I was injured as a result of strangulation over two years ago. My voice is hoarse, my volume is 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?

Jason

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 thyroid cartilage. Your voice is probably the way it is because the cords are no longer in an appropriate position.

We usually 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, closing fairly tightly. When we breathe, the cords 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 (ENT or 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, ask family or friends. However you find the ENT, you need to ask whether he or 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.

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." 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. 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. (Call the state capitol, and ask for the number of the state medical board.) Be clear that you want a laryngologist, not an otolaryngologist.

Another strategy is to call your nearest medical school. (Ask a librarian for the number.) Contact the school's otolaryngology department, and ask the department's secretary if they have a laryngologist on staff. If not, he or she can probably ask one of the faculty members for the name of the nearest laryngologist.

Many ENTs are very competent in the diagnosis and treatment of your problem. Hopefully, you will be spared the hassle of finding a laryngologist.