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Miley Cyrus's Undetected Condition Required Surgery

— Singer is currently on vocal rest

MedpageToday
A photo of Miley Cyrus smoking a cigarette

Singer and actress Miley Cyrus is typically very outspoken. But don't expect to hear anything from her for a while. She's been put on vocal rest after . Apparently, Cyrus has unknowingly had a vocal cord issue for years, which was detected only last month when she was .

Although the specific issue was not disclosed, she was treated by Steven Zeitels, MD, who directs the Massachusetts General Hospital (MGH) Center for Laryngeal Surgery and Voice Rehabilitation. Zeitels has been dubbed the "," as many of the most famous voices in the world, including Steven Tyler, Julie Andrews, Adele, Lionel Richie, and Sam Smith, have sought him out to treat various vocal cord issues.

Following treatment, Cyrus will be on vocal rest for several weeks, although she doesn't necessarily intend to be completely at rest. The "We Can't Stop" singer posted a picture on Instagram showing her exercising on a Pilates barrel with the caption "On vocal rest not body."

How is the voice produced?

The voice is produced by the vibration of the vocal folds which are two bands of tissue that lie opposite of each other in the larynx or "voice box." They are composed of a variety of tissues including epithelium, lamina propria, striated muscle, nerves, blood vessels, and cartilage.

When at rest, the vocal folds are open to allow an individual to breathe. To produce voice, the brain precisely coordinates a series of events. First, the folds come together in a firm but relaxed way. Once the folds are closed, air from the lungs passes through them, causing vibration and thus making sound. The sound from this vibration then travels through the throat, nose, and mouth (resonating cavities). The size and shape of these cavities, along with the size and shape of the vocal folds, help to determine voice quality.

Variety within an individual voice is the result of lengthening or shortening, tensing, or relaxing the vocal folds. Moving the cartilages to which the folds are attached, makes these adjustments possible. For example, shortening and relaxing the vocal folds makes a deep voice; lengthening and tensing them produces a high-pitched voice.

What is vocal abuse?

Vocal abuse is any behavior or occurrence that strains or injures the vocal folds (or vocal cords). This may include excessive talking, throat clearing, coughing, inhaling irritants, smoking, screaming, or yelling. Vocal misuse is improper voice usage such as speaking too loudly or at an abnormally high or low pitch. Frequent vocal abuse and misuse can damage the vocal folds and cause temporary or permanent changes in vocal function, voice quality, and possible loss of voice.

Who may be at risk for a disorder of vocal abuse or misuse?

Disorders of vocal abuse and misuse are the most prevalent and preventable of the types of voice disorders. Anyone, from infants to the elderly, who uses his or her voice excessively may develop a disorder related to vocal abuse. Lawyers, teachers, clergy, cheerleaders, and professional voice users such as singers and actors often develop these types of voice disorders.

What are some of the disorders of vocal abuse and misuse?

The most common disorders resulting from vocal abuse and misuse involve the lamina propria. The superficial lamina propria (SLP), often referred to as "Reinke's space," is the top layer of the lamina propria that plays a key role in vocal fold vibration. Loosely structured, it is located just underneath the epithelium covering the vocal folds. Disorders involving Reinke's space include laryngitis, vocal nodules and cysts, vocal polyps, vocal cord hemorrhage, and papillomatosis.

How are disorders of vocal abuse and misuse treated?

Many disorders of vocal abuse and misuse are reversible. The best treatment is to identify and eliminate the vocal behavior that created the voice disorder. In many cases, a brief period of voice therapy is helpful so that the individual can learn good vocal techniques such as proper breath support for speech or eliminating forceful voicing.

Since the mid-20th century, the field of phonosurgery has grown. It encompasses a variety of surgical procedures aimed at restoring the voice. These procedures can be used to treat two categories of vocal injury:

  • Diseases where abnormal tissue prevents the normal vibration of the vocal cords
  • Vocal cord disorders caused by an abnormal position and/or tension of the vocal folds

Phonomicrosurgical techniques have evolved over the past several years, as microsurgical procedures have improved, allowing for better instrumentation and visualization of the vocal cords during the procedure. CO2 microlasers, pulsed dye laser, and potassium titanyl phosphate lasers have also been introduced into the armamentarium.

Prior to any microphonosurgery, laryngeal surgeons carefully diagnose any lesions, using a stroboscope. The instrument is comprised of a synchronized, flashing light passed through a flexible, or rigid endoscope. It enables the practitioner to visualize vocal fold vibrations.

In March 2019, Zeitels of his phonomicrosurgical procedures done over the past 20 years. His review, entitled "The Art and Craft of Phonomicrosurgery in Grammy Award-Winning Elite Performers," focused on a patient cohort of 18 elite performers who had collectively won 80 Grammy Awards out of 242 nominations.

The following conditions were described in Zeitels' cohort of 18 patients:

  • 15 cases of significant loss of SLP pliability
  • 6 cases of varices and/or ectasias leading to vocal hemorrhage
  • 9 cases of vocal polyps
  • 6 cases of fibrovascular nodules
  • 1 case of arytenoid granuloma
  • 4 cases of SLP scarring () from prior microlaryngeal surgery
  • 4 cases of SLP sulcus from long-term phonotrauma
  • 1 benign cyst
  • 2 cases of precancerous dysplasia
  • 2 cases of invasive carcinoma

Zeitels concluded: "Optimizing singers' care provides surgeons with extremely complex technical, emotional, social, and financial challenges. Focused analysis of managing elite performing vocalists effectively integrates a range of essential issues, which provide key insights to assist clinicians treating non-performing patients requiring phonomicrosurgery."

Michele R. Berman, MD, and Mark S. Boguski, MD, PhD, are a wife and husband team of physicians who have trained and taught at some of the top medical schools in the country, including Harvard, Johns Hopkins, and Washington University in St. Louis. Their mission is both a journalistic and educational one: to report on common diseases affecting uncommon people and summarize the evidence-based medicine behind the headlines.