Voice disorders

Up to 10% of the adult population in the UK are affected by voice disorders

The voice box (or larynx) is the gateway into the lungs and contains the vocal cords which part when you breathe in or out. If they are brought together when you breathe out, they vibrate, and it’s this vibration that generates your voice. Hoarseness (or dysphonia) refers to an alteration in the sound of your voice.

Hoarseness usually occurs because of either a change in the surface lining of the vocal cords or a change in their motion. Often there are other symptoms that are associated with hoarseness such as cough or throat pain.

Most causes of hoarseness are short-lived and usually resolve without the need for medical or surgical intervention.

Here are some common causes of hoarseness

The vocal cords or the tiny joints of the voice box may swell due to infection, allergy or trauma
Inhaled substances such as cigarette smoking, gastric acid reflux and post-nasal drip from rhino-sinusitis may irritate and inflame the vocal cord surface
A wide range of lesions on the vocal cords, such as singer’s nodules, cysts, scar and inflammatory tissue (called granulation) roughen the surface of the cords
The vocal cords may be paralyzed by injury to the nerves that supply their muscles due to certain neurological conditions or by trauma or surgery. This will reduce the movement in one or other vocal cord, causing hoarseness and sometimes difficulty in breathing and swallowing
A cancerous growth on the vocal cord is perhaps the biggest fear

I would like to see you urgently if your hoarseness has lasted more than 2 weeks particularly if you have the following associated features:

You are finding it difficult to breathe and/ or your breathing has become noisy
Constant throat and ear pain, especially if it’s on one side
If food and fluid seem to go down the windpipe causing you to cough and splutter stop
If you are struggling to swallow
If you acough up blood
If you have noticed a new neck lump
If you have lost a lot of weight in a short space of time
If you are a heavy smoker and/ or a high alcohol consumer

What to expect when you visit me with a voice problem

You can be rest assured that I have many years of experience in managing the full breadth and depth of both benign and cancerous conditions of the voice box, windpipe and the swallowing apparatus.

It is vitally important I obtain a detailed, amplified view of your voice box. I will pass a lubricated flexible endoscope with a high definition camera at its end, through your nose and into your throat. This will be broadcast onto a large video screen where you and I will both be able to see the surface detail and movements of your vocal cords.

I will perform a video-stroboscopic assessment on every hoarse patient I review. A video-stroboscopy test visually slows down the vibration and surface contact of the vocal cords as they meet each other. This is a very important part of the examination because it allows me to identify subtle imperfections on the vocal cord surface caused by scar or buried cysts for example, that may not be immediately apparent with a simple endoscopic examination.

Sometimes the camera allows me to visualise the subglottis and upper trachea, areas that lie immediately underneath the vocal folds. Swelling or a lesion in this area may be relevant to some conditions that affect your voice.

Further tests may include a high-resolution CT scan of the voice box windpipe and chest and an MRI scan of the neck.

My approach to treating your voice condition

The myriad of different conditions causing a hoarse voice have unique treatment options. I will discuss the specifics in detail with you at the consultation; however, there are some important general principles of management that I commonly employ for all voice conditions

1. Medicines

Many conditions just need medicines such as a course of antibiotics and anti-inflammatory preparations. Any exacerbating conditions that irritate the voice box such as gastroesophageal reflux or rhinosinusitis should be treated on their own merit.

2. Surgery

An operation is required to excise discrete lumps on the vocal cords. If I am suspicious of a cancerous lesion, a biopsy will be performed.

I will usually perform a microlaryngoscopy. This involves placing a metal tube through the mouth to obtain a magnified view of the voice box under a microscope. It involves a short general anaesthetic and, in most cases, ventilation without the need for a tube (jet ventilation); this set up affords me unobstructed access to your voice box and windpipe.

It Is vitally important that an ENT surgeon with a specialist interest in laryngology and complex airway reconstruction (or both), manage your voice box. An inappropriate operation risks worsening the voice through damaging scar tissue formation.

I have numerous years of experience in using fine dissecting instruments and laser technology to cleanly remove vocal cord lesions whilst preserving the delicate normal surrounding structures.

Other treatments I may offer include injection of steroid, Botox and filler material and sometimes placement of a permanent implant through an open neck approach (thyroplasty).

I have a specialist interest in the management of complex voice-box and upper airway conditions, including narrowed and scarred airways from trauma and surgery performed by other surgeons. These require specific surgical techniques and approaches.

3. Speech Therapy

A very important aspect of voice treatment includes collaborative work with a speech therapist. Speech therapists are experts in rehabilitating voice disorders through focussed voice-physiotherapy. This is important, because many patients develop tension in the muscles of the voice box and abnormal compensatory behaviours that need to be corrected to give an optimal outcome.

This is extremely important for professional Voice users such as singers, broadcasters and teachers.

4. Good vocal hygiene

I and my speech therapy colleagues will provide you comprehensive guidance on vocal hygiene measures to look after your voice box before, during and long after any treatment we recommend.