My wife has always had a mild "Bette Davis" voice, gravelly and low tone. Over the past year it has become more so. She is otherwise healthy, 34, used to smoke (stopped four years ago) and drinks occasionally. The gravelly voice seems to be worse in the morning. She also occasionally has no voice at all when she attempts to speak and has to "search" for her voice. This has happened to her about 10 times over the past 10 weeks. We are not in our hometown and won't be for another four weeks. Should this be checked immediately?

J.N.

Normally, we use exhaled air to produce speech. The vocal cords play an important role in speech: They vibrate, creating a tone that the tongue, lips, teeth and palate shape into speech. We have a limited ability to control the pitch of this tone. With training, singers may augment this ability, improving what is known as their vocal range.
The clarity of speech depends a great deal on the health of the vocal cords. Even a tiny nodule on one vocal cord can lead to speech that is hoarse or gravelly. If you can imagine the dull note produced by a lax guitar string, or the sound produced by a clarinet with a cracked reed, then you will understand why vocal quality deteriorates when the vocal cords are less than pristine.

In your wife's case, years of smoking have already given her a deeper-than-normal voice. Smoking causes edema (swelling) of the tissue that coats the vocal cords. "Swelling" means an increase in water content, and this in turn means that the cords are heavier than normal. Heavier vocal cords produce a lower tone than lighter vocal cords, just as thick guitar strings produce a lower note than slender guitar strings.

But her voice isn't just deeper, it's also gravelly. To explain this I'll have to resort to further analogy: Her vocal cords are heavier, but it is NOT as though she exchanged slender guitar strings for heavy-duty guitar strings. It's more like she smeared mustard on the slender guitar strings to make them heavier. In other words, her vocal cords are unnaturally heavier -- they weren't designed to carry all of this extra weight. Consequently, her swollen vocal cords produce a note that is deeper and lacks clarity.

Unfortunately, after many years of smoking, this swelling may be permanent. It's surgically correctable, but your wife probably wouldn't seriously consider surgery just to get rid of her Bette Davis voice. Of much greater concern is the fact that her voice appears to be getting even worse, even though she quit cigarettes four years ago.

There are many possible explanations, but the most probable is inflammation. In other words, something else (besides cigarettes) is aggravating her already challenged vocal cords. This "something else" could be stomach acid and digestive enzymes gastroesophageal reflux disease, better known as GERD), postnasal drainage of inflammatory mucus (due to allergic rhinitis or chronic sinusitis), use of asthma inhalers or other inhaled medications or drugs, smog or other toxic fumes and so forth.

Since her symptoms are worse in the morning, my suspicion is that we are dealing either with GERD or postnasal drainage. Does she hawk up a big juicy one in the morning? (I really LOVE my work!) If not, then we are dealing with GERD.

Now, you may have noticed that I have yet to invoke the C word (cancer). That's because of her youth (cancers are uncommon in this age group) and the fact that her symptoms are intermittent. (Voice symptoms from cancer tend to be constant and progressive.) Nevertheless, early cancer (carcinoma in situ) can, at times, masquerade as inflammatory disease. Thus, she shouldn't breathe a sigh of relief until she has been examined by an ear, nose and throat doctor.

In other words, the person REALLY capable of giving you and your wife the reassurance you need is the doctor who actually looks at her vocal cords. Even if you are out of town, she can still be appropriately diagnosed, and the correct treatment can be initiated.