Throat
Hoarseness
Mouth Sores
Sore Throats
Swallowing Problems
Tonsils and Adenoids Tonsillectomy Procedures
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Hoarseness
What Is Hoarseness?
Hoarseness is a general term that describes abnormal voice changes. When hoarse, the voice may sound breathy, raspy, strained, or there may be changes in volume (loudness) or pitch (how high or low the voice is). The changes in sound are usually due to disorders related to the vocal cords that are the sound producing parts of the voice box (larynx). While breathing, the vocal cords remain apart. When speaking or singing, they come together, and as air leaves the lungs, they vibrate, producing sound. Swelling or lumps on the vocal cords prevent them from coming together properly and changes the way the cords vibrate, which makes a change in the voice, altering quality, volume, and pitch.
What Are The Causes Of Hoarseness?
Acute Laryngitis: There are many causes of hoarseness. Fortunately, most are not serious and tend to go away in a short period of time. The most common cause is acute laryngitis, which usually occurs due to swelling from a common cold, upper respiratory tract viral infection, or irritation caused by excessive voice use such as screaming at a sporting event or rock concert.
Vocal Nodules: More prolonged hoarseness is usually due to using your voice either too much, too loudly, or improperly over extended periods of time. These habits can lead to vocal nodules (singers’ nodes), which are callous-like growths, or may lead to polyps of the vocal cords (more extensive swelling). Both of these conditions are benign. Vocal nodules are common in children and adults who raise their voice in work or play.
Gastroesophageal Reflux: A common cause of hoarseness is gastro-esophageal reflux, when stomach acid comes up the swallowing tube (esophagus) and irritates the vocal cords. Many patients with reflux-related changes of voice do not have symptoms of heartburn. Usually, the voice is worse in the morning and improves during the day. These people may have a sensation of a lump in their throat, mucus sticking in their throat or an excessive desire to clear their throat. It is very important to realize that this condition is usually seen in the absence of any other symptoms, although patients are almost always surprised to realize that their stomach contents can cause such trouble with their voice and throat. Many of these patients can be helped with subtle behavioral or lifetime changes.
Smoking: Smoking is another cause of hoarseness. Since smoking is the major cause of throat cancer, if smokers are hoarse, they should see an otolaryngologist.
Other Causes: Many unusual causes for hoarseness include allergies, thyroid problems, neurological disorders, trauma to the voice box, and occasionally, the normal menstrual cycle.
Who Can Treat My Hoarseness?
Hoarseness due to a cold or flu may be evaluated primary care physicians. When hoarseness lasts longer than two weeks or has no obvious cause it should be evaluated by an otolaryngologist (ear, nose and throat doctor). Problems with the voice are best managed by a team of professionals who know and understand how the voice functions. These professionals are otolaryngologists, speech/language pathologists, and teachers of singing, acting, or public speaking. Voice disorders have many different characteristics that may give professionals a clue to the cause.
How Is Hoarseness Evaluated?
An otolaryngologist will obtain a thorough history of the hoarseness and your general health. Your doctor will usually look at the vocal cords with either a mirror placed in the back of your throat, or a very small, lighted flexible tube (fiberoptic scope) may be passed through your nose in order to view your vocal cords. Videotaping the examination or using stroboscopy (slow motion assessment) may also help with the analysis.
These procedures are not uncomfortable and are well tolerated by most patients. In some cases, special tests (known as acoustic analysis) designed to evaluate the voice, may be recommended. These measure voice irregularities, how the voice sounds, airflow, and other characteristics that are helpful in establishing a diagnosis and guiding treatment
When should I see an otolaryngologist (ENT doctor)?
Hoarseness lasting longer than two weeks especially if you smoke
Pain not from a cold or flu
Coughing up blood
Difficulty swallowing
Lump in the neck
Loss or severe change in voice lasting longer than a few days
How Are Vocal Disorders Treated?
The treatment of hoarseness depends on the cause. Most hoarseness can be treated by simply resting the voice or modifying how it is used. The otolaryngologist may make some recommendations about voice use behavior, refer the patient to other voice team members, and in some instances recommend surgery if a lesion, such as a polyp, is identified. Avoidance of smoking or exposure to secondhand smoke (passive smoking) is recommended to all patients. Drinking fluids and possibly using medications to thin the mucus are also helpful.
What Can I Do to Prevent and Treat Mild Hoarseness?
* If you smoke, quit.
* Avoid agents that dehydrate the body, such as alcohol and caffeine.
* Avoid secondhand smoke.
* Drink plenty of water.
* Humidify your home.
* Watch your diet–avoid spicy foods.
* Try not to use your voice too long or too loudly.
* Use a microphone if possible in situations where you need to project your voice.
* Seek professional voice training.
* Avoid speaking or singing when your voice is injured or hoarse.
Mouth Sores
If you have been bothered by a sore in your mouth that made it painful to eat and talk, you are not alone. Many otherwise healthy people suffer from recurrent mouth sores.
Two of the most common recurrent oral lesions are fever blisters (also called cold sores) and canker sores (aphthous ulcers). When they occur in the mouth, it may be difficult to distinguish one from the other. Since the treatment and cause of these two sores are completely different, it is extremely important to know which is which.
What Are Fever Blisters (Cold Sores)?
These are common names for fluid filled blisters that commonly occur on the lips. They also can occur in the mouth, particularly on the gums and roof of the mouth (hard palate), but this is rare. Fever blisters are usually painful; in fact, the pain may precede the appearance of the lesion by a few days. The blisters rupture within hours, then crust over. They last about 7-10 days.
Causes Of Fever Blisters
Fever blisters result from a herpes simplex virus which becomes active. This virus is latent (dormant) in afflicted people, but can be activated by conditions such as stress, fever, trauma, hormonal changes, and exposure to sunlight. When lesions reappear, they tend to form in the same location.
Can Fever Blisters Be Spread?
Yes, the time from blister rupture until the sore is completely healed is the time of greatest risk for spread of infection. The virus can spread to your own eyes and genitalia, as well as to other people.
Prevention Tips For Fever Blisters:
* avoid mucous membrane contact when a lesion is present
* do not squeeze, pinch or pick at the blister
* wash hands carefully before touching your eyes or genital area, or another person
Despite all caution, it is important to remember that it is possible to transmit herpes virus even when no blisters are present.
Treatment For Fever Blisters
Treatment consists of coating the lesions with a protective barrier ointment containing an antiviral agent, for example 5% acyclovir ointment. Presently, there is no cure, but there is much research activity underway in this field. Contact your doctor or dentist for the latest information.
What Are Canker Sores?
Canker sores (also called aphthous ulcers) are small, shallow ulcers occurring on the tongue, soft palate, or inside the lips and cheeks. They are quite painful, and usually last 5-10 days.
Causes Of Canker Sores
The best available evidence suggests that canker sores result from an altered local immune response associated with stress, trauma, or local irritants, such as eating acidic foods (i.e., tomatos, citrus fruits and some nuts.)
Can Canker Sores Be Spread?
No, since they are not caused by bacteria or viral agents, they cannot be spread locally or to anyone else.
Treatment For Canker Sores
The treatment is directed toward relieving discomfort and guarding against infection. A topical corticosteroid preparation such as triamcinolone dental paste (Kenalog in Orabase 0.1%Æ) is helpful. Unfortunately, no cure exists at present.
What About Other Sores?
For any mouth lesion that does not heal in two weeks, you should see your physician or dentist.
Sore Throats
What Causes A Sore Throat?
Sore throat is a symptom of many medical disorders. Infections cause the majority of sore throats and are contagious. Infections are caused either by viruses such as the flu, the common cold, mononucleosis, or by bacteria such as strep, mycoplasma, or hemophilus.
While bacteria respond to antibiotic treatment, viruses do not.
Viruses: Most viral sore throats accompany flu or colds along with a stuffy, runny nose, sneezing, and generalized aches and pains. These viruses are highly contagious and spread quickly, especially in winter. The body builds antibodies that destroy the virus, a process that takes about a week.
Bacteria: Strep throat is an infection caused by a particular strain of streptococcus bacteria. This infection can also damage the heart valves (rheumatic fever) and kidneys (nephritis), cause scarlet fever, tonsillitis, pneumonia, sinusitis, and ear infections.
Tonsillitis is an infection of the lumpy tissues on each side of the back of the throat. Healthy tonsils do not remain infected. Frequent sore throats from tonsillitis suggest the infection is not fully eliminated between episodes. A medical study has shown that children who suffer from frequent episodes of tonsillitis (such as three- to four- times each year for several years) were healthier after their tonsils were surgically removed.
The most dangerous throat infection is epiglottitis, caused by bacteria that infect a portion of the larynx (voice box) and cause swelling that closes the airway. This infection is an emergency condition that requires prompt medical attention. Suspect it when swallowing is extremely painful (causing drooling), when speech is muffled, and when breathing becomes difficult. A strep test may miss this infection.
Allergy: The same pollens and molds that irritate the nose when they are inhaled also may irritate the throat. Cat and dog danders and house dust are common causes of sore throats for people with allergies to them.
Irritation: During the cold winter months, dry heat may create a recurring, mild sore throat with a parched feeling, especially in the mornings. This often responds to humidification of bedroom air and increased liquid intake. Patients with a chronic stuffy nose, causing mouth breathing, also suffer with a dry throat. They need examination and treatment of the nose.
Reflux: An occasional cause of morning sore throat is regurgitation of stomach acids up into the back of the throat. To avoid reflux, tilt your bedframe so that the head is elevated four- to six-inches higher than the foot of the bed. You might find antacids helpful. You should also avoid eating within three hours of bedtime, and eliminate caffeine and alcohol. If these tips fail, see your doctor.
Tumors: Tumors of the throat, tongue, and larynx (voice box) are usually (but not always) associated with long-time use of tobacco and alcohol. Sore throat and difficulty swallowing, sometimes with pain radiating to the ear, may be symptoms of such a tumor. More often the sore throat is so mild or so chronic that it is hardly noticed. Other important symptoms include hoarseness, a lump in the neck, unexplained weight loss, and/or spitting up blood in the saliva or phlegm.
When Should I See a Doctor For A Sore Throat?
Whenever a sore throat is severe, persists longer than the usual five- to seven- day duration of a cold or flu, and is not associated with an avoidable allergy or irritation, you should seek medical attention. The following signs and symptoms should alert you to see your physician:
* Severe and prolonged sore throat
* Difficulty breathing
* Difficulty swallowing
* Difficulty opening the mouth
* Joint pain
* Earache
* Rash
* Fever (over 101_)
* Blood in saliva or phlegm
* Frequently recurring sore throat
* Lump in neck
* Hoarseness lasting over two weeks
When Should I Take Antibiotics For A Sore Throat?
Antibiotics are drugs that kill or impair bacteria. Penicillin or erythromycin (well-known antibiotics) are prescribed when the physician suspects streptococcal or another bacterial infection that responds to them. However, a number of bacterial throat infections require other antibiotics instead. Antibiotics do not cure viral infections, but viruses do lower the patient's resistance to bacterial infections. When such a combined infection occurs, antibiotics may be recommended. When an antibiotic is prescribed, it should be taken as the physician directs for the full course (usually 10 days). Otherwise the infection will probably be suppressed rather than eliminated, and it can return. Some children will experience recurrent infection despite antibiotic treatment. When some of these are strep infections or are severe, your child may require a tonsillectomy.
Should Other Family Members be Treated or Cultured?
When a strep test is positive, many experts recommend treatment or culturing of other family members. Practice good sanitary habits; avoid close physical contact; and sharing of napkins, towels, and utensils with the infected person. Handwashing makes good sense.
What If My Throat Culture Is Negative?
A strep culture tests only for the presence of streptococcal infections. Many other infections, both bacterial and viral, will yield negative cultures and sometimes so does a streptococcal infection. Therefore, when your culture is negative, your physician will base his/her decision for treatment on the severity of your symptoms and the appearance of your throat on examination.
How Can I Treat My Sore Throat?
A mild sore throat associated with cold or flu symptoms can be made more comfortable with the following remedies:
* Increase your liquid intake.
* Warm tea with honey is a favorite home remedy.
* Use a steamer or humidifier in your bedroom.
* Gargle with warm salt water several times daily: 1/4 tsp. salt to 1/2 cup water.
* Take over-the-counter pain relievers such as acetaminophen (Tylenol Sore ThroatÆ, TempraÆ) or ibuprofen (Motrin IBÆ, AdvilÆ).
Swallowing Trouble
Swallowing Disorders
Difficulty in swallowing (dysphagia) is common among all age groups, especially the elderly. The term dysphagia refers to the feeling of difficulty passing food or liquid from the mouth to the stomach. This may be caused by many factors, most of which are temporary and not threatening. Difficulties in swallowing rarely represent a more serious disease, such as a tumor or a progressive neurological disorder. When the difficulty does not clear up by itself in a short period of time, you should see an otolaryngologist–head and neck surgeon.
How You Swallow
People normally swallow hundreds of times a day to eat solids, drink liquids, and swallow the normal saliva and mucus that the body produces. The process of swallowing has four stages:
1. The first is oral preparation, where food or liquid is manipulated and chewed in preparation for swallowing.
2. During the oral stage, the tongue propels the food or liquid to the back of the mouth, starting the swallowing response.
3. The pharyngeal stage begins as food or liquid is quickly passed through the pharynx, the canal that connects the mouth with the esophagus, into the esophagus or swallowing tube.
4. In the final, esophageal stage, the food or liquid passes through the esophagus into the stomach.
Although the first and second stages have some voluntary control, stages three and four occur by themselves, without conscious input.
What Causes Swallowing Disorders?
Any interruption in the swallowing process can cause difficulties. It may be due to simple causes such as poor teeth, ill fitting dentures, or a common cold. One of the most common causes of dysphagia is gastroesophageal reflux. This occurs when stomach acid moves up the esophagus to the pharynx, causing discomfort. Other causes may include: stroke; progressive neurologic disorder; the presence of a tracheostomy tube; a paralyzed or unmoving vocal cord; a tumor in the mouth, throat, or esophagus; or surgery in the head, neck, or esophageal areas.
Symptoms Of Swallowing Disorders
Symptoms of swallowing disorders may include:
* drooling;
* a feeling that food or liquid is sticking in the throat;
* discomfort in the throat or chest (when gastroesophageal reflux is present);
* a sensation of a foreign body or "lump" in the throat;
* weight loss and inadequate nutrition due to prolonged or more significant problems with swallowing; and
* coughing or choking caused by bits of food, liquid, or saliva not passing easily during swallowing, and being sucked into the lungs.
Who Evaluates And Treats Swallowing Disorders?
When dysphagia is persistent and the cause is not apparent, the otolaryngologist–head and neck surgeon will discuss the history of your problem and examine your mouth and throat. This may be done with the aid of mirrors or a small tube (flexible laryngoscope), which provides vision of the back of the tongue, throat, and larynx (voice box). If necessary, an examination of the esophagus, stomach, and upper small intestine (duodenum) may be carried out by the otolaryngologist or a gastroenterologist. These specialists may recommend X-rays of the swallowing mechanism, called a barium swallow or upper G-I, which is done by a radiologist.
If special problems exist, a speech pathologist may consult with the radiologist regarding a modified barium swallow or videofluroscopy. These help to identify all four stages of the swallowing process. Using different consistencies of food and liquid, and having the patient swallow in various positions, a speech pathologist will test the ability to swallow. An exam by a neurologist may be necessary if the swallowing disorder stems from the nervous system, perhaps due to stroke or other neurologic disorders.
Possible Treatments For Swallowing Disorders
Many of these disorders can be treated with medication. Drugs that slow stomach acid production, muscle relaxants, and antacids are a few of the many medicines available. Treatment is tailored to the particular cause of the swallowing disorder.
Gastroesophageal reflux can often be treated by changing eating and living habits, for example:
* eat a bland diet with smaller, more frequent meals;
* eliminate alcohol and caffeine;
* reduce weight and stress;
* avoid food within three hours of bedtime; and
* elevate the head of the bed at night.
If these don't help, antacids between meals and at bedtime may provide relief.
Many swallowing disorders may be helped by direct swallowing therapy. A speech pathologist can provide special exercises for coordinating the swallowing muscles or restimulating the nerves that trigger the swallow reflex. Patients may also be taught simple ways to place food in the mouth or position the body and head to help the swallow occur successfully.
Some patients with swallowing disorders have difficulty feeding themselves. An occupational therapist can aid the patient and family in feeding techniques. These techniques make the patient as independent as possible. A dietician or nutritional expert can determine the amount of food or liquid necessary to sustain an individual and whether supplements are necessary.
Once the cause is determined, swallowing disorders may be treated with:
* medication
* swallowing therapy
* surgery
Surgery is used to treat certain problems. If a narrowing or stricture exists, the area may need to be stretched or dilated. If a muscle is too tight, it may need to be dilated or released surgically. This procedure is called a myotomy and is performed by an otolaryngologist–head and neck surgeon.
Many causes contribute to swallowing disorders. If you have a persistent problem swallowing, see an otolaryngologist–head and neck surgeon.
Tonsils and Adenoids
Insight Into Tonsillectomy and Adenoidectomy
Tonsils and adenoids are masses of tissue that are similar to the lymph nodes or "glands" found in the neck, groin, and armpits. Tonsils are the two masses on the back of the throat. Adenoids are high in the throat behind the nose and the roof of the mouth (soft palate) and are not visible through the mouth without special instruments.
Tonsils and adenoids are near the entrance to the breathing passages where they can catch incoming germs, which cause infections. They "sample" bacteria and viruses and can become infected themselves. Scientists believe they work as part of the body's immune system by filtering germs that attempt to invade the body, and that they help to develop antibodies to germs.
This happens primarily during the first few years of life, becoming less important as we get older. Children who must have their tonsils and adenoids removed suffer no loss in their resistance.
What Affects Tonsils And Adenoids?
The most common problems affecting the tonsils and adenoids are recurrent infections (throat or ear) and significant enlargement or obstruction that causes breathing and swallowing problems.
Abscesses around the tonsils, chronic tonsillitis, and infections of small pockets within the tonsils that produce foul-smelling, cheese-like formations can also affect the tonsils and adenoids, making them sore and swollen. Tumors are rare, but can grow on the tonsils.
When Should I See My Doctor?
You should see your doctor when you or your child suffer the common symptoms of infected or enlarged tonsils or adenoids.
The Exam
The primary methods used to check tonsils and adenoids are:
* Medical history
* Physical examination
* Throat cultures/Strep tests
* X-rays
* Blood tests
What Should I Expect At the Exam?
Your physician will ask about problems of the ear, nose, and throat and examine the head and neck. He or she will use a small mirror or a flexible lighted instrument to see these areas.
Cultures/strep tests are important in diagnosing certain infections in the throat, especially "strep" throat.
How Are Tonsil And Adenoid Diseases Treated?
Bacterial infections of the tonsils, especially those caused by streptococcus, are first treated with antibiotics. Sometimes, removal of the tonsils and/or adenoids may be recommended. The two primary reasons for tonsil and/or adenoid removal are (1) recurrent infection despite antibiotic therapy and (2) difficulty breathing due to enlarged tonsils and/or adenoids.
Such obstruction to breathing causes snoring and disturbed sleep that leads to daytime sleepiness in adults and behavioral problems in children. Some orthodontists believe chronic mouth breathing from large tonsils and adenoids causes malformations of the face and improper alignment of the teeth.
Chronic infection can affect other areas such as the Eustachian Tube – the passage between the back of the nose and the inside of the ear. This can lead to frequent ear infections and potential hearing loss.
Recent studies indicate adenoidectomy may be a beneficial treatment for some children with chronic earaches accompanied by fluid in the middle ear (otitis media with effusion).
In adults, the possibility of cancer or a tumor may be another reason for removing the tonsils and adenoids.
Tonsillitis And Its Symptoms
Tonsillitis is an infection in one or both tonsils. One sign is swelling of the tonsils. Other signs or symptoms are:
* Redder than normal tonsils
* A white or yellow coating on the tonsils
* A slight voice change due to swelling
* Sore throat
* Uncomfortable or painful swallowing
* Swollen lymph nodes (glands) in the neck
* Fever
* Bad breath
Enlarged Adenoids And Their Symptoms
If you or your child's adenoids are enlarged, it may be hard to breathe through the nose.
Other signs of constant enlargement are:
* Breathing through the mouth instead of the nose most of the time
* Nose sounds "blocked" when the person speaks
* Noisy breathing during the day
* Recurrent ear infections
* Snoring at night
* Breathing stops for a few seconds at night during snoring or loud breathing (sleep apnea)
Tonsillectomy Procedures
Unfortunately, there may be a time when medical therapy (antibiotics) fails to resolve the chronic tonsillar infections that affect your child. In other cases, your child may have enlarged tonsils, causing loud snoring, upper airway obstruction, and other sleep disorders. The best recourse for both these conditions may be removal or reduction of the tonsils and adenoids. The American Academy of Otolaryngology—Head and Neck Surgery recommends that children who have three or more tonsillar infections a year consider a tonsillectomy; the young patient with a sleep disorder should be a candidate for removal or reduction of the enlarged tonsils.
The Tonsillectomy Today
The first report of tonsillectomy was made by the Roman surgeon Celsus in 30 AD. He described scraping the tonsils and tearing them out or picking them up with a hook and excising them with a scalpel. There are now other procedures available – the choice may be dictated by the extent of the procedure and other considerations such as pain and post-operative bleeding. A quick review of each procedure follows:
* Cold knife (steel) dissection: The procedure requires the patient to undergo general anesthesia; the tonsils are completely removed with minimal post-operative bleeding.
* Electrocautery: Electrocautery burns the tonsillar tissue and assists in reducing blood loss through cauterization..
* Harmonic scalpel: This medical device uses ultrasonic energy to vibrate its blade at 55,000 cycles per second. Invisible to the naked eye, the vibration transfers energy to the tissue, providing simultaneous cutting and coagulation. Proponents of this procedure assert that the end result is precise cutting with minimal thermal damage.
* Bipolar Radiofrequency Ablation (Coblation): This procedure produces an ionized saline layer that disrupts molecular bonds without using heat. As the energy is transferred to the tissue, ionic dissociation occurs. This mechanism can be used to remove all or only part of the tonsil. It is done under general anesthesia in the operating room and can be used for enlarged tonsils and chronic or recurrent infections. The advantages of this technique are less pain, faster healing, and less post operative care.
Consult with an otolaryngologist regarding the optimum procedure to remove or reduce your tonsils and adenoids.
Surgery For Tonsils and Adenoids
Your child: Talk to your child about his/her feelings and provide strong reassurance and support throughout the process. Encourage the idea that the procedure will make him/her healthier. Be with your child as much as possible before and after the surgery. Tell him/her to expect a sore throat after surgery. Reassure your child that the operation does not remove any important parts of the body, and that he/she will not look any different afterward. If your child has a friend who has had this surgery, it may be helpful to talk about it with that friend.
Adults and children: For at least two weeks before any surgery, the patient should refrain from taking aspirin or other medications containing aspirin. (WARNING: Children should never be given aspirin because of the risk of developing Reye's syndrome).
* If the patient or patient's family has had any problems with anesthesia, the surgeon should be informed. If the patient is taking any other medications, has sickle cell anemia, has a bleeding disorder, is pregnant, has concerns about the transfusion of blood, or has used steroids in the past year, the surgeon should be informed.
* A blood test and possibly a urine test may be required prior to surgery.
* Generally, after midnight prior to the operation, nothing (chewing gum, mouthwashes, throat lozenges, toothpaste, water) may be taken by mouth. Anything in the stomach may be vomited when anesthesia is induced, and this is dangerous.
When the patient arrives at the hospital or surgery center, the anesthesiologist or nursing staff may meet with the patient and family to review the patient's history. The patient will then be taken to the operating room and given an anesthetic. Intravenous fluids are usually given during and after surgery.
After the operation, the patient will be taken to the recovery area. Recovery room staff will observe the patient until discharged. Every patient is special, and recovery times vary for each individual. Many patients are released after 2–10 hours. Others are kept overnight. Intensive care may be needed for select cases.
Your ENT specialist will provide you with the details of pre-operative and postoperative care and answer any questions you may have.
After Surgery
There are several postoperative symptoms that may arise. These include (but are not limited to) swallowing problems, vomiting, fever, throat pain, and ear pain. Occasionally, bleeding may occur after surgery. If the patient has any bleeding, your surgeon should be notified immediately.
Any questions or concerns you have should be discussed openly with your surgeon, who is there to assist you.
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