships with their little buddies for the duration of the trial) had the mucosal layer of the vocal folds removed. (That's the top layer.)  Then the rats' larynges were examined between 3-90 days at 5 different times. 

This image is pulled from Springer online: Operative Techniques in Laryngology

This image is pulled from Springer online: Operative Techniques in Laryngology

 

Researchers found that a vocal fold tissue structure regenerated quickly (like, within 5 days) with intercellular junctions and multi layered epithelium (the tissue on the very outside of the vocal folds that receives the biggest impact during vibration). 

However, atypical permeability of this layer of the TVF's was seen up to 5 weeks after surgery. This means that if you have vocal surgery, you should be sure to keep tabs on your vocal use for many weeks following surgery, as there is a very elevated risk for further damage as your body continues to rebuild where the surgeon worked. Intact structure does not necessarily mean you can demand vocal use you were using before surgery.

Scarring Woes

Scarring is frequently seen after surgery and results in issues with phonation. So obviously we want to minimize scarring. We can't exactly massage the vocal folds to soften this scar tissue, but perhaps gentle vocal exercises that stretch and contract the tissues, as well as utilize resonant voice can help

Another study by Branski et al from 2006 really looks at how a vocal fold wound heals, including inflammation and swelling, as well as scarring. Again, we're talking our animal friends' vocal folds. Scarring develops when there is an increased inflammatory response following an injury. The study discusses differences in lesions to the vocal folds, including nodules, polyps and cysts. Particularly interesting to me, was the suggestion that a cyst, especially one at the midpoint of the vocal fold, might be due to injury associated with impact stress. (Which further convinces me that my vocal fold cyst from years ago was likely a product of a poorly coached belting role I performed during High School.)

Lesions and Surgery

The Branski article suggests that vocal fold lesions are probably the body's way of healing a wound, much in the way a scar results from a cut. Applicable to many of my patients is the discussion of chemical vocal fold injury from LPR, and that 50% of patients with voice disorders also have LPR or GERD, or both. We must also consider the effect of reflux on the healing process after surgery.

So, how long should a person realistically expect to be on complete vocal rest after surgery? For 2 weeks-5 weeks post injury, epithelium remains permeable and impacted by the wound healing process. I say impacted and not weakened, because epithelialization (restoring structural integrity) occurs rapidly between 3-5 days after injury.  Complete rest during this rapid healing time with a very strict ease back into phonation over 2-5 weeks appears to win here. 

We're still learning so many things about how this delicate tissue heals itself, we can only recommend based on the information we have now. Every patient heals differently, and the degree of surgical manipulation will vary case to case. 

Resources:

Leydon, Ciara, Imaizumi, mitsuyoshi, Yang, David, Thibeault, Susan L., & Fried, Marvin P. Structural and functional vocal fold epithelial integrity following injury. Laryngoscope 2014, Dec. 124 (12) 2764-2769

Branski, Ryan C, Verdolini, Katherine, Sandulache, Vlad, Rosen, Clark A., & Hebda, Patricia. Vocal fold wound healing: A review for clinicians, Journal of Voice, 2006 Vol 20, No 3, pp 432-442