Hoarse raspy voice- how and why?

Thank you. I’ve been seen by a lot of ENTs who have said they have referred me for SALT, however there hasn’t been any SALT appointments because there were no services. I’ve seen ENTs for a camera up the nose 4/5 times, they all referred me for SALT but there never was any appointments or services available. The last ENT was very “no visible issues, I’d like to refer you for counselling as it’s probably psychological” I pushed back and insisted on SALT, but it seems he never referred me and noted I should be based under the NHS trust who had no services (which he said wasn’t true) just NHS chaos for 4 years.

So I am probably overthinking it, but only because I really want the therapy! I really can’t afford to pay for it.

 

I probably meant refer to counselling rather than psychiatry, I just meant yes, they dismiss you as having mental issues rather than physical. I’m naturally an extrovert chatterbox and would talk people’s ear off, given the chance! Pretty sure it’s not an stress/anxiety/depression issue.
Ironic that an ENT would send someone who is struggling to speak to talking therapy.

 

Moving from busy Vancouver to quiet woods didn't seem to make any difference in my ME. I do think it's overall healthier. It's certainly much nicer to go outside and hear absolute quiet, or maybe some wildlife call, than to hear city noise. There are times when I can't hear any man-made noise, which is probably quite rare for much of the human population.

I really don't miss city life.

 

Yes rare indeed!

 

I don't think you're overthinking anything, I think you're trying to get access to the service you should have had many years ago. Do you know which trusts (if any) that you could be referred to have SLT services at the moment? If there aren't any, then it may be another pointless trip to ENT. If there are, then it would be good to know which one to ask to be referred to.

If you're not able to find that out, I know a couple of SLTs in the UK who might know a way to find out. If you private messaged me with your town/postcode/whatever is needed to know which trusts you can be referred to, I would be happy to ask them. No guarantees, but if you can't find out for sure which service you need to be referred to, it could be worth asking them.

There's just no point in going to ENT again and again if there's no SLT service for you to be referred to. You're in a horrible situation, my heart goes out to you.

 

The thing is, the situation changes over time. The trust which had no services in 20/21 referred me to the neighbouring trust. They took a year to see me and refer to SALT but then asked to see me in 23 and I hadn’t been referred. The second trust wasn’t happy about me going out of area as the lack of service had since resolved in my area(eyeroll)and didn’t refer me to SALT who wouldn’t accept me anyway due to my postcode.
Now I’ve moved to a totally different major city. The first trust recently offered me an in-person appointment! So it’s taken a year for me to be at the top of the new list to see ENT again. That’s just the way the NHS is from Covid days onwards.

Same with my ME referrals, 3 years of delays then snakes and ladders back to the start in new city, a year to get an appointment.

 

I had the same experience with six different ENTs and six CT scans. They never saw anything that concerned them on the CT scans even though they could see that my sinuses were swollen when they made the appointment. By the time I had the CT scans, the problem would resolve itself. It wasn't until years later I saw a younger recently graduated ENT who went further than just looking at my sinuses and checked down the back of my throat at the same time, that I was diagnosed with Silent reflux. The other ENTs were seen 20 years ago or earlier and back then medical school didn't teach about Silent reflux because it wasn't a recognized medical condition then. Even when I went to the ER because I was having trouble breathing, the doctor I saw didn't know enough to ask me to breath through my nose instead of just having me take deep breaths through my mouth.

I had a friend who had the same problem as you with hoarseness. She was always told that she needed to have a humidifier in the room and that would solve her problem. It wasn't until years later that she saw a young ENT and was finally diagnosed with Silent reflux. In both our cases, once we had the right diagnoses we were able to fix our health issues. I'm not saying that this is what you have, but a lot of doctors don't know about Silent reflux.

 

I’m already on medications to control my actual reflux which predate the issues.

 

Well. I had my appointment and I couldn’t have imagined it would go so well!
The consultant had a senior speech therapist with him. They did the camera up my nose - then asked me to make various noises. They removed the camera and played back the video of my voice box to show me where the issues were! Then gave me two exercises to do to help retrain my voice and preserve it.

I absolutely could not praise them enough, they did exactly what I needed, it was so weird. There was no battle, or objection handling, or having to think a step ahead, which just shows how easy it can be with a good team. They must see this day in day out and have come up with having a speech therapist there to assess your movements at the same time as the consultant reviews you.

He said it’s muscle tension dysphonia, I am quite stiff and also sometimes holding my breath. I explained I’m in a lot of exertion and pain just being there, which he said makes sense I am tensing, and he expects also the “little muscles” of the voice box fatigue easily just like all my others do. By stiffening up I’m holding my vocal cords apart. I just need to get them to remember how to relax.

 

Sounds like it went well and you got the help you needed and wanted, great news. I’m really pleased for you @MrMagoo and thank you for updating the rest of us!

 

Thanks.
It also made me ponder, the last ENT wanted me to go to counselling. Was he trying to address the issue of “stress” the wrong way? Being upright and operating is stressful for me, it puts a huge strain on my physical being. It’s not stressful because I’m anxious, I’m in pain and uncomfortable. How often is stress confused with psychological stress by medics?

 

It’s a really good point. And while there are links between physical and emotional stress, cause and effect I think may get confused with respect to us. I like to think of it in the mechanical physics sense that any system under load will experience stress. And when the load exceeds capacity, problems occur!

 

Wonderful news! I’m delighted for you that you got a joint assessment with the ENT and a speech & language Therapist – I used to do those joint assessments and they work so well, so much better than seeing the ENT first and then the SLT.

Will you see the SLT again or was it a once-and-done? If you find that after implementing what they suggested, you could still do with a bit more guidance, you could contact the SLT/ the SLT department directly to schedule a session or two.

So happy for you that you finally got the consultation you should have had years ago, and didn’t have to deal with any unpleasantness.

Agree. There is no evidence that counselling helps muscle tension dysphonia, which is common.

In psychogenic voice disorders, which are less common, the SLT is still the person who treats you. Psychiatrists and psychologists are only involved if the problem persists despite voice therapy. Complete voice loss that lasts for quite a while can be a sign of a psychogenic voice disorder, but can occur in other voice disorders too. The history gives you clues. If complete voice loss is preceded by hoarseness that gets worse over time, then you're likely dealing with muscle tension dysphonia rather than a psychogenic voice disorder. Voice therapy during the hoarse period would likely have prevented complete voice loss in that scenario.

Stress is relevant to both muscle tension dysphonia and psychogenic voice disorders, but physical tension is more relevant to muscle tension dysphonia.

For anyone who's interested, there are some good articles at this site:
https://britishvoiceassociation.org.uk/voicecare_muscle-tension-dysphonia.htm (Muscle Tension Dysphonia) https://britishvoiceassociation.org.uk/voicecare_stress-emotion-voice.htm (Psychogenic Voice Disorders)

 

90%? At least.

 

Thank you. I think I’m “one and done” and the exercises are helping already. I was sure it was muscle tension dysphonia, the advice is to see a SALT to review your individual way of using your voice box, they don’t like generic advice for this, but even just understanding that I tense up and steel myself and that contributes to the croak, is helpful!
I loved seeing it on the video, it was so helpful to understand what’s going on. And maybe it’s something that’s quite common in ME and chronic pain and needs more promotion of awareness.


They were very professional but reading between the lines they didn’t give the last ENT’s report much credit.