- Filed under: Reflux
Your Voice is Trying to Tell You Something – Listen Up!
Dr. Clark Rosen is a Co-Director of the UCSF Voice and Swallowing Center, Chief of the Division of Laryngology, Professor of Otolaryngology-Head and Neck Surgery and the Lewis F Morrison MD Endowed chair of Laryngology.
Dr. Rosen’s illustrious career as a leader in the field is highlighted by many avenues of contribution. From establishing world-class training programs at the University of Pittsburg and UC San Francisco, to sharing his knowledge across the globe.
His passion for education and collaboration is evident in his seven textbooks (several of which set the standard of practice), thirty-six book chapters, and well over two hundred peer-reviewed publications. His thirst for knowledge is only sated in constant research that pushes forward the creation of what is possible.
As a result of these endeavors, Dr. Rosen is a sought-after speaker internationally and has enjoyed major service to multiple publications and professional societies. He is also a founding member of the Fall Voice Conference, and has served as an officer for the American Academy of Otolaryngology-Head and Neck Surgery (AAOHNS), as well as the American Laryngological Association (ALA).
“What’s wrong with your voice?”
Do you suddenly sound like Janis Joplin? Kermit the Frog? Did you wake up this morning and not recognize the voice coming out of your mouth as your own? Or perhaps by the end of the day, you sounded like you’d smoked a carton of cigarettes in the last twelve hours? What is going on?
Your voice is trying to tell you something. It may be something small and inconsequential, or it may be ominous and life threatening. The best thing you can do is listen to your voice.
As with many things in life, the devil is in the details. There are many causes of hoarseness, defined here as a change from your baseline or “normal” voice. Let’s explore what “hoarseness” means, what the most common causes are, and then how to navigate figuring it all out.
What is hoarseness?
Hoarseness can mean different things to different people. A computer programmer who works from home can tolerate a lot more vocal aberration than a professional singer or high school teacher. The most common experience for any individual with hoarseness is a change in the quality of the voice. People may experience vocal instability, breathiness, a change in pitch, or a “roughness” to their voice. Some people report that they, “never know what will come out.” Occasionally, the voice quality may sound normal, but individuals experience excessive fatigue or even pain with speaking (odynophonia). One thing is certain – we live in a communication age, and our voice is essential to our social and occupational life.
Are you drinking enough water?
It’s true! A very common condition that affects the voice is inadequate hydration. The vocal folds vibrate in a gelatinous fluid and the better you are hydrated, the better your voice will perform. Inadequate hydration, caffeine, alcohol, and excessive exercise can all lead to “relative dehydration” – which can have a significant negative impact on the voice. The best preventive care for this is drink more water. The body, and especially the vocal cords, need to be well hydrated to stay healthy and function at their prime.
Try increasing your daily water intake. Men should drink over 3.5 liters of water a day and women should drink over 2.5 liters a day. A good measure is to drink until your urine is a pale yellow.
Are you taking medications?
In addition to caffeine and alcohol, various medications can cause dryness and irritation of the throat. Many common medication categories that can dry the throat include antihistamines, tri-cyclic antidepressants, SSRIs; additionally, asthma inhalers can be particularly damaging.
Talk to your doctor about your medication regimen and the potential impact on your voice.
How are you using your singing voice?
One of the most common causes of hoarseness arises from too much voice use. This can involve screaming, yelling, crying and/or excessive loud voice use – not to mention singing. Early on in these scenarios, the vocal cords (clinically termed, vocal folds) can develop swelling, but if the voice “overuse” is limited, the voice will recover quickly, in about 7-10 days.
However, extended, repeated, and/or severe voice use can lead to lasting physical changes of the vocal folds, called lesions – commonly referred to as “vocal nodules” or “nodes.” These lesions are best thought of as “calluses” of the vocal cords. While the most extreme cases may require surgical intervention, the best treatment course is usually therapy, therapy, therapy, and more therapy with a speech pathologist and voice coach.
Rest that voice! Follow up is necessary if that is not enough.
Do you have reflux?
Another common cause of hoarseness is reflux. Stomach contents can regurgitate into your throat and cause dysphonia and other symptoms such as throat clearing, cough, post-nasal drip, excessive throat mucus, and the sensation of a lump in the throat (globus). Reflux-induced throat symptoms (laryngopharyngeal, or “silent,” reflux) may or may not be associated with the more common symptoms of heartburn and regurgitation.
Hoarseness related to reflux can be very difficult to manage. Who likes trying to lose weight? Who likes giving up midnight snacks, coffee, and alcohol – just to name a few? Is taking a lot of the fun out of life worth a little vocal strain? Maybe being hoarse isn’t that bad…right?
Given that we need our voices, and that chronic irritation from reflux can lead to more serious conditions – it turns out we should listen up and make sure our hoarseness is not being caused by reflux.
After all the lifestyle choices associated with reflux and hoarseness have been addressed, if you’re still sounding like a frog being strangled, it’s time to see your friendly neighborhood clinician.
Have you addressed all of the above? Time for a scope.
If someone is hoarse longer than two weeks without any recent viral illness, a common precursor to cough, throat discomfort and hoarseness, they should consult with an otolaryngologist and have their vocal cords looked at. The exam involves inserting a small, flexible camera through the nose for a direct visual examination of the throat. This is done in the office, takes less than two minutes, and is close to painless. This examination is essential for anyone experiencing a change in their voice longer than two weeks in duration1.
What your clinician sees determines what comes next.
“Looks like you may be suffering from reflux.”
Your physician may see signs of reflux – in spite of the fact that you are now thin, drink water like you’re drowning, eat like a rabbit and don’t drink coffee, alcohol, or smile much anymore…sigh.
In this instance, your physician may opt to try alginate therapy (Reflux Gourmet is the best example); this creates a temporary barrier in the stomach when needed that protects the esophagus and throat from reflux – allowing for protection and healing. This has been shown to significantly improve hoarseness and/or throat discomfort due to reflux.2 Another option would be acid-reducing drugs, such as PPIs and H2 blockers.
“Looks like you may be suffering from abnormal vocal compensation.”
Another common cause of hoarseness is a medical diagnosis known as muscle tension dysphonia. Muscle tension dysphonia (MTD) can occur after a viral infection, especially if someone uses their voice a lot while they are ill, or without any obvious cause. This problem comes from an imbalance between muscle tension and airflow through the voice box, or larynx. This hoarseness is frequently associated with vocal fatigue and throat pain with speaking. A common history is starting the day with a normal voice – then as the day proceeds, and with increasing voice use, the voice becomes hoarse, and discomfort occurs with speaking. Muscle tension dysphonia is usually the result of the body’s attempt to compensate for underlying vocal pathology. Even after the vocal pathology has healed or been adequately treated, the MTD can persist. A metaphor for MTD and errant muscle compensation is when an individual with lumbar stenosis develops hip problems from trying to compensate for the back pain and weakness. Fortunately, this condition is usually treated successfully by working with a speech-language pathologist.
“Looks like there may be something sinister.”
The most serious condition that can cause hoarseness is cancer of the vocal folds. Although the most common cause of this type of cancer is smoking, cancer of the vocal folds can also occur in people who have never smoked; any chronic irritation, such as from reflux or environmental pollutants, can be precursors. A throat examination by an experienced clinician is easily performed and is essential to ensure that cancer is not the cause of the hoarseness. An early diagnosis of vocal cord cancer has a greater than 95% cure rate, and thus, early detection is crucial. There is no substitution for an endoscopic vocal fold examination by a trained expert.
“What else could be causing my hoarseness?”
Another common cause of hoarseness is advancing age. As we get older, our vocal folds atrophy and get weaker. Unfortunately, age-related vocal fold changes (presbylarynx) are part of the normal aging process. “I sound like a little old lady.” is a very frequent patient complaint we see in the clinic these days. Although there is no cure for aging, there are numerous surgical and non-surgical treatments that can mediate the symptoms and help delay the inevitable decline. Other less common causes of hoarseness that can be ruled out with endoscopy include vocal fold polyps, cysts, hemorrhage, rare neurological disorders, vocal fold paralysis, scar, papilloma, and other benign vocal fold growths.
“What do we do now?”
Once an accurate diagnosis of the cause of hoarseness has been made, treatment targeting underlying factors such as lifestyle, reflux, and/or voice therapy can be successful in restoring full vocal function. In rare cases, surgery may be required.
Here’s hoping you partied hard last night – singing at the top of your lungs, eating late, enjoying all the delicious vices on the naughty lists, because you finally got over your cold, and now you are grinning from ear to ear! Let me hear you shout out – I recognize that voice!
If not, listen to what your voice may be telling you. It’s shouting as loud as it can.
Referenced:
(1) Stachler RJ, Francis DO, Schwartz SR, Damask CC, Digoy GP, Krouse HJ, McCoy SJ, Ouellete DR, Patel RR, Reavis CCW, Smith LJ, Smith M, Strode SW, Woo P, Nnacheta LC. Clinical Practice Guideline: Hoarseness (Dysphonia) (Update). Otolaryngol Head Neck Sur. 2018 Mar;158(1_suppl):S1-S42. doi: 10.1177/0194599817751030.
(2)Leiman DA, Riff BP, Morgan Set al. Alginate therapy is effective treatments for GERD symptoms: a systematic review and meta-analysis and meta-analysis. Dis Esophagus 2017; 30:1-9