Throat, voice and respiration:
Inflammation of the larynx can lead to pain in this area. Often these are “simple” viral inflammations, sometimes associated with coughing and often with hoarseness. If the pain at swallowing is very severe and has a fulminant course, if fever and worsening of the general condition are added, as well as muffled speech (no hoarseness) and shortness of breath, then it could be an inflammation of the epiglottis (epiglottitis), an extremely threatening disease, which can occur mostly in children, rarely in adults. Fortunately, their occurrence has become rarer today, as many children are vaccinated against the pathogen (Haemophilus influenzae type b, HIB).
Compulsive throat clearing
Almost all diseases in the larynx area also lead to throat clearing. Sometimes, clearing one’s throat is a symptom of subjectively unobserved reflux (reflux of acid from the stomach, for example, in a loosened sphincter of the oesophagus). It is often forgotten that even an inappropriate use of the voice can lead to throat clearing. The clearing of the throat itself, in turn, leads to renewed irritation and to further harrumphing by means of a vicious circle, and the symptom becomes increasingly independent. It is important to have a precise phoniatric examination to identify and correct possible causes. Then, so-called “vocal hygiene measures” are recommended: First of all, attention should be paid to a sufficient intake of liquid (such as water or herbal tea, but no coffee or sweetened beverages) to liquefy the viscous mucus often present at the same time. Smokers should reduce the consumption of nicotine or refrain altogether from smoking. The sucking of unsweetened and menthol-free candies can provide relief. In stubborn cases, an ice-water therapy can be carried out. Clearing the throat is basically to be avoided, as it damages the vocal folds. In addition, the permanent throat clearing noise is often perceived as very disturbing by other people in a communication situation.
Coughing in which mucus is transported upwards (productive cough), is usually treated by the family doctor, the internist or the pulmonologist. In otorhinolaryngology, we see above all, those patients who suffer from an irritative cough. It is indicated as “being high in the throat” and the patient usually points spontaneously to the throat area. The cough is mostly dry. Most of the examinations at the family doctor were unremarkable, especially with regard to asthma or cardiovascular disease. Presumably, there has already been a evaluation of the medical history and a discontinuation of those medications that can classically cause side effects such as irritative cough (e.g., psychotropic drugs, contraceptives, antihypertensives). If the cough is acute and is associated with hoarseness, there is often a (viral) inflammation (laryngitis), for which the therapy primarily consists in resting the voice and to carry out steam inhalations. Chronic irritative cough may also be caused by pollutants in the breathing air (for example, in the workplace, smoking), by malfunctioning air conditioners and by diseases of the nose, sinuses or larynx. Also (usually unnoticed) acid belching (gastroesophageal reflux, GERD) can cause irritation of the larynx. It is not uncommon for a irritable cough to occur in cases of incorrect use of voice in speaking professions and with very dry mucous membranes. As a rarity, even a hard foreign body in the ear canal may be the cause or another disease that can affect the vagus nerve and thus cause irritative cough. Not so rare is a “nervous” or “psychogenic” irritative cough. In all cases, there is an in-depth questionnaire (anamnesis) at the beginning of the consultation, followed by a detailed examination of the neck, nose and ears, including a phonological examination of the vocal cords by means of stroboscopy. Depending on the findings, a corresponding therapy is then initiated. Sometimes different factors interact, so over time different therapies have to be combined.
Spitting blood (haemoptysis)
Haemoptysis is the spitting out of saliva with more or less blood added. It may result from bleeding gums, nasal bleeding from the nasopharynx, or from minor bleeding of the entire mucous membrane of the pharynx, and requires close control, often with endoscopes, to exclude more serious diseases. Delineations include blood vomiting (haematemesis) or haemoptysis (where saliva consists predominantly or solely of blood), which can be potentially threatening symptoms of lung or stomach bowel disease, and belong in the care of the family doctor or specialist.
Hoarseness can have many causes. Often the cause is a viral infection and by resting the voice and with a little patience, the voice recovers all by itself. Sometimes, however, there is a “chronic” voice problem and patients do not complain of massive hoarseness, but “just” a limited voice performance: “The voice is not loud enough”, “the voice doesn’t keep up”, “the voice is rough or husky”. In many cases these are malfunctions or simply “overexertions”. In pronounced cases, these even lead to organic changes, so-called vocal cord nodules, in children known as cry nodules, or as singer nodules in singers. The therapy consists in a logopaedic exercise therapy, possibly supported by an operative intervention. With children one is more cautious with a logopaedic therapy, because they find it difficult to put what they have learned into practice in everyday life. Here it is advisable to wait with a therapy until after puberty and ask the parents to pay attention to a quiet speech environment. However, diagnostic assessment by a specialised physician is also essential for children, to exclude other, more serious causes of hoarseness (in children, for example, juvenile papillomatosis).
In adults with functional voice disorders, a logopaedic therapy is initiated as early as possible, not least to maintain the ability to work. Today, most people work in a profession where a good voice is needed, if not even a prerequisite, while at the turn of the century many people were still working in a more crafting profession. This is why vocal disorders are much more common in specialist medical surgeries today than in the past. In particular, in people with highly vocal-oriented occupations (e.g., counsellors, call centre agents, teachers) voice problems are steadily increasing. For teachers, the situation is aggravated by noise and adds to the overexertion of the voice. It would therefore be desirable to advise young adults before and during their education and, if necessary, to accompany them with voice training. A special and very common form of voice disorder is hoarseness in the elderly, the so-called “seniors voice” (Presbyphonia). In the course of life, the vocal folds get thinner and thus the voice function worsens. In women the voice often gets deeper, and higher in men. This not only concerns us normal speakers, but also professional singers and speakers whose careers may be affected by such age-related changes. An improvement of the aged voice can be tried by vocal therapy or vocal lip augmentation, but not always succeeds with a satisfactory result. In these cases, one has to accept the situation – as with other age disorders as well. Maybe the saying of the famous opera singer Luciano Pavarotti will help us: “Without voice you are nobody, with voice you are far from being somebody.”
A vocal cord augmentation may also be indicated if, after minor upper respiratory tract infections, but also after surgery on the thyroid, cervical spine or heart, the vocal cord nerve is temporarily or permanently paralysed (recurrent paresis, vagus palsy, paresis of the superior laryngeal nerve). In any case, a check-up by a phoniatric specialist should be carried out as early as possible and voice therapy should be started to avoid malfunction.
Some patients complain less about hoarseness than about abnormal sensations in the area of the larynx. “It burns or itches”, “I have a lump in my throat”, “I constantly need to clear my throat”. These patients may have voice dysfunction, but more commonly there are larynx problems associated with the stomach (acid reflux), medications (e.g., asthma sprays) or lack of “voice hygiene”. Good “voice hygiene” means everything that improves the voice, such as taking in a lot of liquid, paying attention to a good nasal breathing, not straining the voice, avoidance of smoky rooms and being a non-smoker.
Many patients who visit the specialist with a voice problem, are primarily afraid of a malignant disease, such as larynx cancer.
It is undisputed that voice problems and malignant tumours are more common in smokers than in non-smokers. Although larynx cancer occurs in only a few smokers, most patients with larynx cancer are smokers.
Fortunately, among the organic laryngeal changes, we often find benign diseases such as polyps or cysts, and rarely a malignant change. However, vocal problems that last longer than four weeks belong in the care of an ENT specialist. He or she can accurately examine the larynx, even with strong gag reflex, with the help of appropriate optical devices and in many cases show the findings in an image or video to the patient.
Vocal Cord Dysfunction
Vocal cord dysfunction (VCD) is a “dysfunction” of the vocal cords that can narrow or even close, leading to a sudden shortness of breath. VCD is colloquially also called “laryngospasm” and it can even lead to unconsciousness in particularly severe cases. Thus, VCD is an intermittent, functional, respiratory distress-inducing laryngeal obstruction during inspiration or expiration.
The data on how often VCD is found in the population varies greatly depending on the examination and varies between 2.5–30% of all patients with respiratory distress. VCD can occur alone or together with asthma and is responsible for the medically intractable part of the respiratory distress (dyspnoea).
VCD is not a homogeneous disease, but a complex disease in whose development various factors may be involved.
Recurrent irritation of the laryngeal mucosa can lead to a protective reflex of the vocal folds, regardless of the respiratory cycle, and they move closer to each other (adduction) or become completely closed (laryngospasm). Triggering factors can be a nasal discharge (post nasal drip, PND), acid reflux (gastroesophageal reflux/GERD and laryngopharyngeal reflux/LPR), inhalation stimuli (pollen, smoke, cold air), but also neurological diseases, cervical spine problems, laryngeal inflammation and vocal cord paralysis.
A psychosomatic component often plays a role, but is not always the primary cause. In this case, the transitions to anxiety and panic disorders and also to hyperventilation are fluent.
In VCD, the respiratory distress, which is usually reported in the area of the neck, occurs as an attack and manifests itself from one breath to the next. The following triggers are most common: Coughing, choking, irritants in the air, physical exercise, mental agitation.
The diagnosis is sometimes difficult to make. The paradoxical vocal cord mobility can rarely be seen in the examination of the larynx with the help of a fibre endoscope, and sometimes the pulmonary function test reveals a striking inspiratory flow-volume curve. The gold standard is for the physician the direct evidence of a VCD seizure in the laryngoscopic examination. Often, however, despite extensive investigations no direct evidence is found, which however does not exclude VCD. In these cases, the doctor relies on an exact survey of the patients, who are often able to describe their problem so clearly that the suspicion of VCD is close.
The first manifestation of VCD is often experienced as life-threatening. VCD seizures clinically impress as acute emergency situations with stridor-stricken patients (sound at inhalation) and maximal struggling for breath. It often happens that VCD patients need to be intubated and ventilated at the emergency department. But: VCD is self-limiting. Therefore, it is important that the patient acquires an understanding of the symptoms and the apparent contradiction of life-threatening respiratory distress and the comparatively harmless disorder.
Asthma therapy is usually ineffective in VCD patients. Informing the patient is therefore the most effective therapy.
By understanding, the patient can put fears away, paving the way for a problem-solving respiratory therapy, with the goal to replace the functionally paradoxical airway obstruction with an opposing, opening breathing technique. Breathing through the nose, diaphragm-emphasised breathing and “throat-relaxed breathing” are also important.
Voice medical opinion
As phoniatrician I am able to issue voice medical opinions, which are required upon admission for training as a speech therapist or at various schools for singing, musicals and theatre. The service is not covered by statutory health insurance. I am also happy to examine and advise people who want to train for a speaking profession and are unsure about their voice performance.
The normal swallowing act is extremely complex. In all 50 muscle pairs, 6 cranial nerves, the upper three cervical nerves and various brain centres are involved in the undisturbed act of swallowing and it takes place in an area that is in addition to swallowing, also responsible for breathing and for speaking. In finely tuned coordination, the course of the swallowing process adapts to the consistency of the substance to be swallowed. So it is not surprising that dysphagia is a common symptom, be it now and then, when we “choke on something”, or be it frequently after brain infarcts, degenerative brain diseases, after surgeries or even in inflammatory or tumorous changes in the mouth and pharynx. Addressing the various diseases would lead too far and should be confined to one of the most common dysphagia problems in practice, where in particular older people complain about swallowing problems.
Swallowing, like all other bodily functions, undergoes a natural ageing process, so that swallowing disorders become more likely with age (presbyphagia). In addition, older people are more likely to suffer from disorders that may cause difficulty in swallowing, or take medicines that increase their difficulty of swallowing. Older people do not have the same reserves when swallowing as younger people. While a young person can drink a glass of water in a headstand, it is no longer possible for older people to eat on the sofa without choking. Older people should sit upright while eating, with their feet on the ground. They should concentrate on the food and not talk at the same time and they often have to swallow vigorously or wash down the food with a glass of water. In elderly people should be ensured that the teeth are repaired or in case of a denture, its firm positioning is assured, so that the food can be chewed well. At best, even an adjustment of the consistency of the food is necessary. Dry, fibrous foods (such as chewy meat), but also foods of mixed consistency (e.g. fruit salad in syrup) or whole-grain products with small seeds are difficult to chew and swallow. Also problematic are certain tablets, which should be ground or taken with liquid.
At the beginning of each swallowing examination in our surgery is the conversation, which already gives indications as to whether it is a severe swallowing disorder or “only” a “difficult” swallowing. Unwanted weight loss or persistent pneumonia can indicate a serious swallowing problem. In this case, it must be clarified exactly whether a portion of the food penetrates the respiratory tract unnoticedly (silent aspiration). A swallowing examination involves not only the normal ear, nose and throat examination, but also a special swallowing examination, in which the swallowing act of swallowing different consistencies can be observed by means of a flexible optic device (fibre optic endoscopic evaluation of swallowing, FEES). Sometimes additional dynamic x-ray examinations of the swallowing process and possibly a check-up by a gastrointestinal specialist are needed. At the end of each swallowing examination counselling takes place on behavioural measures for swallowing and in cases of severe dysphagia swallowing therapy with a specially trained speech therapist.
Respiratory distress (dyspnoea), vocal cord dysfunction (VCD)
A blockage of the airways, especially in the area of the pharynx and the larynx, should be regarded as an absolute and urgent emergency situation. Almost always during inhalation one hears a noise (inspiratory stridor), which is caused by the bottleneck, also sometimes with the exhalation (for example pseudocroup). In acute dyspnoea with stridor, an emergency department should be consulted immediately.
But there are also respiratory distress attacks, which are due to a dysfunction in the larynx (vocal cord dysfunction, VCD). They are very distressing for the patient, but never cause suffocation. Often, the attack is preceded by a coughing fit and patients are screened for lung disease, particularly asthma, without any conspicuous findings. In these cases, coaching combined with respiratory therapy and supportive medication can relieve the discomfort.