VOICE

VOICE DISEASES

Nodules and Polyps

Description

Nodules and polyps are common, benign (non-cancerous) growths that develop at the middle of the vocal folds. Mature nodules are similar to “calluses” within the vocal fold tissue and usually develop on both vocal folds. Polyps tend to be more fluid-filled than nodules, and visible blood vessels may feed into them. Polyps may develop on one or both vocal folds. Typical symptoms for both nodules and polyps include hoarseness, effortful voice, and rapid vocal fatigue.

Causes

Both nodules and polyps are thought to be caused by vocal fold trauma during talking or singing. The reason is that the middle of the vocal folds, where the growths occur, receives the greatest amount of impact during voice production. Other factors may also increase the likelihood that nodules or polyps will develop. Such factors include smoking, alcohol use, caffeine, drying medications, allergies, exposure to noxious chemicals, and gastric reflux.

Treatments

For nodules, voice therapy is almost always recommended as the first line of treatment. In addition to voice hygiene intervention, voice production is usually addressed using Resonant Voice Therapy, Vocal Function Exercises, Accent Method, Confidential Voice Therapy, Biofeedback, or other methods, discussed in Part Two. In some cases, after voice therapy has been completed, voice is improved but is not yet back to normal. In such cases, patients may wish to talk with their physicians about laryngeal microsurgery and its possible benefits. For polyps, voice therapy may be recommended as the first part of treatment, as for nodules. However, in some cases, surgery is recommended first, followed by voice therapy. Voice therapy for polyps is usually similar to therapy for nodules.

Cysts

Description

Cysts in the vocal folds are similar to cysts other places in the body. They are essentially fluid-filled sacs surrounded by a layer of “skin.” Often, a single cyst forms at the middle of one vocal fold, where impact stress is greatest. The other vocal fold usually develops a “reactive swelling” caused by the cyst hitting up against it. Although physicians can usually distinguish a cyst from other similar-appearing lesions such as nodules and polyps by regular clinical examination, the final diagnosis can be made only if the cyst is surgically removed and inspected under a microscope.

Causes

No one really knows the exact causes of vocal fold cysts. Because they often form at the middle of the vocal fold, where impact stress is the greatest during voicing, most people think that voice use does play some role in their development.

Treatments

Cysts do not go away with voice therapy alone. However, voice therapy is usually the first treatment approach, for two reasons. First, the cyst may be surrounded by swelling, and the opposite fold usually has swelling as well; voice therapy should be effective for reducing the swelling, and thus, improving symptoms. Second, the results from voice therapy can help to make the diagnosis: If a lesion goes away with therapy, then it probably wasn’t a cyst. If it doesn’t go away, then it might be a cyst, and surgery may be appropriate.

Polypoid Degeneration

Description

Despite the similarity in their names, “polypoid degeneration,” also called Reinke’s edema, looks a bit different from polyps. Whereas polyps are distinct lesions that usually form at the middle of one or both vocal folds, polypoid degeneration involves irregular swelling and “ballooning” along the whole length of both vocal folds. A tale-tell symptom is extremely low speaking pitch, especially in women.

Causes

Often, polypoid degeneration is seen in persons who have used their voices heavily, and who have also been exposed to irritants such as smoke, chemicals, or gastric reflux. Heavy alcohol use may increase the likelihood of this condition.

Treatments

Treatment depends on the patient’s needs, and the severity of the lesions. If the swelling is so large that it starts to obstruct the airway, surgery is indicated. If, instead, the swelling is slight, then voice therapy is usually used as a first approach. Therapy is often successful at reducing the swelling and improving symptoms.

Hemorrhage

Description

Hemorrhaging within the vocal folds involves bleeding into the tissue. Small vessel ruptures can cause tiny, visible capillaries sometimes called “varices” (varix, singular) or “capillary ectasias.” Larger bleeds involve a broader perfusion of blood into the tissue. 

Causes

One cause of hemorrhaging in the vocal folds is extremely loud voice use, for example, screaming. Other types of heavy voice use can also cause broken capillaries in the folds. Sometimes visible blood vessels feed into vocal fold lesions and help to maintain them. This occurs sometimes for polyps and often with cancerous tumors.

Treatments

The treatment of vocal fold hemorrhage depends on the cause. If the bleed is new and extensive, the treatment of choice is usually complete voice rest for several days or even a few weeks. More commonly in Europe than in the United States, medications may also be prescribed, which are thought to assist in blood absorption. Patients are advised to avoid blood thinners including aspirin and alcohol when possible. If prominent vessels persist, or if they are due to benign or cancerous lesions, surgery may be undertaken to both remove the lesions and cauterize the vessels.

Sulcus

Description

Sulcus literally means “groove.” In the most general sense, a vocal fold sulcus is a groove that forms in the vocal fold tissue. Many clinicians use the term “sulcus vocalis” to refer to any type of groove in the vocal folds. Other clinicians distinguish between different types of grooves and “sulci” (plural of “sulcus”). A “physiologic sulcus” is a shallow groove running from the front to the back of a vocal fold, which is seen in many people and may not cause any trouble for the voice at all. “Sulcus vergeture” is a somewhat deeper groove, and may produce voice symptoms. True “sulcus vocalis” is a deep pit in the vocal fold tissue, which goes all the way to the muscle, and can severely impair voice. Common complaints of sulci are voice weakness, fatigue, and a “reedy” or “veiled” sound.

Causes

There is debate about the cause of vocal fold sulci. In some cases, they may result from a cyst that has ruptured. In other cases, they may be present from birth.

Treatments

Although voice therapy may help to improve some of the symptoms of sulcus, usually therapy does not make the symptoms go away entirely. In such cases, surgery may be used. The type of surgery depends on the type of sulcus; the outcome of surgery is variable, ranging from distinct improvement to, unfortunately, little change in symptoms.

Bowing

Description

Bowed vocal folds are literally folds that look like two bows joined at the front and back. The back and front of the vocal folds may come together, but the middle part stays open. Typical symptoms are weak voice and vocal fatigue.

Causes

The most common cause of bowing is “presbylarynx,” which literally means “old larynx.” However, bowing can also occur in young persons. In many cases, bowing at any age comes from a subtle lack of “nerve” input to the vocal folds. The result is a lack of closure in the middle part of the vocal folds, and over time, also a loss of muscle bulk in the vocal folds adding to difficulty with closure. There is also speculation that bowing might be caused by muscular over-use, especially if seen in young adults.

Treatments

Almost always, the first line of treatment for bowing is voice therapy. Therapy can be used to exercise the vocal folds and to bulk them up to get the best vocal fold closure possible during voicing. Therapy can also help to reduce the over-activity of other muscles that often occurs as a compensation for poorly closing vocal folds.
Specific voice therapy programs that address these goals include Vocal Function Exercises, pushing exercises, Lee Silverman Voice Treatment, Resonant Voice Therapy, or Accent Method. In extreme cases of bowing or with persons too cognitively impaired to successfully use behavioral methods, one or both vocal folds may be injected with material to add bulk. 

Granulomas

Description

Granulomas are comprised of grainy tissue that builds up in the larynx, usually at the back of the vocal folds near the cartilage called the “vocal process.” Sometimes, a granuloma is seen on one vocal process, and a ulcerated pit is seen on the other vocal process where the granuloma hits up against it. This combination is referred to as a classic “cup and saucer” appearance.

Causes

Many granulomas are clearly caused by the reflux of stomach acids onto the back of the vocal folds. Otherwise, granulomas can be caused by the insertion of airway tubes during surgery, the prolonged use of airway tubes after surgery, and some disease states such as tuberculosis and HIV+. There is some evidence that a low pitch and overactivity of the back part of the larynx may also contribute to granulomas in some cases.

Treatments

Gastric reflux treatment is almost always part of the treatment program for granulomas, even if a person is not known for certain to have reflux. This treatment usually involves a combination of medication and dietary regulations. If the lesions are very large or do not respond to medication, then treatment may proceed with either microsurgery or voice therapy, or both. Because granulomas often recur, the treatment program is usually comprehensive in order to address several of the factors known to increase the risk of recurrence (ongoing reflux treatment and change of voice use patterns).

Vocal Fold Paralysis and Paresis

Description

Vocal fold paralysis is a condition in which one or more nerves to the vocal folds work poorly, and the vocal fold does not move or deform normally. In most cases, the vocal folds do not close, or do not close well. Also, the vocal folds may not elongate normally to produce high pitches. In other cases, which are more rare, the vocal folds do not come apart properly, and breathing can be difficult. Paresis is a similar condition, only less severe.

Causes

Many different things can cause vocal fold paralysis and paresis. One of the most common causes appears to be viral: A person gets a cold or upper respiratory flu, resulting in a temporary laryngitis that then does not resolve normally. Other common causes are surgery (chest, neck or shoulder surgery), heart problems, and more rarely, tumors or brain diseases.

Treatments

Before treatment plans can be made, an attempt is usually made to determine the cause of the paralysis or paresis. If the condition followed a respiratory infection and laryngitis, or if no cause can be found, the condition is usually assumed to be viral.
Special tests may be conducted to determine if the paralysis or paresis is new or old, and if it is getting worse or getting better (“laryngeal electromyography”). Further treatment will be planned based on the initial findings. Clearly, if the patient is having difficulty breathing, surgery may be performed first to improve the airway. Otherwise, in some cases a “wait and see” approach will be taken, especially if symptoms are not severe. Or, voice therapy may be started to help improve vocal fold closure using programs such as Vocal Function Exercises, pushing exercises, Resonant Voice, Accent Method, or Lee Silverman Voice Treatment. Finally, in some cases microsurgery is used to mechanically reposition the affected vocal fold so that it gets good closure with the other one, thereby improving voice and even swallowing.

Spasmodic Dysphonia

Description

Spasmodic dysphonia (SD) is a type of “focal dystonia.” In general, a focal dystonia is a condition in which movement is abnormal in an isolated body part, especially during meaningful tasks (such as speech). In spasmodic dysphonia, which affects voice, vegetative functions such as coughing, laughing, and even singing may be normal. Two types of SD are recognized. In adductory SD (AD-SD), the more common type, the voice shuts off as the vocal folds spasm shut abruptly at irregular intervals during speech. In abductory SD (AB-SD), the voice feels as though it “gives way” during speech, as the vocal folds themselves may fail to come together and maintain normal contact.

Causes

The exact causes of SD are unknown. However, in many cases, the cause appears to involve a minor nerve or brain abnormality that is unrelated to any other disease. The abnormality does not cause any other problems besides speech problems. For AD-SD, one set of research findings suggests that the cause may involve abnormal reactions to stimulation of the vocal fold nerves. Rarely, SD or at least a condition that sounds like it, may be caused by stress.

Treatments

Currently, the main treatment of choice for SD involves the use of a very small amount of “botulinum toxin” (also called “botox”) injected into one or both vocal folds or in other muscles near them. With these injections, the treated vocal fold is temporarily weakened and the spasms are reduced. When the effect wears off, usually within about 3-5 months, spasms tend to recur and the patient returns for another injection. There is some evidence that a limited number of voice therapy sessions, aimed at minimizing the force of vocal fold contact (for AD-SD), may enhance the effect of the “botox” and make it work longer. Confidential Voice Therapy and yawn-sigh therapy are examples of treatments that are often used in voice therapy for AD-SD.
When SD-like symptoms are related to stress, voice therapy is the treatment of choice. In such cases, therapy may focus on stretching and relaxation.

Puberphonia

Description

Puberphonia involves the persistence of adolescent voice after puberty, especially in the absence of organic causes. The condition is most commonly seen in males who continue to use a high pitch in speech. Occasionally, puberphonic voice is encountered also in females who use a high-pitched “little girl” voice.

Causes

The causes of puberphonia have not been systematically studied. It is assumed that either “learning” or psychological causes contribute to the problem.

Treatments

Usually, puberphonia can be successfully treated with voice therapy. Typical approaches include reassurance that there is no physical problem causing the high pitch, and laryngeal massage. A normal-pitched voice often can be elicited during the first or second therapy session. The main challenge at that point is for the patient to accept and habituate the new “adult” sound or role.

Transgender Voice Problems

Description

Transgender voice problems occur when a person of a given biological gender (male or female) wishes to appear as a person of the opposite gender. Such problems are more commonly encountered in biological males who strive for a female image than the reverse.

Causes

Transgender voice problems are caused by anatomical differences between male and female voice production systems, and a mismatch between biological capabilities and social propensities. Additionally, cultural factors tend to influence voice inflection and language in gender-specific ways. Thus, a mismatch between voice inflection and language on one hand, and intended gender on the other hand, also cause confusion in gender identification.

Treatments

Transgender voice treatment may include behavioral, medical, and surgical interventions. Behavioral intervention refers to voice and speech therapy, and is a critical component of treatment success. Medical interventions sometimes involve hormone treatments in conjunction with other aspects of transgender management.

The success of surgical interventions for voice is varied; sometimes observable voice changes are attained and sometimes not. Voice therapy is often key in helping to optimize a surgical outcome.