The three of us have developed significant and enduring vocal symptoms (10+ months) after contracting covid-19 infection early in 2020. None of us were hospitalised, and we have struggled for answers for this ongoing symptom. This lesser known sequelae has not been recognised as a common complication. Yet we, two doctors and a voice artist who connected through online long covid groups, have suffered notable distress and disability through this symptom and wish to raise the profile of vocal issues that are being experienced in long covid to the medical community.
Our spectrum of symptoms has varied from intermittent to persistent hoarseness, discomfort or pain, and dyspnoea. None of us had prior vocal issues. As two of us are doctors, the resultant functional disability has impacted on our core ability of communicating effectively with patients, colleagues, and medical students/trainees. It has hindered our return to work, as well as speaking with family and friends. As one of us is a professional voice artist, the resultant symptoms have also had a significant impact on occupation. In the early stages of the pandemic, reports of vocal symptoms as a result of covid-19 were limited in both medical literature and media.
The covid symptom study, using results from the Zoe app, has since published data which reports that vocal hoarseness constitutes 19% of initial symptoms of covid-19. [1] We were surprised that this is not included in government information about the disease. In online long covid support groups, individuals have reported various voice and throat symptoms which have continued, despite weeks of self care and primary care assessment. There was consensus, from lived experience, that the symptoms seem to relapse and remit over time. Symptoms include hoarseness as well as others such as those described by sufferers as the “covid strangle”, difficulty in swallowing, nocturnal choking, sometimes accompanied by pain and pressure on the chest. Some diagnoses given after specialist review ranged from dysphonia, variable upper airway obstruction, muscle tension disorder, ‘lax vox’, laryngo-pharyngeal reflux to vocal cord distortion possibly due to lung inflammation or breathing pattern disorder.
Access to investigations and medical opinions have been hard to come by throughout the pandemic, as the focus of both primary and secondary care remains with acute respiratory and life threatening complications. The ability to perform aerosol generating procedures such as laryngoscopy is limited due to the infection risks involved, as well as a lack of personal protective equipment (PPE), and reorganisation of services to remote consultations, and cancellation of all but acute and cancer related care pathways, including routine Ear, Nose & Throat (ENT) clinics and limitations to Speech and Language Therapy (SALT).
As with other long covid symptoms, there is much debate about the aetiology of pathology weeks to months after acute infection; many patients remain worried without effective clinical assessment, treatment, and rehabilitation. Many have faced diagnostic and treatment bias when it came to seeking support from clinicians who have not been aware of the possible link between covid-19 and dysphonia. This is partly due to reduced services, clinician confidence, knowledge of local guidelines, or a reluctance to refer. Sometimes symptoms were labelled as psychogenic resulting in suboptimal care and underdiagnosis of pathology. So, we feel education of clinicians is key regarding voice complications. Indeed we feel that because the vocal symptoms are part of a multisystem disorder, national guidance or future research regarding exploration of the cause and impact of long covid symptoms needs to empower clinicians to think beyond their speciality, at pan-system pathological processes when investigating and rehabilitating dysphonia.
One of the authors summed up her experience, “As a professional voice artist, I practised quality vocal hygiene prior to covid and during onset which included everything from diet and hydration to avoiding whispering. Four months after covid, the severe daily hoarseness continued. ENT and pulmonary specialist investigations led to speech therapy at six months after the initial virus. Each specialist concluded they were uncertain with the cause of the continued vocal distortion. I noticed that exertion exacerbated the symptoms. Even today, almost 11 months post covid, I have intermittent hoarseness upon exertion such as making the bed, lifting heavy items or prolonged conversation.”
A European epidemiological study found that the 26.8 % of covid cases in their study had dysphonia. [2] Considering the large volume of long covid affected patients, the availability of ENT and SALT services may be mis-matched, and should be part of the multidisciplinary service for long covid clinics. The pandemic has resulted in “major disruption to all aspects of clinical delivery, workforce, and research for ENT/laryngology SALT.” [3] It is unclear when any of these areas will resume operations and whether permanent changes to clinical practice, professional remits and research priorities will follow. However, significant opportunity exists in the post‐covid era within the soon to be set up network of long covid clinics. These clinics offer us a chance to re‐evaluate current practice, embrace opportunities, and evaluate new ways of working. Indeed, one of us has just been referred to the English National Opera’s Breathe research project which is devoted to covid rehabilitation of breath and voice. [4] Nevertheless, many others remain with persistent and undiagnosed covid vocal disability, getting by through supporting each other.
Ashish Chaudhry: GP Partner, Undergraduate and Postgraduate Educator, Lower Broughton Health Centre.
Jeannie McGinnis: Professional voice artist and speaker.
Amali Lokugamage: consultant obstetrician & gynaecologist and honorary associate professor. Whittington Health NHS Trust and University College London.
Declaration of interests: None declared.
References
- COVID Symptom Study. Could non-classic symptoms indicate mild COVID? https://covid.joinzoe.com/post/symptoms (2020).
- Lechien, J. R. et al. Features of Mild-to-Moderate COVID-19 Patients With Dysphonia. J. Voice 892–1997 (2020).
- Patterson, J. M. et al. COVID‐19 and ENT SLT services, workforce and research in the UK: A discussion paper. Int. J. Lang. Commun. Disord. 55, 806–817 (2020).
- ENO Breathe. About ENO Breathe | ENO Baylis |English National Opera. https://eno.org/discover-opera/eno-baylis/eno-breathe/.