voice disorders

• Functional vocal hyperfunction


  Phonotrauma and vocal misuse
• Secondary organic vocal pathology

  • Nodules
  • Contact ulcers
  • Polyps
  • Edema
  • Traumatic laryngitis
  • Thickening of vocal folds
  • Reinke's Edema
• Vocal hyperfunction


  Too much muscle force and physical effort in the systems of respiration, phonation and resonance
• Respiration


  1. Regulation for breathing is basically involuntary and highly automatic in everyday speech

  2. Individuals can learn to take in quick breaths and then extend them over prolonged periods of continuous voicing

  3. Most common problem is an attempt to speak on inadequate expiration

  4. Elevation of shoulders and use of accessory neck muscles during inhalation is a sign of incorrect breathing

  5. Some patients will also use their chest and abdominal muscles in competition with one another

  6. Often improper utilization of expirations
• Phonation


  1. Voice or phonation is produced by vibrations of the vocal folds

  2. Phonation is produced by expiratory airflow coming from the lungs, passing between the approximated vocal cords and setting the vocal folds in vibration

  3. The elasticity and tenseness of the vocal cords will determine the frequency of vibration

  4. The speed of vibration will determine the frequency (fast = high frequency) and the perceived pitch of a voice

  5. The intensity of phonation or the perceived loudness of the voice is dependent on the vigor and velocity of the air pressure below the vocal cords

  6. Faulty approximation of the vocal cords often a problem

  7. Many voice problems originate from the space between vocal cords (glottis)

  8. The vocal cords are brought together and separated by muscle contractions

  9. The quality of sounds of phonation is dependent on the glottal posture of the vocal cords, their thickness, elasticity and degree of approximation

  10. Sometimes the vocal cords are approximated too tightly together and the flow of air (to set the vocal cords vibrating) is prevented

  11. An opposite problem is when the vocal cords are brought together too loosely and breaths escape between them resulting in a whispered or breathy voice

  12. Pitch deviations (too high or too low) requires unnecessary muscle energy to maintain the necessary vocal fold adjustments of length and mass to produce the 'artificial' voice

  13. Initiation of phonation at the beginning of words are known as glottal attack
• Phonotrauma


  The laryngeal mechanisms are used excessively in various non-verbal abusive ways such as continuous coughing, laughing, excessive crying or smoking
• Vocal misuse


  Excessive or inappropriate voicing e.g. hard vocal attack, wrong voice pitch, speaking too loudly or speaking too much
• Resonance


  1. Much of the beauty or quality of the voice is produced by the resonating chambers that begin within the larynx itself, extend into the pharynx, the oral cavity and the nasal cavity above

  2. Voice originates from the vibrating vocal cords but it is amplified in the upper airway cavities of the neck and head

  3. This amplification is called resonance

  4. Certain sounds and frequencies are amplified selectively, depending on the shape, surface and restrictions of the resonating cavities

  5. The resonating cavities have particular compatible natural vibrations that respond optimally to certain frequencies of the sound spectrum, known as resonance frequencies

  6. If the sound wave frequencies in the upper airway are compatible with the natural resonance, natural amplification and resonance will occur

  7. Many cavity resonators are altered by changes in shape and surface so that the natural resonant frequencies will change

  8. Some speakers alter or diminish their natural resonance potential by using various hyperfunctional behaviors

  9. The first resonating cavity that has an immediate influence on the glottal voice is within the larynx itself

  10. The oral opening of the mouth continuously change

  11. One form of hyperfunction that can be identified is in a patient with mandibular restriction (talking though one's teeth)

  12. Some patients display problems of nasal resonance that are related to variations in coupling the oral and nasal cavities together
• Nodules


  • Most common benign lesions of the vocal folds in children & adults
  • Caused by continuous abuse of the larynx and misuse of the voice
  • Generally bilateral whitish protuberances on the glottal margin of each vocal fold (anterior-middle third junction)
  • Variations are documented nodules can range between 1-4 in number
  • Nodules are responsive to voice therapy
• Nodule therapy


  1. Identify phonotraumatic-misuse

  2. Reduce occurrence of abuse-misuse

  3. Search with PT for facilitation approaches

  4. Use facilitation approach that works best as a practice method
• Larger and long-established nodules = surgery (if therapy did not work)
• Nodules prior to puberty are more common in boys
• LPR – increase susceptibility to nodules
• Factors contributing to nodules

  • Hyperfunctioning
  • Personality type
  • Children (sometimes) behavioural problems, etc.
• Polyps


  • Abnormality of the superficial lamina propria (usually on the same site as nodules)
  • Lesion is deeper than with nodules
  • Usually unilateral BUT a reactive lesion can occur across from the polyp
  • Polyps are often precipitated by a single vocal event= haemorrhaging on the membrane at the point of max glottal contact
  • Result: formation of either a translucent, fibrotic, hyaline, haemorrhagic or mixed polyp that adds mass to the vocal fold
  • Additional phonotrauma will irritate the area further resulting in growth of the polyp
• Polyp treatment


  1. Start with voice therapy and then surgery if little or no improvement is noted

  2. Patient cooperation is extremely important! Counselling!
• Traumatic laryngitis


  • Swelling of the vocal folds as a result of excessive and strained vocalization
  • Common causes: yelling and screaming, abrupt and strained voice usage, chronic coughing, habitual throat clearing, forceful singing
  • These conditions cause tissue surfaces of true and false vocal cords to experience intense friction, thermal agitation and molecular breakdown
  • Edema is accompanied irritation and increased blood accumulation
  • Elimination of phonotrauma and voice misuse = edema subsides, and vocal cords return to normal
  • Voice rest (less than a week) is recommended
  • If hyperfunctioning continues over time, temporary edema may become permanent polypoid thickening, polyps, nodules, hyperkeratosis or scarring
• Reinke's Edema and vocal fold thickening

  • Chronic diffuse swelling of the superficial lamina propria of the vocal folds
  • Also called polypoid corditis/ polypoid laryngitis or polypoid degeneration of the vocal folds
  • Gelatinous material forms in the Reinke's space, bilaterally (usually)
  • Associated with smoking, LPR and chronic vocal hyperfunctioning
  • Unilateral Reinke's edema is sometimes referred to as a pseudocyst- associated with vocal fold paresis
  • Often affects the anterior 2/3 of the glottal margin (vibrating portion of the vocal folds)
  • In severe cases, may result in dyspnea – effect on functioning?
• Muscle tension dysphonia (MTD)

  • Persistent dysphonia resulting in excessive laryngeal musculoskeletal tension and associated hyperfunctional true and false vocal fold vibratory patterns
  • Occurs in the absence of laryngeal structural abnormalities
  • Can be primary (without obvious aetiology) or secondary (compensatory response to an organic or psychogenic or neurological aetiology)
• Laryngeal and supra-laryngeal configurations in MTD

  1. Anterior-posterior compression

  2. Medial compression

  3. Sphincter like combination of these 2
• Factors contributing to MTD

  • Deviant body posture
  • Misuse of neck and shoulder muscles
  • High stress levels
  • Excessive voice use
  • LPR
  • Signs of depression
• Difficulty to differentiate between MTD and other forms of dysphonia (overlap to a certain degree- diagnosis is important)
• When differentiating between MTD and spasmodic dysphonia: hyper-adduction of the laryngeal structures are across all tasks with MTD but with spasmodic dysphonia it is more intermittent
• Also, severity is worse with spasmodic dysphonia in connected speech than in vowel prolongation where no difference will be perceived with MTD
• Ventricular phonation


  • Also known as false vocal fold phonation
  • May be produced by vibration of the approximating ventricular folds BUT more often it is produced by the true vocal folds vibrating in an abnormal fashion due to the false vocal folds riding or loading the true vocal folds
  • May become a substitute voice if resection had to be done due to severe disease; voice is low pitched due to large mass of vibratory tissue or due to the combined mass of the true and false vocal folds; also limited pitch variability and a monotone voice
  • Good approximation is limited - voice therefore hoarse or breathy
  • An unpleasant sounding voice
  • May cause diplophonia
  • Also, many times ventricular phonation is a symptom of other conditions (such as paralysis)
• Diplophonia


  • It means double voice
  • This is produced with two (2) concurrent distinct frequencies (tones) occurring
  • Caused by irregular vocal fold vibration
  • Usually heard in patients with mass lesions
• Phonation breaks


  • Temporary loss of voice that may occur for only part of a word, a whole word, a phrase or a sentence
  • Usually after prolonged hyperfunctioning
• Pitch breaks


  • Two kinds:
  • Developmental phenomenon seen primarily in boys during puberty
  • Caused by prolonged vocal hyperfunctioning especially speaking at an inappropriate pitch level
  • Also caused by vocal fatigue
  • Warning signs that the vocal mechanism is over worked
• Psychogenic voice disorders


  • Functional/hysteric/conversion/psychogenic aphonia
  • Mutational falsetto/ puberphonia
  • Conversion dysphonia
  • Conversion muteness and selective mutism
  • Conversion falsetto (in women)
  • Infantile voice in woman
  • Soft voice
• Functional/hysteric/conversion/psychogenic aphonia


  • Patient speaks in a whisper but continues to speak in the same rhythm and prosody of normal speech, only voice is lacking
  • Rule out organic factors by referring for a comprehensive assessment with ENT (if the diagnosis is correct the Dr will state that the vocal folds are functioning normally)
  • Aronson (1990) refers to a conversion aphonia at the somatization of an emotional disorder and can be created by anxiety, stress, depression or interpersonal conflict
  • Unresolved psychological conflict results in dysfunction of some bodily system
  • If they respond favourably in voice therapy, it is not a conversion aphonia
  • Teamwork with psychologists and/or psychiatrists is important
  • Onset differs: may be gradually or even sporadically
  • Sometimes occur after patient experienced some laryngeal pathology (initial pathology is organic and then the aphonia persists)
  • They communicate well by gesture, whisper or by a high-pitched shrill sounding weak voice
  • Usually do not avoid communications situations and they communicate effectively using facial expressions, hands and highly intelligible whispered speech
  • They usually self-refer to the therapist or voice clinic
  • Usually recovers their voices in the first session of therapy
  • Good prognosis!
  • May need counselling with a psychologist!
• Mutation falsetto / puberphonia

  • Singing point of view: when someone can extend the singing voice well beyond the chest register, producing a falsetto/ loft register
  • Concerned when the falsetto voice is the speaking voice
  • Failure to change from the higher pitched voice of pre-adolescence to the lower pitched voice of adolescence and adulthood
  • Rapid physical changes they have experienced may have been complicated by increased adult-like feelings and responsibilities
  • As a coping mechanism the young men may continue to use their prepubescent voices
  • Usually uncover normal speaking voice with minimal voice therapy, but may need psychological counselling
  • Coughing = adult like pitch
  • Digital manipulation may also be used
  • Monitoring of the voice = auditory feedback by playing back voice recordings!
• Conversion dysphonia


  • Some of the most abnormal or disturbed voices have no organic causes
  • Patient may be using a normal respiration system in an incorrect balance between initiating the airstream with the onset of phonation, such as beginning voice after much expiratory air has been expelled
  • Patient may take in too small a breath or too large a breath for producing normal voice
  • Or the vocal folds may be brought together in a lax manner, producing breathiness or in a tight manner producing symptoms of harshness or tightness
  • Or inappropriate pitch levels, excessive mouth opening, head positioning or jaw positioning may alter the quality of voice
  • Resonance = nasality added
  • Patient may report other problems such as weight loss, difficulty swallowing, throat and neck pain, excessive coughing or other somatic abnormalities
  • Psychological complaints such as worry, avoidance of responsibility, shyness, excessive fears, etc.
• Aronson (1990): "A psychogenic voice disorder broadly synonymous with a functional one but has the advantage of stating positively, based on exploration of its causes, that the voice disorder is a manifestation of one or more types of psychological disequilibrium – such as anxiety, depression, conversion, or personality disorder- which interferes with normal volitional control over phonation."
• Patient may be able to produce normal voice in the assessment, however SLP should consider the weight of the emotional factors influencing voice in daily living
• Often a mixture of emotional problems and faulty voice usage (hyperfunctioning may be present)
• The misuse may lead to secondary organic pathology
• Collaboration with psychologists or psychiatrists and / or vocal coaches of the singing or speaking voice is important
• Voice


  The audible sound produced by phonation
• Speaking


  • Requires a combination of highly coordinated interactions between the systems of respiration, phonation, resonance, and articulation
• Phonation


  The physical act of sound production by means of vocal fold interaction with the exhaled air stream