What the voice is?

‘Voice’ is the sound produced by the vibration of the vocal cords produced by air passing through the larynx carrying the wires closer together. Your voice is an extremely valuable resource and is the most usual form of communication. Our voice is invaluable both for our social interaction as well as for occupying people. Proper care and use of your voice improves the likelihood of having a healthy voice for your entire life.

How do I know if I have a voice problem?

Voice problems occur with a change in the voice, often described as hoarseness, harshness, or a raspy quality. People with voice problems frequently complain of or notice changes in pitch, loss of voice, loss of stamina, and sometimes a sharp or dull pain associated with voice use. Other voice problems may accompany a change in singing ability that is most noticeable in the upper singing range. A more serious problem is indicated by regurgitation of blood or when blood is present in the mucus. These require immediate attention by an otolaryngologist.

What is the most common cause of a change in your voice?

Voice changes sometimes after an upper respiratory tract infection can last up to two weeks. Typically, the respiratory tract infection or cold causes swelling of the vocal cords and changes their vibration resulting in an abnormal voice. Reduced voice use (voice rest) usually improves the voice after an upper respiratory infection, cold, or bronchitis. If the voice does not return to its normal characteristics and capabilities within two to four weeks after a cold, a medical evaluation by an ear, nose, and throat doctor is recommended. An examination of the throat after a change in voice lasting more than one month is especially important for smokers. (Note: A change in voice is one of the earliest and most important symptoms of throat cancer Early detection greatly increases the effectiveness of treatment).

Six tips for identifying voice problems

Ask yourself the following questions to determine if you have an unhealthy voice:

• Is your voice hoarse or raspy?
• Does your throat often feel raw, sore, or strained?
• Does talking require more effort?
• Do you find yourself repeatedly clearing your throat?
• Will people regularly ask you if you have a cold when they don't?
• Have you lost your ability to reach some high notes when singing?

A wide range of problems can lead to changes in your voice. Seek medical attention when voice problems persist.

The tonsils are two clusters of tissue located on either side of the back of the throat. The adenoids are located at the top of the throat behind the nose and roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, causing difficulty breathing. They are also removed when recurrent tonsil infections or strep throat cannot be successfully treated with antibiotics. Surgery is most often performed in children.

The procedure to remove the tonsils is called a tonsillectomy; the removal of the adenoids is an adenoidectomy. Both procedures are often performed at the same time; therefore, the surgery is known as tonsillectomy and adenoidectomy, or T&A.

T&A is an outpatient surgical procedure that lasts between 30 and 45 minutes and is performed under general anaesthesia. Typically, the young patient will remain in the hospital or clinic for several hours after surgery for observation. Children with severe obstructive sleep apnoea and very young children are usually admitted overnight to the hospital for close monitoring of respiratory status. An overnight stay may also be required if there are complications such as excessive bleeding, severe vomiting or low oxygen saturation.

When the tonsillectomy patient arrives home.

Most children take seven to ten days to recover from surgery. Some may recover more quickly; others may take up to two weeks for a full recovery. The following guidelines are recommended:

Drink: The most important requirement for recovery is that the patient drinks plenty of fluids. Beginning immediately after surgery, children can have fluids such as water or apple juice. Some patients experience nausea and vomiting after surgery. This usually occurs within the first 24 hours and resolves only after the effects of the anesthesia wear off. Contact your doctor if there are signs of dehydration (urinating less than 2-3 times a day or crying without tears).

Eat: In general, there are no dietary restrictions after surgery, but some doctors recommend a soft diet during the recovery period. The sooner the child eats and chews, the faster the recovery will be. Tonsillectomy patients may be reluctant to eat because of a sore throat; consequently, some weight loss may occur, which is regained after resuming a normal diet.

Fever: Low grade fever may be observed the night of surgery and one to two days after surgery. Contact your doctor if the fever is higher than 102°.

Activity: activity may slowly increase, with a return to school after normal eating and drinking resumes, pain medication is no longer required, and the child sleeps through the night. Travel on aeroplanes or away from a medical facility is not recommended for two weeks after surgery.

Breathing: The parent may notice snoring and mouth breathing due to swelling in the throat. Breathing should return to normal when the swelling goes down, 10 to 14 days after surgery.

Scars: a crust will form where the tonsils and adenoids were removed. These scabs are thick, white and cause bad breath. This is normal. Most scabs fall off in small pieces five to ten days after surgery.

Bleeding: with the exception of small spots of blood from the nose or saliva, no bright red blood should be seen. If such bleeding occurs, contact your doctor immediately or take your child to the emergency room.

Pain: Almost all children who have a tonsillectomy/adenoidectomy will have mild to severe throat pain after surgery. Some may complain of ear pain (called referred pain) and some may have pain in the jaw and neck.

Pain control: your doctor will prescribe pain medication based on your age, medical history and pain management requirements.

It may come as a surprise to you the variety of medical conditions that can lead to voice problems. The most common causes of hoarseness and vocal difficulties are described below. If you become hoarse frequently or your voice changes without warning and for a prolonged period of time, please consult your otolaryngologist (ear, nose and throat) for an evaluation.

Acute laryngitis

Acute laryngitis is the most common cause of loss of hoarseness and voice that starts suddenly. Most cases of acute laryngitis are caused by a viral infection that results in inflammation of the vocal cords. When the vocal cords become inflamed, they vibrate differently, leading to hoarseness. The best treatment for this condition is to stay well hydrated and to rest or reduce the use of the voice. Severe injury to the vocal cords can result from vigorous voice use during an episode of acute laryngitis. As most acute laryngitis is caused by a virus, antibiotics are not effective. Bacterial infections of the larynx are much less common and are often associated with difficulty breathing. Breathing problems during an emergency evaluation warrant illness.

Chronic laryngitis

Chronic laryngitis is a non-specific term and an underlying cause must be identified. Chronic laryngitis can be caused by acid reflux disease, by exposure to irritants such as smoke, and by low-grade infections such as fungal infections of the vocal cords in people who use asthma inhalers. Chemotherapy patients or other people whose immune system is not working well may get these infections as well.

Laryngopharyngeal Reflux Disease (LPRD)

Reflux of gastric juices into the throat can cause a variety of symptoms in the oesophagus (swallowing tube) as well as in the throat. Hoarseness (chronic or intermittent), trouble swallowing, a lump in the throat sensation or sore throat are common symptoms of stomach acid irritation of the throat. Please note that LPRD can occur without any symptoms of the heartburn and frank regurgitation that traditionally accompany gastro-oesophageal reflux disease (GORD).

Voice misuse and abuse

Speaking is a physical task that requires the coordination of breathing with the use of various muscle groups. It should come as no surprise that, as in any physical task, there are efficient and inefficient ways of using your voice. Excessively loud, prolonged, and/or inefficient voice use can lead to vocal difficulties, just as improper lifting can lead to back injuries. Excessive tensionin of the neck and laryngeal muscles, coupled with poor breathing technique during speech leads to vocal fatigue, increased vocal strain and hoarseness. Voice misuse and overuse puts you at risk of developing benign vocal cord injuries (see below) or vocal cord haemorrhage.

Common situations that are associated with the misuse of voice:

• Talking in noisy situations
• Excessive use of mobile phones
• Using the phone with the handset cradled on the shoulder
• Inappropriate use of pitch (too high or too low) when speaking
• Do not use amplification when speaking publicly

Benign lesions of the vocal cords

Benign non-cancerous tumours on the vocal cords are most often caused by misuse or overuse of the voice, which causes trauma to the vocal cords. These lesions (or ‘bumps’) on the vocal cord(s) then vibrate the vocal cords and produce hoarseness. The most common vocal cord lesions are nodules, polyps and cysts. Vocal nodules (also known as nodes or singing nodes) are similar to ‘calluses’ on the vocal cords. They occur on both vocal cords facing each other at the point of maximum wear and tear, and are usually treated with voice therapy to eliminate the vocal trauma they are causing. Contrary to common belief, vocal nodules are very well treatable and intervention leads to improvement in most cases. Vocal cord polyps and cysts are the other common benign lesions. These are sometimes related to misuse or overuse of the voice, but can also occur in people who do not use their voice correctly. These types of problems usually require microsurgical treatment for healing, with voice therapy employed in a combined treatment approach in some cases.

Vocal cord haemorrhage

If you experience sudden loss of voice following shouting, yelling, or other intense vocal tasks, you may have developed a vocal cord hemorrhage. vocal cord hemorrhage occurs when one of the blood vessels on the surface of the vocal cord ruptures and the soft tissues of the vocal cord fill with blood. It is considered a vocal emergency and is treated with complete voice rest until the haemorrhage resolves. If you lose your voice after vigorous voice use, consult your otolaryngologist as soon as possible.

Vocal cord paralysis and paresis

Hoarseness and other problems can occur related to problems between the nerves and muscles within the voice box or larynx. The most common neurological condition affecting the larynx is a paralysis or weakness of one or both vocal cords. Involvement of both vocal cords is rareand is usually manifested by noisy breathing or difficulty getting enough air when breathing or speaking. When one vocal cord is paralysed or weak, the voice is usually the problem rather than breathing. A vocal cord may be paralysed or weakened (paresis) from a viral infection of the throat, after surgery on the neck or chest, from a tumour or growth along the laryngeal nerves, or for unknown reasons. Vocal cord paralysis usually presents with a soft, breathy voice. Many cases of vocal cord paralysis recover within several months. In some cases, however, the paralysis will be permanent, and may require active treatment to improve the voice. The choice of treatment depends on the nature of the vocal cord paralysis, the degree of vocal impairment, and the vocal needs of the patient. While they are not able to make paralysed vocal cords move again, there are good treatment options to improve the voice. One option includes unilateral vocal cord paralysis surgery that repositions the vocal cords to improve the contact and vibration of the paralysed vocal cord and the non-paralysed vocal cord. There are a variety of surgical techniques used to achieve this. Voice therapy can be used before or after surgical treatment of paralysed vocal cords, or it can also be used as the sole treatment. (For more information, see the Vocal cord paralysis sheet).

Laryngeal Cancer

Throat cancer is a very serious condition that requires immediate medical attention. Chronic hoarseness warrants evaluation by an otolaryngologist to rule out laryngeal cancer. It is important to remember that immediate attention to changes in the voice facilitate early diagnosis. Remember to listen to your voice as it could be saying something. Laryngeal cancer is highly curable if diagnosed in its early stages (For more information, see the Laryngeal Cancer Fact Sheet).

Who is in a kindergarten?

The 2000 census reported that of the nation's 19.6 million preschool children, grandparents cared for 21 percent; 17 percent were cared for by their father (while their mother was employed or in school); 12 percent were in day care; nine percent were cared for by other relatives; seven percent were cared for by a family day care provider in their home; and six percent received care in day care centres or preschools. More than one-third of preschool children (7.2 million) had no regular childcare provision and were presumably in maternal care.

Day care centres are defined as those that are primarily engaged in caring for infants or children, or in providing pre-kindergarten education, where medical and/or behavioural correction care are not a primary function or main element. Some may or may not have significant educational programmes, and some may care for older children when they are not in school.

What are your child's risks of being exposed to a communicable disease in a day care centre?

Medline, a service of the National Library of Medicine and the National Institutes of Health, reports that day care centres present some degree of increased health risk to children, due to exposure to other children who may be ill.

When your child is in day care, the risk is higher for viral upper respiratory tract infection (affecting the nose, throat, mouth, larynx) and the common cold, ear infections and diarrhoea. Some studies have tried to link asthma to day care. Other studies suggest that exposure to germs at daycare actually improves your child's immune system.

Studies suggest that the average child will have between eight and ten colds a year, lasting ten - 14 days each, and occurring mainly in the winter months. This means that if a child has two colds from March to September, and eight colds from September to March, lasting two weeks, the child will be sick more than half the winter.

At the same time, children in a day care centre, exposed to the exchange of upper respiratory tract viruses every day, are expected to have three to ten episodes of otitis media per year. This is four times the incidence of children who stay at home.

When does your child have to stay at home instead of at day care or school?

Simply put, children become sick after being exposed to other sick children. Some guidelines to follow are as follows:

• When your child has a temperature above 100 degrees, keep him/her at home. Fever is a sign of potentially contagious infection, even if the child feels fine. Schools usually advise to keep the child at home until a period of fever has existed for 24 hours.

   

• When other children in the nursery have a known contagious infection, such as chicken pox, throat infections or conjunctivitis, keep your child at home.
• Children taking antibiotics should be kept at home until they have taken the medicine for one or two days.
• If your child is vomiting or has diarrhoea, the young patient should not be with other children. Other signs of illness are inability to swallow fluids, weakness or lethargy, sunken eyes, a soft depressed spot on the top of the baby's head, crying without tears, and dry mouth.

Can you prevent your child from getting sick in a day care centre?

The short answer is no. Exposure to other sick children will increase the likelihood that your child can catch the same illness, particularly with the common cold. The main rule is to keep your children at home if they are sick. However, you can:

• Teach your child to wash their hands before eating and after using the toilet. Infection is spread more by children carrying dirty toys and hands in their mouths, so check your child's daily hygiene care practices for cleanliness.
• Have your child examined by a doctor prior to enrolment in a day-care centre or school:
  • Look for otitis (inflammation) in the ear. This is an indicator of ear infections in the future.
  • Review with you any allergies your child may have. This will help determine if the diet offered at the day care centre may be harmful to your child.
  • Examine the child's tonsils for infection and size. Enlarged tonsils could indicate that your child cannot get a restful night's sleep, resulting in a tired condition during the day.
• Alert the day care centre manager when your child is ill, and include the nature of the illness.

Childcare has become a necessity for millions of families. Monitoring your own child's health is key to preventing unnecessary illness. If a serious illness occurs, do not hesitate to have your child examined by a doctor.

Could his medication be affecting his voice?

Some medications such as prescription, over-the-counter, and herbal supplements can affect the functioning of your voice. If your doctor prescribes a medication that negatively affects your voice, make sure that the benefit of taking the medication outweighs the problems with your voice.

Most medications affect the voice by drying out the protective mucus layer that covers the vocal cords. The vocal cords must be well lubricated to function properly; if the mucosa dries out, speech will be more difficult. This is why hydration is an important component of vocal health.

Medications can also affect the voice by thinning blood in the body, which makes bruising or hemorrhaging of the vocal cord more likely if trauma occurs, and by causing fluid retention (edema), which enlarges the vocal cords. Medications from the following groups can adversely affect the voice:

• Antidepressants
• Muscle relaxants
• Diuretics
• Antihypertensives (blood pressure medication)
• Antihistamines (allergy medications)
• Anticholinergics (asthma medications)
• High-dose Vitamin C (greater than five grams per day)
• Other medications and associated conditions that may affect the voice include:
• Angiotensin-converting-enzyme (ACE) inhibitors (blood pressure medication) may induce a cough or excessive throat clearing in as many as 10 percent of patients. Coughing or excessive throat clearing can contribute to vocal cord lesions.
• Oral contraceptives may cause fluid retention (edema) in the vocal cords because they contain estrogen.
• Estrogen replacement therapy post-menopause may have a variable effect.
• An inadequate level of thyroid replacement medication in patients with hypothyroidism.
• Anticoagulants (blood thinners) may increase chances of vocal cord hemorrhage or polyp formation in response to trauma.
• Herbal medications are not harmless and should be taken with caution. Many have unknown side effects that include voice disturbance.

NOTE: Contents of this fact sheet are based on information provided by The Center for Voice at Northwestern University.

What is GERD?

Gastroesophageal reflux disease, or GERD, occurs when acid from the stomach backs up into the esophagus. Normally, food travels from the mouth, down through the esophagus and into the stomach. A ring of muscle at the bottom of the esophagus, the lower esophageal sphincter (LES), contracts to keep the acidic contents of the stomach from "refluxing" or coming back up into the esophagus. In those who have GERD, the LES does not close properly, allowing acid to move up the esophagus.

When stomach acid touches the sensitive tissue lining the esophagus, it causes a reaction similar to squirting lemon juice in your eye. This is why GERD is often characterized by the burning sensation known as heartburn.

Occasional heartburn is normal. However, if heartburn becomes chronic, occurring more than twice a week, you may have GERD. Left untreated, GERD can lead to more serious health problems.

Who gets GERD?

Anyone can have GERD. Women, men, infants and children can all experience this disorder. Overweight people and pregnant women are particularly susceptible because of the pressure on their stomachs. Recent studies indicate that GERD may often be overlooked in infants and children. In infants and children, GERD can cause repeated vomiting, coughing, and other respiratory problems such as sore throat and ear infections. Most infants grow out of GERD by the time they are one year old.

Tips to Prevent GERD

• Do not drink alcohol
• Lose weight
• Quit smoking
• Limit problem foods such as:
• • Caffeine
  • Carbonated drinks
  • Chocolate
  • Peppermint
  • Tomato and citrus foods
  • Fatty and fried foods
  Wear loose clothing
• Eat small meals and slowly

What are the symptoms of GERD?

The symptoms of GERD may include persistent heartburn, acid regurgitation, and nausea. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be sever enough to mimic the pain of a heart attack, hoarseness in the morning, or trouble swallowing. Some people may also feel like they have food stuck in their throat or like they are choking. GERD can also cause a dry cough and bad breath.

What are the complications of GERD?

GERD can lead to other medical problems such as ulcers and strictures of the esophagus (esophagitis), cough, asthma, throat and laryngeal inflammation, inflammation and infection of the lungs, and collection of fluid in the sinuses and middle ear. GERD can also cause a change in the esophageal lining called Barrett's esophagus, which is a serious complication that can lead to cancer.

What causes GERD?

Physical causes of GERD can include: a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach.

Lifestyle factors that contribute to GERD include:

• alcohol use
• obesity
• pregnancy
• smoking
• Certain foods can contribute to GERD, such as:
• citrus fruits
• chocolate
• caffeinated drinks
• fatty and fried foods
• garlic and onions
• mint flavorings (especially peppermint)
• spicy foods
• tomato-based foods, like spaghetti sauce, chili, and pizza

When should I see a doctor?

If you experience heartburn more than twice a week, frequent chest pains after eating, trouble swallowing, persistent nausea, and cough or sore throat unrelated to illness, you may have GERD. For proper diagnosis and treatment, you should be evaluated by a physician.

How can my ENT help?

Otolaryngologists, or ear, nose, and throat doctors, and have extensive experience with the tools that diagnose GERD and they are specialists in the treatment of many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation, Barrett's esophagus, and ulcerations of the esophagus.

How is GERD diagnosed?

GERD can be diagnosed or evaluated by clinical observation and the patient's response to a trial of treatment with medication. In some cases other tests may be needed including: an endoscopic examination (a long tube with a camera inserted into the esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour esophageal acid testing, esophageal motility testing (manometry), emptying studies of the stomach, and esophageal acid perfusion (Bernstein test). Endoscopic examination, biopsy, and x-ray may be performed as an outpatient in a hospital setting. Light sedation may be used for endoscopic examinations.

While most people with GERD respond to a combination of lifestyle changes and medication. Occasionally, surgery is recommended.

Lifestyle changes include: losing weight, quitting smoking, wearing loose clothing around the waist, raising the head of your bed (so gravity can help keep stomach acid in the stomach), eating your last meal of the day three hours before bed, and limiting certain foods such as spicy and high fat foods, caffeine, alcohol,.

Medications your doctor may prescribe for GERD include: antacids (such as Tums, Rolaids, etc.), histamine antagonists (H2 blockers such as Tagamet,), proton pump inhibitors (such as Prilosec, Prevacid, Aciphex, Protonix, and Nexium), pro-motility drugs (Reglan), and foam barriers (Gaviscon). Some of these products are now available over-the-counter and do not require a prescription.

Surgical treatment includes: fundoplication, a procedure where a part of the stomach is wrapped around the lower esophagus to tighten the LES, and endoscopy, where hand stitches or a laser is used to make the LES tighter.

Are there long-term health problems associated with GERD?

GERD may damage the lining of the esophagus, thereby causing inflammation (esophagitis), although usually it does not. Barrett's esophagus is a pre-cancerous condition that requires periodic endoscopic surveillance for the development of cancer.

For more information on GERD or to find an otolaryngologist near you, visit www.entnet.org. www.entnet.org.

Your child has been diagnosed with allergic rhinitis, a physiological response to specific allergens such as pet dander or ragweed. The symptoms are fairly simple -- a runny nose (rhinitis), watery eyes, and some periodic sneezing. The best solution is to administer over-the-counter antihistamine, and the problem will resolve on its own ….right?

Not really – the interrelated structures of the ears, nose, and throat can cause certain medical problems which trigger additional disorders – all with the possibility of serious consequences.

Simple hay fever can lead to long term problems in swallowing, sleeping, hearing, and breathing. Let's see what else can happen to a child with a case of hay fever.

Ear infections:

One of children's most common medical problems is otitis media, or middle ear infection. These infections are especially common in early childhood. They are even more common when children suffer from allergic rhinitis (hay fever) as well. Allergic inflammation can cause swelling in the nose and around the opening of the Eustachian tube (ear canal). This swelling has the potential to interfere with drainage of the middle ear. When bacteria laden discharge clogs the tube, infection is more likely.

Sore throats:

The hay fever allergens may lead to the formation of too much mucus which can make the nose run or drip down the back of the throat, leading to "post-nasal drip." It can lead to cough, sore throats, and husky voice. Although more common in older people and in dry inland climates, thick, dry mucus can also irritate the throat and be hard to clear. Air conditioning, winter heating, and dehydration can aggravate the condition. Paradoxically, antihistamines will do so as well. Some newer antihistamines do not produce dryness.

Snoring:

Chronic nasal obstruction is a frequent symptom of seasonal allergic rhinitis (hay fever) and perennial (year-round) allergic rhinitis. This allergic condition may have a debilitating effect on the nasal turbinates, the small, shelf-like, bony structures covered by mucous membranes (mucosa). The turbinates protrude into the nasal airway and help to warm, humidify, and cleanse air before it reaches the lungs. When exposed to allergens, the mucosa can become inflamed. The blood vessels inside the membrane swell and expand, causing the turbinates to become enlarged and obstruct the flow of air through the nose. This inflammation, or rhinitis, can cause chronic nasal obstruction that affects individuals during the day and night.

Enlarged turbinates and nasal congestion can also contribute to headaches and sleep disorders such as snoring and obstructive sleep apnea, because the nasal airway is the normal breathing route during sleep. Once turbinate enlargement becomes chronic, it is irreversible except with surgical intervention.

Pediatric sinusitis:

Allergic rhinitis can cause enough inflammation to obstruct the openings to the sinuses. Consequently, a bacterial sinus infection occurs. The disease is similar for children and adults. Children may or may not complain of pain. However, in acute sinusitis, they will often have pain and typically have fever and a purulent nasal discharge. In chronic sinusitis, pain and fever are not evident. Some children may have mood or behavior changes. Most will have a purulent, runny nose and nasal congestion even to the point where they must mouth breathe. The infected sinus drains around the Eustachian tube, and therefore many of the children will also have a middle ear infection.

Seasonal allergic rhinitis may resolve after a short period. Administration of the proper over-the-counter antihistamines may alleviate the symptoms. However, if your child suffers from perennial (year round) allergic rhinitis, an examination by specialist will assist in preventing other ear, nose, and throat problems from occurring.

There are many different reasons why your voice may sound hoarse or abnormal from time to time, and some of these reasons are things that you can not really control. An example would be catching a common cold virus that causes laryngitis. Sure, you can wash your hands frequently and try to avoid people with colds, but virtually everyone catches a cold with a bit of laryngitis now and again. What you probably did not know is that there are steps you can take to prevent many voice problems. The following steps are helpful for anyone who wants to keep their voice healthy, but are particularly important for people who have an occupation, such as teaching, that is heavily voice-related.

Key Steps for Keeping Your Voice Healthy

• Drink plenty of water. Moisture is good for your voice. Hydration helps to keep thin secretions flowing to lubricate your vocal cords. Drink plenty (up to eight 8-ounce glasses is a good minimum target) of non-caffeinated, non-alcoholic beverages throughout the day.
• Try not to scream or yell. These are abusive practices for your voice, and put great strain on the lining of your vocal cords.
• Warm up your voice before heavy use. Most people know that singers warm up their voices before a performance, yet many don't realize the need to warm up the speaking voice before heavy use, such as teaching a class, preaching, or giving a speech. Warm-ups can be simple, such as gently gliding from low to high tones on different vowel sounds, doing lip trills (like the motorboat sound that kids make), or tongue trills.
• Don't smoke. In addition to being a potent risk factor for laryngeal (voice box) cancer, smoking also causes inflammation and polyps of the vocal cords that can make the voice very husky, hoarse, and weak.
• Use good breath support. Breath flow is the power for voice. Take time to fill your lungs before starting to talk, and don't wait until you are almost out of air before taking another breath to power your voice.
• Use a microphone. When giving a speech or presentation, consider using a microphone to lessen the strain on your voice.
• Listen to your voice. When your voice is complaining to you, listen to it. Know that you need to modify and decrease your voice use if you become hoarse in order to allow your vocal cords to recover. Pushing your voice when it's already hoarse can lead to significant problems. If your voice is hoarse frequently, or for an extended period of time, you should be evaluated by an Otolaryngologist (Ear, Nose, and Throat physician.)

Laryngeal cancer is not as well known by the general public as some other types of cancer, yet it is not a rare disease. The American Cancer Society estimates that in 2005 almost 10,000 new cases of laryngeal cancer will be diagnosed, and close to 3,800 people will die from laryngeal cancer in the United States. Even for survivors, the consequences of laryngeal cancer can be severe with respect to voice, breathing, or swallowing. It is fundamentally a preventable disease though, since the primary risk factors for laryngeal cancer are associated with modifiable behaviors.

Risk Factors Associated With Laryngeal Cancer

Development of laryngeal cancer is a process that involves many factors, but approximately 90 percent of head and neck cancers occur after exposure to known carcinogens (cancer causing substances). Chief among these factors is tobacco. Over 90 percent of laryngeal cancers are a type of cancer called squamous cell carcinoma (SCCA), and over 95 percent of patients with laryngeal SCCA are smokers. Smoking contributes to cancer development by causing mutations or changes in genes, impairing clearance of carcinogens from the respiratory tract, and decreasing the body's immune response.

Tobacco use is measured in pack-years, where one pack per day for one year is considered one pack-year. Two pack-years is defined as either one pack per day for two years, or two packs per day for one year (Longer terms of pack years are determined using a similar ratio.) Depending upon the number of pack-years smoked, studies have reported that smokers are about 5 to 35 times more likely to develop laryngeal cancer than non-smokers. It does seem that the duration of tobacco exposure is probably more important overall to cancer causing effect, than the intensity of the exposure.

Alcohol is another important risk factor for laryngeal cancer, and acts as a promoter of the cancer causing process. The major clinical significance of alcohol is that it potentiates the effects of tobacco. Magnitude of this effect is between an additive and a multiplicative one. That is, people who smoke and drink alcohol have a combined risk that is greater than the sum of the individual risks. The American Cancer Society recommends that those who drink alcoholic beverages should limit the amount of alcohol they consume, with one drink per day considered a limited alcohol exposure.

Other risk factors for laryngeal cancer include certain viruses, such as human papilloma virus (HPV), and likely acid reflux. Vitamin A and beta-carotene may play a protective role.

Signs and Symptoms of Laryngeal Cancer

Signs and symptoms of laryngeal cancer include: progressive or persistent hoarseness, difficulty swallowing, persistent sore throat or pain with swallowing, difficulty breathing, pain in the ear, or a lump in the neck. Anyone with these signs or symptoms should be evaluated by an Otolaryngologist (Ear, Nose and Throat Doctor). This is particularly important for people with risk factors for laryngeal cancer.

Treatment of Laryngeal Cancer

The primary treatment options for laryngeal cancer include surgery, radiation therapy, chemotherapy, or a combination of these treatments. Remember that this is a preventable disease in the vast majority of cases, because the main risk factors are associated with modifiable behaviors. Do not smoke and do not abuse alcohol!

What is laryngopharyngeal reflux (LPR)?

Food or liquids that are swallowed travel through the esophagus and into the stomach where acids help digestion. Each end of the esophagus has a sphincter, a ring of muscle, that helps keep the acidic contents of the stomach in the stomach or out of the throat. When these rings of muscle do not work properly, you may get heartburn or gastroesophageal reflux (GER). Chronic GER is often diagnosed as gastroesophageal reflux disease or GERD. en el estómago o de la garganta. Cuando estos anillos de los músculos no funcionan correctamente, puede obtener la acidez o reflujo gastroesofágico (RGE). GER crónica se diagnostica a menudo como el reflujo gastroesofágicoenfermedad o GERD.

Sometimes, acidic stomach contents will reflux all the way up to the esophagus, past the ring of muscle at the top (upper esophageal sphincter or UES), and into the throat. When this happens, acidic material contacts the sensitive tissue at back of the throat and even the back of the nasal airway. This is known as laryngopharyngeal reflux or LPR.

During the first year, infants frequently spit up. This is essentially LPR because the stomach contents are refluxing into the back of the throat. However, in most infants, it is a normal occurrence caused by the immaturity of both the upper and lower esophageal sphincters, the shorter distance from the stomach to the throat, and the greater amount of time infants spend in the horizontal position. Only infants who have associated airway (breathing) or feeding problems require evaluation by a specialist. This is most critical when breathing-related symptoms are present.

What are symptoms of LPR?

There are various symptoms of LPR. Adults may be able to identify LPR as a bitter taste in the back of the throat, more commonly in the morning upon awakening, and the sensation of a "lump" or something "stuck" in the throat, which does not go away despite multiple swallowing attempts to clear the "lump." Some adults may also experience a burning sensation in the throat. A more uncommon symptom is difficulty breathing, which occurs because the acidic, refluxed material comes in contact with the voice box (larynx) and causes the vocal cords to close to prevent aspiration of the material into the windpipe (trachea). This event is known as "laryngospasm."

Infants and children are unable to describe sensations like adults can. Therefore, LPR is only successfully diagnosed if parents are suspicious and the child undergoes a full evaluation by a specialist such as an otolaryngologist. Airway or breathing-related problems are the most commonly seen symptoms of LPR in infants and children and can be serious. If your infant or child experiences any of the following symptoms, timely evaluation is critical.

• Chronic cough
• Hoarseness
• Noisy breathing (stridor)
• Croup
• Reactive airway disease (asthma)
• Sleep disordered breathing (SDB)
• Frank spit up
• Feeding difficulty
• Turning blue (cyanosis)
• Aspiration
• Pauses in breathing (apnea)
• Apparent life threatening event (ALTE)
• Failure to thrive (a severe deficiency in growth such that an infant or child is less than five percentile compared to the expected norm)

What are the complications of LPR?

In infants and children, chronic exposure of the laryngeal structures to acidic contents may cause long term airway problems such as a narrowing of the area below the vocal cords (subglottic stenosis), hoarseness, and possibly eustachian tube dysfunction causing recurrent ear infections, or persistent middle ear fluid, and even symptoms of "sinusitis." The direct relationship between LPR and the latter mentioned problems are currently under research investigation.

How is LPR diagnosed?

Currently, there is no good standardized test to identify LPR. If parents notice any symptoms of LPR in their child, they may wish to discuss with their pediatrician a referral to see an otolaryngologist for evaluation. An otolaryngologist may perform a flexible fiberoptic nasopharyngoscopy/laryngoscopy, which involves sliding a 2 mm scope through the infant or child's nostril, to look directly at the voice box and related structures or a 24 hour pH monitoring of the esophagus. He or she may also decide to perform further evaluation of the child under general anesthesia. This would include looking directly at the voice box and related structures (direct laryngoscopy), a full endoscopic look at the trachea and bronchi (bronchoscopy), and an endoscopic look at the esophagus (esophagoscopy) with a possible biopsy of the esophagus to determine if esophagitis is present. LPR in infants and children remains a diagnosis of clinical judgment based on history given by the parents, the physical exam, and endoscopic evaluations.

How is LPR treated?

Since LPR is an extension of GER, successful treatment of LPR is based on successful treatment of GER. In infants and children, basic recommendations may include smaller and more frequent feedings and keeping an infant in a vertical position after feeding for at least 30 minutes. A trial of medications including H2 blockers or proton pump inhibitors may be necessary. Similar to adults, those who fail medical treatment, or have diagnostic evaluations demonstrating anatomical abnormalities may require surgical intervention such as a fundoplication.

The term vocal cord lesion (physicians call them vocal "fold" lesions) refers to a group of noncancerous (benign), abnormal growths (lesions) within or along the covering of the vocal cord. Vocal cord lesions are one of the most common causes of voice problems and are generally seen in three forms; nodules, polyps, and cysts.

Vocal Cord Nodules (also called Singer's Nodes, Screamer's Nodes)

Vocal cord nodules are also known as "calluses of the vocal fold." They appear on both sides of the vocal cords, typically at the midpoint, and directly face each other. Like other calluses, these lesions often diminish or disappear when overuse of the area is stopped.

Vocal Cord Polyp

A vocal cord polyp typically occurs only on one side of the vocal cord and can occur in a variety of shapes and sizes. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances.

Vocal Cord Cyst

A vocal cord cyst is a firm mass of tissue contained within a membrane (sac). The cyst can be located near the surface of the vocal cord or deeper, near the ligament of the vocal cord. As with vocal cord polyps and nodules, the size and location of vocal cord cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem. Surgery followed by voice therapy is the most commonly recommended treatment for vocal cord cysts that significantly alter and/or limit voice.

Reactive Vocal Cord Lesion

A reactive vocal cord lesion is a mass located opposite an existing vocal cord lesion, such as a vocal cord cyst or polyp. This type of lesion is thought to develop from trauma or repeated injury caused by the lesion on the opposite vocal cord. A reactive vocal cord lesion will usually decrease or disappear with voice rest and therapy.

What Are The Causes Of Benign Vocal Cord Lesions?

The exact cause or causes of benign vocal cord lesions is not known. Lesions are thought to arise following "heavy" or traumatic use of the voice, including voice misuse such as speaking in an improper pitch, speaking excessively, screaming or yelling, or using the voice excessively while sick.

What Are The Symptoms Of Benign Vocal Cord Lesions?

A change in voice quality and persistent hoarseness are often the first warning signs of a vocal cord lesion. Other symptoms can include:

• Vocal fatigue
• Unreliable voice
• Delayed voice initiation
• Low, gravelly voice
• Low pitch
• Voice breaks in first passages of sentences
• Airy or breathy voice
• Inability to sing in high, soft voice
• Increased effort to speak or sing
• Hoarse and rough voice quality
• Frequent throat clearing
• Extra force needed for voice
• Voice "hard to find"

When a vocal cord lesion is present, symptoms may increase or decrease in degree, but will persist and do not go away on their own.

How Is The Diagnosis Of A Benign Vocal Cord Lesion Made?

Diagnosis begins with a complete history of the voice problem and an evaluation of speaking method. The otolaryngologist will perform a careful examination of the vocal cords, typically using rigid laryngoscopy with a stroboscopic light source. In this procedure, a telescope-tube is passed through the patient's mouth that allows the examiner to view the voice box (images are often recorded on video). The stroboscopic light source allows the examiner to assess vocal fold vibration. Sometimes a second exam will follow a trial of voice rest to allow the otolaryngologist an opportunity to assess changes in the vocal cord lesion. Other associated medical problems can contribute to voice problems, such as: reflux, allergies, medication's side effects, and hormonal imbalances. An evaluation of these conditions is an important diagnostic factor.

How Are Benign Vocal Cord Lesions Treated?

The most common treatment options for benign vocal cord lesions include: voice rest, voice therapy, singing voice therapy, and phonomicrosurgery, a type of surgery involving the use of microsurgical techniques and instruments to treat abnormalities on the vocal cord.

Treatment options can vary according to the degree of voice limitation and the exact voice demands of the patient. For example, if a professional singer develops benign vocal cord lesions and undergoes voice therapy, which improves speaking but not singing voice, then surgery might be considered to restore singing voice. Successful and appropriate treatment is highly individual and includes consideration of the patient's vocal needs and the clinical judgment of the otolaryngologist.

Everyone has gastroesophageal reflux (GER), the backward movement (reflux) of gastric contents into the esophagus. Extraesophageal Reflux (EER) is the reflux of gastric contents from the stomach into the esophagus with further extension into the throat and other upper aerodigestive regions. In infants, more than 50 percent of children three months or younger have at least one episode of regurgitation a day. This rate peaks at 67 percent at age four months. But an infant's improved neuromuscular control and the ability to sit up will lead to a spontaneous resolution of significant GER in more than half of infants by age ten months and four out of five at age 18 months.

Researchers have found that 10 percent of infants (younger than 12 months) with GER develop significant complications. The diseases associated with reflux are known collectively as Gastro-Esophageal Reflux Disease (GERD). Physically, GERD occurs when a muscular valve at the lower end of the esophagus malfunctions. Normally, this muscle closes to keep acid in the stomach and out of the esophagus. The continuous entry of acid or refluxed materials into areas outside the stomach can result in significant injury to those areas. It is estimated that some five to eight percent of adolescent children have GERD.

What symptoms are displayed by a child with GERD?

GER and EER in children often cause relatively few symptoms until a problem exists (GERD). The most common initial symptom of GERD is heartburn. Heartburn is more common in adults, whereas children have a harder time describing this sensation. They usually will complain of a stomach ache or chest discomfort, particularly after meals. el ardor de estómago. ardor de estómago es más común en adultos, mientras que los niños tienen más dificultades para describir esta sensación. Por lo general, se quejan de un dolor de estómago o malestar en el pecho, especialmente después de las comidas.

More frequent or severe GER and EER can cause other problems in the stomach, esophagus, pharynx, larynx, lungs, sinuses, ears and even the teeth. Consequently, other typical symptoms could include crying/irritability, poor appetite/feeding and swallowing difficulties, failure to thrive/weight loss, regurgitation ("wet burps" or outright vomiting), stomach aches (dyspepsia), abdominal/chest pain (heartburn), sore throat, hoarseness, apnea, laryngeal and tracheal stenoses, asthma/wheezing, chronic sinusitis, ear infections/fluid, and dental caries. Effortless regurgitation is very suggestive of GER. However recurrent vomiting (which is not the same) does not necessarily mean a child has GER.

Unlike infants, the adolescent child will not necessarily resolve GERD on his or her own. Accordingly, if your child displays the typical symptoms of GERD, a visit to a pediatrician is warranted. However, in some circumstances, the disorder may cause significant ear, nose, and throat disorders. When this occurs, an evaluation by an otolaryngologist is recommended.

How is GERD diagnosed?

Most of the time, the physician can make a diagnosis by interviewing the caregiver and examining the child. There are occasions when testing is recommended. The tests that are most commonly used to diagnose gastroesophageal reflux include:

• pH probe: A small wire with an acid sensor is placed through the nose down to the bottom of the esophagus. The sensor can detect when acid from the stomach is "refluxed" into the esophagus. This information is generally recorded on a computer. Usually, the sensor is left in place between 12 and 24 hours. At the conclusion of the test, the results will indicate how often the child "refluxes" acid into his or her esophagus and whether he or she has any symptoms when that occurs.
• Barium swallow or upper GI series:: The child is fed barium, a white, chalky, liquid. A video x-ray machine follows the barium through the upper intestinal tract and lets doctors see if there are any abnormal twists, kinks or narrowings of the upper intestinal tract.
• Technetium gastric emptying study: The child is fed milk mixed with technetium, a very weakly radioactive chemical, and then the technetium is followed through the intestinal tract using a special camera. This test is helpful in determining whether some of the milk/technetium ends up in the lungs (aspiration). It may also be helpful in determining how long milk sits in the stomach.: El niño es alimentado con leche mezclada con tecnecio, un producto químico muy débilmente radiactivo, el tecnecio y luego es seguido por el tracto intestinal con una cámara especial. Esta prueba es útil para determinar si parte de la leche / tecnecio termina en los pulmones