Our voice is invaluable for both social interaction as well as livelihood. The ability to properly swallow is equally invaluable from both the standpoint of enjoying our favorite meal to ensuring that we are able to properly nourish our bodies. Dr. Kimmelman works with his patients to restore and maintain the proper care and use of their voices and swallowing function.

Voice
What is voice and how is it produced?
The sound of the human voice is created by vibrations of the vocal cords as air passes outward from the lungs and through the larynx (the “voice box”). The "Adam's apple," seen most prominently on men, forms the front of the larynx. When the speaker presses the vocal cords together like a valve, the air passes gently between them, causing them to vibrate and producing sound. The sound is then modified and enhanced by the throat, cheeks, tongue, lips, soft palate and sinuses, all of which participate in the creation of human speech.

It is important to know that the prime purpose of the vocal cords is to protect the airway from the entry of food and drink during swallowing. During the course of evolution animals have evolved the ability to use the larynx as an organ of communication. But if we did not have a larynx, we would have to deal with repeated episodes of aspiration (entry of food and liquids into the trachea, or windpipe) that lead to pneumonia, lung scarring and eventually death from asphyxiation.

What are voice disorders?
A normal voice is judged according to whether the pitch, loudness, and quality are adequate for communication and suit a particular person. A person may use a pitch which is too high or too deep, intensity that is too loud or too soft, or voice quality may be too hoarse, breathy, or nasal. Sometimes a voice may seem inappropriate for an individual, such as a high-pitched voice in an adult male.

Voice is a problem when the pitch, loudness, or quality calls attention to itself rather than to what the speaker is saying. It is also a problem if the speaker experiences pain or discomfort when speaking or singing. Some common signs of a voice disorder include:
  • Hoarseness
  • Vocal fatigue
  • Breathy voice quality
  • Change in pitch range of the voice
  • Excessive coughing
  • Excessive throat clearing
  • Change in voice after a cold or flu
What causes a voice problem?
There are a variety of causes of voice problems. People can become hoarse temporarily by cheering too loudly at a football game or using a pitch level that is too high or too low. Other misuses of the voice, such as an improper breathing pattern or excessive smoking, can also result in a voice problem. Some prescription, over-the-counter, and herbal medications including can affect the function of your voice.

Voice changes sometimes follow an upper respiratory infection or cold due to swelling of the vocal cords and changes in their vibration pattern. Reduced voice use (voice rest) typically improves the voice after an upper respiratory infection, cold, or bronchitis. If voice does not return to its normal characteristics and capabilities within two to four weeks after a cold, a medical evaluation is recommended. A throat examination after a change in the voice lasting longer than one month is especially important for smokers because of the possibility of cancer as a cause of the hoarseness. Other causes of voice change are vocal cord weakness of paralysis (stroke, lung cancer, neuropathy), vocal cord polyps or nodules, gastroesophageal reflux disease, thyroid disease, allergy, inhalations of irritating substances or medications, endotracheal intubation during surgery, neurological disorders (spasmodic dysphonia, multiple sclerosis) and external neck trauma.

How are voice disorders diagnosed?
Dr. Kimmelman will begin his evaluation with a thorough medical history and description of the events leading up to your visit. He will thoroughly review your medical history to determine whether any of the factors that cause voice disturbances are present.

Next he will perform a comprehensive examination of the head and neck. This will include and endoscopic procedure to observe the vocal tract structures. The vocal cords will be observed for the detection of muscular weakness or paralysis, deformity, inflammation, polyps, tumors, nodules, granulomas and infection.

In addition to the examination Dr. Kimmelman may order additional testing, such as:
  • Imaging studies (CT scan, MRI scan) to detect structural abnormalities in the larynx, soft tissues of the neck, thyroid gland and airway)
  • Videostroboscopy to delineate the vibratory characteristics of the vocal cords
  • Direct laryngoscopy, an operative procedure under general anesthesia, to obtain tissue for analysis of tumors, inflammation or infection. Tissue removal is accomplished under the guidance of a microscope using microinstuments or lasers.
  • Vocal assessment by a Speech and Language Specialist. Formerly known as “Speech Pathologists,” these highly trained professionals are experts at voice analysis and rehabilitation. They use advanced testing, such as acoustic analysis, aerodynamic evaluation and voice therapy to diagnose and treat abnormal function of the vocal tract.
How are voice disorders treated?
Depending on the cause Dr. Kimmelman has a number of options available:
  • Gastroesophageal reflux disease is treated with diet modification, proton pump inhibitors to stop acid production and lifestyle modification (elevation of head during sleep, no late night meals, etc.)
  • Vocal cord polyps may require operative intervention and smoking cessation.
  • Vocal cord cancer is treated with surgery and/or radiation therapy.
  • Functional voice problems (vocal misuse and abuse, derangements of pitch and breath control and others) require the assistance of a speech and language specialist.
  • Neurological disorders, such as paralysis or spasmodic dysphonia, may require surgery and/or medications.
  • Vocal hygiene includes following a daily regimen to achieve and maintain a healthy voice including maintaining adequate hydration (6-8 glasses of water per day), minimizing exposure to noxious chemicals, no smoking of cigarettes, and the avoiding of excessive shouting, screaming or other loud voice use.

Swallowing
How Does Swallowing work?
Swallowing is a very complex act, requiring the normal function of the brain, several nerves, more than 25 muscles and two muscular valves, as well as an open, non-constricted throat and esophagus. The act of swallowing normally occurs in three phases.

In the first phase, food or liquid is contained in the mouth by the tongue and palate (oral cavity). This phase is the only one we can control.

The second phase of swallowing begins with a complex series of reflexes. The food is thrust from the oral cavity into the throat (pharynx). At the same time, two other events occur: A muscular valve at the bottom of the pharynx opens, allowing food to enter the swallowing tube (esophagus), and the vocal cords close prevent food from entering the airways. This second phase of swallowing takes less than half a second.

The third phase of swallowing begins when food enters the esophagus. The esophagus, which is about nine inches long, is a muscular tube that produces waves of coordinated contractions (peristalsis). As the esophagus contracts, a muscular valve at the end of the esophagus opens and food is squeezed into the stomach like toothpaste out of a tube. The third phase of swallowing takes six to eight seconds to complete.

How do you know if you have a swallowing problem?
The medical term for difficulty swallowing is dysphagia. Normally, individuals rarely choke during a meal. Occasionally, food will stick in the esophagus for a few seconds (especially solid foods) but will pass spontaneously or can be washed down easily with liquids. However, there are a number of symptoms that require evaluation for a possible swallowing problem, including:
  • Frequent choking on food
  • Hesitancy in food passage for more than a few seconds
  • Pain when swallowing
  • Recurring pneumonia (an indication that food may be going into the lungs rather than the esophagus)
Some people are unaware that they have swallowing problems because they compensate unconsciously by choosing foods that are easier to eat, or they eat more slowly. If you think you may be experiencing a swallowing problem, Dr. Kimmelman recommends that you undergo an evaluation.

What Conditions cause Dysphagia?
  • Neurological derangements: Myasthenia gravis, stroke, dysfunction of the autonomic nervous system, Achalasia (tightness of the junction of the esophagus and stomach with secondary stretching and ballooning of the esophagus)
  • Autoimmune: Scleroderma, polymyositis
  • Age: Presbyesophagus, a degeneration of the muscles and nerves of the esophagus causing defective peristalsis
  • Benign Tumors or Cancer of the Thyroid, Trachea, Esophagus, Lung, Stomach or Pharynx
  • Anxiety: Globus hystericus, a common condition in which the muscles of the entrance to the esophagus are too tight when the person is not eating, giving the sensation of tightness of the throat. The swallowing process, however, is normal.
  • Gastroesophageal Reflux Disease is a common problem that can lead to disruption of function of the throat, voice box and esophagus.
  • Surgery of the head and neck, chest, brain, all of which can either directly damage the throat and esophageal tissue or interfere with the nerves that supply them
  • Medications which dry the secretions and slow the activity of the smooth muscle of the esophagus. Some medicines and supplements induce reflux.
  • Trauma to the esophagus from ingestion of caustic substances, foreign bodies of the esophagus, burns from ingestion of scalding liquids and penetrating wounds.
  • Enlargement of the heart due to heart failure
  • Congenital anomalies and malformations of the esophagus, heart or great vessels exiting and entering the heart
  • Endocrine diseases: Diabetes mellitus
  • Infections of the esophagus (Candida albicans (a fungus), Tuberculous enlargement of lymph nodes in the mediastinum (Space between the heart and lungs)
How Are Swallowing Problems Diagnosed?
Dr. Kimmelman will begin his evaluation by first gathering general health information, details of your swallowing symptoms and previous medical problems. He will then perform a physical examination including endoscopy, as described above in the voice section, to help him determine whether or not the problem is in the mouth, throat, voice box, esophagus or stomach. In addition Dr. Kimmelman may order or perform additional testing swallowing problem:
  • Cineradiography is an imaging test in which a video camera is used to film the images of the dynamic swallowing process from the mouth to the intestines. The patient swallows a barium preparation (liquid or other form that lights up under X-ray) and an X-ray machine with videotaping capability is used to view its movement through the esophagus.
  • Esophagoscopy is an operative procedure that allows direct inspection of the lining of the esophagus.
How Are Swallowing Problems Treated?
The form of treatment Dr. Kimmelman recommends will depend on the type of swallowing problem you have. Sometimes, the problem will resolve itself without treatment. Medicines to reduce acid production and reflux may be indicated. If the esophagus is narrowed, Dr. Kimmelman may recommend using a special tool called an esophageal dilator to stretch an esophagus narrowed from acid reflux. However, the problem may be complex, and Dr. Kimmelman may recommend additional medical or surgical treatment.