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COVID-19 and Voice Problems

Giselle Maartens. Speech Therapist.

 

Our experience at the Pretoria Voice Clinic:

In South Africa, COVID-19 has been with us for more than a year now.

As an Ear, Nose and Throat Specialist (ENT) and a Speech Language Therapist (SLT) working in the field of voice at the Pretoria Voice Clinic, we are starting to see more and more voice, airway and breathing problems related due to COVID-19, in our clinical case load.

Literature has indicated that respiratory/pulmonary and laryngeal complications are associated with COVID-19 infection. This can influence people on a physical, functional, and emotional level. This poses a challenge for people who use their voices for their vocation, or for singers. Even in cases where voice is just used on a social level, if communication breakdown occurs due to poor voice it can have a negative influence on the message.

 

Respiratory consequences

Some of the most common respiratory changes following COVID-19 are fatigue and dyspnea/shortness of breath. Lung damage and respiratory sequelae can even occur in less seriously ill COVID-19 cases. While some pulmonary lesions will gradually heal and disappear, others can form scar tissue which stiffen the lungs, and cause shortness of breath. This could be debilitating for professional voice users, and even more so for singers and teachers of singing.

 

Laryngeal consequences

Any upper respiratory tract infection (URTI) causes inflammation of the upper airway, which includes the vocal folds. In the case of the COVID-19 virus, the virus itself causes inflammation. When an URTI affects the lungs, one can cough a lot. When you have COVID-19 you are likely to experience long periods of coughing that won’t stop. Coughing brings the vocal folds forcefully together to strongly force air out, clearing any mucous from the lungs and throat. The already inflamed throat and vocal folds from the infection experience quite a battering from this level of coughing which further irritates the vocal folds and laryngeal area. This increases the swelling of the vocal folds causing them to be stiffer and less flexible. This means they are unable to vibrate freely and the sound of your voice changes often to a raspy or rough quality, with a deeper-pitch and even reducing it to a whisper.  

 

Prolonged intubation can cause potential damage to the vocal system and upper airway. Placement of the endotracheal tube irritate the throat tissue, making your throat sore and your voice sound raspy. Mild throat swelling or edema may occur after a breathing tube is removed. These symptoms of irritation and swelling can lead to coughing or frequent throat clearing which further irritate the vocal system. In cases where prolonged intubation was needed, glottis injuries are more common. Laryngeal abnormalities may include airway stenosis (narrowing), laryngeal stenosis below, at, or above the vocal folds, vocal fold mucosal / vibration abnormalities and scarring, vocal fold fixation (unilateral vocal fold immobility) and post-intubation phonatory insufficiency. These complications can cause hoarseness, difficulty swallowing and trouble breathing.

 

Other laryngeal complications involve vocal fold paralysis and paresis due to periods of intubation, or as a result from viral-related injury to the vagus nerve (responsible for vocal fold muscle function and sensation to part of the larynx). The possibility of developing laryngeal sensory neuropathy post COVID-19, may occur, as it can follow any viral infection.

In the literature it has been documented that singers experience respiratory compromise and complains of vocal fatigue post COVID-19 infection, indicating that singers may suffer lingering reduction of respiratory and phonatory function.

 

Other consequences

Chronic fatigue has been documented as a common consequence of COVID-19 infection, which can be associated with voice complaints.

Another affect that the COVID-19 pandemic has on voice and communication are on the educational community. Teachers and lectures are conducting classes online. This brings a whole new set of vocal demands to teachers and educators. Some of the symptoms recorded were dry throat, effort in addressing remote classes, hoarseness after giving classes, and difficulties with the use of headphones.

 

Diagnosis and treatment

To diagnose vocal fold injury, scarring, paralysis or paresis, a view of the larynx is required to visualize abnormal tissue as well as observation of the function of the vocal folds. A video-stroboscopy assessment done by an ENT with a special interest in voice, can visualize the movement of the vocal folds and the mucosal wave. 

 

Treatment for voice related complaints after COVID-19 infections include voice therapy. Voice therapy can sometimes help shrink scar tissue or abnormal growths on the vocal folds, and addresses functionality of the respiratory, laryngeal / vibratory and resonator systems. Some growths or scar tissue of the vocal folds or upper airway that can develop from breathing tubes require surgical intervention for removal.

 

What can you do to treat your COVID-19 hoarse voice?

Although you might not be able to prevent a hoarse COVID-19 voice, there are things you can do to treat it if you’re sick.

• Keep well hydrated.

Drink 1½ – 2 litres of fluid that doesn’t contain caffeine or alcohol per day (unless advised otherwise by a doctor).

Try gentle steaming with hot water. Breathe in and out gently through your nose or mouth. The steam should not be so hot that it brings on coughing.

• Try to avoid persistent, deliberate throat clearing, and if you can’t prevent it, make it as gentle as possible.
• Chewing gum or sucking sweets can help promote saliva flow, which lubricates the throat and can help reduce throat clearing. Avoid medicated lozenges and gargles, as these can contain ingredients that irritate the throat.
• A healthy diet, to minimize episodes of acid reflux that can exacerbate the situation in your throat.
• You do not need to be on total voice rest. Using your voice for a few short words every so often during the day keeps the vocal folds mobilised, and that is a good thing.
• Don’t deliberately choose to whisper, it puts the voice box under strain. Aim to use your normal voice, even if it sounds croaky. Avoid straining to force the voice to sound louder.
• Avoid talking over background noise such as music or television, as this cause you to raise your volume.
• You may notice that your voice becomes tired more quickly than normal. This is expected. Take a break from talking when your voice feels tired, to give it time to recover.

References:

1. M R Naunheim et la. Laryngeal complications of COVID-19. Laryngoscope Investig Otolaryngology. 2020
2. L Helding et al. COVID-19 After effects: Concerns for singers. Journal of Voice, 2020.
3. K Nemr et al. COVID-19 and the teacher’s voice: self-perception and contributions of speech therapy to voice and communication during the pandemic. Clinics, 2021.
4. J M Patterson, et al. COVID-19 and ENT SLT services, workforce, and research in the UK: A discussion paper. International Journal of Language Communication Disorders, 2020.
5. Cleveland Voice Clinic post on website. What is “COVID-19 Voice” and what causes it? April 2021.
6. Patient information. Therapy Department. “Advice for people experiencing voice problems after COVID-19”. NHS University Hospitals.

Endoscopic posterior advancement flap for posterior glottic stenosis

Introduction video of the Pretoria voice clinic. Causes of hoarseness.

Introduction video of the Pretoria voice clinic. Dysphonia.

Bilateral vocal fold polyps post Covid infection, Intubation

Mid vocal fold polyp post Covid intubation

Trachea/sub-glottic stenosis post Covid intubation.

Dilatation with Trachealator

Diode laser resection

Office video laryngo tracheoscopy

Granuloma/Trachea stenosis, post Covid intubation.

Cintocare Hospital and Pretoria Voice Clinic celebrations of World Voice Day Giselle Maartens Introduction

World voice day 2021,Giselle Maartens Speech Therapist. Voice care for professional voice users

Deirdré Blignaut Rautenbach Summertime

Deirdré Blignaut Rautenbach, Soprano

Cintocare Hospital and Pretoria Voice Clinic celebrations of World Voice Day 2021 Complete video

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LUMPS, BUMPS AND A MASS LESION ON YOUR VOCAL CORD

At the Pretoria Voice Clinic we see many patients presenting with lesions or growths on their vocal folds.                                                            

Their main presenting symptom are hoarseness or problems with their singing voice.                                                                                                        

There is no concensus in the literature regarding the nomenclature of mass lesions on the vocal cords.                                                                           

This is causing a lot of confusion for patients and doctors alike.

What lesion is this on your vocal cords?

Vocal cord nodules? or Vocal cord polyp with a secondary lesion on the other vocal cord? or Vocal cord cyst with a secondary lesion on the other vocal cord? or Bamboo nodules? or Fibrous lesion? or Granuloma? or Papilloma? 

The answer is we do not always know.

The most common lesions that we see on vocal cords are haemorrhagic polyps, vocal cord nodules which are less frequently seen and vocal cord cysts.

 

Factors to take into consideration are:       

History of voice usage is important. 

Vocal overuse, professional voice users such as teachers.                                      Phono traumatic event like shouting, screaming.                                                    History of tobacco and alcohol use.         

Findings at flexible and rigid video laryngo stroboscopic features.                        Response to medical or proper voice therapy.

In some cases, the only diagnosis can be made by examination of the vocal cords and biopsy under direct examination under general anaesthetics in hospital.

 

Vocal Cord Nodules:

Vocal cord nodules are usually secondary to vocal overuse.

They are common in professional voice users such as teachers, singers, lawyers, judges, and preachers.

They are also common in children with vocal overuse.

Patients usually presents with hoarseness or having problems with their singing voice. 

The best way in observing these lesions are either by rigid or flexible video laryngo stroboscopic evaluation done at our voice clinic.

Video laryngo stroboscopic features of vocal nodules are:

They are fairly symmetric and present on both vocal cords.                                  They have minimal influence on vocal fold vibration.                                                It causes an hourglass configuration.            

They usually respond well to voice therapy and rarely needed to be removed surgically.

Vocal Cord Polyps:

Vocal cord polyps are usually secondary to a phono traumatic event such as vocal misuse, such as screaming, yelling or during throat clearing.

Patients usually presents with hoarseness or having problems with their singing voice. 

The best way in observing these lesions are either by rigid or flexible video laryngo stroboscopic evaluation done at our voice clinic.

 

Video laryngo stroboscopic features of a vocal cord polyp:

They are usually present on only one vocal cord, there may be secondary lesions present on the other vocal cord. This might have the appearance which looks like bilateral vocal cord nodules.                                                                

They have minimal to moderate influence on vocal fold vibration.                     

It causes an hourglass configuration with glottic insufficiency.                              They usually respond well to good voice therapy alone and surgery is only indicated if   they do not disappear on voice therapy alone and still causing hoarseness.

Vocal Cord Cysts:

Vocal cord cysts are sac like lesions filled with fluid usually located in the mid vocal fold.

There are usually two types of cyst, mucous retention cysts or keratin cysts. They can be congenital (born with it) or acquired.

Patients usually presents with hoarseness.

They can be either superficial in the vocal cord or deeper in the vocal ligament. The deeper ones affect the voice more than the superficial one and they are also more difficult to treat with poorer voice outcomes.                        

Polypoid Corditis (Reinke’s edema) are also saclike lesions on the vocal folds usually associated with smoking and vocal overuse.

Vocal Pseudo Cysts:

A vocal cord pseudo-cyst is a distinct cystic lesion on the mid free margin of the vocal fold.

They are usually secondary to a phono traumatic event such as vocal misuse, such as screaming, yelling or during throat clearing.

Some suggest that they form on the vocal cords due do vocal cord paralysis.

Vocal cord granuloma:

A vocal cord granuloma is an inflammatory mass usually located on the back part of one focal fold over the vocal process. They can also be present on both vocal folds.

A vocal cord granuloma is usually caused by phono- traumatic events such as vocal overuse.

They can also be caused by pressure, ulceration and inflammation caused by an endo tracheal tube passed through the vocal folds during surgery.

Laryngo pharyngeal reflux is a common contributing factor.

They usually respond well to medical therapy such as antibiotics, anti-reflux medication and good voice therapy.

In some cases, they can be quite refractive to treatment and need to be removed in the operation theatre. A biopsy is also needed if the lesion looks suspicious for cancer.

At our clinic we have successfully treated a few cases with surgical removal with a CO2 laser, intra-lesional cortisone and Botox to paralyse the vocal fold to reduce phono trauma.

Laryngeal papilloma:

Vocal cord papilloma are wart like growths on the vocal cords caused by the papilloma virus. They can occur in young children or in older adult people.

Young children usually present with hoarseness or upper airway obstruction.

Papillomatous lesions need to be removed if they are causing upper airway obstruction or suspicious of laryngeal cancer.

 

Several options of treatment are available:

– Frequent observation with video laryngo stroboscopy.

– Office flexible video laryngoscopy with blue laser (angiolytic laser) ablation.

– Micro-direct laryngoscopy in theatre, under general aneshetics and removal with   cold steel, laser, micro-debridor or coblation.

Each technique has their own advantages and disadvantages.

the principle is to remove the papilloma without damaging the underlying lamina propria of the vocal folds. Damage to the underlying lamina propria of the vocal folds may lead to scar formation on the vocal folds with permanent hoarseness.

 

Laryngeal cancer

Cancerous lesions can also present as a mass on the vocal cords. Patients frequently presents with hoarseness, but only if the mass lesion is present on the vibrating part of the vocal cord.

When it occurs on the free mid margin of the vocal fold it frequently leads to voice problems. If it does not occur on the free edge, the patient might present much later.

Other symptoms might be throat irritation, throat clearing, swallowing problems and referred pain to the ears.

Vocal cord cancers are more frequent in patients using tobacco and alcohol. Treatment might include surgical removal or radiotherapy.