Voice & Swallowing


Man Experiencing Pain While SwallowingAt Northwest ENT and Allergy Center, we provide complete, leading-edge medical care for vocal-function and swallowing disorders. We are one of a few medical practices in the metro Atlanta area that provide comprehensive care for voice and swallowing disorders. Complete Diagnosis, Treatment & Therapy for:

  • Hoarseness & laryngitis
  • Effortful or painful speech
  • Vocal fatigue
  • Inability to project
  • Frequent throat clearing
  • Persistent voice changes, instability or cracking
  • Strained or strangled voice
  • Breathy or soundless voice
  • Low, raspy or rough voice
  • Wobbly, shaky or irregular voice
  • Double or “gargle” voice
  • Age-related vocal changes
  • Persistent choking or coughing
  • Neurological voice disorders
  • Polyps, cysts, nodules & lesions
  • Vocal-fold impairment, paresis & paralysis
  • Laryngeal cancer
  • Laryngopharyngeal reflux
  • Swallowing difficulty
  • Intubation trauma

Transnasal Esophagoscopy

Transnasal Esophagoscopy (TNE) represents the latest advancement in diagnosis of esophageal-related diseases. With the miniaturization of high resolution cameras, it is now possible to create ultra thin endoscopes that are capable of reaching the stomach. Because of the small size of these endoscopes, they can now be passed through the nose with ease. This means that patients no longer need sedation for routine esophagoscopy.

In the past, when a patient complained of difficulty swallowing or had complaints of chronic heartburn, they would be sent for either a barium swallow study or a traditional flexible esophagoscopy. Barium swallow studies are often unreliable. These studies can miss changes in the lining of the esophagus, which may represent small cancers or pre cancerous lesions. Traditional esophagoscopy requires the use of sedation, which carries certain risks. In addition, patients often have to spend hours preparing and recovering from the procedure. This necessitates taking time off of work or school (for both the patient and often another family member).

With the advent of TNE, patients can have the esophagoscopy right in the office setting without any additional medication. The entire procedure takes less than 10 minutes, and the patient can return to work or school the same day. This saves a lot of time and energy.

At Northwest ENT and Allergy Center, we utilize the latest TNE technology with distal chip video recording. The staff has extensive experience with this procedure, and we provide a comfortable and safe environment in which the procedure is performed.

Videostroboscopy

Videostroboscopy is a specialized method of illuminating the vocal cords that is synchronized with vocal cord vibration to provide what appears to be a slow-motion view of vocal cord movement and vibration. Good results require a stable vocal cord vibratory pattern (saying “EEEE…”) and a source to synchronize the stroboscopic light source, a microphone applied to the neck. This procedure is best done in conjunction with video recording videolaryngostroboscopy (LVS) for detailed review following examination and the ability to compare examinations. The features most helpful in the diagnostic process include the vocal fold closure pattern, vocal fold vibratory pattern, and the mucosal wave of each vocal fold during phonation. The stroboscopic flash can be synchronous or asynchronous with the frequency of vibration. A synchronous pattern will give the appearance of a motionless cord. When the flash is slightly asynchronous, if gives the impression of slow motion. Please click on the video below to see an example.

Endoscopic Laryngeal Video Strobocopic Exam

Chronic Cough

Chronic cough is a cough that does not resolve after correction or resolution of the primary illness. CHRONIC COUGH IS NOT A DISEASE IN ITSELF. IT IS A SYMPTOM OF ANOTHER ONGOING DISORDER. Direct visualization of the vocal cords and voice box are imperative for diagnosis.

Common Causes:

  • LPR/GERD (esophageal reflux of stomach contents into the voice box or throat)
  • Allergy, allergic rhinitis,sinusitis
  • Tumors
  • Smoking
  • Asthma
  • Pneuomonia/bronchitis
  • Aspiration of foreign objects into the lungs in children
  • Medications

Laryngopharyngeal reflux (LPR) or gastroesophageal reflux disease (GERD) refers to backward flow of stomach acid and other stomach contents into the esophagus, larynx, and pharynx. If acid moves into the throat, this can result in chronic irritation or spasm of the airways, which can cause shortness of breath and coughing. In many individuals, no sensation of heartburn is felt and their only symptom may be cough.

Allergy, sinus problems, and postnasal drip can also cause chronic cough, which can be difficult to detect. Sometimes CT scan of the sinuses or allergy testing is necessary for diagnosis.

Asthma is a disease of the lungs and trachea, resulting in difficulty breathing or wheezing. Often patients will have abnormal breathing tests. However, some asthma sufferers have chronic cough as their only symptom with normal lung functions tests, and this is termed cough-variant asthma. Asthma symptoms can be aggravated by cold air, exposure to air pollutants or pollen, smoke, or perfumes.

Infections, caused by virus, bacteria or fungus, such as bronchitis or pneumonia can cause coughing. Remember, viral infections do not respond to antibiotics. Sometimes, viral upper respiratory infections often result in a protracted cough even after the infection has cleared, termed a post-viral cough.

Certain medications, notably ACE inhibitors [enalapril (Vasotec), captopril (Capoten) etc.] used in treating high blood pressure, can cause chronic cough.

Less common causes can also include tumors, either benign or malignant, sarcoidosis or other lung disease.

If chronic cough persists a patient should be evaluated by his or her doctor. It is important to exclude: tumor, allergy, LPR/GERD, asthma, postnasal drip, drug side effect, interstitial lung disease, or other unusual infections.

Flex Laryngoscopy

Flexible fiberoptic laryngoscopy is the most common type of examination used to visualize the areas of the throat and voice box. The exam utilizes a thin flexible endoscope containing fiberoptic cable that can be manipulated to examine areas not normally seen by traditional examination techniques. After a local anesthetic has been applied to the nasal cavity, the endoscope is inserted through the nose and passed into the throat under direct visualization. Most patients tolerate this examination without much difficulty.

This examination technique provides a view of the structures of the throat, including the back of the nose (nasopharynx), the back of the mouth (oropharynx), the voice box (larynx), and the entrance to the swallowing passages (hypopharynx). With the patient awake and relaxed, it is the best method for evaluating vocal cord motion. Because the tip can be directed, this endoscope allows examination of all areas of the throat. Flexible fiberoptic laryngoscopy can be combined with stroboscopy to further examine vocal cord vibratory capability.

Advances in technology have significantly improved the image quality available through flexible scopes. Cameras have been miniaturized to fit on the end on an endoscope, so that the camera can be place right up against the vocal cords to obtain a truly great image. With this cutting edge technology at Northwest ENT and Allergy Center, it has improved our ability to diagnose lesions and other abnormalities in the throat.

Hoarseness/Dysphonia

Dysphonia is any impairment in the vocal organ’s ability to produce voice sounds. Dysphonia can describe a voice that is hoarse or weak, or excessively breathy, harsh, or rough, but some kind of phonation is still possible. Aphonia occurs when phonation or voicing is impossible.

All dysphonia is caused by some kind of interruption of the ability of the vocal folds to vibrate normally during exhalation. During normal phonation, the vocal folds come together to vibrate in a simple, open/closed cycle, altering the airflow from the lungs. One can think of vocal cords as bow strings that vibrate with varying lengths and tensions to produce certain pitches and sounds. Louder sounds are produced by increasing the volume of air flow of the vocal cords themselves.

Weakness (paresis) or complete lack of movement (paralysis) of one vocal cord or one side of the larynx can prevent cyclic vibration and lead to irregular movement in one or both sides of the voice box. This irregular motion is heard as roughness.

Dysphonia has one of two causes: organic or functional. Organic dysphonia comes about due to an outside cause effecting the function of the larynx. Functional dysphonia occurs as the result of a behavior when voicing or when a compensatory behavior alters normal voice function.

Organic Dysphonia

  • Laryngitis
    • Acute: viral / bacterial
    • Chronic: smoking / GERD / LPR (Laryngopharyngeal Reflux)
  • Reactive Lesions
    • Vocal cord nodules
    • Vocal cord polyps
    • Vocal fold cysts
  • Reinke’s Edema (Mostly caused by smoking)
  • Neoplasm
    • Premalignant: dysplasia, Laryngeal papillomatosis
    • Malignant: Squamous cell carcinoma
  • Trauma
    • Surgery / intubation
    • Accidental: blunt / penetrating / thermal
  • RARE
    • Endocrine (Hypothyroidism / hypogonadism)
    • Hematological (Amyloidosis)
    • Inhaled corticosteroids in asthmatics/COPD
    • Sinusitis
    • Lung cancer
    • Parkinson’s disease

Functional Dysphonia

  • Psychogenic
  • Vocal abuse or misuse
  • Idiopathic

Dysphonia is measured using a variety of examination tools that allow the clinician to see the pattern of vibration of the vocal folds, principally laryngeal videostroboscopy. Flexible laryngoscopy is a tool sometimes used as the first step to rule out maliganancy or any mass effect on the vocal cords.

LPR

Laryngopharyngeal reflux or LPR is an extension of gastroesophageal reflux disease or GERD. There are two sphincter muscles located in the esophagus which close the food tube at its upper and lower portions. If both the upper and lower esophageal sphincters don’t function properly, acid that has back flowed into the esophagus penetrates the throat and voice box. This is called Laryngopharyngeal Reflux, or LPR. When the lower esophageal sphincter is not functioning properly, there is a back flow of stomach acid into the esophagus, called gastroesophageal reflux disease or GERD.

You can suffer from LPR without experiencing any heartburn or other GERD symptoms. In order for refluxed acid to cause heartburn, it has to stay in the esophagus long enough to cause irritation. Also, the esophagus is hearty and isn’t as sensitive to irritation as the throat is. Therefore, if stomach contents or acid pass quickly through the esophagus and subsequently pool in the throat, heartburn symptoms will not occur but LPR symptoms will.

Symptoms of Laryngopharyngeal Reflux:

  • Continual throat clearing
  • Chronic throat irritation or sore throat
  • Chronic cough
  • Hoarseness/Dysphonia
  • Dysphagia (difficulty swallowing)
  • Constant sensation of something in the throat, termed Globus sensation
  • Swallowed food comes back up
  • Post nasal drainage
  • Spasm of the larynx (voice box)
  • Difficulty breathing/Wheezing
  • Heartburn

Diagnosis:
The history of your symptoms and your physical exam may lead to other tests to be performed. First flexible laryngoscopy, which is a procedure used to see changes of the throat and voice box. If you are also having difficulty with your voice, videostroboscopy may be indicated. Flexible esophagoscopy or EGD is done if a patient complains of difficulty with swallowing. Your ENT surgeon can see if there are any scars or abnormal growths in the esophagus that need to be biopsied, or if there is any inflammation of the esophagus caused by refluxed acid. Rarely, 24-hour pH testing is used to see if too much stomach acid is moving into the upper esophagus or throat. Two pH sensors are used, one located at the bottom of the esophagus and one at the top, allowing acid movement to be tracked.

Treatment:
Treatment for LPR and GERD are the same.

  • Lifestyle changes, including not eating 3 hours before bedtime, elevating the head of bed, drinking more water.
  • Diet modifications, including avoiding caffeine, high fat foods, alcohol, milk products, and mint.
  • Medications to reduce stomach acid (Proton Pump Inhibitors, Histamine Receptor Antagonists, and over-the-counter remedies). Relatively high doses over an extended period of time (6 monthhs or greater) may be required to reverse the tissue injury to the larynx.
  • Surgery to prevent reflux. Surgery to tighten the junction between the stomach and esophagus, called the Nissen Fundoplication. It tightens the junction by wrapping the top part of the stomach around the junction between the stomach and esophagus and sewing it in place.

Vocal Cord Nodules

A vocal cord nodule, or singer’s nodule, is an abnormal mass of tissue that grows on the vocal cords typically at the junction of the anterior and middle two-thirds of the vocal fold, where contact is most forceful during singing, talking loudly, or yelling. Nodules are caused by strenuous or abusive voice practices such as yelling and coughing. The nodule reduces or obstructs the ability of the vocal cords to vibrate and produce a normal voice. Symptoms include hoarseness, painful speaking, voice breaks, and reduced vocal range for singers. On flexible laryngoscopy or video stroboscopy, nodules appear as symmetrical swellings on both sides of the vocal cords.

Nodules can be found in both children and adults, but most frequently adult females. Professions most at risk for developing vocal cord nodules include teachers, cheerleaders, politicians, actors, preachers, singers, and military drill instructors. Symptoms of vocal nodules include vocal fatigue and hoarseness or breathiness. Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an appointment with an otolaryngologist.

Although vocal cord nodules certainly alter a patient’s voice, they are not malignant and cause no overall negative health consequences. With vocal cord nodules, the most detrimental situations arise when professional success depends on consistently producing a rich and powerful vocal tone, for example: singers, actors, litigation lawyers, broadcasters.

Treatment

Treatment involves both voice rehabilitation and vocal hygiene. Vocal rehabilitation usually involves vocal training, speech therapy, and, occasionally, vocal rest. Vocal hygiene involves increased water intake, decreasing caffeine, avoidance of dehydration, and sometime anti-reflux medicine to produce the most stable and healing environment for the vocal cords.

In some cases, surgery may be required. Removal of vocal cord nodules is a relatively safe and minor surgery; however, surgery can alter the voice permanently. Under general anesthesia, long thin microscissors and microknives are used to remove the nodules. Post-operative voice rest is usually necessary.

Symptoms of vocal nodules include vocal fatigue and hoarseness or breathiness. Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an appointment with an otolaryngologist.

Vocal Cord Polyps

A vocal cord polyp is an abnormal mass of tissue emanating typically from one vocal cord, but it can be on both. They appear as a swelling or bump (like a nodule), a stalk-like growth, or a blister-like lesion. Most polyps are larger than nodules and usually appear asymmetrically. A nodule is also more of a firm nodularity at a specific location whereas a polyp is usually a less firm consistency and may occur anywhere along the length of the vocal cord. Vocal cord polyps may be called by other names, such as polypoid degeneration or Reinke’s edema. They are often caused by vocal abuse and smoking. Depending upon the nature of the polyp, it can cause a wide range of voice disturbances.

Vocal fold polyps have a broad spectrum of appearances, from hemorrhagic (blood filled) to edematous, pedunculated to sessile, and gelatinous to hyalinized. Much like vocal cord nodules, vocal fold polyps result from phonotrauma; however, they can arise from a single episode of vocal cord hemorrhage.

Polyps usually involve the edge of the vocal fold lining, although they may also be found along the upper or lower borders. Occasionally, a more diffuse pattern termed polypoid degeneration, or Reinke edema, is observed as well.
Polyps interrupt the vibration of the vocal fold by increasing the mass and reducing its ease of movement, as well as by not allowing proper closure of the cords throughout speaking.

In most cases, surgery is required. Removal of vocal cord polyps is a relatively safe and minor surgery; however, surgery can alter the voice permanently. Under general anesthesia, long thin microscissors and microknives are used to remove the polyps. Post-operative voice rest is usually necessary.

Symptoms of vocal nodules include vocal fatigue and hoarseness or breathiness. Hoarseness or breathiness that lasts for more than two weeks may signal a voice disorder and should be followed up with an appointment with an otolaryngologist

Zenker’s Diverticulum

A Zenkers diverticulum is a pouch that develops in the lower throat (hypopharynx) just above the upper esophageal sphincter (UES). Food may become trapped there, causing difficulties in swallowing, bad breath, regurgitation, chronic coughing and irritation. To repair a Zenker’s Diverticulum endoscopically, a special laryngoscope is inserted through the mouth and the pouch in the hypopharynx is identified. Once identified, a special stapler is used to cut the party wall between the pouch and esophagus, which then resolves the problem. The patient is kept overnight and sent home the next day on a liquid advancing to soft diet.

Video of a Zenker’s Diverticulum prior to Endoscopic Repair
Video of a Zenker’s Diverticulum after endoscopic stapler repair