I had surgery to take out a benign tumor on the right side of my thyroid. Afterwards, I lost my voice. The right side of the vocal cord was irritated by the anesthetic tube during the surgery. It has been five months without improvement on my very weak voice. Is there any hope of getting my voice back?

K.

The short answer to your question is yes, but you will almost certainly need an operation.

And now for the long-winded answer. The vocal cords are a pair of muscular structures attached at one end, forming a V. The point of the V is immediately behind the Adam's apple cartilage (the thyroid cartilage). The V is perched above the windpipe (trachea) like an eagle sitting atop a tree. When we speak, the vocal cords come together tightly. There is little gap between them when this happens, which enables us to generate a lot of air pressure within our lungs and trachea. We use this high pressure to cough, yell, sing, speak loudly and so forth. If a cord is injured or paralyzed, it may no longer be possible for the cords to come completely together, and there may be a gap. If you think of this as an "air leak," you will understand why your voice is so weak.

The recurrent laryngeal nerves control the muscles that move the vocal cords. These nerves pass behind the thyroid gland and can be stretched or cut during a thyroidectomy. Alternatively, your vocal cords may have been torn, dislocated or paralyzed by the tube that the anesthesiologist placed in your trachea before your operation began (placement of this tube is known as intubation).

If I were your doctor, I would first take a complete medical and surgical history, paying particular attention to your "weak voice" symptom. Is it constantly weak, or is it occasionally normal? Has it improved at all in the last five months? Have you ever experienced this before? Are you certain your voice was normal before the operation? Was it weak immediately afterward, or did it become weak gradually? Who told you your vocal cord "was irritated by the anesthetic tube during surgery" -- your surgeon or the anesthesiologist? Has your surgeon undertaken any investigations to learn the cause of your problem? What were the results?

Next, I would perform a complete head and neck examination. In particular, I would examine your vocal cords. While some ENTs are quite good at examining the cords using a mirror and a headlight, I prefer a flexible fiberoptic scope. With a fiberoptic scope, I can take as long as I want to look at your vocal cords, and the image has better magnification than I could get with a mirror. I can videotape the exam and review it later. I can also show the videotape to patients, so they can see the problem for themselves.

Before inserting the scope, I examine the patient's nasal cavities to determine which is "more open." I spray that cavity with a combination decongestant and anesthetic. Then I pass the scope through your nose. Usually, there is a tickling sensation or uncomfortable pressure, but pain is rare.

From this exam, I could learn whether a vocal cord is paralyzed or paretic (partially paralyzed), or if it was dislocated or cut. Weak voice can have many other causes, however, and this exam could reveal some other explanation.

By now, I would have a pretty good idea as to the cause of your weak voice and might be able to make a treatment recommendation. If not, I would investigate further by reviewing your surgeon's notes and the anesthesiologist's record. I might also need to speak with one or both of them. Nevertheless, the job of the doctor is not to assign blame, but to treat your problem.

As I mentioned earlier, it is likely that your treatment will be surgical. For example, if your recurrent laryngeal nerve was severed, an operation called a thyroplasty could restore your voice strength. In this operation, the surgeon removes a rectangular "window" from your thyroid cartilage. Through this window, the surgeon places a pre-shaped plastic block that pushes the paralyzed cord over to the midline. The non-paralyzed cord is now able to meet the paralyzed cord, forming the tight join necessary for a strong voice. Lacerated or dislocated cords can be repaired surgically, too.

If it was unclear whether the nerve was stretched or cut, most ENTs would defer treatment for six months. If the nerve were only stretched, it might take this long to recover function. A study called an EMG (electromyogram) can help your doctor determine whether the muscles have permanently lost their nerve input or are about to recover.

So, your job is to find an ENT who will give you proper attention. If you live near a medical school, you might call the otolaryngology department and ask whether there's a laryngologist on staff. A laryngologist is a surgeon who specializes in larynx (voice box) problems. If you consult one or more ENTs from your community, question them carefully about their experience in treating such problems.

One last piece of advice. If you are told "nothing can be done" for your problem, don't accept this answer until you have heard it from a laryngologist.