Introduction

Dr. Bob: Welcome to The Dr. Bob Show. Thank you for dropping by, trying to learn a little bit about making yourself healthier and happier. That's what we are going to be doing. I hope that this week you've had a good one but I hope that you have been exercising 20 minutes seven days a week. Start that day off with a good breakfast, hopefully fruit and fiber and if you can, get that 8 hours of sleep. See how much better it makes you feel. And most of all, what is it we like, it's laughter in your life. We've got a great show lined up for you.

We've got an outstanding guest. He is a board certified otorhinolaryngologist. That's an ENT doctor and we are going to be talking about hoarseness. Do you get hoarseness every year? If you do, we are going to learn about what you can do. What are some of the causes? Why you are getting hoarseness? Could it be dangerous? Is it a warning sign of cancer? When do you see the doctor? We will be talking about all of those things. We've got a lot to learn on this show. Later on we will be talking about urticaria. What's that? Well, that's simply hives. We will also be talking about sinusitis. What is some tips on treating people that have recurrent sinusitis? Is all heartburn due to GERD or esophageal reflux disease? No and we will be talking about those other causes and what the treatment is. So, you will want to stay tuned. We've got a great show and I want you to learn more about how to stay healthy.

Dr. Bob: We're going to be talking with Clifford Johnson. I call him Chip Johnson, a long time friend of mine. He is a board certified ENT. That's an otorhino-laryngologist. That's the longest name in medicine. We are going to be talking about hoarseness. Chip, welcome to the Dr. Bob Show.

Dr. Johnson: Thank you for having me.

Dr. Bob: Chip, is there a difference between ENT and otorhinolaryngologist?

Dr. Johnson: Not at all.

Dr. Bob: What does the ENT doctor basically do?

Dr. Johnson: Well, ENT doctor is a physician that treats not only the medical illnesses of the ears, nose and throat but also the surgical ramifications of those same illnesses.

Dr. Bob: And what kind of training does an ENT physician have?

Dr. Johnson: Normally he will do a year of internship, a year of general surgery, and then three or four years of ear, nose and throat specialized training.

Dr. Bob: Did you ever think you would get out of training?

Dr. Johnson: Well, it wasn't too bad when we were going through it but I am glad that we are through.

Dr. Bob: Let's talk about hoarseness. What causes hoarseness? Why do people get hoarse?

Dr. Johnson: Very simply, hoarseness is a distortion of the lining of the vocal cords which disrupts the normal air flow from the lungs out across the vocal cords and makes your voice squeaky, makes it harsh, makes it gravely. Depending on the condition, the type, the resonance of the voice changes.

Dr. Bob: Now, the vocal cords, I think most everybody knows. Where are they really located?

Dr. Johnson: The vocal cords are in the larynx.

Dr. Bob: Now, the larynx. Where would that be?

Dr. Johnson: That's the voice box and the voice box is right below the tongue and right above the lungs.

Dr. Bob: And, what if we look at vocal cords. What do they look like? Is it a string like a violin string or what is it like?

Dr. Johnson: Vocal cords are white and pearly when they are in their normal color, when they are not inflamed, when they are not distorted. They will look like a V and when the vocal cords are open, when you breath in, the V obviously is open. When you speak, when you make a voice, the vocal cords come together. The air coming from the lungs causes the edge of the vocal cord to vibrate and that's what gives you your particular voice.

Dr. Bob: What are the common causes of hoarseness?

Dr. Johnson: Many causes of hoarseness. Inflammation or infection, trauma which can be externally induced or internally induced by abuse of the voice and, of course, neoplastic with tumors that can either be benign or malignant.

Dr. Bob: Are there any nerves that are important and muscles that tighten up the vocal cords?

Dr. Johnson: The main nerve that works the vocal cord is called a recurrent laryngeal nerve and this nerve is particularly important when a surgeon does a thyroidectomy or operates on the thyroid gland because it runs right behind the thyroid gland and if you are not careful, you can damage that nerve and leave you with a paralysis of one side of the voice box which, in turn makes you hoarse.

Dr. Bob: So, the thyroid surgeon really needs to be careful on that. Let's talk about a vocal cord nodule. What is a? I've heard of nodules on there. Are they pre-cancerous?

Dr. Johnson: They are not pre-cancerous in most cases. The rule of thumb is that the term vocal cord nodule is a totally benign condition. Now, you can see this in adults or you can see it in children. It is brought on by vocal abuse. Now, in children they are called screamers nodes because these kids usually live in big families, they are vying for attention, and they are abusing their voice. We will ask these parents in the office, "does this child yell a lot"? "Well, yes he does. He yells all the time." So, you will see that in children. In adults you will, they are also called singer's nodes and preacher's nodes.

Dr. Bob: Preacher's nodes?

Dr. Johnson: Because they tend to get excited in the pulpit and abuse their voice. Now, a vocal nodule is in very simple terms, a callous of the vocal cord that occurs between the anterior one-third and the posterior two-thirds of the vocal cord. Obviously, if you have a little knot on your vocal cord, it is going to prevent the vocal cord from coming all the way together, more air escapes from the lungs and gives you a hoarser voice.

Dr. Bob: What do you do for it?

Dr. Johnson: In kids you try to get them in speech therapy because you have to change, not what they are saying but how they say it. If you can modify a child's speech patterns, there is a good chance you won't have to do anything to that nodule. Sometimes the nodules are large enough that you physically have to remove the nodule and this can be done manually through a microscope and a laryngoscope which is a device that allows the physician to look directly at the vocal cords. And in a lot of cases now, we are using a laser to shave these vocal nodules off. It's less dramatic to the cord and gives you a much better result.

Dr. Bob: Is it easy to take a vocal cord nodule out? Do you have to put the patient under anesthesia? Can you do it under local? How do you do it?

Dr. Johnson: We most often do it under general anesthesia. It can be done under local anesthesia but in my experience, the patient has been much more comfortable if they undergo general anesthesia and are asleep.

Dr. Bob: Do you ever get any doctor's nodules because the doctor talks too much?

Dr. Johnson: Well, not very often.

Dr. Bob: Now, in a preacher's nodule, if you tell somebody vocal cord rest, do these ever go away? I mean, you just don't talk for three weeks, what happens?

Dr. Johnson: Well, that is the treatment of choice. We will also treat these folks with steroids, both by mouth and inhaled. We encourage them to keep their voice box very moist, drink a lot of fluid and will put them on moisturizing agents. If they are a smoker, we very strongly encourage them not to smoke and then voice rest.

Dr. Bob: Is there any pre-cancerous lesion that you find on the vocal cord? You've mentioned smokers and hoarseness. I begin to think of, you know, that's one of the things that causes cancer of the throat. How about leukoplakia? Is that a pre-cancerous?

Dr. Johnson: Well, obviously cancer of the vocal cords is a great fear and when a lot of people come see me, that's what they are primarily interested in.

Dr. Bob: And, Chip, we are going to come back and we are going to be talking about, "How do you know if you've got cancer of the vocal cord"? Is there any tips of the trade that we can find out but first, let's talk to a patient who had hoarseness and see how they came out.

A Patient's Experience with Hoarseness:

Patient: I first noticed the hoarseness from what was looked like an allergic reaction to me.

Dr. Bob: How long ago was that?

Patient: Gee, that's been 8 years ago maybe.

Dr. Bob: And how frequent were you getting hoarseness?

Patient: All too frequently. It was, for me, it was almost like having a head cold the year round.

Dr. Bob: So, you would get hoarse in the morning and get better as the day goes on or you would have spells where you lost your voice?

Patient: Very very hoarse in the morning and spells when I would lose my voice.

Dr. Bob: How long did those spells last?

Patient: Oh, sometimes three or four days.

Dr. Bob: Could you tell that you were getting a cold from your allergies or getting an infection and that was what was making you hoarse or was it just drainage?

Patient: Well, it must have been the allergies simply because there was no way to get the thing well. There was no medicine that seemed to do any good. I took a lot of medicines for it.

Dr. Bob: Did you have to clear your throat a lot?

Patient: Oh, constantly.

Dr. Bob: And could you feel the drainage in the back of your throat?

Patient: I could.

Dr. Bob: And how often would you get a sinus infection that would get down into your throat and make you hoarse?

Patient: Oh, maybe two to three times a year.

Dr. Bob: And, did the hoarseness keep you from, or embarrass you when you would talk to people.

Patient: Oh, everytime I answered the phone, they said, "you must have a terrible cold". Oh no, that's allergies.

Dr. Bob: Did you get your allergies fixed?

Patient: Yes, I did. I got on a regimen of………

Dr. Bob: Some medicines.

Patient: Medicines and allergy shots.

Dr. Bob: And what have they done for you?

Patient: Well, they have made all the difference in the world.

Dr. Bob: In what respect? How, how's your hoarseness?

Patient: Well, I would say 90% better. I very rarely get that now.

Dr. Bob: So, instead of four or five times a year or two to three times a year, you now get them maybe once a year?

Patient: Exactly and I don't have that head cold around the year.

Dr. Bob: Yeah, all the time.

Patient: Yes.

Dr. Bob: Instead when you wake up now, hoarseness would be a rare thing?

Patient: Exactly.

Dr. Bob: Hoarseness can be a serious thing or it can be a simple thing. We are talking with Dr. Clifford "Chip" Johnson, of ENT Consultants of East Tennessee and we have learned about vocal cord nodules. We've learned about the V of the vocal cords and they vibrate from air coming from the lungs to make noise. Anything that interferes with that, causes hoarseness. Now, we were talking about pre-cancerous or cancer or smoking. Tell me about cancer of the throat, larynx or vocal cords.

Dr. Johnson: Most often, folks that have a cancer of the vocal cords, will have a history of smoking at some time in the past. I have seen folks that stress smoke have cancer. I have seen folks that stopped smoking ten years ago that have developed a cancer of the vocal cords. So, the sooner you quit smoking, the better.

Dr. Bob: That's a key issue. In almost all illnesses if we could stop smoking, we wouldn't have a lot of problems. So, if we can stop smoking. What are the symptoms likely to be?

Dr. Johnson: The main thing that you see is a persistent hoarseness. If you have a hoarseness or a significant voice chance over the last two to three weeks, you should see your family physician, let him evaluate you, and if he feels that you have a significant hoarseness, he should refer you to an ear, nose and throat doctor that can evaluate that hoarseness in the office. Now, there are several ways that we do that. First of all, I will sit down and I will talk to the patient about length of the symptoms, the severity of the symptoms, have they coughed up any blood? Then, I would look at the vocal cords. Fortunately now, technology has advanced to the point that we are able to put a little fiberoptic scope through the nose or mouth and look directly at the vocal cords. The patient is able to see this on the monitor in the office at the time….

Dr. Bob: At the same time you are doing it.

Dr. Johnson: At the same time we do it. We can take photographs so that when I talk to the patient about the condition, he can refer to the picture. Now, what we normally see when we see a cancer of the vocal cord, is a reddish, sometimes whitish heaped up warty looking ugly thing on the vocal cords.

Dr. Bob: When you look down and see it, you say, "ugh-oh…."

Dr. Johnson: You say, "this is ugly". They can usually say, "Oou, I see what you are talking about". Now, what we try to establish at that time is how advanced is this lesion? Does it involve just the vocal cord? Does it spread to other parts of the voice box? Because depending on the extent of the lesion, that will determine the treatment that we advise. Always we take the patient to surgery and do a biopsy so that we have a pathologically proven diagnosis. From there we go into treatment plans which can be as simple as radiation therapy. Sometimes we combine radiation therapy with surgery and chemotherapy. If vocal cord cancer is caught early enough, it is greater than 90% curable.

Dr. Bob: Hey, that's really good to know, that's good to know. Do you ever see people that come in and they just had three weeks of hoarseness and they've got vocal cord cancer that's not 90% treatable?

Dr. Johnson: We do.

Dr. Bob: So, we can………

Dr. Johnson: And sometimes there is denial there on the patient's behalf, ugh, but sometimes the cancer can be above the vocal cords in the larynx and not really effect the motion or the air flow through the vocal cords so, they may have a fairly normal voice with a little more extensive lesion. These folks will usually have a lot more pain when they swallow, when they talk than the vocal cord folks will have.

Dr. Bob: How about if somebody gets hoarseness two or three times a year? Doctor, I just, twice a year I am getting hoarse and what can you do to prevent that? What's the common cause of recurrent hoarseness? Other than screamers, and…..

Dr. Johnson: Well, we have several causes there. One, the most usual cause is an upper respiratory infection. Now, this can be associated with allergy. It can be associated with folks who get recurrent sinusitis with drainage and edema or swelling of the vocal cords because of that. That's usually the most common cause. Another cause is reflux or GERD disease.

Dr. Bob: What does the vocal cord look like in a common cold, upper respiratory infection, sinus infection with drainage?

Dr. Johnson: Instead of the vocal cord being white and pearly looking, it will be almost gelatinous in appearance. It will be bubbled up, swollen, just look like ugh, some jello sitting on the vocal cord. And, of course, that swollen tissue doesn't conduct air well. So, you get your hoarseness that way.

Dr. Bob: How about GERD, esophageal reflux disease? That's where acid comes up and…

Dr. Johnson: That's correct. With GERD you will see more of a redness on the posterior portion of the vocal cord because this is where the acid hits first. So, you will see redness and swelling over the aretnoid cartilages which are the little hinges of the vocal cords that extend anteriorly on the vocal cords themselves.

Dr. Bob: So, you can look at the throat, look at the vocal cord with pretty assuredness tell somebody if their hoarseness is due to reflux disease.

Dr. Johnson: We also like history to go along with it.

Dr. Bob: Heartburn on a full stomach when I have it… Do you refer those patients back to their primary care doctor or do you tell them to elevate the head of their bed, take some protein, some ugh….inhibitors?

Dr. Johnson: Most of the folks have come from their primary care. I will call the primary care doctor, tell him what I have found. Some will say, will you treat that? Others will say, just send them back and I will take care of it. Then I will follow up with them in a month, six weeks to be sure that they are getting a reduction in their symptoms.

Dr. Bob: Now, great medicines and I was thinking of the word, proton pump inhibitor just a minute ago like Nexium and Prilosec and Prevacid. Those…. Upper respiratory inf….. I hear people all the time, "I've got to give a talk, I'm getting hoarse. What can you do to save me?" Anything you can do to get somebody's hoarseness to go away over 24 hours.

Dr. Johnson: Well, my greatest nightmare… (Dr. Bob laughter) was when I had several friends in the theatre department at UT and they would be putting on a musical and, of course, they would practice and rehearse and rehearse and two days or one day before opening, the star would come in… (Dr. Johnson speaking with a raspy voice) help, help with a raspy voice (Dr. Johnson speaking with a normal voice) and there are some things you can do such as big doses of oral steroids, vaporization, inhaler steroids but the biggest help is not to talk…….

Dr. Bob: Voice rest…

Dr. Johnson: So…..

Dr. Bob: which they don't want to hear.

Dr. Johnson: So, you are in a real bind for a 24-hour cure. Now, over a few days, you certainly get better but as we said earlier, voice rest is the key there.

Dr. Bob: Very briefly… somebody with hoarseness, when do they see the doctor?

Dr. Johnson: After two to three weeks of….

Dr. Bob: Two to three…….

Dr. Johnson: persistent hoarseness, or let's say hoarseness is progressively worsening over a week or two period of time.

Supplemental Interview

Dr. Bob: Mark, what is this?

Dr. Mark Overholt:
This is a flexible rhinoscope that allows us to look in people's nose, ears, and their throats, their vocal cords if they are hoarse.

Dr. Bob: Now, looking at my vocal cords, that's in my throat, isn't it?

Dr. Overholt: Yes, right down here.

Dr. Bob: Now, why are you going to look through my nose to look at my throat? Why don't I just open my mouth?

Dr. Overholt: If you come to see an ear, nose and throat doctor for hoarseness, you are likely to have this kind of examination.

Dr. Bob: Is it easier to look at the vocal cords with this than in the old days when we had a mirror?

Dr. Overholt: The mirror still works great but many people have a gag reflex and are not able to tolerate the old time mirror and so the rhinoscope is an alternative better way for those people.

Dr. Bob: Is this going to hurt me?

Dr. Overholt: Shouldn't hurt a bit. Now, we'll go around the corner, and this is your voice box.

Dr. Bob: Ugh…

Dr. Overholt: Down at the very bottom there are two white structures that are moving in and out those are the vocal cords and as you can see, we get an excellent picture of what the vocal cord does. We can see all around the larynx or putting the scope in where somebody who may have cancer………… and we are going back up and through your nose and you are all done.

Dr. Bob: Great. How about that? That was painless. I was expecting a lot of problems and maybe some gagging and some problems. So, you really, the spray in the back of the nose and this keeps people from gagging as much and from having problems.

Dr. Overholt: I can't remember the last time I had difficulty doing a flexible scope on somebody that I wanted to look at their vocal cords with the telescope.

Dr. Bob: Is it fun doing a rhinolarygoscopy on your daddy?

Dr. Overholt: Very fun (laughter).

Conclusion of Interviews

Dr. Bob: I want to thank Dr. Chip Johnson for a wonderful discussion on hoarseness. Bottom line: hoarseness over three weeks should be evaluated. Progressive, severity of hoarseness needs to be evaluate. If you've got hoarseness, you need to get it checked. See your doctor.

And now for those questions from you, the viewing audience. I've got three really excellent questions we are going to try and get to on this show.

Letters

Letter #1: Dr. Bob, is heartburn always due to GERD? First of all, what's GERD?

Response #1: It's gastroesophageal reflux disease. People eat a meal and they get heartburn after they eat a meal. They eat, lie down, go to bed, lie down and they get heartburn then if they have eaten before they lie down. Are there other types of heartburn? You better bettcha. Well, the most common cause in the old days used to be a heartburn due to ulcers. Stomach ulcers or duodenal ulcers and these now we know 95% of them are most likely due to a bacteria called helicobactor pylori. To make it shorter, we say H-pylori bacteria. And you've probably heard about that on the Dr. Bob Show. This is a bacteria that begins to work on the lining of the stomach of the duodenum and it causes a gnawing sensation right in the pit of the stomach or a little bit above the pit of the stomach. The nice thing about this is that it can be treated. It's due to a bacteria and we can get antibiotics for that. It's usually a combination of three different antibiotics and you have to take them altogether and that's a lot of pills. And maybe an antibiotic and an antacid and something with Bismuth in it like Pepto Bismol. That will get rid of the H-pylori for somebody that is having recurrent ulcers. Important, if you have chronic ulcer symptoms, it could be involving the stomach and you need to be sure than an ulcer in the stomach is not a malignancy. Don't spend too much time treating it with over-the-counter medications. See your doctor. Have your doctor evaluate that. It's a serious problem and it can be treated and you can live happily ever after.

Dr. Bob: Question # 2.

Letter #2: Dr. Bob, as soon as I get over one sinus infection, I get another one. Are there any tricks of the trade on getting rid of sinus infections?

Response #2: There are two parts of that question. # 1. Chronic sinusitis, one infection after the other is frequently because of a blocked sinus and it never gets really adequately treated. Sinuses are holes in the head. There's maxillary, ethmoids, frontal, and in the middle of the head there is the sphenoid sinuses. And those sinuses can get blocked and when they get blocked and we treat, we may get 90% better and get off the antibiotic, it begins to grow and grow and grow and you start getting headache and yellow or green discolored nasal exudate and you don't feel good and you feel toxic and here it comes again and you get another antibiotic. It goes on and on. An underlying allergy can cause that. An abnormal nose, your anatomy can do that. But there is one little area where all the sinuses drain. We call an osteomeatal unit and that can only be seen with a coronal CT scan of the sinus. Let me go into those words. That's a coronal CT scan of the sinus. That will walk right through that drainage area right there and it will tell the doctor what he can do to try and get rid of that sinus disease. Sometimes it's a simple surgical procedure that we go and do what we call endoscopic windows and we open up the drainage area there. Now, tricks of the trade for sinus infections, decongestants, saline nasal spray, an antibiotic three to four weeks if it's chronic recurrent sinusitis. Acute sinusitis, well, maybe we don't need anything for that but chronic recurrent usually needs prolonged antibiotics. The bugs are getting smarter than our antibiotics now and so frequently we need longer courses. If you've got recurrent sinusitis, work out a good program with your doctor.

Dr. Bob: And, the last question.

Letter #3: Dr. Bob, I've got hives. I itch all over. What's the cause of hives and what can I do to get them to go away?

Response #3: Interesting question. It really bothers lots and lots of people. Hives is simply histamine that's released into the skin. It's usually stored in mast cells and the mast cells what we call degranulate, histamine gets under the skin and we have itchy welts and it just drives us crazy when we get that. Good antihistamine - Zyrtec, Allegra, Claritin excellent antihistamines to help suppress the hives. What can cause the hives? Food can do it. Chronic infection can do it. Medications can do it. Hay fever time of the year can do it and stuff that we are in contact with like soaps, detergents, fabric softeners, all those things can be causes.

Closing

Dr. Bob: That's all the time that we've got for this show. I hope you have enjoyed it as much as I have. Remember, I want you to exercise 15-20 minutes seven days a week. Start that day off with a breakfast of fruit and fiber. Be sure you get eight hours sleep and most of all, what do we like, it's laughter in your life.

If you have a question for Dr. Bob, write to The Dr. Bob Show - 6700 Baum Drive, Suite 1, Knoxville, TN 37919 or send your e-mail to letters at letters@drbobshow.com