Dysphonia ~ what is it?

The term dysphonia simply means ‘difficulty making voice sounds’. It is not a speech disorder but rather, a problem with the larynx (voice box).

When functioning well, the larynx generates voice by using complex and coordinated control of the vocal folds. The folds then vibrate to create sound as air from the lungs passes across them. Generally speaking, voice disorders can be classified into four main categories: Structural, Neurogenic, Functional and Psychogenic.

Structural: occur due to a physical abnormality in the larynx. These disorders are sometimes self limiting, or able to be treated and restored to function, with or without residual voice issues.

Neurogenic: can be caused by a variety of central nervous system disorders, or by damage or interference with the nerve that supplies the larynx (RLN, recurrent laryngeal nerve).

Functional: are caused by poor muscle functioning, or coordination. Functional voice disorders can occur in isolation or as a result of adaptation to physical changes, neurological conditions, faulty technique, or psychological factors.

Psychogenic: some people experience voice loss as a result of a traumatic experience or other psychological trauma. These conditions can best be managed with appropriate counselling and support.

Depending on the underlying cause, voice disorders may be managed medically or through vocal retraining with a speech pathologist; or commonly by a combination of both. Other health professionals may also be helpful in improving vocal function.

Dysphonia can have an impact psychological wellbeing so it is important to seek support. This can come from a psychologist, counsellor, close family or friend , or from members of the Australian Dysphonia Network who understand what it is like to live with a voice disorder. You can contact us using our Contact Form, follow us on facebook, or join ‘Dysphonia- lets talk about it‘ the closed discussion group on facebook.

The following is a list of voice disorders by category. It is not exhaustive, but gives an indication of the wide range of conditions that are associated with dysphonia. (Information on each condition will be added in the near future).

Structural Voice Disorders include: Nodules, Laryngitis, Haemorrhage, Cysts, Ulcers, Granuloma, Trauma, Polyps, Papilloma, Cancer of the larynx.

Neurogenic Voice Disorders include:  Benign Essential Tremor, Vocal Fold Paresis or Paralysis, Spasmodic Dysphonia  also known as  Laryngeal Dystonia, Myasthenia Gravis, Multiple Sclerosis, Parkinsons Disease.

Functional Voice Disorders include:   Muscle Tension Dysphonia, Puberphonia,  Conversion Disorder

You can download our simple Intro to dysphonia brochure here.

If you are wondering whether you have a voice disorder, take a look at Do you have a voice disorder ? a brief checklist provided by Sydney based Speech Pathologist, Judith Rough.

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Vocal Nodules

Nodules are benign (noncancerous) growths on the vocal folds (cords) that are most commonly caused by voice misuse / overuse, poor vocal habits, and can also be related to  other conditions including gastro-oesophageal reflux disease.

Nodules develop as soft, swollen spots on each vocal fold, and over time, these spots develop into harder callous-like growths known as nodules.

Nodules result in symptoms such as hoarseness, breathiness, or harshness when talking and the voice can sound ‘rough’ or ‘scratchy’. They may also lead to a decrease in vocal range and volume, and cause the voice to tire easily when talking. Nodules can be diagnosed by an Otolaryngologist  (ENT) who specialises in voice disorders or a speech pathologist.

Treatment for nodules is always behavioural but can be medical or surgical, depending on the severity of vocal fold damage and the cause of the nodules.

Polyps

Vocal polyps can take a number of forms and can appear on either one or both of the vocal folds. They can appear as a swelling or bump (similar to a nodule), a stalk-like swelling, or a blister-like lesion. Polyps are larger than nodules and can be thought of like a blister, compared to a nodule, which would be thought of like a callous.

Vocal polyps have similar symptoms to nodules, and are also often the result of poor voice use. However, unlike nodules, polyps may occur after a single, traumatic event to the voice, such as yelling at a concert  OR after long-term chronic misuse. Other common causes of polyps include long-term cigarette smoking, hypothyroidism and chronic reflux.

Like nodules, treatment for polyps depends on the severity of vocal fold damage, their size and cause, it may involve medical, surgical or behavioural management.

Laryngitis

Laryngitis occurs when the larynx (voice box) becomes inflamed and vocal folds (cords) become swollen and cannot vibrate properly.

Common causes of laryngitis include:  viral infection (such as a cold or flu), bacterial infection (although this is less common) and overuse or strain, caused by yelling, or long periods of talking or singing. Chronic laryngitis can also be caused by smoking or excessive alcohol use, exposure to irritants such as fumes, dust and chemicals, reflux or repeated overuse of your voice.

Laryngitis is considered chronic or long term when it lasts for more than three weeks. Symptoms include: sounding hoarse or losing your voice. Normally you will recover from laryngitis without any treatment, however vocal rest is advised to avoid permanent damage.

Vocal Fold (cord) Haemorrhage

Haemorrhage occurs when a blood vessel breaks, leading to collection of blood within the layers of the vocal folds, (more or less like bruises of the vocal fold), however haemorrhage can cause long term damage if not evaluated and managed properly.

Vocal haemorrhage typically presents with symptoms like a sudden change in the sound or quality of the voice, hoarseness, a rough voice and vocal fatigue (voice tires easily with use).

Common causes of vocal fold haemorrhages include an intense and traumatic voice event such as screaming yelling or singing loudly, coughing excessively and voice overuse or misuse. Diagnosis of vocal haemorrhage can be completed by a specialist Otolaryngologist during examination using laryngoscopy +/- stroboscopy. This is particularly important for singers and frequent voice users to prevent further damage.

A vocal fold haemorrhage is treated with voice rest and can worsen if the voice is continually used, potentially causing irreversible vocal fold scarring.

Vocal Fold Cysts

Vocal­fold cysts differ from vocal nodules, but the two can be confused. Cysts are less common than nodules and they typically affect only one vocal fold

Vocal cysts lie within the tissue of the vocal fold and are lined either by mucous membrane or by skin, therefore they contain mucus or keratin. Cysts frequently occur as a result of vocal trauma but unlike nodules, they do not respond well to voice therapy so surgery is generally the most appropriate treatment.

Contact Ulcers and Granulomas

Vocal fold ulcers (also known as contact granuloma), are raw and often raised areas on the lining of the vocal folds. They usually occur at the back of the vocal fold where the vocal ligament meets is attached to the cartilage.

Vocal fold ulcers can be the result of vocal abuse and trauma caused by forceful speech or prolonged periods of increased pressure on the vocal cords during speech. Reflux of stomach contents (laryngopharyngeal reflux) can also be a contributing factor in the development of contact ulcers. Some ulcers can develop after instrumentation of the larynx for example after anaesthetic intubation.

Signs and symptoms of ulcers include throat pain while speaking or swallowing, voice fatigue and varying degrees of hoarseness.

Diagnosis normally involves a direct inspection of the vocal folds through endoscopy and occasionally a biopsy sample is taken so that the ulcer can be examined for cancerous cells.

Treatment varies depending on the cause of the ulcer, but If GORD is a factor, anti-reflux treatments will be necessary.

If forceful voice misuse is the primary cause, voice therapy is recommended to reduce forceful contact on the ulcerated area. Surgery is an option to remove ulcers, however this is generally considered a last resort as there is a high recurrence rate if the underlying factors are not addressed.

At times, antibiotics are also administered to prevent bacterial infections while the ulcers / granuloma are healing.

Laryngeal Trauma 

Laryngeal trauma describes damage to the larynx and vocal folds. Laryngeal trauma has many causes including, but not limited to, accidents, surgical damage, medically induced lesions and functional lesions. Some laryngeal trauma can be caused by excessive and improper use of the voice.

As laryngeal trauma has many causes, there are many management strategies and this needs to be based on source problem. Treatment options include drug therapy, voice re-education and surgery.

Papilloma

Vocal papillomas are growths that occur in the airway, most commonly on the vocal folds (cords). They are generally noncancerous tumors caused by the human papilloma virus (HPV). Because of their most common position on the vocal cords (the entry to the lungs), they can go on to cause airway obstruction, voice change and breathing difficulty.

Papilloma are generally treated by surgical removal to restore voice and breathing. In some cases papillomas can spread into the lungs causing further difficulties.

Cancer of the Larynx

Persistent dysphonia (with or without difficulty swallowing), pain on swallowing, referred pain in the ear or the presence of a lump in the neck, may indicate the presence of laryngeal cancer; especially in smokers. Red flag signs include coughing up blood, ear pain, difficulty breathing or swallowing especially with a history of smoking. Any persistent hoarseness beyond a few weeks  in a current or former smoker should be further investigated by visualisation of the larynx.

Expert assessment should be undertaken as a matter of urgency. Treatment options vary, and include laser surgery and radiotherapy both of which can be very successful for some cancer types.

Essential Tremor

Essential tremor (previously referred to as benign essential tremor), is a movement disorder which involves a tremor of the arms, hands or fingers and sometimes also involves the head, vocal folds or other body parts during voluntary movements suchas eating and writing.

When the voice is affected, the tremor causes it to sound shaky and unstable impacting on a person’s ability to communicate confidently with others.

Essential tremor is commonly described as an action tremor (ie the tremor intensifies when attempting to use the affected muscles)

The cause of Essential Tremor is unknown, and it is often misdiagnosed as Parkinson’s disease, although these conditions can co-occur.

Symptoms of Essential Tremor affecting the voice include poor voice quality i.e. the voice sounds ‘old’, vocal weakness, low volume, vocal fatigue and embarrassment.

Not everyone diagnosed with Essential Tremor will require treatment, however there are many treatment options depending on the severity of symptoms. These options include medication, botulinum toxin, deep brain stimulation and voice therapy. High intensity focused ultrasound is also a treatment option that is gaining popularity. Lifestyle strategies that can help manage symptoms include avoiding caffeine and stress and getting adequate sleep.

Vocal Fold Paralysis or Paresis 

Effective vocal fold movement is required to create fluent voice sounds. These movements are the result of a sequence of finely co­ordinated muscle contractions which are are controlled by the superior and the recurrent laryngeal branches of the vagus nerve.

Damage to either of these nerves can lead to a weakening of the related muscle resulting in a weak and breathy voice. However, the most common cause of damage to the nerves supplying the larynx is idiopathic which is thought to be related to post-viral inflammation.

Nerve injury can be the result of inadvertent damage during neck surgery, particularly surgery on the thyroid gland, carotid artery or cervical spine. Occasionally surgery in the chest (the lungs, heart, oesophagus) can result in recurrent laryngeal nerve paralysis or paresis. Injury to the recurrent laryngeal nerve, is also a noted complication of endotracheal incubation and may be permanent or temporary

It is important to exclude more sinister causes of nerve damage such as a tumour at the base of the skull, neck or chest. For this reason imaging of these regions with CT scan or MRI is often performed.

 

Spasmodic Dysphonia (Laryngeal Dystonia)

Spasmodic Dysphonia (SD) is a focal form of dystonia – (meaning that it targets one set of muscle at any one time). It is a neurological condition that causes ‘spasms’ of the larynx which lead to interruptions in fluent speech. These interruptions (or voice breaks) are frequently misunderstood which can result in delayed diagnosis.

SD can cause the voice to break up, be breathy or to have a tight strangled quality. Either way communication can be tiring and frustrating.

Current best practice treatment of SD is Botulinum toxin injections into the affected laryngeal muscle approximately 3-4 monthly.

Myasthenia Gravis 

Myasthenia Gravis is a chronic neuromuscular autoimmune disease which causes muscle weakness and fatigue. It can affect any part of the body but most commonly the eyes, the mouth, the throat and the limbs. Swallowing is also commonly affected by the disease.

When Myasthenia Gravis impacts on the voice, symptoms may include breathiness, monotone and mono-loudness, vocal fatigue while speaking, and vocal recovery with rest .

There are a range of treatment for Myasthenia Gravis, however as fatigue is an associated symptom that affects both gross motor movements and voice production, oral medications that reduce fatigue are considered helpful.  More  Detailed information on MG can be found HERE .

 

Multiple Sclerosis

Multiple Sclerosis is a chronic neurological disease characterised by episodes of dysfunction of the nervous system that come and go over several decades. Commonly, long periods of normal function occur in between these episodes. (For more detailed information go to Multiple Sclerosis Australia.

Speech and voice problems are common symptoms of Multiple Sclerosis. Speech problems include dysarthria (difficulty using muscles to form words) and dysphonia including hoarseness and poor volume and pitch control. Many people find speech therapy beneficial.

 

Parkinsons Disease

Parkinson’s Disease is a degenerative disorder of the central nervous system. It causes a range of symptoms affecting many aspects of life (for more detailed information  visit www.parkinsons.org.au. )

Specific Voice symptoms can include: breathiness, mono-pitch, mono-loudness, difficulty initiating speech and short, fast rushes of speech.

People with Parkinson’s Disease who have voice disorders typically benefit from voice therapy, in particular a program known as Lee Silverman voice Treatment (LSVT). This therapy is specifically targeted at those with Parkinson’s Disease and focuses on intensive, high effort speech exercises and increasing vocal loudness in a functional way. Those seeking LSVT should ensure their voice specialist has obtained specific training in this area.

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