How about other parts of the body?
The history must also assess the status of the respiratory (breathing), gastrointestinal (gut), endocrine (hormone), neurological and psychological systems. Disturbances in any of these areas may be responsible for voice complaint. Selected common examples are discussed or illustrated later in this booklet.
Problems anywhere in the body must be illicited during the medical history. Because voice function relies on such complex brain and other nervous system interactions, even slight neurological dysfunction may cause voice abnormalities; and voice impairment is sometimes the first symptom of serious neurological diseases such as myasthenia gravis, multiple sclerosis and Parkinson's disease.
A history of a sprained ankle may reveal the true cause of voice dysfunction, especially in a singer, actor or speaker with great vocal demands. Proper posture is important to optimal function of the abdomen and chest. The imbalance created by standing with the weight over only one foot frequently impairs support enough to cause compensatory vocal strain, leading to hoarseness and voice fatigue. Similar imbalances may occur after other bodily injuries. These include not only injuries that involve support structures, but also problems in the head and neck, especially whiplash injuries. Naturally, a history of laryngeal trauma or surgery pre-dating voice dysfunction raises concerns about the anatomical integrity of the vocal fold; but a history of interference with the power source through abdominal or thoracic surgery may be just as important in understanding the cause and optimal treatment of vocal problems.
Does anxiety have anything to do with the voice?
When the principal cause of vocal dysfunction is anxiety, the physician can often accomplish much by assuring the patient that no organic (physical) difficulty is present and by stating the diagnosis of anxiety reaction. The patient should be counseled that anxiety-related voice disturbances are common, and that recognition of anxiety as the principal problem frequently allows the disorder to be overcome. Tranquilizers and sedatives are rarely necessary and are undesirable because they may interfere with fine motor control, affecting voice adversely. Recently, Beta-adrenergic blocking agents such as propranolol hydrochloride (eg, Inderal) have achieved some popularity in the treatment of pre-performance anxiety in singers and instrumentalists. Beta-blockers should not be used routinely for voice disorders and pre-performance anxiety. They have significant effects on the cardiovascular system and many potential complications, including hypotension, thrombocytopenic purpura, mental depression, agranulocytosis, laryngospasm with respiratory distress, and bronchospasm. In addition, their efficacy is controversial. If anxiety or other psychological factors are an important cause of a voice disorder, their treatment by a psychologist or psychiatrist with special interest and training in voice problems is extremely helpful. This therapy should occur in conjunction with voice therapy.
What about hormones?
Hormones are complex, natural chemicals that affect a variety of bodily functions. Endocrine (hormone-producing organs) problems also have marked vocal effects, primarily by causing accumulation of fluid in the superficial layer of the lamina propria, altering the vibratory characteristics. Mild hypothyroidism typically causes a muffled sound, slight loss of range and vocal sluggishness. Similar findings may be seen in pregnancy, during use of oral contraceptives (in about 5% of women), for a few days prior to menses and at the time of ovulation. Premenstrual loss of vocal efficiency, endurance and range is also accompanied by a propensity for vocal fold hemorrhage which may alter the voice permanently. The use of some medications with hormonal activity can also permanently injure a voice. This is particularly true of substances that contain androgens (male hormones) as discussed above.
Do stomach problems or hiatal hernia affect the voice?
Gastrointestinal disorders commonly cause voice complaints. The sphincter (a one-way valve) between the stomach and esophagus is notoriously weak. In gastroesophageal reflux laryngitis, stomach acid refluxes through this weak sphincter into the throat allowing droplets of the irritating gastric acid to come in contact with the vocal folds, and even to be aspirated into the lungs. Reflux may occur with or without a hiatal hernia. Common symptoms of reflux laryngitis are hoarseness especially in the morning, prolonged vocal warm-up time, bad breath, sensation of a lump in the throat, chronic sore throat, cough, and a dry or "coated" mouth. Typical heartburn is frequently absent. Over time, uncontrolled reflux may cause cancer of the esophagus and larynx. So, this condition should be treated aggressively and conscientiously.
Physical examination of the larynx usually reveals a bright red, often slightly swollen appearance of the arytenoid mucosa which helps establish the diagnosis. A barium esophagogram with water siphonage may provide additional information but is not needed routinely. In selected cases, 24 hour pH impedence monitoring provides the best analysis and documentation of reflux, and pharyngeal monitoring might prove useful. The mainstays of treatment are elevation of the head of the bed (not just sleeping on pillows), use of antacids, and avoidance of food for 3 or 4 hours before sleep. Avoidance of alcohol and coffee is also beneficial. Medications that block stomach acid secretion are also useful, including cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), omeprazole (Prilosec), lansoprazole (Prevacid), dexlansoprazole (Dexilant) and others. In some cases, surgery to repair the lower esophageal sphincter and cure the reflux may be more appropriate than life-long medical management. This option has become much more attractive since the development of laparoscopic surgery which has drastically decreased the morbidity associated with this operation.
Do lung problems cause voice disorders?
Respiratory problems are especially problematic to singers, other voice professionals, and wind instrumentalists, but they may cause voice problems in anyone. Support is essential to healthy voice production. The effects of severe respiratory infection are obvious and will not be enumerated. Restrictive lung disease such as that associated with obesity may impair support by decreasing lung volume and respiratory efficiency. However, obstructive pulmonary disease is the most common culprit. Even mild obstructive lung disease can impair support enough to cause increased neck and tongue muscle tension and abusive voice use capable of producing vocal nodules. This scenario occurs even with unrecognized asthma and may be difficult to diagnose unless suspected, because many such cases of asthma are exercised-induced. Vocal performance is a form of exercise, whether the performance involves singing, giving speeches, sales or other forms of intense voice use. Individuals with this problem will have normal pulmonary function clinically and may even have normal or nearly normal pulmonary function test findings at rest. However, as the voice is used intensively, pulmonary function decreases, effectively impairing support and resulting in compensatory abusive technique. When suspected, this entity can be confirmed through a methacholine challenge test performed by a pulmonary (lung) specialist.
Treatment of the underlying pulmonary disease to restore effective support is essential to resolving the vocal problem. Treating asthma is rendered more difficult in professional voice users because of the need in some patients to avoid not only inhalers but also drugs that produce even a mild tremor. The cooperation of a skilled pulmonologist specializing in asthma and sensitive to problems of performing artists is invaluable.