Inefficient Voice Use
Inefficient voice use or vocal overuse can lead to a variety of vocal problems. When excess tension is being used in the muscles of the voice box, it is referred to as muscle tension dysphonia. If these patterns persist, they can cause swelling or edema of the vocal folds, or even benign lesions.
The diagnosis for inefficient voice use is made by taking a thorough history, performing a complete head and neck examination, and performing laryngeal stroboscopy.
Inefficient voice use and muscle tension dysphonia are best treated with voice therapy.
Vocal Fold Nodules
Nodules are symmetric, benign (not cancer) lesions which form at the midpoint of both vocal folds. These lesions form in response to heavy voice use, often with some vocal inefficiency. They are often seen in both professional and amateur singers, and are almost exclusively seen in young women and pre-adolescent boys. Nodules can impair vocal fold closure and vibration. They often cause painless hoarseness that worsens with prolonged voice use and improves with voice rest.
The diagnosis of vocal fold nodules is made by taking a thorough history, performing a complete head and neck examination, and performing laryngeal stroboscopy. Diagnosis is more difficult when laryngoscopy is performed without stroboscopy. Generally, the appearance is characteristic enough to make the diagnosis without needing to perform a biopsy.
The treatment for nodules is voice therapy. While voice rest or steroids may decrease some of the inflammation of the vocal folds surrounding the nodules, they do not address the main issue. Using voice therapy, patients generally are able to soften the nodules and get voice improvement. Often, the voice improves even if the nodules remain.
Nodules in some patients become hard and calloused. These patients do not get sufficient improvement with voice therapy. In these cases, phonomicrosurgical resection of the nodules may be considered. This should always be weighed carefully as any procedure will leave some scar on the vocal folds.
Vocal Fold Polyps
Vocal fold polyps are benign (not cancer) masses of the vocal cords which are generally found at the midpoint of the vocal cord. They are thought to form in response to excess stress on the vocal fold. They may be either on one side only (unilateral) or on both sides (bilateral). They are generally softer than nodules. Polyps can impair vocal fold vibration and closure, causing hoarseness and sometimes a sensation of a lump in the throat.
The diagnosis of vocal fold polyps is made by taking a thorough history, performing a complete head and neck examination, and performing laryngeal stroboscopy. Generally, the appearance is characteristic enough to make the diagnosis without needing to perform a biopsy.
While voice rest may improve surrounding edema (swelling) of the vocal folds, it will not address the true underlying issue and voice is likely to become problematic again after a period of voice rest. As these lesions form because of inefficient voice use, voice therapy is generally the first step in treating these lesions. Smaller polyps may resolve completely with improved vocal hygiene and vocal efficiency. However, these lesions often require intervention. Depending on the polyp’s size and location, your doctor may discuss resection of the polyp in the operating room or awake laser ablation of the polyp.
Vocal Fold Cysts
Vocal fold cysts are benign (not cancer) masses which are located deeper in the vocal fold. The manner of formation of vocal fold cysts is not entirely clear, but most experts currently believe they result from plugging of a mucous gland. The gland continues to make mucous which then accumulates. Because cysts are found deeper in the vocal fold, they tend to impair vibration of the vocal fold more than polyps. This impairment in vibration as well as in closure of the vocal folds causes hoarseness.
The diagnosis of vocal fold cysts is made by taking a thorough history, performing a complete head and neck examination, and performing laryngeal stroboscopy. Generally, the appearance is characteristic enough to make the diagnosis without needing to perform a biopsy.
Cysts generally require phonomicrosurgical resection in the operating room. Because of the location of the cyst, this surgery is very technically demanding, requiring the surgeon to dissect out the cyst while preserving the overlying vocal fold cover. Re-draping of this cover after excision minimizes scar tissue formation. Voice therapy is often indicated to improve voice use patterns prior to surgery. This will assist in the healing process.
Unilateral Vocal Fold Paralysis
Vocal fold paralysis is immobility of the vocal fold – cannot open and close – because of damage to the nerve that controls it. This nerve is called the recurrent laryngeal nerve. Vocal fold paralysis can be unilateral, meaning one vocal fold does not move, or bilateral, meaning both vocal folds do not move – see separate section on bilateral vocal fold paralysis. Vocal fold paralysis can often happen without an apparent cause. This is felt to because of a viral infection. The other most common reasons for the nerve not to work are damage or stretching of the nerve during surgery or a tumor in the neck or the chest pressing on the nerve. Lastly, the breathing tube placed during many surgeries may damage branches of the nerve, causing temporary or permanent damage.
Unilateral vocal fold paralysis generally causes patients to have a breathy, hoarse voice. They may have difficulty swallowing or feel that they run out of air when they talk. This results from a failure of the vocal folds to close against one another.
The diagnosis of vocal fold paralysis is made by taking a thorough history, performing a complete head and neck examination, and performing laryngoscopy with possible stroboscopy. If this diagnosis is made and there was no recent surgery to explain the paralysis, it is important to obtain a CT (CAT) scan of the neck and chest to ensure there are no tumors causing the paralysis.
Patients may spontaneously recover function of the vocal fold for up to one year after the injury. During this time, patients may suffer from difficulty with communication and even difficulty with swallowing. Neither voice rest nor voice therapy has been shown to improve the rate or likelihood of recovery. In order to improve voice during this team, the voice team may recommend an injection laryngoplasty. During this procedure, a needle is passed into the vocal fold and a temporary filler is injected to push the paralyzed vocal fold to the middle. This allows for a stronger, less effortful voice. Research suggests that an early injection does lead to better permanent voice outcomes.
If, after one year, the vocal cord remains paralyzed, the surgeon may recommend a surgery called a Thyroplasty. This procedure is done in the operating room. In this procedure, the surgeon exposes your voice box cartilage through an incision in the neck and uses a plastic shim to push the vocal cord towards its partner.
Vocal Fold Atrophy / Presbylarynges / Ageing Voice
Like the rest of the body, the vocal folds change with age. The muscles in the vocal folds (thyroarytenoid muscle) become thinner. The gelatinous tissue in the vocal folds that allows vibration, called the superficial lamina propria, becomes less pliable. These changes result in vocal folds that do not have the same level of contact or ease of vibration that they did at a younger age. Patients with vocal atrophy often present with a higher pitched, breathy voice. They may have difficulty projecting their voice.
The diagnosis of vocal fold paralysis is made by taking a thorough history, performing a complete head and neck examination, and performing laryngoscopy with stroboscopy.
Initial treatment for atrophy is voice therapy to improve vocal efficiency. Some experts believe this can also strengthen the muscles of the vocal cords, though there is disagreement on this point. If the desired voice is not achieved, injection laryngoplasty or bilateral thyroplasty may be considered for treatment.
When acid made in the stomach that flows backwards into the esophagus, it may cause a constellation of symptoms. This is referred to as gastroesophageal reflux disease or GERD. The most common symptom of acid reflux is heartburn. If acid passes through the esophagus and irritates the throat, it is referred to as laryngopharyngeal reflux (LPR) and may cause a different constellation of symptoms including: dry cough, post-nasal drip, throat clearing, sensation of a lump in the throat, or a change in voice.
Diagnosis of LPR is generally made based on the constellation of symptoms given by the patient in conjunction with the appearance of the larynx on laryngoscopy with stroboscopy.
Treatment consists of a series of diet and lifestyle changes. If this is insufficient, medications may be used to decrease the amount of acid produced in the stomach.
Essential tremor is a neurological disease characterized by involuntary movement of the affected body part. This is made more severe with intentional movement. While tremor most commonly affects the hands and arms, it can be seen in the larynx as well. At this point, the cause of tremor is not known. Laryngeal tremor causes an unsteady voice, which can range from mild tremulousness to breaks.
Diagnosis of laryngeal tremor is made by taking a careful history and performing a head and neck examination. The clinicians may also wish to examine motion of the extremities. Laryngoscopy should reveal a rocking motion of the entire voice box as tremor generally involves the muscles of the larynx and pharynx. This should continue regardless of the sound being made. The Laryngologist and Speech-Language Pathologist examining the patient will work to distinguish tremor from a condition called spasmodic dysphonia. This can be difficult and is complicated by the fact that in 25% of patients, they coexist.
Treatment of laryngeal tremor is difficult. Voice therapy tends to be of little help. In some severe cases, Botulinum injections may be useful. These tend to be less effective than when Botulinum is used to treat spasmodic dysphonia. Medications including beta-blockers are sometimes useful. Often, if it has not already been done, an evaluation by a neurologist may be helpful to better guide medication therapy.
Spasmodic dysphonia (SD) is a movement disorder of the voice box that is mediated by the brain. This type of movement disorder is called a dystonia, and there are several of these with the most common being Writer’s Cramp. Dystonias are characterized by task specific characterization, meaning that the spasms only happen while speaking. Interestingly, actions like singing, laughing and swallowing are often unaffected. SD has two forms: Adductor SD (AdSD) causes the vocal folds to involuntarily close forcefully during speech causing a strained speech while Abductor SD (AbSD) causes the vocal folds to involuntarily open during voicing causing breathy breaks.
Diagnosis of spasmodic dysphonia is made by taking a careful history, performing a complete head and neck examination with particular attention to motion anomalies, and performing laryngoscopy. During laryngoscopy, the team will examine the motion of the voice box while the patient says certain characteristic phrases in an effort to bring out the spasms.
The mainstay of treatment for spasmodic dysphonia is Botulinum injections. Botulinum, or BOTOX, is used to weaken the muscles of the voice box, reducing their ability to spasm.
You can find more information at the website for the National Spasmodic Dysphonia Association (http://www.dysphonia.org)
Vocal Process Granuloma
A granuloma is a benign (not cancer) growth that is seen at the back of the vocal fold, and is caused by irritation or trauma. The vocal process is the cartilage at the back part of the vocal cord, and it has very little skin covering it. Because of this, trauma at this area can irritate the cartilage. Trauma and irritation may be from speaking, singing, throat clearing, or acid reflux. These also often for after a breathing tube is placed. Granulomas can cause a sore throat, a feeling of a lump, pain in the throat, or a change in voice.
Diagnosis of vocal process granuloma is made by taking a careful history, performing a complete head and neck examination, and performing laryngoscopy.
Treatment for vocal process granuloma consists of voice therapy and treatment of acid reflux. If conservative therapy fails, your team may consider using botulinum toxin, excision in the operating room, or laser ablation in the office. Surgery and laser ablation are only used if conservative therapy fails because there is a high rate of recurrence after excision.
Reinke's Edema / Polypoid Corditis
Reinke’s Edema, or polypoid corditis, is a benign (not cancer) reaction that takes place exclusively in patients who smoke. The layer of the vocal fold under its skin, called the “superficial lamina propria,” fills with irritated tissue. If left untreated, this can enlarge the vocal folds and give them the appearance of large polyps. Reinke’s Edema causes patients to have a lower pitched voice with a gravely quality. If it is allowed to grow untreated, it can impair the airway.
Diagnosis of Reinke’s Edema is made by taking a careful history, performing a complete head and neck examination, and performing laryngoscopy with stroboscopy.
The first step in treating Reinke’s Edema is smoking cessation. In early cases, this may be sufficient to improve voice to an acceptable level. If this fails, options include KTP laser ablation or direct microlaryngoscopy.