How Common is Hoarseness?

At some point, we all have suffered from a hoarse voice whether from illness or from yelling. However, it was unclear exactly how common this malady is until now... and apparently, the answer is "very common"...

According to a study looking to answer this question, hoarseness affected 17.9 million adults in 2012.   The average age was 49 years old and 63% were women. Overall, 10% saw a health care professional for their hoarseness and 40% were given a diagnosis.

Infectious laryngitis was the most common diagnosis mentioned (685±86 thousand cases, 17.8±2.0%). Gastroesophageal reflux disease was mentioned in 308±54 thousand cases (8.0±1.4%).

33% reported their voice problem to be a significant problem. Bad enough that the mean number of days the hoarseness lasted was about 56 days. Because of the hoarseness, patients missed work about one week in the past year.

A general rule of thumb is to see your local ENT if the hoarseness lasts more than 1 week. Intervention can be performed to minimize the duration of hoarseness as well as to alleviate the morbidity associated with this problem.

Another general rule of thumb is to minimize using your voice if it becomes unexpectedly hoarse.

Reference:
The prevalence of voice problems among adults in the United States. Laryngoscope. 2014 Apr 29. doi: 10.1002/lary.24740.

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30% of Patients with Reflux will NOT Respond to Medications

Specifically, patients who are suffering with throat symptoms of reflux will often not respond to proton-pump inhibitor (PPI) medications. Such throat symptoms include throat-clearing, phlegmy throat, cough, hoarseness, and globus. Known as LPR (laryngopharyngeal reflux), a study was done measuring the pH at the throat level after 4+ weeks of twice daily PPI.

This retrospective study found that although 67.4% had symptom normalization, 32.6% of patients showed no subjective or objective treatment response. For all patients whose symptoms did not normalize, pH scores also did not normalize.  For individuals whose symptoms normalized but whose pH scores did not normalize, there was a significant decrease in upright pH score.

Based on these findings, one should NOT assume that lack of response to reflux medications indicative of reflux being an incorrect diagnosis. Further study with a pH or impedance monitoring should be performed in non-responders to help figure out what is going on.

Reference:
Effects of Proton Pump Inhibitor Therapy for Laryngopharyngeal Reflux on Posttreatment Symptoms and Hypopharyngeal pH. Otolaryngol Head Neck Surg. 2014 Mar 19. [Epub ahead of print]

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How to Describe Hoarseness?

At heart, physicians are science geeks. And when it comes to a raspy voice, one can go truly bananas in how exactly to describe how a raspy voice sounds.

For the layperson, when asked to describe a hoarse voice, one often gets imprecise answers to a question most feel ridiculous... I often get a blank look with an answer that goes something like "You know... raspy... it's not clear." Unfortunately, such a description is inadequate. Even when using more descriptors like deeper/higher than normal, onset delays, pitch breaks, breathy, click, tight, etc, more information is needed.

There are 2 fundamental ways to more precisely convey the characteristics of how a raspy voice sounds and to document change (better/worse) over time.

Method #1 - Perceptual Tests

Developed by Dr. Robert Bastian, I personal prefer this method as it is more intuitive and replicable by anybody including the patient.

1) Maximum Phonation Time (MPT) - How many seconds can a single note be sustained for with a single breath? This test provides a rough measure of lung capacity and how "breathy" a voice is. The more breathy a voice is, the lower the MPT.
2) Pitch Range - What is the lowest and highest note a person can say/sing (I use a piano keyboard). Provides information on how much vocal cord swelling and length is present (the more swollen the vocal cords are, the deeper the pitch just like a violin string). I also typically like the patient to glide up and down from their lowest and highest note as it provides some additional information on neurological/muscular control of their voice depending on how smoothly it is performed.
3) Swell Tests - Essentially, the test involves singing a song (I use Happy Birthday) very quietly an octave higher than your normal pitch. If onset delays or pitch breaks are heard, does suggest the presence of a small bump (nodule, cyst, polyp, etc) on the vocal cords.

One can also add documentation of yell, cough, throat-clearing, and speaking voice.

Method #2 - Objective Tests

This type of testing can only be performed with the help of instruments and provides "numbers" that can be documented. It is more difficult to "hear" the voice looking at just these numbers, but does provide a more rigorous way to actually "measure" the voice quality. There are now even iPhone apps that can obtain such data.

The basic measures include:
1) Shimmer - Measures how much variation in loudness is present. Think of a volume knob being turned up and down slightly. Normal is less than 3%.
2) Jitter - Measures how much variation in pitch is present. Think of going up and down on the equalizer slightly. Normal is less than 1%.
3) MPT is also measured.
4) Fundamental frequency (f0) - Measure of how high/low a person's voice sounds (pitch).

One can go crazy and also add intensity, glottal noise, ratio, tremor, spectrum, EGG-pitch, EGG-intensity, EGG-jitter, EGG-shimmer, EGG-noise, CQ, CQ perturbation, CI, CI perturbation, opening rate, etc.

Regardless of the method, with this type of information, the actual degree and characterization of the vocal quality can be measured, documented, and tracked over time. Also, when communicating with other health professionals, such measures provide for an efficient and understandable way to describe a patent's voice with a colleague.

Of course, from the patent's perspective, they "just want to sound better," but this is how professionals do it.

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New Video on Thyroid Surgery and Its Complications

A new video has been created regarding how the thyroid gland is removed along with potential complications that may occur with this surgical procedure.

This video creation was a collaborative effort between myself and Dr. Henson, the general surgeon who performed the actual operation portrayed in the video. Assistance by Robin Earl and the surgical staff at Fauquier Hospital were invaluable as well.

Read more about the surgery here or watch the video!

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Dr. Chang Quoted in the Wall Street Journal

The Wall Street Journal on 3/15/13 published a story on how voice therapy and vocal surgery can dramatically improve a person's vocal quality... seemingly taking years away from how you sound.

In this story, Dr. Chang was quoted a few times and even included a patient he has treated successfully with voice surgery to restore his voice.

In regards to how aging can create muscle atrophy and bowing resulting in:

"It creates a breathy, raspy voice," says Christopher Y. Chang, an otolaryngologist at Fauquier Ear, Nose & Throat Consultants in Warrenton, Va.

Later in the WSJ article, surgical intervention is discussed and introduced Mr. James Driver, a Warrenton, VA jewelry repair storeowner who Dr. Chang treated:

"In the procedure, called injection augmentation of the vocal folds, a doctor threads an endoscope through the patient's nose or mouth into the throat, then injects a tiny amount of collagen, fat, hyaluronic acid or a gel filler into the vocal cords to plump them up. The substances usually last three to six months. If the procedure works, a doctor may recommend inserting silicon or Gore-Tex implants to fatten the cords permanently.

In 2011, James Driver was felled by an episode of temporary paralysis that left one of his vocal cords frozen. The 57-year-old owner of a Virginia jewelry-repair business worked with a therapist and did throat exercises on his own, but he could only manage a whisper. "You had to be right next to him with your ear to his mouth" to hear him, says his wife, Erin.

The couple sought out Dr. Chang, who recommended an injection. The day after the procedure, Mr. Driver was speaking at near regular volume. A year later, he's still going strong, though he hears his own voice as being slightly raspier than it used to be. "It made a huge difference," Mrs. Driver says."

 Read the full article here.

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Book on Hoarseness

My fellowship mentor, Dr. James Thomas, taught me much of all I know about the voicebox both when it works and when it doesn't leading to hoarseness.

Much of his knowledge is imparted in a book he wrote which is now available for purchase on Amazon.com. Although healthcare professionals interested in the voice will find the book very helpful, it is written in such a way that any layperson without a medical background can also find it understandable and helpful.

Check it out here!

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Julie Andrews and Her "Botched Throat Surgery"

It has already been well-publicized that the former singing sensation Julie Andrews underwent some type of throat surgery in 1997 after which she never regained her phenomenal 4-octave voice thus relegating her to more conventional roles of being an actress without the singing. This "botched throat surgery" per Julie Andrews lead to a lawsuit that was ultimately settled.

It is unknown precisely what type of (presumed) vocal cord pathology was present as well as what type of surgical approach was used to try and fix it. In a recent interview, she stated:

"The operation that I had left me without a voice and without a certain piece of my vocal chords"

However, given her aggressive and active singing career prior to surgery, she probably had vocal cord nodules, a benign growth that occurs due to vocal overuse, a situation not uncommon with professional singers.

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results (not unusual with professional singers whose livelihoods depend on singing), there are more aggressive ways to address vocal cord nodules with possible resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement. Furthermore, as with any more invasive treatments to obtain a "quick fix", scar formation may occur leading to permanent voice changes, usually for the worse which obviously happened with Julie Andrews.

What are some of these more invasive treatments beyond voice therapy? To reiterate, these procedures also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent irreversible hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

• Steroid injection to the vocal cord nodule(s) can possibly resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis. Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Read more about vocal cord nodules here.

Source:
Julie Andrews' Voice Isn't Coming Back, But She's Not Staying Silent. Huffington Post 12/5/12

PUBLIC LIVES; Julie Andrews Sues Throat Surgeon. NYT 12/15/99

Julie Andrews Settles Lawsuit Against Doctors. ABC News 9/7/12

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Dr. Chang Quoted in Voice Council Magazine

Dr. Christopher Chang was quoted in a Nov 4, 2012 article published in Voice Council Magazine.

The Voice Council Magazine is based out of United Kingdom and focuses on "practical insight for the emerging vocalist."

The article by Megan Gloss was focused on why Celine Dion cancelled her concert 2/22/12 in Las Vegas (a viral laryngitis), a subject I already blogged about here.

Read the published Voice Council article here.

Source:
Celine Dion's Viral Voice. Voice Council Magazine 2/22/12.

Viral Infections and Singing — More From Dr. Chang. Voice Council Magazine 2/22/12.

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How Does Cervical Spine Surgery Potentially Cause Voice and Swallow Problems? [video]

It is not unusual for an ENT surgeon to see patients with swallowing and voice difficulties after cervical spine surgery. In particular, the ACDF surgery (Anterior Cervical Discectomy and Fusion).

The key to understanding these issues is to first understand the anatomy involved.

The cervical spine is located in the back of the neck. In front of this spine is the esophagus (swallowing tube) and voicebox.

As such, when a spine surgeon goes through the FRONT of the neck in order to perform cervical spine surgery located in the BACK of the neck, (s)he has to move the esophagus and voicebox over to the side.

A plate is than fixated to the spine to fuse the cervical vertebral bodies.

Because of such manipulation of the esophagus and voicebox, it is not uncommon for a patient to complain of hoarseness and difficulty swallowing after surgery.

Fortunately, such problems usually dissipate with time, but not always. Swallowing complaints may last over 1 year. [more info]

Watch the video describing ACDF and how it can affect voice and swallow.

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Steroid Injection to Eliminate Vocal Cord Nodules

Vocal cord nodules are most always due to excessive voice use leading to "callous" formation on the vocal cord lining, much like shoveling dirt will eventually lead to callous formation on the hands.

Traditional standard of care management of vocal cord nodules is voice therapy and avoidance of any activities leading to voice abuse (screaming, yelling, etc). However, resolution of nodules with such behavior focused treatment takes months. However, although it takes a while for the nodules to resolve with this treatment method, they typically do not come back.

For patients who are more "impatient" for results, there are more aggressive ways to address vocal cord nodules with resolution within weeks. However, the caveat is if the underlying voice behavior that led to nodule formation in first place is not addressed, the vocal cord nodule WILL recur after initial resolution/improvement.

Recently, there have been several studies that have shown that steroid injection directly into vocal cord nodule can resolve or reduce the nodule resulting in improved vocal quality within weeks. Such local injection technique has mainly been performed in the treatment of spasmodic dysphonia (botox injection), vocal cord granulomas, and vocal cord paralysis.

In the most recent study published Oct 2011, researchers have found that in a group of 80 patients, 44% had complete resolution of the nodule and another 49% had improvement within 4 weeks after injection of the nodule with Kenalog 40. 8% had recurrence of the nodule after initial improvement due to persisting in a high voice-use occupation. 4 patients suffered vocal cord atrophy and 2 patients developed a white plaque that resolved spontaneously 1-2 months after injection.

Watch a video how a "local injection" to the vocal cord can be performed (video shows injection of vocal cord granuloma rather than nodule, but overall approach is identical).

Beyond voice therapy and steroid injections, there are other ways of dealing with vocal cord nodules, but also have a high risk of recurrence if underlying abusive voice behavior that led to the nodule formation in first place is not first addressed.

• Surgical excision can be performed, but can lead to permanent scar formation during the healing process that can lead to persistent hoarseness.

• Botox injection can also be pursued which causes a "partial" vocal cord paralysis preventing the repetitive trauma in the region of the vocal cord nodule.

Read more about vocal cord nodules here.

References:
Local steroid injection via the cricothyroid membrane in patients with a vocal nodule. Arch Otolaryngol Head Neck Surg. 2011;137(10):1011-1016. doi:10.1001/archoto.2011.168

Steroid injection to vocal nodules using fiberoptic laryngeal surgery under topical anesthesia. Eur Arch Otorhinoloaryngol. 2004. 261(9):489-492.

Laryngeal steroid injection. Curr Opin Otolarngol Head Neck Surg. 2009. 17(6): 424-426.

Office Steroid Injections of the Larynx. Laryngoscope. 2006. 116(10):1735-1739.

Percutaneous corticosteroid injection for vocal fold polyp. Arch Otolaryngol Head Neck Surg. 2009. 135(8):776-780.

Intracordal injection of dexamethasone. Pract Otorhinoloaryngol (Basel). 1964. 57(3):496-500.

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