Voice and Swallowing

Hoarseness

Abnormal changes in the voice are called “hoarseness.” When hoarse, the voice may sound breathy, raspy, strained, or show changes in volume or pitch (depending on how high or low the voice is). Voice changes are related to disorders in the sound-producing parts (vocal cords or folds) of the voice box (larynx). While breathing, the vocal cords remain apart. When speaking or singing, they come together and, as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal cords hinder vibration, altering voice quality, volume, and pitch.

What are the causes of hoarseness?
Acute Laryngitis: The most common cause is acute laryngitis—swelling of the vocal cords that occurs during a common cold, upper respiratory tract viral infection, or from voice strain. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis.

Voice Misuse:

  • Speaking in noisy situations
  • Excessive use
  • Telephone use with the handset cradled to the shoulder
  • Using inappropriate pitch (too high or too low) when speaking
  • Not using amplification when public speaking

Benign Vocal Cord Lesions: Prolonged hoarseness can occur when you use your voice too much, or too loudly for extended periods of time. These habits can lead to nodules, polyps, and cysts. Vocal nodules (singers’ nodes) are callus-like growths of the vocal cords. Vocal cord polyps and cysts also occur in those who misuse their voice, but can also occur in those who do not.

Vocal Hemorrhage: If you experience a sudden loss of voice following a yell or other strenuous vocal use, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage occurs when one of the blood vessels on the surface of the vocal cords ruptures and the soft tissues fill with blood. It is considered a vocal emergency and should be treated with absolute voice rest and examination by an otolaryngologist (ear, nose, and throat doctor).

Gastroesophageal Reflux (GERD): A common cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal cords. Many patients with reflux-related changes of voice do not have heartburn. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.

How is hoarseness treated?
Hoarseness due to a cold or flu may be evaluated by family physicians, pediatricians, and internists who have learned how to examine the larynx. When hoarseness lasts longer than two weeks or has no obvious cause, it should be evaluated by an otolaryngologist. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists, speech/language pathologists, and teachers of singing, acting, and public speaking. Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy.

How is hoarseness evaluated?
Otolaryngologists will obtain a thorough history of a patient’s hoarseness and general health. They will then evaluate the voice and do a complete ear, nose, and throat exam. This includes examination of the vocal cords. Doctors usually look at the vocal cords either with a mirror placed in the back of the throat, or with a very small, lighted flexible tube (fiberoptic scope) that is passed through the nose to view the vocal cords. Videotaping or stroboscopy (slow-motion assessment) may also help with the analysis. These procedures are well tolerated by most patients. In some cases, special tests designed to evaluate the voice may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in diagnosing and guiding treatment.

When should I see an otolaryngologist?

  • If hoarseness lasts longer than two weeks, especially if you smoke
  • If you do not have a cold or flu
  • If you are coughing up blood
  • If you have difficulty swallowing
  • If you feel a lump in the neck
  • If you observe loss or severe changes in voice lasting longer than a few days
  • If you experience pain when speaking or swallowing
  • If difficulty breathing accompanies your voice change

How are vocal disorders treated?
The treatment of hoarseness depends on the cause. Many common causes of hoarseness can be treated simply by resting the voice or modifying how it is used. An otolaryngologist may make some recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help.

How to prevent hoarseness
Specialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification to help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overusing their voice by yelling and screaming, benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patient’s problem is specifically related to singing, a singing teacher may help to improve the patients’ singing techniques.

GERD and LPR

What is GERD?
Gastroesophageal reflux disease, often referred to as GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from “refluxing” or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid and other contents of the digestive tract to move up–to “reflux”–the esophagus.

When stomach acid touches the sensitive tissue lining the esophagus and throat, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

In some cases, reflux can be silent, with no heartburn or other symptoms until a problem arises. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens often over a long period of time.

What is LPR?
During gastroesophageal reflux, the contents of the stomach and upper digestive tract may reflux all the way up the esophagus, beyond the upper esophageal sphincter (a ring of muscle at the top of the esophagus), and into the back of the throat and possibly the back of the nasal airway. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or something “stuck.” Some patients have hoarseness, difficulty swallowing, throat clearing, and difficulty with the sensation of drainage from the back of the nose (“postnasal drip”). Some may have difficulty breathing if the voice box is affected. Many patients with LPR do not experience heartburn.

In infants and children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep-disordered breathing, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnea), apparent life-threatening event (ALTE), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical.

What are the symptoms of GERD and LPR?
The symptoms of GERD may include persistent heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be severe enough to mimic the pain of a heart attack. GERD can also cause a dry cough and bad breath. (Symtoms of LPR were outlined in the last section.)

While GERD and LPR may occur together, patients can also have GERD alone (without LPR) or LPR alone (without GERD). If you experience any symptoms on a regular basis (twice a week or more), then you may have GERD or LPR. For proper diagnosis and treatment, you should be evaluated by your primary care doctor or an otolaryngologist—head and neck surgeon (ENT doctor).

Who gets GERD or LPR?
Women, men, infants, and children can all have GERD or LPR. These disorders may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters. It should also be noted that some patients are just more susceptible to injury from reflux than others. A given amount of refluxed material in one patient may cause very different symptoms in other patients.

Unfortunately, GERD and LPR are often overlooked in infants and children, leading to repeated vomiting, coughing in GERD, and airway and respiratory problems in LPR, such as sore throat and ear infections. Most infants grow out of GERD or LPR by the end of their first year, but the problems that resulted from the GERD or LPR may persist.

What role does an ear, nose, and throat specialist have in treating GERD and LPR?
A gastroenterologist, a specialist in treating gastrointestinal orders, will often provide initial treatment for GERD. But there are ear, nose, and throat problems that are caused by reflux reaching beyond the esophagus, such as hoarseness, laryngeal nodules in singers, croup, airway stenosis (narrowing), swallowing difficulties, throat pain, and sinus infections. These problems require an otolaryngologist—head and neck surgeon, or a specialist who has extensive experience with the tools that diagnose GERD and LPR. They treat many of the complications of GERD and LPR, including: sinus and ear infections, throat and laryngeal inflammation and lesions, as well as a change in the esophageal lining called Barrett’s esophagus, a serious complication that can lead to cancer.

Your primary care physician or pediatrician will often refer a case of LPR to an otolaryngologist—head and neck surgeon for evaluation, diagnosis, and treatment.

How are GERD and LPR diagnosed and treated?
GERD and LPR can be diagnosed or evaluated by a physical examination and the patient’s response to a trial of treatment with medication. Other tests that may be needed include an endoscopic examination (a long tube with a camera inserted into the nose, throat, windpipe, or esophagus), biopsy, x-ray, examination of the esophagus, 24 hour pH probe with or without impedance testing, esophageal motility testing (manometry), and emptying studies of the stomach. Endoscopic examination, biopsy, and x-ray may be performed as an outpatient or in a hospital setting. Endoscopic examinations can often be performed in your ENT’s office, or may require some form of sedation and occasionally anesthesia.

Most people with GERD or LPR respond favorably to a combination of lifestyle changes and medication. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Some of these products are now available over the counter and do not require a prescription.

Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention. Such treatment includes fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES, and endoscopy, where hand stitches or a laser are used to make the LES tighter.

Swallowing Disorders

Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time, you should see an otolaryngologist—head and neck surgeon.

Symptoms of swallowing disorders may include:

  • Drooling
  • A feeling that food or liquid is sticking in the throat
  • Discomfort in the throat or chest (when gastro esophageal reflux is present)
  • A sensation of a foreign body or “lump” in the throat
  • Weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing
  • Coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs
  • Voice change

How are swallowing disorders diagnosed?
When dysphagia is persistent and the cause is not apparent, the otolaryngologist—head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors. Sometimes a small tube (flexible laryngoscope) is placed through the nose and the patient is then given food to eat while the scope is in place in the throat. These procedures provide visualization of the back of the tongue, throat, and larynx (voice box). These procedures are called FEES (Fiber optic Endoscopic Evaluation of Swallowing) or FEESST (Flexible Endoscopic Evaluation of Swallowing with Sensory Testing). If necessary, an examination of the esophagus, named TransNasal Esophagoscopy (TNE), may be carried out by the otolaryngologist. If you experience difficulty swallowing, it is important to seek treatment to avoid malnutrition and dehydration.

How are swallowing disorders treated?
Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.

Gastro esophageal reflux can often be treated by changing eating and living habits in these ways:

  • Eat a bland diet with smaller, more frequent meals.
  • Eliminate tobacco, alcohol and caffeine.
  • Reduce weight and stress.
  • Avoid food within three hours of bedtime.
  • Elevate the head of the bed at night.

If these don’t help, antacids between meals and at bedtime may provide relief.

Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or stimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully. Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist or a speech language pathologist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.

Once the cause is determined, swallowing disorders may be treated with:

  • medication
  • swallowing therapy
  • surgery

Surgery is used to treat certain problems. If a narrowing exists in the throat or esophagus, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be dilated or released surgically. This procedure is called a myotomy and is performed by an otolaryngologist—head and neck surgeon.

Many diseases contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist—head and neck surgeon.

What causes swallowing disorders?
Any interruption in the swallowing process can cause difficulties. Eating slowly and chewing thoroughly can help reduce problems with swallowing. However, difficulties may be due to a range of other causes, including something as simple as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastro esophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: hypertension; diabetes; thyroid disease; stroke; progressive neurologic disorder; the presence of a tracheotomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.

Swallowing difficulty can also be connected to some medications including:

  • Nitrates
  • Anticholinergic agents found in certain anti-depressants and allergy medications
  • Calcium tablets
  • Calcium channel blockers
  • Aspirin
  • Iron tablets
  • Vitamin C
  • Antipsychotic
  • Tetracycline (used to treat acne)
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