Understanding Voice Production

Normal Voice – कैसे बनती है आवाज:

1. Air from Lungs: सांस chest से निकलती है
2. Through Larynx (Voice Box): हवा voice box से गुज़रती है
3. Vocal Cords Vibrate:
   • Two vocal cords (फीते की तरह) हैं larynx में
   • जब हम बोलते हैं, ये close होते हैं और vibrate करते हैं
   • यह vibration sound produce करता है
4. Modified by Throat, Mouth, Tongue: Final voice shape होती है

Vocal Cords (आवाज की रस्सियां):

• Two folds of tissue
• Covered by delicate mucosa
• Very sensitive
• Need to be smooth, flexible, and symmetric for good voice

How Smoking Damages Voice

Immediate Effects (Short-term):

1. Irritation & Inflammation

• Smoke = hot, toxic chemicals
• Directly irritates vocal cord mucosa
• Redness, swelling
• “गला खरखरा” feel होना
• Voice “भारी” लगती है

2. Dryness

• Smoke dries out mucosa
• Vocal cords need lubrication to vibrate smoothly
• Dry cords = hoarse, rough voice
• Constant throat clearing

3. Mucus Hypersecretion

• Irritation → excess mucus production (body’s defense)
• “गला फंसा हुआ” feel
• Chronic cough (smoker’s cough)
• Need to keep clearing throat

Chronic Effects (Long-term – Years of Smoking):

1. Reinke’s Edema (Polypoid Corditis)

“Smoker’s Larynx” – सबसे Common Chronic Change

What Happens:

• Reinke’s space (layer under vocal cord mucosa) में fluid accumulation
• Vocal cords swell हो जाते हैं
• Become thick, baggy, polypoidal (थैली जैसे)
• Usually bilateral (both sides)

Result:

• Voice becomes very deep, hoarse, rough
• Women particularly affected (female voice को male जैसा लगता है)
• Permanent change

Treatment:

• Stop smoking – ESSENTIAL!
• If no improvement → microlaryngeal surgery (cords की cleaning)
• Voice therapy

2. Chronic Laryngitis

• Persistent inflammation
• Vocal cords thickened, red
• Voice always hoarse
• Throat discomfort

3. Leukoplakia (Pre-cancerous)

⚠️ Warning Sign!

• White patches on vocal cords
• Due to chronic irritation
• Dysplasia हो सकता है (abnormal cells)
• Can transform to cancer
• Needs biopsy, close monitoring

4. Laryngeal Cancer – Most Serious

85-90% laryngeal cancers में smoking major risk factor

Why Smoking Causes Cancer:

• Tobacco smoke contains 70+ carcinogens (cancer-causing chemicals)
• Direct contact with laryngeal mucosa
• Chronic irritation → dysplasia → carcinoma
• DNA damage

Types:

• Glottic (Vocal Cord) Cancer – Most Common:
  • Hoarseness EARLY symptom (because affects voice)
  • Better prognosis if detected early
• Supraglottic (Above Cords):
  • Hoarseness LATE symptom
  • May present with throat pain, difficulty swallowing first
• Subglottic (Below Cords): Rare

Types of Tobacco & Relative Risk

1. Bidi (बीड़ी) – MOST DANGEROUS for Throat!

Very Common in हरदोई और UP

• Why Worse than Cigarette:
  • No filter → all smoke directly enters
  • Higher tobacco content
  • Needs more puffs to keep lit → more smoke inhalation
  • Hotter smoke
• Laryngeal cancer risk: 3-5x higher than cigarettes
• Myth: “Bidi natural hai, safe है” – COMPLETELY FALSE!

2. Cigarettes (सिगरेट)

• Filter reduces some toxins but still very harmful
• Risk proportional to:
  • Number per day
  • Years smoked
  • “Pack-years” calculation (Packs/day × Years)

3. Gutka/Tobacco Chewing (गुटखा/तंबाकू)

• Mainly affects oral cavity (mouth, tongue)
• But can also affect larynx (saliva swallowed with carcinogens)
• Combined smoking + chewing → HIGHEST RISK

4. Hookah/Hukkah (हुक्का)

• Myth: “Water filters toxins” – FALSE!
• One hookah session = smoking 100 cigarettes equivalent
• Same carcinogens present
• Laryngeal damage similar

Clinical Features – Symptoms

Benign (Non-Cancer) Voice Changes:

1. Hoarseness (Gala Baithna/Awaaz Bhaari)

• Voice rough, raspy
• Deep pitch (especially women notice)
• Fluctuating – better some days, worse others
• Worse in morning, improves during day

2. Throat Discomfort

• Chronic irritation
• “गला खरखरा”
• Need to clear throat constantly

3. Chronic Cough (Smoker’s Cough)

• Productive – mucus
• Worse in morning
• Improves after few hours

4. Vocal Fatigue

• Voice “tires” quickly
• Difficulty speaking for long

⚠️ Red Flag Symptoms (Cancer Warning Signs):

1. Persistent Hoarseness (2+ Weeks)

• MOST IMPORTANT WARNING SIGN!
• Any hoarseness >2 weeks MUST be evaluated
• Especially if smoker

2. Progressive Worsening

• Voice getting progressively worse
• Not improving with rest या medicines

3. Hemoptysis (Cough with Blood)

• Even small amount – serious sign
• Needs immediate evaluation

4. Dysphagia (Swallowing Difficulty)

• Especially with solid food
• Pain while swallowing (odynophagia)

5. Neck Lump

• Lymph node enlargement
• May indicate spread

6. Shortness of Breath/Stridor

• Tumor obstructing airway
• Emergency situation

7. Weight Loss

• Unintentional
• General malaise

Diagnosis at Prime ENT Center

1. History

Dr. Harshita Singh will ask:

• Smoking History (VERY Important!):
  • क्या smoke करते हैं? (Bidi, cigarette, hookah?)
  • कितने per day?
  • कब से? (How many years?)
  • Pack-years calculation
  • Chewing tobacco भी?
  • Alcohol consumption? (Combined risk बढ़ जाता है)
• Voice Symptoms:
  • कब से hoarse है?
  • Progressive या stable?
  • Any other symptoms (cough, blood, pain)?
• Occupational: Professional voice user? (teacher, singer?)

2. Clinical Examination

Indirect Laryngoscopy:

• Mirror examination
• Basic assessment
• Limited view

3. Videolaryngoscopy – GOLD STANDARD

Performed by Dr. Harshita Singh at Prime ENT Center

Procedure:

• Flexible endoscope through nose
• Reaches larynx
• HD camera visualization on screen
• Can record video
• Patient can see their own vocal cords
• OPD procedure, painless, takes 2-3 minutes

What We Look For:

• Vocal cord appearance:
  • Color (normal = pearly white, smooth)
  • Swelling?
  • Polyps?
  • Leukoplakia (white patches)?
  • Mass/growth?
• Vocal cord movement:
  • Symmetric vibration?
  • Complete closure?
  • Any paralysis?
• Surrounding structures:
  • Arytenoids, ventricles, false cords
  • Any extension of disease

4. Biopsy – If Suspicious Lesion

• When Needed: Any abnormal growth, leukoplakia
• Procedure:
  • Direct laryngoscopy under GA (general anesthesia)
  • Small tissue sample लेते हैं
  • Send for histopathology
• Purpose: Rule out malignancy, confirm diagnosis

5. Imaging (If Cancer Suspected)

• CT/MRI Neck: Assess tumor extent, lymph nodes
• Chest X-ray/CT: Check for metastasis या lung pathology

Treatment at Prime ENT Center

For Benign Voice Changes (Reinke’s Edema, Chronic Laryngitis):

Step 1: SMOKING CESSATION – Non-Negotiable!

बिना cigarette/bidi छोड़े कोई treatment effective नहीं होगा

• Quit Strategies:
  • Set quit date
  • Remove all cigarettes/bidis
  • Nicotine replacement therapy (patches, gum)
  • Counseling – we provide at Prime ENT
  • Support groups
  • Medications (varenicline, bupropion) if needed
• Timeline for Voice Improvement After Quitting:
  • 2 weeks: Circulation improves
  • 1-3 months: Cough reduces, breathing easier
  • 3-6 months: Voice quality starts improving
  • 1 year: Significant improvement
  • But some changes (like Reinke’s edema) may be permanent

Step 2: Voice Therapy

• Speech-Language Pathologist (SLP):
  • Voice exercises
  • Proper vocal hygiene education
  • Breathing techniques
• Voice Hygiene:
  • Hydration (8-10 glasses water daily)
  • Avoid throat clearing (swallow instead)
  • Steam inhalation
  • Avoid shouting, whispering

Step 3: Medical Treatment

• Medications for reducing inflammation
• Proton pump inhibitors (if reflux contributing)

Step 4: Surgery (If Needed)

Microlaryngeal Surgery for Reinke’s Edema:

• If voice not improving despite smoking cessation
• Under microscope, vocal cords की “cleaning”
• Excess fluid, polypoidal tissue removal
• Day care procedure usually
• Important: Surgery alone not enough – must quit smoking!

For Laryngeal Cancer:

Treatment depends on stage (early vs advanced)

Early Stage (T1/T2):

• Radiation Therapy: Voice preservation possible
• Endoscopic Laser Surgery: Tumor excision through endoscope

Advanced Stage (T3/T4):

• Laryngectomy (voice box removal) may be needed
• Radiation + Chemotherapy
• Voice rehabilitation (electrolarynx, tracheoesophageal puncture)

Prognosis:

• Early glottic cancer: 80-90% 5-year survival
• Advanced stage: Much poorer
• Key Message: EARLY DETECTION SAVES LIFE AND VOICE!

Prevention

Primary Prevention:

• Don’t Start Smoking/Tobacco: Ever!
• Say NO to peer pressure
• Educate youth

If Smoking – QUIT NOW!

• Risk reduces significantly after quitting
• 10 years smoke-free → risk approaches non-smoker levels
• Benefits start immediately:
  • 20 minutes: Heart rate drops
  • 12 hours: CO levels normalize
  • 2 weeks: Circulation, lung function improve
  • 1 year: Heart disease risk halved

Regular Screening for High-Risk:

• If heavy smoker (>20 pack-years)
• Annual laryngoscopy examination
• Early detection

Message to Smokers