A wide variety of disorders can lead to vocal difficulty, a raspy or unstable voice, and hoarseness. If you have been experiencing any of these issues for more than two weeks, it is important to schedule an appointment with an ear, nose, and throat doctor or speech pathologist to get to the bottom of the problem. The multidisciplinary team at the Penn Medicine Becker ENT & Allergy Center can diagnose voice disorders using videostroboscopy, a minimally-invasive test that uses a tiny camera to look at the back of the throat and deeper nasal structures and create a personalized treatment plan to address any underlying issues that come up.
What Are the Symptoms of a Voice Disorder?
An individual experiencing a voice disorder may have a voice quality with one or more of the following features:
- Rough, raspy, or husky (hoarse)
- Strained, choppy, with breaks
- Weak, breathy, or whispery
- Too high or too low in pitch
- Significantly altered pitch from what is their norm
Other symptoms may include:
- The inability to project/yell
- Tension or pain in your throat/neck when you speak
- Feeling that your throat/larynx gets tired after use
- Feeling of a “lump” in the throat with speaking or swallowing (or at rest)
- Pain or discomfort on the outside of the throat or neck by a gentle touch
- Loss of singing ability
- Burning in the throat with or without use
- Feeling short of breath while speaking/running out of air while talking
These are just some of the symptoms of a voice disorder. If you have been experiencing one or more of the above symptoms for more than 2 weeks, it is recommended that you make an appointment for an evaluation with our New Jersey and Philadelphia ENT doctors
How Is a Voice Disorder Diagnosed?
If you have been experiencing one or more of the above symptoms that have been ongoing for 2 or more weeks, you should see a specialist for a thorough voice evaluation. A specialist may include an Otolaryngologist (Ear Nose and Throat doctor) or a speech-language Pathologist who specializes in Voice Disorders (often also called a Voice Pathologist). The specialist will ask about your symptoms and other medical history and should examine your vocal folds and larynx using one or more of the following tests:
Videostroboscopy: This is a test that can visualize your larynx using a camera called an endoscope. There are two types of endoscopes: flexible endoscope and rigid endoscope. A flexible endoscope is a small skinny camera that looks up through your nose and hangs over the back of your throat to view your larynx. It does not hurt and only takes one or two minutes to perform the test. Your examiner will give you some numbing medication for maximum comfort. A rigid endoscope is a firmer but still small camera that looks into your mouth and peers over the back of your tongue to look down at your larynx via your mouth and a mirror inside the camera. It does not go down your throat and also does not hurt. Both endoscopes use light sources called a strobe light that allows the examiner to view the vocal folds vibrating in slow motion. This strobe light is very important for proper diagnosis and you should ensure your examiner is using this type of test.
- Imaging tests: X-rays, CT scans, MRIs, and EMGs can show growths, other tissue problems, or nerve issues in the throat. If your examiner/physician feels this test is necessary for your voice complaint, he/she may send you for one in addition to the videostroboscopic examination.
How Is a Voice Disorder Treated?
For a voice disorder, treatments depend on what the root cause is. Treatment may include:
- Lifestyle changes. Some lifestyle changes may help reduce or stop symptoms. These can include not yelling or speaking as loudly, and resting your voice regularly if you speak or sing excessively. Many voice disorders are caused by misuse/overuse of the voice and these lifestyle changes can eliminate these if caught early enough.
- Voice therapy (also called Speech Therapy). Working with a speech-language pathologist (who specializes in voice) can help with many voice disorders. Voice therapy is essentially like physical therapy for your vocal cord muscles. Therapy will include some sort of combination of physical exercises as well as instruction to change maladaptive speaking (or singing) patterns if applicable.
- Medications. Some voice disorders, depending on the etiology, may be improved with medication. For example, antacid medication may be used for laryngopharyngeal reflux; or nasal sprays/allergy medication for allergies affecting your voice.
- Injections. For some voice disorders, botulinum toxin injections are appropriate and in some cases, fat or other fillers can be injected into the vocal folds. These are very specific treatments for specific voice disorders. It is important to have a thorough evaluation and proper diagnosis before embarking on this treatment.
- Surgery. Vocal fold surgery may be used to restore laryngeal function, as is often in the case of vocal fold paralysis, a large vocal fold polyp, or vocal fold cyst. For some procedures, a patient can remain comfortably awake in the office instead of under general anesthesia in the operating room. If growths are caused by cancer, other treatments, such as radiation therapy, may be needed.
Voice Disorders We Treat at Penn Medicine Becker ENT & Allergy
Structural Changes of the Vocal Folds
Vocal Fold Bowing/Presbylarynges
- 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
- 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.
Laryngitis: Acute and Chronic
- repeated episodes of acute laryngitis
- vocal misuse/overuse/abuse
- poor hydration/vocal hygiene
- air pollutants
- dehydrating medications
- gastroesophageal reflux disease/laryngopharyngeal reflux disease (also known as acid reflux)
- repeated vomiting
Leukoplakia and Hyperkeratosis
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.
Scar and Sulcus Vocalis
- 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
Vascular Lesions: Vocal Fold Hemorrhage and Varices
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
Vocal Fold Nodules
Neurogenic Voice Disorders
Organic (Essential) Vocal Tremor
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
There are many possible causes of vocal fold paralysis/paresis, including:
- surgical trauma
- cardiovascular disease
- lung disease
- neurological diseases
- 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-Related Dysphonia
Other Voice Disorders
Muscle Tension Dysphonia
- high pitch
- low volume
- breaks in phonation and frequency
- neck and throat tension
Upper Airway Disorders
- Shortness of breath
- Feeling of throat tightness
- Frequent coughing
- Noisy breathing called “stridor” which sounds like whistling
- Strenuous breathing which is often more effortful during inhalation