Squeaky Voice

Hello everyone

I feel a bit guilty with this question as is seems so trivial compared to what so many of you suffer on a daily basis but it’s something that has puzzled me since being diagnosed in June.

I have a problem speaking. In everything I’ve read about asthma they say that if you cannot complete a sentence you should seek medical advice. I would say that I rarely have a full voice. The muggy weather seems to make it worse. Sometimes no sound at all comes out when I try to speak. Not even a whisper! It is worse outside, when I go indoors it returns after a while but stays very squeaky. I can honestly say that the only time I have a full voice is if I am sitting perfectly still indoors or in the car. If I’m going in and out of buildings it is very bad which makes shopping embarrassing because I can’t hold a conversation with the assistants. Speaking on the telephone is a nightmare. People say they feel guilty phoning me because I sound as if I’m gasping for breath but I don’t feel as if I am. One minute I can be absolutely fine and the next my voice can be very high and squeaky, crackly broken or non existent. It often just disappears in mid sentence.

I have mentioned this to my GP but she just smiles as if I’m imagining it and never comments. The trouble is this never happens in the surgery because I’ve usually been travelling in the car for 20mins then sitting in quietly in the cool waiting room for half an hour (She’s always late!) My husband gets frustrated and tells me not to talk because he can’t make out what I’m saying - he says just nod or shake your head!

My peak flow varies from day to day but is usually in the 320 -480 it is always over 400 when I visit the GP which she says is excellent even for anyone without asthma. At my last visit she doubled my dose of Clenil Modulite which seems to have stopped my cough and wheeze therefore making it easier to sleep, the Ventolin inhaler helps when I can’t get my breath though sometimes it takes several attempts but it does nothing for the voice problem at all. My only other symptoms are tightness around the chest and lethargy. My husband suggested making a voice recording and taking it to the surgery but this seems a bit extreme and my friend suggested demanding a second opinion but either of these options could put me on the wrong side of the GP and she’s really very nice and kind.

Should I be concerned about my lack of voice or is it something all asthmatics have to put up with?

Thanks for reading this

LizB

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Hi Liz,

I'm sorry to hear that you're having this problem - it sounds extremely frustrating, please don't feel guilty for wanting to find a solution to it! Absolutely nobody's problems are trivial - if it matters to you, then it's worth asking and deserves an answer.

First of all, you are right to say that generally, not being able to complete a sentence is a sign of a severe attack which needs immediate emergency medical treatment. However, there is a difference between not being able to complete a sentence because you are too breathless, and not being able to complete a sentence because of a weak voice. The former will be associated with a feeling of severe breathlessness, probably worsened by minimal activity like walking a few steps. The latter will not usually be associated with severe breathlessness, and you should be able to exert yourself as much as you usually can, certainly to the degree where you can comfortably walk around your house and so on. Inability to talk due to a weak or hoarse voice is not a medical emergency, although if you are in any doubt as to which catagory your speech problems fall in to, you should be cautious and seek medical advice in any case.

Whilst not a medical emergency, I would agree that speech problems like this are extremely annoying and frustrating! I can relate to your problems as I suffer from a very weak and fatigible voice at times - in my case, it's partially related to actual physical damage to my vocal cords from being intubated and having a tracheotomy in the past. As far as I recall from your previous posts, you've not had a severe enough attack to need to be intubated in an Intensive Care department? I'm assuming you've also never had a tracheotomy for any reason or any other form of surgery to your throat or voice box. Have you ever had a general anaesthetic for any reason? Most GAs do involve intubating you, ie putting a tube down your throat and into your lungs, and in very rare cases this can do damage to your vocal cords.

Assuming none of the above apply to you, one of the potential culprits is your inhaled steroid, your Clenil Modulite. Inhaled steroids are known to cause drying and atrophy of the vocal cords, which can produce the symptoms you are describing. The difficulties with change in atmosphere are quite typical, and I've experienced them too - in particular, my voice appears to really dislike a dry atmosphere. I find shops a problem, too - they are so aggressively air conditioned that they are very drying. The presence of respiratory irritants such as perfumes in department stores doesn't really help, either - they tend to irritate the vocal cords too.

Obviously, inhaled steroids are a really important part of asthma treatment, and you certainly should not stop them because of the possibility that they may be causing your weak voice. Unfortunately, all inhaled steroids can have this effect, and there is not really a suitable alternative treatment that you can take. Using a spacer with your inhaler will help, and you should be really thorough and diligent about rinsing your mouth out and gargling after using your inhaler, to minimise the residue left in your throat.

Gasto-oesophageal reflux can also contribute to damage to your vocal cords and a weak or hoarse voice, as well as making asthma symptoms worse - and I think I recall you saying in a previous post that you have suffered from reflux in the past? Asthma medications can make reflux worse, as bronchodilators like salbutamol can also dilate the valve between the stomach and the oesophagus. It's possible to have so-called 'silent' reflux that is causing problems despite not producing the typical symptoms of heartburn and so on - so this may be an issue even if you are not aware it at the moment. If you are not currently on treatment for reflux, it might be worth asking your doctor if they will consider a trial of a Proton Pump Inhibitor (PPI) medication like omeprazole or lansoprazole, to see if this makes a difference to you.

Post nasal drip due to allergic rhinitis can also cause hoarseness and changes in your voice, as well as worsening your asthma. Rhinitis is, of course, very common in association with asthma, especially in people who also have an aspirin allergy. I notice from your profile that you are already on loradatine, which is a good treatment for allergies, but there are other treatments available if you have rhinitis symptoms that are not completely controlled. Nasal steroids can be helpful, and your doctor can prescribe a tablet from the class known as leukotriene antagonists, montelukast (Singulair) or zafirlukast (Accolate), which are targetted anti-allergy treatments that are effective in many people for rhinitis and for allergic asthma. These tablets are thought to often work particularly well in people who have asthma associated with aspirin allergy (Samter's triad).

Other things that contribute to this problem are heavy smoking and drinking, particularly together - and second hand smoke can also be a problem, so you may notice that you are worse if you're in a smoky environment.

I find that my voice is a lot worse if I get dry, or if my throat gets dry. I make sure that I drink a lot of water, and if I am out socially and talking to people, sometimes I suck a (sugar-free) boiled sweet to stimulate saliva production. I find that saline nebs do help to improve things when it's particularly bad - as you don't have a nebuliser, steam inhalation can have much the same effect. As with asthma, to an extent you can learn what your triggers are and try to avoid them.

This is a significant problem, which is obviously having an impact on your quality of life. Your doctor should not be ignoring it; you have a right to try to get this sorted. I would suggest you go back to your doctor, make an appointment solely for this problem, and explain how much of an impact it is having. Ask for a referral to an ENT consultant to get this looked at further. At the end of it all, it may be that it is the simple things that I have mentioned that are the explanation, and there may be a few simple things that can be done to help. An ENT consultant will be able to look into things thoroughly, though, and suggest the best course of action.

One other thing that I am concerned about, reading your post - you say that your peak flow varies from 320 to 480. This is quite a large variation - if your best is 480, then 320 represents a drop of over 30%. If this is happening on a regular basis, then your asthma may not be particularly well controlled. In addition, if it sometimes takes several puffs of your salbutamol to get relief of your cough and wheeze, this is another potentially worrying sign. I would suggest you ask your doctor to review your asthma control and see if you need any extra treatment. As I have said, the leukotriene antagonists are often felt to be particularly useful in people with aspirin/salicylate sensitivity, so that might be a logical next step.

Hope this helps, do let us know how you get on.

Take care,

Em H

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Thanks Em

Hello Em

Thank you for the detailed reply to my post. It must have taken you ages. You are right I have not had an emergency admission for asthma I was diagnosed after a bout of wheezing and gasping for breath which lasted a few weeks followed by a bad chest infection which took 6 weeks to clear. When I read how poorly you all get and how many drugs and admissions it takes to keep your symptoms at bay I wonder if I have asthma at all or if it was a misdiagnosis!

As it happened my GP was away today and I saw someone else. My voice was only slightly misbehaving but she had no hesitation in referring me to an ENT Consultant. She wasn’t concerned about my peak flow as she said when they first saw me in May it was down to 220 so today at 340 it was fine. She doesn’t want to interfere with medication until she hears from ENT. It took 18 months to get an appointment at the allergy clinic so it could be a long wait.

By the way I've never smoked but I've had several operations and over the years my throat has really suffered with allergy swellings etc.

Hope you are keeping a better since your last admission

Best wishes

Liz B

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I've just read Em reply and I think some of this relates to me, I have problems with my throat which gets very dry when talking for a while. I'm also waiting for ENT appointment.