My husband has been gradually (over two years) losing his voice. An ear, nose and throat doctor told him he had acid reflux disease and put him on Prilosec. This did not help. He has no signs of heartburn and is not overweight, nor does he have bad eating habits. His voice seems to be normal only when he has a bad cold. He does not smoke or drink. Could this possibly be an allergy? His voice was never really deep to begin with, but he cannot talk loudly and is constantly trying to clear his throat.

Jeannie

I'm afraid you haven't described his voice very well. From your letter, I gather that his main problem is poor volume, or what some folks would call "a weak voice." You do not describe his voice as being either breathy or hoarse. To an ear, nose and throat doctor (ENT), each of these problems suggests a different list of possible explanations. (This list is what doctors refer to as a differential diagnosis.)

Could this be gastroesophageal reflux disease (GERD), even though he is not overweight, does not have heartburn or bad eating habits and takes Prilosec (omeprazole)? Yes, it could be. We have previously discussed the sort of lifestyle and diet that are most appropriate for GERD sufferers. If your husband violates many of these rules, he may continue to have significant reflux problems even if he takes Prilosec religiously. Prilosec, by the way, merely reduces the acidity of the gastric juices that are refluxed; it doesn't stop the reflux. That's why the lifestyle and dietary rules are so important.

Let's get back to his voice problem. If it isn't GERD, what else could it be? To understand poor volume, you need to know how we generate volume. Good volume (the ability to produce a loud voice) requires excellent lung capacity and breath control. We speak with exhaled air. If there is any limitation to our ability to inhale or exhale, then the voice may suffer. Asthma, emphysema and bronchitis are three common diseases that can limit the ability to inhale or exhale air, but there are many other possibilities.

Breath control requires effective use of the nerves and muscles that control the airway. Public speakers know the importance of the diaphragm for projecting a strong voice. The diaphragm is a large, sheet-like muscle that separates the abdomen from the chest. Proper use of the diaphragm is not automatic; it must be learned. Singers and other professional voice users learn very early how to optimize their voice through appropriate use of the diaphragm, as well as other respiratory muscles.

The nerve that controls the diaphragm is called the vagus nerve. A branch of the vagus nerve, the recurrent laryngeal nerve, controls the vocal cords. Thus, any condition that injures the vagus nerve could cause voice changes, including the loss of vocal volume.

The vagus nerve emerges from a part of the brainstem called the medulla oblongata. It exits the skull through a hole, the jugular foramen, and is accompanied by the internal jugular vein. It descends in the neck in the carotid sheath, accompanied by the carotid artery and internal jugular vein. As it descends in the neck and chest, the vagus nerve travels near the thyroid gland, the esophagus, the trachea and the heart.

Why the anatomy lesson? Because problems anywhere along the course of the vagus nerve could harm the nerve.

In other words, your husband's poor vocal volume could be due to any of the host of diseases that afflict the brain, thyroid, heart, lungs and so forth. Or it could be something trivial, related to the way he uses his larynx -- a "bad vocal habit." Allergy is possible, although unlikely. (Why would it get BETTER during a cold?) To get to the bottom of this problem, your husband needs to be examined carefully by an internal medicine specialist, and also by an ENT who is comfortable treating subtle voice problems. If you live near a medical school, you might want to call the ENT department and ask whether it has a laryngologist (voice specialist) on staff.