In our Long Covid series, Gemma Clunie considers a patient presenting with swallowing and voice issues
Could the patient’s symptoms be unrelated to Covid-19?
Use the history to determine if the patient’s voice or swallowing problem relates to Covid-19 infection.
• Voice overuse – for example from frequent use of virtual communications.1
• A sudden or gradual deterioration in voice or swallowing that does not correlate with Covid-19 infection.
• New onset pain on swallowing or voicing.
In these cases, refer to other specialties in the usual way.
Was the patient previously intubated or tracheostomised because of Covid-19?
The management of patients with voice and swallowing difficulties after Covid-19 infection will differ depending on whether they were admitted to hospital, particularly if they required intubation or tracheostomy.2-4 These patients should be under the care of an ICU or respiratory clinic. Any persistent issues with voice or swallowing should be referred to ENT for laryngoscopic evaluation. The use of the Post-ICU Presentation Screen – community version (PICUPS-Community tool) developed by the Intensive Care Society (ICS) is recommended for self-reported symptom triage. It monitors functional and symptom change after ICU admission for Covid-19.5
What initial action should you take for patients with swallowing difficulties?
If possible, differentiate between an oropharyngeal dysphagia and oesophageal difficulties.6
The breathlessness and fatigue experienced by patients with long Covid may lead to swallowing difficulties because of problems co-ordinating the breath-swallow pattern. They may struggle to finish meals or find certain textures challenging to eat. One recent study showed 15% patients self-reported dysphagia symptoms after mild to moderate Covid-19 infection.7
Initial advice includes:
• Eating little and often.
• Taking time over meals.
• Choosing softer diet options.
• Avoiding distractions and talking while eating and drinking.
• Dietary supplementation.
• Optimising oral hygiene.
If patients are describing heartburn or reflux symptoms, these may be treatable with a trial of pharmaceutical options and dietary and lifestyle advice.
When do I need to refer?
Red flags for patients complaining of swallowing difficulties include:
• Chest infections – either repeated, or a single episode combined with reported dysphagia.
• Weight loss.
• Persistent coughing and throat clearing, a wet or weak voice when eating and drinking.
• Choking episodes.
• Pain on swallowing.
As well as medical treatment of chest infections, patients with red flag symptoms should be referred as a priority based on symptom profile, for example to speech and language therapy, dietetics, gastroenterology or ENT.
Referral may also be necessary for patients with persistent dysphagia in the absence of red flag symptoms if initial management has been ineffective.
What action should you take for patients with voice difficulties?
Early research shows that up to 25% of mild to moderate Covid-19 cases may experience dysphonia symptoms.7 This could include:
• Vocal fatigue or strain.
• Voice breaks or pitch changes.
• Voice loss.
• A weak, breathy voice.
Breathlessness or ongoing cough will aggravate dysphonia and may be the underlying cause, so management of these symptoms is vital. Similarly, treatment of acid reflux or heartburn and allergies will often help voice problems.
First-line advice for patients with voice difficulties includes:
• Steam inhalation – for lubrication of the vocal tract.
• Ventilation and humidification of the workspace or home.
• Avoid throat clearing – sip water instead.
• Avoid smoking, caffeine, excessive alcohol and dusty environments.
• Avoid throat lozenges – they give temporary relief but won’t help voice problems.
• Rest the voice – take regular breaks from talking.
Stress, anxiety and depression can have a negative impact on the voice. Mental health support should be explored where appropriate, and gentle stretches can help to release muscle tension in the throat and neck.
If dysphonia persists or worsens, the patient should be referred to a joint ENT-speech and language therapy voice clinic for assessment, particularly as they recover and have increased vocal demands, for example when they return to work.8
What about other throat symptoms?
Some patients with long Covid experience ongoing throat sensitivity, globus, altered sense of taste and smell and dry mouth.4 These symptoms should resolve as they recover and can be helped using the vocal hygiene techniques. Also, review medications that can exacerbate symptoms.9 In patients with kidney disease or autoimmune disorders their underlying condition may need to be optimised to manage dry mouth or altered sense of taste.10,11 Patients with problematic, persistent globus or throat sensitivity may require ENT referral.
When should you consider long Covid clinic referral?
Platforms such as Your Covid Recovery are likely to be of benefit in the early stages. Long Covid clinics are made up of multidisciplinary team members.12 They may not be the most appropriate referral for patients with swallowing and voice problems if the team does not have speech and language therapists, dietitians or ENT surgeons. But if the patients have breathlessness and fatigue as well as swallowing and voice difficulties, a long Covid clinic referral will be beneficial.
Gemma Clunie is a clinical specialist speech and language therapist at Imperial College Healthcare NHS Trust and a National Institute for Health Research (NIHR) clinical doctoral fellow at Imperial College London
1 Kenny C. Dysphonia and Vocal Tract Discomfort While Working From Home During Covid-19. Journal of Voice 2020 sciencedirect.com/science/article/pii/S0892199720303842
2 Piazza C, Filauro M, Dikkers F et al. Long-term intubation and high rate of tracheostomy in Covid-19 patients might determine an unprecedented increase of airway stenoses: a call to action from the European Laryngological Society. Eur Arch Otorhinolaryngol 2020;278:1-7 ncbi.nlm.nih.gov/pmc/articles/PMC7275663/
3 Rouhani M, Clunie G, Thong G et al. A Prospective Study of Voice, Swallow, and Airway Outcomes Following Tracheostomy for Covid-19. The Laryngoscope 2020 pubmed.ncbi.nlm.nih.gov/33341953/
4 Naunheim M, Zhou A, Puka E et al. Laryngeal complications of Covid-19. Laryngoscope Investigative Otolaryngology 2020;5:1117-24
5 Intensive Care Society. Post-ICU Presentation Screen community version (PICUP Community). https://www.ics.ac.uk/ICS/Guidelines/PDFs/PICUPs_Community.aspx?WebsiteKey=10967510-ae0c-4d85-8143-a62bf0ca5f3c
6 Cook I. Diagnostic evaluation of dysphagia. Nature Clinical Practice Gastroenterology & Hepatology 2008;5:393-403
7 Lechien J, Chiesa-Estomba C, Cabaraux P et al. Features of Mild-to-Moderate Covid-19 Patients With Dysphonia. Journal of voice : official journal of the Voice Foundation 2020
8 Opinion. We need to do more to understand chronic vocal symptoms of covid-19. BMJ 2021 tinyurl.com/42de3twj
9 Tan E, Lexomboon D, Sandborgh-Englund G et al. Medications That Cause Dry Mouth As an Adverse Effect in Older People: A Systematic Review and Metaanalysis. Journal of the American Geriatrics Society 2018;66:76-84
10 Bots C, Brand H, Poorterman J et al. Oral and salivary changes in patients with end stage renal disease (ESRD): a two year follow-up study. British Dental Journal 2007;202:E7
11 Maeshima E, Furukawa K, Maeshima S et al. Hyposalivation in autoimmune diseases. Rheumatol Int 2013;33:3079-82
12 NICE. Covid-19 rapid guideline: Managing the long-term effects of Covid-19 NG 188. In: Excellence NIfHaC, ed2020