Spotlight on Special Topics in Voice Disorders

The Voice and Swallowing Institute
New York Eye and Ear Infirmary of Mount Sinai
310 E. 14th Street
New York, NY  10003
TEL: (212) 979-4119

Spotlight On: Allergies and "Postnasal Drip"

ALLERGIES can result in a build up of excessive mucus on the vocal folds

PHOTO: ALLERGIES can result in a build up of excessive mucus on the vocal folds.

Allergies are abnormal immune responses to things in our environment that would not otherwise be harmful. Typical symptoms are itching, eye redness and tearing, nasal blockage, and production of large quantities of clear mucus by the nose. Allergies can also result in an altered voice. Most allergic symptoms that affect voice are nasal and result in an altered resonance or timbre of the voice, but occasionally, the vocal folds may become swollen or inflamed as well and cause the voice to become hoarse.

Just as much of a problem, and not so well-known, is the fact that medicines commonly used to treat allergies may also harm the voice. Antihistamines aid allergy sufferers by reducing the amount of mucus the body manufactures and drying out the body’s mucous membranes. This is very harmful for the vocal folds, which require a certain minimum amount of lubrication to function well. Since these medicines are available over-the-counter, people cannot rely on their physician to watch for these problems. Steroids, taken both in pill and nasal spray form, help by calming down the allergy-sufferer’s overactive immune system. They can also result in inadequate immune function, particularly in the throat, and infections can develop. These infections are usually fungal, and thus are not cured by regular antibiotics.

"Postnasal drip" is a term that has more meaning in advertising than in medicine. It is common to attribute throat discomfort – like a sensation of heavy phlegm – to "postnasal drip." Sometimes, inflammation of the nasal passages and the resulting mucus production does produce these symptoms. But they may also be caused by a number of other medical disorders. Allergies are usually seasonal or occur in response to a specific stimulus, like dust or smoke.

If symptoms are more consistent than this, or if factors that cause the problem are hard to pin down, or if symptoms fail to clear with adequate treatment of the nasal passages – measures like saline nasal spray, antihistamines, and steroid nasal sprays – “postnasal drip” may not be responsible at all. These types of symptoms can be caused by reflux, by muscle tension dysphonia, by chronic dehydration or by a number of other medical conditions.

Voice changes from allergies or “postnasal drip” do not have to be accepted as inevitable or untreatable. An evaluation at The Voice and Swallowing Institute, can help you find out if they are indeed the result of allergies, or from medicines used to treat them, or from something else entirely.

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SPOTLIGHT ON: ASTHMA

Asthma is a disease of the lungs that causes tightening of the muscles around the airways, and   inflammation   of the tissues that line the airways. Both of these events have the potential to cause considerable difficulty breathing, with symptoms such as wheezing, sensation of tightness and shortness of breath, and coughing. Anything that interferes with easy breathing, such as asthma, has the potential to cause problems with the voice.

This is especially true for people who have to use their voice loudly or for prolonged periods of time, such as teachers, salespeople, and performers. There are two common groups of medications that are routinely used by individuals with asthma; bronchodilators and steroids. The bronchodilators relax the muscles around the airway to prevent them from constricting, and are also used to relax the muscles once they have become constricted (asthma “attacks”). Therefore, bronchodilators are used as a means of preventing asthma attacks and to obtain relief once an attack has occurred.

Steroids manage the inflammation of the tissues that line the airways, and therefore help prevent asthma attacks from occurring. Some of these medications can cause voice changes. Rinsing the mouth after taking these medications, as commonly advised, does not help relieve vocal symptoms, because the water used to rinse the mouth does not also rinse the mucosa of the vocal folds. (If it did, you’d quickly begin coughing and choking!)

If you have asthma and you are experiencing vocal changes, it is probably a good idea to be evaluated by a   laryngologist  . At The Voice and Swallowing Institute, we will try to determine whether your voice problem is associated with your asthma, the medications you are taking to control the asthma, or due to factors un-related to your asthma. We will work with you and your pulmonologist to help you manage your asthma and gain relief from your vocal symptoms.

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SPOTLIGHT ON: The Older Voice

With advancing age, the vocal fold muscle and mucosal covering can lose mass, appearing thinned as in the open vocal folds above

PHOTO: ATROPHIC VOCAL FOLDS - With advancing age, the vocal fold muscle and mucosal covering can lose mass, appearing thinned as in the open vocal folds above.

As we grow older, the structures of the larynx change, often causing changes in the voice production system that results in vocal symptoms. Structural changes include loss of muscle fibers, thinning of the mucosal tissue that covers that vocal folds, and changes in the proteins and other molecules that make up the mucosal tissue.

These alterations can often lead to incomplete closure of the vocal folds during each cycle of vibration and irregular vibration.

ATROPHIC VOCAL FOLDS - The loss of vocal folds mass, associated with aging, can result in irregular mucosal wave vibration during voicing, and a "spindle-shaped" gap during phonation instead of complete closure, as in the photo above

PHOTO: ATROPHIC VOCAL FOLDS - The loss of vocal folds mass, associated with aging, can result in irregular mucosal wave vibration during voicing, and a "spindle-shaped" gap during phonation instead of complete closure, as in the photo above.

The incomplete closure of the vocal folds can reduce the dynamic range of the voice, making it difficult to speak sufficiently loud. The irregular vibration can make the voice sound rough, as if the speaker has a “frog” in the throat. In an effort to compensate for these changes, many people will contract the muscles of the vocal tract more, and generally use more effort to speak. This can lead to a sensation of fatigue.

Age-related changes in the way the nerves and muscles function can result in a wobble, or tremor to the voice. The pitch of the voice may be raised in men, or lowered in women, and the overall range of pitches at which an individual is capable of speaking may be reduced. It may be that some of these vocal changes are associated with menopause in women, or changes in the breathing capacity or circulatory changes.

As a group, however, these voice changes have come to be referred to as “presbyphonia” and are often dismissed as the inevitable result of growing older. But some of these voice changes can be overcome , usually with voice therapy. If you have been experiencing bothersome vocal changes, and feel that they may be a result of aging, make an appointment at the Institute to learn more about your larynx and voice, and what can be done to alleviate your vocal symptoms.

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SPOTLIGHT ON: Gastric Reflux

Gastric reflux, called laryngopharyngeal reflux when it rises up to affect structures in the throat, is the backwards flow of stomach juices, including acid and digestive enzymes, up the esophagus. In the past several years it has become apparent that it can affect the voice, sometimes profoundly.

To learn more about this disease, its potential effect upon the voice, and ways to manage it, read about laryngopharyngeal reflux and see our Reflux Precautions  (PDF) suggestions.

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SPOTLIGHT ON: Smoking

We know how hard it is to quit smoking. But the fact remains that the inhaled irritants and super-heated air from smoking cause irritation and swelling of the larynx and vocal folds and put you at risk for developing vocal fold cancer. Smoking causes other voice problems as well, such as Reinke's edema. There is no safe amount to smoke. Even if you just smoke a little, you are at risk for voice problems and serious disease.

Hoarseness can be an early sign of vocal fold cancer. Smokers who are hoarse for more than a week or two need to have their vocal folds checked, whether or not they consider the voice quality a problem. An evaluation at The Voice and Swallowing Institute can address this, or see your local otolaryngologist (ear, nose & throat doctor). The most important thing is not to delay a visit to the doctor. Identifying cancer early is very much a matter of life or death.

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SPOTLIGHT ON: Acute Laryngitis

When the temperature drops, the weather changes and we all begin to get colds or the flu. With these upper respiratory infections come fatigue, muscle aches, sneezing, coughing and often laryngitis. The laryngitis may be the most debilitating aspect of the illness because it can be painful and rob us of our ability to communicate, socialize and work.

What is Laryngitis?

Laryngitis is an inflammation of the vocal folds of the voice box. They can become inflamed due to infection, overuse or irritation. When your vocal folds are inflamed they do not vibrate smoothly and you develop a hoarse, strained and sometimes barely audible voice.

Laryngitis can be short lived (acute) or long lived (chronic). The typical laryngitis should be acute and last less than two weeks. When symptoms are present longer than two weeks, there may be a more serious problem.

The symptoms of laryngitis can be caused by numerous factors. The most common cause is a viral upper respiratory in infection. Vocal abuse in the form of smoking or yelling commonly leads to laryngitis. The medical condition of laryngopharyngeal reflux is also a well known cause of laryngitis. This occurs when stomach acid refluxes into the throat and irritates the vocal folds. Most people with this condition actually do not have any symptoms of heartburn or indigestion.

Generally, laryngitis should resolve in a few days and certainly within two weeks. The symptoms often improve by themselves. Your symptoms can initially be treated with voice rest, conservative voice use and general rest to get your whole body stronger. Drinking water and throat lozenges may also be helpful. Mentholated cough drops should be avoided as these can be extremely irritating to the vocal folds.

Danger Signs

If you have laryngitis for longer than two weeks or you are a professional voice user you should seek the opinion of an Otolaryngologist. The doctor will listen to your voice and should then look at your vocal folds with an endoscope. The endoscope may be a flexible fiberoptic tube that is passed through the nose or a rigid endoscope passed through the mouth. A superior instrument for evaluating the vocal folds is a laryngovideostroboscope. This uses a rigid endoscope and a strobe light to view the vibration for vocal folds in slow motion through the mouth. This is essential because it is the vibration that creates your voice. If the vibration is abnormal you will sound hoarse. The entire examination is quick and pain free.

Treatment 

Treatment for laryngitis depends on the cause of the problem and the speed at which your voice needs to return to normal. If the laryngitis is due to a viral infection supportive care is the best treatment. Use your voice more conservatively, do not clear your throat, avoid whispering, rest, drink lots of water, use a humidifier at home, avoid smoke and limit alcohol and caffeine intake.

If you are a professional voice user, such as a singer or lawyer, you may need your voice to return more quickly for an important engagement. In that case, discuss this with your Otolaryngologist as treatment with steroids may be warranted. For more chronic laryngitis the underlying cause must be determined and then that needs to be treated. The list of causes may range from laryngopharyngeal reflux, which is treated medically, to a vocal fold polyp which is treated surgically.

If you are a smoker you should stop smoking and see an Otolaryngologist to make sure cancer is not involved. When vocal fold cancer is detected early, it can usually be treated successfully with surgery or radiation.

Prevention

Often prevention is the best course of action. When you are sick or you feel laryngitis developing the best thing to do is take care of yourself and your voice. Use your voice only when you need to and follow the steps mentioned above. Hopefully this will keep you from losing your voice and keep you out of the doctor’s office.

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