Types of Voice Disorders

 

The following information on voice disorders is intended to supplement what a certified speech language pathologist or otolaryngologist has already told you. The descriptions of these voice disorders should not be used as the only source of your information, so we recommend that any individual with a voice problem be seen by an otolaryngologist for an examination.

 

Voice disorders fall into three main categories: organic, functional, or a combination of the two. Organic voice disorders fall into two groups: structural and neurogenic. Structural disorders involve something physically wrong with the mechanism, often involving tissue or fluids of the vocal folds. Neurogenic disorders are caused by a problem in the nervous system. A functional disorder means the physical structure is normal, but the vocal mechanism is being used improperly or inefficiently.

A final category of voice disorder is the psychogenic disorder, in which a poor voice quality becomes a symbolic, or outward, manifestation of some unresolved psychological conflict.

The tricky part with categorizing voice disorders is that often times, different types of disorders will interact.

For instance:

  • Individuals with a neurogenic or structural disorder may develop a functional (relating to use of the muscles) component as they attempt to compensate for their voice disorder.
  • Individuals with poor muscle function may develop a structural lesion (growth).

On the other hand, there are some ways in which voice disorders don't interact, but do cause other unhealthy factors to arise.

  • Individuals with any voice disorder may develop a psychogenic, or emotional component, because the voice disorder can be so emotionally devastating. However, we do not consider this to be a psychogenic voice disorder.
  • Individuals with a psychogenic disorder may develop an additional structural or functional component.
  • Poor muscle function can become habitual, but it will not cause a permanent problem in the nervous system.

 

A few lesions are considered pre-malignant, but in general, the common vocal lesions (nodules, polyps, cysts, granulomas) will NOT turn into cancer. Please read our note about cancer.

 

CLICK ON A VOICE DISORDER

ORGANIC

STRUCTURAL: Structural disorders are caused by some lesion (physical abnormality) of the larynx.

 

NEUROGENIC: Neurogenic Voice Disorders are caused by some problem in the nervous system as it interacts with the larynx. See the Anatomy 301 section in our page about the voice for more information. Briefly, two nerves come from the brain to the larynx and control the movement of the larynx. The most important of the two nerves, the recurrent laryngeal nerve, comes down and wraps around the aorta before going back up to attach to the larynx on the left side. Because of this position in the neck, the recurrent laryngeal is vulnerable to damage during cardiac, pulmonary, spinal and thyroid surgeries. When the nerve is damaged, it causes a paresis (weakness) or paralysis (complete lack of movement) in the vocal fold of the affected side. Other neurogenic voice disorders are related to other kinds of problems in the central nervous system.

FUNCTIONAL:

Functional disorders are caused by poor muscle functioning. All functional disorders fall under the category of muscle tension dysphonia. The different disorders listed here refer to different patterns of muscle tension.

PSYCHOGENIC:

Psychogenic disorders exist because it is possible for the voice to be disturbed for psychological reasons. In this case, there is no structural reason for the voice disorder, and there may or may not be some pattern of muscle tension. While it is quite common for a psychogenic component to exist in a voice disorder, voice disorders that are caused by a psychological disorder are relatively rare. The two most common types of psychogenic disorders are listed on the right.

 


A special note about
CANCER

Laryngeal cancer is not considered a voice disorder. Cancer in the larynx or anywhere in the throat can cause a related voice problem, but our concern is not treating the voice disorder, it is treating the cancer. The voice may be disordered after cancer surgery, or after radiation therapy, in which case, the voice is treated as is any other voice disorder. See our links page for web sites relating to laryngectomies and other information regarding throat cancer.

You probably know that unexplained hoarseness is one of the warning signs of cancer. If you have a change in your voice quality that lasts several weeks and can't be explained, it's a good idea to have your larynx examined by a doctor. This is especially true if you have a risk of cancer related to smoking or exposure to other inhaled carcinogens.

If you have a diagnosis of hyperkeratosis or leukoplakia on your vocal folds, your doctor will be watching you carefully because those are considered pre-malignant lesions (they could possibly turn to cancer). If you have any other kind of voice disorder, it WILL NOT turn to cancer.


Structural Disorders:
Contact Ulcers

The Lesion and Effect on Vibration

A contact ulcer is a sore on the mucosal tissue of the posterior part of the larynx, usually on the arytenoid cartilage or very posterior portion of the vocal fold (also called the vocal cord; refer to our explanation of this terminology). It appears similar to a canker sore in the mouth. A contact ulcer can be quite painful. Contact ulcers are very similar in cause, effect, and treatment to granulomas.

Structural Disorders:
Cysts

The Lesion and effects on vibration

A cyst is a growth that forms beneath the surface layer of the vocal fold mucosa. It causes a gap between the two vocal folds (also called vocal cords; refer to our explanation of this terminology) and prevents normal vibration. Or it may cause some portion of the vocal fold mucosa to become stiff, which would also prevent normal vibration, affecting the voice quality and ease of vocal production.

 

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This cyst is watery in texture.

Sound of Voice

The voice may have a range of sound from normal to breathy to very rough and hoarse.

Complaints

May include:
  • abnormal voice quality
  • vocal fatigue
  • discomfort after extensive talking

Cause

The exact cause of any cyst is usually unknown. It often can occur with minute bleeding (hemorrhage) in the mucosa of the vocal fold. The bleeding resolves, but leaves a tiny bit of scar tissue, and the cyst forms around it. The cyst may be solid, filled with fluid, or even filled with blood. The initial bleed may be caused by a relatively short period of intense vocal fold vibration, such as severe coughing or screaming. However this is not always the case. Contributing factors may include taking medication to reduce platelet function (aspirin and non-steroidal anti-inflammatory drugs). Another contributing factor may be menstruation, which makes a woman slightly more vulnerable to hemorrhage. Cysts are typically found on one vocal fold, but can be found on both. It is also common for a nodule to form on the opposite vocal fold (vocal cord) in response to the additional pressure from the cyst.

Treatment

Cysts may resolve by simply reducing vocal fold impact for a time. However, they often require surgical removal. Pre- and post-surgical functional voice therapy usually improves the surgical result.

Structural Disorders:
Granuloma

The Lesion and Effects on Vibration

A granuloma is a benign growth that typically occurs in the posterior (back) part of the larynx, either directly on the vocal fold (also called vocal cord; see the explanation of this terminology), or on one of the mucosal surfaces nearby. The growth may prevent glottic closure, causing vibration to be weak or non-existent. This could cause a weak or breathy voice, or frequent "breaks" in the voice. Or the lesion may interfere with vibration, causing a rough, irregular sound. The voice may fatigue easily and become worse sounding with continued use. A lesion that is not directly on the vocal fold may not interfere with voice quality, but can be very irritating and even painful. A large enough lesion may obstruct the airway.

 

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This granuloma is considered quite large, and has formed on one of the mucosal surfaces nearby the vocal fold.

Sound of Voice

Ranges from normal to breathy to extremely rough and hoarse. Often worsens with increased voice use.

Complaints

May include:
  • abnormal voice quality
  • vocal fatigue
  • discomfort or pain associated with increased talking
  • interference with breathing
  • a sense of something irritating in the throat that needs to be cleared or coughed away

Cause

The granuloma is actually one of the body's ways of healing or protecting itself from an inflammatory or infectious process. It is believed to be related to an infectious process within the cartilage of the larynx. Granulomas can occur in a number of ways, but most are related to some acute or chronic injury, such as:
  • trauma from intubation during surgery
  • an extended bout of coughing or other vocal trauma
  • chronic reflux (see our explanation of GERD/LPRD)
  • chronic mild trauma such as frequent throat-clearing

Granulomas may occur from any single or combination of the above, but it is often difficult to determine an exact cause.

Whatever the initial cause, vocal fold trauma or impact will usually make the granuloma worse. Loud or excessive talking, throat-clearing, coughing, grunting, and effortful vocal production can all cause the granuloma to grow larger.

Treatment

Treatment for granuloma can be frustrating, as the lesion can be quite tenacious. Many surgeons prefer to remove the lesion immediately, but recurrence is common. At the Lions Voice Clinic, the first line of treatment for granulomas is medical and functional:
  • Anti-reflux medications are prescribed to eliminate any burning from acid reflux. Also, the patient is counseled about dietary, lifestyle, and mechanical precautions to alleviate GERD/LPRD.
  • A short course of steroids is prescribed to reduce the inflammation and, hopefully, the size of the granuloma.
  • Antibiotics are given to alleviate any infectious process.
  • Speech therapy is initiated to help identify sources of high vocal fold impact, and to teach techniques to reduce the impact while talking.

The above treatment may be enough to cause the granuloma to resolve. However, sometimes surgery is required to remove the lesion.

Surgery

Medical and functional therapy may be enough to cause the granuloma to resolve. However, sometimes surgery is required to remove the lesion.

Some things you should know about surgery:

  • It is done under general anesthesia.
  • The area is often injected with steroids immediately after removal of granuloma.
  • Total voice rest is prescribed for 3-5 days after surgery.
  • Voice use is minimal at first, with a very gradual return to complete voice use (1-4 months, depending on the surgical wound and the extent and type of voice use required).
  • Functional treatment is continued, voice use is monitored, and medical treatment may be used again.

Granulomas are known for recurring, which can be frustrating to the patient, and patients frequently come to the Lions Voice Clinic after multiple surgeries. These patients are usually frustrated and looking for another answer. However, they're often surprised to hear that another surgery may just aggravate an already inflamed area, and that speech therapy is an important part of the treatment process. Fortunately, this treatment program turns out to be successful in the vast majority of cases.


Structural Disorders:
Hemorrhage

The Lesion and Effects on Vibration

A hemorrhage occurs when a tiny blood vessel within the vocal fold (also called vocal cord; see the explanation of this terminology) bursts, creating a bleed into the mucosal covering. The accumulation of blood under the surface of the vocal fold makes the fold stiff, which makes vibration more difficult. The amount of the bleed can vary greatly, and so can the effect on the voice, but often it is large enough to prevent vibration of the affected vocal fold altogether. Small hemorrhages may cause only slight changes in voice quality, which could go unnoticed by someone using their voice actively.

Sound of Voice

A hemorrhage is typically an acute (sudden) event, and the voice may suddenly "cut out" or become very weak, breathy, or rough. A person experiencing a hemorrhage may suddenly find themselves unable to produce a sound. This resolves over time as the blood accumulation subsides.

Complaints

May include:
  • sudden decrease in voice quality
  • loss of pitch range
  • loss of volume
  • loss of vocal control

Cause

A hemorrhage occurs when there is sudden high impact, or prolonged impact to the vocal folds, and is more likely to occur when the blood vessels in general are already more susceptible to hemorrhage. This may happen when some anticoagulant, such as aspirin products, or some vasodilator, such as alcohol products, are used. It is also more common in women during their menstrual period. Therefore, we caution women suffering from menstrual cramps not to take aspirin, have a drink, then go out on stage and scream!

Treatment

It is possible that a small hemorrhage will have resolved to a large extent before it is even diagnosed, in which case reduced and careful voice use should allow for complete resolution. A person with a very recent and substantial hemorrhage is advised to undergo several days of total voice rest. This is one of the few times when we advise no voice use at all. After a maximum 5 days of silence, there should be enough resolution of the hemorrhage to resume voice use gradually. The extent of vocal decrement can very greatly, as can the demands of the voice user. Professional voice users with a hemorrhage are generally advised to undergo some voice therapy and/or monitoring during the first month or two following the incident, in order to prevent further damage.  This is why it is important to be seen very soon after any sudden decline or loss of voice.

Sometimes the bleed becomes encapsulated into a cyst or polyp. This may still resolve on its own, but the likelihood is greater that it will have to be surgically removed. At the Lions Voice Clinic, we prefer to try several months of intensive voice therapy before resorting to surgical removal. In therapy, techniques are taught that will promote safe voice use for the postoperative period, should surgery be necessary.

 


Structural Disorders:
Hyperkeratosis

Please check back later for information on this disorder.  A picture of vocal folds with hyperkeratosis is found below.

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Structural Disorders:
Laryngitis

Please check back later for information on this disorder.


Structural Disorders:
Leukoplakia

Please check back later for information on this disorder. A picture of a larynx with hyperkeratosis is found below.

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Structural Disorders:
Nodules (a.k.a. "Singer's Nodes")

The Lesion and Effects on Vibration

Nodules are blister-like or callous-like swellings that form just below the epithelial surface of the vocal folds (also called vocal cords; see the explanation of this terminology). They occur on both vocal folds and are symmetrical. The nodules appear as small bumps along the mid portion of the vocal folds, where the vocal folds come into contact with each other. The nodules may create a gap between the two vocal folds allowing air to escape and prevent normal vibration. They may also stiffen the mucosal tissue, causing irregular vibration and a rougher sound.

 

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These are considered to be early nodules. As nodules mature, they typically become smaller, more defined, harder and callous-like.

 

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These nodules are smaller and more well-defined.

Sound of Voice

May range from normal to breathy to very hoarse and strained. The inability to sing high, soft notes is one of the hallmarks of nodules. When the individual tries to sing high and soft, there is a delay in the onset of the sound, with an audible air escape, and then the sound starts abruptly.

Complaints

May include:
  • abnormal voice quality
  • limited pitch and volume
  • vocal fatigue
  • discomfort after extensive voice use

Cause

Nodules typically occur in people who use their voice in an intense manner over an extended period of time. The nodules appear as small bumps along the mid portion and are a result of the thickening of the surface layer of the vocal folds. The nodules are a natural response to increased trauma, similar to calluses on the hands.

Treatment

When the trauma is reduced through functional voice therapy, the nodules nearly always resolve. Surgery is rarely needed and is usually contraindicated if the individual has not learned to reduce the trauma. This would likely cause the nodules to recur.

Structural Disorders:
Papilloma

Please check back later for information on this disorder.  A picture of laryngeal papilloma is found below.

 

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Structural Disorders:
Polyps

The Lesion and Effect on Vibration

Polyps are similar to cysts in that they are growths arising from the vocal fold (also called vocal cord; see the explanation of this terminology) mucosa. They may be solid or fluid filled, and can become quite large. Their effects on vibration depend on their size and their location on the vocal folds.

 

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A fairly large polyp on the right vocal fold. This polyp has a more watery texture, and resolved after treatment with voice therapy. The individual now has a healthy voice.

 

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This polyp has a more solid texture. During phonation and inhalation it moved above and below the glottis as if on a hinge. Like the first picture, this polyp was removed surgically.

Sound of Voice

May vary from normal to severely dysphonic (very poor voice quality).

Complaints

May include:
  • abnormal voice quality
  • vocal fatigue
  • discomfort after extensive talking
  • a sense of something irritating in the throat that needs to be cleared or coughed away
  • problems with breathing, if the polyp is very large

Cause

Like cysts, polyps may result from some sort of trauma or impact to the vocal folds, or arise for some unknown reason. Although polyps tend to more associated with sudden, acute trauma, smokers polyps are a reaction of the vocal fold mucosa to the chronic insult of smoking. They cause the well-known "smoker's voice."

Treatment

Like cysts, polyps may resolve on their own with improved vocal hygiene, but are more likely to require surgical removal. At the Lions Voice Clinic, surgical removal of polyps is done after a course of functional voice therapy to optimize surgical results. Smoker's polyps are not likely to be removed unless the individual stops smoking, because continued smoking almost ensures that the polyps will return.

Functional Disorders:
Muscle Tension Dysphonia

One of the most common voice disorders we treat is muscle tension dysphonia (MTD). The root word phon means "sound". Phonation refers to the sound made by the voice. The term dysphonia means there is something wrong with the voice. However, muscle tension dysphonia can also refer to a voice that sounds normal, but causes pain, discomfort, or fatigue to the voice user. MTD is known as a functional disorder; that is, there is nothing structurally wrong with the voice. There are no nodules, polyps, paralysis, etc.. Rather, the muscles do not function properly, which causes poor sound, discomfort, or a sensation of increased effort.

Symptoms of Muscle Tension Dysphonia

Different individuals may have very different symptoms of MTD. In fact, MTD can mimic most structural voice disorders.

Possible voice characteristics of MTD
  • rough, hoarse, gravely, raspy, coarse
  • weak, breathy, airy, leaky, backward, hollow
  • strained, pressed, squeezed, tight, tense, choked, effortful
  • jerky, shaky, halting,
  • suddenly cutting out, squeezing shut, breaking off, changing pitch, or fading away
  • giving out gradually, or becoming weaker or more tense as voice use continues
  • excessively high or low pitch
  • inability to produce a loud voice
  • inability to produce a clear voice
  • inability to sing notes that used to be easy

Possible sensations of MTD

  • pain or discomfort anywhere in the throat area associated with voice use
  • a tight choking sensation associated with voice use
  • a sensation of fatigue or effort that increases with voice use
  • some area of the neck is tender to the touch
  • a feeling of the need to clear the throat frequently
  • a feeling of a lump in the throat

Causes of Muscle Tension Dysphonia

There are many specific, individual reasons why use of the vocal mechanism becomes abnormal. Some general causes are very common:

  • prolonged illness
  • continued voice use during laryngitis due to illness
  • prolonged overuse
  • prolonged underuse (such as after a surgery)
  • trauma, such as an injury, chemical exposure, or emotionally traumatic event

These may lead to an abnormal vocal response, causing the individual to compensate by using extra effort while talking.

The onset of MTD can be very subtle. The individual is usually unaware of the extra effort, but this extra effort typically recruits muscles that are not part of the larynx itself. The result may or may not be a stronger voice, but it usually starts a vicious cycle where more and more effort is required. This cycle may continue for months or even years before the individual becomes aware that his or her voice is abnormal. The reason why some individuals adapt one style of muscle tension over another is unknown.

Treatment of Muscle Tension Dysphonia

Functional therapy is usually the only treatment available. BUT:
  • should only be done after a thorough evaluation by ENT physician
  • should be done with a certified speech language pathologist who specializes in voice disorders
  • may require only a few sessions, or may take many months for complete relief, but generally some relief is gained within the first 4 to 6 sessions
  • in the case of emotional stress, some counseling or stress management may be very helpful or even necessary

Occasionally, medical or surgical treatments may be tried.

  • Botox injections may be useful in severe cases
  • Surgery to reduce the size of ventricular folds has been tried but is not done at the Lions Voice Clinic
  • Muscle relaxants are NOT useful for muscle tension dysphonia - the action of the drugs is not localized to the vocal mechanism, so in order to provide enough relaxation for the vocal mechanism, the individual is often unable to function for day to day living

Types of Muscle Tension Dysphonia

Muscle tension in the vocal mechanism can exhibit itself in many ways. Each individual is different. But here are a few common patterns:


For the purpose of this web site, we have categorized Muscle Tension Dysphonia into these patterns of muscle tension. However, there is not a one-to-one correspondence between the pattern of muscle tension and the sound of the voice or the experience of the individual. Any of the muscle tension patterns can result in a distinct and individual pattern of discomfort and/or poor voice quality. Also, treatment for Muscle Tension Dysphonia is highly individual, and depends more upon how the individual responds to retraining than upon the paattern of muscle tension. Everyone can improve with therapy, but the actual course of therapy varies greatly from person to person and from therapist to therapist.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Anterior-Posterior Constriction

Muscle tension pattern

The arytenoid cartilages bend forward during voice use, and/or the epiglottis bends backwards, causing the larynx to squeeze from front to back (anterior to posterior). As effort increases, the squeezing continues, causing a vicious cycle. The squeezing in a front-to-back direction may put pressure on the vocal folds such that they bow (see Vocal Fold Bowing), causing poor vibration. In extreme cases, especially in children, the arytenoids may actually vibrate against the epiglottis.

Sound of Voice

Ranges from normal to extremely squeezed and tight sounding. The voice may sound rough if the squeezing causes irregular vibration of the vocal folds. "Froggy" sound if arytenoids and epiglottis vibrate.

Complaints

May include:
  • poor voice quality
  • discomfort
  • pain that increases with voice use but may be constant even during rest
  • fatigue and decline of voice quality with voice use

Cause

Prolonged voice overuse, or continued voice use while vocal mechanism is impaired, or prolonged use of a tense style of speaking. Sometimes related to emotional stress.

Treatment:

Functional therapy.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Hyperabduction

Muscle tension pattern

The vocal folds (also called vocal cords; see the explanation of this terminology) do not come together to produce voice. They may appear to be pulled apart as the person phonates.

Sound of Voice

Weak, breathy, airy, very soft, hollow, breaks in voicing,

Complaints

Effort and fatigue from voice use; voice is ineffective

Cause

Sometimes abnormality in vocal mechanism causes pain, leading to protective avoidance of voicing. Emotional or stress component is common.

Treatment

Functional therapy, often combined with psychotherapy. Occasionally, injections of a substance to bulk up the vocal folds and provide better closure are helpful as a temporary meausre.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Hyperadduction

Muscle tension pattern

The vocal folds (also called vocal cords; see the explanation of this terminology) adduct (come together) very tightly, producing a valve that restricts airflow. The larynx may look normal on exam, but the sound and sensation are not.

Sound of Voice

Ranges from normal to extremely tight, pressed, squeezed, strangled, forced or effortful. Tension may be irregular, causing a stopping/starting or shaking effect.

Complaints

May include:
  • poor voice quality
  • effort and fatigue, usually increasing with continued voice use
  • pain
  • discomfort

Cause

Prolonged overuse or continued voice use when the vocal mechanism is impaired. Tense style of voice use can cause this pattern of muscle tension dysphonia to become habitual over time. Emotional component may be present.

Treatment

Functional therapy. Occasionally Botox injections are helpful.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Pharyngeal Constriction

Muscle tension pattern

Muscle of the pharynx (throat) contract excessively while talking, leaving the throat very constricted.

Sound of Voice

Ranges from normal to very tight or squeezed, may be tremulous, or may be backward and throaty sounding.

Complaints

May include:
  • poor voice quality
  • discomfort
  • pain that increases with voice use but may be constant even during rest
  • fatigue
  • decline of voice quality with voice use

Cause

Prolonged voice overuse, or continued use while vocal mechanism is impaired, or prolonged use of a tense style of speaking. Sometimes emotional stress.

Treatment

Functional therapy.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Ventricular Phonation

Also called plica ventricularis, ventricular dysphonia, or false cord phonation.

Muscle tension pattern

The ventricular folds come together and vibrate instead of, or along with, the vocal folds (also called vocal cords; see the explanation of this terminology). The ventricular folds, also known as the false vocal cords, are mounds of fleshy tissue just above the true vocal folds (see About the Voice). Though the ventricular folds are not muscular, they can be brought together and vibrated. However, they were not meant to vibrate, so they can't vibrate very fast (for high pitches) or very strongly (for loud sounds). Pressure from the ventricular folds can be strong enough to keep the true vocal folds from vibrating.

Sound of voice

The voice sounds very rough and strained, sometimes not quite human, limited in pitch and volume.

Complaints

May include:
  • poor voice quality
  • fatigue, especially with attempts at loud voice use
  • pain or dryness with voice use
  • sometimes no discomfort at all

Cause

If the true vocal folds are impaired or cannot vibrate for some reason, the ventricular folds may be recruited. Most often, the cause is continued use of voice while true vocal folds (vocal cords) are impaired. Sometimes, it could be extreme strain in response to a trauma.

Treatment

In extreme cases, medical or surgical treatments may be tried, but only after functional therapy has failed. In some cases, ventricular phonation is the best alternative if the true vocal folds will always be too impaired to vibrate.

Functional Disorders -
Specific Patterns of Muscle Tension Dysphonia:
Vocal fold (Vocal Cord) Bowing

Muscle tension pattern

Vocal folds (also called vocal cords; see the explanation of this terminology) don't come together to vibrate. Instead, they leave a gap, allowing air to leak through.

 

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This picture illustrates moderate bowing.

Sound of Voice

Weak, breathy, hollow, backward, sometimes rough or scratchy.

Complaints

Fatigue from voice use, undependable voice, sense of effort when talking, poor volume, voice gets weaker with continued talking.

Cause

Usually over exertion, sometimes when individual is in poor condition (vocal fold bowing is sometimes referred to as presbylarynges, which means "the laryngeal status of old age"). This assumes that the vocal folds are bowed because the muscle in the vocal folds has atrophied (wasted away) due to old age. Senior citizens are often told that they must accept their voice quality as a natural part of getting old. Other times, surgery is offered to "plump up" the vocal folds in order to get them to come together again. In the Lions Voice Clinic, we see many individuals of all ages with vocal fold bowing. Also, the senior citizens we see with vocal fold bowing range in voice use from minimal to very heavy voice use. This suggests to us that bowing is not just caused by wasting away of the muscles. We believe it is more often caused by compensatory muscle tension, usually in the anterior-posterior direction, which squeezes the vocal folds apart.

Treatment

In the Lions Voice Clinic, we treat bowing successfully with functional therapy, in a wide variety of individuals. We rarely find that surgery is necessary.

Neurogenic Disorders:
Paralysis/Paresis

Abnormal Movement Pattern

One or both vocal folds (also called vocal cords; see the explanation of this terminology) do not move, often causing a gap between the two vocal folds, which allows air to leak through and disrupts vibration. Typically, there is some nerve regrowth into the paralyzed vocal fold but movement may or may not return if the nerve regrowth is random. If the damage is permanent and there is no movement at all to the vocal fold, it is considered a paralysis. If there is some movement but movement is reduced, it is called a paresis, which means "weakness."

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In this picture the left vocal fold does not move; it is paralyzed near the midline. Seen in open position, the vocal folds do not fully open. Because the left vocal fold is paralyzed the arytenoid appears to "droop." In a normal larynx, the left vocal fold would be symmetrical with the right.

 

Sound of the voice

May be weak, breathy, rough, diplophonic (two pitches occurring at the same time), or just a whisper.

Complaints

May include
  • Lack of volume
  • Lack of vocal strength
  • Vocal fatigue, which increases with voice use
  • Poor voice quality
  • Shortness of breath
  • Swallowing problems

Cause

Damage to one of the two nerves that go from the brain to the larynx, most commonly the recurrent laryngeal nerve (see Anatomy 301: The Role of the Nervous System). Vocal fold paralysis can result from surgeries such as anterior spinal fusion, and thyroid, cardiac, and pulmonary surgeries. It is also possible for a virus to cause damage to the nerve, often without any other symptoms of the virus.

Treatment

In people with mild voice impairment and moderate vocal demands, functional voice therapy is often effective. However, multiple surgical options are also available to people who do not obtain a satisfactory result with speech therapy.

The principal goal of surgical treatment for paralysis is to move the vocal fold into a position so that it can effectively be used by the mobile vocal fold on the other side to produce vibration (see About the Voice).

Injections: Moving the immobile vocal fold (vocal cord) can be done by injecting it with a substance to bulk it up and move it toward the center. The material can be temporary (Cymetra is used at the Lions Voice Clinic. It is a foamy substance that usually lasts about 6 months.) or permanent (Teflon, which is rarely used in the Lions Voice Clinic because it is known to migrate). Injection of a small amount fat from elsewhere on the body can also be performed which can give a permanent result. However, the results vary as far as how well the grafted fat survives. Injections are performed through the mouth and typically in the operating room. The person can usually go home the same day as the injection. In select situations, injections can be performed in our clinic.

Implants: Another option for a bothersome immobile vocal fold (vocal cord) is a procedure called a thyroplasty. In a thyroplasty, a solid piece of material is placed through a window made in the cartilage of the larynx. The larynx is approached through a small incision in the neck. A window is made in the thyroid cartilage and the material is placed in the immobile vocal fold to move it toward the middle. The procedure is performed with the person awake so that the voice can be tested and the implant modified as needed. Different surgeons use different materials (Silastic blocks, hydroxadhesive or goretex). All of these materials produce good results. At the Lions Voice Clinic, we use silastic implants.

Reinnervation: A third option for unilateral vocal fold immobility due to nerve dysfunction is reinnervation. In this procedure, a nerve is "borrowed" from one of the neck muscles and "hooked into" the recurrent laryngeal nerve. In our clinic, we see the most consistent high quality voice with this procedure. A disadvantage is that 6 to 12 months are needed for the nerve to start functioning to provide substantial voice improvement. Because of this, a vocal fold injection is used to temporarily move the vocal fold to the middle. Following a reinnervation, the vocal fold will not actually move, but will have excellent position, bulk and muscle tone so that is can meet the other vocal fold at the midline.


Neurogenic Disorders:
Spasmodic Dysphonia (SD)
a.k.a. Laryngeal Dystonia (LD)

The Disorder and Effects on Vibration

Spasmodic Dysphonia (SD) is the common name for Laryngeal Dystonia. Dystonia is a neurologic movement disorder, caused by a problem in the nervous system. Dystonias can affect many parts of the body, and when a dystonia affects the larynx, it is called Laryngeal Dystonia or Spasmodic Dysphonia. The vocal folds (also called vocal cords; see the explanation of this terminology) vibrate normally, but they spasm intermittently during speech.

Spasmodic Dysphonia was called spastic dysphonia until about 15 years ago. Spasmodic Dysphonia or Laryngeal Dystonia are more correct terms.

There are two kinds of laryngeal spasms, creating three kinds of Spasmodic Dysphonia.

Adductor Spasmodic Dysphonia

This is the most common type of SD. The thyroarytenoid muscle (the muscle that lies within each vocal fold) contracts strongly and suddenly as in a muscle spasm. This causes the vocal folds to suddenly squeeze together very tightly. The result is a sudden breaking, stopping, or strangling of the voice.

Abductor Spasmodic Dysphonia

This less common form of SD causes the posterior cricoarytenoid muscle (the muscle that draws the vocal folds apart) to contract suddenly, causing the vocal folds to pull apart suddenly. The result is a sudden "blowing out" or breathiness of the voice.

Mixed Spasmodic Dysphonia

This is the most rare form of SD, in which both adductor and abductor spasms are present during speech.

Sound of voice

  • Adductor SD: the voice sounds tense, tight, strained, strangled, with sudden stoppages of the voice.
  • Abductor SD: the voice sounds breathy, weak, leaky, with sudden blowouts

Complaints

May include
  • Poor voice quality, may be so severe that speech is unintelligible
  • Loss of control of the voice
  • Fatigue, strain, and effort associated with voice use

Cause

Though we know that Spasmodic Dysphonia is a neurologic disorder, the exact cause is unknown; for more discussion, we recommend the web sites of the National Spasmodic Dysphonia Association or the Dystonia Medical Research Foundation.

Treatment

There is no cure for SD. However, treatment using Botox injections is often very helpful, especially for Adductor SD. Botox is the nickname for Botulinum Toxin, which is a strain of botulism, a powerful poison. When small amounts of Botox are injected into the vocal folds, the muscle is weakened, and the spasms are reduced or eliminated. The injections cause weakness or breathiness to the voice for the first few weeks, but then the voice strengthens and is without spasms for an average of three months. The spasms gradually return, and more Botox must be injected.

In the case of abductor SD, the Botox is injected into the posterior cricoarytenoid muscle (the abductor muscle) to reduce abductor spasms.

At the Lions Voice Clinic, you will be evaluated jointly by Drs. Goding and Michael for Spasmodic Dysphonia. If you are diagnosed with SD, you will be offered Botox injections and functional therapy. The majority of patients find that a combination of therapies is best; the Botox reduces the muscle spasms, and the functional therapy reduces habits of effortful overcompensation that make speech even worse.

Botox Treatment and the Nervous System

When a nerve gets the signal from the brain to fire, chemicals called neurotransmitters are released from the nerve into the muscle fibers, causing the muscle to contract. Botox works by preventing the release of the neurotransmitters. This prevents the contraction of the muscle. Actually, the Botox is injected in such small amounts that it only affects the muscle fibers near the injection site, not the entire muscle. Therefore, the muscle contraction is weakened, but not entirely eliminated.

We talk about the Botox wearing off, but that is not quite what happens. The tiny ends of the nerve fibers near the injection site eventually die off from the Botox. However, new nerve endings grow, much like the roots of a plant. The regrowth of active nerve endings allows the release of neurotransmitters again, so that the muscle contraction is no longer weakened. The gradual strengthening of muscle contraction makes it feel as if the Botox effect is wearing off.

Botox can be used to treat other voice disorders in addition to SD. These include Benign Essential Tremor and severe Muscle Tension Dysphonia.

If you're going to receive Botox injections...

How long does it take?

The injection process will only take a few minutes. Then we'll ask you to wait a few minutes after your injection, to make sure you feel OK.

Does it hurt?

Most people say it's a little painful for a short time, like getting a tetanus shot. No anesthesia is used, because most people prefer avoiding additional injection. It's helpful if you relax, just like that tetanus shot. It's fine if you want to have someone come with you and hold your hand.

How do we know the needle is in the right muscle?

At the Lions Voice Clinic, we use EMG (electromyographic) guidance. That means the needle is attached to a tiny wire that sends a signal to the electromyograph machine, which in turns gives a signal about the activity of the muscle. When the needle is in place, we will have you activate the muscle by performing a specific task such as saying "eee" or sniffing. Electrical energy caused by the contraction is sent through the wire to the electromyograph, and a "crackling" sound confirms that the needle is in the correct muscle. Before your injection, a round disc called an electrode will be applied to your forehead and another strapped around your left wrist. These provide grounding and reference for the electrical signal. In the case of adductor SD when the thyroarytenoid muscle is injected, there will be two injections, one for each side. In the case of abductor SD, only one side at a time is injected. This is because the injection is going into the muscle that pulls the vocal folds apart and allows you to breathe. If both sides are weakened at the same time, breathing could be impaired (you wouldn't like that!). After several injections, often a dose is found that allows for simultaneous injections on both sides, without compromising breathing.

How soon does the injection take effect?

Usually in the next three days. Sometimes people can feel a difference the next morning, but more often it takes a day or two. If you don't feel any effect within a week, call us. Sometimes the strongest effect is felt first, and other times the effect builds over the first week. Individual reactions are hard to predict.

What are the side effects?

Side effects are minimal, because the amount of Botox is so small, and the area it affects is very small. Both side effects are related to the intended purpose of the Botox, to weaken the vocal folds.

In the first week, a few people notice choking or coughing when they drink thin liquids like water. It is the same effect when you get water "down the wrong pipe." To avoid this, sip carefully; don't chug-a-lug. Many people cough a little when they first take a drink after the injection takes effect, and then they remember to sip more slowly. It is rarely a problem, and rarely lasts more than a week.

The other, more common side effect is that your voice may become weak and breathy for some period of time after the injection. This is because the vocal folds are weak and cannot come together strongly to provide a strong vibration. This is what prevents the spasm. In time the breathiness resolves and the voice becomes stronger, but still does not spasm. The degree of breathiness and the length of time the voice stays breathy are related to the dose of Botox, and to the individual reaction. In general, the larger the dose, the longer the voice stays breathy, but also, the longer the spasms are prevented after the breathiness resolves.

Some people cannot tolerate any breathiness or weakness in their voice, and therefore they have frequent, small doses of Botox. Others can tolerate several weeks of breathiness, but in exchange they get more months of improved voice quality. It may take a few injections before you know your best dose and timing schedule.

How will I know when I should get another injection?

The spasms will return gradually, and at first they will not be as strong as they were before the injection. Spasms typically get worse over a period of weeks or months. During that time, techniques you learned in voice therapy are the most helpful. Because injections are only given once a month, typically on the fourth Tuesday of the month, you should make your appointment for your next injection accordingly. If the spasms start coming back during the third week of the month, you can probably wait another month. But if they come back early in the month, you may want to make your appointment for the end of the month. One thing is certain: no one ever wants to wait so long they get back to the level of spasms they had before their first injection!


Neurogenic Disorders:
Tremor (Benign Essential Tremor)

The Disorder and Effects on Vibration

Benign Essential Tremor is a disorder that causes shaking of the voice. Benign means that the disorder will not harm your health. Essential means that the tremor is not associated with any other disease state, such as the tremor associated with Parkinson's Disease. When Benign Essential Tremor affects the voice, vocal fold vibration is normal, but the entire larynx shakes slightly, causing an extra vibration, or tremor, at about 5-7 cycles per second. Sometimes the larynx can be seen to tremor even at rest, but usually the tremor begins when the person begins to speak. Benign Essential Tremor tends to occur in older persons, though persons in their 50's may also be afflicted.

Sound of voice

A steady shaking or wobbling of the voice, ranging from gentle and continuous to a staccato, almost hiccuping sound. The easily-recognized sound of Katherine Hepburn is a famous example of Benign Essential Tremor. The tremor is rhythmic and steady, at 5-7 cycles per second, and it occurs in all speech contexts. It may vary in intensity with changes in pitch or volume, and, like all voice disorders, tends to get worse in stressful situations.

Complaints

May include:
  • Poor voice quality, with "old-sounding" characteristics
  • Vocal weakness and low volume
  • Vocal fatigue increasing with voice use
  • Embarrassment

Cause

Tremor is caused by a central nervous system problem that can also cause tremor of the hand, head, or other extremities. Tremor may be hereditary. Benign Essential Tremor sometimes occurs along with Spasmodic Dysphonia, so that there are vocal fold spasms as well as continuous shaking. The reason for this is unknown.

Treatment

There is no treatment that will eliminate the tremor. Often, the individual with tremor tries to stop the tremor while talking, but ends up creating more tension and making the tremor worse. Functional voice therapy can help reduce this effortful compensation, improve voice quality, and make speech easier. When the tremor is severe and causes voice breaks, Botox injections may help reduce the severity and the strain, though they will not eliminate the tremor altogether. At the Lions Voce Clinic, many patients with tremor have found a short course of functional therapy to be helpful, but only a few have found Botox to be helpful enough to continue getting injections every few months.

There are also a number of pharmacological (drug) treatments that are helpful for some people. There are several classes of drugs that may be helpful, including beta-blockers, anti-seizure medications, and psychotropic drugs. We encourage individuals who are diagnosed with Benign Essential Tremor to see a neurologist, to confirm the diagnosis, rule out other neurologic problems, and discuss a course of drug treatment. Some of the drugs that are helpful in reducing tremor have unwanted side effects, or may be conflict with drugs the individual is already taking. Therefore it is important to coordinate this treatment between the neurologist and primary care physician.

More information about this topic can be found at the International Tremor Foundation web site at: www.essentialtremor.org. Another good site is www.diseases-explained.com/EssentialTremor/index.html. This is provided as a link at the first site.

Botox Treatment for Benign Essential Tremor

Botox is the nickname for Botulinum Toxin, which is a strain of botulism, a powerful poison. When a minute amount of Botox is injected into a muscle, it weakens the muscle contraction. In the case of Tremor, it does not stop the tremor, but weakens the severity of the tremor. The Botox is injected into the thyroarytenoid muscle within the vocal fold. The thyroarytenoid muscle is responsible for the strength of the staccato, hiccuping effect of the tremor.

How does Dr. Goding know the needle is in the right muscle?

At the Lions Voice Clinic, Dr. Goding uses EMG (electromyographic) guidance. That means the needle is attached to a tiny wire that sends a signal to the electromyograph machine, which in turns gives a signal about the activity of the muscle. When the needle is in place, Dr. Goding will have you say "eeee," which will cause the muscle to contract. Electrical energy caused by the contraction is send through the wire to the electromyograph, and Dr. Goding can hear the "crackling" sound that tells him the needle is in the correct muscle. Before your injection, Dr. Goding or the nurse will apply round disks called electrodes to your clavicle. These provide grounding for the electrical signal. It sounds scary, but you won't feel a thing, and it's not at all dangerous.

There will be two injections, one for each side.

How long does it take?

The injection process will only take a few minutes. Then we'll ask you to wait about 15 minutes after your injection, to make sure you feel OK. You only have to wait after your first injection.

Does it hurt?

Most people say it's a little painful for a short time, like getting a tetanus shot. No anesthesia is used, because that would hurt more! Sometimes the first injection hurts the most, because people are the most nervous, and more likely to tense their muscles. It's helpful if you relax, just like that tetanus shot. It's fine if you want to have someone come with you and hold your hand. By your second injection, you won't bat an eye.

How soon does the injection take effect?

Usually in the next three days. Sometimes people can feel a difference the next morning, but more often it takes a day or two. If you don't feel any effect within a week, call us. Sometimes the strongest effect is felt first, and other times the effect builds over the first week. Individual reactions are hard to predict.

What are the side effects?

Side effects are minimal, because the amount of Botox is so small, and the area it affects is very small. Both side effects are related to the intended purpose of the Botox, which is to weaken the vocal folds.

In the first week, you may notice some choking or coughing when you drink thin liquids like water. It is the same effect when you get water "down the wrong pipe." To avoid this, sip carefully; don't chug-a-lug. Many people cough a little when they first take a drink after the injection takes effect, and then they remember to sip more slowly. It is rarely a problem, and rarely lasts more than a week.

The other side effect is that your voice may become weak and breathy for some period of time after the injection. This is because the vocal folds are weak and cannot come together strongly to provide a strong vibration. This is what reduces the staccato, hiccuping sound of the tremor. The tremor will still be there, but should be more gentle. With less interference from the tremor, it is easier to talk and make yourself understood. The degree of breathiness and the length of time the voice stays breathy are related to the dose of Botox, and to the individual reaction. In general, the larger the dose, the longer the voice stays breathy, but also, the longer the tremor is reduced after the breathiness resolves. Some people cannot tolerate any breathiness or weakness in their voice, and therefore they have frequent, small doses of Botox. Others can tolerate several weeks of breathiness, but in exchange they get more months of the optimal effect. It will take several injections before you know your best dose and timing schedule.

How will I know when I should get another injection?

The tremor gradually becomes stronger over a period of weeks or months. During that time, techniques you learned in voice therapy are the most helpful. Because injections are only given once a month, on the fourth Tuesday of the month, you should make your appointment for your next injection accordingly.


Psychogenic Disorders:
Conversion Dysphonia/Aphonia

This disorder exists when there is psychological trauma or conflict that is manifested physically. In the case of conversion dysphonia or aphonia (complete loss of voice), there may be a single traumatic event such as an accident, death, or psychologically damaging event, and there is change of voice within a short time. Or, there may be a long term psychologically damaging circumstance, such as sexual abuse, that may be manifested soon or many years later. In the case of conversion disorder, the individual may undergo functional voice therapy to gain control over his or her voice, but in most cases the voice disorder will not resolve unless there is also psychotherapy to address the underlying problem.


Psychogenic Disorders:
Juvenile Voice/Mutational Falsetto/Puberphonia

This disorder exists when there is some psychological reason for an individual to resist the maturing and lowering pitch of the adult voice, and maintains the higher pitch of a preadolescent. This disorder is much more common in adolescent males, but can also exist in females. The voice therapist may be able to elicit a normally low-pitched voice by engaging the individual in certain vocal tasks, but if the psychological resistance is strong, psychotherapy may be necessary to maintain the more adult voice quality.

It is also possible that the post-pubertal voice does not develop because there is some physical problem with the voice at the time of the pubertal voice change, such as a prolonged upper respiratory infection or intubation. In that case, the disorder is not considered psychogenic and usually responds quickly and easily to functional therapy.


Neurogenic Disorders:
Other Neurogenic Disorders

The voice may be impaired in persons with other neurologic diseases such as:

  • Parkinson's Disease
  • Myasthenia Gravis
  • Amyotrophic Lateral Sclerosis (ALS, a.k.a. Lou Gherig's disease)

The voice may also be impaired in persons who suffer a stroke or other brain injury and have damage to any part of the speech system. When there is damage to the brain causing some impairment of the speech system, including the voice, it is termed dysarthria.

In the case of these neurogenic disorders, there is rarely any medical treatment that will help the voice, over and above the medical treatment given for the primary disease. Botox injections (see Spasmodic Dysphonia) may be helpful if there is extreme tension in the larynx. A surgical procedure to bring the vocal folds into closer contact (see Paralysis/Paresis) if there is extreme weakness of the vocal folds. Functional voice therapy may be useful to teach techniques for efficient compensation.


Structural Disorders:
Trauma

Accidents can cause a variety of fractures, lacerations, and other injuries to the larynx. These injuries and their effects on the voice vary widely, as does treatment. Fortunately, many severe injuries can be treated well with surgery and therapy, and a normal or near-normal voice may often result.


Structural Disorders:
Miscellaneous Growths

There are a number of other kinds of growths that can occur within the larynx. Most are non-life-threatening, and their impact of voice quality can vary greatly. Luckily, most growths can be treated medically or surgically.

  

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Deirdre D. Michael - micha008@umn.edu
Date Last Modified: 1/12/12