Symptoms of a Voice Disorder
Many patients suffering from a Voice Disorder experience the following symptoms: shortness of breath, cronic hoarseness or raspiness, frequent urge to cough or throat clearing, loss of vocal range, heartburn, vocal fatigue, loss of control or projection, acidic taste in the mouth and/or voice cuts out for no reason.
Hoarseness refers to any abnormal voice (also known as dysphonia), but all hoarse voices do not sound alike. Characteristics that can be seen in some hoarse voices include: breathiness (as in the classic Marilyn Monroe voice), roughness, decreased loudness, inability to project the voice, strain, or the complete lack of a voice (aphonia). Many of these terms are subjective and can be caused by many different conditions, including the ones described below.
Laryngitis refers to inflammation of the vocal cords and the area around them. Laryngitis can produce a rough voice, decreased loudness, and even aphonia (see above). The inflammation can have many different causes, including allergies, environmental irritants, a cold, the flu, bronchitis, sinusitis, and other respiratory infection.
Laryngopharyngeal Acid Reflux (LPR)
LPR is caused by stomach acid coming up from the esophagous and irritating the larynx and pharynx. This condition is different from gastroesophageal reflux disease (GERD). In GERD, the acid causes inflammation of the esophageal lining, and the main symptom is heartburn. In LPR, the acid produces inflammation of the lining of the larynx and pharynx. Common symptoms in LPR include a dry cough, frequent throat clearing, and a feeling that something is stuck in the throat. However, heartburn is often not seen in LPR, because the esophageal lining is much tougher than the laryngeal or pharyngeal lining; therefore it is easier for the acid to inflame the larynx and pharynx without irritating the esophagous. Heartburn is usually not seen unless the lining of the esophagous or stomach is inflamed. This condition is usually treated with lifestyle and dietary modifications and with medication.
MTP refers to an abnormal speaking pattern, resulting in the improper use of the muscles of the voice box. MTP may be the primary problem causing the voice disorder (often called muscle tension dysphonia or MTD), or it may be present as a result of another problem. The symptoms of MTP include soreness of the muscles around the larynx and a voice that fatigues easily.
Recurrent Respiratory Papillomatosis (RRP)
(RRP) is a disease in which tumors grow inside the larynx, vocal cords and trachea. It affects both children and adults and is caused by the Human Papilloma Virus (HPV). Depending on the location and extent of the disease, RRP will present with hoarseness and/or shortness of breath.
Spasmodic dysphonia is a voice disorder caused by involuntary movements of one or more muscles of the larynx or voice box. Individuals who have spasmodic dysphonia may have occasional difficulty saying a word or two, or they may experience significant difficulty in communication. Although stress does not cause this disease, it can make the voice worse. In the early stages of the disease, many patients find that singing is easier than talking. There are two types of spasmodic dysphonia (SD). The more common is adductor SD; here the vocal cords squeeze together too much, making it difficult for a person to “get words out” and causing a strained voice. In the other type, abductor spasmodic dysphonia, the voice becomes very breathy when a patient attempts to pronounce certain consonants such as “k.”
When vocal cord paralysis occurs on one side only, the paralyzed cord will shift away from midline. One treatment (see vocal cord paralysis section) is to “push” the cord back to midline by injecting a substance in the vocal cord itself. In the past, Teflon has been used for this purpose, and it has the advantage of being a relatively permanent material. However, one major disadvantage is that an inflammatory reaction can occur around the Teflon, forming a mass of very firm tissue known as a Teflon granuloma. This granuloma can prevent the vocal fold from vibrating, thus impairing voice; it can also be large enough to cause airway obstruction and breathing difficulties. Treatment for symptomatic granulomas is usually surgical removal. Presently, Teflon is only used for some uncommon and very specific indications. Injectables that are currently available work well but are only temporary (lasting approximately 3-12 months depending on the substance).
Vocal Cord Cancer
The majority of cancers in this area originate from squamous cells that normally are located in the mucosal lining of the cord. The earliest symptom is usually hoarseness, which is one reason why we recommend that you be evaluated by an otolaryngologist, if you have hoarseness lasting greater than 3 weeks. Risk factors for this cancer include smoking and alcohol use. There also may be an association with Human Papilloma Virus (HPV). For early, less severe, vocal cord cancers, either surgery or radiation are very successful in curing this disease. More advanced cases usually require both surgery and radiation and sometimes chemotherapy.
Vocal Cord Granuloma
A granuloma is a particular type of laryngeal lesion that represents the body’s response to chronic irriation or trauma. This is usually seen after prolonged intubation and is made worse by stomach acid.
Vocal Cord Nodule
Vocal cord nodules are a nodule or mass of tissue that grow on both vocal folds (vocal cords). They are similar to calluses and are usually the result of talking loudly or in a noisy environment. These are usually treated with voice therapy.
Vocal Cord Paralysis
Vocal cord paralysis is a voice disorder that occurs when one (unilateral) or both (bilateral) of the vocal cords do not move. Normally, our vocal cords move apart when we breathe and together when we talk. In unilateral paralysis, the paralyzed cord is usually in a position such that the normal cord cannot meet it during speech. This produces a gap between the cords and can cause symptoms such as a breathy voice, decreased loudness and vocal fatigue. Treatment includes temporarily or permanently moving the paralyzed vocal cord to midline. Reinnervation, when another nerve is attached to the paralyzed nerve, can also give good results under certain conditions. In bilateral paralysis, both vocal cords are at the midline position and they cannot move apart during breathing. This usually produces airway obstruction, and the voice is much less affected. There are a variety of surgical procedures designed to treat bilateral vocal cord paralysis.
Vocal Cord Polyp
Vocal cord polyps represent benign lesions that may have a variety of appearances. Polyps may be single or multiple, involve one cord or both, and may be big or small. These cause a hoarse voice and are usually treated with a combination of voice therapy and surgery.
Professional and Occupational Voice Users
Voice coaching and lessons can assist professional and occupational voice users. UCNI includes a vocologist who can work one-on-one with patients to provide the best possible results for improved voice quality.
Professional and occupational voice users are defined as individuals who use their voices daily as an essential part of their job. Such occupations range from professional performers (singers, actors, actresses and broadcast personalities) to public speakers and care providers (teachers, clergy, salespeople, courtroom attorneys, telemarketers, physicians, nurses and receptionists). UCNI has a dedicated team of professionals available to assist these professionals to help them achieve their highest vocal quality potential.
Diagnostic Testing and Treatment for Voice Disorders
Flexible Fiberoptic Laryngoscopy
Flexible fiberoptic laryngoscopy is the most common type of examination used to visualize the areas of the throat and voice box. The exam uses a thin, flexible endoscope containing fiberoptic cable that can be manipulated to examine areas not normally seen by traditional examination techniques. The endoscope is inserted through the nose and passed into the throat under direct visualization. Most patients tolerate this examination without much difficulty.
Laryngeal Electromyography (LEMG)
Laryngeal electromyography (LEMG) is a test that gives information about the motor activity within the tiny muscles that control the vocal cords. This information is not available by any other test. This activity is important because it has implications for diagnosis and for predicting recovery of function. Diagnostically, LEMG is essential in determining the neuromuscular status of the vocal cords. Subtle weakness in the vocal cords may not be seen on endoscopic examination and may only be evident after an LEMG is performed. In cases of vocal cord motion impairment, LEMG can effectively distinguish vocal cord paralysis from impairment caused by scarring.
Laryngeal Sensory Testing
Sensory testing involves administration of a discrete pulse of air via a port, or opening, in a transnasally placed, thin, flexible endoscope, in order to elicit an airway protective reflex. Decreased or absent sensation can cause aspiration (food to go into the trachea instead of the esophagous).
Rigid Transoral Laryngoscopy
Rigid transoral laryngoscopy is one type of examination used to visualize the voice box. The examination utilizes a rigid endoscope (device used to examine internal structures) to visualize the vocal cords. The endoscope is inserted into the back of the mouth; it has an angled lens, which allows the physician to look down at the vocal cords. This examination results in a magnified view of the vocal cords with high image quality. It is best for studying abnormal growths on the vocal cords. Without stroboscopy, this technique cannot evaluate the vocal cord vibrations.
Speech therapy is often prescribed for patients with certain voice disorders. It is a form of treatment in which a therapist analyzes the way a patient uses his or her voice and attempts to correct abnormal speech patterns through vocal exercises. These abnormal patterns promote worsening or prevent resolution of certain conditions that may affect the voice. Elimination of these may help to cure the disorder.
This is similar to rigid transoral laryngoscopy, except that a strobe light is used instead of a constant light. This allows evaluation of the vibrations of the vocal cords during phonation. Stroboscopy should be done in most patients with hoarseness.
A voice evaluation involves a series of tests designed to analyze the voice and help determine what is wrong. The voice evaluation is designed around the patient’s problem and may last only a few minutes. Evaluations for complex voice disorders can last an hour, especially if the voice therapist is evaluating the patient for different forms of therapy.
Vocal Cord Cancer Evaluation
This involves a careful history and a head and neck exam. Evaluation of the vocal cords is usually done by flexible fiberoptic laryngoscopy or by rigid transoral laryngoscopy. The addition of stroboscopy can be helpful, depending on the location and extent of the disease. This evaluation can identify masses or lesions suspicious for vocal cord cancer. However, a biopsy is needed to definitively diagnose this condition.