Coping with colds: upper respiratory infections and the voice
by Sara Harris (Specialist Speech and Language Therapist and Team member, The Lewisham Voice Clinic, London)
The ‘common cold is anything but! It encompasses a wide range of viruses that cause similar symptoms. These are all too familiar and include blocked noses, sneezing, chronic catarrh, sore throat, headache and a feeling of being generally unwell (malaise). The infections that cause these symptoms are known by doctors as ‘upper respiratory tract infections’ (URTIs). Because they are viral in nature they are unlikely to respond to antibiotics unless a secondary bacterial infection develops.
The Airway’s Cleaning System
The mucous membranes that line the nose, throat and chest are the airway’s cleaning system. Dust and other inhaled particles catch in the mucus and are wafted along by small hair-like structures (cilia) upwards from the lungs and larynx and downwards from the nose, Eustachian tube (the tube connecting the ear to the throat) and throat before being swallowed (the mucus transport blanket). Normally the mucus is thin and watery and we are unaware of this process. However, URTIs damage the mucous membrane so that the cilia no longer transport the mucus in the usual way. Infected mucous membranes are inflamed and swollen and produce increased amounts of mucus and inflammatory fluids. These dry and thicken as they can no longer be transported away by the normal mucus transport blanket resulting in the all too familiar symptoms of catarrh that blocks our noses or is coughed up from the lungs. The damage to the mucous membrane and its cilia takes up to 6 weeks to recover, which is why catarrh and coughs seem to hang on long after the initial infection has cleared up.
Although symptoms are generally experienced mainly in the upper airway, the infection can also affect the lower airway causing irritation and inflammation in the Eustachian tubes, voice box (larynx) and lungs. If the Eustachian tube is affected the infection can spread to the middle ear causing earache (otitis media). Swelling may also block the Eustachian tube allowing fluid to collect in the middle ear. This will affect hearing, which becomes muffled, and may also cause earache.
When the larynx is infected (laryngitis), the vocal cords (vocal folds) become swollen and stiff giving the voice a rough, hoarse quality that is deeper in pitch than usual. In extreme cases the voice starts to cut out and may be almost reduced to a whisper.
If the chest becomes infected (bronchitis), coughing develops. At first the cough may feel tickly and irritable but as the infection develops and the mucus transport blanket is damaged, mucus thickens and the cough becomes productive and sometimes painful.
URTIs usually take a day or so to develop (the prodromal period) when the person affected notices sneezing, a tickly nose and/or a more irritable throat. There is usually a feeling of general malaise. Then the more typical symptoms develop and are at their worst for two to three days before slowly beginning to recover.
Usually people will have more or less recovered from an URTI in a week or so, although the catarrh may drag on for longer. Laryngitis is also usually acute over 2 to 3 days before beginning to recover. Most people feel their voice is more or less better after 5-7 days; however, it may take 10-14 days before the vocal folds return to normal. Bronchitis and coughs also tend to last longer and may take up to 6 weeks to recover completely.
For professional voice users, particularly teachers, singers and actors, URTIs can be difficult to manage. If the voice is hoarse or unreliable work may be significantly affected or simply impossible. Lost working days can be disruptive and worrying, particularly if they result in no pay. So, what can we do?
We can’t prevent URTIs unfortunately, but we can do things to reduce our chances of catching them.
- Wash your hands after travelling and particularly before eating/drinking.
- If washing facilities are limited carry antibacterial wipes to use on your hands before eating/drinking.
- Use antibacterial wipes to clean the telephone/commonly used surfaces if someone you live with has an URTI.
- Don’t share cups/glasses cutlery/toothbrushes/food or towels.
When an URTI strikes – what can we do?
You begin to feel tickly and irritated in the nose and throat and you know you are coming down with an URTI. Nothing is going to prevent the infection from running its course but you can and should treat the symptoms.
The blocked nose and excess mucus
- Keep your nose and throat warm and wet. Saline nasal sprays are soothing. They thin down sticky mucus and wash away any inhaled irritants while the salt has a mildly antiseptic effect.
- Drink plenty of water and keep well hydrated. Mucus is predominantly made of water. If you do not drink enough, mucus will thicken and dry. You know you are properly hydrated when urine is almost colourless (‘pee pale’).
- Steam is your friend. It gets water directly to thick, dry mucus, thinning it and making it easier to clear. It soothes irritation and reduces swelling of the mucous membranes.
- Turn off air conditioning and reduce air convection heating. Keep the atmosphere more humid (open a window, keep leafy plants around, spray some water into the room or keep a wet towel over the radiator).
- Beware decongestant medicines. Decongestants temporarily shrink the nasal membranes by constricting blood vessels in the nose. The nose feels clearer for a short time before the constricted blood vessels dilate again and the nose re-blocks. Persistent use of these medications can create a vicious circle. If you really need them, follow the manufacturer’s instructions carefully and do not use them for more than 7 days.
- Ask your local pharmacist for a suitable pain killer to soothe the earache.
- Inhale steam to reduce swelling in the Eustachian tube and allow the middle ear to drain.
- Sipping hot drinks and sucking lozenges is soothing and the action of swallowing may help the Eustachian tube to open allowing fluid from the middle ear to drain.
- Yawning may also help to open the Eustachian tubes allowing fluid to drain.
- If the muffled hearing and glue ear persist after the earache has gone and the infection has recoveredtry holding your nose firmly and trying to blow air through it (Valsalva manoeuvre). This will often inflate the Eustachian tube allowing any remaining fluid in the middle ear to drain.
- If the earache is severe see your GP for advice, medication and/or a referral to an ENT surgeon.
- If the glue ear and poor hearing persist after the infection has gone and does not resolve with yawning and the Valsalva manoeuvre, see your GP and seek a referral to an ENT surgeon.
The Sore Throat
- Sucking medicated lozenges can help reduce throat pain from an infection but the claims of some companies may overstate the effectiveness of their products. Often it is the action of swallowing that is helpful as it increases saliva production and keeps the throat muscles moving.
- Hot drinks are soothing and help prevent dehydration.
- Gargling with soluble aspirin is often recommended for reducing throat pain from an URTI. While effective at reducing pain, aspirin affects blood vessels making them more fragile and likely to bleed. Clotting is also slowed so any bleeds continues for longer than usual. Singers hoping to perform are better to avoid aspirin during an URTI.
- Gargling with salt water can lubricate and help reduce throat pain. It has the added benefit that it is free of any side effects.
- Gargling with medicated preparations can also help. It is best to consult your GP or a pharmacist to find a suitable brand.
- Paracetamol taken systemically is effective at reducing throat pain and the general malaise associated with URTIs such as headache, aching and fever.
Sometimes the voice is apparently unaffected or only mildly affected by an URTI. However, inflammation in the nose and throat is frequently present in the larynx and vocal folds, even if the patient is unaware of any significant voice change. Symptoms to watch out for are:
- Your speaking voice is lower in pitch.
- Reduction in your singing voice range.
- Slow voice onset on some notes.
- Voice breaks in the upper singing range.
- A breathy vocal quality.
- Increased vocal effort when singing or speaking.
When these symptoms are present singers are best to cancel that evening’s performance and undertake complete voice rest (see below). Laryngitis makes singers more prone to injury and no one wants to be remembered for a poor performance. It is better to have one cancellation than risk vocal injury that necessitates a long period of recovery.
Occasionally laryngitis is severe. The voice may be reduced to a whisper or extremely hoarse and breathy. Voicing often cuts out and may become pitch unstable. Speaking feels effortful and uncomfortable. The best treatment is:
- Complete voice rest. Do not talk, write notes for necessary communication and/or let your voicemail take the strain.
- Try not to cough – sip water or suck a lozenge to reduce tickling and irritation.
- Inhale steam every few hours. This helps reduce inflammation and hydrates the vocal folds/chest.
- Sleep as much as possible and eat healthily with plenty of fruit and vegetables.
- Avoid smoking, atmospheric irritants and alcohol.
- Treat any acid reflux with antacids such as Gaviscon and seek medical advice from your GP if this does not control it. Acid tricking around already inflamed vocal folds is not a good idea!
Acute laryngitis normally settles down within two /three days of voice rest. Should your voice fail to return to normal within three weeks ask your GP for a referral to an ENT surgeon/laryngologist so your larynx can be examined and appropriate medical care provided.
Coughing/chest infection (Bronchitis)
URTIs can affect the lungs causing the bronchi to become inflamed and irritable and mucus secretions to become thicker and harder to clear. The irritation produces coughing which is abusive to the vocal folds, increasing their risk of injury.
- Steam inhalation will reduce inflammation, thin down thick mucus and reduce irritation and coughing.
- If the voice is affected, rest it.
Coughs caused by URTIs are usually productive. The damage to the mucus blanket transport makes it difficult to clear thick mucus so that the cough lasts for longer than the other URTI symptoms. It can take up to 6 weeks for the cilia to regenerate and the cough to resolve.
Dry coughs do not respond to the above treatment. If any cough persists longer than 6 weeks it should be discussed with the GP in case further investigations are needed.
Upper respiratory tract infections are an unavoidable nuisance. However, the advice above should help reduce the symptoms. Remember; if you use your voice a lot at work take a day or so off. It is better to take a short time off than risk a vocal injury that will take a longer time to heal.
Acknowledgments: With thanks to Tom Harris, John Rubin, Kristine Carroll-Porczynski and Jackie Ellis for their input and editing.