Voice Disorders

Nodules are calluses on the vocal folds that occur with improper voice use or overuse. They are most common in children and females. Nodules prevent the vocal folds from meeting in the midline and produce an hourglass-shaped deformity on the folds' closure, resulting in a raspy, breathy voice. Usually, these will respond to speech therapy. Occasionally (20 percent of the time), they may persist after intensive speech therapy and could require meticulous microlaryngeal surgery.

Polyps are benign lesions of the larynx, usually located on the phonating margin (edge) of the vocal folds, which prevent the vocal folds from meeting in the midline. Polyps can interfere with voice production and may produce a hoarse, breathy voice that tires easily. These may respond to conservative medical therapy and intensive speech therapy. If the lesion fails to respond, meticulous microsurgery may be indicated. Laryngeal polyps occur most frequently in adult males. One of the cofactors may be laryngeal reflux disease (caused by stomach acid that travels up the esophagus).

Laryngitis sicca is caused by inadequate hydration of the vocal folds. Thick, sticky mucus prevents the folds from vibrating in a fluid, uniform manner.

Vocal fold hemorrhage is a very rare occurrence that usually is caused by aggressive or improper use of vocal folds (e.g., cheerleading). It is a result of the rupture of a blood vessel on the true vocal fold, with bleeding into the tissues of the fold.

Cancerous lesions, when detected early, can be treated with either radiation or surgery and have a cure rate approaching 96 percent. 

Incompetent larynx, also called impaired vocal fold mobility, is a condition where one or both of the vocal folds do not move appropriately. This can be due to paralysis, paresis, scarring or inflammation of the crico-arytenoid joint.

Vocal fold paralysis or paresis results from a lesion of the neural or muscular mechanism and can manifest in the following three forms:

• Unilateral vocal fold paralysis prevents movement in one vocal fold. When one weakened vocal fold does not move well enough to meet the other fold in the midline during speech, air leaks out too quickly. This causes the voice to sound breathy and weak, making it necessary for the speaker to take more frequent breaths during speech.
• Bilateral vocal fold paralysis occurs when both vocal folds have movement problems. With both vocal folds paralyzed in the midline position, the person has difficulty breathing and a tracheotomy may be necessary to establish an airway. If both folds are paralyzed near the midline, although the voice may be good, the airway may be compromised. If both folds are paralyzed far apart, there may be no voice.
• Vocal fold bowing can result from neural, muscular, traumatic, congenital or functional causes, with or without vocal fold atrophy, resulting in vocal weakness. 

Presbylaryngis is a condition that is caused by the thinning of the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and, therefore, do not meet in the midline. As a result, the patient has a hoarse, weak or breathy voice. This condition can be corrected by an injection of fat or other material into both vocal folds to achieve better closure.

Laryngeal dystonia, or spasmodic dysphonia (SD), is a voice disorder caused by involuntary movements of one or more muscles of the larynx. Two major types of spasmodic dysphonia exist, although most are a mixture of both types:

• Adductor SD, with spasms causing sporadic vocal fold closures, are identified by a strained, strangled voice.
• Abductor SD, with spasms causing sporadic (occasional) vocal fold closures, produces a voice with interruptions of air.

Functional disorders of the larynx are a class of conditions that are the result of inappropriate movement of the laryngeal muscles:

• Muscle tension disorder occurs when excessive laryngeal muscle tension squeezes the vocal folds and surrounding muscles into a “fist” configuration, preventing air from moving through the vocal folds to enable normal vibration. The voice is reduced to a “squeaky” sound.
• Dysphonia plica ventricularis is a laryngeal function disorder caused by phonation of the ventricular folds (false folds), rather than the true vocal folds. When the ventricular folds are squeezed together, the resulting voice is harsh and strained.
• Paradoxical vocal fold dysfunction is the result of the vocal folds coming together during inspiration, instead of normally opening to allow air to flow freely. This can alarm the patient and those nearby, as the patient is gasping for air. Frequently, these patients are seen in the emergency room (ER) and treated (incorrectly) for asthma. The typical symptom of this disorder is phonation during inspiration. The diagnosis can be determined by the history and physical exam, and confirmed by examination of the larynx with a flexible fiber optic laryngoscope during an attack. Treatment may involve several specialties, especially speech-language pathology.

Laryngopharyngeal reflux disease (LPRD) occurs when stomach contents and acids back up into the esophagus or throat. The esophagus has two sphincters (bands of muscle fibers that close off the tube) to help keep the contents of the stomach where they belong. The term "reflux" means "a backward or return flow," and usually refers to the backward flow of stomach contents and acids up through the sphincters and into the esophagus or throat. If the reflux makes it all the way up through the upper sphincter and into the back of the throat, it is called laryngopharyngeal reflux disease (LPRD). The structures in the throat (pharynx, larynx and lungs) are much more sensitive to stomach acid and digestive enzymes, so smaller amounts of reflux into this area can result in more damage.