OUT OF COMMITTEE: Voice | World Voice Day 2022: Q&A
Want to offer your patients timely advice on taking care of their voices for World Voice Day? AAO-HNS Voice Committee Members, James J. Daniero, MD, Chair, Thomas L. Carroll, MD, and Libby J. Smith, DO, offer answers to questions you may hear in clinic.
My voice is getting hoarse. Why?
Dr. Smith: “Hoarseness” is defined as an abnormal change in voice quality, such as raspy, strained, breathy, weak, higher or lower in pitch, inconsistent, fatigued, tremulous, or requiring more effort to talk. This usually happens when there is a problem in the sound-producing parts (vocal cords or folds) of the voice box (larynx). While breathing, the vocal folds remain apart. When making sound, the vocal folds come together and, as air leaves the lungs, they vibrate, producing sound. Anything that alters vibration or closure of the vocal folds results in hoarseness.
What can cause hoarseness? And what can be done to help?
There are many reasons hoarseness can develop. The following are some of the most common causes of hoarseness. General rule is that an examination of the larynx by an otolaryngologist (ear, nose, and throat doctor) is necessary if hoarseness persists more than four weeks, or sooner if a professional voice user or if they have risk factors for developing malignancy (i.e., smoking).
Acute Laryngitis: The most common cause is acute laryngitis. Swelling of the vocal folds can happen with a common cold, breathing tract viral infection, or from voice strain. Serious injury to the vocal folds can occur when talking while having laryngitis.
Treatment: Supportive care (AKA: be gentle with your voice, hydrate). Antibiotics and steroids are often not needed. This is often managed by primary care practitioners.
Benign Vocal Fold Lesions: Nodules, polyps, and cysts usually occur after prolonged trauma to the vocal folds from talking too much, too loudly, or with bad technique.
Treatment: After looking at the larynx to confirm this diagnosis, treatment includes learning proper voicing technique with voice therapy, adequate hydration, and sometimes require surgery.
Precancerous / Cancerous Lesions: Precancerous or cancerous lesions on the vocal folds lead to hoarseness. If hoarseness lasts four weeks, or if you are at higher risk of developing throat cancer (i.e., smoker), then your larynx needs to be evaluated by an otolaryngologist.
Treatment: Biopsy is needed to confirm diagnosis. Based upon the location and extent of disease, treatment can include surgery, radiation therapy, and/or chemotherapy.
Neurological Diseases or Disorders: Hoarseness can happen in those with Parkinson’s or after a stroke. A rare disorder called spasmodic dysphonia can also create hoarseness or breathing. A paralyzed vocal fold, commonly after surgery or viral illness, may also cause of a weak, breathy voice. Determining the cause of vocal fold paralysis is important and helps determine treatment. This is often done in conjunction with a neurologist.
Treatment: Treatment differs greatly depending upon the type of neurologic disorder. There are specialized voice techniques for patients with Parkinson’s disease, but evaluation is also very important for them even if they do not feel they have swallowing problems. A stroke can result in a myriad different disorders, such as dysarthia (mumbled speech), vocal fold paralysis (vocal fold does not move), and dysphagia (difficulty swallowing). Speech therapy or the use of assistive communicative devices can often help. Vocal fold paralysis, regardless of if it is due to a neurologic condition or more likely from surgery, is often treated with surgery to augment of the vocal fold. Spasmodic dysphonia and essential tremor of voice are traditionally treated with repeated botulinum toxin injections.
Vocal Fold Atrophy / Presbylaryngeus: As we age, our vocal folds become thinner (decreased bulk) and floppy (decreased tone). This is not due to talking too much or too little, it is just a fact of life. Voice inconsistency, decreased projection, and raspiness are common.
Treatment: Sometimes reassurance that hoarseness is not due to cancer is all that is needed for peace of mind. Treatment of vocal fold atrophy includes voice therapy and sometimes vocal fold injection.
1. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Surg. 2018 Mar;158(1_suppl):S1-S42.
2. Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellette DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update) Executive Summary. Otolaryngol Head Neck Surg. 2018 Mar;158(3):409-426.
My voice gets tired toward the end of the day. Should I be concerned?
Dr. Carroll: There are many potential causes for the voice getting tired after a day of talking, also called vocal fatigue, and nearly all are benign. Age-related thinning of the vocal folds (atrophy), decreased motion of one vocal fold (paresis), benign vocal fold lesions (nodules, polyp, cyst) and scarring of the vibration layer of the vocal fold can all lead to recruitment of other muscles inside and outside the larynx to compensate for the changes in how the vocal folds are not normally functioning.
This compensation has a common name: muscle tension dysphonia (MTD). The gap that forms between the vocal folds from any of these causes creates a “leaky valve,” allowing excess air to escape inappropriately through the vocal folds during phonation. This inappropriate loss of air from where the vocal folds meet (the glottis) is called glottic insufficiency; it causes the changes that people experience in vocal quality, effort, strain, and fatigue. Because the same muscles outside the larynx that compensate for voice problems elevate our larynx during swallowing, many people with glottic insufficiency also complain of a lump in their throat when they swallow. This is one of the many causes of a “globus” sensation.
The most important step in addressing vocal fatigue is an appropriate workup, including examination of the vocal folds themselves and, in many centers, an evaluation by a speech and language pathologist (SLP). The vocal folds are often visualized with a common in-office examination called a laryngoscopy. This exam is performed with a flexible camera introduced through the nose or a rigid telescope introduced through the mouth.
Stroboscopy, a special adjunct to laryngoscopy that can reveal the vocal folds vibrating in slow motion, is used to diagnose more subtle pathologies and assess how the pathology is affecting how the vocal folds meet during vibration. These exams are essential for both confirming the suspected diagnosis and differentiating the more common pathologies from other, less common but more concerning causes for voice changes. MTD is often given as a primary diagnosis when otolaryngologists exam the larynx with a flexible laryngoscope under normal light and see the muscles and structures above the larynx squeezing together, blocking the view of the true vocal folds during phonation. Stroboscopy is an excellent adjunct when the flexible exam does not clearly reveal a pathology beyond this observed squeezing; it can reveal the underlying pathology and reason for the patient’s MTD. SLPs, when available early in the patient’s workup, are invaluable to understanding if the patient’s complaint and vocal problem are amenable to voice therapy.
Treatment of vocal fatigue usually consists of voice therapy and/or a surgical intervention to treat the underlying disease process. The order of which treatment is administered first depends on the patient and pathology. Some patients will do well with voice therapy alone, while others with larger benign lesions and significant atrophy require vocal fold augmentation or lesion excision before therapy begins in order to achieve their ultimate improvement. The goal of these treatments is to increase the efficiency of vocal fold closure during vibration, thus improving the glottic insufficiency, relieving MTD and ultimately improving vocal fatigue, hoarseness, and other associated complaints.
Various quality of life studies show that patients with vocal fatigue are often quite happy with the results they achieve. Previously avoiding social gatherings or other engagements that involve talking later in the day, these patients find they withdraw less, and that everyday communication becomes easier.
My throat always feels dry, and it often also affects my voice. How can I get rid of my dry throat?
Dr. Daniero: Of course, the easy answer is to drink more water. Despite our best attempts, in our busy day-to-day lives we often do not reach the recommended eight glasses of water per day. However, there are also hidden ways that we lose extra water each day that should also be avoided. These include eliminating caffeine sources, such as coffee, tea, and sodas. Although these beverages are often consumed when we are thirsty, this does not mean that they add to the body’s overall hydration. In fact, highly caffeinated beverages like energy drinks and coffee are powerful diuretics that actually subtract from one’s water glass tally, pushing the overall goal well beyond the recommended eight glasses. There are also many common medications—particularly those used for allergies, blood pressure, chronic pain, and depression—that create dry mucus membranes of the throat and vocal cords. Medication induced dryness can easily be overlooked, especially when there is a long list of medications, which can overlap in their combined drying potential.
In addition to total body dehydration, breathing dry air can be a significant contributor to throat dryness. Regions with low humidity and cold temperatures requiring the building heat to be turned on can draw the moisture out of the sinuses, throat, and lungs as we are breathing.
The nose is the humidifier and filter for the air we breathe and therefore adding hydration to the nasal cavity can help the body counteract dry air passing down into the throat and airway. This can be improved by using nasal saline sprays frequently throughout the day. Furthermore, mouth breathing can bypass this system and introduce dry air directly to the throat. Addressing nasal congestion with nasal steroids or possibly even surgery for severe cases can help reduce mouth breathing and increase overall airway humidification.
Ultimately, adding external humidification and lubrication to the airway can also help reduce dryness. This can be achieved by using a steam inhaler device, available at most pharmacies, or using a bedside humidifier. Similarly throat lozenges and certain decaffeinated teas can help with coating the throat due to the effect of their demulcent ingredients. Demulcents, such as pectin, glycerin, honey, and syrup, are ingredients that form protective coatings of the mucus membrane lining of the throat and vocal cords. Menthol-based lozenges, while temporarily soothing, may cause irritation of the throat when used for prolonged periods. Lozenges based on fruit pectin and/or glycerin can lubricate the throat and vocal cords without the other effects of menthol.
Finally, a good indicator to determine if your vocal cords may be dry is to correlate it with dryness in the mouth. If your mouth is dry, then you can assume your vocal cords (only a few inches away) are also dry and less likely to vibrate efficiently—this relationship is often underrecognized.