Philadelphia Ear, Nose and Throat Associates: PENTA

Medications


  What drugs are used for vocal dysfunction?


Antibiotics

When antibiotics are used to treat vocal dysfunction secondary to infection, high doses to achieve therapeutic blood levels rapidly are recommended and a full course (usually 7 to 10 days) should be administered.  Starting treatment with an intramuscular injection may be helpful if there is time pressure.


Steroids

Corticosteroids are potent anti-inflammatory agents and may be helpful in managing acute inflammatory laryngitis.  Although many laryngologists recommend using steroids in low doses (methylprednisone 10 mg), the author has found higher doses for short periods to be more effective.  Depending on the indication, dosage may be prednisolone 60 mg or dexamethasone 6 mg intramuscularly once, or a similar starting dose orally, tapered over 3 to 6 days.  Regimens such as a dexamethasone [Decadron] or methylprednisolone [Medrol] dose pack may also be used.  If any question exists that the inflammation may be of infectious origin, antibiotic coverage is generally recommended.  Care must be taken not to prescribe steroids excessively.  Anabolic steroids which have received so much attention because of their abuse by athletics, are not used for voice treatment, and may damage (masculinize) the voice.


Aspirin and Other Pain Medicines

Aspirin and other analgesics frequently have been prescribed for relief of minor throat and laryngeal irritations.  However, the platelet dysfunction caused by aspirin predisposes to hemorrhage, especially in vocal folds traumatized by excessive voice use in cases of vocal dysfunction.  Mucosal hemorrhage can be devastating to a professional voice user, and people who depend on extensive voice use should avoid aspirin products altogether unless they are absolutely necessary for treatment of special medical conditions.  Acetaminophen is the best substitute, as even most common nonsteroidal anti-inflammatory drugs such as ibuprofen may interfere with the clotting mechanism. 

Pain is an important protective physiologic function.  Masking it risks incurring grave vocal damage that may be unrecognized until after the analgesic or anesthetic wears off.  If a patient requires analgesics or topical anesthetics to alleviate laryngeal discomfort, the laryngitis is severe enough to warrant canceling a vocal performance.  If the analgesic is for headache or some other discomfort not intimately associated with voice production, symptomatic treatment should be discouraged until demanding vocal commitments have been completed.

 

Antihistamines and mucolytics

Antihistamines may be used to treat allergies. However, because they tend to cause dryness and are frequently combined with sympathomimetic or parasympatholytic agents (decongestants) that further reduce and thicken mucosal secretions, they may reduce lubrication to the point of producing a dry cough. This dryness may be more harmful than the allergic condition itself. Mild antihistamines in small doses should be tried between voice commitments, but they should generally not be used for the first time immediately before performances if the vocalist has had no previous experience with them. Their adverse effects may be counteracted to some extent with mucolytic expectorants that help liquify thick mucous and increase the output of thin respiratory tract secretions. Guaifenesin, the most commonly prescribed mucolytic, thins and increases secretions. Mucinex (Reckitt Benckiser) is one of the convenient and most effective preparations of guaifenesin available. These drugs are relatively harmless and may be very helpful to patients who experience thick secretions, frequent throat clearing, or "postnasal drip." Steroids are a highly effective alternative to antihistamines for treating an acute allergic insult prior to voice commitment.


Diuretics

In the premenstrual period, altered estrogen and progesterone levels are associated with changes in pituitary activity.  An increase in circulating antidiuretic hormone results in fluid retention in Reinke's space (superficial layer of the lamina propria) as well as other tissues.  The fluid retained in the vocal fold during inflammation and hormonal fluid shifts is bound,  not free water.  Diuretics do not remobilize this fluid effectively and dehydrate the patient.  Additionally, they produce decreased lubrication, thickened secretions, and persistently edematous vocal folds.  They have no place in the treatment of pre-menstrual voice disorders.  If they are used for other medical reasons, their vocal effects should be monitored closely.


Sprays and Inhalants

The use of analgesic topical sprays is extremely dangerous and should be avoided.  Diphenhydramine hydrochloride [Benadryl], 0.5% in distilled water, delivered to the larynx as a mist is a formerly popular treatment that may be helpful for its vasoconstrictive properties, but it is also dangerous because of its analgesic effect.  It should not be used.  Other topical vasoconstrictors that do not contain analgesics may be beneficial in selected cases.  Oxymetazoline hydrochloride [Afrin] is particularly helpful in rare, extreme circumstances.  Propylene glycol 5% in a physiologically balanced salt solution may be delivered by large-particle mist and can provide helpful lubrication shortly before performance, particularly in cases of laryngitis sicca after air travel or in dry climates.  Such treatment is harmless and may also provide a beneficial placebo effect.  Water or saline solution delivered via a vaporizer or steam generator is frequently effective and sufficient.  This therapy should be augmented by oral hydration, which is the mainstay of treatment for dehydration.  Voice users should monitor their state of hydration by observing their urine color ("pee pale").