Voice Disorders
Sore Throat
Swallowing Disorders
Gastroesophageal Reflux Disease (GERD)
Transnasal Esophagoscopy (TNE)
The larynx (voicebox) is located in the mid-neck area. It is composed of a cartilage framework with intrinsic and extrinsic muscles that provide motion for both speech and swallowing. The vocal cords are made up of muscles with a layer of mucous membrane. These muscles and mucous membranes will vibrate with contractions that produce sounds, or voice, that your mouth then forms into speech. The vocal cords can vibrate up to 800 times per second. The motion of the vocal cords is under neurologic control.
The signs and symptoms of voice disorders include:
- Hoarseness (dysphonia)
- Vocal fatigue
- Weak or breathy voice
- Loss of singing range
- Loss of voice (aphonia)
- Pitch breaks or abnormally high or low pitched voice
- Strained voice
- Vocal tremor
- Pain while speaking or singing
Common conditions which may cause changes in the voice include:
- Laryngitis (viral, bacterial or inflammatory)
- Gastroesophageal reflux disease
- Vocal cord nodules or polyps
- Growths, tumors or cancer of the voicebox
- Paralysis of the vocal cords
- Disorders of the thyroid
- Sinusitis
- Myasthenia gravis
- Spastic dysphonia (involuntary movements or muscle spasms of the vocal cords)
- Paradoxical vocal cord dysfunction (the vocal cords move inward with breathing when they are supposed to move outward)
To evaluate your condition your physician will attempt to look at the vocal cords, which is sometimes done using a mirror. The physician may also perform a flexible fiber-optic examination of the larynx. This is a good way to identify any growths, inflammation, infection, ulcerations or paralysis of the vocal cords. Because the vocal cords vibrate so rapidly, a special examination called videostroboscopy may be recommended. These procedures are done in our office.
Because there are many different underlying causes and reasons for vocal dysfunction, treatment options vary depending on the nature of the disorder. Treatment options may be very simple such as voice rest, simple medical management, control of environmental or behavioral causative factors, or speech therapy. More severe problems may require surgery, biopsy or other treatments. Diagnosis is the most important initial step after which your physician will make treatment recommendations to you.
Flexible Fiberoptic Examination of the Larynx
A flexible fiberoptic examination involves placing a small, flexible tube through the nose and down the throat to visualize the vocal cords. It is a quick and simple procedure. It is painless with use of just topical analgesia. It is performed safely and effectively in the office.
Videostroboscopy
Videostroboscopy is one of the most practical techniques currently available for recording and observing the motion of the vocal cords. It allows for easy examination of the vibration of the vocal cords during speaking or singing. Videostroboscopy makes the visual images of the vibration appear to be seen in either stop action or slow motion. Thus, minute abnormalities which influence the voice can be seen. From the resulting visual images, an accurate diagnosis of conditions and diseases of the vocal cords, including masses or lesions, abnormal motion, inflammation, broken blood vessels, scarring and other disorders can be made.
Videostroboscopy is a simple and painless procedure that is done in the office with just an anesthetic spray applied to the throat and the nose. The examination is conducted by an ear, nose and throat doctor. To help the physician view the vocal cords, a small, angled telescope is placed into your mouth or a flexible telescope may be placed through your nose. You will be asked to repeat several words and make specific sounds to make your vocal cords vibrate. This action is recorded so that it can be reviewed later. The examination lasts only a few minutes and is not painful. You will be able to talk throughout the examination and view what is happening on a video monitor. In many cases the findings are reviewed with a speech pathologist so he/she can complement the physician in formulating the best treatment plan for the patient. Treatment options may include medication, vocal exercises, speech therapy and in some cases, surgery.
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SORE THROAT
A 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.
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 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.
Allergies may also be the root cause of a sore throat. 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.
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.
An occasional cause of morning sore throat is regurgitation of stomach acids up into the back of the throat. To avoid reflux, tilt your bed frame 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 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.
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
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SWALLOWING DISORDERS
Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. If the difficulty does not clear up by itself in a short period of time, you should see an ear, nose and throat physician.
People normally swallow hundreds of times a day to eat, drink, and swallow the normal saliva and mucus that the body produces. Thus, any interruption in the swallowing process can be very problematic. The difficulty swallowing may be due to simple causes such as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastroesophageal reflux. Other causes may include: stroke; progressive neurologic disorder; the presence of a tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.
The symptoms of swallowing disorders may include:
- drooling;
- a feeling that food or liquid or a foreign body is stuck in the throat;
- discomfort in the throat or chest (when gastroesophageal reflux is present);
- weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing; and
- coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs.
When dysphagia is persistent and the cause is not apparent, the ENT physician will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope), which provides vision of the back of the tongue, throat, and larynx (voice box). If necessary, an examination of the esophagus, called a Transnasal Esophagoscopy may be carried out by the otolaryngologist. The physician may also involve a speech pathologist in the assessment.
Many swallowing disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Gastroesophageal reflux can often be treated by changing eating and living habits including:
- eating a bland diet with smaller, more frequent meals;
- eliminating alcohol and caffeine;
- reducing weight and stress;
- avoiding food within three hours of bedtime; and
- elevating the head of the bed at night.
Surgery is used to treat certain problems. If a narrowing or stricture exists, 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 it is performed by an ear, nose and throat doctor (an Otolaryngologist).
Many causes contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist - head and neck surgeon.
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GASTROESOPHAGEAL REFLUX DISEASE (GERD)
Your stomach is filled with acid. Its purpose is to help digest the food you eat. Believe it or not, this acid is as strong as battery acid. Your stomach is built to handle it. Your esophagus Is not. When acid backs up into your esophagus, it can cause the burning sensation known as heartburn. Almost everyone has occasional heartburn. But if these symptoms occur two or more days a week for at least three months, you may have acid reflux disease (GERD). Acid reflux occurs when the lower esophageal sphincter – the valve separating the esophagus and stomach—does not close properly, allowing acid to back up into the esophagus. In short, acid reflux disease is chronic heartburn.
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 either caused by or associated with GERD, such as hoarseness, laryngeal (singers) nodules, croup, airway stenosis (narrowing), swallowing difficulties, throat pain, and sinus infections. These problems require an ear, nose and throat doctor (otolaryngologist). They treat many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation and lesions, as well as a change in the esophageal lining called Barrett’s esophagus, which is a serious complication that can lead to cancer.
Most people with GERD respond favorably to a combination of lifestyle changes and medication. On occasion, surgery is recommended. 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.
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TRANSNASAL ESOPHAGOSCOPY (TNE)
An endoscope is an instrument used to examine an interior part of the body. Endoscopes may be either rigid or flexible, and they have a light at the end that illuminates the area for visibility. During transnasal esophagoscopy (TNE), a thin, flexible endoscope is inserted through the nose and down the throat in order to gain view of the vocal folds, larynx (voicebox), esophagus, or other structures of the throat. Patients do not need to be sedated before undergoing TNE. Because intravenous sedative medication is not required before TNE, the risk of complications is lower than with conventional endoscopy. The most common complication associated with TNE is nosebleed.
A TNE may be used to examine patients who have swallowing difficulties (dysphagia) due to obstructive or mechanical problems. In one study, transnasal endoscopy led to correct diagnosis of the cause of dysphagia in 100% of patients. A TNE may also be done to examine patients who have a mass in the neck, throat, airway, or esophagus. A TNE may also be useful in assessing patients with sleep apnea to check for obstruction in the throat. Patients suffering from gastroesophageal reflux disease (GERD) may also benefit from TNE, as it can reveal manifestations of GERD in the esophagus. For patients with GERD and asthma, challenging symptoms such as chronic cough can be better understood through TNE. The procedure allows physicians to view the effects of GERD in the throat, effects that are far more common than previously realized and that may increase patients’ risks for cancer of the larynx and hypopharynx.
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