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Voice Disorders

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 laryngoscopy and/or video stroboscopy, 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.

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Table of Contents

What Are the Symptoms of a Voice Disorder?
How Is a Voice Disorder Diagnosed?
How Is a Voice Disorder Treated?
Voice Disorders We Evaluate at Penn Medicine Becker ENT & Allergy
Frequently Asked Questions about Voice Disorders

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
Tremulous/unstable
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

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) — Recognizing Voice Disorders: Common Symptoms and Signs

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 may examine your vocal folds and larynx using one or more of the following tests:

Videostroboscopy

The test utilizes an endoscope to visualize the larynx. There are two types of endoscopes: flexible endoscope and rigid endoscope.

Flexible Endoscope

A flexible endoscope is a medical device used to visualize the larynx by inserting a small camera through the nose and positioning it at the back of the throat. It does not hurt and only takes a few minutes to perform the test. Your examiner will give you some numbing medication for maximum comfort.

Rigid Endoscope

A rigid endoscope is a small camera that is used to examine the larynx by being inserted into the mouth and peering over the back of the tongue. It does not go down your throat and also does not hurt. Both endoscopes use light sources called 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

Medical imaging techniques such as X-rays, CT scans, MRIs, and EMGs can detect growths, tissue abnormalities, or nerve conditions 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 video stroboscopic examination.

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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)

Collaborating with a speech-language pathologist who specializes in voice can be beneficial for individuals with 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 is a potential treatment option for restoring laryngeal function in cases such as vocal fold paralysis, large vocal fold polyps, or vocal fold cysts. For some procedures, a patient can remain comfortably awake in the office instead of under general anesthesia in the operating room. If growths are cancerous, other treatments like radiation therapy may be necessary.

Voice Disorders We Evaluate at Penn Medicine Becker ENT & Allergy

Structural Changes of the Vocal Folds

Vocal Fold Bowing/Presbylarynges

What is vocal fold bowing?

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

What are the symptoms of vocal fold bowing?

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.

How is vocal fold bowing treated?

Treatment for vocal fold bowing/presbylaryngis most commonly involves 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

What are cysts?

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.

What are the symptoms of cysts?

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

How are cysts treated?

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.

Granuloma/Contact Ulcer

What is a granuloma/contact ulcer?

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).

Laryngeal Papillomatosis

What is laryngeal papillomatosis?

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).

What causes laryngeal papillomatosis?

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

How is granuloma treated?

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: Acute and Chronic

What is acute laryngitis?

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.

What causes acute laryngitis?

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

How is acute laryngitis treated?

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.

What is chronic laryngitis?

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

How is chronic laryngitis treated?

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 and Hyperkeratosis

What is Leukoplakia?

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.

Polyps

What is a polyp?

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). One cause of vocal fold polyps is trauma to the vocal folds (i.e. misuse/abuse of the voice).

What are the symptoms of polyps?

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).

How are polyps treated?

Depending on the type and size of the polyps, treatment may vary. Some 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

What is Reinke’s edema?

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.

What are the symptoms of Reinke’s edema?

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.”

How is Reinke’s edema treated?

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.

Scar and Sulcus Vocalis

What is a scar/sulcus?

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.

What are the symptoms of a scar/sulcus?

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.

How is a scar/sulcus treated?

Repairing a scar/sulcus once it has already occurred may be 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 Lesions: Vocal Fold Hemorrhage and Varices

What are vascular lesions?

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.

Vocal Fold Cancer

What causes vocal fold cancer?

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.

What are the symptoms of vocal fold cancer?

One common 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).

How is vocal fold cancer diagnosed?

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

How is vocal fold cancer treated?

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 a relatively high rate of successful treatment and can often be treated with surgery alone if caught in its earlier stages. It is important to try to obtain early diagnosis and treatment when possible.

Vocal Fold Nodules

What are vocal fold nodules?

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.

How are vocal fold nodules treated?

The first line of treatment for nodules is often voice therapy. Nodules can often 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 may 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.

Neurogenic Voice Disorders

Organic (Essential) Vocal Tremor

What is essential vocal tremor?

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.

What are the symptoms of essential vocal tremor?

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.

How is a vocal tremor treated?

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

How is Spasmodic Dysphonia treated?

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

What is vocal fold paralysis/paresis?

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).

Parkinson’s Disease-Related Dysphonia

What is Parkinson’s disease?

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.

What are the symptoms of Parkinson’s related dysphonia (Hoarseness)?

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.

How is Parkinson’s related dysphonia treated?

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.

Other Voice Disorders

Muscle Tension Dysphonia

What are the symptoms of muscle tension 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.

How is muscle tension dysphonia treated?

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 massage specialists and possibly other forms of therapy may be recommended. Medical or surgical management should not be necessary for MTD.

Puberphonia

Upper Airway Disorders

What is an upper airway disorder?

An upper airway disorder is described as a difficulty breathing due to a functional or physiologic problem with the glottis/upper trachea. This would not include problems with the lungs or lower bronchial tubes.

What are the symptoms of an upper airway disorder?

Some symptoms associated with upper airway blockage include hoarseness (dysphonia), shortness of breath, feeling of throat tightness, frequent coughing, and/or noisy breathing called “stridor” which sounds like whistling. Strenuous breathing which is often more effortful during inhalation is also common.

What is Paradoxical Vocal Fold Motion?

Paradoxical Vocal Fold Motion (PVFM), also known as vocal cord or vocal fold dysfunction or laryngospasms, is marked by inappropriate closure (adduction) of the vocal folds during breathing.

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Frequently Asked Questions about Voice Disorders

What causes voice disorders?

Voice disorders can be caused by a variety of conditions affecting the “voice box” (larynx), such as vocal nodules or polyps, cysts, lesions on the vocal folds or larynx, trauma to the larynx from intubation during surgery, or nerve damage. Vocal nodules are calluses on the vocal cords that can cause hoarseness and other changes to your voice. Nodules occur when excess strain is placed on the vocal cords, such as from shouting, speaking for long periods of time without rest, and incorrect singing technique.

What is the treatment of voice disorder?

The treatment of voice disorder depends on the underlying cause. Treatment options can include surgical treatment, medical management for underlying conditions, voice therapy to improve vocal technique and increase vocal range, and lifestyle changes to reduce strain on the vocal cords, such as avoiding smoking or drinking alcoholic beverages. Voice therapy can help with developing proper vocal techniques and increasing vocal range while reducing strain on the vocal cords. Lifestyle changes are important to reduce stress placed on the larynx. If there is an underlying medical condition causing the disorder, treating the condition may resolve any associated voice issues.

Which medicine is best for voice?

The best medicine for voice disorders depends on the underlying cause. In many cases, voice therapy is the best option. A voice specialist can assess your health condition and recommend an individualized treatment plan to improve vocal technique, increase vocal range, and reduce strain on the vocal cords. Voice therapy may include a combination of speaking and singing exercises tailored to meet each individual’s needs. Additionally, lifestyle changes such as avoiding smoking and dietary changes to reduce relux can help reduce stress placed on the larynx. If there is an underlying medical condition causing the disorder, treating the condition may resolve any associated voice issues.

Can voice disorders be cured?

Voice disorders can be cured with the help of muscle relaxation techniques, speech-language pathology treatment, and voice therapy techniques. Depending on the underlying cause of the disorder, various treatments may be necessary, including anti-inflammatory medication, vocal hygiene strategies to reduce vocal abuse, and exercises to reduce muscle spasms in the larynx. Voice therapy is often recommended to improve vocal technique and increase vocal range while reducing strain on the vocal cords. With proper treatment, many individuals are able to recover from their voice disorder.

How can I do voice therapy at home?

Voice therapy at home can be done with vocal cord movement exercises, such as humming or lip trills. Additionally, practice vocals range of pitches and tones without straining the voice. It is important to consult with a throat specialist before starting exercises at home to ensure that they are safe for you and tailored to your individual needs. It is best to work with a qualified voice therapist who can provide customized instruction and management options to help you improve your vocal technique and reduce strain on the vocal cords.

Who needs voice therapy?

Voice therapy techniques are exercises used to improve vocal technique and increase vocal range while reducing strain on the vocal cords. These techniques may be necessary for individuals with vocal cord paralysis, vocal cord dysfunction, or a neurological disorder. Speech-language pathology treatment is often recommended to help these individuals improve their speech and communication skills. Voice therapy exercises may include humming or lip trills, practicing vocal range of pitches and tones without straining the voice, proper breathing techniques, and relaxation exercises.

What are voice therapy techniques?

Voice therapy techniques are exercises used to help people with voice disorders improve their vocal technique and increase vocal range while reducing strain on the vocal cords. Symptomatic voice therapy involves a variety of speech-language pathology treatment strategies such as vocal warm-ups, breath control, pitch and volume control, resonance exercises, posture and body awareness exercises, articulation exercises, relaxation practices, and vocal hygiene instructions such as avoiding speaking while tired or hoarse. Additionally, voice therapists may provide advice on proper nutrition for laryngeal health and lifestyle modifications to reduce stress placed on the larynx.

What additional precautions can be implemented to protect one’s voice?

To protect your voice, it is important to avoid smoking and practice vocal behavior that does not strain or overuse the vocal cords. Additionally, it is important to seek regular health care from providers who specialize in vocal health and can help diagnose any problems with the larynx. Speech-language pathologists can also provide additional advice and guidance on lifestyle modifications such as avoiding talking when tired or hoarse, maintaining a healthy diet and drinking plenty of water, and taking vocal rest days when necessary.