About Voice Disorders

Our voice is one of the characteristics that make us uniquely different from each other. It is the primary instrument with which we project our personalities and influence others. The voice originates in the larynx or “voice box”. The voice box (larynx) consists of cartilage, muscle and mucous membranes situated at the top of the windpipe (trachea) and the base of the tongue. Sound is produced when air pushes from the lungs causing the mucous membrane lining the vocal folds vibrate. The vocal cords are also responsible for helping to protect the upper airway during swallowing to prevent aspiration.

The quality of the voice depends on the condition and movement of the vocal folds. If the vocal folds become swollen, inflamed, develop growths or become paralyzed, they cannot vibrate properly. This can result in a voice disorder.

Voice problems may arise from various local and systemic diseases, trauma, or improper use. Some of the most common causes of voice dysfunction:

• Illness such as common colds or upper respiratory infections
• Allergies
• Esophageal reflux
• Vocal misuse (screaming, prolonged singing out of range)
• Aging
• Scarring from neck surgery or from trauma to the front of the neck
• Drinking
• Smoking
• Cancer
• Thyroid problems
• Neurological disorders
• Psychological stress
  

Symptoms

Common symptoms of a voice disorder include:

• Hoarseness - Hoarseness is the most common symptom of a voice disorder. Anyone who has had hoarseness for more than a week should see a doctor. In the majority of cases, hoarseness and other voice problems are a result of vocal abuse and overuse. In some cases, however, hoarseness may be a symptom of vocal cord paralysis, neurologic disease, acid reflux, thyroid disorders or cancer.
• Breathy vocal quality
• Chronic cough or excessive throat clearing
• Vocal strain or fatigue
• Inability to speak loudly
• Loss of voice
• Reduced pitch range or sudden change in overall pitch
• Sudden or gradual change in overall vocal quality
• Tremulous quality in the voice
• Decreased breath support during speech

Types of Voice Disorders

There is a wide array of voice disorders. These are some of the more commonly seen types of voice disorders:

• Laryngitis - is an inflammation or swelling of the vocal folds caused by excessive use of the voice, bacterial or viral infections, or irritants such as inhaled chemicals or stomach acid that has backed up into the throat.
• Polyps on the vocal folds -polyps are benign growths similar to vocal nodules but are softer and more like blisters than calluses. They most often form on only one vocal cord. Chronic misuse of the voice is often associated with vocal fold polyps.
• Nodules on the vocal folds - Vocal nodules are small, benign (noncancerous) callus-lile growths on the vocal cords, usually related to vocal abuse. Nodules are the most common type of voice disorder among teachers and professional singers.
• Cysts on the vocal folds - Cysts are collections of fluid in sac-like formations on the vocal folds.
• Vocal fold paralysis - Vocal cord paralysis (or paresis) is a common disorder caused by one or both of the vocal cords not opening or closing properly. Someone who has vocal cord paralysis often also has difficulty swallowing and coughing because food or liquids can slip into the trachea and lungs.
• Muscle Tension - The vocal folds are basically two muscles with mucous layers. When the vocal folds, or the surrounding muscles become too tense, vibrations of the vocal folds is disturbed. This can lead to vocal fatigue or strain with prolonged use.
• Neurologic voice disorders (spasmodic dysphonia) - Spasmodic dysphonia is a voice disorder caused by involuntary movements of one or more muscles of the voice box (larynx), causing the voice to sound strained or strangled.
• Paradoxical Vocal Fold Dysfunction (PVFD) is a breathing problem that occurs when the vocal folds close instead of open. PVFD is common in athletes and is often misdiagnosed as asthma. In fact, patients may be seen by multiple specialists before a diagnosis is made.
  Common symptoms of PVFD include: wheezing, shortness of breath, voice changes, dry cough, exposure to cigarette smoke, exercise, and tightness of the throat and chest.

Diagnosis of Voice Disorders

Diagnosing voice disorders starts with a detailed history and a thorough physical examination. At the Riesberg Institute we provide several diagnostic methods to help determine the cause of a voice disorder, including:

• Basic mirror exam -- By placing a small laryngeal mirror at the back of the throat, Dr. Riesberg can inspect the vocal folds for abnormalities.
• Flexible laryngoscopy -- A narrow, flexible viewing tube is inserted into the nose to allow Dr. Riesberg to view the vocal folds. The tube has a light at one end and a viewing piece or camera at the other.
• Video stroboscope -- A video camera combined with a flashing light source offers a slow-motion view of vocal fold movement. A slow motion effect is created by the video examination which is not possible by direct examination with the naked eye. The procedure provides valuable information any pathology on the vocal folds, the fine patterns and movements of vocal fold vibration, and the structural characteristics of the larynx. The video recording provides a permanent record of the examination which can be reviewed by the physician and speech pathologist.
• Vocal Acoustic Analysis -- This test measures irregularities in the sound produced by vocal fold movements.
• Direct laryngoscope -- Doctors use a rigid viewing scope to examine vocal folds.

Treatment Options

Once the diagnosis is determined, Dr. Riesberg may recommend one or more of the following treatments:

Medications

Medical intervention is also available for treating voice disorders. Certain medications be taken orally, injected into the vocal folds, or applied topically during surgery -- depending on the underlying cause of the voice disorder. Dr. Riesberg has advanced training in the medical treatment of voice disorders.

Voice Therapy

May times the first, and most effective, treatment for vocal disorders is practicing proper hygiene and hydration. Like any other part of the body, the vocal folds need regular rest and fluids. The purpose of voice therapy is to help you attain the best possible voice and the most relief from the vocal symptoms. Our office is staffed with a Speech-Language Pathologist who can provide guidance about how to use and rest the voice.

Surgery Options

Removal of lesions -- Lesions (nodules/polyps) usually only form on the vocal folds after a prolonged period of abuse. They can occur from a combination of events such as a respiratory infection (hard coughing) or chronic misuse of the voice. When a permanent lesion forms, it takes up space between the edges of the vocal folds and disturbs the vibration of the vocal folds, and disrupts the airflow to the lungs. To regain normal vibrations and airflow, the lesion must be surgically removed. Surgical options are usually made after a trial of voice therapy.

Bulk injection -- If vocal folds are determined to be too far apart, due to weakness or extreme muscle tension, Dr. Riesberg may inject or implant a substance such as body fat or collagen (a synthetic material) to add bulk to vocal folds. This moves the folds closer together so they can more easily make contact. This provides a temporary treatment allow time for the body to recover for and vocal fold trauma.

Botulinum (Botox) toxin treatments -- The purpose of this treatment is to decrease muscle spasms or abnormal movements for people who have spasmodic dysphonia (a neurological movement disorder that affects the vocal muscles of the larynx). During the treatment, tiny amounts of purified toxin are injected into muscles, causing them to relax for up to five - six months.

Thyroplasty -- This surgical procedure adjusts the cartilage (were the vocal folds are attached) by pushing the folds together. This is often used for vocal fold paralysis or paresis. Thyroplasty has the added benefit of not disturbing the movement of vocal fold lining tissue, which helps preserve the voice.

Swallowing Disorders

The act of swallowing is an orchestrated event involving many muscles. Problems may occur in the mouth (oral stage) involving the lips or tongue. The pharynx (pharyngeal stage) with foods sticking in the throat or things going down the wrong way. And finally, the esophagus (esophageal stage) involving problems with the tube leading to the stomach.

Symptoms

The most common signs of a swallowing problem include:

• Coughing while eating or drinking, or very soon after eating or drinking
• Your voice sounds wet or gurgly during or after eating
• Multiple swallows are needed on a single mouthful of food
• Increased congestion in the chest after eating or drinking
• Difficulty or increased effort to chew or swallow
• Fatigue or shortness of breath while eating
• Spike in temperature
• Weight loss associated with increased slowness in eating
• Recurrent unexplained pneumonia or upper respiratory infections
• Weight loss
• Drooling or leakage from the mouth and lips

Evaluation

At the Riesberg Institute we offer FEES (Fiberotic Endoscopic Evaluation of Swallowing evaluations. The test involves passing a flexible scope through the nose and recording video images while the patient eats and drinks. A physician reviews the exam and makes a medical diagnosis, and a speech pathologist makes recommendations for rehabilitation and/or compensatory techniques to make swallowing easier.

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Reflux Disease

Silent acid reflux disease can also cause problems with the speaking. It also affects the singing voice; professional voice users may notice the following common symptoms:

• Reduced range
• Gaps in the range
• Vocal fatigue
• Throat clearing
• Cough
• Feeling as though there is a lump in the throat

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