Voice Disorders

Vocal fold bowing is a condition that develops secondary to the thyroarytenoid muscle atrophying. Vocal fold bowing is most frequently seen in older people, and in that case, is called presbylarynges (thought to be part of the normal aging process). Vocal fold bowing and atrophy can also occur when you have a paralyzed vocal fold.

An individual with vocal fold bowing will most often have a weak, breathy voice. Individuals can also have a rough/strained vocal quality due to compensation for the vocal fold weakness. People with vocal fold bowing often complain of difficulty being heard/projecting and sometimes feel that they run out of air while speaking. The severity of voice quality can vary depending on the severity of the bowing and atrophy.

Treatment for vocal fold bowing/presbylarynges is most often treated successfully in a voice therapy program specifically designed to strengthen and re-balance the laryngeal musculature. In most severe cases or for people who do not benefit from voice therapy, there are a few surgical options (such as fat injections or a laryngoplasty) that are available to help the vocal folds close, which will improve voice quality.

Cysts are benign (non-cancerous), fluid-filled growths that can be present congenitally (since birth) or can be acquired later in life. Cysts typically occur unilaterally on the vocal folds (one-sided), but can occur bilaterally (both sides). Cysts occur under the mucosa of the vocal fold and cause the vocal fold to be stiff in the area of the cyst.

Vocal symptoms of cysts can vary depending on the size of the cyst. Patients can vary from mildly dysphonic (hoarse) to severely dysphonic.

The typical treatment for a cyst is surgical removal. However, a short period of voice therapy before surgery may be recommended if you have a significant amount of vocal fold inflammation and/or poor voicing patterns, to ensure that you do not quickly re-injure the mechanism due to poor voicing habits. Post-operative voice therapy will likely be recommended as well, to aid in the healing of the vocal folds and ensure that proper voice usage is maintained after surgery. Additionally, if the cyst is not causing you to be too symptomatic, voice therapy may be beneficial to learn to use the voice as effectively as possible if surgery is not wanted by the patient. Cysts are benign and do not have to be removed for medical purposes.

A granuloma, or contact ulcer, is a benign (non-cancerous) area of inflammation typically located on the back part of the larynx (or vocal process). Contact granulomas may occur bilaterally (both sides) or unilaterally (one side).

These lesions are often associated with:

• Injury from intubation following surgery or long term airway ventilation
• Esophageal reflux which is thought to irritate the tissue of the back of the larynx and put this area at higher risk of irritation/ulceration (i.e. granuloma or contact ulcer)
• Vocal misuse/abuse – especially the use of a pressed, loud, low-pitched voice quality

Unless the area of inflammation is large, the presence of a granuloma often does not affect the vibration of the vocal folds and therefore does not significantly impact voice quality. However, many patients complain of:

• throat pain
• throat irritation
• lump in the throat sensation
• vocal fatigue
• frequent urge to throat clear/mucus sensation in the throat

Typically, the first line of treatment for a granuloma/contact ulcer is medicinal management of reflux. Additionally, patients will be strictly instructed to cease any throat clearing or coughing in order to decrease further irritation of the lesion. Voice therapy may also be beneficial. Voice therapy can help improve voicing patterns to decrease pressure on the posterior portion of the larynx, allowing for healing of the lesion.

These lesions may take many months to resolve. Surgical management is typically not recommended because the lesions usually return after surgery (often larger than before). However, if medicinal management and behavioral techniques do not improve the lesions or if the lesions are impacting the quality of life; in-office lasers, steroids, or last-resort surgical management may be offered or warranted.

Laryngeal papillomas are wart-like lesions, usually benign (non-cancerous), that can develop on the vocal folds, within the airway, or within the supraglottis (base of tongue, pharyngeal walls, tonsillar area, uvula, etc).

Laryngeal papilloma is caused by the human papillomavirus (HPV).

Symptoms of papillomatosis can vary depending on the amount of papilloma lesions and the areas in which they are present. Symptoms can vary from mild to severe dysphonia (hoarseness). Some people also experience shortness of breath when lesions occur in the trachea or when lesions on the vocal folds are so severe that they begin to block the glottis (upper airway).

Laryngeal papillomas often require repeated surgical management, with initial biopsy to ensure that the lesions are, in fact, benign. Surgical management may be done in the OR or with an in-office laser depending on the severity of the disease.

Laryngitis means inflammation (swelling) of the vocal fold mucosa (cover). This can cause anywhere from mild to severe dysphonia (hoarseness). In some cases, complete voice loss can occur.

The cause of acute laryngitis is usually associated with an upper respiratory infection/viral infection.

The most effective treatments for acute laryngitis include hydration (both direct and systemic: i.e. drinking water and steam inhalation), antibiotics or steroids if needed, and rest (both vocal and physical). A cough suppressant may be beneficial as well if coughing is present because prolonged, aggressive coughing can cause long-term damage to the vocal fold mucosa.

Chronic laryngitis is prolonged inflammation to the vocal fold tissue that is not associated with infection/illness. Voice quality can range from mildly to severely dysphonic.

The causes of chronic laryngitis can include:

• repeated episodes of acute laryngitis
• vocal misuse/overuse/abuse
• smoking
• poor hydration/vocal hygiene
• air pollutants
• allergies
• dehydrating medications
• gastroesophageal reflux disease/laryngopharyngeal reflux disease (also known as acid reflux)
• repeated vomiting

Treatment for chronic laryngitis involves identifying and resolving potential factors that may be contributing to chronic laryngitis. Medicinal treatment may be warranted depending on the etiology and/or voice therapy to identify and resolve specific voicing patterns contributing to the inflammation and prolonged hoarseness.

Leukoplakia is a pre-diagnostic term meaning “white plaque” which describes the appearance of a thick white substance that covers the vocal folds in diffuse patches, usually on the top surface of the vocal folds. The pathology of leukoplakia is variable and may include both benign and malignant lesions.

Hyperkeratosis is a layered buildup of keratinized cell tissue and is distinctive for its leaf-like appearance. It consists of an overgrowth of irregular margins on the vocal folds.

Both hyperkeratosis and leukoplakia are treated as cautionary signs for possible future malignancy. People who have such lesions should avoid exposure to tobacco smoke, chemical inhalants, and other irritants. Often, a biopsy will be conducted to determine the current pathology of these lesions. Your physician then may want to perform a laser procedure to remove the Leukoplakia depending on the size and outcome of the biopsy. He/she may also just watch the lesion to ensure it does not grow/change over time.

A vocal fold polyp is a benign, fluid-filled lesion which can be found unilaterally ( ) or bilaterally (two-sided) on the vocal folds. Polyps may appear broad-based and more blister-like (sessile) or may appear to be attached by a stalk (pedunculated). Vocal fold polyps are thought to be caused by trauma to the vocal folds (i.e. misuse/abuse of the voice).

Vocal symptoms of polyps can vary greatly, depending on their size, location, and type (sessile vs. pedunculated). A polyp can cause symptoms that range from mild to severe hoarseness with breaks in the voice and diplophonia (dual voice sound when speaking).

Depending on the type and size of the polyps, treatment may vary. Many polyps will ultimately require surgical removal for the best resolution of symptoms. However, voice therapy can also be beneficial in the treatment of vocal fold polyps, specifically if a polyp is new, soft, sessile, and small. Voice therapy is often recommended initially to decrease inflammation surrounding a polyp (regardless of type) and to improve negative voice habits that may have caused a polyp to form in the first place. Post-surgical voice therapy is always recommended as well to limit the chances of a polyp recurrence and to aid in the proper reformation of vocal habits.

Reinke’s edema occurs when the layer under the surface lining of the vocal fold (Reinke’s Space) fills with fluid due to long-standing vocal trauma, almost always caused by smoking. In the most severe cases, the entire membranous portion of the vocal folds becomes filled with thick, gelatinous fluid, and the vocal folds look like enlarged fluid-filled balloons.

Reinke’s edema tends to result in a consistent change in voice quality, including mild to moderate dysphonia characterized by a low pitch and husky hoarseness. This is typically what people refer to as a “smoker’s voice.”

Treatment for Reinke’s edema may vary depending on the severity. The first line of management is for the patient to stop smoking in order to decrease overall inflammation. If Reinke’s edema is so severe that it is blocking part of the airway or causing significant quality of life issues for a patient, surgical management may be necessary. These can be done in the OR or in some cases with a laser in the office. Voice therapy is valuable post-operatively in these cases for the establishment of improved vocal hygiene and improved voice production.

Scarring of the vocal fold means that the mucosa (covering of the vocal fold) is tethered to the underlying tissue and cannot vibrate freely. Vocal fold sulcus is slightly different and means that the good tissue in the Reinke’s space of the vocal folds (or the superficial lamina propria) is missing (or may be filled with scar) and therefore cannot vibrate normally.

Scar/sulcus can occur in many ways. It can result from:

• vocal fold lesions that have been present for a long time and have become fibrous over time and more scarlike in nature
• surgery of the vocal folds which resulted in scarring
• repeated hemorrhaging of the vocal folds
• radiation used to treat head and neck cancer
• other repeated irritation/inflammation/trauma to the vocal folds
• Scar/sulcus can also be congenital

A patient with a scar/sulcus will have irregular vibration of the vocal folds, and will therefore present with hoarseness, breathiness, and increased effort to produce voice. A higher pitched, strained voice quality is often a specific sound related to scar and sulcus. Severity of these symptoms can vary greatly depending on the length and depth of the scar/sulcus, and the way each individual’s vocal folds react to or vibrate around the scar/sulcus.

Repairing a scar/sulcus once it has already occurred is very difficult. There are some surgical options which can occasionally benefit a patient with a scar/sulcus (which can be discussed with your physician). Voice therapy is a good route to try first in order to improve voicing patterns and provide more efficient speaking techniques to aid with quality of life and also to work on exercises to try and soften the scarred area of the vocal fold.

Vascular vocal fold lesions occur due to a traumatic (usually sudden onset) injury to the small blood vessels of the vocal folds. A vocal fold hemorrhage often occurs when a small blood vessel on the top surface of the vocal fold breaks, causing bleeding into the layer under the surface lining of the vocal fold known as Reinke’s space. A varix is a collection of blood capillaries that have hardened over time.

A hemorrhage often causes sudden and significant voice change. For some, however, a hemorrhage may not change the voice significantly.

Varix may not change the voice significantly or at all depending on its placement. Varix on the vibrating edge of the vocal fold will tend to cause more significant hoarseness than one formed elsewhere. For a non-professional voice user, varices are typically not of concern. However, for those who rely on their voice for a living, even a small disruption in normal vocal fold vibration may be significant and require treatment.

The ideal treatment for hemorrhage is one week of strict voice rest, followed by conservative voice use for a bit more time depending on how the vocal folds have healed. Typically, this will allow for spontaneous resolution of the hemorrhage. In most cases, no further treatment will be necessary. In some cases, a vocal fold may continue to hemorrhage due to an engorged/enlarged blood vessel and will call for the need for cauterization of the blood vessel that is continuing to bleed.

Treatment for varix can vary depending on the effect it is having on a patient. Some varices never cause voice issues and do not require treatment. Other varices may cause a hemorrhage to occur or may be interfering with vocal fold closure. In those cases, these varices may also be cauterized by your physician.

Vocal fold cancer, also known as vocal fold carcinoma, is thought to be caused by chronic irritation of the laryngeal epithelium and mucosa by such agents as tobacco, smoke, and alcohol. It may also have other causes like HPV but these are less common. Cancer may also occur in other areas of the larynx external to the true vocal folds, such as the supraglottis or base of tongue.

The main symptom of vocal fold cancer is hoarseness. The severity of dysphonia (hoarseness) can vary depending on the location of the tumor on the vocal fold and the extent of the tumor. Vocal fold cancer does not necessarily cause pain, so it is important to get examined if you are experiencing hoarseness (especially if you have a smoking or heavy alcohol use history).

Whenever a suspicious lesion is identified during a laryngeal exam, a surgical biopsy will likely be conducted to excise tissue samples for histopathological analysis and a definitive diagnosis.

If the presence of malignancy is confirmed, treatment options include surgical excision and in some cases radiation or chemotherapy (or a combination approach). Laryngeal cancer has one of the best rates of successful treatment of any type of cancer and can often be treated with surgery alone if caught in its earlier stages.

Vocal fold nodules are benign (non-cancerous) lesions, typically found bilaterally (on both vocal folds). Vocal fold nodules are most often the result of voice abuse, misuse, or overuse over an extended period of time. The repeated impact on the surface of the vocal folds often results in callous like lesions. Nodules can vary in size greatly, from pin-size to quite large.

The effect nodules have on the voice varies greatly depending on the size of the lesions and how long they have been there for. Nodules typically cause some degree of hoarseness and may cause vocal fatigue (tiredness) or a feeling of vocal strain. In singers, nodules often cause a loss of access to the upper register and/or a husky/heavy quality to the voice.

The first line of treatment for nodules is always voice therapy. Nodules can almost always be remediated with voice therapy, which not only avoids surgery but also teaches better voicing habits in order to avoid the recurrence of nodules. If surgery is performed without initially attempting voice therapy, nodules often quickly recur due to poor voice usage and phonotraumatic voice habits (i.e misuse and abuse of the voice). For a patient who has been fully compliant, has worked with a skilled and specialized voiced therapist, and the nodules still persist, surgery may be warranted.

Essential tremor is a central nervous system disorder that is characterized by rhythmic movements (tremor) of various body parts, which can include the larynx/voice.

Laryngeal tremor is most noticeable during prolonged vowels or sustained voicing because the rhythm of the tremor can be easily detected during these voicing tasks. Connected speech will likely be negatively affected as well, but can often be more difficult to discern.

Unfortunately, there is no easy, consistent treatment for essential vocal tremor. There are various procedural management strategies (from Cymetra injections to Botox injections) that can be attempted in order to decrease a laryngeal tremor, and this may vary from patient to patient. In addition, tremor-based voice therapy may prove helpful in order to re-train speaking patterns to help decrease a listener’s perception of a patient’s tremor and help a patient feel better understood. This will not actually eliminate the tremor but may make a patient feel more confident with his/her voice quality.

Spasmodic dysphonia (SD) is a neurogenic voice disorder that is considered a focal dystonia specific to the larynx. There are two types of spasmodic dysphonia: Adductor and Abductor.

Spasmodic dysphonia can be accompanied by a vocal tremor.

Adductor spasmodic dysphonia (ADSD)

This is the most common type of spasmodic dysphonia and results in a voice that sounds “strained-strangled” with frequent voice breaks that interrupt the continuity of phonation. ADSD tends to affect voiced sounds most often (such as /d/ /a/ /e/). Intermittent periods of normal voicing may occur during speech production, during both laughter and singing, or during angry outbursts. Some patients are able to reduce the frequency and severity of spasms by speaking at a pitch that is higher than normal. The severity of symptoms of ADSD can vary greatly between patients.

Abductor spasmodic dysphonia (ABSD)

This is a virtual “mirror image” of the adductor type. Instead of the vocal folds spasming closed, the vocal folds spasm open creating an involuntary moment of no voice, which is accompanied by a burst of air. Voice onset may appear normal, then the loss of voice ensues with continued speaking. The vocal fold spasms appear to occur primarily during the production of unvoiced consonants (such as /p/, /f/, /s/). Often, patients report that their voices improve when they are angry, when they increase intensity, or when altering pitch. Voice quality tends to worsen when patients are anxious or fatigued.

Spasmodic dysphonia is most commonly treated with Botox. Some patients choose not to treat their SD at all. Voice therapy is typically not beneficial for SD unless patients have developed poor compensatory voicing habits due to their SD. In that case, voice therapy may be beneficial after Botox injections to try and help patients speak as efficiently as possible.

Vocal fold paralysis/paresis is the most commonly found neurogenic (arising from the nerves) voice disorder. Vocal fold paralysis/paresis may be unilateral (one-sided) or bilateral (both sides) and is most commonly caused by nerve involvement of the recurrent laryngeal nerve, or, occasionally (but less commonly) by the superior laryngeal nerve. The location and type of injury along the nerve pathway will determine the type of paralysis/paresis and the resultant voice quality. The difference between paresis and paralysis is the severity of which the nerve is injured (partial = paresis, complete = paralysis).

There are many possible causes of vocal fold paralysis/paresis, including:

• surgical trauma
• cardiovascular disease
• lung disease
• neurological diseases
• idiopathic
  • In fact, about 30 to 35% of vocal fold paresis or paralysis have no known cause/etiology and are considered idiopathic. In many of these cases, patients report that hoarseness began following a viral infection or a slight feeling of illness.

Patients with vocal fold paralysis/paresis often complain of a weak, breathy voice quality with vocal fatigue. They may also complain of physical fatigue with speaking which is the result of the increased effort to produce voice and the loss of air while voicing due to incomplete closure of the vocal folds.

In some cases, patients may present with bilateral vocal fold paralysis and may have additional symptoms depending on where their vocal folds are paralyzed.

Those whose vocal folds are paralyzed in the abducted (open) position will present with essentially no voice or a whisper/breathy quality. They will feel very winded when trying to speak as air is leaking through their vocal folds. Additionally, these patients may have difficulty eating/drinking thin liquids or thinner foods (such as soups) as they tend to aspirate (go down their wind pipe). The vocal folds are supposed to be the first layer of protection for the airway, but a patient with a bilateral vocal fold paralysis in the open position cannot close their vocal folds for protection during swallowing.

Patients with bilateral paralysis in the adducted position (closed position), may present with improved voice quality, but will likely have significant difficulty breathing as they cannot open their vocal folds to take a breath in, depending on the glottic opening (airway size) left from the paralysis. This can be life-threatening and these patients may require a tracheostomy to breathe.

Treatment for unilateral paralysis/paresis can vary greatly, depending on the location of the vocal fold, the extent of the nerve damage, and the effect it is having on the patient’s quality of life. Treatment ranges from voice therapy to temporary surgical management to permanent surgical management. These decisions will be made with you and your voice team.

For both types of bilateral paralysis, surgical management is almost always required to improve the quality of life for the patient.

Parkinson’s disease is a neurodegenerative disorder. Symptoms generally develop slowly over the years. The progression of symptoms is often a bit different from one person to another due to the diversity of the disease. People with PD may experience tremor in various parts of the body (mainly at rest) limb rigidity, gait and balance problems, as well as speech, voice and/or swallowing problems. The cause of PD remains largely unknown. Although there is no cure, treatment options vary and can include medications, surgery, and various therapies. While Parkinson’s Disease itself is not fatal, disease complications can be serious.

An individual with Parkinson’s disease will have a high probability of developing atrophy of the vocal folds (see Vocal fold bowing/atrophy/Presbyphonia) and therefore may experience a weak, breathy, voice quality with decreased ability to project/raise the voice. Additionally, specific to Parkinson’s disease alone, patients often lack the awareness of appropriate volume during speech due to a disruption in the sensory loop feedback from the vocal output back to his/her brain, and will therefore present with a very quiet speaking volume (unrelated to actual vocal fold physiology). People often report that others cannot understand them or cannot hear them.

Treatment for Parkinson’s related dysphonia is almost always successfully treated through a highly specialized voice therapy protocol designed specifically for those with Parkinson’s Disease called Lee Silverman Voice Therapy (LSVT). It is an intensive program that works on both the sensory feedback deficit found in those with Parkinson’s as well as the physiologic deficits of the actual vocal fold and respiratory musculature. In some cases, vocal fold atrophy/bowing may be so severe that some patients may also require surgical management to improve vocal fold closure, but even in those cases LSVT will likely still be required for the sensory feedback portion of dysphonia.

Muscle tension dysphonia (MTD) is described as dysphonia/hoarseness/voice disruption without any physiologic abnormality found the vocal folds. Often, patients with MTD will report periodic pain in the sites of the larynx, neck, and other areas from the neck up. Patients with MTD may report large variability in their voice, from moments of complete normal voice to moments of aphonia (complete voice loss), but there can be patients with MTD who have more moderate dysphonia at all times.

Due to the typically healthy appearance of the patient’s vocal folds in true MTD, voice therapy is always the first choice for treating this disorder and will likely be accompanied by laryngeal/neck massage. In most severe cases, the aid of physical therapy or full body massage specialists and possibly other forms of therapy may be recommended. Medical or surgical management should not be necessary for MTD.

Puberphonia is also known as functional falsetto. The laryngeal mechanism goes through a dramatic change in both males and females during puberty. The male voice lowers about one octave during mutation and the female voice lowers one to three semitones. When this acoustic change does not take place following the normal physical maturation, an individual is said to have puberphonia. This occurs more frequently in males than females but can occur with both. This does not mean that the physiologic change has not taken place, but simply that an individual has functionally not learned how to adapt to the new anatomy.

The voice qualities associated with puberphonia include:

• high pitch
• low volume
• breathiness
• breaks in phonation and frequency
• neck and throat tension

Voice therapy is always the treatment of choice with this disorder. Laryngeal/neck massage will likely accompany voice therapy.