A person’s voice serves as their vocal signature. In many social situations, it defines our interactions with the people around us. When our voice fails to work for us, it can result in unintended social isolation and poor performance. Studies have shown that up to 30% of Americans suffer from a voice problem at some point in their lives. Up to 28 million Americans are affected daily in their work activities. It is for this reason that voice problems should not be ignored, especially those that persist for greater than 2 weeks.
The first step in managing a voice problem is a formal evaluation by an otolaryngologist (ENT). A laryngologist, a subspecialist otolaryngologist, is a physician who is especially trained to deal with voice and airway issues. The evaluation consists of a routine head and neck exam and a special video exam of the vocal cords known as a videostroboscopy. The video exam takes very close images of the vocal cords and allows the physician to see their function in slow motion. South Florida ENT is fortunate to have the only fully high definition videostroboscopy system in South Florida, which allows for the most detailed and comprehensive examination of the voicebox. The videostrobe can help identify very subtle changes in the vocal cords that may adversely impact a patient’s voice.
Voice problems vary widely in their cause. At times, it may be related to a compensatory behavior to changes following a cold or the effect of laryngopharyngeal reflux (LPR or “silent reflux). These reasons can often be treated with medicine or voice therapy. More insidious causes, such as nodules, polyps, or even certain laryngeal cancers, may require surgery. A laryngologist is skilled in performing minimally invasive surgery to remove only the disease while preserving the normal vocal cord for the best vocal outcome. Some procedures, such as vocal fold injections, can be performed in the office to avoid lost time at work or with friends. Voice therapy, performed by a licensed speech language pathologist (SLP), may be used as an additional treatment following surgery to encourage the best vocal habits and prevent recurrence of the underlying problem.
The good news is that many patients do well and are able to regain their previous vocal function. By working with a laryngologist and a voice therapist, many patients find their voice is better than when they started, and they are now more eager to engage both socially and professionally. If you should find that you are not happy with your voice, make an appointment today at one of our convenient locations.
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 mild hoarseness?
- If you smoke, quit.
- Avoid agents which 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 in situations where you need to protect your voice.
- Seek professional voice training.
- Avoid speaking or singing when your voice is injured or hoarse. Don’t sing when you are sick.
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.
Forty-five percent of normal adults snore at least occasionally, and 25 percent are habitual snorers. Problem snoring is more frequent in males and overweight persons, and it usually grows worse with age. Snoring is an indication of obstructed breathing. Therefore, it should not be taken lightly. An otolaryngologist can help you to determine where the encumbrance may be and offer solutions for this noisy and often embarrassing behavior.
What causes snoring?
The noisy sounds of snoring occur when there is an obstruction to the free flow of air through the passages at the back of the mouth and nose. This area is the collapsible part of the airway (see illustration) where the tongue and upper throat meet the soft palate and uvula. Snoring occurs when these structures strike each other and vibrate during breathing.
In children, snoring may be a sign of problems with the tonsils and adenoids. A chronically snoring child should be examined by an otolaryngologist, as a tonsillectomy and adenoidectomy may be required to return the child to full health.
People who snore may suffer from:
- Poor muscle tone in the tongue and throat. When muscles are too relaxed, either from alcohol or drugs that cause sleepiness, the tongue falls backwards into the airway or the throat muscles draw in from the sides into the airway. This can also happen during deep sleep.
- Excessive bulkiness of throat tissue. Children with large tonsils and adenoids often snore. Overweight people have bulky neck tissue, too. Cysts or tumors can also cause bulk, but they are rare.
- Long soft palate and/or uvula. A long palate narrows the opening from the nose into the throat. As it dangles, it acts as a noisy flutter valve during relaxed breathing. A long uvula makes matters even worse.
- Obstructed nasal airways. A stuffy or blocked nose requires extra effort to pull air through it. This creates an exaggerated vacuum in the throat, and pulls together the floppy tissues of the throat, and snoring results. So, snoring often occurs only during the hay fever season or with a cold or sinus infection.
- Also, deformities of the nose or nasal septum, such as a deviated septum (a deformity of the wall that separates one nostril from the other) can cause such an obstruction.
Why is snoring serious?
Socially: It can make the snorer an object of ridicule and causes others sleepless nights and resentfulness.
Medically: It disturbs sleeping patterns and deprives the snorer of appropriate rest. When snoring is severe, it can cause serious, long-term health problems, including obstructive sleep apnea.
What is obstructive sleep apnea?
When loud snoring is interrupted by frequent episodes of totally obstructed breathing, it is known as obstructive sleep apnea. Serious episodes last more than ten seconds each and occur more than seven times per hour. Apnea patients may experience 30 to 300 such events per night. These episodes can reduce blood oxygen levels, causing the heart to pump harder.
The immediate effect of sleep apnea is that the snorer must sleep lightly and keep his muscles tense in order to keep airflow to the lungs. Because the snorer does not get a good rest, he may be sleepy during the day, which impairs job performance and makes him a hazardous driver or equipment operator. After many years with this disorder, elevated blood pressure and heart enlargement may occur.
Is there a cure for heavy snoring?
Heavy snorers, those who snore in any position or are disruptive to the family, should seek medical advice to ensure that sleep apnea is not a problem. An otolaryngologist will provide a thorough examination of the nose, mouth, throat, palate, and neck. A sleep study in a laboratory environment may be necessary to determine how serious the snoring is and what effects it has on the snorer’s health.
What treatments are available?
Treatment depends on the diagnosis. An examination will reveal if the snoring is caused by nasal allergy, infection, deformity, or tonsils and adenoids.
Snoring or obstructive sleep apnea may respond to various treatments now offered by many otolaryngologist—head and neck surgeons:
- Uvulopalatopharyngoplasty (UPPP) is surgery for treating obstructive sleep apnea. It tightens flabby tissues in the throat and palate, and expands air passages.
- Thermal Ablation Palatoplasty (TAP) refers to procedures and techniques that treat snoring and some of them also are used to treat various severities of obstructive sleep apnea. Different types of TAP include bipolar cautery, laser, and radiofrequency. Laser Assisted Uvula Palatoplasty (LAUP) treats snoring and mild obstructive sleep apnea by removing the obstruction in the airway. A laser is used to shrink the uvula and tighten a specified portion of the palate in a series of small procedures in a doctor’s office under local anesthesia. Radiofrequency ablation—some with temperature control approved by the FDA—utilizes a needle electrode to emit energy to shrink excess tissue in the upper airway including the palate and uvula (for snoring), base of the tongue (for obstructive sleep apnea), and nasal turbinates (for chronic nasal obstruction).
- Genioglossus and hyoid advancement is a surgical procedure for the treatment of sleep apnea. It prevents collapse of the lower throat and pulls the tongue muscles forward, thereby opening the obstructed airway.
If surgery is too risky or unwanted, the patient may sleep every night with a nasal mask that delivers air pressure into the throat; this is called continuous positive airway pressure or “CPAP”.
Do you recommend the use of over-the-counter devices?
More than 300 devices are registered in the U.S. Patent and Trademark Office as cures for snoring. Some are variations on the old idea of sewing a sock that holds a tennis ball on the pajama back to force the snorer to sleep on his side since snoring is often worse when a person sleeps on his back. Some devices reposition the lower jaw forward; some open nasal air passages; a few others have been designed to condition a person not to snore by producing unpleasant stimuli when snoring occurs. But, if you snore, the truth is that it is not under your control. If anti-snoring devices work, it is probably because they keep you awake.
Self-help for the light snorer
Adults who suffer from mild or occasional snoring should try the following self-help remedies:
- Adopt a healthy and athletic lifestyle to develop good muscle tone and lose weight.
- Avoid tranquilizers, sleeping pills, and antihistamines before bedtime.
- Avoid alcohol for at least four hours and heavy meals or snacks for three hours before retiring.
- Establish regular sleeping patterns.
- Sleep on your side rather than your back.
- Tilt the head of your bed upwards four inches.
Open your jaw all the way and shut it. This simple movement would not be possible without the Temporo-Mandibular Joint (TMJ). It connects the temporal bone (the bone that forms the side of the skull) and the mandible (the lower jaw). Even though it is only a small disc of cartilage, it separates the bones so that the mandible may slide easily whenever you talk, swallow, chew, kiss, etc. Therefore, damage to this complex, triangular structure in front of your ear, can cause considerable discomfort.
Where is the Temporo-Mandibular Joint?
You can locate this joint by putting your finger on the triangular structure in front of your ear. Then move your finger just slightly forward and press firmly while you open your jaw all the way and close it. You can also feel the joint motion in your ear canal.
How does the Temporo-Mandibular Joint work?
When you bite down hard, you put force on the object between your teeth and on the Temporo-Mandibular Joint. In terms of physics, the jaw is the lever and the TMJ is the fulcrum. Actually, more force is applied (per square foot) to the joint surface than to whatever is between your teeth because the cartilage between the bones provides a smooth surface, over which the joint can freely slide with minimal friction.
Therefore, the forces of chewing can be distributed over a wider surface in the joint space and minimize the risk of injury. In addition, several muscles contribute to opening and closing the jaw and aid in the function of the TMJ.
What causes TMJ pain?
In most patients, pain associated with the TMJ is a result of displacement of the cartilage disc that causes pressure and stretching of the associated sensory nerves. The popping or clicking occurs when the disk snaps into place when the jaw moves. In addition, the chewing muscles may spasm, not function efficiently, and cause pain and tenderness.
Damage to the TMJ is often caused by…
- Major and minor trauma to the jaw
- Teeth grinding
- Excessive gum chewing
- Stress and other psychological factors
- Improper bite or malpositioned jaws
What are the symptoms?
- Ear pain
- Sore jaw muscles
- Temple/cheek pain
- Jaw popping/clicking
- Locking of the jaw
- Difficulty in opening the mouth fully
- Frequent head/neck aches
The pain may be sharp and searing, occurring each time you swallow, yawn, talk, or chew, or it may be dull and constant. It hurts over the joint, immediately in front of the ear, but pain can also radiate elsewhere. It often causes spasms in the adjacent muscles that are attached to the bones of the skull, face, and jaws. Then, pain can be felt at the side of the head (the temple), the cheek, the lower jaw, and the teeth.
A very common focus of pain is in the ear. Many patients come to the ear specialist quite convinced their pain is from an ear infection. When the earache is not associated with a hearing loss and the eardrum looks normal, the doctor will consider the possibility that the pain comes from TMJ.
There are a few other symptoms besides pain that TMJ can cause. It can make popping, clicking, or grinding sounds when the jaws are opened widely. Or the jaw locks wide open (dislocated). At the other extreme, TMJ can prevent the jaws from fully opening. Some people get ringing in their ears from TMJ.
How is TMJ pain treated?
Because TMJ symptoms often develop in the head and neck, otolaryngologists are appropriately qualified to diagnose TMJ problems. Proper diagnosis of TMJ begins with a detailed history and physical, including careful assessment of the teeth occlusion and function of the jaw joints and muscles. An early diagnosis will likely respond to simple, self-remedies:
- Rest the muscles and joints by eating soft foods.
- Do not chew gum.
- Avoid clenching or tensing.
- Relax muscles with moist heat (1/2 hour at least twice daily).
In cases of joint injury, apply ice packs soon after the injury to reduce swelling. Relaxation techniques and stress reduction, patient education, non-steroidal anti-inflammatory drugs, muscle relaxants or other medications may also offer relief.
Other treatments for advanced cases may include fabrication of an occlusal splint to prevent wear and tear on the joint, improving the alignment of the upper and lower teeth, and surgery. After diagnosis, your otolaryngologist may suggest further consultation with your dentist and oral surgeon to facilitate effective management of TMJ pain.
Tonsils and adenoids are on the body’s first line of defense—our immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose at the risk of their own infection. But at times, they become more of a liability than an asset and may even trigger airway obstruction or repeated bacterial infections. Your ear, nose, and throat specialist can suggest the best treatment options.
What are tonsils and adenoids?
Two 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.
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, swallowing, and sleep 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 a doctor?
You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.
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.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.
Other methods used to check tonsils and adenoids are:
- Medical history
- Physical examination
- Throat cultures/Strep tests – helpful in determining infections in the throat
- X-rays – helpful in determining the size and shape of the adenoids
- Blood tests – helpful in determing infections 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 if there are recurrent infections despite antibiotic therapy, and/or 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.
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.
How to prepare for surgery
- Talk to your child about his/her feelings and provide strong reassurance and support.
- 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 may be taken by mouth (including chewing gum, mouthwashes, throat lozenges, toothpaste, water.) 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 unique, and recovery time may vary.
Your ENT specialist will provide you with the details of preoperative and postoperative care and answer any questions you may have.
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.
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
- Bad breath
Enlarged adenoids and their symptoms
If your 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
- stops for a few seconds at night during snoring or loud breathing (sleep apnea)