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Dysphonia (Hoarseness)

What is dysphonia?

 Dysphonia is a symptom of alteration in the quality of the voice. The sound of the voice may be harsh or hoarse, and the affected person may sound strained when making an extra effort to be able to speak. 

Diseases that compromise the quality of the voice affect patients of all ages and sex, although it is more frequent in teachers, older adults and people who use their voice as a work tool such as singers, instructors, announcers or telephone operators. 

What Causes Dysphonia?

Changes in voice quality generally represent a vocal cord problem which can be caused by a large number of medical conditions. 

Most cases are a minor condition, caused by an upper respiratory infection, which usually resolves within 3 weeks. In the case of a respiratory tract infection, dysphonia is generally accompanied by general malaise, runny nose, sore throat or cough. Other minor causes of dysphonia can be: tobacco or alcohol consumption, excessive use of the voice, gastric reflux or inhalation of irritants. 

However, having any change in voice quality that persists for more than 3 weeks is prudent to seek medical attention. Since it could be caused by some other medical condition less likely to resolve spontaneously which could cause irreversible damage to the vocal cords and your voice. 

Changes in voice quality that do not resolve naturally are usually caused by misuse or abuse of the voice; particularly in people who use their voice in a professional way. Therefore, a timely diagnosis and treatment of any affectation in the vocal cords prevents absence from work, and psychological or economic consequences. 

In the same way, it is important to emphasize the importance of going to a voice specialist when having any change in the tone of voice for more than 3 weeks since persistent dysphonia can be an early sign of cancer of the vocal cords or lung, mainly in smokers. 

What to do if I have dysphonia with a cold or a sore throat?

  • Avoid or eliminate tobacco use. 
  • Don't use your voice more than necessary, but don't whisper or speak in a low voice. A soft, calm voice is best for your throat. 
  • Cancel any nonessential commitments.
  • Drink plenty of warm fluids without caffeine (coffee or green / black tea).
  • Try natural throat lozenges that are lubricating and do not numb the throat. 
  • Avoid eucalyptus or menthol-based throat lozenges as they numb and dry the throat. Sensations such as itching or a sore throat are there for a reason: they tell us to take care of and rest our voice. 

Do you have dysphonia for more than three weeks?

It is important to see a voice specialist or laryngologist to be able to properly evaluate, diagnose and treat your problem. 

Without a doubt, the best way to prevent a problem with your voice is to eliminate tobacco use, and improve the use of your voice, particularly if you use it professionally. 

Go to our blog called vocal care: http://192.168.100.55/en/cuidado-vocal/ to learn better habits in the use of the voice. 

* This information does not take the place of your doctor's advice. Please consult your healthcare provider for information about a specific medical condition. 

References

Digitales, C. (n.d.). Disfonía, Una enfermedad silenciosa. Retrieved May 25, 2021, from https://www.achs.cl/portal/ACHS-Corporativo/newsletters/pymes-achs-al-dia/Paginas/Disfonia-la-enfermedad-silenciosa.aspx

Hoarseness. (2020, December 14). Retrieved May 25, 2021, from https://www.nidcd.nih.gov/health/hoarseness#1

Stachler, R. J., Francis, D. O., Schwartz, S. R., Damask, C. C., Digoy, G. P., Krouse, H. J., . . . Nnacheta, L. C. (2018). Clinical practice guideline: Hoarseness (dysphonia) (update). Otolaryngology–Head and Neck Surgery, 158(1_suppl). doi:10.1177/0194599817751030

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Cerumen (Earwax) Impaction

¿What is earwax?

Cerumen, commonly called earwax, is produced by small glands located at the outer part of our external ear canal. Cerumen not only protects the skin in our ear external canal from infection by reducing moisture and creating an acidic environment. It also prevents foreign bodies (like insects) or dust from entering the ear canal, and reduces the exposure to loud noises that could potentially damage the inner ear.

¿How does Cerumen get impacted?

As cerumen is produced it traps old skin and/or dust in our externa ear canal, and with jaw movements and chewing motions it is naturally moved towards the entrance of the ear. In normal circumstances simply cleaning the excess cerumen from the outer area of your ear is enough and should be all the cleaning you need to do.

However, this natural cleansing mechanism can be affected by many health conditions.

A few examples are:

⦁ A reduced diameter of the external ear canal: some people have naturally a narrower/small ear canal or excess hair growth which can cause the earwax to build up. However, this can also be caused by ear infections, genetic malformations of the skull or ear canal (such as Down Syndrome), bony growths inside of the ear canal and non-cancer or cancer tissue growth.

⦁ Excess or dense production of ear wax: some people produce an excessive amount of earwax, and as we age the glands in our ear canal produce a more dense/think earwax, which over exceeds or interrupts our natural cleansing mechanisms. Also, ear wax can be over produced as a response to a foreign body or trauma such as over use of self-cleansing objects such as Q-tips or overuse of headphones.

⦁ Overuse of cotton swabs or Q-Tips: use of cotton swabs seem harmful if they are used to clean the out part of the ear, without introducing it into the ear canal. When introduced deep into the ear canal it not only stimulates your body to produce more ear wax, it also pushes the ear wax further in, creating a more dense and hard to remove plug.

source: https://dizziness-and-balance.com/disorders/unilat/otitis.html
source: Tomar, M., Devi, H.P., Khundrakpam, R., Pant, A., & Saha, R. (2018). Study for evaluation of etiology , clinical presentation , audiometric assessment and spontaneous healing of traumatic perforation of tympanic membrane.

How do I know I have ear way accumulation or impaction?

Ear wax accumulation is usually asymptomatic. However, a few patients can suffer from:

⦁ Sudden or gradual hearing loss.

⦁ Ear pain

⦁ Blocked/itchy ears

⦁ Dizziness

⦁ Cough

How can I prevent earwax accumulation or impaction?

⦁ Avoid introducing any object into your ear canal. I always tell my patients, “the ear should be cleaned with your elbows”.

⦁ Try to “soften” the earwax: Use a baby dropper or eye dropper to apply 2- 3 drops of baby oil, mineral oil or liquid Vaseline once a day into your ear canal.

⦁ Use warm water to help the natural ear wax cleaning process: while taking a shower gently aim the stream of the shower head into your ear canal (avoid strong water jet streams) this will soften the ear wax and help remove any excess in the outer part of your ear.

⦁ Dry your ear canal: you can do this by simply aiming a hair drying with the cold setting (avoid hot air) into your ear canal for a few minutes after shower or swimming.

⦁ Visit your favorite ear nose and throat specialist: if there is any discomfort in your ears, or you know you tend to suffer from earwax impaction, it is recommended to have your ears check by a specialist every 6 months or when then symptoms occur.

* This information does not take the place of your doctor's advice. Please consult your healthcare provider for information about a specific medical condition.

References

Guest, J., Greener, M., Robinson, A., & Smith, A. (2004). Impacted cerumen: Composition, production, epidemiology and management. QJM, 97(8), 477-488. doi:10.1093/qjmed/hch082

Seth et al. (2017). Clinical Practice Guideline (Update): Earwax (Cerumen Impaction). Head and Neck Surgery, Vol. 156(1S) S1–S29


Tomar, M., Devi, H.P., Khundrakpam, R., Pant, A., & Saha, R. (2018). Study for evaluation of etiology , clinical presentation , audiometric assessment and spontaneous healing of traumatic perforation of tympanic membrane.

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Noise Induced Hearing Loss

What are the mayor structures of the ear?

The ear is divided in three main parts (see image below):

the external ear: formed by the ear lobe, the external ear canal and the ear drum or tympanic membrane.

the middle ear: includes the small bones (ossicles) called malleus, incus and stapes. The middle ear is ventilated and inner pressure is equalized via a narrow tube located at the back of the nose called the Eustachian tube.

the inner ear: includes a spiral-shaped structure called cochlea. The cochlea has small hair like structures called stereocilia which perceive sound waves and transduce them into electrical impulses that can be interpreted by the brain.

Source: Kiversal. (2019, December). The ear: structure and functions. Blog of Kiversal. https://blog.kiversal.com/en/the-ear-structure-and-functions/.

How do we perceive sound?

Sound waves hit your ear lobe, channels down to your external ear canal which makes the ear drum vibrate. This vibration jiggles the small bones in the middle ear. Then, the vibration is passed into the cochlea which stimulate the sterocilla, creating electrical impulses which are then transmitted and perceived as sound in your brain.

What causes hearing loss?

Two of the most common causes of hearing loss in adults are due to the natural aging process, also called presbycusis, and noise induced hearing loss. Every time you are exposed to a loud sound you have the potential risk of damaging your hearing. An excessive amount of sound, causes intense stimulation to the small hair like structures in your inner ear. These intense vibrations can cause permanent damage: meaning not reversible.

Two of the most common causes of hearing loss in adults are due to the natural aging process, also called presbycusis, and noise induced hearing loss. Every time you are exposed to a loud sound you have the potential risk of damaging your hearing. An excessive amount of sound, causes intense stimulation to the small hair like structures in your inner ear. These intense vibrations can cause permanent damage: meaning not reversible. According to the World Health Organization, there are approximately 1.1 billion young individuals at risk of permanently damaging their hearing due to exposure of unsafe levels of noise which includes: bars, nightclubs, cinemas, concerts, live events, fitness classes and listening to music or video game consoles over personal audio devices.

Individuals exposed to constant loud noises are three times likely to irreversibly lose their hearing at an early age. Early loss of hearing is a direct cause of depression, personal isolation, inability to communicate, inefficient job performance and frustration.

There are many other causes of hearing loss including head injury, illness and certain medication that can be toxic for the inner ear.

There are more than 200 medications on the market that are known to be toxic to the inner ear. Risk of ototoxicity depends on the way of administering the medication (intravenously has the highest risk), dose, age, and general health condition. You should ask your doctor if you are at risk before taking any medication. Just a few examples are:

⦁ Non-Steroidal Anti-Inflammatory Drugs (NSAIDs), such as aspirin, ibuprofen, or naproxen.

⦁ Certain antibiotics, including aminoglycosides.

⦁ Certain chemotherapy drugs for cancer treatment.

⦁ Blood pressure pills and diuretics.

⦁ Quinine-based medications (Chloroquine, Quinacrine Hydrochloride, Quinine Sulfate).

How to prevent can early hearing loss?

The number one thing you can do to keep your hearing as healthy as possible is to avoid or limit exposure to loud noises. Some of the common sources are:

⦁ Loud music (concerts, live events, fitness classes)

⦁ Heavy machinery

⦁ Gun fire

⦁ Excessive use of head phones for prolonged periods of time.

Noise is measured with a complex mathematic algorithm called decibels: in general terms the higher the decibels the stronger the wave sound and impact in our ear.

The World health Organization main recommendations are:

⦁ Exposure to 85 dB for a maximum limit of eight hours per day.

⦁ Followed by at least ten hours of recovery time at 70 dBA or lower.

⦁ Noise levels above 140 dB are not considered safe.

See the image below to learn the decibel levels of common everyday sounds:

Source: A Complete Guide to Noise-Induced Hearing Loss. EarQ. (2020, April). https://www.earq.com/hearing-health/articles/guide-to-noise-induced-hearing-loss.

This does not mean you should avoid listening to music or going concerts. The best way to prevent any hearing damage is to be aware of the noise level and how long you are exposed to it. Remember, once it passes a certain level, then it can permanently damage your hearing.

How can I prevent Noise induced hearing loss?

⦁ Wear earplugs: conventional ear plugs can reduce noise by 20-30 decibels. If your job involves loud noises there are high fidelity earplugs called `musicians earplugs which reduce noise levels while maintaining the quality of the original sound.

⦁ Respect the 60/60 rule: When listening to music with a personal audio device, limit the sound to 60% volume for no more than 60 minutes a day. Currently, most smartphones allow you to set a limit on the sound volume. So, limiting sound to a maximum of 60% can prevent any permanent hearing damage in the future.

⦁ Use over-the-ear headphones: devices that sit over your ears are safer since they are further away from the structures inside your ear.

⦁ Download smartphone apps: There are many smartphone apps that monitor the volume level of your smartphone or your surroundings. This can increase awareness and warn you if you are exposed to dangerous noise levels.

⦁ Take a break and recover: When exposed to loud noises at concerts, nightclubs or live events give your ears time to recover, and take breaks from the loud noise. Also, after a night out to a nightclub or after a concert, take at least 10 hours of ‘quiet’ to give your ears time to recover from the stress.

Remember noise induced hearing loss is preventable!

If you take care of the amount of sound you are exposed to and use effective prevention measures you will be able to enjoy sounds for a long time!

* This information does not take the place of your doctor's advice. Please consult your healthcare provider for information about a specific medical condition.

References

A Complete Guide to Noise-Induced Hearing Loss. EarQ. (2020, April). https://www.earq.com/hearing-health/articles/guide-to-noise-induced-hearing-loss.

Banzet, E. (2019, May). Noise-Induced Hearing Loss. speechandhearing.ca / paroleetaudition.ca. https://speechandhearing.ca/noise-induced-hearing-loss/.

Flint, P. W., & Cummings, C. W. (2021). Cummings Otolaryngology: head and neck surgery -Noise-Induced Hearing Loss. In Cummings Otolaryngology: head and neck surgery (pp.2140-2152). essay, Elsevier.

Noise Induced Hearing Loss among University Students Using Portable Entertainment Player. (2018). International Journal of Otorhinolaryngology, 5(1), 01–02. https://doi.org/10.13188/2380-0569.1000025

Prutsman, D. J. (2020, October). List of Ototoxic Medications. Sound Relief Hearing Center. https://www.soundrelief.com/list-of-ototoxic-medications/.

World Health Organization. (n.d.). Making listening safe. World Health Organization. https://www.who.int/activities/making-listening-safe.

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¿Qué es la Toxina Botulínica?

Botulinum toxin is a drug of bacterial origin with the ability to block muscle movement. This is why it is used for aesthetic benefits as it paralyzes certain muscles of facial expression. By avoiding continuous movement certain expressions, such as raising the eyebrow or frowning, counteracts or diminishes the wrinkles caused by the continuous movement of certain muscles of the face. It is also used in different diseases in which it is necessary to paralyze one or a group of muscles, for example involuntary muscle spasm, torticollis or spasticity in cerebral palsy.

Being a minimally invasive and reversible treatment, it has become one of the treatment of choice to reduce expression lines and wrinkles. Being a temporary treatment, the risk of application and side effects are minimal. Among the most common are allergic reactions to the toxin, or their own during application such as hematoma (bruise), pain at the application site, temporary redness and blockage of unwanted muscle movement. 

Today there are a variety of botulinum toxins for sale varying in intensity and brands. Just to mention a few: Botox, Dysport, Nabota, Xeomin among others. The brand or type of toxin to apply depends on the doctor. 

What is the purpose of Botulinum Toxin? 

The objective of using botulinum toxin is to avoid excessive muscle contraction, minimizing wrinkles on the skin. The treatment is generally individualized to achieve natural results, avoiding the frozen and unsightly appearance. 

The best time to apply Botulinum Toxin?

An ideal age for its application has not currently been described. Logically, the best time is to avoid dynamic expression lines, which begin around 30 to 40 years, depending on the quality, care and color of the skin, as well as age, sun exposure, muscular activity and style of lifetime.  

The objective of the application of botulinum toxin is not to modify or freeze the facial expression of the patient, but to individualize the dose of toxin for each patient to delay and smooth wrinkles caused by excessive movement of some muscles in the face. 

What is the duration of botulinum toxin?

The average duration is 4 to 6 months, although it varies in each patient, and depends on the type of botulinum toxin or brand applied, age, lifestyle, muscle activity, current medication and frequency of application of botulinum toxin. 

* This information does not take the place of your doctor's advice. Please consult your healthcare provider for information about a specific medical condition.