Voice Disorders

A voice disorder occurs when a medical condition (caused by vocal abuse or miscellaneous pathologies) disturbs the normal functioning of one's production of speech. There are numerous ways in which a voice disorder can present. Many voice disorders are quite common; so much so, that one may not even realize they have this condition. Others are very rare and less commonly seen by most clinicians in the field of speech and language. Some common voice disorders include cysts, vocal nodules or polyps, cancers, gastroesophageal reflux disease (GERD), spasmodic dysphonia and other forms of vocal cord paralysis. Voice disorders impact various parts of the larynx (commonly referred to as our “voice box”), particularly our vocal cords. The human vocal mechanism contains two vocal cords that form a “V” shape when they are open as we breathe, and also come together, parallel to and approximating one another when we speak. They vibrate against one another, as air from our lungs passes through the cords, into the pharynx, finally producing sound when we use our voice.

Temporary hoarseness may be caused by bacteria or viruses. The resulting laryngitis is usually treated with antibiotics (if it is bacterial), vocal rest and lots of fluids. Interestingly, the hoarseness and a feeling of fullness in the throat may be the only symptoms of the infection.

Cysts are fluid-filled sacs that form on the vocal cords, typically caused by vocally abusive behaviors, such as prolonged yelling, or can also be caused by trauma to the vocal cords, such as an accident or any severe injury to the larynx. Generally, the best course of action when one discovers they have a vocal cord cyst is to have it surgically removed. Cysts on the vocal cords cause the person to have a breathy voice, or even a hoarse voice, as they prevent the vocal cords from vibrating as they typically would to create “normal” sounding speech production. Vocal cord cysts tend to be deeper within the cord itself, rather than on its surface, as is the case with polyps.

Vocal nodules and polyps are perhaps some of the most common voice disorders a speech pathologist will encounter. Vocal nodules are localized growths or calluses that form on the vocal cords at the point of maximum trauma, where the cords hit together with the most intensity. They tend to be bilateral (one on each of the two vocal cords) and can appears as pinkish in beginning stages, later turning more white or grey in later stages. Vocal nodules cause the vocal cords to vibrate less frequently, causing a lower than typical pitched voice that is either breathy or hoarse. Vocal nodules are most commonly seen in children that scream loudly on the playground (unknowingly abusing their vocal cords), or in adults that use vocally abusive practices, such as teachers/professors, coaches, singers, cheerleaders, etc. Nodules can be treated either through voice therapy with a speech pathologist, or through surgery in more serious cases. Typically, being seen by an ENT to remove nodules is a last resort if speech therapy does not produce the desired result. Polyps are similar to nodules, in that they are masses that grow on the vocal cords, but they tend to be softer and larger than nodules, and are typically fluid-filled. Polyps usually occur on just one vocal cord, but can present bilaterally as well. Polyps are more frequently seen in adults than in children and also cause a breathy or hoarse sounding voice. They are typically caused by voice misuse or can be caused by a hemorrhage (bleeding within the vocal cords), typically due to one isolated instance of severe vocal abuse (a loud scream when one is extremely scared or startled).

Laryngeal cancers account for approximately 2% of all cancers. They are more commonly seen in men than women and more than 50% of all cases are caused by prolonged smoking. Preliminary indicators of this type of cancer include hoarseness in the voice, broadening of the larynx, difficulty swallowing, lumps in the neck or having trouble breathing efficiently. A speech pathologist is involved in all stages of laryngeal cancer, including the chemotherapy, radiation therapy, and even subsequent surgery that may follow. A patient may have to undergo either a partial or total laryngectomy (removal of the larynx) to help cure this type of cancer. Partial laryngectomies look to maintain as much laryngeal functioning (voice usage and swallowing) as possible. Unfortunately, a total laryngectomy is used when no other options present themselves. While laryngeal cancers are somewhat rare, it is important to include them in the list of voice disorders.

Gastroesophageal reflux disease (GERD) is more commonly known as heartburn or acid indigestion, commonly associated with a sore throat, burning in the chest or hoarseness of the voice. Other times, no outward symptoms are noticed. GERD occurs when food goes in the stomach and then, leaks back into the esophagus, typically causing a burning sensation or even the feeling of something being stuck in one's throat. There are many common treatment options to help a patient suffering from GERD. The most common is use of over the counter or prescription-based antacids, in addition to keeping one's head propped upwards at night while sleeping, and changes in dietary habits to include less acidic foods and drinks (avoiding coffee/caffeine, tomatoes, spicy foods, citrus fruits, etc.)

Vocal cord paralysis can occur from accidental injury, nerve damage and neurological diseases, tumors and strokes. Paralysis of the vocal cords can occur unilaterally (on just one vocal cord) or bilaterally (on both vocal cords). Unilateral vocal cord paralysis is more commonly seen, where the impacted vocal cord cannot move inwardly, causing a weak, breathy, hoarse sounding voice. In some cases, the working vocal cord may move so much in order to compensate, that one's voice may sound almost “normal.” In other cases, when the cords do not touch, aphonia occurs (the inability to produce voice). Bilateral vocal cord paralysis can lead to swallowing difficulties, as well. Aphonia occurs with bilateral vocal cord paralysis more commonly and can cause additional breathing difficulties.

Spasmodic dysphonia (SMD) is caused by involuntary spasms within the larynx, and is considered a loss of control of one's voice. Commonly, there are many side effects associated with SMD, particularly emotional stress, anxiety and occupational/social challenges. There are two major types of SMD, including Adductor Spasmodic Dysphonia (ADSD) and Abductor Spasmodic Dysphonia (ABSD). ADSD is the most common type of SMD, caused by too much pressure when the vocal cords are trying to close, resulting in vocal cords that are so tight, that the voice may seem strained, strangled or effortful, even unintelligible at times. The most common treatment for ADSD is Botox injections into the vocal cords directly, used to weaken the muscles and make them more functional. The voice may sound breathy at first, but after several months of Botox treatment, it tends to normalize once again. Speech therapy is often sought out to help with voice education and other helpful strategies to maintain a healthy voice. On the other hand, ABSD occurs when the vocal cords are so open, that there is no voicing at all. This lack of voicing tends to be sporadic and fleeting throughout a conversation, resulting in decreased vocal volume, with the normal voice interjecting throughout the spasms. It is difficult to speak, resulting in shorter, more effortful sentences in conversation. For ABSD, Botox is the recommended treatment as well. Speech therapy is also recommended for relaxation exercises and easy-onset speaking strategies to be taught. It should be noted that a mixed SMD can occur as well, where both the adduction and abduction dysphonias are combined, but this is very rare and presents as a total aphonia and is quite difficult to treat.

To prevent voice disorders, it is helpful to remember to use proper vocal hygiene whenever possible. Remember to drink plenty of water (6-8 ten ounce glasses per day), exercise regularly, get plenty of rest and avoid lying down after eating. It is also important to speak in a clear voice as opposed to a whisper and to avoid other vocally abusive behaviors such as excessive coughing, screaming or throat clearing. Avoid smoking and eating acidic or fatty foods, whenever possible. Following these tips to keep our voices healthy will help reduce the risk of voice disorders, no matter how common or uncommon they may be.