Common Voice Disorders

Vocal Fold Nodes or Nodules

These can be thought of as calluses of the vocal cords and are generally due to some form of trauma. The most common cause is voice abuse. In children they are often called "screamers nodes." Other factors which seem correlated are poor vocal hygiene, such as excessive voice use or singing during a significant upper respiratory infection, or chronic coughing and throat clearing which may be due to other underlying medical conditions such as gastroesophageal reflux or asthma.

Vocal nodules are often broken down into soft and hard nodules or early and late nodules. If one likens vocal nodules to calluses on the hands, then soft or early nodules are like the calluses that a non-manual laborer gets after a weekend of gardening, whereas hard or late nodules are like the changes that occur on the hands of someone who performs heavy manual labor for many years. The nodules become essentially scars.

The pathology in vocal nodules is confined to the surface covering of the vocal cord, where a thickening is seen which causes stiffness that interferes with vocal cord vibration, hence, the hoarse voice quality.

Surgery is typically avoided in the treatment of vocal cord nodules since the scarring which may result from removal of the nodule may interfere more with vocal cord motion than the nodule itself. Sometimes surgery is necessary for the most advanced vocal fold nodules, but this is quite rare. Voice rest or reduction in the amount of use, as well as learning proper use of the voice, are the mainstays of treatment. Typically speech / voice therapy is the treatment of choice. Any exacerbating underlying medical conditions must of course also be treated.

Vocal Fold Polyps/Reinke's Edema

hese again are usually traumatic or irritative in origin. Polyps are fleshier than nodules and not necessarily bilateral as are nodules. A single polyp may arise from a specific traumatic event. Reinke's edema is a clinical term used to describe a common form of chronic laryngitis, wherein the entire covering of the vocal cords becomes polypoid and swollen. The condition is most often associated with irritation from tobacco smoke and/or alcohol. Gastroesophageal reflux is felt to play a causative role in many cases. These irritating substances are often coupled with some form of underlying voice abuse. The treatment is usually surgical excision, although occasionally a small polyp may respond to voice therapy. It is essential that the underlying irritating condition be treated or stopped, or the chronic laryngitis will return.

Vocal Fold Cysts

The exact cause of vocal cord cysts is unknown. They may be congenital, or may result when a damaged area of the vocal cord heals. In this case the pathology is just under the surface of the vocal cord. Special surgical techniques which remove the cyst from the vocal cord while keeping trauma to the overlying surface of the vocal cord at a minimum are used to remove cysts.

Vocal Fold Paralysis

The first step in treating a patient with vocal fold paralysis is trying to ascertain the cause of the paralysis. This usually requires imaging studies of the neck and chest. In some cases a cause is never found. Such cases are usually attributed to a viral infection of some sort. A variety of treatments exist depending on the severity of the paralysis. Two nerves innervate each side of the larynx and any combination of the four nerves may be involved. Sometimes special testing known as laryngeal electromyography (EMG) is necessary to define which, if any nerves are involved and what the prognosis for recovery is.

Treatments range from voice therapy to strengthen the remaining innervated muscles, to injection of substances into the paralyzed vocal cord, to a variety of operations designed to either push or pull the paralyzed vocal cord back to a more normal position for improved speech. This sometimes requires an incision in the neck, and at other times can be performed endoscopically; that is, working through the mouth. Sometimes, if both vocal cords are completely paralyzed, the patient may have trouble breathing, in which case laser surgery may be used to open a larger breathing aperture. Sometimes a tracheotomy is necessary either temporarily or permanently.

Reflux Laryngitis

Reflux laryngitis refers to irritation of the larynx from stomach contents which reflux back up into the throat. Sometimes patients are unaware of the actual reflux and may have no obvious clinical symptoms. Treatment is aimed at stopping the reflux. The mainstay of treatment is often lifestyle changes including, but not limited to, avoidance of alcohol and tobacco, weight loss, changing dietary habits, and sleeping with the head of the bed elevated. A variety of potent medications exist to change the quality of stomach secretions which can often help. Sometimes special testing such as a 24 hour pH probe study, esophagogram or esophageal manometry are necessary to fully evaluate this condition. In some instances, referral to a gastroenterologist or abdominal surgeon for antireflux surgery is necessary. Antireflux surgery can often be accomplished laparoscopically.

Spasmodic Dysphonia or Focal Laryngeal Dystonia

This is a neurologic disorder in which control of laryngeal function is altered. By far the most common variety is adductor laryngeal dystonia in which the vocal cords shut prematurely and too forcefully during phonation leading to a strained or strangled quality to the voice. An abductor variety also exists in which the voice is excessively breathy. Spasmodic dysphonia often also has a component of tremor associated with the actually spasms.

The mainstay of treatment is speech / voice therapy and Botulinum Toxin injections. (See information under Spasmodic Dysphonia / Botox.)

Laryngeal Papilloma

This represents an infection of the larynx with the papilloma virus. The condition tends to be more pronounced in children, though adults can be affected as well. Rarely the condition can spread to involve the trachea and lungs. Although a variety of antiviral medications have been tried in this condition, none has achieved widespread acceptance, because of toxicity and recurrence once the medication is stopped. The mainstay of treatment remains carbon dioxide laser ablation. The procedure usually must be repeated when the infection recurs, as the laser does not actually cure the infection. In some children laser ablation must be repeated frequently, sometimes even monthly. In adults, partly because of the larger airway, laser treatments usually don't need to be repeated so frequently. After repeated laser treatments, scarring of the larynx may result in other voice problems.

Bowing of the Vocal Folds

Bowing can result from several underlying conditions. Sometimes with age, simple atrophy of the vocal cords results in some bowing and therefore a weaker voice. A condition known as sulcus vocalis, in which a portion of the vocal cord covering becomes pitted and possibly adherent to the underlying vocal ligament, can cause a bowed appearance to the vocal cord. Partial paralysis, or weakness of a vocal cord may also give it a bowed appearance. Treatment usually begins with speech / voice therapy to strengthen the vocal fold muscles. If this is less than optimally successful, then often the vocal cord(s) is augmented with an injection of fat or collagen. Other surgical procedures to medialize the bowed vocal cord may also be helpful.

Muscle Tension Dysphonia / Hoarseness

This is a form of involuntary and inappropriate vocal use on the part of the patient. In general, the muscles of phonation, i.e. the vocal folds, are being overused. The extrinsic musculature around the larynx and at the front of the neck may also be palpably tight and sore. The condition may develop as a maladaptive compensation for some other vocal pathology, or irritant such as gastroesophageal reflux. Occasionally, muscle tension dysphonia may develop in an attempt to use a hoarse, weak voice during or following an upper respiratory infection. Voice therapy is usually the treatment of choice, coupled with identification of any underlying medical conditions that may be exacerbating the problem.

Vocal Fold Granulomas

Granulomas usually develop after acute trauma to the posterior part of the vocal fold opening. The most common etiology is intubation of the larynx during surgery for some other condition. The breathing tube, which is inserted through the larynx, rubs on the posterior part of the opening, and then in an aborted attempt at healing, the granuloma forms. Usually there are exacerbating conditions such as gastroesophageal reflux which further irritate the area and prevent proper healing. A severe upper respiratory infection, chronic coughing or throat clearing, or pitching the voice inappropriately may also result in granuloma formation. Treatment can be quite difficult and frustrating, because if the granuloma is removed surgically, it results in another wound to the area which might simply form another granuloma. Speech therapy, voice rest, steroids, antireflux therapy, and antibiotics can sometimes clear up granulomas after a period of time. Some special surgical techniques, such as injecting the base of the granuloma with a long acting form of steroid after removal, along with the above medical management can sometimes lead to resolution in very severe cases.

Laryngeal Cancer

Laryngeal cancer is a serious, life-threatening disorder. The major risk factors are tobacco and alcohol use. The most common warning signs of laryngeal cancer are voice change, painful or difficult swallowing, coughing up of blood and a lump in the neck. Treatment includes surgery, radiation therapy, chemotherapy and combinations of them. When detected early, most laryngeal cancer can be cured with preservation of the larynx. For patients with advanced cancers requiring laryngectomy (removal of the voice box), excellent techniques for voice rehabilitation exist.

Laryngeal Trauma

Laryngeal trauma can be the result of a blunt, penetrating object, hitting a steering wheel during a motor vehicle accident, or iatrogenic (the result of other medical interventions such as intubation). The aims of treatment are to maintain and restore a normal airway and voice.

Vocal Fold Hemorrhage and Vascular Lesions

These lesions may occur as the result of acute injury such as screaming, coughing or other trauma. Some vascular lesions may be connected with hormonal changes such as occur during the menstrual cycle. Sometimes hormonal manipulation may be helpful in resolving these lesions. At other times, surgical intervention is required, though great care must be taken not to further damage the overlying vocal cord covering