The commonest causes of voice problems
are short term upper respiratory tract
infections and are managed by and
general practitioners. But if it goes on
for longer than three weeks patients
should be referred up to see a
specialist. The commonest causes of
longer term problems with the voice are
firstly, tension that is tightness of the
larynx and the muscles around it and
this can result from either stress and
worry but it can be secondary to other
things too. It can be a leftover of a
upper respiratory tract infection, or it may be
that as we get older we simply are using the
wrong muscles to talk with. All of these
things can be diagnosed in the clinic.
Another common cause of voice problems
is reflux. Reflux is epidemic in the
western world. People are getting more
and more overweight and their diets
aren't as good as they could be and so
acid coming up from the stomach cannot
only affect the gullet, the oesophagus, but
it can also affect the larynx as well,
causing inflammation and voice problems.
The tools that we use in the outpatients
are small telescopes that allow us to
have a look at the throat and these may
either be passed through the mouth but
more commonly these days we tend to pass
them through the nose, which gives us
beautiful views of the throat and allow
us to diagnose voice problems at an
early stage and get people accurate
treatments and diagnosis. As a
laryngologist I work as part of a team
and most specifically we work with
speech and language therapists. They have
many functions and it's best that we
communicate together on a regular basis
to help the patients achieve their
therapeutic goals.
When one chord is not
moving properly in the voice box it
results in hoarseness, which is very
breathy in nature. People find it difficult
to generate any power.
In fact they have to produce about eight
times the normal power to get the kind
of voice that most people will generate
normally. This is very tiring and they
run out of breath. Also because the vocal
cords don't come together properly, food
and drink might go down the wrong way
and this can lead to problems eating and
drinking, particularly problems with
fluids and very occasionally can lead to
repeated chest infections. Now most
people with vocal cord paralysis get better over
a period of six months to a year,
and during that time they can be managed
easily, by a combination of speech and
language therapy, and vocal cord
injections. Where the paralysis is more
permanent, however, we use a different
approach. Here we have to push the cords
closer together on a permanent basis and
the tried-and-tested method of doing
this is to create a small block of
medical grade plastic called silastic
and to carve it into a wedge shape that
fits into the side of the voicebox and
pushes the chords closer together. Most
recently, however, we started to introduce
a brand-new technique called laryngeal
re-innovation and this is where you can
take one of the spare nerves in the neck,
yes we do have spare nerves that don't
do very much, and you can connect it up
to the paralysed vocal cord to give it
bulk, tone, and position.
This is where the top part of the gullet, which has a
sphincter on it called the
cricopharyngeal, doesn't relax properly
when you swallow and as a result
pressure tends to build up on top and as
it builds over time it causes a little
hernia to develop, a little pouch forms at
the top due to the pressure. Over time
this can get bigger and bigger and is
often three or four centimeters in size
by the time it's diagnosed. If it gets
very big it can actually become the
preferred route for food.
When patients have this problem the
pouch can fill up with fluid and food
and this can spill over onto the lungs
and cause pneumonia and infections. Most
of the time, however, patients present much
earlier than that with a chronic cough
and with a feeling of food coming back
into the mouth and sometimes a gurgling
noise in the neck. This is diagnosed by
performing a special x-ray called a
barium swallow. The pouch can be easily
managed in the vast majority of patients
and the commonest way of dealing with
it, is to pass a telescope under a general
anesthetic, through the mouth down onto
the pouch, and then divide the barrier
between the pouch and the oesophagus
using a staple gun. Most recently we've
introduced the addition of a laser to
this operation, which allows us under
high magnification to divide the fine
fibres of the muscle that's been causing
the problem. This operation used to be a
very big operation, but these days
patients are generally discharged the
following day, just as they are after the
endoscopic operation.
It used to be almost routine to remove tonsils, in
children in the 50s and 60s, as they were
thought to be the cause of lots of upper
respiratory tract infections and ill-health in later life.
We now know that
it's not necessary to remove them routinely.
Things aren't really quite so
clear-cut, however, and sometimes patients
are getting tonsillitis, which is really
interfering with their quality of life
and giving them a lot of time off work.
Tonsillectomy is not to be undertaken
lightly, especially in adults. In children
it's a very safe operation with a very
low risk of bleeding. Patients in
adulthood having had a tonsillectomy
will have pain for a good week and
possibly ten days, and they need to be
warned about that. They also need to have
somebody at home with them for a full
week. There is no real advantage between
the bipolar method, the coblation
method and the laser method they're just
different ways of doing the same thing,
and different surgeons will have
different preferences for these
different methods. There is no evidence
that any of those three methods really
have different outcomes, although the
laser one may take rather longer than
the other two. Tonsillectomy for snoring
can help but you have to select the
patients extremely carefully and they
have to be aware of what all the
potential side effects are as well.