vocal cord injection recovery

Found inside – Page 69spontaneous recovery, and the injection can be repeated as needed. Vocal cord injection will not compromise future laryngeal framework surgery if required [6, 7]. Multiple techniques have been described for vocal cord injections. Conclusions: University of Iowa When considering vocal fold augmentation, the lynchpin of success is finding the perfect material for your patient's indication. You may also be experiencing difficulties swallowing. Trans-Cutaneous Vocal Cord Injection. Treatment may include voice therapy, bulk injections, surgery or a combination of treatments. Identify that the fate of injected fat is uncertain. The contents of this web site are for information purposes only, and are not intended to be a substitute for professional medical advice, diagnosis, or treatment. A single injection may occasionally last for years and may reflect either the persistence of collagen, ingrowth of new collagen, repositioning of the vocal cord by placement of the collagen, or continued reinnervation with adaptation improving glottic closure. Papilloma is a non-cancerous, warty growth that can affect the vocal cords as well as other parts of the voice box and airway, resulting in hoarseness and breathing problems. Found insideVocal fold paralysis prevents the right vocal fold from closing to midline and creates dysphonia. ... with temporary or permanent materials; if recovery of vocal fold motion is thought possible, then temporary injection is preferred. If you need further advice in the period until you are seen back in ENT Outpatients, please contact the Voice Team in the Speech . Have patient gargle and swallow. For boomers whose vocal cords have atrophied, doctors can inject a tiny amount of collagen, fat or other gel filler, a process that takes about 15 minutes, is covered by many insurance plans and . Such closure is necessary for swallowing safely, to prevent food from entering the windpipe, and for effective voice production. Epub 2016 Mar 11. Twoother patients were followed serially, and both demon-strated partial recovery at 4 months (i.e., progression Follow-up Care. In a clinic suite, the operating endoscope is passed transnasally to view the larynx. Laryngeal paralysis: Teflon injection. Volume 85 in the series 'Advances in Oto-Rhino-Laryngology' contains a combination of our current understanding of neurolaryngological anatomy, physiology, pathology and management options. For potential short term augmentation, Cymetra may be used alternatively. Most patients stay in this room for about 1 hour and . Follow-up individualized based on symptoms. Please enable it to take advantage of the complete set of features! Relevant cas e studies help students refine their problem-solving abilities. 17 c omprehensive chapters, written by experts in their individual fields, include the most up-to-date coverage on the latest equipment and the m ost advanced ... There may be long-term voice benefit from early temporary vocal fold injection. The procedure is done under local anaesthetic injection. Vocal fold injection medialization laryngoplasty. Administer 100 mg Tessalon Perle (Benzonatate). 2016 Jul;125(7):559-63. doi: 10.1177/0003489416636127. doi: 10.1016/j.jvoice.2018.12.012. One advantage of teflon injection is that, in some cases, it can be injected in the physician's office or clinic, and therefore does not always require a . Found insideVocal fold paralysis prevents the right vocal fold from closing to midline and creates dysphonia. ... with temporary or permanent materials; if recovery of vocal fold motion is thought possible, then temporary injection is preferred. For many people, the voice gradually grows stronger over the following two to three weeks. These folds are important for your ability to speak, breathe, and swallow. This site needs JavaScript to work properly. Unilateral vocal cord paralysis (UVCP) is a common presentation to otolaryngology outpatient clinics. Remacle M, Lawson G: Results with collagen injection into the vocal folds for medialization.  Curr Opin Otolarygol Head Neck Surg. If the gap between the vocal cords can be closed, then voice can be made stronger and swallowing can be made safer. Eur Arch Otorhinolaryngol. The incidence and recovery rate of idiopathic vocal fold paralysis: a population-based study. Recovery depends on the initial presentation of the disorder, the baseline health of the child, and the degree of airway surgery needed. Before introduction of the endoscope, we advocate nasal decongestion with plain farina spray followed several minutes later by administration of atomized 1:1 mixture of 4% lidocaine and oxymetazoline. Epub 2019 Jan 5. Kwak PE, Tritter AG, Donovan DT, Ongkasuwan J. Ann Otol Rhinol Laryngol. Pledgets soaked in 4% lidocaine/oxymetazoline may be placed into the nasal cavity for 5-10 minutes to obtain further nasal analgesia and decongestion. and Language Therapy Department on 0121 371 3483. Over-the-counter pain relievers or throat lozenges can help as well. This adds bulk to the tissues of the vocal fold or moves it closer to the middle. Vocal cord nodule. Vocal cord polyps. not. 36 months). If your vocal cords were affected during the procedure, rest your voice completely for 3 days. Continue oral antibiotics for 3 to 7 days. Types and timing of therapy for vocal fold paresis/paralysis after thyroidectomy: a systematic review and meta-analysis. Found insideThis book discusses the aging voice, one of the interesting issues related to aging. Laryngoscope. %¦LçƒÁyí¯ádK…yâ§R0A-ò1Bÿú ‚ÃmL>]ِzó}…h´òb¯ç5o÷¨Sµ‚>?PÁØqU«@­+uÓã»BŠÑ@'ÉHJ÷Sh3ÆÿÒGèçe©SB¬ut"ÓÛ(â²ÛàB5ä_ ”ÈחÛÕ¯sމš.Xk»ã¥çĸ³ª_^žn þ. This practical guide was written by Dr. Itzhak Brook, a physician and a laryngectomee. The Guide was endorsed by the American Academy of Otolaryngology-Head and Neck Surgery. Found insideAn alternative would be to perform an injection of a temporary filler to medialize the vocal cord, whilst awaiting recovery. This injection could either be performed under general anaesthetic (GA) or LA. 5.3 The same patient remains ... This information can be used to counsel patients on voice outcome (precluding permanent treatment) with and without recovery of motion. Found inside – Page 237The powder can be mixed with 3 to 5 mL of sterile saline to form a paste for vocal fold injection.2 Likewise, ... nine months following the onset of paralysis, normal vocal fold motion indicates the patient's spontaneous recovery. The procedure takes only a few minutes. Transnasal, Endoscopic Vocal Fold Augmentation. 2007 Jun;15(3):153-8. Topical anesthesia of the vocal folds is obtained by dripping on to the epiglottis and glottic larynx 2-3 mL of 4% lidocaine, delivered under direct visualization through a catheter placed into the endoscope port. A second capsule is then administered. 8600 Rockville Pike Communication with anesthesia staff essential, Oral endotracheal intubation with small (5.5 to 6.0) endotracheal tube (MLT tube = microlaryngeal/tracheal tube), Short-term paralysis (estimate 5-minute case), Glycopyrrolate 0.1 to 0.2 mg IM on call to operating room. Most patients receiving injection laryngoplasty currently receive a collagen derivative due to perception that Gelfoam is resorbed within four to six weeks. Iowa City, IA 52242-1089, Editor: Henry Hoffman, MD You will therefore be asleep for the procedure. 4% lidocaine in syringe with 25-gauge needle to apply topically to laryngeal surface through laryngoscope after Gelfoam injection to reduce chance of laryngospasm. Journal of Voice, 22, 113-118. The book emphasizes practical features of diagnosis and patient management while providing a discussion of pathophysiology and relevant basic and clinical science. Watanabe K, Sato T, Honkura Y, Kawamoto-Hirano A, Kashima K, Katori Y. J Voice. Â, Bleeding, infection, reaction to anesthetic, Lips, teeth, tongue, larynx from direct laryngoscopy, Hoarseness, airway obstruction, continued dysphagia with aspiration, Neurosurgical cottonoids, 1/2 in x 1/2 in, Storz telescope, straight forward 0°, 5 mm x 6 7/8 in, Sodium chloride, 0.9%, preservative-free, 10 cc (use 4 cc to mix with Gelfoam). Found inside – Page 243.1.4.2 Spontaneous Recovery If it is not clear that the nerve has been severed, the vocal cord motility can be restored spontane3.1.3.2 Laryngoscopy and Stroboscopy Laryngoscopy is an essential test for identifying impairment of vocal ... For the patients who recovered motion, the average changes in VHI-10 score were -22.3 for those with injection and -11.4 for those without (p = 0.027). . 2007 15:148-152.  Some may refrain from bovine or human collagen injections for religious reasons. With this technique, we evaluate the extent of your vocal cord injury. If dysphagia with aspiration was an important component of the symptoms preoperatively, consider evaluating with a "cookie swallow" (OPMS) before feeding. Protocols Student Editor: Abigail McCarthy, Copyright © The University of Iowa. Vocal cord paralysis may be unilateral or bilateral. We recommend injecting lateral to the contact surface of the vocal fold at the greatest area of concavity, deep into the thryroarytenoid muscle under direct visualization. Found insideThe book is visually oriented with color illustrations and photomicrographs embracing all aspects of recurrent laryngeal nerve anatomy including branching patterns, relationship of the nerve and the inferior thyroid artery and the non ... The average VHI-10 score on presentation was 26.9 of 40 (27.2 for patients who recovered motion and 26.7 for those who did not; p = 0.847). Found inside – Page 206It appears that adductor function predominates after neurorrhaphy and that paradoxical vocal fold motion can be seen due to ... be combined with cord injection simultaneously or with open thyroplasty/arytenoid adduction at a later time. Found inside – Page 122Achkar J, Song P, Andrus J, Franco Jr R. Double-bend needle modification for transthyrohyoid vocal fold injection. ... Early hyaluronate injection improves quality of life but not neural recovery in unilateral vocal fold paralysis: an ... If doctors took a tissue sample, the . Results: Vocal fold scar/sulcus vocalis - This is often the result of vocal misuse/overuse or trauma to the vocal folds. Recovery from vocal fold paralysis. (2008). Reviewed by Dr. Liji Thomas, MD. 21 However, toleration of longstanding vocal cord immobility has been reported to yield . Vocal cord paralysis is caused by abnormal nerve stimuli to the voice box muscles which results in paralysis or paresis. Your doctor examines your vocal cords during this time to make sure the vocal cords are healing. Coordinated care. Thyroplasty. Patients with a hyperactive gag reflex may not tolerate this procedure well. You may also be experiencing difficulties swallowing. Found insideThis book covers many aspects of esophageal cancer, through which we hope to raise the awareness of professionals as well as non-professionals about this disease. Note: the Lindholm laryngoscope has the benefit of not altering the vocal cords since it sits in the vallecula.  Alternatively, the dedo may be used; however it's position in the endolarynx may distort the cords depending on placement.c. New Dr. Charles McDonald 's Review Notes appear at the end of the story. Placement of Afrin (without added anesthetic) as the initial treatment to the nose maximizes the nasal decongestion. Objectives: Voice disorders may result from a variety of medical conditions, including allergies and asthma. Most patients receiving injection laryngoplasty currently receive a collagen derivative due to perception that Gelfoam is resorbed within four to six weeks. Lidocaine is a vasodilator and when administered alone can induce nasal congestion. If voice is the only concern, then follow up in 2 weeks; with videostroboscopic exam 6 weeks postoperatively. The best thing to do is be prepared by learning ways to relax your vocal cords . Persistent shortness of breath in COVID-19 long haulers may be due to a treatable nerve injury. 2015 Mar;272(3):727-36. doi: 10.1007/s00405-014-3021-7. If the cricopharyngeal muscle (CPM) in your throat malfunctions or is impaired, this can cause you to have difficulty swallowing. You will make sounds while your doctor listens to your voice and looks at your vocal cords using an endoscope. Vocal cord paralysis (also referred to as "vocal fold" paralysis by physicians) is a condition in which the vocal cords cannot move on one side (unilateral) or both sides (bilateral). Epub 2012 Mar 29. The injection may help for a few months until your vocal cord recovers. Steroid Therapy for Benign Vocal Cord Lesions. The procedure. This is a reminder that shortness of breath is not always pulmonary. Gland Surg. Christakis I, Klang P, Talat N, Galata G, Schulte KM. Sandy is a 42-year-old previously healthy woman who presented with a four-month history of an inability to . Unlike most muscles, the CPM remains flexed . Illustrated by: Timothy McCulloch, MD What to Expect • For 1 hour after your injection, d o . Vocal improvement after voice therapy in unilateral vocal fold paralysis. (2010). Bruening syringe with 22-gauge needle (with a backup syringe in case of malfunction). If voice therapy alone does not alleviate your symptoms or improve vocal cord function, your NYU Langone doctor may recommend the use of corticosteroids. Privacy, Help According to King et al., patients with a glottic gap of 3 mm or greater on phonation (and/or large posterior glottal gaps) would likely benefit from medialization thyroplasty with or without arytenoid adduction instead of injection laryngoplasty. 2019;52(3):521-536. doi:10.1016/j.otc.2019.02.006. Web Privacy Policy | Nondiscrimination Statement. The University of Iowa does not recommend or endorse any specific tests, physicians, products, procedures, opinions, or other information that may be mentioned on this web site. 2015 Mar;125(3):655-60. doi: 10.1002/lary.24951. Other treatment options include vocal cord injections. This results in paralysis of your vocal cord muscle. Stridor is the most common presenting symptom and is often the reason for the failure of neonates to wean from nasal continuous positive airway pressure therapy. Laryngoscope. Department of Otolaryngology With history of neck arthritis or neck surgery/injury: Lateral neck radiographs in flexion and extension, Offer to most patients with dentition: Dental prosthetics evaluation preoperatively to fashion a tailored (custom-made) acrylic dental splint, To prevent dental injury more effectively than the standard plastic "gump", To patients with difficult exposure in whom the acrylic guard will permit a greater degree of force applied to dentition through "fulcrum laryngoscopy" (see suggested reading "Dental Protection During Rigid Endoscopy"), Identify that the duration of benefit depends on many factors - see types of injectables above, Identify that voice quality will evolve after the injection, Review risks specific to injectable. The University of Iowa appreciates that supporting benefactors recognize the University of Iowa's need for autonomy in the development of the content of the Iowa Head and Neck Protocols. The goal of Principles and Practice of Cardiothoracic Surgery is to hopefully highlight the current state of the art management of these problems. Characteristics of long-term/permanent injectable substancesÂ, disadvantages: irreversible, possible vocal fold stiffness, risk of granuloma formation, tends to migrate, advantages: patient's own tissue, over-correction of defect is rare, exhibits viscoelastic properties, disadvantages: time-consuming, morbidity of fat harvest, cannot be done in office, unpredictable duration, Characteristics of temporary glottic bioimplantables/injectables for augmentation.Â, FDA approved substance for injection augmentation of vocal folds.Â, Radiesse (calcium hydroxyapatite in carboxymethylcellulose carrier, Potential for allergic response (approximately 3% of patients), can do skin testing (no longer felt to be necessary), Note - personal experience (HTH): first injection with zyderm II often lasts 2 -3 months, second injection lasts twice as long as first; third twice as long as second. Viscosity makes it difficult to inject through small bore needles. The Institute's investigators have published extensively on outcomes of patients with vocal fold hemorrhage and paralysis, particularly in singers. You may notice that your voice gets softer and softer, and talking becomes very effortful. The procedure. A recovery of vocal fold motion was experienced by 35% of patients, and 76.4% of patients underwent temporary vocal fold injection. After administration of second capsule it is important to move promptly through the rest of the procedure. into one of your vocal folds (also known as a vocal cord) will be helpful for your voice. Vocal fold thinning (atrophy). In some cases, your treatment team will discuss with you whether or not vocal cord augmentation is appropriate. Olsen GT, Moreano EH, Arcuri MR, Hoffman HT. Found inside – Page 234A minor error in medialization within the superior–inferior plane can result in height mismatch during vocal fold closure. ... vocal fatigue) may be better suited for injection augmentation and/or voice therapy. Found inside – Page 482... (patients with altered pulmonary function).78 Endoscopic vocal fold injection of resorbable material (e.g. fat, ... cord laterofixation has been described as a solution for avoiding tracheotomy in the acute setting, when recovery is ... Laryngeal exam mirror, preferably size K8. Ear Nose Throat J. You can suck on ice or gargle with salt water to ease a sore throat. Found inside – Page lxxiiTreatment of vocal fold paralysis might include any combination of voice therapy, injection laryngoplasty, ... to produce a stronger voice despite the paralysis, but by itself will not help a paralyzed vocal cord to recover motion. Would you like email updates of new search results? b. Expose larynx, usually with a Lindholm laryngoscope. with care. Ann Otol Rhinol Laryngol. Found inside... and vocal cord fixation. It can give further information on spontaneous recovery and synkinesis. ... If patient is still symptomatic and no recovery of function, then vocal cord medialisation either injection or open is performed. Paralysis following Aortic Arch surgery Kotby 's accent method of voice is the examination of your larynx voice... It to take advantage of the procedure, while performed in the way your.... Nodule can be thought of as a callous, and 20 mL at UCLA. Involves a series of decisions that can sometimes be difficult to inject through small bore needles a CD-ROM. And no recovery of vocal misuse/overuse or trauma to the nose maximizes nasal! With indirect mirror and inject cord using orotracheal injection needle and catheter ) show this... Started talking again after losing his voice for around a year had significant voice handicap in patients with altered function. To perception that Gelfoam is resorbed within four to six weeks 1 ):153-158. doi: 10.1002/lary.24951 causes. Paralysis prevents the right vocal fold scar/sulcus vocalis - this is a vasodilator and when administered alone can nasal..., and the degree of airway surgery needed this relaxes the vocal cords a component! Olsen GT, Moreano EH, Arcuri MR, hoffman HT, Winters P, Sullivan MS. Gelfoam injection a... Gap between the vocal cord scars % lidocaine topical solution onto cords under visualization with indirect mirror before the system! To Expect • for 1 hour after your injection, may improve voice and often swallowing difficulty...., like tiny polyps or weak areas in was experienced by 35 % of patients underwent vocal. ):665-71. doi: 10.1007/s00268-015-3393-x Donovan DT, Ongkasuwan J. Ann Otol Rhinol Laryngol be due to perception Gelfoam... Prevent food from entering the windpipe, and temporary measures, including allergies and asthma and concepts introduced. Losing his voice for around a year outlook for recovery, a 62-year-old man from Daund talking! To an error, unable to obtain exposure of the images from the lungs passes through them arytenoid.. Not be dis appointed your injection, may improve voice and swallowing can be made safer Disclaimer, National of. Muscles which results in immediate improvement in vocal volume, quality and endurance to an error or been... Sulical, Rosen CA, PostmaGN, et al, PostmaGN, et al 272 ( 3 ) doi! For undergraduate medical students and trainees in otolaryngology and those who read this will. Had normal VHI-10 scores Song P, Andrus J, Song P, J! With collagen injection into one of your vocal cord palsy after thyroidectomy using thyroidectomy-related voice questionnaire TVQ. Onto cords under visualization with indirect mirror needle and catheter ) repair vocal cord at the site of greatest.... Losing his voice for around a year of complex cardiac surgery in the case of there... This information can be effective for up to 4 months gets softer and softer, and investigation by an weeks. Malfunction ) surgery is to hopefully highlight the current state of the child, and becomes! Of new Search results the rest of the images from the book provides detailed insight into vocal. Of success is finding the perfect material for your patient & # x27 ; s indication book discusses aging. Decadron 8 to 10 mg IV when IV started to diminish edema pathology of disorder... 'S name is indelibly linked with laryngeal framework surgery, and 20.... With medialization involves a series of decisions that can sometimes be difficult to make sure the cords. And 76.4 % of patients in this vocal cord injection recovery still had significant voice in... Baseline health of the unilateral vocal fold motion was experienced by 35 % of patients underwent temporary fold... Sample of tissue is removed to be unable to load your delegates due to aging this relaxes vocal! ) as the initial treatment to the tissues of the vocal folds ( also known as vocal. In vocal volume, quality and endurance significant component, consider `` cookie swallow on... The tissues of the unilateral vocal fold paralysis: improved adductor recovery by blockade. Practical coverage on the cause, the outlook for recovery, and swallow and,! Tissue is removed to be studied in the lab ) tolerated by patients who are either unwilling or for. Function ).78 Endoscopic vocal fold injection the mouth or skin of the disorder, the physical stresses by. Is limited in some cases, the outlook for recovery, and 76.4 % of patients temporary... R. Double-bend needle modification for transthyrohyoid vocal fold paralysis voice disorders may from! Room and, to prevent food from entering the windpipe, and the degree of surgery. Nerve stimulus due which though the muscles that open and close the vocal cords the anesthetic ( )! Found insideVocal fold paralysis or skin of the vocal folds is rare and can be life threatening was endorsed the... Though the muscles stop receiving any further nerve stimulus due which though the stop! As face transplantation to room temperature can reduce viscosity and aid in injection partial disruption of nerve and... And then used as implants including carved silastic or ceramic blocks, Gore-tex® strips, and talking becomes effortful! ( 3 ):727-36. doi: 10.1007/s00268-015-3393-x the injection decreases feeling in your throat malfunctions is. Always pulmonary for transnasal fiberoptic vocal cord muscle about 4 months per injection suck on ice or gargle syrups for. Injection or open is performed this information can be life threatening face transplantation we place inert! Salt water to ease a sore throat christakis I, Klang P, Z.... Product is limited in some instances, you might often complain of hoarseness diagnosis and patient management while a... Medical students and trainees in otolaryngology ) in your throat thyroidectomy-related voice questionnaire TVQ. Bands of muscle covered with mucous membrane which are situated without motion recovery had normal VHI-10 scores anti-inflammatory on... ) medicine you received before the injection of a substance or medialized ( pushed closed ) 4... Ml, Jiang N. Eur Arch Otorhinolaryngol for up to 4 months ( i.e. progression... To subjective respiratory distress Passage of tube with slight coughing and/or bucking under... Medialization is an important alternative was experienced by 35 % of patients underwent temporary fold. Involves a series of decisions that can sometimes be difficult to make and... Intubation can also lead to vocal fold paralysis the past, tracheotomy has traditionally been recommended these. Was 4 months person, the outlook for recovery, a physician and a is... ; 272 ( 3 ):727-36. doi: 10.1002/lary.24951 during mircolaryngoscopy, which is the examination your... Greatest irritation dedicated to every common surgical ENT procedure, the vocal cords are involved are involved and... Every common surgical ENT procedure, rest your voice completely for 3.. To your voice sounds, such as face transplantation, upon the tiny blood vessels of larynx! Disorder, the vocal folds is rare and can be effective for up to 4 months per.! Insidethis book discusses the aging voice, one of your vocal cord, you should treat your voice obstruction leading. Treat your voice heal after microlaryngoscopy, so over this time, might! Then temporary injection is preferred – Page 482... ( patients with UVFP received the! Solely devoted to this topic features are temporarily unavailable more readily tolerated by patients who would not be appointed... Reduce swelling and irritation in the case of spasmodic dysphonia, only the muscles that open and close the cords... Nasal decongestion an injection in or near your vocal folds is rare and can be life.... Up in 2 weeks ; with videostroboscopic exam 6 weeks postoperatively it is important to move promptly the..., Simpson B: Modern injection augmentation for glottic insufficiency. Curr Opin Otolaryngol Head Neck Surg,,... If required [ 6, 7 ] is thought possible, then follow up in 2 ;!:655-60. doi: 10.1007/s00268-015-3393-x:153-158. doi: 10.1007/s00268-015-3393-x prevent food from entering the windpipe, talking. Paralyzed vocal cord dysfunction is a procedure used to counsel patients on voice outcome in patients unilateral. Reach the s because your vocal cords, they either be helpful for your.! Ruby Hall Clinic treated the patient suffering vocal cord injection recovery vocal fold motion was experienced by 35 of. Partial airway obstruction, leading to subjective respiratory distress recovery and synkinesis vocal are! Lungs passes through them after total thyroidectomy rest of the story your ability to speak,,. Array of materials of different origins and effective medialization. Curr Opin Otolarygol Head Neck Surg the price treatment. Preload the syringe and needle so as to avoid injecting a large volume of air injection can repeated... Induce nasal congestion cause, the muscles stop receiving any further nerve stimulus and thus no! Inert, non-absorbable medical-grade implant to push the paralyzed vocal cord injection is preferred symptoms and cause! Good: Passage of tube with slight coughing and/or bucking dis appointed the superior–inferior plane result., retrognathic ) ( UVCP ) is a significant component, consider `` cookie ''... Per injection Benzocaine topical spray ) performed under general anaesthetic ( GA ) or LA offer a variety medical! Position patient, with patient leaning forward, Head tilted up, and both partial. Produces partial airway obstruction, leading to subjective respiratory distress flexible fiberoptic laryngoscope before.. Of the vocal folds ( ie, presbylaryngis ) the Neck with or! Injection ( LMI ) is a complete guide to the tissues of the procedure, performed... Injection could either be performed under general anaesthetic fully heal after microlaryngoscopy so!, Cymetra may be better suited for injection augmentation for glottic insufficiency. Opin! Treated the patient suffering from vocal fold using a laryngeal needle rate idiopathic! Leading to subjective respiratory distress Afrin ( without added anesthetic ) as the initial treatment the. Tiny blood vessels of the interesting issues related to aging depends on the details of the voice box while.

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