About Your Voice

What Is Voice?

“Voice” is the sound made by vibration of the vocal cords caused by air passing out through the larynx bringing the cords closer together. Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voice is invaluable for both our social interaction as well as for most people’s occupation. Proper care and use of your voice improves the likelihood of having a healthy voice for your entire lifetime.

How Do I Know If I Have A Voice Problem?

Voice problems occur with a change in the voice, often described as hoarseness, roughness, or a raspy quality. People with voice problems often complain about or notice changes in pitch, loss of voice, loss of endurance, and sometimes a sharp or dull pain associated with voice use. Other voice problems may accompany a change in singing ability that is most notable in the upper singing range. A more serious problem is indicated by spitting up blood or when blood is present in the mucus. These require prompt attention by an otolaryngologist.

What Is The Most Common Cause Of A Change In Your Voice?

Voice changes sometimes follow an upper respiratory infection lasting up to two weeks. Typically the upper respiratory infection or cold causes swelling of the vocal cords and changes their vibration resulting in an abnormal voice. Reduced voice use (voice rest) typically improves the voice after an upper respiratory infection, cold, or bronchitis. If voice does not return to its normal characteristics and capabilities within two to four weeks after a cold, a medical evaluation by an ear, nose and throat specialist is recommended. A throat examination after a change in the voice lasting longer than one month is especially important for smokers. (Note: A change in voice is one of the first and most important symptoms of throat cancer. Early detection significantly increases the effectiveness of treatment.)

Six Tips To Identify Voice Problems

Ask yourself the following questions to determine if you have an unhealthy voice:

• Has your voice become hoarse or raspy?
• Does your throat often feel raw, achy, or strained?
• Does talking require more effort?
• Do you find yourself repeatedly clearing your throat?
• Do people regularly ask you if you have a cold when in fact you do not?
• Have you lost your ability to hit some high notes when singing?

A wide range of problems can lead to changes in your voice. Seek out a physician’s care when voice problems persist.

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist—head and neck surgeon if you have any sustained changes to your voice.

Common Problems That Can Affect Your Voice

It may come as a surprise to you the variety of medical conditions that can lead to voice problems. The most common causes of hoarseness and vocal difficulties are outlined below. If you become hoarse frequently or notice voice change for an extended period of time, please see your Otolaryngologist (Ear, Nose, and Throat doctor) for an evaluation.

Acute Laryngitis

Acute laryngitis is the most common cause of hoarseness and voice loss that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that leads to swelling of the vocal cords. When the vocal cords swell, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce your voice use. Serious injury to the vocal cords can result from strenuous voice use during an episode of acute laryngitis. Since most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much rarer and often are associated with difficulty breathing. Any problems breathing during an illness warrants emergency evaluation.

Chronic Laryngitis

Chronic laryngitis is a non-specific term and an underlying cause should be identified. Chronic laryngitis can be caused by acid reflux disease, by exposure to irritating substances such as smoke, and by low grade infections such as yeast infections of the vocal cords in people using inhalers for asthma. Chemotherapy patients or others whose immune system is not working well can get these infections too.

Laryngopharyngeal Reflux Disease (LPRD)

Reflux of stomach juice into the throat can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a lump in the throat sensation, or throat pain are common symptoms of stomach acid irritation of the throat. Please be aware that LPRD can occur without any symptoms of frank heartburn and regurgitation that traditionally accompany gastro esophageal reflux disease (GERD).

Voice Misuse and Overuse

Speaking is a physical task that requires coordination of breathing with the use of several muscle groups. It should come as no surprise that, just like in any other physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged, and/or inefficient voice use can lead to vocal difficulties, just like improper lifting can lead to back injuries. Excessive tension in the neck and laryngeal muscles, along with poor breathing technique during speech leads to vocal fatigue, increased vocal effort, and hoarseness. Voice misuse and overuse puts you at risk for developing benign vocal cord lesions (see below) or a vocal cord hemorrhage.

Common situations that are associated with voice misuse:

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

Benign Vocal Cord Lesions

Benign non-cancerous growths on the vocal cords are most often caused by voice misuse or overuse, which causes trauma to the vocal cords. These lesions (or “bumps”) on the vocal cord(s) alter vocal cord vibration and lead to hoarseness. The most common vocal cord lesions are nodules, polyps, and cysts. Vocal nodules (also known as nodes or singer’s nodes) are similar to “calluses” of the vocal cords. They occur on both vocal cords opposite each other at the point of maximal wear and tear, and are usually treated with voice therapy to eliminate the vocal trauma that is causing them. Contrary to common myth, vocal nodules are highly treatable and intervention leads to improvement in most cases. Vocal cord polyps and cysts are the other common benign lesions. These are sometimes related to voice misuse or overuse, but can also occur in people who don’t use their voice improperly. These types of problems typically require microsurgical treatment for cure, with voice therapy employed in a combined treatment approach in some cases.

Vocal Cord Hemorrhage

If you experience sudden loss of voice following yelling, shouting, or other strenuous vocal tasks, you may have developed a vocal cord hemorrhage. Vocal cord hemorrhage results when one of the blood vessels on the surface of the vocal cord ruptures and the soft tissues of the vocal cord fill with blood. It is considered a vocal emergency and is treated with absolute voice rest until the hemorrhage resolves. If you lose your voice after strenuous voice use, see your Otolaryngologist as soon as possible.

Vocal Cord Paralysis and Paresis

Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition that affects the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rare and is usually manifested by noisy breathing or difficulty getting enough air while breathing or talking. When one vocal cord is paralyzed or weak, voice is usually the problem rather than breathing. One vocal cord can become paralyzed or weakened (paresis) from a viral infection of the throat, after surgery in the neck or chest, from a tumor or growth along the laryngeal nerves, or for unknown reasons. Vocal cord paralysis typically presents with a soft and breathy voice. Many cases of vocal cord paralysis will recover within several months. In some cases however, the paralysis will be permanent, and may require active treatment to improve the voice. Treatment choice depends on the nature of the vocal cord paralysis, the degree of vocal impairment, and the patient’s vocal needs. While we are not able to make paralyzed vocal cords move again, there are good treatment options for improving the voice. One option includes surgery for unilateral vocal cord paralysis that repositions the vocal cord to improve contact and vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to accomplish this. Voice therapy may be used before or after surgical treatment of the paralyzed vocal cords, or it can also be used as the sole treatment. (For more information, see Vocal Cord Paralysis.)

Laryngeal Cancer

Throat cancer is a very serious condition requiring immediate medical attention. Chronic hoarseness warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis. Remember to listen to your voice because it might be telling you something. Laryngeal cancer is highly curable if diagnosed in its early stages. For more information, see Laryngeal Cancer.

Effects of Medications on Voice Could Your Medication Be Affecting Your Voice? Some medications including prescription, over-the-counter, and herbal supplements can affect the function of your voice. If your doctor prescribes a medication that adversely affects your voice, make sure the benefit of taking the medicine outweighs the problems with your voice. Most medications affect the voice by drying out the protective mucosal layer covering the vocal cords. Vocal cords must be well-lubricated to operate properly; if the mucosa becomes dry, speech will be more difficult. This is why hydration is an important component of vocal health. Medications can also affect the voice by thinning blood in the body, which makes bruising or hemorrhaging of the vocal cord more likely if trauma occurs, and by causing fluid retention (edema), which enlarges the vocal cords. Medications from the following groups can adversely affect the voice: Antidepressants Muscle relaxants Diuretics Antihypertensives (blood pressure medication) Antihistamines (allergy medications) Anticholinergics (asthma medications) High-dose Vitamin C (greater than five grams per day) Other medications and associated conditions that may affect the voice include: Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a cough or excessive throat clearing in as many as 10 percent of patients. Coughing or excessive throat clearing can contribute to vocal cord lesions. Oral contraceptives may cause fluid retention (edema) in the vocal cords because they contain estrogen. Estrogen replacement therapy post-menopause may have a variable effect. An inadequate level of thyroid replacement medication in patients with hypothyroidism. Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp formation in response to trauma. Herbal medications are not harmless and should be taken with caution. Many have unknown side effects that include voice disturbance. NOTE: Contents of this fact sheet are based on information provided by The Center for Voice at Northwestern University.

GERD and LPR Insight into the diagnosis, prevention and treatment What are the symptoms of GERD and LPR? Who gets GERD or LPR? How are GERD and LPR diagnosed and treated? and more… 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. Adult lifestyle changes to prevent GERD and LPR Avoid eating and drinking within two to three hours prior to bedtime Do not drink alcohol Eat small meals and slowly Limit problem foods: Caffeine Carbonated drinks Chocolate Peppermint Tomato Citrus fruits Fatty and fried foods Lose weight Quit smoking Wear loose clothing

What is GERD? Gastroesophageal reflux disease, or 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 to move up the esophagus. When stomach acid touches the sensitive tissue lining the esophagus, 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. Occasional heartburn is normal. However, if heartburn becomes chronic, occurring more than twice a week, you may have GERD. Left untreated, GERD can lead to more serious health problems. Who gets GERD? Anyone can have GERD. Women, men, infants and children can all experience this disorder. Overweight people and pregnant women are particularly susceptible because of the pressure on their stomachs. Recent studies indicate that GERD may often be overlooked in infants and children. In infants and children, GERD can cause repeated vomiting, coughing, and other respiratory problems such as sore throat and ear infections. Most infants grow out of GERD by the time they are one year old. Tips to Prevent GERD Do not drink alcohol Lose weight Quit smoking Limit problem foods such as: Caffeine Carbonated drinks Chocolate Peppermint Tomato and citrus foods Fatty and fried foods Wear loose clothing Eat small meals and slowly What are the symptoms of GERD? The symptoms of GERD may include persistent heartburn, acid regurgitation, and nausea. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be sever enough to mimic the pain of a heart attack, hoarseness in the morning, or trouble swallowing. Some people may also feel like they have food stuck in their throat or like they are choking. GERD can also cause a dry cough and bad breath. What are the complications of GERD? GERD can lead to other medical problems such as ulcers and strictures of the esophagus (esophagitis), cough, asthma, throat and laryngeal inflammation, inflammation and infection of the lungs, and collection of fluid in the sinuses and middle ear. GERD can also cause a change in the esophageal lining called Barrett’s esophagus, which is a serious complication that can lead to cancer. What causes GERD? Physical causes of GERD can include: a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors that contribute to GERD include: alcohol use obesity pregnancy smoking Certain foods can contribute to GERD, such as: citrus fruits chocolate caffeinated drinks fatty and fried foods garlic and onions mint flavorings (especially peppermint) spicy foods tomato-based foods, like spaghetti sauce, chili, and pizza When should I see a doctor? If you experience heartburn more than twice a week, frequent chest pains after eating, trouble swallowing, persistent nausea, and cough or sore throat unrelated to illness, you may have GERD. For proper diagnosis and treatment, you should be evaluated by a physician. How can my ENT help? Otolaryngologists, or ear, nose and throat doctors, and have extensive experience with the tools that diagnose GERD and they are specialists in the treatment of many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation, Barrett’s esophagus, and ulcerations of the esophagus. How is GERD diagnosed? GERD can be diagnosed or evaluated by clinical observation and the patient’s response to a trial of treatment with medication. In some cases other tests may be needed including: an endoscopic examination (a long tube with a camera inserted into the esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour esophageal acid testing, esophageal motility testing (manometry), emptying studies of the stomach, and esophageal acid perfusion (Bernstein test). Endoscopic examination, biopsy, and x-ray may be performed as an outpatient in a hospital setting. Light sedation may be used for endoscopic examinations. While most people with GERD respond to a combination of lifestyle changes and medication. Occasionally, surgery is recommended. Lifestyle changes include: losing weight, quitting smoking, wearing loose clothing around the waist, raising the head of your bed (so gravity can help keep stomach acid in the stomach), eating your last meal of the day three hours before bed, and limiting certain foods such as spicy and high fat foods, caffeine, alcohol,. Medications your doctor may prescribe for GERD include: antacids (such as Tums, Rolaids, etc.), histamine antagonists (H2 blockers such as Tagamet,), proton pump inhibitors (such as Prilosec, Prevacid, Aciphex, Protonix, and Nexium), pro-motility drugs (Reglan), and foam barriers (Gaviscon). Some of these products are now available over-the-counter and do not require a prescription. Surgical 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 is used to make the LES tighter. Are there long-term health problems associated with GERD? GERD may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although usually it does not. Barrett’s esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer. For more information on GERD or to find an otolaryngologist near you, visitwww.entnet.org.

Hoarseness

Insight into voice changes

• What causes hoarseness?
• What can you do to treat it?
• When should you see an ENT?
• and more…

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.

Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPRD rather than GERD. The structures in the throat (pharynx, larynx and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage.

Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse, they should see an otolaryngologist.

Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson’s or a stroke, or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice, but sometimes affects breathing. A paralyzed vocal cord may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis.

Other Causes: These include allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation. Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated by an otolaryngologist immediately.

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.

Prevention tips:

• If you smoke, quit.
• Avoid agents that dehydrate the body, such as alcohol and caffeine.
• Avoid secondhand smoke.
• Stay hydrated—drink plenty of water.
• Humidify your home.
• Watch your diet—avoid spicy foods.
• Try not to use your voice too long or too loudly.
• Use a microphone if possible in situations where you need to project your voice.
• Seek professional voice training.
• Avoid speaking or singing when your voice is injured or hoarse.

How Allergies Affect your Child’s Ears, Nose and Throat

Does your child have allergies? Allergies can cause many ear, nose, and throat symptoms in children, but allergies can be difficult to separate from other causes. Here are some clues that allergy may be affecting your child.

Children with nasal allergies often have a history of other allergic tendencies (or atopy). These may include early food allergies or atopic dermatitis in infancy. Children with nasal allergies are at higher risk for developing asthma.

Nasal allergies can cause sneezing, itching, nasal rubbing, nasal congestion, and nasal drainage. Usually, allergies are not the primary cause of these symptoms in children under four years old. In allergic children, these symptoms are caused by exposure to allergens (mostly pollens, dust, mold, and dander). Observing which time of year or in which environments the symptoms are worse can be important clues to share with your doctor.

Ear infections:

One of children’s most common medical problems is otitis media, or middle ear infection. In most cases, allergies are not the main cause of ear infections in children under two years old. But in older children, allergies may play role in ear infections, fluid behind the eardrum, or problems with uncomfortable ear pressure. Diagnosing and treating allergies may be an important part of healthy ears.

Sore throats:

Allergies may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to “post-nasal drip.” It can lead to cough, sore throats, and a husky voice.

Sleep Disorders:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis and perennial (year-round) allergic rhinitis. Nasal congestion can contribute to sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Fatigue is one of the most common, and most debilitating, allergic symptoms. Fatigue not only affects children’s quality of life, but has been shown to affect school performance.

Pediatric sinusitis:

Allergies should be considered in children who have persistent or recurrent sinus disease. Depending on the age of your child, their individual history, and an exam, your doctor should be able to help you decide if allergies are likely. Some studies suggest that large adenoids (a tonsil-like tissue in the back of the nose) are more common in allergic children.

How the Voice Works

We rely on our voices every day to interact with others, and a healthy voice is critical for clear communication. But just as we walk without thinking about it, we usually speak without thinking how our body makes it happen. However, knowing how we make sound is useful to maintaining the health and effectiveness of our voices. So this year on World Voice Day, April 16, take a minute to learn how your voice works. The following overview describes the body parts that work together to produce the sounds we make when we speak and sing.

The main parts of voice production:

• The Power Source: Your Lungs
• The Vibrator: Your Voice Box
• The Resonator: Your Throat, Nose, Mouth, and Sinuses

The Power Source: The power for your voice comes from air that you exhale. When we inhale, the diaphragm lowers and the rib cage expands, drawing air into the lungs. As we exhale, the process reverses and air exits the lungs, creating an airstream in the trachea. This airstream provides the energy for the vocal folds in the voice box to produce sound. The stronger the airstream, the stronger the voice. Give your voice good breath support to create a steady strong airstream that helps you make clear sounds.

The Vibrator: The larynx (or voice box) sits on top of the windpipe. It contains two vocal folds (also known as vocal cords) that open during breathing and close during swallowing and voice production. When we produce voice, the airstream passes between the two vocal folds that have come together. These folds are soft and are set into vibration by the passing airstream. They vibrate very fast – from 100 to 1000 times per second, depending on the pitch of the sound we make. Pitch is determined by the length and tension of the vocal folds, which are controlled by muscles in the larynx.

The Resonator: By themselves, the vocal folds produce a noise that sounds like simple buzzing, much like the mouthpiece on a trumpet. All of the structure above the folds, including the throat, nose, and mouth, are part of the resonator system. We can compare these structures to those of a horn or trumpet. The buzzing sound created by vocal fold vibration is changed by the shape of the resonator tract to produce our unique human sound.

When our voices are healthy, the three main parts work in harmony to provide effortless voice during speech and singing.

Keeping Your Voice Healthy

There are many different reasons why your voice may sound hoarse or abnormal from time to time, and some of these reasons are things that you can not really control. An example would be catching a common cold virus that causes laryngitis. Sure, you can wash your hands frequently and try to avoid people with colds, but virtually everyone catches a cold with a bit of laryngitis now and again. What you probably did not know is that there are steps you can take to prevent many voice problems. The following steps are helpful for anyone who wants to keep their voice healthy, but are particularly important for people who have an occupation, such as teaching, that is heavily voice-related.

Key Steps for Keeping Your Voice Healthy

• Drink plenty of water. Moisture is good for your voice. Hydration helps to keep thin secretions flowing to lubricate your vocal cords. Drink plenty (up to eight 8-ounce glasses is a good minimum target) of non-caffeinated, non-alcoholic beverages throughout the day.
• Try not to scream or yell. These are abusive practices for your voice, and put great strain on the lining of your vocal cords.
• Warm up your voice before heavy use. Most people know that singers warm up their voices before a performance, yet many don’t realize the need to warm up the speaking voice before heavy use, such as teaching a class, preaching, or giving a speech. Warm-ups can be simple, such as gently gliding from low to high tones on different vowel sounds, doing lip trills (like the motorboat sound that kids make), or tongue trills.
• Don’t smoke. In addition to being a potent risk factor for laryngeal (voice box) cancer, smoking also causes inflammation and polyps of the vocal cords that can make the voice very husky, hoarse, and weak.
• Use good breath support. Breath flow is the power for voice. Take time to fill your lungs before starting to talk, and don’t wait until you are almost out of air before taking another breath to power your voice.
• Use a microphone. When giving a speech or presentation, consider using a microphone to lessen the strain on your voice.
• Listen to your voice. When your voice is complaining to you, listen to it. Know that you need to modify and decrease your voice use if you become hoarse in order to allow your vocal cords to recover. Pushing your voice when it’s already hoarse can lead to significant problems. If your voice is hoarse frequently, or for an extended period of time, you should be evaluated by an Otolaryngologist (Ear, Nose and Throat physician.)

Laryngeal (Voice Box) Cancer

Laryngeal cancer is not as well known by the general public as some other types of cancer, yet it is not a rare disease. The American Cancer Society estimates that in 2012 there will be about 12,360 new cases of laryngeal cancer (9,840 men and 2,520 women) and about 3,650 deaths (2,880 men and 770 women). Even for survivors, the consequences of laryngeal cancer can be severe with respect to voice, breathing, or swallowing. It is fundamentally a preventable disease though, since the primary risk factors for laryngeal cancer are associated with modifiable behaviors.

Risk Factors Associated With Laryngeal Cancer

Development of laryngeal cancer is a process that involves many factors, but approximately 90 percent of head and neck cancers occur after exposure to known carcinogens (cancer causing substances). Chief among these factors is tobacco. Over 90 percent of laryngeal cancers are a type of cancer called squamous cell carcinoma (SCCA), and over 95 percent of patients with laryngeal SCCA are smokers. Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body’s immune response.

Tobacco use is measured in pack-years, where one pack per day for one year is considered one pack-year. Two pack-years is defined as either one pack per day for two years, or two packs per day for one year (Longer terms of pack years are determined using a similar ratio.) Depending upon the number of pack-years smoked, studies have reported that smokers are about 5 to 35 times more likely to develop laryngeal cancer than non-smokers. It does seem that the duration of tobacco exposure is probably more important overall to cancer causing effect, than the intensity of the exposure.

Alcohol is another important risk factor for laryngeal cancer, and acts as a promoter of the cancer causing process. The major clinical significance of alcohol is that it potentiates the effects of tobacco. Magnitude of this effect is between an additive and a multiplicative one. That is, people who smoke and drink alcohol have a combined risk that is greater than the sum of the individual risks. The American Cancer Society recommends that those who drink alcoholic beverages should limit the amount of alcohol they consume, with one drink per day considered a limited alcohol exposure.

Other risk factors for laryngeal cancer include certain viruses, such as human papilloma virus (HPV), and likely acid reflux. Vitamin A and beta-carotene may play a protective role.

Signs and Symptoms of Laryngeal Cancer

Signs and symptoms of laryngeal cancer include: progressive or persistent hoarseness, difficulty swallowing, persistent sore throat or pain with swallowing, difficulty breathing, pain in the ear, or a lump in the neck. Anyone with these signs or symptoms should be evaluated by an Otolaryngologist (Ear, Nose and Throat Doctor). This is particularly important for people with risk factors for laryngeal cancer.

Treatment of Laryngeal Cancer

The primary treatment options for laryngeal cancer include surgery, radiation therapy, chemotherapy, or a combination of these treatments. Remember that this is a preventable disease in the vast majority of cases, because the main risk factors are associated with modifiable behaviors. Do not smoke and do not abuse alcohol!

Laryngopharyngeal Reflux and Children

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease, or GERD.

Sometimes, acidic stomach contents will reflux all the way up the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up, and in most infants, it is a normal occurrence that resolves in the first year. Only infants who have associated breathing or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a “lump” or something “stuck” in the throat, which does not go away despite multiple swallowing attempts to clear the “lump.” Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This is known as “laryngospasm.”

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist, such as an otolaryngologist (ear-nose-throat doctor). Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

• Chronic cough
• Hoarseness
• Noisy breathing (stridor)
• Croup
• Reactive airway disease (asthma)
• Sleep disordered breathing (SDB)
• Spit up
• Feeding difficulty
• Turning blue (cyanosis)
• Aspiration
• Pauses in breathing (apnea)
• Apparent life threatening event (ALTE)
• Failure to thrive (a severe deficiency in growth such that an infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long-term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction. The latter can cause recurrent ear infections, or persistent middle ear fluid, and even symptoms of sinusitis. The direct relationship between LPR and the latter mentioned problems are currently being researched.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician getting a referral to see an otolaryngologist for evaluation. In the office, he or she may look directly at the voice box and related structures with a flexible scope or order a 24-hour pH monitoring of the esophagus. The otolaryngologist may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box (direct laryngoscopy), trachea and bronchi (bronchoscopy), and esophagus (esophagoscopy). LPR in infants and children remains a diagnosis of clinical judgment, based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment is usually based on successful treatment of GER. In infants and children, basic recommendations may include use of smaller and more frequent feedings, thickening of the food/liquid, and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications, including H2 blockers or proton pump inhibitors, may be necessary. Similar to adults, children with severe symptoms who fail medical treatment or have diagnostic evaluations demonstrating anatomical abnormalities, may require surgical intervention.

Nodules, Polyps and Cysts

The term vocal cord lesion (physicians call them vocal “fold” lesions) refers to a group of noncancerous (benign), abnormal growths (lesions) within or along the covering of the vocal cord. Vocal cord lesions are one of the most common causes of voice problems and are generally seen in three forms; nodules, polyps, and cysts.

Vocal Cord Nodules (also called Singer’s Nodes, Screamer’s Nodes)

Vocal cord nodules are also known as “calluses of the vocal fold.” They appear on both sides of the vocal cords, typically at the midpoint, and directly face each other. Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped.

Vocal Cord Polyp

A vocal cord polyp typically occurs only on one side of the vocal cord and can occur in a variety of shapes and sizes. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances.

Vocal Cord Cyst

A vocal cord cyst is a firm mass of tissue contained within a membrane (sac). The cyst can be located near the surface of the vocal cord or deeper, near the ligament of the vocal cord. As with vocal cord polyps and nodules, the size and location of vocal cord cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem. Surgery followed by voice therapy is the most commonly recommended treatment for vocal cord cysts that significantly alter and/or limit voice.

Reactive Vocal Cord Lesion

A reactive vocal cord lesion is a mass located opposite an existing vocal cord lesion, such as a vocal cord cyst or polyp. This type of lesion is thought to develop from trauma or repeated injury caused by the lesion on the opposite vocal cord. A reactive vocal cord lesion will usually decrease or disappear with voice rest and therapy.

What Are The Causes Of Benign Vocal Cord Lesions?

The exact cause or causes of benign vocal cord lesions is not known. Lesions are thought to arise following “heavy” or traumatic use of the voice, including voice misuse such as speaking in an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick.

What Are The Symptoms Of Benign Vocal Cord Lesions?

A change in voice quality and persistent hoarseness are often the first warning signs of a vocal cord lesion. Other symptoms can include:

• Vocal fatigue
• Unreliable voice
• Delayed voice initiation
• Low, gravelly voice
• Low pitch
• Voice breaks in first passages of sentences
• Airy or breathy voice
• Inability to sing in high, soft voice
• Increased effort to speak or sing
• Hoarse and rough voice quality
• Frequent throat clearing
• Extra force needed for voice
• Voice “hard to find”

When a vocal cord lesion is present, symptoms may increase or decrease in degree, but will persist and do not go away on their own.

How Is The Diagnosis Of A Benign Vocal Cord Lesion Made?

Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient’s mouth that allows the examiner to view the voice box (images are often recorded on video). The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion.

Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication’s side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor.

How Are Benign Vocal Cord Lesions Treated?

The most common treatment options for benign vocal cord lesions include: voice rest, voice therapy, singing voice therapy, and phonomicrosurgery, a type of surgery involving the use of microsurgical techniques and instruments to treat abnormalities on the vocal cord.

Treatment options can vary according to the degree of voice limitation and the exact voice demands of the patient. For example, if a professional singer develops benign vocal cord lesions and undergoes voice therapy, which improves speaking but not singing voice, then surgery might be considered to restore singing voice. Successful and appropriate treatment is highly individual and includes consideration of the patient’s vocal needs and the clinical judgment of the otolaryngologist.

Pediatric GERD (Gastro-Esophageal Reflux Disease) and Your Otolaryngologist

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at age four months. But an infant’s improved neuromuscular control and the ability to sit up will lead to a spontaneous resolute ion of significant GER in more than half of infants by age ten months and four out of five at age 18 months.

Researchers have found that 10 percent of infants (younger than 12 months) with GER develop significant complications. The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs when a muscular valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears and even the teeth. Consequently, other typical symptoms could include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation (“wet burps” or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, if your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose, and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is “refluxed” into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, the results will indicate how often the child “refluxes” acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• Barium swallow or upper GI series: The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in the stomach.
• Endoscopy with biopsies: This most comprehensive test involves the passing down of a flexible endoscope with lights and lenses through the mouth into the esophagus, stomach, and duodenum. This allows the doctor to get a directly look at the esophagus, stomach, and duodenum and see if there is any irritation or inflammation present. In some children with gastroesophageal reflux, repeated exposure of the esophagus to stomach acid causes some inflammation (esophagitis). Endoscopy in children usually requires a general anesthetic.
• Fiberoptic Laryngoscopy: A small lighted scope is placed in the nose and the pharynx to evaluate for inflammation.

What treatments for GERD are available?

Treatment of reflux in infants is intended to lessen symptoms, not to relieve the underlying problem, as this will often resolve on its own with time. A useful simple treatment is to thicken a baby’s milk or formula with rice cereal, making it less likely to be refluxed.

Several steps can be taken to assist the older child with GERD:

• Lifestyle changes: Raise the head of the child’s bed about 30 degrees while they sleep and have the child eat smaller, more frequent meals instead of large amounts of food at one sitting. Avoid having the child eat right before they go to bed or lie down; instead, let two or three hours pass. Try a walk or warm bath or even a few minutes on the toilet. Some researchers believe that certain lifestyle changes such as losing weight or dressing in loose clothing my assist in alleviating GERD. Even chewing sugarless gum may help.
• Dietary changes: Avoid chocolate, carbonated drinks, caffeine, tomato products, peppermint, and other acidic foods as citrus juices. Fried foods and spicy foods are also known to aggravate symptoms. Pay attention to what your child eats and be alert for individual problems.
• Medical Treatment: Most of the medications prescribed to treat GERD either break down or lessen intestinal gas, decrease or neutralize stomach acid, or improve intestinal coordination. Your physician will prescribe the most appropriate medication for your child.
• Surgical Treatment: It is rare for children with GERD to require surgery. For the few children who do require surgery, the most commonly performed operation is called Nissen fundoplication. With this procedure, the top part of the stomach (the fundus) is wrapped around the bottom of the esophagus to create a collar. After the operation, every time the stomach contracts, the collar around the esophagus contracts preventing reflux.

Pediatric Obesity and Ear, Nose and Throat Disorders

Today in the United States, studies estimate that 34 percent of U.S. adults are overweight and an additional 31 percent (approximately 60 million) are obese. Combined, approximately 127 million Americans are overweight or obese. Some 42 years ago, 13 percent of Americans were obese, and in 1980 15 percent were considered obese.

Alarmingly, the number of children who are overweight or obese has doubled in the last two decades as well. Currently, more than 15 percent of 6- to 11-year-olds and more than 15 percent of 12- to 19-year-olds are considered overweight or obese.

What is the difference between designated “obese” versus “overweight?”

Unfortunately, the words overweight and obese are often interchanged. There is a difference:

• Overweight: Anyone with a body mass index (BMI) (a ratio between your height and weight) of 25 or above (e.g., someone who is 5-foot-4 and 145 pounds) is considered overweight.
• Obesity: Anyone with a BMI of 30 or above (e.g., someone who is 5-foot-4 and 175 pounds) is considered obese.
• Morbid obesity: Anyone with a BMI of 40 or above (e.g., someone who is 5-foot-4 and 233 pounds) is considered morbidly obese. “Morbid” is a medical term indicating that the risk of obesity related illness is increased dramatically at this degree of obesity.

Obesity can present significant health risks to the young child. Diseases are being seen in obese children that were once thought to be adult diseases. Many experts in the study of children’s health suggest that a dysfunctional metabolism, or failure of the body to change food calories to energy, precedes the onset of disease. Consequently, these children are at risk for Type II Diabetes, fatty liver, elevated cholesterol, SCFE (a major hip disorder), menstrual irregularities, sleep apnea, and irregular metabolism. Additionally, there are psychological consequences; obese children are subject to depression, loss of self-esteem, and isolation from their peers.

Pediatric obesity and otolaryngic problems

Otolaryngologists, or ear, nose and throat specialists, diagnose and treat some of the most common children’s disorders. They also treat ear, nose and throat conditions that are common in obese children, such as:

Sleep apnea:

Children with sleep apnea literally stop breathing repeatedly during their sleep, often for a minute or longer, usually ten to 60 times during a single night. Sleep apnea can be caused by either complete obstruction of the airway (obstructive apnea) or partial obstruction (obstructive hypopnea—hypopnea is slow, shallow breathing), both of which can wake one up. There are three types of sleep apnea—obstructive, central, and mixed. Of these, obstructive sleep apnea (OSA) is the most common. Otolaryngologists have pioneered the treatment for sleep apnea; research shows that one to three percent of children have this disorder, often between the age of two-to-five years old.

Enlarged tonsils, which block the airway, are usually the key factor leading to this condition. Extra weight in obese children and adults can also interfere with the ability of the chest and abdomen to fully expand during breathing, hindering the intake of air and increasing the risk of sleep apnea.

The American Academy of Pediatrics has identified obstructive sleep apnea syndrome (OSAS) as a “common condition in childhood that results in severe complications if left untreated.” Among the potential consequences of untreated pediatric sleep apnea are growth failure; learning, attention, and behavior problems; and cardio-vascular complications. Because sleep apnea is rarely diagnosed, pediatricians now recommend that all children be regularly screened for snoring.

Middle ear infections:

Acute otitis media (AOM) and chronic ear infections account for 15 to 30 million visits to the doctor each year in the U.S. In fact, ear infections are the most common reason why an American child sees a doctor. Furthermore, the incidence of AOM has been rising over the past decades. Although there is no proven medical link between middle ear infections and pediatric obesity there may be a behavioral association between the two conditions. Some studies have found that when a child is rubbing or massaging the infected ear the parent often responds by offering the child food or snacks for comfort.

When a child does have an ear infection the first line of treatment is often a regimen of antibiotics. When antibiotics are not effective, the ear, nose and throat specialist might recommend a bilateral myringotomy with pressure equalizing tube placement (BMT), a minor surgical procedure. This surgery involves the placement of small tubes in the eardrum of both ears. The benefit is to drain the fluid buildup behind the eardrum and to keep the pressure in the ear the same as it is in the exterior of the ear. This will reduce the chances of any new infections and may correct any hearing loss caused by the fluid buildup.

Postoperative vomiting (POV) is a common problem after bilateral myringotomy surgery. The overall incidence is 35 percent, and usually occurs on the first postoperative day, but can occur up to seven days later. Several factors are known to affect the incidence of POV, including age, type of surgery, postoperative care, medications, co-existing diseases, past history of POV, and anesthetic management. Obesity, gastroparesis, female gender, motion sickness, pre-op anxiety, opiod analgesics, and the duration of anesthetic all increase the incidence of POV. POV interferes with oral medication and intake, delays return to normal activity, and increases length of hospital stay. It remains one of the most common causes of unplanned postoperative hospital admissions.

Tonsillectomies:

A child’s tonsils are removed because they are either chronically infected or, as in most cases, enlarged, leading to obstructive sleep apnea. There are several surgical procedures utilized by ear, nose and throat specialists to remove the tonsils, ranging from use of a scalpel to a wand that emits energy that shrinks the tonsils.

Research conducted by otolaryngologists found that:

Morbid obesity was a contributing factor for requiring an overnight hospital admission for a child undergoing removal of enlarged tonsils. Most children who were diagnosed as obese with sleep apnea required a next-day physician follow-up.

A study from the University of Texas found that morbidly obese patients have a significant increase of additional medical disorders following tonsillectomy and adenoidectomy for obstructive sleep apnea or sleep-disordered breathing when compared to moderately obese or overweight patients undergoing this procedure for the same diagnosis. On average they have longer hospital stays, a greater need for intensive care, and a higher incidence of the need for apnea treatment of continuous positive airway pressure upon discharge from the hospital. The study found that although the morbidly obese group had a greater degree of sleep apnea, they did benefit from the procedure in regards to snoring, apneic spells, and daytime somnolence.

What you can do

If your child has a weight problem, contract your pediatrician or family physician to discuss the weight’s effect on your child’s health, especially prior to treatment decisions. Second, ask your physician about lifestyle and diet changes that will reduce your child’s weight to a healthy standard.

Secondhand Smoke

Access to quality healthcare for children is forwarded by the availability of good healthcare information. With this year’s release of a new surgeon general’s report on secondhand smoke, the following information should be shared with patients.

New Warning on Secondhand Smoke

The Surgeon General released new evidence this year—July 2006—supporting the fact that secondhand smoke, smoke from a burning cigarette and the smoke exhaled by the smoker, represents a dangerous health hazard.

The new report states that there is no risk-free level of secondhand smoke exposure. Although secondhand smoke is dangerous to everyone, fetuses, infants, and children are at most risk. Even brief exposures can be harmful to children. This is because secondhand smoke can damage developing organs, such as the lungs and brain.

Infants and Children Effects and Exposure

Babies of mothers who smoked and those exposed to smoke are more likely to die from Sudden Infant Death Syndrome (SIDS) than babies who are not exposed to smoke.

Babies of mothers who smoked and those exposed to smoke after birth have weaker lungs and thereby increased risk of more health problems.

Children with asthma exposed to secondhand smoke experience more frequent and severe attacks.

Children exposed to secondhand smoke are at increased risk for ear infections and are more likely to need an operation to insert ear tubes for drainage.

Youth and Teens Effects and Exposure

Secondhand smoke exposure causes respiratory symptoms, including cough, phlegm, wheeze, and breathlessness, among school-aged children.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Statistics

More than 4,000 different chemicals have been identified in secondhand smoke and at least 43 of these chemicals cause cancer.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children less than five years of age live in homes with at least one adult smoker.

28 percent of high school aged children are exposed to secondhand smoke in their own homes.

A recent study found that 34 percent of teens begin smoking as a result of tobacco company promotional activities.

Among middle school students who were current smokers, 71 percent reported never being asked to show proof of age when buying cigarettes in a store, and 66 percent were not refused purchase because of their age.

Checklist for Protection Against Secondhand Smoke:

Young children

• Remember that you are a powerful role model. If you don’t smoke, your children are less likely to smoke.
• Make your home and car smoke-free spaces. Put up no-smoking stickers and signs in your home.
• Make sure you and your kids aren’t exposed to second-hand smoke at daycare, school, or friends’ homes.
• Support businesses and activities that are smoke-free. Let other businesses owners know that you can’t support their businesses until they become 100 percent smoke-free too.
• If you can’t find a smoke-free restaurant and must go to one that allows some smoking, ask to sit in the nonsmoking section.
• If your asthma or COPD is triggered by smoke, don’t risk it—stay away from any place that allows smoking.
• Support laws that restrict smoking.
• Youth and Teens

Parents

• Talk to your children about smoking; they’ll be less likely to smoke than if you ignore the problem.
• Support tobacco education in the schools and ban all smoking on school grounds, on school buses, and at school-sponsored events for students, school personnel, and visitors.
• Ask that schools enforce the policy and consistently administer penalties for violations and that this is communicated in written and oral form to students, staff, and visitors.
• Vote for public smoking restrictions as an important component of the social environment that supports healthy behavior, reducing the number of opportunities to smoke, and making smoking less socially acceptable.
• Support tax increases on tobacco products so young people cannot afford them.

Teens

• If your friends smoke, ask them in a caring way to quit or at least not to smoke around you.
• Peers, siblings, and friends are powerful influences on you and others. Understand that the most common situation for first trying a cigarette is with a friend who already smokes.

Families

• Work together to uphold restrictions on tobacco advertising and promotions.

Sources and Resources

The Health Consequences of Involuntary Exposure to Tobacco Smoke: Children are Hurt by Secondhand Smoke. A Report of the Surgeon General, U.S. Department of Health and Human Services, 2006; Available at:www.surgeongeneral.gov/library/secondhandsmoke/factsheets/factsheet2.html.

CDC. Tobacco Use, Access & Exposure to Tobacco Among Middle & High School Students, US 2004 MMWR. Vol. 54(12) April 2005.

American Legacy Foundation. 2004 National Youth Tobacco Survey. 2005

CDC. Cigarette Use Among High School Students – United States, 1991-2003. Morbidity and Mortality Weekly Report 2004; 53(23): 499-502.

King C, Siegel M. The Master Settlement Agreement with the Tobacco Industry and Cigarette Advertising in Magazines. New England Journal of Medicine 2001; 345: 504-511.

Sore Throats

Insight into relief for a sore throat

• What causes a sore throat?
• What are my treatment options?
• How can I prevent a sore throat?
• and more…

Infections from viruses or bacteria are the main cause of sore throats and can make it difficult to talk and breathe. Allergies and sinus infections can also contribute to a sore throat. If you have a sore throat that lasts for more than five to seven days, you should see your doctor. While increasing your liquid intake, gargling with warm salt water, or taking over-the-counter pain relievers may help, if appropriate, your doctor may write you a prescription for an antibiotic.

What are the causes and symptoms of a sore throat?

Infections by contagious viruses or bacteria are the source of the majority of sore throats.

Viruses: Sore throats often accompany viral infections, including the flu, colds, measles, chicken pox, whooping cough and croup. One viral infection, infectious mononucleosis, or “mono,” takes much longer than a week to be cured. This virus lodges in the lymph system, causing massive enlargement of the tonsils, with white patches on their surface. Other symptoms include swollen glands in the neck, armpits and groin; fever, chills and headache. If you are suffering from mono, you will likely experience a severe sore throat that may last for one to four weeks and, sometimes, serious breathing difficulties. Mono causes extreme fatigue that can last six weeks or more and can also affect the liver, leading to jaundice-yellow skin and eyes.

Bacteria: Strep throat is an infection caused by a particular strain of streptococcus bacteria. This infection can also damage the heart valves (rheumatic fever) and kidneys (nephritis), cause scarlet fever, tonsillitis, pneumonia, sinusitis and ear infections. Symptoms of strep throat often include fever (greater than 101°F), white draining patches on the throat, and swollen or tender lymph glands in the neck. Children may have a headache and stomach pain.

Tonsillitis is an infection of the lumpy-appearing lymphatic tissues on each side of the back of the throat.

Infections in the nose and sinuses also can cause sore throats, because mucus from the nose drains down into the throat and carries the infection with it.

The most dangerous throat infection is epiglottitis, which infects a portion of the larynx (voice box) and causes swelling that closes the airway. Epiglottitis is an emergency condition that requires prompt medical attention. Suspect it when swallowing is extremely painful (causing drooling), when speech is muffled, and when breathing becomes difficult. Epiglottitis may not be obvious just by looking in the mouth. A strep test may overlook this infection.

Other causes

Allergies to pollens and molds such as cat and dog dander and house dust are common causes of sore throats.

Irritation caused by dry heat, a chronic stuffy nose, pollutants and chemicals and straining your voice can also irritate your throat.

Reflux, or a regurgitation of stomach acids up into the back of the throat, can cause you to wake up with a sore throat.

Tumors of the throat, tongue and larynx (voice box) can cause a sore throat with pain radiating to the ear and/or difficulty swallowing. Other important symptoms can include hoarseness, noisy breathing, a lump in the neck, unexplained weight loss and/or spitting up blood in the saliva or phlegm.

HIV infection can sometimes cause a chronic sore throat, due not to HIV itself but to a secondary infection that can be extremely serious.

When should I see a doctor?

Whenever a sore throat is severe, persists longer than the usual five-to-seven day duration of a cold or flu, and is not associated with an avoidable allergy or irritation, you should seek medical attention. The following signs and symptoms should alert you to see your physician:

• Severe and prolonged sore throat
• Difficulty breathing
• Difficulty swallowing
• Difficulty opening the mouth
• Joint pain
• Earache
• Rash
• Fever (over 101°)
• Blood in saliva or phlegm
• Frequently recurring sore throat
• Lump in neck
• Hoarseness lasting over two weeks

How will I be tested for a sore throat?

To test for strep throat, your doctor may want to do a throat culture, a non-surgical procedure that uses an instrument to take a sampling of the infected cells.  Because the culture will not detect other infections, when it is negative, your physician will base his/her decision for treatment on the severity of your symptoms and the appearance of your throat on examination.

What are my treatment options?

A mild sore throat associated with cold or flu symptoms can be made more comfortable with the following remedies:

• Increase your liquid intake.
• Warm tea with honey is a favorite home remedy.
• Use a steamer or humidifier in your bedroom.
• Gargle with warm salt water several times daily: ¼ tsp. salt to ½ cup water.
• Take over-the-counter pain relievers such as acetaminophen (Tylenol Sore Throat^®, Tempra^®) or ibuprofen (Motrin IB^®, Advil^®).

If you have a bacterial infection your doctor will prescribe an antibiotic to alleviate your symptoms. Antibiotics are drugs that kill or impair bacteria. Penicillin or erythromycin (well-known antibiotics) are prescribed when the physician suspects streptococcal or another bacterial infection that responds to them. However, a number of bacterial throat infections require other antibiotics instead.

Antibiotics do not cure viral infections, but viruses do lower the patient’s resistance to bacterial infections. When such a combined infection occurs, antibiotics may be recommended. When an antibiotic is prescribed, it should be taken as the physician directs for the full course (usually 7-10 days). Otherwise the infection may not be completely eliminated and could return. Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may be a candidate for a tonsillectomy.

How can I prevent a sore throat?

• Avoid smoking or exposure to secondhand smoke. Tobacco smoke, whether primary or secondary, contains hundreds of toxic chemicals that can irritate the throat lining.
• If you have seasonal allergies or ongoing allergic reactions to dust, molds, or pet dander, you’re more likely to develop a sore throat than people who don’t have allergies.
• Avoid exposure to chemical irritants. Particulate matter in the air from the burning of fossil fuels, as well as common household chemicals, can cause throat irritation.
• If you experience chronic or frequent sinus infections you are more likely to experience a sore throat, since drainage from nose or sinus infections can cause throat infections as well.
• If you live or work in close quarters such as a child care center, classroom, office, prison, or military installation, you are at greater risk because viral and bacterial infections spread easily in environments where people are in close proximity.
• Maintain good hygiene. Do not share napkins, towels and utensils with an infected person. Wash your hands regularly with soap or a sanitizing gel, for 10-15 seconds.
• If you have HIV or diabetes, are undergoing steroid treatment or chemotherapy, are experiencing extreme fatigue or have a poor diet, you have reduced immunity and are more susceptible to infections.

Special Care for Occupational and Professional Voice Users

Who is an Occupational or Professional Voice User?

An occupational or professional voice user is anyone whose voice is essential to their job. We are all accustomed to thinking of singers, actors, actresses, and broadcast personalities as professional voice users. Indeed, special or unique qualities of the voice are often the essential feature of their careers. But what about other occupational voice users?

Teachers, clergy, salespeople, courtroom attorneys, telemarketers, and receptionists are also people for whom spoken communication is an essential part of what they do, and there are countless other professions that rely heavily on the voice. In spite of this era of email and Internet communications, we can’t really imagine an effective classroom, pulpit, or courtroom without voice. Can you imagine the difficulties of a physician conveying sensitive or complex information to a patient or colleague, or a business executive conducting a meeting without voice? Once you pause to consider a world without voice communications, you realize that voice is crucial to many professions.

Why is the Voice Important?

Voice is something that is often taken for granted. Many people, including many occupational voice users, don’t pay attention to their voice until they develop a significant problem with it. These voice problems then have an adverse effect upon their ability to do their job. Consider, for example, a school teacher. Arguably, this is the most vocally demanding profession. Teachers are using their voices constantly, often in noisy rooms with poor acoustics. One recent 2004 research article found that 11 percent of teachers participating in the study reported a current voice problem. Non-teachers expressing voice problems comprised only 6.2 percent of the participants.

A similar ratio was evident when participants were asked about ever having a voice disorder in their lifetime. Teachers reported an incidence of 57.7 percent, while non-teachers reported a 28.8 percent incident rate. In another study, about 20 percent of teachers had missed work due to their voice, while only 4 percent of non-teachers had missed a day due a voice related ailment. It is thus very clear from the medical literature that high voice demands in the workplace can have health consequences for the individual, and productivity consequences for the employer. Research is ongoing into strategies to enhance the vocal health of individuals in professions with high voice demands.

What can be done about these issues?

As with many ailments, awareness is key. First, people must be made aware of voice-related occupations. A person may not know that they are in such a profession until a voice problem brings the issue to the forefront.

Secondly, one needs to be aware that high voice demand occupations do place you at greater risk for developing vocal difficulties, and that you have to listen to your own voice in order to recognize when you are developing problems. Do not accept hoarseness as part of the job. Be aware that there are steps you can take to help prevent voice problems. (For more information, see Maintaining a Healthy Voice Fact Sheet.)

Finally, know that proper evaluation and treatment can take care of most voice-related problems, and can set you up to succeed at even the most demanding voice-related occupation. If you listen to your voice and find that it is complaining to you, seek out your local Otolaryngologist (Ear, Nose and Throat Doctor) for an evaluation and treatment recommendations.

Surgical Treatment for Obstructive Sleep Apnea

Introduction

Obstructive sleep apnea (OSA) is a serious health condition characterized by a repetitive stopping or slowing of breathing that can occur hundreds of times during the night. This often leads to poor quality sleep and excessive daytime sleepiness. Risks of untreated sleep apnea include high blood pressure, stroke, heart disease, and motor vehicle accidents. It is estimated that 1 in 5 Americans have at least mild OSA.

A variety of surgical and non-surgical options are available for the treatment of snoring and sleep apnea. Medical options include positive pressure (i.e. CPAP), oral appliances, and weight loss. Many of these treatment options depend on regular, long-term adherence to be effective. In patients having difficulty with other treatments, surgical procedures for the nose and throat can be a beneficial alternative. Surgical therapy can also be effective when used as an adjunct to improve tolerance and success with CPAP or an oral appliance.

Surgical Treatments

Nose

Increased nasal congestion has been shown to cause or contribute to snoring, disrupted sleep, and even sleep apnea. It is also a leading cause of failure of medical treatments for OSA, such as CPAP or an oral appliance. Nasal obstruction may result from many causes including allergies, polyps, deviated septum, enlarged adenoids, and enlarged turbinates.

Medical treatment options, such as a nasal steroid spray or allergy management, may be helpful in some patients. Structural problems, such as a deviated septum, often benefit from surgical treatment. One surgical option, known as radiofrequency turbinate reduction (RFTR), can be performed in the office under local anesthesia. RFTR uses radiofrequency to shrink swollen tissues in each side of the nose.

Upper throat (palate, tonsils, uvula)

In many patients with OSA, airway narrowing and collapse occurs in the area of the soft palate (back part of the roof of the mouth), tonsils, and uvula. The specific type and combination of procedures that are indicated depend on each individual’s unique anatomy and pattern of collapse. Therefore the procedure selection and surgical plan must be customized to each patient. In general, these procedures aim to enlarge and stabilize the airway in the upper portion of the throat.

The surgery is performed in an operating room under general anesthesia, either as an outpatient or with an overnight hospital stay. The recovery varies depending on the patient and the specific procedures performed. Many patients return to school/work in approximately one week and return to normal diet and activity at two weeks. Throat discomfort, particularly with swallowing, is common in the first two weeks and usually managed with medications for pain and inflammation. Risks include bleeding, swallowing problems, and anesthesia complications, although serious complications are uncommon.

The tonsils and adenoids may be the sole cause of snoring and sleep apnea in some patients, particularly children. In children, and in select adults, with OSA and enlarged tonsils/adenoids, tonsillectomy/adenoidectomy alone can provide excellent resolution of snoring, sleep apnea, and associated symptoms.

Lower throat (back of tongue and upper part of voice box)

The lower part of the throat is also common area of airway collapse in patients with OSA. The tongue base may be larger than normal, especially in obese patients, contributing to blockage in this area. The tongue may also collapse backward during sleep as the muscles of the throat relax, particularly when some patients sleep on their back. The epiglottis, or upper part of the voice box, may also collapse and contribute to airway obstruction.

Multiple procedures are available to reduce the size of the tongue base or advance it forward out of the airway. Other procedures aim to advance and stabilize the hyoid bone which is connected to the tongue base and epiglottis. A more recent technology involves implantation of a pacemaker for the tongue (‘hypoglossal nerve stimulator’) which stimulates forward contraction of the tongue during sleep. As with palatal surgery, the most appropriate type of procedure varies from one individual to another, and is primarily determined by each patient’s anatomy and pattern of obstruction.

The procedures are done under general anesthesia, often with overnight hospital observation. Recovery and risks vary depending on the procedure(s) performed, but are generally similar to procedures in the upper throat.

Skeletal procedures

For the most part, the above procedures involve surgical enlargement and stabilization inside the airway. For some patients, particularly those with developmental or structural changes of the jaw or other facial bones, surgical or orthodontic procedures on the bones of the face, jaw, or hard palate (roof of the mouth) may be beneficial.

Orthodontic procedures to widen the palate (palatal or maxillary expansion) may be useful treatment options in some pediatric patients. Maxillomandibular advancement surgery includes a number of procedures designed to move the upper jaw (maxilla) and/or lower jaw (mandible) forward, thus opening the upper and/or lower airway, respectively. Although full maxillomandibular advancement surgery can provide effective enlargement and stabilization of the airway, the potential benefits must be cautiously weighed against the potential increased risks of complications, longer recovery, and changes in the cosmetic appearance of the face.

What should I know before considering surgery?

Surgery is an effective and safe treatment option for many patients with snoring and sleep apnea, particularly those who are unable to use or tolerate CPAP. Proper patient and procedure selection is critical to successful surgical management of obstructive sleep apnea. Talk to your Ear, Nose and Throat doctor for a complete evaluation and to learn what treatment may be best for you.

Swallowing Disorders

Insight into complications and treatment

• What are the symptoms of swallowing disorders?
• How are swallowing disorders diagnosed?
• How are swallowing disorders treated?
• and more…

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.

How do we swallow?

People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four related stages:

• The first stage is the oral preparation stage, where food or liquid is manipulated and chewed in preparation for swallowing.
• The second stage is the oral stage, where the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.
• The third stage is the pharyngeal stage which begins as food or liquid is quickly passed through the pharynx, the region of the throat which connects the mouth with the esophagus, then into the esophagus or swallowing tube.
• In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach.

Although the first and second stages have some voluntary control, stages three and four occur involuntarily, without conscious input.

What are the symptoms of swallowing disorders?

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
• Antipsychotics
• Tetracycline (used to treat acne)

Tips for Healthy Voices

Voice problems usually are associated with hoarseness (also known as roughness), instability, or problems with voice endurance. If you are unsure if you have an unhealthy voice, ask yourself the following:

• Has your voice become hoarse or raspy?
• Does your throat often feel raw, achy or strained?
• Has it become an effort to talk?
• Do you repeatedly clear your throat?
• Do people regularly ask you if you have a cold when in fact you do not?
• Have you lost your ability to hit some high notes when singing?

Voice problems arise from a variety of sources including voice overuse or misuse, cancer, infection, or injury. Here are steps that can be taken to prevent voice problems and maintain a healthy voice:

Drink water (stay well hydrated): Keeping your body well hydrated by drinking plenty of water each day (6-8 glasses) is essential to maintaining a healthy voice. The vocal cords vibrate extremely fast even with the most simple sound production; remaining hydrated through water consumption optimizes the throat’s mucous production, aiding vocal cord lubrication. To maintain sufficient hydration avoid or moderate substances that cause dehydration. These include alcohol and caffeinated beverages (coffee, tea, soda). And always increase hydration when exercising.

Do not smoke: It is well known that smoking leads to lung or throat cancer. Primary and secondhand smoke that is breathed in passes by the vocal cords causing significant irritation and swelling of the vocal cords. This will permanently change voice quality, nature, and capabilities.

Do not abuse or misuse your voice: Your voice is not indestructible. In every day communication, be sure to avoid habitual yelling, screaming, or cheering. Try not to talk loudly in locations with significant background noise or noisy environments. Be aware of your background noise—when it becomes noisy, significant increases in voice volume occur naturally, causing harm to your voice. If you feel like your throat is dry, tired, or your voice is becoming hoarse, stop talking.

To reduce or minimize voice abuse or misuse use non-vocal or visual cues to attract attention, especially with children. Obtain a vocal amplification system if you routinely need to use a “loud” voice especially in an outdoor setting. Try not to speak in an unnatural pitch. Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords with subsequent hoarseness and a variety of problems.

Minimize throat clearing: Clearing your throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing. The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux, laryngopharyngeal reflux disease, sinus and/or allergic disease.

Moderate voice use when sick: Reduce your vocal demands as much as possible when your voice is hoarse due to excessive use or an upper respiratory infection (cold). Singers should exhibit extra caution if one’s speaking voice is hoarse because permanent and serious injury to the vocal cords are more likely when the vocal cords are swollen or irritated. It is important to “listen to what your voice is telling you.”

Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voices are invaluable for both our social interaction as well as for most people’s occupation. Proper care and use of your voice will give you the best chance for having a healthy voice for your entire lifetime.

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist—head and neck surgeon if you have any sustained changes to your voice.

Tonsillitis

Tonsillitis refers to inflammation of the pharyngeal tonsils (glands at the back of the throat, visible through the mouth). The inflammation may involve other areas of the back of the throat, including the adenoids and the lingual tonsils (tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis, and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Due to improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare..

Who gets tonsillitis?

Tonsillitis most often occurs in children, but rarely in those younger than two years old. Tonsillitis caused by bacteria (streptococcus species) Streptococcus species typically occurs in children aged 5 to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient’s history often helps identify the type of tonsillitis present (i.e., acute, recurrent, chronic).

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS), Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis. (i.e., “strep throat”).

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

• Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days, but may last up to two weeks despite therapy.
• Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
• Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
• Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history. A physical examination of a young patient with tonsillitis may find:

• Fever and enlarged inflamed tonsils covered by pus.
• Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis (“strep throat”) associated with the presence of palatal petechiae (tiny hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children 5-15 years old.
• Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
• Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
• Signs of dehydration (found by examination of skin and mucosa)
• The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise, and low-grade fever accompany acute tonsillitis.
• A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
• Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
• Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw, difficulty opening the mouth, and pain referred to the ear may be present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended. Peritonsillar abscess may need more urgent treatment to drain the abscess.

Tonsils and Adenoids Post-Op

The tonsils are two clusters of tissue located on both sides of the back of the throat. Adenoids sit high in the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics. The surgery is most often performed on children.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both procedures are often performed at the same time; hence the surgery is known as a tonsillectomy and adenoidectomy, or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for several hours after surgery for observation. Children with severe obstructive sleep apnea and very young children are usually admitted overnight to the hospital for close monitoring of respiratory status. An overnight stay may also be required if there are complications such as excessive bleeding, severe vomiting, or low oxygen saturation.

When the tonsillectomy patient comes home

Most children take seven to ten days to recover from the surgery. Some may recover more quickly; others can take up to two weeks for a full recovery. The following guidelines are recommended:

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids..Starting immediately after surgery, children may have fluids such as water or apple juice. Some patients experience nausea and vomiting after the surgery. This usually occurs within the first 24 hours and resolves on its own after the effects of anesthesia wear off. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions after surgery, but some physicians will recommend a soft diet during the recovery period. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed the night of the surgery and for a day or two afterward. Contact your physician if the fever is greater than 102º.

Activity. Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication is no longer required, and the child sleeps through the night. Travel on airplanes or far away from a medical facility is not recommended for two weeks following surgery.

Breathing: The parent may notice snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when swelling subsides, 10-14 days after surgery.

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is normal. Most scabs fall off in small pieces five to ten days after surgery.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (so called referred pain) and a few may have pain in the jaw and neck .

Pain control: Your physician will prescribe pain medication for the young patient such as acetaminophen, ibuprofen acetaminophen with codeine, or acetaminophen with hydrocodone. The pain medication will be in a liquid form or sometimes a rectal suppository will be recommended. Pain medication should be given as prescribed. Contact your physician if side effects are suspected or if pain is not well-controlled. If you are troubled about any phase of your child’s recovery, contact your physician immediately.

Tonsils and Adenoids

Insight into tonsillectomy and adenoidectomy

• What conditions affect the tonsils and adenoids?
• When should I see a doctor?
• Common symptoms of tonsillitis and enlarged adenoids
• and more…

Tonsils and adenoids are the body’s first line of defense as part of the immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose, but they sometimes become infected. At times, they become more of a liability than an asset and may even cause airway obstruction or repeated bacterial infections. Your ear, nose, and throat (ENT) specialist can suggest the best treatment options.

What are tonsils and adenoids?

Tonsils and adenoids are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two round lumps in the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth or nose without special instruments.

What affects tonsils and adenoids?

The two most common problems affecting the tonsils and adenoids are recurrent infections of the nose and throat, and significant enlargement that causes nasal obstruction and/or breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling white deposits can also affect the tonsils and adenoids, making them sore and swollen. Cancers of the tonsil, while uncommon, require early diagnosis and aggressive treatment.

When should I see a doctor?

You should see your doctor when you or your child experience the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she may use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests – helpful in determining infections in the throat
• X-rays – helpful in determining the size and shape of the adenoids
• Blood tests – helpful in determing infections such as mononucleosis
• Sleep study, or polysomnogram-helpful in determining whether sleep disturbance is occurring because of large tonsils and adenoids.

Tonsillitis and its symptoms

Tonsillitis is an infection of the tonsils. One sign is swelling of the tonsils. Other symptoms are:

• Redder than normal tonsils
• A white or yellow coating on the tonsils
• A slight voice change due to swelling
• Sore throat, sometimes accompanied by ear pain.
• Uncomfortable or painful swallowing
• Swollen lymph nodes (glands) in the neck
• Fever
• Bad breath

Enlarged tonsils and/or adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. If the tonsils and adenoids are enlarged, breathing during sleep may be disturbed. Other signs of adenoid and or tonsil enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Chronic runny nose
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Restlessness during sleep, pauses in breathing for a few seconds at night(may indicate sleep apnea).

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Removal of the tonsils (tonsillectomy) and/or adenoids (adenoidectomy) may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness, and may even cause behavioral or school performance problems in some children.

Chronic infections of the adenoids can affect other areas such as the eustachian tube–the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and buildup of fluid in the middle ear that may cause temporary hearing loss. Studies also find that removal of the adenoids may help some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., prednisone) is sometimes helpful.

How to prepare for surgery

Children

• Talk to your child about his/her feelings and provide strong reassurance and support
• Encourage the idea that the procedure will make him/her healthier.
• Be with your child as much as possible before and after the surgery.
• Tell him/her to expect a sore throat after surgery, and that medicines will be used to help the soreness.
• Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
• It may be helpful to talk about the surgery with a friend who has had a tonsillectomy or adenoidectomy.
• Your otolaryngologist can answer questions about the surgical procedure.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome). Your doctor may ask to you to stop taking other medications that may interfere with clotting.

• Tell your surgeon if the patient or patient’s family has had any problems with anesthesia or clotting of blood. If the patient is taking medications, has sickle cell anemia, has a bleeding disorder, is pregnant, or has concerns about the transfusion of blood, the surgeon should be informed.
• A blood test may be required prior to surgery.
• A visit to the primary care doctor may be needed to make sure the patient is in good health at surgery.
• You will be given specific instructions on when to stop eating food and drinking liquids before surgery. These instructions are extremely important, as anything in the stomach may be vomited when anesthesia is induced.

When the patient arrives at the hospital or surgery center, the anesthesiologist and nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient closely until discharge. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer your questions.

After surgery

There are several postoperative problems that may arise. These include swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding from the mouth or nose may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately. It is also important to drink liquids after surgery to avoid dehydration.

Any questions or concerns you have should be discussed openly with your surgeon.

Vocal Cord Paralysis

What Is Vocal Fold (cord) Paresis And Paralysis?

Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles). Paralysis is the total interruption of nerve impulse, resulting in no movement; paresis is the partial interruption of nerve impulse, resulting in weak or abnormal motion of laryngeal muscles. Paresis/paralysis can happen at any age, from birth to advanced age, in males and females, from a variety of causes. The effect on patients may vary greatly, depending on the patient’s use of his or her voice: A mild vocal fold paresis can be the end to a singer’s career, but have only a marginal effect on a computer programmer. If you notice any change in your voice quality, immediately contact an otolaryngologist—head and neck surgeon.

What Nerves Are Involved?

Vocal fold movements are a result of the coordinated contraction of various muscles that are controlled by the brain through a specific set of nerves.

The superior laryngeal nerve (SLN) carries signals to the cricothyroid muscle. Since this muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to each higher note. Sometimes patients with SLN paresis/paralysis may have a normal speaking voice but an abnormal singing voice.

The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles responsible for opening vocal folds (as in breathing, coughing), closing the folds for vibration during voice use, and closing them during swallowing. The RLN goes into the chest cavity and curves back into the neck until it reaches the larynx. Because the nerve is relatively long and takes a “detour” to the voice box, it is at greater risk for injury from different causes–infections and tumors of the brain, neck, chest, or voice box. It can also be damaged by complications during surgery in the head, neck, or chest, that directly injure, stretch, or compress the nerve. Consequently, the RLN is involved in the majority of cases of vocal fold paresis/paralysis.

What Are the Causes?

The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve over time or whether it may be permanent. When a reversible cause is present, surgical treatment is not usually recommended, given the likelihood of spontaneous resolution of the problem. Despite advances in diagnostic technology, physicians are unable to detect the cause in about half of all vocal fold paralyses, referred to as idiopathic (due to unknown origins). In these cases, paralysis or paresis might be due to a viral infection affecting the voice box nerves (RLN or SLN), or the vagus nerve, but this cannot be proven in most cases. Known reasons can include:

Inadvertent injury during surgery: Surgery in the neck (thyroid gland, carotid artery) or in the chest (lungs, esophagus, heart, or large blood vessels) may inadvertently result in RLN paresis or paralysis. The SLN may also be injured during head and neck surgery.

Complication from endotracheal intubation: Injury to the RLN may occur when breathing tubes are used for general anesthesia or assisted breathing. However, this type of injury is rare, given the large number of operations done under general anesthesia.

Blunt neck or chest trauma: Any type of penetrating, hard impact on the neck or chest region may injure the RLN; impact to the neck may injure the SLN.

Tumors of the skull base, neck, and chest: Tumors (both cancerous and non-cancerous) can grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.

Viral infections: Inflammation from infections may directly involve and injure the vagus nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting nerves in the body may also affect the nerves to the voice box.

What Are the Symptoms?

Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.

Voice changes: Hoarseness; breathy voice; extra effort on speaking; excessive air pressure required to produce usual conversational voice; and diplophonia (voice sounds like a gargle).

Airway problems: Shortness of breath with exertion, noisy breathing, and ineffective cough.

Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and food sticking in throat.

How Is Vocal Fold Paralysis/Paresis Diagnosed?

An otolaryngologist—head and neck surgeon conducts a general examination and then questions you about your symptoms and lifestyle (voice use, alcohol/tobacco use). Examining the voice box will determine whether one or both vocal folds are abnormal, and will help determine the treatment plan.

Laryngeal electromyography (LEMG) measures electrical currents in the voice box muscles that are the result of nerve inputs. Looking at the pattern of the electric currents will indicate whether there is recovery or repair of nerve inputs and the degree of the nerve input problem. During the LEMG test, patients perform a number of tasks that would normally elicit characteristic actions in the tested muscles. Because a wide list of diseases may cause nerve injury, further tests (blood tests, x-rays, CT scans, etc) are usually required to identify the cause.

What Is the Treatment?

The two treatment strategies to improve vocal function are voice therapy (like physical therapy for large muscle paralysis), and phonosurgery, an operation that repositions and/or reshapes the vocal folds to improve voice function. Voice therapy is normally the first treatment option. After voice therapy, the decision for surgery depends on the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and the cause of paresis/paralysis, if known.

The Voice and Aging

As we age, our voices change. The most dramatic voice changes are those during childhood and adolescence. The larynx (or voice box) and vocal cord tissues do not fully mature until late teenage years. Hormone-related changes during adolescence are particularly noticeable among boys. The rapid changes in the size and character of the larynx causes characteristic pitch breaks and voice “cracking” during puberty as we learn to use our rapidly changing voice instruments.

After several decades of relatively stable voice, noticeable change can occur in the later years of life. As our bodies age, we lose muscle mass, our mucous membranes thin and become more dry, and we lose some of the fine coordination that we had in younger years. It is no surprise that these changes occur in the larynx as well, and this leads to changes in our voice. Your doctor may call these changes vocal cord atrophy or bowing, presbyphonia, or presbylaryngis.

Changes in the Voice as We Age

Below is a list of commonly reported voice changes as we age:

• Higher pitch voice in men
• Lower pitch voice in women
• Reduced volume and projection of the voice (or “thin” voice)
• Reduced vocal endurance
• Difficulty being heard in noisy situations
• Tremor or shakiness in the voice

These symptoms are amplified by the reduced hearing ability that commonly occurs in our peers as we age.

NOTE: Much of the time, hoarseness and vocal difficulties are not simply age related change. Any change that you notice in your voice should be a warning sign that something may be wrong. See your otolaryngologist (ear, nose, throat doctor). Almost all voice problems are highly treatable.

What Can Be Done About Age-Related Voice Change?

If you are bothered by your voice, take action today. As a first step, consider taking the Voice- Related Quality of Life quiz available on the Academy’s World Voice Day Web site. By answering a short series of questions, you’ll be able to measure the quality of your voice.

Secondly, consider a vocal fitness program (i.e. voice therapy), as healthy voice use is key to voice preservation. Under the guidance of a speech-language pathologist, a vocal fitness program can make a big difference.

Finally, some people are candidates for medical or surgical treatment to improve the steadiness, strength, or endurance of the voice. See your Otolaryngologist for further information.

Overall Body Fitness Can Fuel Your Voice

Most of us want to maintain our youthful fitness and the same holds true for the voice. Maintaining excellent overall body fitness will help keep your voice healthy. Keep vocally fit as well—in many cases the more active you stay vocally, the stronger your voice will be. Healthy vocal exercises may not seem as obvious as healthy exercises in the gym, so professional guidance from a voice therapist or voice coach is very helpful. Some things you may do on your own though include: reading a book or paper aloud for 10-15 minutes, 2 or 3 times a day, as well as singing with the radio.