DIsorders of Voice, Swallowing and Cough
Professional singers, actors, and other voice users who rely on their voices for their
livelihood require a higher level of care for their voice problems.  Dr. Zalvan has
extensive experience with our region's singers: theater groups, conservatories, and chorus
both on a local and national level. From amateurs to professional, children and adults,
proper diagnosis is key to an excellent outcome. When medical treatment and voice
therapy is not sufficient to solve the problem, surgery might be recommended.  These
surgeries should only be performed by a
laryngologist.  Suspension microlaryngoscopy
with microflap technique is the gold standard treatment for the majority of these benign
lesions of the voice box.  
Polyps, cysts, scar tissue, and sometimes nodules can be removed
under high power magnification.  Specialized techniques of
microflap excision minimize
surrounding damage to the vocal cords and allow for excellent healing with return of the
normal singing or speaking voice.  There are minimal complications and little discomfort
from the surgery.  Voice therapy with a specialized speech pathologist with a classical
singing background is essential both before and after surgery for full recovery with an
optimal performing voice.

Chronic cough can be debilitating, embarrassing, and uncomfortable.  People often seek multiple medical
opinions from many different doctors.  In the end, the cough continues.  Up to
40-50% of chronic cough (not
asthma, sinusitis, or allergy) is due to
Laryngopharyngeal Reflux (LPR) disease or a Neurogenic Cough
.  LPR is reflux into the throat region with chronic cough, voice change, throat clearing, phlegm,
lump in the throat, and throat discomfort with problems swallowing.  A Neurogenic Cough is a cough that is
usually preceded by a tickle sensation, made worse by talking, eating, cold air, laughing, and often occurs in
spasms. Dr. Zalvan is currently involved in numerous research projects exploring the cause and treatments of
this cause of cough.  He is the regional expert in sensory related cough neuropathies and has spoken
internationally on this sometimes difficult topic.

People with a paralyzed vocal cord often have a breathy, weak voice; in addition, they may aspirate - have
food or liquid go into the lungs.  An outdated way of thinking is to wait for the nerve to heal.  Why have
severe hoarsness, shortness of breath, fatigue, and trouble eating ?  
Vocal Fold medialization surgery can
help to close the voice box, provide a stronger, more natural voice, and help prevent aspiration.  This can be
accomplished by an injection of material into the vocal folds to help push them together (
).  This injection is either performed in the office under topical anesthesia, or in the operating
room.  Another procedure requires a small incision over the Adam's apple and the placement of a small
implant to push the paralyzed vocal fold toward the midline (
Medialization Thyroplasty).  Both are short
procedures, easily tolerated, and with great results for improved voice and swallowing ability.

Difficulty swallowing can occur from many different causes.  At the Institute, we have a full range of
diagnostic tools to help identify the cause of the swallowing problem.  We perform office based
esophagoscopy TNE
- an alternate way of examining the esophagus in the office with topical anesthesia and
no sedation (no risks of anesthesia, no down time or missed work, minimal discomfort, and immediate
results).  In addition,
pH (acid) testing using the Restech system, FEES (Flexible Endoscopic Evaluation of
MBS (Modified Barium Swallow) can all pinpoint the cause.  Medical and Surgical treatments
exist for many swallowing problems. Many of these techniques have been introduced to this region by Dr.
Zalvan. Our speech pathologists are experts in the treatment of many of these disorders.  They offer advanced
therapeutic techniques, electrical stimulation of the swallowing muscles, and guided swallowing exercises to
help return a person's swallow to normal.  We have an abundance of experience with
Head and Neck cancer
patients who have undergone surgery or
chemoradiation and have subsequent swallowing problems or are
feeding tube dependent.
The newest technique for curing diseases of the vocal folds and voice box includes the use
of a
KTP laser. Dr. Zalvan, who lectures nationally and internationally on this topic offers
this technique at the Institute for Voice and Swallowing Disorders.  This laser has an
affinity for blood vessels allowing it to target abnormal blood vessels and blood supply
leading to resolution of lesions such as
vocal fold polyps, papilloma, dilated blood vessels,
precancerous and cancerous conditions
.  This procedure is primarily performed in the
office under topical anesthesia with little or no recovery time.  Not only does this
effectively remove the lesions, it does so with minimal or no surrounding damage to the
vocal folds and thus minimal or no scar formation.  The ultimate result is an improved
voice and cure without the need for general anesthesia
KTP Laser in Office Setting
KTP Laser in the OR
LPR - Laryngopharyngeal Reflux - is not GERD.  LPR is the reflux of stomach contents
into the region of the laryngopharynx.  Most people with LPR do not have GERD
symptoms.  GI evaluation is often negative in patients with LPR. Unlike GERD, LPR is
diagnosed primarily based on symptoms, physical findings, and response to treatment.  
The most commons symptoms are
hoarseness, chronic cough, throat clearing, a lump in
the throat feeling, mucus, trouble swallowing, and sour taste
, usually in combination.  
Physical findings vary and are visualized endoscopically – either with a flexible
laryngoscope or video-stroboscopy (the gold-standard of laryngeal diagnosis). In addition,
office-based Trans-Nasal Esophagoscopy can help with diagnosis and with surveillance
for esophageal cancer and Barrett’s.  Some studies have shown an association of
esophageal adenocarcinoma with LPR and a chronic cough or the other symptoms above
may be the only sign.
Recent research demonstrates our DIET based approach works as
well, if not better than PPI
(proton pump inhibitors like Prilosec). We are now working
with patients to STOP their many years of PPI use.
Zalvan C, Reilly E. Symptomatic vallecular cysts:
diagnosis and management with the KTP laser
Eur Arch Otorhinolaryngol
DOI 10.1007/s00405-016-4026-1. April 2016
Monsoon Jet Ventilation system - We are the only center in the region to use this
technology. Jet ventilation allows for general anesthesia without the need for a breathing
tube. A catheter, 1/10 in size is inserted under direct vision. This minimizes potential
damage singers. There is less postoperative discomfort and better visualization during
SINGERS - TIPS to SING by before SURGERY: Make sure your surgeon is a
LARYNGOLOGIST (either by fellowship training or senior with more than 75% of the
practice devoted to the care of the professional voice). Ensure the anesthesiologist has
extensive experience with singers, uses a small tube if one is used, has other options
(LMA, jet, apneic), and understands the importance of the vocal folds and supporting
structures. I HIGHLY recommend surgery with the use of the Monsoon Jet System.
Professional Voice Evaluation and Surgery
Laryngopharyngeal Reflux - LPR
KTP Laser  Microsurgery of the vocal folds - Microlaryngoscopy
Chronic Cough
Vocal Fold Paralyis - Surgery - Injection laryngoplasty, Thyroplasty
Dysphagia - Swallowing Disorders