Voice loss Part 2 – Treatment options

In the first part of this article, we understand how our voice is produced, and in simple terms, how we lose our voice. Losing our voice is a problem for anyone as we are always communicating our wishes, dreams, love and needs to others.

So what can we do if we lose our voice? Firstly, we should not panic as common things happen commonly, and the commonest cause by far, is an acute viral laryngitis. The swelling from acute laryngitis is usually maximal at three days, after which the swelling subsides gradually, and the voice gradually returns to normal. During the inflamed phase, sufferers are best advised not to use their voice, as continuing voice use could damage and permanently scar the vocal cord lining. This scarring could result in a permanent hoarse voice by impairing the movement of the mucosal lining over the vocal ligaments.

Losing one’s voice is not unusual at all and most voices recover very quickly. If our voice doesn’t return to normal and you remain hoarse beyond three weeks, medical attention to make a diagnosis and to prevent long term irreversible damage would be recommended. Your ENT Surgeon can easily inspect your voice box by performing a flexible endoscopic examination of the larynx. So what conditions can cause chronic loss of voice that can be seen by endoscopy?

A growth on one or both vocal cords can prevent optimal closure of the cords. Excess air then leaks through the gap and voice production is impaired in terms of quality as well as intensity of the voice. Commonly the early formation of vocal cord nodules is the cause. Two non-cancerous thickening of the vocal cords on exactly opposite vocal cord surfaces prevent the cords from coming together well. With the leak, the voice is lost, and we try even harder to produce a voice by speaking louder. This means that the nodules can get bigger, and the hoarseness continues. Treatment here is primarily by speech therapy to re-educate the user how to use their voice better like a singer. If the nodules are too large and /or speech therapy has not worked, then phonosurgery to trim away the nodules may be necessary. If a growth is seen only on one vocal cord, then early surgery may be necessary to exclude cancer. Here the lesion is examined close up, excised and sent for testing. If it is cancerous, then follow up treatment protocols will be advised. However if the lesion looks like a cyst or a polyp under close up endoscopic examination during surgery, the lesion is removed with gentle and careful preservation of the vocal cord lining. This is called phonosurgery and requires great skill. The removal of the lesion is both diagnostic (as we sent the lesion for testing to know what it is) as well as also therapeutic (as the hoarse voice is treated as well)

A total loss of one’s voice is a catastrophe. This is unusual but it happens when one of the two vocal cords is paralysed. They are unable to meet in the midline, the gap is left wide open and therefore no turbulence or voice can be made. The cause here is damage to the nerve that moves the vocal cord. This nerve travels from our brain, down our neck pass our thyroid gland and even as far down as our lung, before turning around to innervate our voice box, one on each side. Cancer in the neck, lung cancer, strokes, penetrating trauma and surgery to the neck and thyroid are the usual causes that damage this nerve. If this is the case and recovery is not forthcoming, the voice can be improved by surgical treatment that pushes the affected cord to the center to a “closed” position. By re-siting the affected vocal cord to the midline “closed” position, surgeons allow the voice to be reproduced again when the normally functioning opposite vocal cord moves and easily close the gap. Rushing air from the lung re-vibrates the cords once again, turbulence of the air is produced and a voice is regenerated again. This particular treatment is important for these paralyzed vocal cords sufferers, as aside from a more normal voice, upper body strength is improved with an improved cough to maintain a clean and sputum free lung.

Remember, our voice is important and most loss of voice conditions are mild, short-lasting with full recovery. A persistent hoarse voice should not be regarded as normal as diagnosis is easily made with endoscopy in a clinic setting. Timely treatment ensures a good quality strong voice either by medication, speech therapy, surgery or all a combination of treatment to suit the problem.

The Chinese version of this article was published in Hong Kong Economic Journal on 22 Feb 2016 and 7 Mar 2016

Voice loss Part 1 – How our voice is produce and lost

Humans are social beings. We communicate with others using our voice as well as body language. So it naturally becomes a problem when we lose our voice.

We make our voice in our larynx. Here sit two ligaments called vocal cords, that are joined together in the front and sit apart at the back, like an open “V”. The vocal cords are covered with a soft mucosa lining, and lie horizontally immediately above our windpipe, acting as two guards protecting our airway.

So how do these two vocal cords make a voice? We need two things to occur for sound to be made. First the two vocal cords are brought together by a muscle, and at the same time, air from our lung is expelled through these closed cords. The air passing through our cords cause the mucosa covering to vibrate, and hence a sound (voice) is made. The pitch of this sound, our voice, is changed by other muscles tightening or relaxing the tension of the vocal ligaments. When the vocal ligaments are tightened, the voice becomes higher pitched, like when we strum a tightly stretched guitar string to create a higher note. For a lower tone sound, the tension is reduced, and a lower, more bass voice is produced. The voice of children, adult males and adult females also vary due to the size of the vocal cords and the “laryngeal” box that it sits in. A shorter vocal cord in a smaller box as in children produce a shriller, high tone voice whilst at the other extreme, a longer vocal cord in a bigger box of an adult male produces a deeper voice. Here the analogy is that of a child ukulele as compared to an adult double bass. The female adult voice is somewhere in between. So that is how the voice is made. Speech and language which strings sounds together to form words is different. Speech that form words of what we want to say, in the form of phonetics as well as the tone in tonal languages like Putonghua and Cantonese, comes from movements of our tongue above our voice box.

So how do we lose our voice? The commonest cause is an acute inflammation of our larynx (acute laryngitis) e.g. when we catch the flu. The lining of the vocal cords become swollen, inflamed and stiff and the inflammation causes pain when we try to speak. As air passes through the cords, the vibration is impaired. Making a sound is difficult as well as painful, and the voice changes to a very hoarse rasp or total loss altogether.

Another way that voice production can be impaired is if there is a growth on a vocal cord that prevents both the vocal cords from coming together perfectly. Conditions that could do this are e.g. cancer of the vocal cords commonly seen in smokers. These growths tents open the gap between the cords, and allows air to leak through the gap, making voice production inefficient at best, and sometimes impossible at worst.

The ultimate voice loss occurs when the vocal cords cannot come together. This is definitely an uncommon condition. We need both vocal cords to vibrate to make a sound. When one of the vocal cords cannot be drawn close, the gap between the vocal cord is too wide for turbulence of the air, and therefore sound, to made by the passing air. It is the same as when we try to whistle. We can only make a whistle with “closed” lips and not an “open” mouth. Here the reasons why a cord cannot “close” is usually due to damage to the nerve that supplies the “closing” muscle of that vocal cord.

To lose one’s voice is not unusual at all and most voices recover very quickly. However, a persistent hoarse voice or loss of voice for more than three weeks is not normal. If this continues, further medical attention for a diagnosis would normally be advised.

  

The Chinese version of this article was published in Hong Kong Economic Journal on 1 Feb 2016

The blocked nose and its impact on your health – What can be done?

In the previous article, we discuss the impact of a blocked nose and how many of us may not be aware we are blocked nor the health implications. So what can we do?

For any blocked nose, there are two components. Firstly a reversible component that is usually due to the congestion of the nasal lining. Secondly there is a non-reversible component due to a bent septum or excessive tissue that has built up over time and has become non-reversible.  These may exist in isolation by themselves, or co-exist and collaborating together to narrow the nasal airway to the detriment of your health.

Saline nose douching, topical steroid sprays and antihistamines as well as rest can reduce the reversible component of the blocked nose. When we are stressed and do not have enough sleep, our nasal vessels are more likely to be congested. In individuals with only allergy related blockage, this is very effective treatment, which is usually required seasonally, or long term for as long as the offending allergen/s is in your environment e.g. house dust, molds, pollens, etc. A good regimen of care will also reduce the severity of the other down line impacts of a congested nose e.g. sinusitis, mouth breathing and sore throats. In some case with headaches, the reduction in contact between the internal nasal tissues as well as reduced congestion and re-venting of the sinuses also reduces or abolishes these headaches.

However even after a trial of medical treatment, you may still find your nose blocked, and the treatment only partially effective. An endoscopic examination of the nose with possible imaging of the sinuses may declare that the obstruction is substantial due to pre-existing anatomical changes in the nose. The septum may be bent, the nasal lining now too swollen and thickened, nasal polyps may have formed which no longer can be reduced and/or the sinuses are chronically infected, and their openings now are too blocked for medical treatment to reverse the condition. Under these conditions, together with a clear history of symptoms and signs, surgery may be the solution. Surgery may include straightening the septum, reducing the turbinate size, removing the nasal polyps, re-venting the sinus openings and rinsing out the sinuses, or any of these combinations. Essentially the aim is to undertake whatever is necessary to improve the nasal airway and to permit natural re-venting of the sinuses.

So we can now breathe better after surgery and our overall health and sleep has improved. But does it end with surgery? Our environment usually remains the same; there is house dust, molds and pollens around us still. Some of us are still going to require saline irrigation of the nose and nasal sprays for the allergic flare-ups. Well funnily enough, opening the nasal airway by surgery does not only just improve airflow, it also improves the access for delivery of saline during nasal douching, and drug delivery via nasal sprays. That is the bad news. The good news is that most of us do not require long-term medical treatment… and all of us will live and sleep better now that the nose breathes better.

The Chinese version of this article was published in Hong Kong Economic Journal on 20 July 2015

The blocked nose and its impact on your health

Who hasn’t had a blocked nose? Especially when we have a cold and, thank goodness that the blocked nose, runny nose, sneezing as well as fever last only a few days. So can you imagine having a blocked nose all the year round? Most of us cannot imagine this! Yet most of us who live in polluted cities like Hong Kong probably are walking around with a blocked nose; a chronically blocked nose that creeps up on us so slowly that we never even guessed it.

Aside from smelling fragrances, the aroma of food, the appreciation of flavor as well as making our face look more beautiful, our nose has another far more important job. It protects our lungs by warming, filtering and cleansing the air before it reaches our delicate lungs. If the air is dirty, it causes our turbinates to swell inside so as to narrow or even block our nasal passages so that the air cannot enter. Our nose secretes mucus to wash away the dust and pollen, and if that is not enough, it gets all itchy and makes us sneeze so we can blow out the dust-filled mucus. So what happens to us when our nose gets chronically blocked? Actually quite a lot can happen. It affects our nose, our sinuses and eyes, our ears, our throat and finally our beauty sleep.

When the nose is blocked, we experience a nasally voice and have a postnasal drip. As the sensitive turbinates inside the nose swell up, they may make contact with one another or with the septum, and this sometimes causes “Sluder’s headaches” with pain of one/both temples, at the top and/or the back of the head. This may sometimes be mistaken for the more uncommon migraine.

When the lining of the nose is swollen, it also blocks the openings of structures that open into the nose. Blockage of any of the sinuses that drain into the nose can cause sinus pressure headaches above, below, between or behind the eyes as well as at the top of the head. A bacterial sinusitis can also occur if the sinuses cannot drain themselves. Our tear ducts also drain into the nose so a blocked nose may cause our eyes to “flood” more with tearing, impairing our clear vision. This can be troublesome indeed.

At the back of the nose lies the opening to the Eustachian tubes that re-pressurise our middle ear compartment. If the nose, and therefore the tube is blocked, a lower middle ear pressure can result. This is the same feeling we experience when a plane lands. Sometimes though it can be very painful especially for children. Longstanding obstruction of this tube often leads to repeated middle ear infections and/or perforated eardrums, and hearing problems especially in children.

So our nose is block. That is not a problem as we can breathe though our mouth, right? Correct…we can breathe through our mouth but why then do we need a nose? Actually most of us would automatically start to breathe though our mouth without realizing it when our nose is blocked. This leads to so many things like dry lips, bad breath, repeated mouth ulcers, sore throats that lead to large tonsils and repeated tonsil infections. Breathing and speaking through our mouth becomes a problem too. As the mouth gets drier, we cannot sense that we are breathing in less air than we should so. So when we speak, we cannot project our voice well. So we compensate by powering up our voice box to do all the work and that is why we end up with a hoarse voice.

Finally the blocked nose and the compensatory mouth breathing affects even our sleep. Although the mouth is a larger opening for air, inside our throat sits our mobile tongue and also tonsils. These sometimes are sucked in and obstruct during sleep, as the nose cannot act as its usual passage for air intake. Snoring, poor quality sleep and maybe even obstructive sleep apnea then occurs. Over time, the poor quality sleep we get every night makes us irritable, easily frustrated, gives us oily skin with acne, eye bags and a generally darker facial complexion.

All the above can occur because of a chronically blocked nose. The interesting thing is that many of us remain unaware that is happening as the process is such a gradual one. However, as quietly as it can be blocked, thankfully it can also be reversed with medication and/or surgery. So yes… we can still get the beauty sleep in our beautiful city…and all because of a nose!in our beautiful city…and all because of a nose! 

The Chinese version of this article was published in Hong Kong Economic Journal on 1 June 2015

Sinus and nose-related headaches – Treatment

In the last article, we discussed the causes of sinus and nose related headaches. These include causes such as:

·        nose allergy,

·        a bent nasal septum blocking the sinus opening or in contact with the    

         opposite nasal lining,
·        a narrowed sinus opening/s with a sinus infection and
·        an obstructed sinus with a negative sinus pressure

Sometimes possibly all of the above can be present in the same person at the same time. All of these conditions can stimulate and irritate the trigeminal nerve, which then generates the headache that we feel.

Treatment begins with the correct diagnosis. A full external and internal endoscopic examination of the nose should be undertaken. In instances when a sinus-related cause is suspected e.g. facial pains above, behind and below the eyes, and at the top of the head, a CT scan of the sinuses can exclude sinus disease. X-ray of the sinuses are traditionally undertaken but for a more comprehensive picture, CT scans provide a great deal more information as well as serve as the roadmap for sinus surgery should that be required.

Usually common things happen commonly, and by far the commonest nasal cause of a headache is inflammation of allergy or infection. If infection is seen, a simple course of antibiotics can be undertaken. Nasal allergy is easily treated also by avoiding the allergen e.g. house dust or pollen, saline nasal irrigation, topical nasal steroids and/or antihistamines. The reduction in the inflammation desensitizes the nasal lining as well as reduces the possibility of nasal lining contact and sinus obstruction.

Perhaps the next most likely cause for nasal irritation is when two opposing nasal linings touch one another forming a trigger point. This is likely to occur when the nasal septum is bent inside the nose. Often the patient would be aware of the bent septum as they are aware of a blocked nose, more on one side than the other although both may be equally blocked.

Sometimes a frank sinus infection is seen on endoscopy. Then antibiotic treatment with nasal decongestants also, would normally suffice, as sinus surgery is not the usual first line treatment modality. However in situations when the sinus condition becomes chronic without relenting or recurrent, then usually a more permanent solution to re-open the sinus drainage and re-vent the sinuses may be indicated. Nowadays, sinus surgery is extremely high tech, using endoscopes for minimally invasive surgery. Surgery is targeted at re-opening the natural openings of the sinuses. To make the surgery even less traumatic, when appropriate, the sinus openings can be re-dilated with inflatable balloons; this technique is known as balloon sinuplasty.

So to summarize, nose and sinus-related headaches are not altogether that uncommon especially today in our polluted modern world. It should be differentiated from all the other causes of headaches by its picture. Treatment of these headaches are usually very successful once the correct diagnosis has been established, as there is often a triggering point that fires off the nerve-endings of the trigeminal nerve that gives us these so-called Sluder’s headaches. You can almost imagine Dr. Sluder himself having a bad headache when he first described it too! 

The Chinese version of this article was published in Hong Kong Economic Journal on 5 Jan 2015

Sinus and nose-related headaches – Why? & Causes

Headaches! We have all had them. There are many causes of headaches but this article relates to that arising from conditions that affect the nose and sinuses. Our nose is very sensitive. It has to be as it forms one of our earliest sense organ for finding food as well as arousing us to the presence of danger from predators or our changing environment. Many of us know the nose as an organ of smell (and therefore flavor) and this sensation comes from the olfactory nerve. The nose however has another nerve supply that provides us with the sensation of heat, cold, dry, humid and of course, pain. This sensation arises from the fifth nerve of our brain called the trigeminal nerve.

 

You all know this nerve, which innervates your face, eyes, nose, sinuses and teeth. It burns and gives you a headache if you do somersaults underwater in the swimming pool or take too much wasabi on your sushi. Your face burns from the inside and your eyes water. This is when your trigeminal nerve is being hyper-stimulated.

 

This same nerve is responsible for the headaches one can get from sino-nasal disease. If someone has nasal allergy, and especially if the septum (the bone inside your nose that separates the right from the left nostril) is bent, the lining of the nose expands considerably. When the hypersensitive linings touches one another, they can cause a localized headache at the top of the head, the temples or the back of the head. This kind of headache, or nerve pain, is known as Sluder’s neuralgia or Sluder’s headache.

 

Our sinuses are air-filled cavities inside our skull. These cavities have very narrow openings into the nose. Again, due to:

 

·        a nose allergy,

·        a bent septum blocking the sinus opening,

·        a narrowed sinus opening/s from recurrent infection

·        or all of the above in the same person at the same time,

 

The sinus opening/s become blocked. When this happens, a negative pressure is generated within the sinus and this can cause facial pains and headaches. If, on the other hand, there is a bacterial infection with pus formation, the pus will build up an intense pressure from within the sinus causing pain too. This change in pressure stimulates the nerve endings in the nose and sinuses, causing a sinus headache.

 

If only specific sinuses are affected like the frontal sinuses above the eyes, then a headache above and behind the eye may be felt.  Sinus headaches are peculiar in that the pain changes in intensity with position, being usually more painful when the head is lowered i.e. tying the shoelaces or picking something from the floor. Also the bony surface of the face just outside the inflamed sinus is painful to applied pressure from outside the face.

 

Naturally, as you now understand that sino-nasal inflammation can cause headaches, you will realize that any infection of the inside of the nose can do this too. Even when we are stressed, the nose lining inside swells up and this can manifest as a headache. Equally cancers of the nose, sinuses and nasopharynx can cause headaches as they stimulate the trigeminal nerve or block the sinus openings. Cancers are thankfully much, much less common than allergies. However in any case, any persistent or recurring headaches is best investigated for its cause and the correct treatment offered.

 

 

The Chinese version of this article was published in Hong Kong Economic Journal on 22 Dec 2014

Epistaxis / Nosebleeds – What to do

Nosebleeds can happen when you least expect it. At the very least, they are alarming especially with small children, and at the worst, possibly life threatening. So what can you do about the bleeding nose and what action should you take after it has stopped bleeding?

The first thing is to stop the “stoppable” bleeding. Bleeding that comes from the front of the nose can be stopped by pressure. All other bleedings from the middle or back of the nose stops only by your own blood clotting or with medical attention. The first thing to do in a nose bleed is place your head forward, breathe through the mouth and press gently but firmly on the soft part of the nose. This is the lowest third of the nose that you can wiggle with your fingers. Placing your head forward means that you will be less likely to choke and swallow your blood, and any continuing bleeding is clear to see. Pressure should be applied for 15 minutes and this is usually more than enough to stop the small bleed, as our blood will effectively clot in less than 3 minutes. If you are on blood-thinning medication, this can take much longer.

After releasing the pressure, if there is no further active bleeding, this suggests that the bleeding is from the front of the nose. Dry weather and a long flight travel in a dry cabin may be the cause and applying some Vaseline ointment inside the nostrils will help. Seeking the early attention of your ENT Physician would be recommended so that a good check up can be done to prevent further bleeds and treating the underlying cause. You can usually expect that the nose will be clearly visualized with an endoscope of the front, middle and back of the nose. Sometimes a scan of the sinuses may be required as the cavities of the sinuses are not usually visible to the naked eye or endoscope. If a bleeding point is identified, it can be electro-cauterized and this is very successful in preventing future bleeding in 90% of cases. If a nasal allergy causing rhinitis exists, this is also easily treated with medication.

If the bleeding is especially heavy and/or does not stop, it is usually from the middle to the back of the nose. Here the reason is because the vessels are larger and we cannot physically press on them as they are situated inside the face. Situations such as this will require immediate attention at your nearest hospital as you may have lost a lot of blood. Your attending doctor’s priority would be to stop the bleeding first. This is usually undertaken with nasal packs placed into the nose. They are uncomfortable to put in but their intention is life saving. They may then possibly refer you to the ENT Physicians to identify with their special endoscopes where the bleeding is coming from, and treat you accordingly. Nowadays modern endoscopes for the body cavities have revolutionized epistaxis care. After identifying the bleeding point, if appropriate, the source maybe cauterized.

 

Nosebleeds are frightening for the sufferer as well as family and friends. Thankfully the majority of nosebleeds are minor and easily stopped by pressure as mentioned above. If the bleeding is unduly heavy and does not stop, urgent hospital attention should be sought.

The Chinese version of this article was published in Hong Kong Economic Journal on 29 Sept 2014