Speaking up about voice disorders

Voice disorders are issues with the pitch, volume, tone, and other aspects of vocalisation, stemming from dysfunction of the vocal cords. This is an umbrella category that comprises several conditions that can affect the voice. In this article, a consultant ENT surgeon explains the types of voice disorders and how they can be addressed.

What are voice disorders?

The vocal cords are two strips of tissue inside the larynx, located in the throat. When air is pushed out of the lungs and passes through these strips, they vibrate, causing a sound that is what we know as voice. When the vocal cords don’t move or vibrate normally, the voice can become garbled, hoarse, quivery, pitchy, strained, choppy, indistinct, or breathy. Patients may complain of tension, a lump, or pain in their throat when they speak.

Voice disorders are categorised into organic (issues with the structure of the cords, voice box, or lungs), neurological (issues with the nerves), and functional (issues with the muscle control of the cords and voice box; some patients can also develop a voice disorder under emotional duress).

What causes voice disorders?

There are many conditions in which the vocal cords can become dysfunctional or impaired, such as:

Laryngitis, a viral infection in the upper respiratory tract. It causes the vocal cords to swell
Inflammation, such as from chronic coughing, smoking, inhaler use, and frequent acid reflux.
Vocal cord paralysis (complete or partial), due to nerve injury or malfunction in the cords. This could arise from infection, injury (such as during surgery), a stroke, or cancer. Neurological conditions can also contribute, such as Parkinson’s disease, multiple sclerosis, and amyotrophic lateral sclerosis (ALS). This may be accompanied by difficulty breathing or wheeziness, due to the cords being paralysed in an open or closed position.
Spasmodic dysphonia, where nerve issues make the cords spasm and twitch.
Muscle tension dysphonia, where the muscles in the throat get too tight.
Vocal abuse, stemming from too much tension and overuse, like singing or shouting for a long time. A vocal cord can rupture from vocal abuse, leading to bleeding, which must be seen to as soon as possible, as there is a risk of losing the voice.
Lesions, which are noncancerous growths like nodules, polyps, and cysts.

How are voice disorders diagnosed?

Diagnosing a vocal disorder requires more than simply listening to the patient speak (or try to). A doctor or ENT specialist may begin an examination by asking the patient about their medical history and their experience with their voice disorder. Aside from adding background information that can help inform treatment, the doctor will be able to observe how the patient speaks and breathes, and how their tongue and throat move. During this portion, the doctor may ask the patient to say certain phrases or make sounds in order to further assess their condition.

After the initial examination, a doctor will look at the condition of the vocal cords through the mouth in what is called a laryngoscopy. This involves a thin, flexible scope with a light that is inserted into the throat via the nose. This enables the doctor to see down the throat and at the vocal cords and voice box. Other tests that may be employed in the diagnostic process include:

Laryngeal electromyography (EMG), which looks at the electrical activity in the throat muscles, to see if signals are being transmitted or received correctly. This involves a small needle being placed in the muscles to record the amount of activity.
Stroboscopy, where strobe lights are used to show how the vocal cords move when one speaks. A camera records a video for further analysis
Imaging tests like CTs and MRIs, which can show growths, masses, and lesions in the throat.

How are voice disorders treated?

Some patients can improve with short-term vocal rest and lifestyle adjustments, like taking the effort to speak more softly, no more smoking, drinking more water, and doing warm-up vocal exercises before singing or long periods of speaking.

Those with more complex issues will need more interventional treatment. This may entail:

Speech and language therapy. A speech-language pathologist works with the patient by providing exercises and adaptations for their voice disorder, such as breathing pattern alterations and methods to relax or strengthen the muscles in the throat.
Medication. If the voice disorder is caused by infection or inflammation from acid reflux, then medications can be significantly beneficial. Hormonal problems can also be treated with hormonal therapies.
When medications and speech therapy are not sufficient, then procedures and surgery are explored, such as:
Laryngoscopy. Removes lesions on the vocal cords, most often employing minimally invasive techniques.
Thyroplasty. Manipulating the vocal cords by moving or reshaping them to improve function.
Injection laryngoplasty. Botox, which causes temporary paralysis when injected, can help with muscle spasms. Fillers or fat can be injected into the cords to help them close better, allowing for more complete sounds.
Medialisation laryngoplasty. The implantation of a device to help the vocal cords close.