Hoarseness and Voice

People often lose their voice and become hoarse with laryngitis, which is usually a viral, self-limiting illness. If the voice change persists for more than two or three weeks, then a thorough examination of the larynx is necessary. Some people simply overuse their voice in the course of their occupation (teachers, professional singers, actors, and salespeople). Professional singers may be using poor technique, creating a strain on their vocal cords. Allergy, nasal congestion, and postnasal drip can contribute to hoarseness as well. Laryngopharyngeal reflux is a problem where a layer acid comes up from the stomach, inflaming the posterior portion of the larynx. A fiber-optic laryngoscopy is necessary to completely examine the larynx. The findings can include swollen vocal cords, nodules, or polyps. Particularly in smokers, a precancerous or cancerous growth needs to be ruled out. Weakness or paralysis of a vocal cord may be discovered. This originates somewhere along the course of the laryngeal nerve which travels from the base of the skull, briefly enters chest, and then returns to the larynx to enervate the vocal cords. A direct examination under anesthesia may be necessary for further evaluation or removal of the vocal cord lesion.

Tonsils and Adenoid Enlargement

Tonsils and adenoids are lymph tissue in the back of the throat and above the palate, respectively. Particularly in children, one or both of these structures can be enlarged. They may be subject to frequent infection. Infection in the adenoid area can introduce bacteria behind the eardrum causing frequent middle ear infections. Patients present with obstructive symptoms such as persistent daytime mouth breathing, nasal congestion due to poor drainage in the back of the nose, and loud snoring at night. Obstruction can result in sleep apnea (see below). At times, the enlarged tonsils and adenoids are due to acute infection and inflammation. A trial of antibiotics and possibly corticosteroids may reduce the swelling. When this condition persists, tonsillectomy and adenoidectomy may be indicated. This procedure is usually very effective in relieving the obstructive symptoms.

Throat Pain

Throat pain that persists should be investigated. Transient oral pain may be due to a viral syndrome, excessive dryness, or oral infection. Examination and culture can determine the cause. Pain in the back of the throat may indicate persistent infection within the tonsil tissue or tonsillitis. In previous generations, tonsils were often removed during childhood. However, with a shift to a more conservative approach, there are many adults with tonsils that continue to get infected or attract debris present in the mouth. Tonsillectomy is indicated in those patients with repeated infections.

There are other causes of throat pain and a thorough evaluation can reveal suspicious lesions or tumors that need biopsy and treatment. People who smoke cigarettes and/or drink alcohol are at higher risk of oral cancer than the general population.

HPV and Oral Pharyngeal Cancer

Human papillomavirus (HPV) is a group of related viruses that are spread from skin to skin contact. There are various types, some of which are not associated with cancer. However HPV type 16 and 18 are responsible for the majority of HPV caused cancer. HPV infections are the most common sexually transmitted infections in the United States. In fact more than half of sexually active people are infected with one or more HPV viruses at some point in their lives. Infections are more common in the genital area however oral infections account for approximately 7%.

HPV infections have been linked to cancer of the soft palate, tongue, and tonsils. More than 65% of oral pharyngeal cancers are linked to HPV-16. The incidence is increasing especially among men. Other factors increasing the risk of oral pharyngeal cancer include smoking, increased alcohol consumption, and poor oral hygiene with chronic inflammation.

Most infections with HPV will go away on their own within one or two years. However, some infections do persist and can result in genital or oral warts. Persistent infections do increase the risk of developing cancer. No reliable blood tests exist to detect HPV infection. Woman can have Pap testing of the cervical area to detect ongoing infection. Unfortunately, at the current time, there is no screening method for detecting HPV infection in the oropharyngeal area. There is no pain, redness or fever. Biopsy of warts or other suspicious lesions is the only method of detection. Removal of warts and precancerous lesions can be performed in the office with excisional surgery or electrocautery.

There are two approved HPV vaccines, Gardasil and Cervarix. These vaccines work against HPV-16. Although as yet unproven, there is hope the current vaccines will be shown to prevent oral HPV infection.

People who are diagnosed with HPV-positive oropharyngeal cancer are treated with a combination of modalities including surgery, chemotherapy and radiation. In general, HPV-positive cancer has a better prognosis than HPV-negative oral pharyngeal cancer.

Swallowing Difficulties

Difficulty swallowing (dysphasia) may happen suddenly or gradually over time. A sudden change may be due to a foreign body lodged in the back of the throat or and acute infection in the pharynx or opening to the esophagus. This should be evaluated by a throat specialist as quickly as possible. Gradual difficulty in swallowing may occur in older individuals. The process of swallowing is a highly coordinated movement involving the tongue, muscles of the throat, larynx, and esophagus. Neurologic problems or aging can create difficulties with this process. In some individuals, it is possible to modify the diet successfully to work around this problem.


Laryngopharyngeal reflux (often simply called “reflux” or “GERD,” is much more common than previously thought. Symptoms such as tightness and irritation in the throat, cough, heartburn, and persistent throat clearing can be due to reflux. Acid produced in the stomach can travel back up the esophagus and into the throat. The throat and larynx are more sensitive to acid than the esophagus so it is possible to have primarily throat symptoms and minimal or nonexistent esophageal symptoms, such as traditional ‘heartburn’. The use of a fiber-optic exam of the larynx and pharynx help to make this diagnosis. Treatment should include modifying the diet to avoid acidic foods, fried foods, caffeine, and alcohol especially late in the day. Avoiding large meals late in the evening is very important. In addition, there are now very effective medications that reduce the acid production in the stomach and thereby control the reflux.

These medicines are known as proton pump inhibitors (PPI drugs). Patients who fail to respond to PPI medications and/or diet modification may have another gastric secretion, called pepsin, entering the pharynx and larynx. This substance is not necessarily inactivated by reducing gastric acid. New evidence is showing a class of medication, alginates, has a powerful effect to bind pepsin before it enters the upper airway and throat.

Chronic Cough

Persistent cough can have a variety of causes. It may start with an upper respiratory infection or appear on its own. It can be an annoying problem affecting talking, eating, and sleep. Finding the source of irritation to the airway is not always simple. Environmental factors including dust and cigarette smoke may be involved. Post nasal drip and throat clearing also trigger cough. Nasal obstruction will force individuals to breathe too much through the mouth, bypassing the filtering effect of the nose and introducing cool dry air directly to the trachea where the cough is triggered. Certain medications including a group of blood pressure medication known as ACE inhibitors will induce cough in a small percentage of patients. Asthma and a condition called cough-variant asthma may produce cough as well. We now know that acid reflux (laryngopharyngeal reflux) irritates the airway and can trigger cough too.

The history and exam provide clues as to the source of the cough. Usually a fiber-optic exam of the upper airway provides necessary information. Other tests may include a sinus Cat scan and chest x-ray. Pulmonary and allergy consultation may be required. Treatment will depend on the outcome of the clinical evaluation.

Salivary Gland Disorders and Mouth Dryness

The major saliva glands are in front of the ears (parotid),under the jaw (submandibular), and under the front of the tongue (sublingual). The parotid and submandibular glands can swell acutely from obstruction or infection. Viral or bacterial infection (parotitis/sialadenitis) is a common cause of saliva gland swelling and pain. Small calcium stones can block the duct from draining the normal flow of saliva. This will also present as swelling and pain. A painless swelling or lump that persists more than a few weeks should be investigated by an ear, nose, and throat specialist. Benign and malignant tumors do arise in the salivary glands. Imaging studies and needle biopsy aid in the diagnosis and treatment course.

Excessive oral dryness may be due to a disorder of the saliva glands resulting in diminished saliva flow. Autoimmune testing and biopsy are utilized to help with diagnosis. Many medications have oral dryness as a side effect and some patients are on several of these drugs. The problem is thus multiplied.

The information posted on this page is provided as general, background information in the spirit of service to the reader. In no way should it be interpreted as medical advice. While the practice of Robert Feld, MD, LLC, attempts to convey accurate and current information on this site, this information may contain typographical errors, technical errors, or may at some point become out-of-date. You are advised to confirm the accuracy of any information presented on this site before relying on it in any way.

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(631) 673-6868