SLP 202: Voice Science and Disorders

Unit 3: Voice Habilitation

b) Pharmacological
and Surgical Effects
on Voice

Submitted to: Submitted by:

Dr. Mereen Bency Ann Chacko
1st MSc Speech
Contents
 PHARMACOLOGICAL EFFECTS
o Bacterial Infections
o Allergies
o Oedema
o Pain
o Asthma
o Cough
o Gastric and Laryngopharyngeal reflux
o Stage fright
o Spasmodic dysphonia
o Mood conditions
o Sleep disturbances
o Hormone Imbalances
 SURGICAL EFFECTS
o General anaesthesia
o Cricotracheal resection
o Lateral Neck Dissection
o Tonsillectomy
 REFERENCES
Bacterial Infections
Bacterial infections are any illness or condition caused by bacterial growth or poisons
(toxins). You can get sick from getting harmful bacteria in your skin, gut (GI tract), lungs,
heart, brain, blood or anywhere else in your body.
Harmful bacteria from the environment, an infected person or animal, a bug bite or something
contaminated (like food, water or surfaces) can cause infections.

Medications for Bacterial Infections

1. Penicillin V (Phenoxymethylpenicillin) effect on acute laryngitis
a. Objective Voice Scores: The study used objective voice scores, derived from voice
recordings evaluated by experienced voice specialists, to assess the impact of
Penicillin V. These scores did not significantly differ between the pcV-treated
group and the placebo group at any point during the study.
b. Subjective Voice Scores: Patients also self-reported their vocal symptoms using
subjective voice scores. Similar to the objective scores, there was no significant
difference between the pcV and placebo groups in the severity of reported vocal
symptoms.
c. Resolution of Vocal Symptoms: The rate of resolution of vocal symptoms was the
same in patients who received Penicillin V and those who received a placebo. This
suggests that Penicillin V did not have a significant effect on improving voice-
related symptoms in patients with acute laryngitis.
Reference: Schalen, L., Fex, S., Christensen, P., Kamme, C., Eliasson, I., & Schalen, C.
(1985). Inefficacy of penicillin V in acute laryngitis in adults. Annals of Otology,
Rhinology & Laryngology, 94(1), 117-121.
2. Erythromycin effect on acute laryngitis in adults
a. Erythromycin had a significant effect on voice in patients with acute laryngitis
primarily by reducing the vocal disturbances reported by the patients.
b. The study found that after one week, patients treated with erythromycin reported
significantly fewer voice disturbances compared to those who received a placebo.
c. However, objective evaluations such as endoscopic examinations and listener
ratings of voice did not show a significant difference between the erythromycin
and placebo groups.
d. The subjective improvement in voice symptoms suggests that erythromycin may
have provided symptomatic relief that was not captured by the objective measures
used in the study.
Reference: Stenfors, L. E., & Räisänen, S. (1992). Erythromycin in acute laryngitis in
adults. Archives of Otolaryngology–Head & Neck Surgery, 118(4), 430-433.

Allergies
Allergies occur when your immune system reacts to a foreign substance — such as pollen,
bee venom or pet dander — or a food that doesn't cause a reaction in most people. The
immune system produces substances known as antibodies.
Medications of Allergies
 Antihistamines
Antihistamines are known to have a drying effect on the vocal folds, which can lead to
hoarseness and other vocal issues. These medications work by reducing the production of
histamine, which in turn reduces mucus production in the body. However, this reduction in
mucus can dry out the mucous membranes, including those of the vocal folds, making them
more prone to irritation and injury.
According to the New York Otolaryngology Group, antihistamines such as Allegra
(fexofenadine), Clarinex (desloratadine), and Zyrtec (cetirizine) can dry out the mucus and
vocal folds, potentially leading to a scratchy or hoarse voice. The drying effect reduces the
protective mucus layer on the vocal folds, causing them to rub together more during speech,
which can lead to irritation.
The University of Iowa also notes that antihistamines, including Benadryl
(diphenhydramine), can cause dryness in mucous membranes, leading to hoarseness, sore
throat, and other voice changes. This dryness can make the vocal folds more susceptible to
injuries such as nodules.

Oedema
Oedema is a build-up of fluid in the body which causes the affected tissue to become swollen.
The swelling can occur in one particular part of the body or may be more general, depending
on the cause.

Medications for Oedema

 Diuretics
Diuretics have a significant effect on the vocal folds primarily due to their impact on systemic
hydration.
a. Systemic Dehydration: Diuretics like Lasix (furosemide) induce systemic
dehydration by reducing the body's overall fluid volume. This is evidenced by a
measurable decrease in body weight, indicating loss of water.
b. Increased Phonation Threshold Pressure (PTP): The study found that systemic
dehydration caused by Lasix led to an increase in phonation threshold pressure
(PTP). PTP is the minimum subglottic pressure needed to initiate and sustain vocal
fold oscillation. An increase in PTP suggests that more effort is required for
phonation, indicating a less efficient and potentially strained vocal production.
c. Impact on Vocal Fold Viscosity: The study suggests that systemic dehydration may
increase the viscosity of vocal fold tissues. Higher viscosity means greater resistance
to vocal fold movement, leading to increased phonation effort and potential vocal
strain.
d. Voice Quality: Although not explicitly detailed in the snippet, systemic dehydration
from diuretics can contribute to voice quality issues such as hoarseness and a rough
or strained voice due to the increased PTP and decreased tissue lubrication.
Reference: Verdolini, K., Min, Y., Titze, I. R., Lemke, J., Brown, K., Mersbergen, M.
van, Jiang, J., & Fisher, K. (2002). Biological Mechanisms Underlying Voice Changes
Due to Dehydration. Journal of Speech, Language, and Hearing Research, 45(2), 268–
281. https://doi.org/10.1044/1092-4388(2002/021)

Pain
‌Pain is an uncomfortable sensation that usually signals an injury or illness.

Medications for Pain

 Ibuprofen
a. Ibuprofen distinguishes itself from other oral irritants due to its unique effects on the
throat. Unlike capsaicin and menthol, which primarily irritate the mouth, ibuprofen
causes more prominent and prolonged stinging sensations in the throat. It also
induces itching and tickling sensations that can lead to coughing.
b. Unlike capsaicin, ibuprofen-induced throat irritation is not affected by temperature.
Instead, its irritation is primarily pH-dependent, indicating that ibuprofen interacts
with a different set of sensory receptors, providing a unique sensory experience
compared to other oral irritants.
c. In the study, subjects rated irritation and taste after swallowing aqueous solutions of
ibuprofen prepared with various buffering agents. The results indicated that ibuprofen
caused significantly more irritation in the throat than in the mouth, with throat
irritation characterized mainly by stinging/pricking, itching, and tickling
sensations. Researchers hypothesized that these qualities of throat irritation were pH-
dependent.
d. To test this hypothesis, they conducted a subsequent experiment manipulating the pH
of the solutions. They found that lower pH (more neutral solutions) resulted in
higher perceived irritation. Specifically, the initial irritation was almost twice as
high at the lowest pH compared to the highest pH.
e. It was noted that sensations of itch and tickle in the throat were reported by some
subjects, which sometimes triggered coughing. Excessive throat irritation, regardless
of the cause, can potentially lead to vocal abuse if it results in behaviours such as
throat clearing, coughing, or speaking in a way that strains the vocal cords. Prolonged
or severe throat irritation may contribute to vocal fatigue, hoarseness, or other vocal
issues if not managed appropriately.
Reference: Breslin, P. A. S., Gingrich, T. N., & Green, B. G. (2001). Ibuprofen as a
Chemesthetic Stimulus: Evidence of a Novel Mechanism of Throat Irritation. Chemical
Senses, 26(1), 55–65. https://doi.org/10.1093/chemse/26.1.55
 Aspirin
Aspirin can have a detrimental effect on the voice. Specifically, aspirin, like other NSAIDs,
can increase the risk of vocal fold haemorrhage, which is particularly dangerous for
professional voice users. This is due to aspirin's blood-thinning properties, which can lead to
increased bleeding and damage to the vocal folds. Therefore, it is generally advised for
individuals who rely heavily on their voice, such as singers and speakers, to avoid aspirin and
other non - steroidal anti - inflammatory drugs (NSAIDs) to prevent potential voice issues.
Asthma
Asthma is a major noncommunicable disease (NCD), affecting both children and adults, and
is the most common chronic disease among children. Inflammation and narrowing of the
small airways in the lungs cause asthma symptoms, which can be any combination of cough,
wheeze, shortness of breath and chest tightness.

Medication for Asthma

 Anticholinergic
Anticholinergic medications can cause dysphonia, or hoarseness, through their drying
effect on the vocal folds. The drying effect of anticholinergics can lead to vocal fold
dehydration, which in turn can result in changes to vocal fold function and structure. These
changes may include:
1. Decreased Mucosal Lubrication: The drying effect of anticholinergic
medications can reduce the natural lubrication of the vocal folds, leading to
increased friction and potential damage during vocal fold vibration.
2. Increased Vocal Fold Stiffness: Vocal fold dehydration can make the vocal folds
stiffer, affecting their ability to vibrate smoothly and produce clear sounds.
3. Altered Mucosal Wave: Dehydration can impact the mucosal wave, which is
essential for efficient vocal fold vibration and sound production. Changes in the
mucosal wave frequency and amplitude can contribute to voice quality issues.
4. Higher Phonation Threshold Pressure: Vocal fold dehydration can increase the
pressure required for phonation, leading to vocal strain and effort during speaking
or singing.
5. Increased Vocal Fold Friction: Reduced lubrication due to dehydration can
result in higher levels of friction between the vocal folds, potentially causing
vocal fatigue, discomfort, or hoarseness.‌
Reference: Haft, S., Farquhar, D., Carey, R., & Mirza, N. (2015). Anticholinergic Use Is
a Major Risk Factor for Dysphonia. ˜the œAnnals of Otology, Rhinology &
Laryngology, 124(10), 797–802. https://doi.org/10.1177/0003489415585867

Cough
A cough is your body's way of responding when something irritates your throat or airways.
An irritant stimulates nerves that send a message to your brain. The brain then tells muscles
in your chest and abdomen to push air out of your lungs to force out the irritant. A sudden,
forceful hacking sound to release air and clear an irritation in the throat or airway.

Medication for Cough

 Antitussive (Cough Suppressants)
Cough suppressants (antitussives) often contain an antihistamine and codeine, a narcotic,
which can have a drying effect on vocal tract secretions. Benzonatate (Tessalon) is a non-
narcotic antitussive that works by anesthetizing stretch receptors in the upper respiratory tract
to suppress the cough reflex, but it can cause severe hypersensitivity reactions, including
laryngospasm and bronchospasm. Dextromethorphan, a non-narcotic agent found in many
cough syrups, has effects similar to codeine and is generally effective for voice professionals.
Patients, including singers, should carefully read labels on over – the – counter (OTC)
medications.

Gastric and Laryngopharyngeal Reflux

Acid reflux occurs when acidic stomach contents flow back into the oesophagus, the
swallowing tube that leads from the back of the throat to the stomach.
When acid repeatedly “refluxes” from the stomach into the oesophagus alone, it is known as
gastroesophageal reflux disease (GERD). However, if the stomach acid travels up the
oesophagus and spills into the throat or voice box (called the pharynx/larynx), it is known as
laryngopharyngeal reflux (LPR).

Medication for GERD & LPR

 Proton Pump Inhibitor (PPI)
While Proton Pump Inhibitors (PPIs) are generally considered safe and effective in managing
Laryngopharyngeal Reflux (LPR) and its associated symptoms, there are some potential
negative effects that PPIs may have on voice in certain individuals. Here are some
considerations regarding the potential negative effects of PPIs on voice:
1. Voice Changes: In some cases, individuals may experience voice changes such as
hoarseness, dryness, or altered vocal quality as a side effect of PPI therapy. These
voice changes may be temporary and resolve once the individual stops taking the
medication or adjusts the dosage.
2. Dysphonia: PPIs have been reported to cause dysphonia, which is a broad term for
voice disorders that result in changes in pitch, volume, or quality of the voice.
Dysphonia may manifest as a raspy, strained, or weak voice, which can impact
vocal performance and communication.
3. Throat Irritation: PPIs can sometimes cause throat irritation or a sensation of
throat tightness, which may indirectly affect voice production and quality. This
discomfort in the throat area can lead to vocal strain and changes in voice clarity.
4. Dry Mouth: PPIs have been associated with dry mouth as a side effect, which can
contribute to vocal dryness and discomfort during speaking or singing. Dry mouth
can affect vocal resonance and articulation, potentially leading to voice issues.
5. Potential Allergic Reactions: In rare cases, individuals may experience allergic
reactions to PPIs, which can manifest as swelling of the throat, tongue, or vocal
cords. These allergic reactions can result in voice changes and difficulty in vocal
production.
6. Interaction with Other Medications: PPIs may interact with other medications that
the individual is taking, leading to side effects that could indirectly impact voice
function. It is important to consider potential drug interactions when prescribing PPIs
in individuals with voice concerns.

Stage Fright
Stage fright, or performance anxiety, is state of anxiety or fear which occurs when an
individual is faced with the requirement of performing in front of an audience (either
directly or through a screen, e.g in front of a camera). It affects all kinds of people who have
to appear in front of an audience, even when they are not necessarily speaking. For example,
it can affect musicians, dancers, politicians or athletes.

Medication for Stage Fright

 Beta – Blockers
Beta-blockers can have various effects on the voice.
1. Reduced Vocal Tremors: Beta-blockers are often prescribed to manage conditions like
essential tremor, which can include vocal tremors. By stabilizing these tremors, beta-blockers
can improve vocal steadiness and control.
2. Altered Vocal Quality: Some users may experience changes in voice quality. This can
include a reduction in vocal strength or endurance due to the drug's effect on heart rate
and blood pressure, potentially impacting the body's overall ability to support sustained
vocal effort.
3. Dry Mouth and Throat: Beta-blockers can cause dryness of the mouth and throat,
which may affect vocal clarity and increase the risk of vocal strain or discomfort during
prolonged use of the voice.
4. Potential Impact on Singing: For singers, beta-blockers can be a double-edged sword.
While they may help reduce performance anxiety and stabilize vocal tremors, they can also
lead to a sensation of reduced vocal power and potential changes in vocal timbre.

Spasmodic Dysphonia
‌ pasmodic dysphonia is a voice disorder. It causes involuntary spasms in the muscles of the
S
voice box or larynx. This causes the voice to break and have a tight, strained or strangled
sound.

Medication for Spasmodic Dysphonia

 Muscle relaxant
These medications often lead to a drying effect on mucous membranes, which can result in
hoarseness, a sore throat, voice changes, or even laryngitis. The dryness of the vocal folds
makes them more susceptible to injuries, such as nodules. Additionally, muscle relaxants can
produce a diminished drive to speak and may cause dysarthria, characterized by slow,
slurred, and uncoordinated speech movements.
Muscle relaxants can indeed contribute to acid reflux, which can subsequently lead to voice
problems. Muscle relaxants may relax the lower oesophageal sphincter (LES), the valve
that separates the stomach from the oesophagus. When the LES is relaxed, stomach acid can
more easily reflux into the oesophagus and potentially reach the throat, a condition known as
laryngopharyngeal reflux (LPR). LPR can cause symptoms such as hoarseness, throat
clearing, chronic cough, and a sensation of a lump in the throat, all of which can affect
vocal quality and performance.
Mood Changes
A mood disorder is a mental health condition that primarily affects your emotional state. They
can cause persistent and intense sadness, elation and/or anger. Mood disorders are treatable
— usually with a combination of medication and psychotherapy (talk therapy).

Medications for Mood Changes

 Antidepressant
Antidepressants can have several effects on the voice, which can be of particular concern to
voice professionals and individuals who rely on their vocal performance. Here are some key
considerations:
1. Dry Mouth (Xerostomia): Many antidepressants, particularly tricyclic
antidepressants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), can
cause dry mouth. This dryness can lead to a reduction in saliva production,
which is essential for lubricating the vocal cords. Without adequate lubrication,
the vocal cords can become dry and irritated, leading to hoarseness and
discomfort while speaking or singing.
2. Voice Fatigue: The dry mouth caused by antidepressants can also contribute to
vocal fatigue. This condition can make it difficult to maintain vocal quality over
prolonged periods, affecting both speaking and singing performance.
3. Hoarseness and Throat Irritation: The reduction in saliva can also lead to a
sensation of throat irritation and hoarseness. This is because dry vocal cords
are more susceptible to friction and damage, which can manifest as changes in
voice quality.
4. Impact on Vocal Performance: For professional voice users, these side effects
can be particularly problematic. Dryness and irritation can compromise the ability
to perform consistently and maintain the desired vocal tone and pitch.

Sleep disturbances
Sleep disorders are conditions that affect the quality, amount and timing of sleep you’re able
to get at night. Common sleep disorders include insomnia, restless legs syndrome, narcolepsy
and sleep apnoea. Sleep disorders can affect your mental health and physical health.

Medication for Sleep Disturbances

There are several insights into the effects of insomnia medications on voice:
a. Dry Mouth and Throat: Insomnia medications, particularly those that are
sedative-hypnotics like benzodiazepines and non-benzodiazepine sleep aids (e.g.,
zolpidem, eszopiclone), can cause dry mouth and throat. This dryness can
impact vocal cord lubrication, leading to a rough or hoarse voice.
b. Decreased Saliva Production: Some insomnia medications, including certain
antidepressants used off-label for insomnia (like amitriptyline and trazodone),
have anticholinergic properties that reduce saliva production. Reduced saliva can
make it difficult to speak clearly and can cause discomfort while using the
voice.
 c. Voice Strain: The drying effects of these medications can force individuals to
strain their voice more to produce sound, which can lead to vocal fatigue and
potential damage over time.
d. Reflux Aggravation: Some insomnia medications may relax the lower
oesophageal sphincter, potentially worsening acid reflux. Acid reflux can lead to
laryngopharyngeal reflux, which irritates the vocal cords and can cause
hoarseness or chronic cough.

Hormone Changes
A hormonal imbalance happens when you have too much or too little of one or more
hormones — your body’s chemical messengers. It’s a broad term that can represent many
different hormone-related conditions.

Medications for Hormone Imbalances

Thyroid replacement therapy, used to treat hypothyroidism, can affect voice quality and
function in both positive and negative ways. Here are the key points:
Positive Effects:
1. Improvement in Hoarseness: Hypothyroidism often causes hoarseness. Thyroid
replacement therapy can restore normal thyroid hormone levels, leading to the
resolution of hoarseness and improvement in voice quality.
2. Reversal of Vocal Changes: The therapy can reverse vocal cord dysfunction and
restore reduced vocal range associated with hypothyroidism, normalizing voice
function.
3. Optimization of Laryngeal Function: Thyroid hormones are crucial for the
maintenance of laryngeal tissue and function. Restoring these hormone levels can
improve laryngeal function and voice production.
4. Voice Quality: Individuals may experience improved clarity, pitch, and vocal
range as thyroid hormone levels are normalized.
Negative Effects (Excess Thyroid Hormone Levels):
1. Voice Changes: Excess thyroid hormone (hyperthyroidism) can cause hoarseness,
vocal fatigue, and alterations in vocal quality.
2. Vocal Cord Dysfunction: Abnormal vocal cord movements due to excess thyroid
hormone can impact voice production and control.
3. Reversibility: Voice changes caused by excess thyroid hormone can often be reversed
by adjusting the dosage of thyroid replacement therapy.
Reference: Hari Kumar, K. V. S., Garg, A., Ajai Chandra, N. S., Singh, S. P., & Datta, R.
(2016). Voice and endocrinology. Indian Journal of Endocrinology and Metabolism,
20(5), 590–594. https://doi.org/10.4103/2230-8210.190523
 Oestrogen Replacement Therapy
Hormonal Replacement Therapy (HRT) has been studied for its effects on the voice of
menopausal women. Research has shown that HRT can have an impact on various aspects of
voice production.
1. Habitual Pitch: Menopausal women on HRT were found to have a higher habitual pitch
compared to those not on HRT.
2. Voice Handicap Index-10 (VHI-10) Scores: There was no significant difference in VHI-
10 scores between menopausal women on HRT and those not on HRT.
3. Acoustic Changes: Studies have reported that HRT can influence parameters such as the
speaking fundamental frequency (F0) and vocal intensity in postmenopausal women.
4. Vocal Symptoms: The prevalence of phonatory symptoms did not differ significantly
between menopausal women on HRT and those not on HRT.
Reference: Hamdan, A.-L., Tabet, G., Fakhri, G., Sarieddine, D., Btaiche, R., & Seoud,
M. (2018). Effect of Hormonal Replacement Therapy on Voice. Journal of Voice, 32(1),
116–121. https://doi.org/10.1016/j.jvoice.2017.02.019

Surgical Effects on Voice

 Lateral Neck Dissection
The effects of lateral neck dissection on the voice can be significant, particularly in the initial
period following surgery. Here are the main effects observed:
a. Lower Fundamental Frequencies: Patients who underwent lateral neck dissection
experience a significant lowering of their fundamental frequency (pitch) and
speaking fundamental frequency. This change is most notable within the first month
after surgery and is statistically more significant in patients who had lateral neck
dissection compared to those who did not.
b. Vocal Fold Oedema: There is a higher incidence of vocal fold oedema (swelling) in
patients who had lateral neck dissection. This oedema is particularly noticeable in the
first month after surgery and can persist for several months. Oedema can lead to a
heavier vocal fold mass, which contributes to the lowered pitch.
c. Asymmetric Mucosal Wave: Videostroboscopic examinations reveal a higher
occurrence of asymmetric mucosal waves in the vocal folds of patients who
underwent lateral neck dissection. This condition can affect the smoothness and
regularity of vocal fold vibrations, contributing to voice disturbances.
d. Subjective Voice Quality: Patients self-report a higher incidence of voice quality
issues following lateral neck dissection. These subjective assessments include
complaints of a rough, strained, or breathy voice, and these issues tend to persist
longer than the objective acoustic changes.
e. Voice Weakness and Effort: Patients may experience overall vocal weakness and
increased effort during speech. This can manifest as asthenia (weak voice) and
strain (excessive effort to produce voice), further affecting their ability to
communicate effectively.
Reference: Kim, J. W., Park, E. S., Kim, Y., Jeong, W. J., Choi, S. H., Nam, S. Y., Roh, J.
L., & Cho, S. H. (2014). Lateral neck dissection affects vocal quality in patients with
papillary thyroid carcinoma. Thyroid, 24(3), 512-519.
https://doi.org/10.1089/thy.2012.0616
 Cricotracheal Resection
1. Fundamental Frequency (F0):
a. There was a decrease in mean F0 from 215 Hz pre-surgery to 201 Hz post-
surgery. This reduction indicates a slightly lower pitch in the voice after the
procedure. However, this change was not statistically significant and remained
within the normal range.
2. Voice Disorder Severity:
a. Voice disorder severity, measured by the Cepstral Spectral Index of
Dysphonia (CSID) for sustained vowels, improved significantly from 41 to
25 points post-surgery. This suggests a notable reduction in the severity of
voice disorders for sustained vowel sounds. However, no significant change
was observed for connected speech samples.
3. Voice Handicap Index (VHI) Scores:
a. VHI scores, which measure the perceived impact of voice problems on a
person's quality of life, generally decreased after surgery. This indicates that
participants felt their voice-related quality of life improved post-surgery.
4. Pitch and Prosody:
a. The semitone standard deviation (STSD), a measure of pitch variability, did
not change significantly from pre- to post-treatment. This suggests that the
ability to vary pitch, which is important for natural-sounding speech, was
preserved.
b. Auditory-perceptual ratings showed that 53.7% of participants
experienced a decrease in pitch, 36.4% had no change, and 9.9% had an
increase in pitch from pre- to post-treatment.
Reference: Tanner, K., Dromey, C., Berardi, M. L., Mattei, L. M., Pierce, J. L., Wisco, J.
J., Hunter, E., & Smith, M. E. (2016). Effects of voice-sparing cricotracheal resection on
phonation in women. 127(9), 2085–2092. https://doi.org/10.1002/lary.26429
 General Anaesthesia
The evaluation of vocal functions in the study was conducted through a comprehensive
assessment protocol, which included the following steps:
1. Full clinical history: Personal history and analysis of patient complaints were
obtained to understand the patient's vocal function and any pre-existing conditions.
2. Phoniatric history: Symptoms of vocal fatigue and phonaesthesia were assessed to
evaluate the patient's vocal endurance and strength.
3. Arabic Voice Handicap Index (VHI): The VHI, a patient-based self-assessment tool
consisting of 30 items distributed across functional, physical, and emotional domains,
was used to measure the impact of voice disorders on daily activities, affective
responses to voice disorders, and self-perceptions of laryngeal discomfort and voice
output characteristics.
4. Auditory Perceptual Assessment of Voice (APA): Three expert phoniatri-cians used
a modified GRBAS scale to subjectively assess the patient's voice quality in terms of
overall grade or severity, roughness, breathiness, asthenia, and strain. Dysphonia was
graded on a scale from 0 (normal) to 3 (severe).
 5. Full Laryngeal Examination: Telescopic rigid orolaryngoscopy was performed
using a rigid fibreoptic laryngoscope to visualize the laryngeal structures and identify
any traumatic manifestations, such as vocal fold congestion, erythema, or intubation
granuloma.
The key findings of the study on the effect of general anaesthesia on voice include:
 Postoperative dysphonia was a common occurrence, with patients experiencing voice
changes such as decreased pitch, strained voice quality, breathy quality, and irregular
voice quality after extubation.
 Traumatic laryngeal manifestations due to intubation were the most common causes of
postoperative dysphonia, with evidence of vocal fold congestion, erythema, and
intubation granuloma observed in patients.
 Auditory perceptual assessment revealed mild to moderate voice changes in some
patients one day after the operation, with improvements seen in all perceived
parameters after two weeks.
 The size of the endotracheal tube and the duration of intubation were correlated
with postoperative laryngeal findings, suggesting that using a smaller tube size may
reduce the incidence of postoperative dysphonia.
 Patients using laryngeal mask airway did not show a significant effect on their voice
postoperatively.
Reference: Hamdy, B., Haytham Mamdouh, Ahmed, R., Sohair Adeeb, & Ali, A. (2016).
Effect of general anesthesia on voice. Egyptian Journal of Ear, Nose, Throat and Allied
Sciences. https://doi.org/10.1016/j.ejenta.2016.05.008
References
 Breslin, P. A. S., Gingrich, T. N., & Green, B. G. (2001). Ibuprofen as a Chemesthetic
Stimulus: Evidence of a Novel Mechanism of Throat Irritation. Chemical Senses, 26(1), 55–
65. https://doi.org/10.1093/chemse/26.1.55
 BRITISH VOICE ASSOCIATION : Reflux and voice. (n.d.). Britishvoiceassociation.org.uk.
https://britishvoiceassociation.org.uk/voicecare_reflux-and-voice.htm
 Buysse, D. J., Rush, A. J., & Reynolds, C. F. (2017). Clinical Management of Insomnia
Disorder. JAMA, 318(20), 1973–1974. https://doi.org/10.1001/jama.2017.15683
 Care of the Professional Voice. (2022). Ijhns.com.
https://www.ijhns.com/abstractArticleContentBrowse/IJHNS/28087/JPJ/fullText
 Cleveland Clinic. (2023, September 28). Proton Pump Inhibitors (PPIs): What They Are &
Side Effects. Cleveland Clinic. https://my.clevelandclinic.org/health/articles/proton-pump-
inhibitors
 Effects of Medication on the Voice: Can Medications Harm My Voice? (2012, February 15).
The New York Otolaryngology Group. https://www.nyogmd.com/library/can-the-
medications-i-take-harm-my-voice/
 Effects of Medication on the Voice: Can Medications Harm My Voice? (2012, February 15).
The New York Otolaryngology Group. https://www.nyogmd.com/library/can-the-
medications-i-take-harm-my-voice/
 Haft, S., Farquhar, D., Carey, R., & Mirza, N. (2015). Anticholinergic Use Is a Major Risk
Factor for Dysphonia. ˜the œAnnals of Otology, Rhinology & Laryngology, 124(10), 797–
802. https://doi.org/10.1177/0003489415585867
 Hamdan, A.-L., Tabet, G., Fakhri, G., Sarieddine, D., Btaiche, R., & Seoud, M. (2018). Effect
of Hormonal Replacement Therapy on Voice. Journal of Voice, 32(1), 116–121.
https://doi.org/10.1016/j.jvoice.2017.02.019
 Hamdy, B., Haytham Mamdouh, Ahmed, R., Sohair Adeeb, & Ali, A. (2016). Effect of
general anesthesia on voice. Egyptian Journal of Ear, Nose, Throat and Allied Sciences.
https://doi.org/10.1016/j.ejenta.2016.05.008
 Hari Kumar, K. V. S., Garg, A., Ajai Chandra, N. S., Singh, S. P., & Datta, R. (2016). Voice
and endocrinology. Indian Journal of Endocrinology and Metabolism, 20(5), 590–594.
https://doi.org/10.4103/2230-8210.190523
 Is It Safe to Take PPIs? The Risks of Proton Pump Inhibitors Explained. (n.d.).
Www.michiganmedicine.org. https://www.michiganmedicine.org/health-lab/it-safe-take-ppis-
gastroenterologist-explains-risks
 Kim, J. W., Park, E. S., Kim, Y., Jeong, W. J., Choi, S. H., Nam, S. Y., Roh, J. L., & Cho, S.
H. (2014). Lateral neck dissection affects vocal quality in patients with papillary thyroid
carcinoma. Thyroid, 24(3), 512-519. https://doi.org/10.1089/thy.2012.0616
 Mayo Clinic Q and A: Proton pump inhibitors generally safe when used as directed. (2015,
November 3). Mayo Clinic News Network.
https://newsnetwork.mayoclinic.org/discussion/mayo-clinic-q-and-a-proton-pump-inhibitors-
generally-safe-when-used-as-directed/
 Prescription medications and voice | voice-academy.uiowa.edu - The University of Iowa.
(n.d.). Voice-Academy.uiowa.edu. https://voice-academy.uiowa.edu/prescription-medications-
and-voice
 Reflux and the Voice. (n.d.). Center for Vocal Health | ENT & Laryngology. Retrieved June
10, 2024, from https://www.centerforvocalhealth.com/vocal-health-and-care/reflux-voice-lpr-
7ca5s
 Reid, R. (2022, July 7). #027: The Vocal Impact of Medication: Understanding How It Affects
Your Singing Voice. Rebecca Reid Vocal.
https://www.rebeccareidvocalstudio.com/post/medication
 Schalen, L., Fex, S., Christensen, P., Kamme, C., Eliasson, I., & Schalen, C. (1985).
Inefficacy of penicillin V in acute laryngitis in adults. Annals of Otology, Rhinology &
Laryngology, 94(1), 117-121.
 Stenfors, L. E., & Räisänen, S. (1992). Erythromycin in acute laryngitis in adults. Archives of
Otolaryngology–Head & Neck Surgery, 118(4), 430-433.
 Tanner, K., Dromey, C., Berardi, M. L., Mattei, L. M., Pierce, J. L., Wisco, J. J., Hunter, E., &
Smith, M. E. (2016). Effects of voice-sparing cricotracheal resection on phonation in women.
127(9), 2085–2092. https://doi.org/10.1002/lary.26429
 tarink. (2012, September 21). Do Antihistamines Affect Your Voice? The ENT Center at the
NY Otolaryngology Group. https://nycdoctors.com/2012/09/do-antihistamines-affect-your-
voice/
 Team, S. (2022, August 16). Naproxen side effects and how to avoid them. The Checkup.
https://www.singlecare.com/blog/naproxen-side-effects/
 The Effects of Aspirin (NSAIDs) on the Voice. (2012, May 10). Los Angeles ENT Doctors
ENT Specialists Top Surgeons. https://www.ohniww.org/the-effects-of-aspirin-nsaids-on-the-
voice/
 Themes, U. F. O. (2020, April 26). Medications and the Voice. Ento Key.
https://entokey.com/medications-and-the-voice/
 Verdolini, K., Min, Y., Titze, I. R., Lemke, J., Brown, K., Mersbergen, M. van, Jiang, J., &
Fisher, K. (2002). Biological Mechanisms Underlying Voice Changes Due to Dehydration.
Journal of Speech, Language, and Hearing Research, 45(2), 268–281.
https://doi.org/10.1044/1092-4388(2002/021)
  Wilson, S., & Nutt, D. (2007). Management of insomnia: treatments and mechanisms. The
British Journal of Psychiatry, 191(3), 195–197. https://doi.org/10.1192/bjp.bp.107.036301
 York, E. M. A., PharmD, MPH, BCGP Associate Clinical Professor St John’s University,
College of Pharmacy & Health Sciences Queens, New York Clinical Specialist, Rite Aid
Pharmacy Whitestone, New. (n.d.). Acute Cough—Does Anything Help?
Www.uspharmacist.com. https://www.uspharmacist.com/article/acute-coughdoes-anything-
help