What is Dysphonia?
difficulty in speaking due to a physical disorder of the mouth, tongue, throat, or vocal cords.
Dysphonia is the medical term for disorders of the voice: an impairment in the ability to produce voice sounds using the vocal organs (it is distinct from dysarthria which means disorders of speech, that is, an impairment in the ability to produce spoken words). Thus, dysphonia is a phonation disorder. The dysphonic voice can be hoarse or excessively breathy, harsh, or rough, but some kind of phonation is still possible (contrasted with the more severe aphonia where phonation is impossible).
Dysphonia has either organic or functional causes due to impairment of any one of the vocal organs. However, typically it is caused by some kind of interruption of the ability of the vocal folds to vibrate normally during exhalation. Thus, it is most often observed in the production of vowel sounds. For example, during typical normal phonation, the vocal folds come together to vibrate in a simple open/closed cycle modulating the airflow from the lungs. Weakness (paresis) of one side of the larynx can prevent simple cyclic vibration and lead to irregular movement in one or both sides of the glottis. This irregular motion is heard as roughness. This is quite common in vocal fold paresis.
Dysphonia is measured using a variety of examination tools that allow the clinician to see the pattern of vibration of the vocal folds, principally laryngeal videostroboscopy. The acoustic examination is also common, obtained by recording the sounds made during sustained phonation or whilst speaking. Another tool is electroglottography.
Subjective measurement of the severity of dysphonia is carried out by trained clinical staff. The GRBAS (Grade, Roughness, Breathiness, Asthenia, Strain) scale or the Oates Perceptual Profile are widely used for this purpose. Objective measurement of the severity of dysphonia typically requires signal processing algorithms applied to acoustic or electroglottographic recordings. These include algorithms such as jitter, shimmer, and noise-to-harmonics ratios, but these have been shown to have some critical limitations, particularly for severe dysphonia. Recent advances in signal processing theory have led to more robust algorithms.
 When should a patient seek treatment?
Any person who has been hoarse for four weeks or more should seek medical attention from their family doctor. They may require to be seen by an ear, nose, and throat specialist for further examination including inspection of the larynx. This can be done quite easily (by the specialist!) using an angled mirror, or flexible fiber-optic ‘telescope’. Persistent hoarseness, difficulty in swallowing, sore throat, choking when swallowing (especially fluids), persistent earache, coughing up blood, weight loss, and loss of appetite may indicate a more serious condition and should always be taken seriously.
 How is dysphonia treated?
Each condition has its own specific treatment, and the treatment should also be tailor-made to each individual. The general principles of management are described below. Conservative therapy Every attempt should be made to identify and eliminate causative factors such as stress, smoking, and alcohol. Drink plenty of clear fluid to avoid a dry throat. Rest the voice completely for two to three days. No talking or whispering is allowed. Communicate to others by writing everything down on a notepad. Speech therapy The speech therapist plays an important role in the assessment and treatment of patients with voice disorders, eg Reinke’s edema, vocal cord nodules, and voice misuse. The therapy will take some weeks or months before any improvements are noticed and so the patient must be highly motivated. Medical therapy Upper respiratory tract infections, eg acute laryngitis, are commonly caused by viral infections. Bed rest, regular paracetamol, and saline or soluble aspirin gargles are often adequate. Antibiotics are only indicated when there is a bacterial infection. Nasal sprays such as Beconase are used to treat patients who suffer from chronic inflammation of the sinuses and nasal lining and who get catarrh dripping down the back of the throat. Medications to reduce acid secretion by the stomach are used to treat patients with gastro-oesophageal reflux. Surgery Surgery is indicated for diagnosis (eg tissue biopsies) and treatment (eg removal of tumors and laser surgery). The operation is performed with a fiber-optic viewing ‘telescope’ (endoscope) under general anesthesia. The view of the larynx is magnified with a microscope so that delicate operations can be carried out. The procedure is known as ‘micro laryngoscopy’ or ‘endolaryngeal microsurgery’. Surgical management of non-cancerous causes of voice disorders is only indicated when all the other measures have failed.
From Wikipedia, the free encyclopedia
What is dysphonia?
Dysphonia is a descriptive medical term meaning disorder (dys- ) of voice (-phonia). There are many causes of dysphonia. Fortunately more than half of people with voice complaints have a benign (non-cancerous) cause.
How is voice normally produced?
The generation of voice requires a sound-producing (‘phonatory’) system, a control center, and a network connecting the two.
The larynx (voice box) has a framework of cartilage with muscles attached to different structures. It also has a pair of vocal cords that move apart on breathing in (inspiration) and come closer together on breathing out (expiration).
The vocal cords resemble two small blinds that can be drawn across from the side of the larynx into the middle, thus causing a variable restriction in the amount of air that can pass through.
According to how tightly the muscles tense the edges of the vocal cords and how much breath pressure is applied, the frequency of vibration of the cords can be changed very rapidly, which generates the tone of the sound being produced. The pharynx (area at the back of the throat) and oral cavity act together as a sound resonator.
Understandable voice is produced by coordinated movements of the tongue, lower jaw, and soft palate – the flexible part of the roof of the mouth. This process is called articulation. Clearly, it is a complex system, depending on its success on sophisticated control.
The brain acts as a control center that receives and sends out signals to different parts of the body including the diaphragm, muscles of the chest wall, abdomen, larynx, pharynx, oral cavity, tongue, soft palate, and lower jaw, and co-ordinates their movements.
The crucial nerves that carry the brain’s signals to the muscles of phonation are the laryngeal nerves, which are themselves branches of the 10th cranial nerve – the ‘vagus’ nerve. As with the other cranial nerves, (which all exist in pairs) the vagus arises directly from the brain, rather than from the spinal cord, and travels through a specific opening in the skull to reach its location.
What symptoms do people with dysphonia have?
People with dysphonia may present with hoarseness and a sore or dry throat. A singer may notice that he or she is no longer able to sing in the upper range. There may be other associated symptoms such as a continuous drip at the back of the throat (nasal catarrh) and heartburn.
When should a patient seek treatment?
Any person who has been hoarse for four weeks or more should seek medical attention from their family doctor. They may require to be seen by an ear, nose, and throat specialist for further examination including inspection of the larynx. This can be done quite easily (by the specialist!) using an angled mirror, or flexible fiber-optic ‘telescope’.
Persistent hoarseness, difficulty in swallowing, sore throat, choking when swallowing (especially fluids), persistent earache, coughing up blood, weight loss, and loss of appetite may indicate a more serious condition and should always be taken seriously.
Causes of dysphonia
- Inflammation of the larynx (voice box) over a short (acute) or long (chronic) period of time.
- Lumps (nodules) on the vocal cords (eg singer’s nodules).
- Underactive thyroid gland – hypothyroidism.
- Trauma – any kind of trauma, including surgery, to the vocal cords will inevitably cause scarring and hence affect the vocal fold function. The risk of permanent voice change therefore needs to be discussed prior to surgery on the larynx.
- Vocal cord paralysis – some other surgical operations including removal of the thyroid gland and heart or lung surgery can damage the nerves to the larynx causing either temporary or permanent vocal cord paralysis (palsy).
- Reinke’s edema of the larynx.
- Psychological – voice changes are not uncommon when people are under stress either at work or at home. The voice may be lost suddenly, usually overnight or following a cold. It is important to identify and remove the underlying stress. Speech therapy is very useful for this cause.
The above conditions are commonly seen in ENT (ear, nose, and throat) specialist clinics but there are many other relatively uncommon and rare diseases not mentioned here.
How is dysphonia treated?
Each condition has its own specific treatment, and the treatment should also be tailor-made to each individual. The general principles of management are described below.
Every attempt should be made to identify and eliminate causative factors such as stress, smoking, and alcohol. Drink plenty of clear fluid to avoid a dry throat. Rest the voice completely for two to three days. No talking or whispering is allowed. Communicate to others by writing everything down on a notepad.
The speech therapist plays an important role in the assessment and treatment of patients with voice disorders, eg Reinke’s edema, vocal cord nodules, and voice misuse. The therapy will take some weeks or months before any improvements are noticed and so the patient must be highly motivated.
Upper respiratory tract infections, eg acute laryngitis, are commonly caused by viral infections. Bed rest, regular paracetamol, and saline or soluble aspirin gargles are often adequate.
Antibiotics are only indicated when there is a bacterial infection. Nasal sprays such as Beconase are used to treat patients who suffer from chronic inflammation of the sinuses and nasal lining and who get catarrh dripping down the back of the throat. Medications to reduce acid secretion by the stomach are used to treat patients with gastro-oesophageal reflux.
Surgery is indicated for diagnosis (eg tissue biopsies) and treatment (eg removal of tumors and laser surgery). The operation is performed with a fiber-optic viewing ‘telescope’ (endoscope) under general anesthesia.
The view of the larynx is magnified with a microscope so that delicate operations can be carried out. The procedure is known as ‘micro laryngoscopy’ or ‘endolaryngeal microsurgery’.
Surgical management of non-cancerous causes of voice disorders is only indicated when all the other measures have failed.
Treatment for Persons with Dysphonia and Voice Problems
Synopsis: Millions of Americans have dysphonia a hoarse or raspy voice that can cause pain when speaking and make it difficult to communicate.
Millions with voice problems don’t know treatment available.
Two-thirds of Americans with voice problems don’t seek medical care either because they don’t know treatment is available or because they think the problem will just go away, according to a new study conducted at the Duke Voice Care Center.
That’s concerning, says Seth Cohen, MD, an otolaryngologist at Duke. “Voice disorders aren’t benign nuisances that just go away. They are symptoms of a range of medical conditions from allergies to cancer. When caught early, the right treatment can make a big difference. Left untreated, they can become chronic problems that previous studies show have a major impact on quality-of-life issues, including an increased risk of depression. This study helps us understand the barriers preventing people from seeking treatment when there is so much at stake.”
An estimated 20 million Americans have dysphonia, the clinical umbrella term for a hoarse or raspy voice that can cause pain when speaking and make it difficult to communicate effectively. Previous data link dysphonia to decreased work productivity and social isolation. Patients also incur financial burdens including rising health care costs. Overall, economic losses have been estimated in the billions.
“Dysphonia affects everyone at every age,” says Cohen, author of the study that appears online in the journal Laryngoscope. “You don’t have to have a vocally demanding job to suffer.”
There’s a host of conditions that lead to dysphonia, including tobacco, alcohol, and caffeine use, certain medications, voice overuse/misuse, hearing loss, dry mouth, and reflux. Dysphonia can also be a sign of something more serious, like asthma, lung disease, Parkinson’s, or laryngeal cancer.
“You have no idea what is causing the problem or what the appropriate treatment should be until an evaluation is performed,” says Cohen. That requires the use of a laryngoscope that threads a camera down the throat so doctors can determine the medical cause.
Few dysphonia patients go that route.
In the Duke study of 789 patients in a primary care network, nearly 30 percent (29.1 percent) had dysphonia at least once in their lifetime; 4.3 percent had it for more than four weeks. More than half (54 percent) of those with current dysphonia had missed at least one day of work as a result of their condition. More than three-quarters (77.9 percent) of patients who had dysphonia more than once had never received treatment.
When asked why they didn’t seek treatment:
- 30.4 percent did not know options for treatments were available;
- 33.3 percent thought the problem would go away on its own;
- 26.1 percent didn’t seek care because their physician didn’t ask about vocal problems;
- 14.5 percent thought dysphonia was due to aging;
- 7.2 percent cited expense and insurance coverage;
- 4.3 percent cited travel limitations.
Cohen says it’s important for patients to understand that vocal disorders can get progressively worse when left alone.
“Patients who don’t seek treatment get caught in a vicious cycle. As the problem becomes more chronic, patients seem to be accepting it, but that won’t make the situation better,” he says.
Rather than take vocal disorders for granted, Cohen stresses, “Patients need to become better advocates for their own health. They should talk to their doctor so they can get appropriately evaluated and a personalized treatment plan can be developed.”
This study was funded by the American Academy of Otolaryngology-Head & Neck Surgery Foundation Health. The authors report no conflicts of interest.
Vocal hyperfunction and muscle tension dysphonia
from the voice doctor.net
Information for patients with various muscle, nerve, and functional problems of the vocal cords causing hoarseness.
- Muscle tension dysphonia
- Non-organic dysphonia
Muscle tension dysphonia
Muscle tension gap
The terms “vocal hyperfunction” and “muscle tension dysphonia” have several different meanings depending upon the person using them. To me, muscle tension dysphonia is characterized by the vocal folds typically failing to come completely together because two muscles are pulling in opposite directions simultaneously. The vocal folds have the capacity and ability to assume the correct position for a task but do not because they are pulling against one another in an inefficient fashion. This is most likely a learned behavior.
It is seen as a posterior glottic gap as in this 15-year-old singer above.
As another example, a vocal overdoer (someone who likes to talk) over time may develop vocal nodules. It may take many years for them to enlarge but eventually, they protrude enough that when the vocal cords come together, the cords position themselves so the nodules just barely touch. This leaves the actual vocal folds slightly apart. This is because this is easier to phonate or make a sound than when it is compressed and touching. Squeezing them together dampens the vocal fold vibrations or require extra breath support (volume) to get them vibrating.
Along comes to a surgeon and the nodules are removed. During the post operative checkup, the vocal folds assume the same position they did before surgery – slightly apart. There are no nodules holding them apart, they just assume that position as if the nodules were still there. Muscle memory is playing a role. The abductor (opening) muscles are preventing the vocal folds from completely closing even though they can actually close with the appropriate technique. It is analogous to learning a song on a piano for many years. Then at a party, you try and play the same song on their toy electric piano and it is a tremendous struggle with mistakes flying around like popping popcorn. The piano keys turn out to be closer together and have different resistance to pressing on them. Your brain is not used to this change and your fingers go where they think they should go rather than where they actually need to go. With some practice, you could learn to play this piano as well. Years of behavior need to be relearned.
This is true muscle tension dysphonia. Until the abductor’s muscles stop competing with the closing muscles, the voice remains impaired. Eventually, this gap may close “naturally”.The other common example is a young singer or folk/pop singer who has developed a breathy style of singing. This is achieved by holding the vocal folds apart. It provides a soft quality to the voice and if this is the desired style, then it is wonderful. Numerous singers make very good livings with this style. However, if one is striving for a clear, efficient style of singing, with a high upper range, this muscle tension can severely impair singing. It also tends to impair the bottom extreme of a person’s vocal range as well, because the marked shortening of the folds also tends to set the folds apart.
To a certain extent, the patient can begin to self-train and feel the difference by phonating with a very harsh, biting kind of sound and then with a very soft-edged, breathy sound on the same note and compare the difference.
Hyperfunction representing hypofunction
The term muscle tension dysphonia is frequently misused in another way when the examiner notes that a person’s false vocal cords are squeezing together. Some physicians call this “plicae ventricular”. This squeeze may occur either side to side or front to back. It is typically described as the false vocal folds touching during voicing (side to side). Alternatively, it looks like the back of the voice box (the arytenoids) is touching the front (the epiglottis).
Here is an example of an 80-year-old male with severe vocal cord bowing.
While this superficially appears to be a hyperfunction, this is really masking an underlying hypofunction. The hyperfunction is then not the problem, it is a symptom of the problem. The affected person is trying their hardest to produce a good sound and it is extremely effortful. In some cases, the false vocal cords are the only possible way to phonate, such as after a substantial portion of the true vocal cord has been removed for cancer. Sometimes the extra squeeze merely brings the true vocal folds closer together or supports a weak true vocal fold.
If one could see below the squeezed false vocal folds (and one can with adequate anesthesia) one would typically find that the true vocal cords are not closing completely or are not staying closed. This may represent a neurologic problem, such as partial paralysis of one of the several muscles of the voicebox. It may represent severe vocal cord bowing. The bowing may be so severe that the vocal fold joints actually scissor or cross over one another at the back end just to get the middle of the vocal folds close enough together to even vibrate. This could represent a lack of tension within the vocal cord, a lack of muscle bulk, or a lack of innervation to one of the muscles. If this lack of tension is from the thyroarytenoid muscle weakness (the muscle inside the vocal cord itself), stroboscopy or high-speed photography may best delineate the problem. It can be seen on successive frames of the recording as an initial vocal cord approximation and then as blowing out of the affected vocal fold. Listening to this type of vocal vibration will sound like a sail flapping in the wind, the sailor’s term luffing.
Patients with this condition will complain of vocal fatigue, poor endurance, pain in the voice box (a typically hot, burning, or achy type of pain). This is from excessive use of the neck muscles to support the weakened voice box muscles. The person may have an inability to yell and may have an obligate falsetto. The falsetto is a higher-pitched voice than usual. Think of an older man in your life with a somewhat female sounding voice.
High pitches are created predominantly by the cricothyroid muscle. This muscle is supplied by the superior laryngeal nerve, a different nerve from the one supplying the rest of the vocal box muscles. Because of its separate nerve supply, it often remains healthy even after an injury has impaired the recurrent laryngeal nerve supplying the inside of the voice box. This muscle basically stretches and lengthens the vocal cords to create a higher pitch much like you would tune up a guitar or violin. If we have a vocal cord that is loose or floppy because the muscle within it is failing, the cricoarytenoid muscle may pitch in and tighten the vocal cord, increasing the pitch, but at least now the person has a voice. If the person tries to lower the pitch, the voice just gets softer, breathier, and has less volume. Thus the term obligate (mandatory) falsetto (high pitch) describes the technique just to speak. Therapy directed at relaxing the voice box fails to improve or even makes the voiceless functional.
Video comparing the first two types of muscle tension
Non-organic dysphonia or non-organic hyperfunction
The third condition that can be lumped under the term “hyperfunction”, is a type of non-organic dysphonia. Non-organic dysphonia can present and look like hyperfunction (on video). In this case, the underlying vocal folds are normal and work well, but an inappropriate behavior has developed of squeezing tight the upper part of the voicebox.
A person may develop laryngitis. The vocal cords become swollen and stiff. To get any voice at all the person with laryngitis must squeeze extra hard to get the vocal cords together and vibrating. In the process, the false vocal folds are squeezed closer or may even start vibrating to produce a very deep voice. Now a cold should resolve in a reasonable period, perhaps two weeks. However, because of some secondary gain (and this is usually an unconscious gain), the voice problem seemingly persists. The hoarseness remains even though the swelling is now resolved.
The types of secondary gain I have seen range from the obvious: “If my hoarseness lasts for a few more days, I’ll be able to collect disability” to the very subtle, family or school commitments may have been relaxed because of the illness or the person is just getting a little extra, much-needed attention from those surrounding them.
This non-organic (learned) behavior is very easily and quickly correctable – often during the initial examination – completely restoring a normal voice. Keeping the normal voice may be harder because typically the physician or therapist doesn’t or can’t resolve all the stresses and obligations in a person’s life. The problem may recur unless these other issues are dealt with. This is not “craziness”. This is the way a normal compensatory mechanism becomes the problem itself and it is the way that our minds work. Recognizing the issues goes a long way to restoring and maintaining vocal health.
So, muscle tension dysphonia or vocal hyperfunction can represent a long term learned behavior that needs appropriately directed therapy or vocal training to correct/improve it. It may represent a compensatory mechanism for an underlying weakness, neurologic paresis, or lack of tension (bowing). This almost never improves with therapy directed at relaxing the “hyperfunction”. Voice building exercises or surgical augmentation to reintroduce bulk and support to the affected vocal fold(s) may be a solution. If the underlying problem is stiffness, surgery might be directed at softening the vibrating edge of the vocal cord. Thirdly, one form of non-organic dysphonia is a “hyperfunctioning” supraglottis (the false vocal folds). Therapy directed at restoring the normal voice is usually quite successful. In rare cases, deeper probing into the stresses or obligations perpetuating the condition may be helpful.
*Disclaimer: This information is not intended to be a substitute for professional medical advice. You should not use this information to diagnose or treat a health problem or disease without consulting with a qualified healthcare provider.
Please consult your healthcare provider with any questions or concerns you may have regarding your condition.
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