About your Voice
Common Problems that Can Affect your Voice
Day Care and Ear, Nose, and Throat Problems
Effects of Medications on Voice
Gastroesphageal Reflux (GERD)
How Allergies Affect your Child's Ears, Nose, and Throat
Keeping Your Voice Healthy
Laryngeal (Voice Box) Cancer
Laryngopharyngeal Reflux and Children
Nodules, Polyps, and Cysts
Pediatric GERD (Gastro-Esophageal Reflux Disease)
Pediatric Obesity and Ear, Nose, and Throat Disorders
Special Care for Voice Users

The Voice and Aging

As we age, our voices change. The most dramatic voice changes are those during childhood and adolescence. The larynx (or voice box) and vocal cord tissues do not fully mature until late teenage years. Hormone-related changes during adolescence are particularly noticeable among boys. The rapid changes in the size and character of the larynx causes characteristic pitch breaks and voice “cracking” during puberty as we learn to use our rapidly changing voice instruments.

After several decades of relatively stable voice, noticeable change can occur in the later years of life. As our bodies age, we lose muscle mass, our mucous membranes thin and become more dry, and we lose some of the fine coordination that we had in younger years. It is no surprise that these changes occur in the larynx as well, and this leads to changes in our voice. Your doctor may call these changes vocal cord atrophy or bowing, presbyphonia, or presbylaryngis.

Changes in the Voice as We Age

Below is a list of commonly reported voice changes as we age:

• Higher pitch voice in men
• Lower pitch voice in women
• Reduced volume and projection of the voice (or “thin” voice)
• Reduced vocal endurance
• Difficulty being heard in noisy situations
• Tremor or shakiness in the voice

These symptoms are amplified by the reduced hearing ability that commonly occurs in our peers as we age.

NOTE: Much of the time, hoarseness and vocal difficulties are not simply age related change. Any change that you notice in your voice should be a warning sign that something may be wrong. See your otolaryngologist (ear, nose, throat doctor). Almost all voice problems are highly treatable.

What Can Be Done About Age-Related Voice Change?

If you are bothered by your voice, take action today. As a first step, consider taking the Voice- Related Quality of Life quiz available on the Academy’s World Voice Day Web site. (A print version is also available; see Voice-Related Quality of Life Fact Sheet). By answering a short series of questions, you’ll be able to measure the quality of your voice.

Secondly, consider a vocal fitness program (i.e. voice therapy), as healthy voice use is key to voice preservation. Under the guidance of a speech-language pathologist, a vocal fitness program can make a big difference.

Finally, some people are candidates for medical or surgical treatment to improve the steadiness, strength, or endurance of the voice. See your Otolaryngologist for further information.

Overall Body Fitness Can Fuel Your Voice

Most of us want to maintain our youthful fitness and the same holds true for the voice. Maintaining excellent overall body fitness will help keep your voice healthy. Keep vocally fit as well—in many cases the more active you stay vocally, the stronger your voice will be. Healthy vocal exercises may not seem as obvious as healthy exercises in the gym, so professional guidance from a voice therapist or voice coach is very helpful. Some things you may do on your own though include: reading a book or paper aloud for 10-15 minutes, 2 or 3 times a day, as well as singing with the radio.

Tips for Healthy Voices

Voice problems usually are associated with hoarseness (also known as roughness), instability, or problems with voice endurance. If you are unsure if you have an unhealthy voice, ask yourself the following:

• Has your voice become hoarse or raspy?
• Does your throat often feel raw, achy or strained?
• Has it become an effort to talk?
• Do you repeatedly clear your throat?
• Do people regularly ask you if you have a cold when in fact you do not?
• Have you lost your ability to hit some high notes when singing?

Voice problems arise from a variety of sources including voice overuse or misuse, cancer, infection, or injury. Here are steps that can be taken to prevent voice problems and maintain a healthy voice:

Drink water (stay well hydrated): Keeping your body well hydrated by drinking plenty of water each day (6-8 glasses) is essential to maintaining a healthy voice. The vocal cords vibrate extremely fast even with the most simple sound production; remaining hydrated through water consumption optimizes the throat’s mucous production, aiding vocal cord lubrication. To maintain sufficient hydration avoid or moderate substances that cause dehydration. These include alcohol and caffeinated beverages (coffee, tea, soda). And always increase hydration when exercising.

Do not smoke: It is well known that smoking leads to lung or throat cancer. Primary and secondhand smoke that is breathed in passes by the vocal cords causing significant irritation and swelling of the vocal cords. This will permanently change voice quality, nature, and capabilities.

Do not abuse or misuse your voice: Your voice is not indestructible. In every day communication, be sure to avoid habitual yelling, screaming, or cheering. Try not to talk loudly in locations with significant background noise or noisy environments. Be aware of your background noise—when it becomes noisy, significant increases in voice volume occur naturally, causing harm to your voice. If you feel like your throat is dry, tired, or your voice is becoming hoarse, stop talking.

To reduce or minimize voice abuse or misuse use non-vocal or visual cues to attract attention, especially with children. Obtain a vocal amplification system if you routinely need to use a “loud” voice especially in an outdoor setting. Try not to speak in an unnatural pitch. Adopting an extremely low pitch or high pitch can cause an injury to the vocal cords with subsequent hoarseness and a variety of problems.

Minimize throat clearing: Clearing your throat can be compared to slapping or slamming the vocal cords together. Consequently, excessive throat clearing can cause vocal cord injury and subsequent hoarseness. An alternative to voice clearing is taking a small sip of water or simply swallowing to clear the secretions from the throat and alleviate the need for throat clearing or coughing. The most common reason for excessive throat clearing is an unrecognized medical condition causing one to clear their throat too much. Common causes of chronic throat clearing include gastroesophageal reflux, laryngopharyngeal reflux disease, sinus and/or allergic disease.

Moderate voice use when sick: Reduce your vocal demands as much as possible when your voice is hoarse due to excessive use or an upper respiratory infection (cold). Singers should exhibit extra caution if one’s speaking voice is hoarse because permanent and serious injury to the vocal cords are more likely when the vocal cords are swollen or irritated. It is important to “listen to what your voice is telling you.”

Your voice is an extremely valuable resource and is the most commonly used form of communication. Our voices are invaluable for both our social interaction as well as for most people’s occupation. Proper care and use of your voice will give you the best chance for having a healthy voice for your entire lifetime.

Hoarseness or roughness in your voice is often caused by a medical problem. Contact an otolaryngologist—head and neck surgeon if you have any sustained changes to your voice.

Tonsillectomy Procedures

Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology—Head and Neck Surgery recommends that children who have three or more tonsillar infections a year undergo a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.

The Tonsillectomy Today

The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. Today, the scalpel is still the preferred surgical instrument of many ear, nose, and throat specialists. However, there are other procedures available – the choice may be dictated by the extent of the procedure (complete tonsil removal versus partial tonsillectomy) and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:

• Cold knife (steel) dissection: Removal of the tonsils by use of a scalpel is the most common method practiced by otolaryngologists today. The procedure requires the young patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding.
  
• Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization. Research has shown that the heat of electrocautery (400 degrees Celsius) results in thermal injury to surrounding tissue. This may result in more discomfort during the postoperative period.
  
• Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. The temperature of the surrounding tissue reaches 80 degrees Celsius. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.
  
• Radiofrequency ablation (Somnoplasty): Monopolar radiofrequency thermal ablation transfers radiofrequency energy to the tonsil tissue through probes inserted in the tonsil.  The procedure can be performed in an office setting under light sedation or local anesthesia. After the treatment is performed, scarring occurs within the tonsil causing it to decrease in size over a period of several weeks. The treatment can be performed several times. The advantages of this technique are minimal discomfort, ease of operations, and immediate return to work or school. Tonsillar tissue remains after the procedure but is less prominent. This procedure is recommended for treating enlarged tonsils and not chronic or recurrent tonsillitis.
  
• Carbon dioxide laser: Laser tonsil ablation (LTA) finds the otolaryngologist employing a hand-held CO2 or KTP laser to vaporize and remove tonsil tissue. This technique reduces tonsil volume and eliminates recesses in the tonsils that collect chronic and recurrent infections. This procedure is recommended for chronic recurrent tonsillitis, chronic sore throats, severe halitosis, or airway obstruction caused by enlarged tonsils.
  The LTA is performed in 15 to 20 minutes in an office setting under local anesthesia. The patient leaves the office with minimal discomfort and returns to school or work the next day. Post-tonsillectomy bleeding may occur in two to five percent of patients. Previous research studies state that laser technology provides significantly less pain during the post-operative recovery of children, resulting in less sleep disturbance, decreased morbidity, and less need for medications. On the other hand, some believe that children are adverse to outpatient procedures without sedation.
  
• Microdebrider: What is a “microdebrider?” The microdebrider is a powered rotary shaving device with continuous suction often used during sinus surgery. It is made up of a cannula or tube, connected to a hand piece, which in turn is connected to a motor with foot control and a suction device.
  The endoscopic microdebrider is used in performing a partial tonsillectomy, by partially shaving the tonsils. This procedure entails eliminating the obstructive portion of the tonsil while preserving the tonsillar capsule. A natural biologic dressing is left in place over the pharyngeal muscles, preventing injury, inflammation, and infection. The procedure results in less post-operative pain, a more rapid recovery, and perhaps fewer delayed complications. However, the partial tonsillectomy is suggested for enlarged tonsils – not those that incur repeated infections.
  
• Bipolar Radiofrequency Ablation (Coblation): This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. This causes removal of tissue with a thermal effect of 45-85 C°. The advantages of this technique are less pain, faster healing, and less post operative care.

Consult with an otolaryngologist regarding the optimum procedure to remove or reduce your tonsils and adenoids.

Tonsillitis

What is tonsillitis? Tonsillitis refers to inflammation of the pharyngeal tonsils. The inflammation may involve other areas of the back of the throat including the adenoids and the lingual tonsils (areas of tonsil tissue at the back of the tongue). There are several variations of tonsillitis: acute, recurrent, and chronic tonsillitis and peritonsillar abscess.

Viral or bacterial infections and immunologic factors lead to tonsillitis and its complications. Nearly all children in the United States experience at least one episode of tonsillitis. Because of improvements in medical and surgical treatments, complications associated with tonsillitis, including mortality, are rare.

Who gets tonsillitis?

Tonsillitis most often occurs in children; however, the condition rarely occurs in children younger than two years. Tonsillitis caused by Streptococcus species typically occurs in children aged five to 15 years, while viral tonsillitis is more common in younger children. A peritonsillar abscess is usually found in young adults but can occur occasionally in children. The patient's history often helps identify the type of tonsillitis (i.e., acute, recurrent, chronic) that is present.

What causes tonsillitis?

The herpes simplex virus, Streptococcus pyogenes (GABHS) and Epstein-Barr virus (EBV), cytomegalovirus, adenovirus, and the measles virus cause most cases of acute pharyngitis and acute tonsillitis. Bacteria cause 15-30 percent of pharyngotonsillitis cases; GABHS is the cause for most bacterial tonsillitis.

What are the symptoms of tonsillitis?

The type of tonsillitis determines what symptoms will occur.

• Acute tonsillitis: Patients have a fever, sore throat, foul breath, dysphagia (difficulty swallowing), odynophagia (painful swallowing), and tender cervical lymph nodes. Airway obstruction due to swollen tonsils may cause mouth breathing, snoring, nocturnal breathing pauses, or sleep apnea. Lethargy and malaise are common. These symptoms usually resolve in three to four days but may last up to two weeks despite therapy.
  
  
• Recurrent tonsillitis: This diagnosis is made when an individual has multiple episodes of acute tonsillitis in a year.
  
  
• Chronic tonsillitis: Individuals often have chronic sore throat, halitosis, tonsillitis, and persistently tender cervical nodes.
  
  
• Peritonsillar abscess: Individuals often have severe throat pain, fever, drooling, foul breath, trismus (difficulty opening the mouth), and muffled voice quality, such as the “hot potato” voice (as if talking with a hot potato in his or her mouth).

What happens during the physician visit?

Your child will undergo a general ear, nose, and throat examination as well as a review of the patient’s medical history.

A physical examination of a young patient with tonsillitis may find:

• Fever and enlarged inflamed tonsils covered by pus.
• Group A beta-hemolytic Streptococcus pyogenes (GABHS) can cause tonsillitis associated with the presence of palatal petechiae (minute hemorrhagic spots, of pinpoint to pinhead size, on the soft palate). Neck nodes may be enlarged. A fine red rash over the body suggests scarlet fever. GABHS pharyngitis usually occurs in children aged 5-15 years.
• Open-mouth breathing and muffled voice resulting from obstructive tonsillar enlargement. The voice change with acute tonsillitis usually is not as severe as that associated with peritonsillar abscess.
• Tender cervical lymph nodes and neck stiffness (often found in acute tonsillitis).
• Signs of dehydration (found by examination of skin and mucosa).
• The possibility of infectious mononucleosis due to EBV in an adolescent or younger child with acute tonsillitis, particularly when cervical, axillary, and/or groin nodes are tender. Severe lethargy, malaise and low-grade fever accompany acute tonsillitis.
• A grey membrane covering tonsils that are inflamed from an EBV infection. (This membrane can be removed without bleeding.) Palatal petechiae (pinpoint spots on the soft palate) may also be seen with an EBV infection.
• Red swollen tonsils that may have small ulcers on their surfaces in individuals with herpes simplex virus (HSV) tonsillitis.
• Unilateral bulging above and to the side of one of the tonsils when peritonsillar abscess exists. A stiff jaw may be present in varying severity.

Treatment

Tonsillitis is usually treated with a regimen of antibiotics. Fluid replacement and pain control are important. Hospitalization may be required in severe cases, particularly when there is airway obstruction. When the condition is chronic or recurrent, a surgical procedure to remove the tonsils is often recommended.

Tonsils and Adenoids PostOp

The tonsils are two pads of tissue located on both sides of the back of the throat. Adenoids sit high on each side of the throat behind the nose and the roof of the mouth. Tonsils and adenoids are often removed when they become enlarged and block the upper airway, leading to breathing difficulty. They are also removed when recurrence of tonsil infections or strep throat cannot be successfully treated by antibiotics.

The procedure to remove the tonsils is called a tonsillectomy; excision of the adenoids is an adenoidectomy. Both are usually performed concurrently; hence the procedure is known as a tonsillectomy and adenoidectomy or T&A.

T&A is an outpatient surgical procedure lasting between 30 and 45 minutes and performed under general anesthesia. Normally, the young patient will remain at the hospital or clinic for about four hours after surgery for observation. An overnight stay may be required if there are complications such as excessive bleeding or poor intake of fluids.

When the tonsillectomy patient comes home

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

Drinking: The most important requirement for recovery is for the patient to drink plenty of fluids. Milk products should be avoided in the first 24 hours after surgery. Offer juice, soft drinks, popsicles, and Jell-O (pudding, yogurt, and ice-cream after 24 hours). Some patients experience nausea and vomiting after the surgery caused by the general anesthetic. This usually occurs within the first 24 hours and resolves on its own. Contact your physician if there are signs of dehydration (urination less than 2-3 times a day or crying without tears).

Eating: Generally, there are no food restrictions (other than milk products) after surgery. The sooner the child eats and chews, the quicker the recovery. Tonsillectomy patients may be reluctant to eat because of sore throat pain; consequently, some weight loss may occur, which is gained back after a normal diet is resumed.

Fever: A low-grade fever may be observed several days after surgery. Contact your physician if the fever is greater than 102º.

Activity: Bed rest is recommended for several days after surgery. Activity may be increased slowly, with a return to school after normal eating and drinking resumes, pain medication ceases, and the child sleeps through the night. Travel away from home is not recommended for two weeks following surgery.

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

Scabs: A scab will form where the tonsils and adenoids were removed. These scabs are thick, white, and cause bad breath. This is not unexpected. Most scabs fall off in small pieces five to ten days after surgery and are swallowed.

Bleeding: With the exception of small specks of blood from the nose or in the saliva, bright red blood should not be seen. If such bleeding occurs, contact your physician immediately or take your child to the emergency room. Bleeding is an indication that the scabs have fallen off too early, and medical attention is required.

Pain: Nearly all children undergoing a tonsillectomy/adenoidectomy will have mild to severe pain in the throat after surgery. Some may complain of an earache (because stimulation of the same nerve that goes to throat also travels to the ear), and a few may incur pain in the jaw and neck (due to positioning of the patient in the operating room).

Pain control: Your physician will prescribe appropriate pain medications for the young patient such as codeine, hydrocodone, Tylenol with codeine liquid, or Lortab (hydrocodone with Tylenol). Generally, an acetaminophen (Tylenol, Tempra, Panadol) teaspoon solution is recommended for regular administration to the patient for three or four days after surgery.

If you are troubled about any phase of your child’s recovery, contact your physician immediately.

Vocal Cord Paralysis

What Is Vocal Fold (cord) Paresis And Paralysis?

Vocal fold (or cord) paresis and paralysis result from abnormal nerve input to the voice box muscles (laryngeal muscles).  Paralysis is the total interruption of nerve impulse resulting in no movement of the muscle; Paresis is the partial interruption of nerve impulse resulting in weak or abnormal motion of laryngeal muscle(s).

Vocal fold paresis/paralysis can happen at any age – from birth to advanced age, in males and females alike, from a variety of causes. The effect on patients may vary greatly depending on the patient’s use of his or her voice: A mild vocal fold paresis can be the end to a singer's career, but have only a marginal effect on a computer programmer's career.

What Nerves Are Involved In Vocal Fold Paresis/Paralysis?

Vocal fold movements are a result of the coordinated contraction of various muscles. These muscles are controlled by the brain through a specific set of nerves. The nerves that receive these signals are the:

Superior laryngeal nerve (SLN), which carries signals to the cricothyroid muscle, located between the cricoid and thyroid cartilages. Since the cricothyroid muscle adjusts the tension of the vocal fold for high notes during singing, SLN paresis and paralysis result in abnormalities in voice pitch and the inability to sing with smooth change to each higher note. Sometimes, patients with SLN paresis/paralysis may have a normal speaking voice but an abnormal singing voice.

The recurrent laryngeal nerve (RLN) carries signals to different voice box muscles responsible for opening vocal folds (as in breathing, coughing), closing vocal folds for vocal fold vibration during voice use, and closing vocal folds during swallowing. The recurrent laryngeal nerve goes into the chest cavity and curves back into the neck until it reaches the larynx. Because the nerve is relatively long and takes a "detour" to the voice box, it is at greater risk for injury from quite different causes – such as infections and tumors of the brain, neck, chest, or voice box; as well as complications during surgical procedures in the head, neck, or chest regions – that directly injure, stretch, or compress the nerve. Consequently, the recurrent laryngeal nerve is involved in majority of cases of vocal fold paresis or paralysis.

What Are The Causes Of Vocal Fold Paralysis/Paresis?

The cause of vocal fold paralysis or paresis can indicate whether the disorder will resolve over time or whether it is most likely permanent. When a reversible cause is present, surgical treatment will most likely not be recommended given the likelihood of spontaneous resolution of the paresis or paralysis.   Despite advances in diagnostic technology, physicians are unable to detect the cause in about half of all vocal fold paralyses. These cases are referred to as idiopathic (due to unknown origins). In idiopathic cases, paralysis or paresis might be due to a viral infection affecting the voice box nerves (RLN or SLN) or the vagus nerve, but this cannot be proven in most cases. Known reasons for injury can include:

• Inadvertent injury during surgery: Surgery in the neck (e.g., surgery of thyroid gland, carotid artery) or surgery in the chest (e.g., surgery of the lung, esophagus, heart, or large blood vessels) may inadvertently result in RLN paresis or paralysis. The SLN may also be injured during head and neck surgery.
• Complication from endotracheal intubation: Injury to the RLN may occur when breathing tubes are used for general anesthesia and/or assisted breathing (artificial ventilation). However, this type of injury is rare, given the large number of operations done under general anesthesia.
• Blunt neck or chest trauma:  Any type of penetrating, hard impact on the neck or chest region may injure the RLN; impact to the neck may injure the SLN.
• Tumors of the skull base, neck, and chest:  Tumors (both cancerous and non-cancerous) can grow around nerves and squeeze them, resulting in varying degrees of paresis or paralysis.
• Viral infections:  Inflammation from viral infections may directly involve and injure the vagus nerve or its nerve branches to the voice box (RLN and SLN). Systemic illnesses affecting nerves in the body may also affect the nerves to the voice box.

What Are The Symptoms Of Vocal Fold Paralysis/Paresis?

Both paresis and paralysis of voice box muscles result in voice changes and may also result in airway problems and swallowing difficulties.

• Voice changes: Hoarseness (croaky or rough voice); breathy voice (a lot of air with the voice); effortful phonation (extra effort on speaking); air wasting (excessive air pressure required to produce usual conversational voice); and diplophonia (voice sounds like a "gargle").
• Airway problems: Shortness of breath with exertion, noisy breathing (stridor), and ineffective or poor cough.
• Swallowing problems: Choking or coughing when swallowing food, drink, or even saliva, and food sticking in throat.

How Is Vocal Fold Paralysis/Paresis Diagnosed?

The otolaryngologist—head and neck surgeon will conduct a general examination and then question you regarding your symptoms and lifestyle (voice use, alcohol/tobacco consumption). The examination of the voice box will be undertaken to determine whether one or both vocal folds (cords) is/are abnormal. Determining whether one or both vocal folds are affected is important in the treatment plan. Other tests may be required:

• Laryngeal electromyography (LEMG): LEMG measures electrical currents in the voice box muscles that are the result of nerve inputs. Measuring and looking at the pattern of the electric currents will indicate whether there is recovery or repair of nerve inputs (re-innervation) and the  degree of the nerve input problem.   The test involves the insertion of small needles that can measure electrical currents in the vocal fold muscles. During LEMG patients perform a number of tasks that would normally elicit characteristic actions in the tested muscles.
• Other tests: Because there is a wide list of diseases that may cause a nerve to be injured, further testing is usually necessary (blood tests, x-rays, CT scans, MRI, etc.) to identify the cause(s) of vocal fold paresis/paralysis.

What Is The Treatment For Vocal Fold Paralysis/Paresis?

The two treatment strategies to improve vocal function are voice therapy, the equivalent of physical therapy for large muscle paresis/paralysis; and phonosurgery, an operation that repositions and/or reshapes the vocal fold(s) to improve voice function.  Normally, voice therapy is a first treatment option. After voice therapy, the decision for surgery is dependent on the severity of the symptoms, vocal needs of the patient, position of paralyzed vocal folds, prognosis for recovery, and cause of paresis/paralysis if known.

If you have noticed any change in voice quality, immediately contact an otolaryngologist—head and neck surgeon.

GERD and LPR

Gastroesphageal Reflux (GERD) & Laryngopharyngeal Reflux (LPR)

What Is GERD?

Gastroesophageal reflux, often referred to as 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 and throat, 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.

In some cases, reflux can be SILENT, with no symptoms until a problem arises. Almost all individuals have experienced reflux (GER), but the disease (GERD) occurs when reflux happens on a frequent basis often over a long period of time.

What Is LPR?

During gastroesophageal reflux, the acidic stomach contents may reflux all the way up the esophagus, beyond the upper esophageal sphincter (a ring of muscle at the top of the esophagus), and into the back of the throat and possibly the back of the nasal airway. This is known as laryngopharyngeal reflux (LPR), which can affect anyone. Adults with LPR often complain that the back of their throat has a bitter taste, a sensation of burning, or something “stuck.” Some may have difficulty breathing if the voice box is affected.

In infants and children, LPR may cause breathing problems such as: cough, hoarseness, stridor (noisy breathing), croup, asthma, sleep disordered breathing, feeding difficulty (spitting up), turning blue (cyanosis), aspiration, pauses in breathing (apnea), apparent life threatening event (ALTE), and even a severe deficiency in growth. Proper treatment of LPR, especially in children, is critical.

What Are The Symptoms Of GERD And LPR?

The symptoms of GERD may include persistent heartburn, acid regurgitation, nausea, hoarseness in the morning, or trouble swallowing. Some people have GERD without heartburn. Instead, they experience pain in the chest that can be severe enough to mimic the pain of a heart attack. GERD can also cause a dry cough and bad breath. Some people with LPR may feel as if they have food stuck in their throat, a bitter taste in the mouth on waking, or difficulty breathing although uncommon.

If you experience any symptoms on a regular basis (twice a week or more) then you may have GERD or LPR. For proper diagnosis and treatment, you should be evaluated by your primary care doctor for GERD or an otolaryngologist—head and neck surgeon (ENT doctor).

Who Gets GERD Or LPR?

Women, men, infants, and children can all have GERD. This disorder may result from physical causes or lifestyle factors. Physical causes can include a malfunctioning or abnormal lower esophageal sphincter muscle (LES), hiatal hernia, abnormal esophageal contractions, and slow emptying of the stomach. Lifestyle factors include diet (chocolate, citrus, fatty foods, spices), destructive habits (overeating, alcohol and tobacco abuse) and even pregnancy. Young children experience GERD and LPR due to the developmental immaturity of both the upper and lower esophageal sphincters.

Unfortunately, GERD and LPR are often overlooked in infants and children leading to repeated vomiting, coughing in GER and airway and respiratory problems in LPR such as sore throat and ear infections. Most infants grow out of GERD or LPR by the end of their first year; however, the problems that resulted from the GERD or LPR may persist.

What Role Does An Ear, Nose, And Throat Specialist Have In Treating GERD And LPR?

A gastroenterologist, a specialist in treating gastrointestinal orders, will often provide initial treatment for GERD. But there are ear, nose, and throat problems that are either caused by or associated with GERD, such as hoarseness, laryngeal (singers) nodules, croup, airway stenosis (narrowing), swallowing difficulties, throat pain, and sinus infections. These problems require an otolaryngologist—head and neck surgeon, or a specialist who has extensive experience with the tools that diagnose GERD and LPR. They treat many of the complications of GERD, including: sinus and ear infections, throat and laryngeal inflammation and lesions, as well as a change in the esophageal lining called Barrett’s esophagus, which is a serious complication that can lead to cancer.

Your primary care physician or pediatrician will often refer a case of LPR to an otolaryngologist—head and neck surgeon for evaluation, diagnosis, and treatment.

Diagnosing And Treating GERD And LPR

In adults, GERD can be diagnosed or evaluated by a physical examination and the patient’s response to a trial of treatment with medication. Other tests that may be needed include an endoscopic examination (a long tube with a camera inserted into the nose, throat, windpipe, or esophagus), biopsy, x-ray, examination of the throat and larynx, 24 hour pH probe, acid reflux 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 or in a hospital setting. Endoscopic examinations can often be performed in your ENT’s office, or may require some form of sedation and occasionally anesthesia.

Symptoms of GERD or LPR in children should be discussed with your pediatrician for a possible referral to a specialist.

Most people with GERD respond favorably to a combination of lifestyle changes and medication. On occasion, surgery is recommended. Medications that could be prescribed include antacids, histamine antagonists, proton pump inhibitors, pro-motility drugs, and foam barrier medications. Some of these products are now available over-the-counter and do not require a prescription.

Children and adults who fail medical treatment or have anatomical abnormalities may require surgical intervention. Such 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.

Adult Lifestyle Changes To Prevent GERD And LPR

• Avoid eating and drinking within two to three hours prior to bedtime
• Do not drink alcohol
• Eat small meals and slowly
• Limit problem foods:
• • Caffeine
  • Carbonated drinks
  • Chocolate
  • Peppermint
  • Tomato and citrus foods
• Fatty and fried foods
• Lose weight
• Quit smoking
• Wear loose clothing

Hoarsenes

Insight into voice changes

• What causes hoarseness?
• What can you do to treat it?
• When should you see an ENT?
• and more...

Abnormal changes in the voice are called “hoarseness.” When hoarse, the voice may sound breathy, raspy, strained, or show changes in volume or pitch (depending on how high or low the voice is). Voice changes are related to disorders in the sound-producing parts (vocal folds) of the voice box (larynx). While breathing, the vocal folds remain apart. When speaking or singing, they come together and, as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal folds hinder vibration, altering voice quality, volume, and pitch.

What are the causes of hoarseness?

Acute Laryngitis: The most common cause is acute laryngitis—swelling of the vocal folds that occurs during a common cold, upper respiratory tract viral infection, or from voice strain. Serious injury to the vocal folds can result from strenuous voice use during an episode of acute laryngitis.

Voice Misuse:

• Speaking in noisy situations
• Excessive use
• Telephone use with the handset cradled to the shoulder
• Using inappropriate pitch (too high or too low) when speaking
• Not using amplification when public speaking

Benign Vocal Cord Lesions: Prolonged hoarseness can occur when you use your voice too much, or too loudly for extended periods of time. These habits can lead to nodules, polyps, and cysts. Vocal nodules (singers’ nodes) are callus-like growths of the vocal folds. Vocal fold polyps and cysts also occur in those who misuse their voice, but can also occur in those who do not.

Vocal Hemorrhage: If you experience a sudden loss of voice following a yell or other strenuous vocal use, you may have developed a vocal fold hemorrhage. Vocal fold hemorrhage occurs when one of the blood vessels on the surface of the vocal folds ruptures and the soft tissues fill with blood. It is considered a vocal emergency and should be treated with absolute voice rest and examination by an otolaryngologist (ear, nose, and throat doctor).

Gastroesophageal Reflux (GERD): A possible cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal folds. Other typical symptoms of GERD include heartburn and regurgitation. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump or mucus in their throat and have an excessive desire to clear it.

Laryngopharyngeal Reflux (LPRD): If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called LPRD rather than GERD. The structures in the throat (pharynx, larynx, and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of the reflux into this area can result in more damage.  Many patients with LPRD do not have hearburn or other classic symptoms of GERD.

Smoking: Smoking is another cause of hoarseness. Because smoking is the major cause of throat cancer, if smokers become hoarse, they should see an otolaryngologist.

Neurological Diseases or Disorders: Hoarseness can also appear in those who have neurological diseases such as Parkinson’s or a stroke, or may be a symptom of spasmodic dysphonia, a rare neurological disorder that usually affects only the voice, but sometimes affects breathing. A paralyzed vocal fold may be the cause of a weak, breathy voice. If the hoarseness persists for more than three months and other causes have been ruled out, a neurologist may be helpful for diagnosis.

Other Causes: These include allergies, thyroid problems, trauma to the voice box, and, occasionally, menstruation. Very serious conditions such as laryngeal cancer can also cause hoarseness, which is why it is important to have chronic hoarseness evaluated promptly by an otolaryngologist

How is hoarseness treated?

Hoarseness caused by a cold or flu may be evaluated by family physicians, pediatricians, and internists who have learned how to examine the larynx. Problems with the voice are often best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists, speech/language pathologists, and teachers of singing, acting, and public speaking. Vocal nodules, polyps, and cysts are typically treated with a combination of microsurgery and voice therapy.

How is hoarseness evaluated?

Otolaryngologists will obtain a thorough history of a patient’s hoarseness and general health. They will then evaluate the voice and do a complete ear, nose, and throat exam. This includes examination of the vocal folds by laryngoscopy.  Laryngoscopy may be suggested by the otolaryngologist at any time during an evaluation for hoarseness, but if it persists beyond three weeks it should be evaluated and that evaluation should occur within a maximum of 3 months. The evaluation should be immediate if there is concern about a serious underlying cause is suspected.

Doctors usually look at the vocal folds either with a mirror placed in the back of the throat, or with a very small, lighted flexible tube (fiberoptic scope) that is passed through the nose to view the vocal folds. Videotaping or stroboscopy (slow-motion assessment) may also help with the analysis. These procedures are well tolerated by most patients. In some cases, special tests designed to evaluate the voice may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in diagnosing and guiding treatment.

When should I see an otolaryngologist?

• If hoarseness lasts longer than three weeks, especially if you smoke
• If you do not have a cold or flu
• If you are coughing up blood
• If you have difficulty swallowing
• If you feel a lump in the neck
• If you observe loss or severe changes in voice lasting longer than a few days
• If you experience pain when speaking or swallowing
• If difficulty breathing accompanies your voice change
• If your hoarseness interferes with your livelihood
• If you are a vocal performer and unable to perform

How are vocal disorders treated?

The treatment of hoarseness depends on the cause. Many common causes of hoarseness can be treated simply by resting the voice or modifying how it is used. An otolaryngologist may make some recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Not smoking and avoiding secondhand smoke is recommended to all patients. Drinking fluids and taking medications to thin out the mucus may help.

How to prevent hoarseness

Specialists in speech/language pathology (voice therapists) are trained to assist patients in behavior modification to help eliminate some voice disorders. Patients who have developed bad habits, such as smoking or overusing their voice by yelling and screaming, benefit most from this conservative approach. The speech/language pathologist may teach patients to alter their methods of speech production to improve the sound of the voice and to resolve problems, such as vocal nodules. When a patient’s problem is specifically related to singing, a singing teacher may help to improve the patients’ singing techniques.

Prevention tips:

• If you smoke, quit.
• Avoid agents that dehydrate the body, such as alcohol and caffeine.
• Avoid secondhand smoke.
• Stay hydrated—drink plenty of water.
• Humidify your home.
• Watch your diet—avoid spicy foods.
• Try not to use your voice too long or too loudly. 
• Use a microphone if possible in situations where you need to project your voice.
• Seek professional voice training.
• Avoid speaking or singing when your voice is injured or hoarse.

How the Voice Works

We rely on our voices every day to interact with others, and a healthy voice is critical for clear communication. But just as we walk without thinking about it, we usually speak without thinking how our body makes it happen. However, knowing how we make sound is useful to maintaining the health and effectiveness of our voices. So this year on World Voice Day, April 16, take a minute to learn how your voice works. The following overview describes the body parts that work together to produce the sounds we make when we speak and sing.

The main parts of voice production:

• The Power Source: Your Lungs

• The Vibrator: Your Voice Box

• The Resonator: Your Throat, Nose, Mouth, and Sinuses

The Power Source: The power for your voice comes from air that you exhale. When we inhale, the diaphragm lowers and the rib cage expands, drawing air into the lungs. As we exhale, the process reverses and air exits the lungs, creating an airstream in the trachea. This airstream provides the energy for the vocal folds in the voice box to produce sound. The stronger the airstream, the stronger the voice. Give your voice good breath support to create a steady strong airstream that helps you make clear sounds.

The Vibrator: The larynx (or voice box) sits on top of the windpipe. It contains two vocal folds (also known as vocal cords) that open during breathing and close during swallowing and voice production. When we produce voice, the airstream passes between the two vocal folds that have come together. These folds are soft and are set into vibration by the passing airstream. They vibrate very fast – from 100 to 1000 times per second, depending on the pitch of the sound we make. Pitch is determined by the length and tension of the vocal folds, which are controlled by muscles in the larynx.

The Resonator: By themselves, the vocal folds produce a noise that sounds like simple buzzing, much like the mouthpiece on a trumpet. All of the structure above the folds, including the throat, nose, and mouth, are part of the resonator system. We can compare these structures to those of a horn or trumpet. The buzzing sound created by vocal fold vibration is changed by the shape of the resonator tract to produce our unique human sound.

When our voices are healthy, the three main parts work in harmony to provide effortless voice during speech and singing.

Secondhand Smoke

Access to quality healthcare for children is forwarded by the availability of good healthcare information. With this year’s release of a new surgeon general’s report on secondhand smoke, the following information should be shared with patients.

New Warning on Secondhand Smoke

In July 2006, the Surgeon General released evidence supporting the fact that secondhand smoke, smoke from a burning cigarette and the smoke exhaled by the smoker, represents a dangerous health hazard.

The new report states that there is no risk-free level of secondhand smoke exposure. Although secondhand smoke is dangerous to everyone, fetuses, infants, and children are at most risk. Even brief exposures can be harmful to children. This is because secondhand smoke can damage developing organs, such as the lungs and brain.

Infants and Children Effects and Exposure

Babies of mothers who smoked and those exposed to smoke are more likely to die from Sudden Infant Death Syndrome (SIDS) than babies who are not exposed to smoke.

Babies of mothers who smoked and those exposed to smoke after birth have weaker lungs and thereby increased risk of more health problems.

Children with asthma exposed to secondhand smoke experience more frequent and severe attacks.

Children exposed to secondhand smoke are at increased risk for ear infections and are more likely to need an operation to insert ear tubes for drainage.

Youth and Teens Effects and Exposure

Secondhand smoke exposure causes respiratory symptoms, including cough, phlegm, wheeze, and breathlessness, among school-aged children.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Statistics

More than 4,000 different chemicals have been identified in secondhand smoke and at least 43 of these chemicals cause cancer.

On average, children are exposed to more secondhand smoke than nonsmoking adults.

Approximately 26 percent of adults in the United States currently smoke cigarettes, and 50 to 67 percent of children less than five years of age live in homes with at least one adult smoker.

28 percent of high schoolers are exposed to secondhand smoke in their own homes.

A recent study found that 34 percent of teens begin smoking as a result of tobacco company promotional activities.

Among middle school students who were current smokers, 71 percent reported never being asked to show proof of age when buying cigarettes in a store, and 66 percent were not refused purchase because of their age.

Checklist for Protection Against Secondhand Smoke:

Young children

Remember that you are a powerful role model. If you don’t smoke, your children are less likely to smoke.

Make your home and car smoke-free spaces. Put up no-smoking stickers and signs in your home.

Make sure you and your kids aren’t exposed to second-hand smoke at daycare, school, or friends’ homes.

Support businesses and activities that are smoke-free. Let other businesses owners know that you can’t support their businesses until they become 100 percent smoke-free too.

If you can’t find a smoke-free restaurant and must go to one that allows some smoking, ask to sit in the nonsmoking section.

If your asthma or COPD is triggered by smoke, don’t risk it—stay away from any place that allows smoking.

Support laws that restrict smoking.

Youth and Teens

Parents—

Talk to your children about smoking; they’ll be less likely to smoke than if you ignore the problem.

Support tobacco education in the schools and ban all smoking on school grounds, on school buses, and at school-sponsored events for students, school personnel, and visitors.

Ask that schools enforce the policy and consistently administer penalties for violations and that this is communicated in written and oral form to students, staff, and visitors.

Vote for public smoking restrictions as an important component of the social environment that supports healthy behavior, reducing the number of opportunities to smoke, and making smoking less socially acceptable.

Support tax increases on tobacco products so young people cannot afford them.

Teens—

If your friends smoke, ask them in a caring way to quit or at least not to smoke around you.

Peers, siblings, and friends are powerful influences on you and others. Understand that the most common situation for first trying a cigarette is with a friend who already smokes.

Families—

Work together to uphold restrictions on tobacco advertising and promotions.

Sources and Resources

The Health Consequences of Involuntary Exposure to Tobacco Smoke: Children are Hurt by Secondhand Smoke. A Report of the Surgeon General, U.S. Department of Health and Human Services, 2006; Available at: www.surgeongeneral.gov/library/ secondhandsmoke/factsheets/factsheet2.html.

CDC. Tobacco Use, Access & Exposure to Tobacco Among Middle & High School Students, US 2004 MMWR. Vol. 54(12) April 2005.

American Legacy Foundation. 2004 National Youth Tobacco Survey. 2005

CDC. Cigarette Use Among High School Students – United States, 1991-2003. Morbidity and Mortality Weekly Report 2004; 53(23): 499-502.

King C, Siegel M. The Master Settlement Agreement with the Tobacco Industry and Cigarette Advertising in Magazines. New England Journal of Medicine 2001; 345: 504-511.

Sore Throats

Insight into relief for a sore throat

• What causes a sore throat?
• What are my treatment options?
• How can I prevent a sore throat?
• and more...

Infections from viruses or bacteria are the main cause of sore throats and can make it difficult to talk and breathe. Allergies and sinus infections can also contribute to a sore throat. If you have a sore throat that lasts for more than five to seven days, you should see your doctor. While increasing your liquid intake, gargling with warm salt water, or taking over-the-counter pain relievers may help, if appropriate, your doctor may write you a prescription for an antibiotic.

What are the causes and symptoms of a sore throat?

Infections by contagious viruses or bacteria are the source of the majority of sore throats.

Viruses: Sore throats often accompany viral infections, including the flu, colds, measles, chicken pox, whooping cough, and croup. One viral infection, infectious mononucleosis, or “mono,” takes much longer than a week to be cured. This virus lodges in the lymph system, causing massive enlargement of the tonsils, with white patches on their surface. Other symptoms include swollen glands in the neck, armpits, and groin; fever, chills, and headache. If you are suffering from mono, you will likely experience a severe sore throat that may last for one to four weeks and, sometimes, serious breathing difficulties. Mono causes extreme fatigue that can last six weeks or more, and can also affect the liver, leading to jaundice-yellow skin and eyes.

Bacteria: Strep throat is an infection caused by a particular strain of streptococcus bacteria. This infection can also damage the heart valves (rheumatic fever) and kidneys (nephritis), cause scarlet fever, tonsillitis, pneumonia, sinusitis, and ear infections. Symptoms of strep throat often include fever (greater than 101°F), white draining patches on the throat, and swollen or tender lymph glands in the neck. Children may have a headache and stomach pain.

Tonsillitis is an infection of the lumpy-appearing lymphatic tissues on each side of the back of the throat.

Infections in the nose and sinuses also can cause sore throats, because mucus from the nose drains down into the throat and carries the infection with it.

The most dangerous throat infection is epiglottitis, which infects a portion of the larynx (voice box) and causes swelling that closes the airway. Epiglottitis is an emergency condition that requires prompt medical attention. Suspect it when swallowing is extremely painful (causing drooling), when speech is muffled, and when breathing becomes difficult. Epiglottitis may not be obvious just by looking in the mouth. A strep test may overlook this infection.

Other causes

Allergies to pollens and molds such as cat and dog dander and house dust are common causes of sore throats.

Irritation caused by dry heat, a chronic stuffy nose, pollutants and chemicals, and straining your voice can also irritate your throat.

Reflux, or a regurgitation of stomach acids up into the back of the throat, can cause you to wake up with a sore throat.

Tumors of the throat, tongue, and larynx (voice box) can cause a sore throat with pain radiating to the ear and/or difficulty swallowing. Other important symptoms can include hoarseness, noisy breathing, a lump in the neck, unexplained weight loss, and/or spitting up blood in the saliva or phlegm.

HIV infection can sometimes cause a chronic sore throat, due not to HIV itself but to a secondary infection that can be extremely serious.

When should I see a doctor?

Whenever a sore throat is severe, persists longer than the usual five-to-seven day duration of a cold or flu, and is not associated with an avoidable allergy or irritation, you should seek medical attention. The following signs and symptoms should alert you to see your physician:

• Severe and prolonged sore throat
• Difficulty breathing
• Difficulty swallowing
• Difficulty opening the mouth
• Joint pain
• Earache
• Rash
• Fever (over 101°)
• Blood in saliva or phlegm
• Frequently recurring sore throat
• Lump in neck
• Hoarseness lasting over two weeks

How will I be tested for a sore throat?

To test for strep throat, your doctor may want to do a throat culture, a non-surgical procedure that uses an instrument to take a sampling of the infected cells. Because the culture will not detect other infections, when it is negative, your physician will base his/her decision for treatment on the severity of your symptoms and the appearance of your throat on examination.

What are my treatment options?

A mild sore throat associated with cold or flu symptoms can be made more comfortable with the following remedies:

• Increase your liquid intake.
• Warm tea with honey is a favorite home remedy.
• Use a steamer or humidifier in your bedroom.
• Gargle with warm salt water several times daily: ¼ tsp. salt to ½ cup water.
• Take over-the-counter pain relievers such as acetaminophen (Tylenol Sore Throat®, Tempra®) or ibuprofen (Motrin IB®, Advil®).

If you have a bacterial infection your doctor will prescribe an antibiotic to alleviate your symptoms. Antibiotics are drugs that kill or impair bacteria. Penicillin or erythromycin (well-known antibiotics) are prescribed when the physician suspects streptococcal or another bacterial infection that responds to them. However, a number of bacterial throat infections require other antibiotics instead.

Antibiotics do not cure viral infections, but viruses do lower the patient’s resistance to bacterial infections. When such a combined infection occurs, antibiotics may be recommended. When an antibiotic is prescribed, it should be taken as the physician directs for the full course (usually 7-10 days). Otherwise the infection may not be completely eliminated, and could return. Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may be a candidate for a tonsillectomy.

How can I prevent a sore throat?

• Avoid smoking or exposure to secondhand smoke. Tobacco smoke, whether primary or secondary, contains hundreds of toxic chemicals that can irritate the throat lining.
• If you have seasonal allergies or ongoing allergic reactions to dust, molds, or pet dander, you’re more likely to develop a sore throat than people who don’t have allergies.
• Avoid exposure to chemical irritants. Particulate matter in the air from the burning of fossil fuels, as well as common household chemicals, can cause throat irritation.
• If you experience chronic or frequent sinus infections you are more likely to experience a sore throat, since drainage from nose or sinus infections can cause throat infections as well.
• If you live or work in close quarters such as a child care center, classroom, office, prison, or military installation, you are at greater risk because viral and bacterial infections spread easily in environments where people are in close proximity.
• Maintain good hygiene. Do not share napkins, towels, and utensils with an infected person. Wash your hands regularly with soap or a sanitizing gel, for 10-15 seconds.

If you have HIV or diabetes, are undergoing steroid treatment or chemotherapy, are experiencing extreme fatigue or have a poor diet, you have reduced immunity and are more susceptible to infections.

Swallowing Trouble

Insight into complications and treatment

• What are the symptoms of swallowing disorders?
• How are swallowing disorders diagnosed?
• How are swallowing disorders treated?
• and more...

Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time, you should see an otolaryngologist—head and neck surgeon.

How do we swallow?

People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four related stages:

• The first stage is the oral preparation stage, where food or liquid is manipulated and chewed in preparation for swallowing.
• The second stage is the oral stage, where the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.
• The third stage is the pharyngeal stage which begins as food or liquid is quickly passed through the pharynx, the region of the throat which connects the mouth with the esophagus, then into the esophagus or swallowing tube.
• In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach.

Although the first and second stages have some voluntary control, stages three and four occur involuntarily, without conscious input.

What are the symptoms of swallowing disorders?

Symptoms of swallowing disorders may include:

• drooling
• a feeling that food or liquid is sticking in the throat
• discomfort in the throat or chest (when gastro esophageal reflux is present)
• a sensation of a foreign body or “lump” in the throat
• weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing
• coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs
• voice change

How are swallowing disorders diagnosed?

When dysphagia is persistent and the cause is not apparent, the otolaryngologist—head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors. Sometimes a small tube (flexible laryngoscope) is placed through the nose and the patient is then given food to eat while the scope is in place in the throat. These procedures provide visualization of the back of the tongue, throat, and larynx (voice box). These procedures are called FEES (Fiber optic Endoscopic Evaluation of Swallowing) or FEESST (Flexible Endoscopic Evaluation of Swallowing with Sensory Testing). If necessary, an examination of the esophagus, named TransNasal Esophagoscopy (TNE), may be carried out by the otolaryngologist. If you experience difficulty swallowing, it is important to seek treatment to avoid malnutrition and dehydration.

How are swallowing disorders treated?

Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.

Gastro esophageal reflux can often be treated by changing eating and living habits in these ways:

• Eat a bland diet with smaller, more frequent meals.
• Eliminate tobacco, alcohol and caffeine.
• Reduce weight and stress.
• Avoid food within three hours of bedtime.
• Elevate the head of the bed at night.

If these don’t help, antacids between meals and at bedtime may provide relief.

Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or stimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.

Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist or a speech language pathologist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.

Once the cause is determined, swallowing disorders may be treated with:

• medication
• swallowing therapy
• surgery

Surgery is used to treat certain problems. If a narrowing exists in the throat or esophagus, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be dilated or released surgically. This procedure is called a myotomy and is performed by an otolaryngologist—head and neck surgeon.

Many diseases contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist—head and neck surgeon.

What causes swallowing disorders?

Any interruption in the swallowing process can cause difficulties. Eating slowly and chewing thoroughly can help reduce problems with swallowing. However, difficulties may be due to a range of other causes, including something as simple as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastro esophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: hypertension; diabetes; thyroid disease; stroke; progressive neurologic disorder; the presence of a tracheotomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.

Swallowing difficulty can also be connected to some medications including:

• Nitrates
• Anticholinergic agents found in certain anti-depressants and allergy medications
• Calcium tablets
• Calcium channel blockers
• Aspirin
• Iron tablets
• Vitamin C
• Antipsychotic
• Tetracycline (used to treat acne)

Tonsils and Adenoids

Insight into tonsillectomy and adenoidectomy

• What affects tonsils and adenoids?
• When should I see a doctor?
• Common symptoms of tonsillitis and enlarged adenoids
• and more...

Tonsils and adenoids are on the body’s first line of defense—our immune system. They “sample” bacteria and viruses that enter the body through the mouth or nose at the risk of their own infection. But at times, they become more of a liability than an asset and may even trigger airway obstruction or repeated bacterial infections. Your ear, nose, and throat specialist can suggest the best treatment options.

What are tonsils and adenoids?

Two masses of tissue that are similar to the lymph nodes or “glands” found in the neck, groin, and armpits. Tonsils are the two masses on the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth without special instruments.

What affects tonsils and adenoids?

The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing, swallowing, and sleep problems.

Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.

When should I see a doctor?

You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.

Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she will use a small mirror or a flexible lighted instrument to see these areas.

Other methods used to check tonsils and adenoids are:

• Medical history
• Physical examination
• Throat cultures/Strep tests - helpful in determining infections in the throat
• X-rays - helpful in determining the size and shape of the adenoids
• Blood tests - helpful in determing infections such as mononucleosis

How are tonsil and adenoid diseases treated?

Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended if there are recurrent infections despite antibiotic therapy, and/or difficulty breathing due to enlarged tonsils and/or adenoids. Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children.

Chronic infection can affect other areas such as the eustachian tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and potential hearing loss. Recent studies indicate adenoidectomy may be a beneficial treatment for some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).

In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids. In some patients, especially those with infectious mononucleosis, severe enlargement may obstruct the airway. For those patients, treatment with steroids (e.g., cortisone) is sometimes helpful.

How to prepare for surgery

Children

• Talk to your child about his/her feelings and provide strong reassurance and support
• Encourage the idea that the procedure will make him/her healthier.
• Be with your child as much as possible before and after the surgery.
• Tell him/her to expect a sore throat after surgery.
• Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward.
• If your child has a friend who has had this surgery, it may be helpful to talk about it with that friend.

Adults and children

For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye’s syndrome).

• If the patient or patient’s family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.
• A blood test and possibly a urine test may be required prior to surgery.
• Generally, after midnight prior to the operation, nothing may be taken by mouth (including chewing gum, mouthwashes, throat lozenges, toothpaste, water.) Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.

When the patient arrives at the hospital or surgery center, the anesthesiologist or nursing staff may meet with the patient and family to review the patient’s history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.

After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient until discharged. Every patient is unique, and recovery time may vary.

Your ENT specialist will provide you with the details of preoperative and postoperative care and answer any questions you may have.

After surgery

There are several postoperative symptoms that may arise. These include, but are not limited to, swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.

Any questions or concerns you have should be discussed openly with your surgeon.

Tonsillitis and its symptoms

Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are:

• Redder than normal tonsils
• A white or yellow coating on the tonsils
• A slight voice change due to swelling
• Sore throat
• Uncomfortable or painful swallowing
• Swollen lymph nodes (glands) in the neck
• Fever
• Bad breath

Enlarged adenoids and their symptoms

If your or your child’s adenoids are enlarged, it may be hard to breathe through the nose. Other signs of constant enlargement are:

• Breathing through the mouth instead of the nose most of the time
• Nose sounds “blocked” when the person speaks
• Noisy breathing during the day
• Recurrent ear infections
• Snoring at night
• Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)