The Throat, Your Voice & Swallowing

Doctor, Explain Tonsils and Adenoids
Salivary Glands
Sore Throats
Doctor, Why Am I Hoarse?
A Healthy Voice
Common Voice Disorders
You & Your Voice

Doctor, Explain Tonsils and Adenoids

Insight into tonsillectomy and adenoidectomy

Tonsils and adenoids are masses of tissue that are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two masses on 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 without special instruments.

Tonsils and adenoids are near the entrance to the breathing passages where they can catch incoming germs, which cause infections. They “sample” bacteria and viruses and can become infected themselves. Scientists believe they work as part of the body’s immune system by filtering germs that attempt to invade the body, and that they help to develop antibodies to germs.

This happens primarily during the first few years of life, becoming less important as we get older. Children who must have their tonsils and adenoids removed suffer no loss in their resistance.

What affects tonsils and adenoids?

The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing and swallowing problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.

When should I see my doctor?

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

The Exam

The primary methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests
• X-rays
• Blood tests

What should I expect at the exam?

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

Cultures/strep tests are important in diagnosing certain infections in the throat, especially “strep” throat.

X-rays are sometimes helpful in determining the size and shape of the adenoids. Blood tests can determine problems such as mononucleosis.

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended. The two primary reasons for tonsil and/or adenoid removal are (1) recurrent infection despite antibiotic therapy and (2) difficulty breathing due to enlarged tonsils and/or adenoids.

Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children. Some orthodontists believe chronic mouth breathing from large tonsils and adenoids causes malformations of the face and improper alignment of the teeth.

Chronic infection 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 potential hearing loss.

Recent studies indicate adenoidectomy may be a beneficial treatment for 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., cortisone) is sometimes helpful.

Tonsillitis and its symptoms

Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are:

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

Enlarged adenoids and their symptoms

If you or your child’s adenoids are enlarged, it may be hard to breathe through the nose.

Other signs of constant enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)

Surgery

Your child

Talk to your child about his/her feelings and provide strong reassurance and support throughout the process. 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. 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. If your child has a friend who has had this surgery, it may be helpful to talk about it with that friend.

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).

If the patient or patient’s family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.

A blood test and possibly a urine test may be required prior to surgery.

Generally, after midnight prior to the operation, nothing (chewing gum, mouthwashes, throat lozenges, toothpaste, water) may be taken by mouth. Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.

When the patient arrives at the hospital or surgery center, the anesthesiologist or 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 until discharged. Every patient is special, and recovery times vary for each individual. Many patients are released after 2-10 hours. Others are kept overnight. Intensive care may be needed for select cases.

Your ENT specialist will provide you with the details of pre-operative and postoperative care and answer any questions you may have.

After surgery

There are several postoperative symptoms that may arise. These include (but are not limited to) swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Any questions or concerns you have should be discussed openly with your surgeon, who is there to assist you.

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Salivary Glands

Where Are Your Salivary Glands?

The glands are found in and around your mouth and throat. We call the major salivary glands the parotid, submandibular, and sublingual glands.

They all secrete saliva into your mouth, the parotid through tubes that drain saliva, called salivary ducts, near your upper teeth, submandibular under your tongue, and the sublingual through many ducts in the floor of your mouth.

Besides these glands, there are many tiny glands called minor salivary glands located in your lips, inner cheek area (buccal mucosa), and extensively in other linings of your mouth and throat. Salivary glands produce the saliva used to moisten your mouth, initiate digestion, and help protect your teeth from decay.

As a good health measure, it is important to drink lots of liquids daily. Dehydration is a risk factor for salivary gland disease.

What Causes Gland Problems?

Salivary gland problems that cause clinical symptoms include:

• ObstructionObstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands, usually because stones have formed. Symptoms typically occur when eating. Saliva production starts to flow, but cannot exit the ductal system, leading to swelling of the involved gland and significant pain, sometimes with an infection.Unless stones totally obstruct saliva flow, the major glands will swell during eating and then gradually subside after eating, only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva, leading to more severe pain and swelling in the glands. If untreated for a long time, the glands may become abscessed.It is possible for the duct system of the major salivary glands that connects the glands to the mouth to be abnormal. These ducts can develop small constrictions, which decrease salivary flow, leading to infection and obstructive symptoms.
• InfectionThe most common salivary gland infection in children is mumps, which involves the parotid glands. While this is most common in children who have not been immunized, it can occur in adults. However, if an adult has swelling in the area of the parotid gland only on one side, it is more likely due to an obstruction or a tumor.Infections also occur because of ductal obstruction or sluggish flow of saliva because the mouth has abundant bacteria.You may have a secondary infection of salivary glands from nearby lymph nodes. These lymph nodes are the structures in the upper neck that often become tender during a common sore throat. In fact, many of these lymph nodes are actually located on, within, and deep in the substance of the parotid gland or near the submandibular glands. When these lymph nodes enlarge through infection, you may have a red, painful swelling in the area of the parotid or submandibular glands. Lymph nodes also enlarge due to tumors and inflammation.
• TumorsPrimary benign and malignant salivary gland tumors usually show up as painless enlargements of these glands. Tumors rarely involve more than one gland and are detected as a growth in the parotid, submandibular area, on the palate, floor of mouth, cheeks, or lips. An otolaryngologist-head and neck surgeon should check these enlargements.Malignant tumors of the major salivary glands can grow quickly, may be painful, and can cause loss of movement of part or all of the affected side of the face. These symptoms should be immediately investigated.
• Other DisordersSalivary gland enlargement also occurs in autoimmune diseases such as HIV and Sjцgren’s syndrome where the body’s immune system attacks the salivary glands causing significant inflammation. Dry mouth or dry eyes are common. This may occur with other systemic diseases such as rheumatoid arthritis. Diabetes may cause enlargement of the salivary glands, especially the parotid glands. Alcoholics may have salivary gland swelling, usually on both sides.

How Does Your Doctor Make the Diagnosis?

Diagnosis of salivary gland disease depends on the careful taking of your history, a physical examination, and laboratory tests.

If your doctor suspects an obstruction of the major salivary glands, it may be necessary to anesthetize the opening of the salivary ducts in the mouth, and probe and dilate the duct to help an obstructive stone pass. Before these procedures, dental x-rays may show where the calcified stones are located.

If a mass is found in the salivary gland, it is helpful to obtain a CT scan or a MRI (magnetic resonance imaging). Sometimes, a fine needle aspiration biopsy in the doctor’s office is helpful. Rarely, dye will be injected through the parotid duct before an x-ray of the gland is taken (a sialogram).

A lip biopsy of minor salivary glands may be needed to identify certain autoimmune diseases.

How Is Salivary Gland Disease Treated?

Treatment of salivary diseases falls into two categories: medical and surgical. Selection of treatment depends on the nature of the problem. If it is due to systemic diseases (diseases that involve the whole body, not one isolated area), then the underlying problem must be treated. This may require consulting with other specialists. If the disease process relates to salivary gland obstruction and subsequent infection, your doctor will recommend increased fluid intake and may prescribe antibiotics. Sometimes an instrument will be used to open blocked ducts.

If a mass has developed within the salivary gland, removal of the mass may be recommended. Most masses in the parotid gland area are benign (noncancerous). When surgery is necessary, great care must be taken to avoid damage to the facial nerve within this gland that moves the muscles face including the mouth and eye. When malignant masses are in the parotid gland, it may be possible to surgically remove them and preserve most of the facial nerve. Radiation treatment is often recommended after surgery. This is typically administered four to six weeks after the surgical procedure to allow adequate healing before irradiation.

The same general principles apply to masses in the submandibular area or in the minor salivary glands within the mouth and upper throat. Benign diseases are best treated by conservative measures or surgery, whereas malignant diseases may require surgery and postoperative irradiation. If the lump in the vicinity of a salivary gland is a lymph node that has become enlarged due to cancer from another site, then obviously a different treatment plan will be needed. An otolaryngologist-head and neck surgeon can effectively direct treatment.

Removal of a salivary gland does not produce a dry mouth, called xerostomia. However, radiation therapy to the mouth can cause the unpleasant symptoms associated with reduced salivary flow. Your doctor can prescribe medication or other conservative treatments that may reduce the dryness in these instances.

Salivary gland diseases are due to many different causes. These diseases are treated both medically and surgically. Treatment is readily managed by an otolaryngologist–head and neck surgeon with experience in this area.

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Sore Throats

What Causes a Sore Throat?

Sore throat is a symptom of many medical disorders. Infections cause the majority of sore throats and are contagious. Infections are caused either by viruses such as the flu, the common cold, mononucleosis, or by bacteria such as strep, mycoplasma, or hemophilus.

While bacteria respond to antibiotic treatment, viruses do not.

Viruses: Most viral sore throats accompany flu or colds along with a stuffy, runny nose, sneezing, and generalized aches and pains. These viruses are highly contagious and spread quickly, especially in winter. The body builds antibodies that destroy the virus, a process that takes about a week.

Sore throats accompany other viral infections such as measles, chicken pox, whooping cough, and croup. Canker sores and fever blisters in the throat also can be very painful.

One viral infection takes much longer than a week to be cured: infectious mononucleosis, or “mono.” This virus lodges in the lymph system, causing massive enlargement of the tonsils, with white patches on their surface and swollen glands in the neck, armpits, and groin. It creates a severely sore throat and, sometimes, serious breathing difficulties. It can affect the liver, leading to jaundice- yellow skin and eyes. It also causes extreme fatigue that can last six weeks or more.

“Mono,” a severe illness in teenagers but less severe in children, can he transmitted by saliva. So it has been nicknamed the “kissing disease,” but it can also be transmitted from mouth-to-hand to hand-to-mouth or by sharing of towels and eating utensils.

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.

Because of these possible complications, a strep throat should be treated with an antibiotic. Strep is not always easy to detect by examination, and a throat culture may be needed. These tests, when positive, persuade the physician to prescribe antibiotics. However, strep tests might not detect other bacteria that also can cause severe sore throats that deserve antibiotic treatment. For example, severe and chronic cases of tonsillitis or tonsillar abscess may be culture negative. Similarly, negative cultures are seen with diphtheria, and infections from oral sexual contacts will escape detection by strep culture tests.

Tonsillitis is an infection of the lumpy tissues on each side of the back of the throat.In the first two to three years of childhood, these tissues “catch” infections, sampling the child’s environment to help develop his immunities (antibodies). Healthy tonsils do not remain infected. Frequent sore throats from tonsillitis suggest the infection is not fully eliminated between episodes. A medical study has shown that children who suffer from frequent episodes of tonsillitis (such as three- to four- times each year for several years) were healthier after their tonsils were surgically removed.

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, caused by bacteria that infect a portion of the larynx (voice box) and cause swelling that closes the airway. This infection 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. A strep test may miss this infection.

Allergy: The same pollens and molds that irritate the nose when they are inhaled also may irritate the throat. Cat and dog danders and house dust are common causes of sore throats for people with allergies to them.

Irritation: During the cold winter months, dry heat may create a recurring, mild sore throat with a parched feeling, especially in the mornings. This often responds to humidification of bedroom air and increased liquid intake. Patients with a chronic stuffy nose, causing mouth breathing, also suffer with a dry throat. They need examination and treatment of the nose.

Pollutants and chemicals in the air can irritate the nose and throat, but the most common air pollutant is tobacco smoke. Other irritants include smokeless tobacco, alcoholic beverages, and spicy foods.

A person who strains his or her voice (yelling at a sports event, for example) gets a sore throat not only from muscle strain but also from the rough treatment of his or her throat membranes.

Reflux: An occasional cause of morning sore throat is regurgitation of stomach acids up into the back of the throat. To avoid reflux, tilt your bedframe so that the head is elevated four- to six- inches higher than the foot of the bed. You might find antacids helpful. You should also avoid eating within three hours of bedtime, and eliminate caffeine and alcohol. If these tips fail, see your doctor.

Tumors: Tumors of the throat, tongue, and larynx (voice box) are usually (but not always) associated with long-time use of tobacco and alcohol. Sore throat and difficulty swallowing-sometimes with pain radiating to the ear-may be symptoms of such a tumor. More often the sore throat is so mild or so chronic that it is hardly noticed. Other important symptoms include hoarseness, a lump in the neck, unexplained weight loss, and/or spitting up blood in the saliva or phlegm.

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

When should I take antibiotics?

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 10 days). Otherwise the infection will probably be suppressed rather than eliminated, and it can return. Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may require a tonsillectomy.

Should other family members be treated or cultured?

When a strep test is positive, many experts recommend treatment or culturing of other family members. Practice good sanitary habits; avoid close physical contact, and sharing of napkins, towels, and utensils with the infected person. Handwashing makes good sense.

What if my throat culture is negative?

A strep culture tests only for the presence of streptococcal infections. Many other infections, both bacterial and viral, will yield negative cultures and sometimes so does a streptococcal infection. Therefore, when your culture 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.

How Can I Treat My Sore Throat?

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: ј tsp. salt to Ð… cup water.
• Take over-the-counter pain relievers such as acetaminophen (Tylenol Sore Throat, Tempra) or ibuprofen (Motrin IB, Advil).

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Doctor, Why Am I Hoarse?

Insight into causes, prevention, and when to see an ENT

What Is It?

Hoarseness is a general term that describes abnormal voice changes. When hoarse, the voice may sound breathy, raspy, strained, or there may be changes in volume (loudness) or pitch (how high or low the voice is). The changes in sound are usually due to disorders related to the vocal cords that are the sound producing parts 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 prevent them from coming together properly and changes the way the cords vibrate, which makes a change in the voice, altering quality, volume, and pitch.

What Are the Causes?

Acute Laryngitis: There are many causes of hoarseness. Fortunately, most are not serious and tend to go away in a short period of time. The most common cause is acute laryngitis, which usually occurs due to swelling from a common cold, upper respiratory tract viral infection, or irritation caused by excessive voice use such as screaming at a sporting event or rock concert.

Vocal Nodules: More prolonged hoarseness is usually due to using your voice either too much, too loudly, or improperly over extended periods of time. These habits can lead to vocal nodules (singers’ nodes), which are callous-like growths, or may lead to polyps of the vocal cords (more extensive swelling). Both of these conditions are benign. Vocal nodules are common in children and adults who raise their voice in work or play.

Open Voice Box

Closed Voice Box

Gastroesophageal Reflux: 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 symptoms of heartburn. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump in their throat, mucus sticking in their throat or an excessive desire to clear their throat.

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

Other Causes: Many unusual causes for hoarseness include allergies, thyroid problems, neurological disorders, trauma to the voice box, and occasionally, the normal menstrual cycle.

Who Can Treat My Hoarseness?

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–head and neck surgeon (ear, nose and throat doctor). Problems with the voice are best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologist–head and neck surgeons, speech/language pathologists, and teachers of singing, acting, or public speaking. Voice disorders have many different characteristics that may give professionals a clue to the cause.

How Is Hoarseness Evaluated?

An otolaryngologist will obtain a thorough history of the hoarseness and your general health. Your doctor will usually look at the vocal cords with either a mirror placed in the back of your throat, or a very small, lighted flexible tube (fiberoptic scope) may be passed through your nose in order to view your vocal cords. Videotaping the examination or using stroboscopy (slow motion assessment) may also help with the analysis.

These procedures are not uncomfortable and are well tolerated by most patients. In some cases, special tests (known as acoustic analysis) designed to evaluate the voice, may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in establishing a diagnosis and guiding treatment

When should I see an otolaryngologist (ENT doctor)?

• Hoarseness lasting longer than two weeks especially if you smoke
• Pain not from a cold or flu
• Coughing up blood
• Difficulty swallowing
• Lump in the neck
• Loss or severe change in voice lasting longer than a few days

How Are Vocal Disorders Treated?

The treatment of hoarseness depends on the cause. Most hoarseness can be treated by simply resting the voice or modifying how it is used. The 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. Avoidance of smoking or exposure to secondhand smoke (passive smoking) is recommended to all patients. Drinking fluids and possibly using medications to thin the mucus are also helpful.

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

What can I Do to Prevent and Treat Hoarseness?

• If you smoke, quit
• Avoid agents that dehydrate the body, such as alcohol and caffeine
• Avoid secondhand smoke
• 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.

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A Healthy Voice

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:

1. 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.
2. 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.
3. 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.
4. 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.
5. 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.
6. 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.

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Common Voice Disorders

Most changes in the voice result from a medical disorder. Failure to seek a physician’s care can lead to hoarseness and more serious problems. They include:

• LaryngitisLaryngitis is a swelling of the vocal cords usually due to an infection. A viral infection (a “cold”) of the upper respiratory track is the most common cause for infection of the voice box. When the vocal cords swell in size, they vibrate differently, leading to hoarseness. The best treatment for this condition is to rest or reduce your voice use and stay well hydrated. Since most of these infections are caused by a virus, antibiotics are not effective. It is important to be cautious with your voice during an episode of laryngitis, because the swelling of the vocal cords increases the risk for serious injury such as blood in the vocal cords or formation of vocal cord nodules, polyp, or cysts.
• Vocal cord lesionsBenign noncancerous growths on the vocal cords are caused by voice misuse or overuse and from trauma or injury to the vocal cords. These lesions (“bumps”) on the vocal cord(s) alter vocal cord vibration. This abnormal vibration results in hoarseness and a chronic change in one’s voice quality, including roughness, raspiness, and an increased effort to talk. The most common vocal cord lesions include vocal nodules also known as “singer’s nodes” or “nodes” which are similar to “calluses ” of the vocal cords. They typically occur on both vocal cords opposite each other. These lesions are usually treated with voice rest and speech therapy (to improve the speaking technique thus removing the trauma on the vocal cords). Vocal cord polyp(s) or cyst(s) are other common vocal cord lesions caused by misuse, overuse, or trauma to the vocal cords and frequently require surgical removal after all nonsurgical treatment options (i.e., speech therapy) have failed.
• Gastroesophageal reflux disease and laryngopharyngeal reflux diseaseReflux (backflow of gastric contents) into the throat of stomach acid can cause a variety of symptoms in the esophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), swallowing problems, a foreign body sensation, or throat pain are common symptoms of gastric acid irritation of the throat, called laryngopharyngeal reflux disease (LPRD). LPRD is difficult to diagnose because approximately half of the patients with this disorder have no heartburn symptoms which traditionally accompany gastroesophageal reflux disease (GERD).Your gastric acid can flow up to the throat at any time. The at-night aspect of LPRD is thought to be the hardest to diagnose because there are usually no specific symptoms while the reflux occurs. Consequently, patients will awake with throat irritation, hoarseness, and throat discomfort without knowing the cause. An examination of the throat by an otolaryngologist will determine if stomach acid is causing irritation of the throat and voice box.
• Poor speaking techniqueImproper or poor speaking technique is caused from speaking at an abnormally or uncomfortable pitch, either too high or too low, and leads to hoarseness and a variety of other voice problems. Examples of this condition are when young adult females, in a work environment, consciously or subconsciously choose to speak at a lower than appropriate pitch and with a heavy voice. Percussive speaking, a voice too loud or focusing on the first syllable of each word, is another improper speaking technique that may result in injury or trauma to the vocal cords and muscles causing “vocal fatigue”.Other factors leading to improper speaking technique include insufficient or improper breathing while talking, specifically breathing from the shoulders or neck area instead of from the lower chest or abdominal area. The consequence of this practice is increased tension in the throat and neck muscles, which can cause hoarseness and a variety of symptoms, especially pain and fatigue associated with talking. Voice problems can also occur from using your voice in an unnatural position, such as talking on the phone cradled to your shoulder. This requires excessive tension in the neck and laryngeal muscles, which changes the speaking technique and may result in a voice problem.
• Vocal cord paralysisHoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common condition 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. However, one vocal cord can become paralyzed or severely weakened (paresis) after a viral infection of the throat, after surgery in the neck or cheek, or for unknown reasons.The immobile or paralyzed vocal cord typically causes a soft, breathy, weak voice due to poor vocal cord closure. Most paralyzed vocal cords will recover on their own within several months. There is a possibility that the paralysis may become permanent, which may require surgical treatment. Surgery for unilateral vocal cord paralysis involves positioning of the vocal cord to improve the vibration of the paralyzed vocal cord with the non-paralyzed vocal cord. There are a variety of surgical techniques used to reposition the vocal cord. Sometimes speech therapy may be used before or after surgical treatment of the paralyzed vocal cords or sometimes as the sole treatment. Treatment choices depend on the nature of the vocal cord paralysis as well as the patient’s voice demands.
• Throat cancerThroat cancer is a very serious condition requiring immediate medical attention. When cancer attacks the vocal cords, the voice changes in quality, assuming the characteristics of chronic hoarseness, roughness, or raspiness. These symptoms occur at an early stage in the development of the cancer. It is important to remember that prompt attention to changes in the voice facilitate early diagnosis thus early and successful treatment of vocal cord cancer can be obtained.Persistent hoarseness or change in the voice for longer than two to four weeks in a smoker should prompt evaluation by an otolaryngologist to determine if there is cancer of the larynx (voice box). Different treatment options for this cancer of the voice box include surgery, radiation therapy, and/or chemotherapy. When vocal cord cancer is found early, typically only surgery or radiation therapy is required, and the cure rate is high (greater than 90 percent).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.

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You & 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:

1. Has your voice become hoarse or raspy?
2. Does your throat often feel raw, achy, or strained?
3. Does talking require more effort?
4. Do you find yourself repeatedly clearing your throat?
5. Do people regularly ask you if you have a cold when in fact you do not?
6. 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.

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