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Laryngitis: Causes of Loss of Voice and Hoarseness
Laryngitis (hoarseness) is caused by a variety of process all causing swelling and scarring of the vocal cords.
The voice box (larynx) is a specialized organ in the central portion of the neck that separates air from food so that the air goes to the trachea and food is channeled into the esophagus passing to the stomach. The larynx is structures so that the epiglottis folds over the vocal cords when food is swallowed. Food then falls behind the voice box into the esophagus. When breathing in, air passes forward through the vocal cords. The vocal cords are united in front at a point called the anterior commissure. On the back side of the vocal cords they are hinged by a specialized joint that uses a bone that is attached in such a way that the joint actually rotates in or out of the airway. It does not just bend as most joints do. When the left and right vocal cord joint (cricoarytenoid joint) swings out the back sides of the vocal cords pivot out. When the joint swings in the back side of the vocal cords pivot in bringing the vocal cords together. When you breath in both joint pivot out causing the airway at that point to open maximally (abduct). Air can then pass into the lungs during inspiration. When breathing out quickly, such as when you run, the cords will stay open to allow air to pass in and out without a restriction. When you want to talk the voice box vocal cord joint will pivot in; making the vocal cords on the left and right lay side by side with a narrow slit in between them. The vocal cords open during inspiration. Air rushes into the lungs. During expiration the vocal cords can close causing the air to have to whistle through a 1½ to 1 mm slit. The vocal cords are approximately 1½ inches long and are specially designed to vibrate freely. They have a thin, ivory white surface lining (mucosa) with very thin underlying connective tissue that is loosely connected to the underlying vocal cord muscle. This weakly connected surface can thus vibrate extremely easily. The vocal cords can vibrate at the rate of 2,000 to 3,000/second. This, by design, is the exact frequency of sound that the human ears can hear best.
If anything causes the surface to become thickened or swollen the vocal cords cannot vibrate equally or rapidly. The sound generated is thus irregular. This makes the voice hoarse causing “laryngitis.” What causes these surface changes can vary tremendously.
The most common cause of laryngitis is an infection. These can be a bacterial or viral infection, although viral infects are much more common. The virus attaches to the surface (mucosa), into the mucosal cells, multiply in number (into the millions), and cause the cell to rupture releasing more virus. During a common cold one-half to one-third of all the cells in the vocal cords will be destroyed leaving a raw, uncovered vocal cords. Some viruses are “trophic” to vocal cord cells, but many are not and these will not cause laryngitis. When one-half to one-third of the vocal cord surfaces is destroyed it requires three to six days for those cells to be regrown. Even when they have been replaced the cord has persistent swelling (edema) and increased vascularity. All of these aspects cause the vocal cords to be swollen for a relatively long period. It can cause the vocal cords to be swollen and unable to vibrate normally for two to three weeks. That is why people will be hoarse for that period of time after and upper respiratory tract infection or cold. After a cold it thus necessary to allow the vocal cords to heal. We recommend voice rest, vigorous hydration (lots of fluids), and suppressing cough (cough causes more sheering force on the vocal cords and thus more damage).
Frequently steroids will be given. This causes decreased swelling of the vocal cords. It can make the voice sound better temporarily. If you are on steroids it is important not to overuse your voice because the cord damage will be worsened. Singers, thus, are encouraged not to sing at maximum if they use steroids to recover there voice on a short-term basis. Use of a humidifier (especially in dry Denver) helps to keep the vocal cords
moist. Moist vocal cords can vibrate more easily. We may also recommend using guaifenesin, Humibid, Liquibid, Guaifenex, etc., to cause the mucous glands in the throat to produce more water. This keeps the vocal cords more moist.
If the infection is very severe or if the person pushes their voice while they are having an infection, a scar collection can from on the vocal cords. Mild early formations are called vocal cord polyps. Longer duration scar collections are called vocal cord nodules. These can resolve with lengthy voice rest (6-12 weeks). Nodules less frequently will resolve. On occasion, surgery using laser to vaporize the polyp or nodule may be performed if vocal rest does not resolve the laryngitis.
Different methods of vocal cord damage can also cause vocal cord damage. Acid reflux in the stomach can cause laryngitis. This is a condition where the valves separating the stomach and the esophagus (lowe? esophageal sphincter) becomes leaky. Hydrochloric acid from the stomach can back flow from the stomach up the esophagus and on to the vocal cords. The hydrochloric acid that the stomach produces dissolves meat and food. Left on external skin for as little as five minutes, it can cause a chemical burn. If the acid coats the vocal cords after refluxing while laying reclined (such as when laying flat while sleeping) a chemical burn will occur on the vocal cords. The vocal cords will swell and the person awakens with a sore throat and hoarseness. To prevent this, we recommend not eating two hours prior to going to bed, keeping the head of your bed elevated by 5 inches (this keeps your shoulders higher than your stomach), and the use of acid production blockers (ranitidine, Pepcid, Prilosec, Prevacid or Aciphex). Sometimes patients have little or no other symptoms of acid reflux other than there hoarseness or a mild cough.
Other causes of hoarseness include allergies. Inhaled allergens such as tree pollen, weed pollen, cat dander, mold spores, etc., can coat the vocal cords causing swelling and laryngitis. Chronic sinusitis with frequent puss draining down the back of the throat can also cause the vocal cords to become irritated and swollen. Excessive voice use or yelling can cause such shear forces that cause the vocal cords to cause hoarseness. Any type of damage to the vocal cords causes hoarseness. Even trauma to the voice box such as a neck trauma after a car accident can cause hoarseness.
A less common cause of hoarseness is voice box cancer (laryngeal cancer). This is a disease where the surface cells of the vocal cords have been irritated by smoke or alcohol abuse for years. The cells become damaged and start to multiply leading to the formation of a cancer. Cancer cells accumulate until the vocal cords vibrate poorly causing hoarseness. Generally, because the onset of hoarseness people see there physician. They are referred to an otolaryngologist who can view the vocal cords by the use of a flexible laryngoscope diagnosing a cancer. These tumors are diagnosed early and because they are diagnosed early tend to be more curable.
The key to curing hoarseness is thus having an early examination by an otolaryngologist so a correct diagnosis can be made. If you have more questions please feel free in discussing them with Dr. Culberson during your examination.
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Laryngitis: Causes of Loss of Voice and Hoarseness |
