FREQUENTLY ASKED QUESTIONS ON VOICE DISORDERS
· How are voice disorders diagnosed? What procedures are typically used to diagnose voice disorders?
Voice disorders can be defined as health conditions affecting the production of voice. Also, they may be seen as voice problems which have a negative impact on one’s professional, social and emotional life. They can be recognized for instance by abnormal voice quality (hoarseness, breathiness), by abnormal or unstable pitch, a pitch that is inappropriate for age or gender, problems with producing loud voice, inability to speak for long periods, increased vocal effort, fatigability, tremor, voice spasms, etc.
Problems which affect speech rather than voice (i.e., production of speech sounds, words and sentences rather than production of vocal sound) are not considered voice disorders but rather speech disorders. However, speech problems often co-occur with voice disorders.
2) How are voice disorders diagnosed? What procedures are typically used to diagnose voice disorders?
A patient will undergo various examinations, usually in the following order:
1. A detailed history of the client’s voice complaints, social, work and family environment, necessity of verbal communication, daily habits and lifestyle (such as smoking and alcohol consumption), and self-assessment questionnaires to identify the impact of the voice problem in the life of the individual and others. This may involve filling in specific questionnaires (such as Voice Handicap Index - VHI, Voice-Related Quality of Life - VRQOL, Voice Activity and Participation Profile – VAPP, or others).
2. Observation of the larynx, including the vocal folds (commonly known as the vocal cords). This was traditionally done by placing a mirror in the back of the oral cavity (mouth). Nowadays special laryngoscopes (rigid or flexible) with an attached camera are used. They magnify the laryngeal image and enable a video recording of the examination.
3. Perceptual, acoustic and aerodynamic analysis of voice. Perceptual analysis involves a careful and systematic evaluation of how the voice sounds to the listener. Acoustic analysis involves capturing the voice using a microphone for extraction of various parameters to determine the abnormalities in voice (such as, Fundamental Frequency, Intensity, Jitter, Shimmer, Harmonic-to-Noise Ratio, Voice Range and others). Aerodynamic measurements help to understand how much air is available for voice production and how effectively and efficiently it is used for producing a voice. The aerodynamic measurements may require a facemask or tube placed in the mouth to record air flow, air volume and/or air pressure coming from the lungs. The choice and extent of such investigations depend on the type of voice problem and vary among institutes and countries.
4. Bacterial culture, Biopsy, Electromyography (EMG), and others, if and when necessary.
5. Computed Tomography (CT) or Magnetic Resonance Imaging (MRI), if and when necessary.
These diagnostic procedures allow determination of the cause of a voice disorder and assessment of the degree of voice abnormality. The results are used to plan treatment and to make predictions about how the disorder will respond to that treatment.
Items 1 and 2 are conducted routinely. The examinations may be done several times to better plan the therapy and to evaluate treatment progress. These tests/exams may involve participation of different health practitioners and the type of examination may vary in different countries.
Listeners can usually recognize a voice disorder by the presence of abnormal voice quality (hoarseness, breathiness, abnormal pitch, etc.). Subjectively, a voice disorder can be self-detected also by a permanently worsened ability to produce the voice (phonate), a need to use increased effort to phonate, a tendency for the voice to fatigue, etc.
The following are examples of voice symptoms that you can recognize yourself;
- Your voice sounds worse or weaker than it used to
- Your pitch or loudness range is considerably smaller than it used to be
- You experience tenderness or pain in the voice box, jaw muscles or neck muscles during or after voice production
- Your voice is clearly different from persons of your cultural group and of the same age and gender
- You use too much effort to phonate
- You experience uncontrollable episodes of hoarseness, voice loss, voice breaks, voicing weakness, voice spasms, vocal strain or voice tremor
- You have difficulty maintaining phonation for sufficient lengths of time
- You have difficulty speaking with sufficient loudness
- You have problems maintaining an acceptable conversational pitch that conforms with the expectation of your age and gender.
- Your speaking voice sounds monotonous, and you are unable to use the normal range of pitch changes during speaking or singing
- Your voice sounds too nasal or your voice makes you sound as if you have a cold in the nose
The basic rule of thumb is that you should visit a clinician if your voice continues to be hoarse or disturbed for more than two weeks. Hoarseness and voice limitation caused by a cold or by a temporary disability normally disappear within two weeks. Voice abnormality lasting for more than two weeks indicates that the vocal folds have not healed properly and this is a sufficient reason to visit a clinician. An early diagnosis of the cause of the voice disorder, including cancer, allows an early treatment with minimal harm to your voice box.
You may also seek treatment if you believe that your voice has not undergone any changes but it is not adequate to meet your professional or social demands. The symptoms and signs listed under the item 3) above can be used as guidance for seeking the help of a voice specialist. Specialist intervention may also be provided to trans-sexual clients when their voice does not meet the quality required for their intended gender.
Voice treatment protocols vary depending on your country of residence and training of the voice professionals. Generally, there are two basic types of specialists who are trained to deal with voice disorders:
1) Medical specialists (laryngologists and phoniatricians) and
2) Non-medical specialists (speech therapists, speech-language pathologists, logopedists or voice pedagogues).
In many countries, the diagnosis and therapy is done jointly by these two types of voice specialists. Often, they work in the same department. The order of evaluations varies, however – in some countries and clinics the medical specialists require the client to be seen by a speech-language pathologist before performing medical evaluation. In other countries or clinics, medical specialists see the clients first and decide whether they should be seen by non-medical specialists afterwards.
Whenever a voice disorder occurs, the medical specialists should always be consulted. They have the competence to medically diagnose the origin of the disorder, can recognize potential pathological processes and can arrange medical treatment. They could be either laryngologists or phoniatricians. Laryngologists are clinicians who are specialized in dealing with throat disorders and who are educated in the field of Otorhinolaryngology (medical specialty dealing with Ear – Nose – Throat, or ENT). Not every ENT is specialized in throat disorders, however. Some may specialize rather in ear, nose or swallowing disorders, so it may be useful to ask for a throat specialist, especially if you are a voice professional. In some countries, voice disorders are treated by Phoniatricians. They are a specific kind of ENT, who specialize in voice, speech and hearing disorders and are educated as both laryngologists as well as speech-language pathologists. These professionals are trained only in some countries and they can usually arrange both the medical as well as functional examinations of voice and voice therapy.
Non-medical voice specialists perform functional voice evaluation and functional therapy. These are speech-language pathologists (SLPs), who are specialists in voice problems. In some countries, the speech-language pathologists are called logopedists. (Similarly to ENTs, not all speech-language pathologists deal with voice problems; some may specialize, e.g., in stuttering, child language, swallowing, or other issues related to speech, language and communication disorders). In some countries the non-medical voice therapy is arranged by phoniatricians or by voice pedagogues – the medical specialist should be able to provide you with the proper information and recommend a non-medical specialist when needed.
Because voice disorders can be related to various medical, psychological or functional conditions, after the completion of the initial voice evaluation, you might also be referred to other professionals for additional evaluation or treatment based on your specific condition.
Voice disorders in school-age children are mostly associated with overuse of voice. Examples of voice overuse include:
- excessive screaming and yelling,
- excessive speaking and/or singing with an inappropriate pitch and loudness level (such as making funny characters voice),
Vocal nodules present a typical example of a disorder related to voice overuse. They are very common in school-age population and they occur more frequently in boys than in girls. This is probably related to the more active and aggressive voice use in boys than in girls during school years. In adults, vocal nodules are more common in women than in men.
Voice disorders in children may be acerbated by such things as inadequate hydration, esophageal reflux and upper respiratory infections.
Voice disorders in children can also be found in newborns due to inborn structural abnormalities of the larynx. Examples of such structural abnormalities include subglottic stenosis (narrowing of the airway below the vocal folds), laryngomalacia (soft, immature development of the larynx), or vocal fold paralysis. Some children suffer from laryngeal papilloma - a viral disease that involves the growth of numerous wart-like growths on the vocal folds. Infants can contract papilloma during birth through the vaginal canal of a mother with genital warts.
A rather complex problem is vocal cord dysfunction (VCD). The dysfunction involves breathing and manifests itself by the vocal folds closing when they should be opening to let air pass through them. Causes of the dysfunction may include esophageal reflux, allergies, neurological conditions, exercise, anxiety and/or abnormal laryngeal structure. Symptoms range from a feeling of tightness in the throat to vocal stridor, shortness of breath, wheezing, coughing and in extreme cases passing out. The disorder is often misdiagnosed as asthma.
In puberty, the voice undergoes considerable changes, especially in boys, due to rapidly growing laryngeal structures. This causes temporary instability of voice, which normally disappears after puberty. If the voice keeps sounding childish or keeps being unstable also after puberty, it is considered a disorder.
Most commonly, voice disorders result from combination of voice overuse with mucosal irritations. Mucosa covering the vocal folds is more vulnerable to damage when it is irritated, e.g., due to respiratory infections, allergy, or due to stomach fluids entering larynx (so called “acid reflux”) and when it is insufficiently hydrated. Delicate blood vessels embedded in the mucosa of the vocal folds may rupture from heavy voice use (e.g., shouting or loud voicing) and can form a basis of a disorder. Mucosal damage may progressively lead to growths on the surface of vocal folds like vocal nodules or polyps.
People working in occupations, which require heavy voice use (e.g., teachers, call-centre personnel, etc.) are at the greatest risk of developing such voice disorders. Stress, anxiety, and an unhealthy lifestyle further increase the risk. Smoking and heavy alcohol drinking can also contribute to voice problems, as can talking in environments with low humidity, poor air quality or high levels of background noise.
Besides mucosal changes, laryngeal nerves and muscles may sometimes be affected due to an infection, traumatic event or some pathological process. This causes vocal fold paresis or paralysis. In aged people, the tissues of the voice box undergo changes (e.g., ligaments become stiffer, muscles loose volume and become weaker) which causes the voice to change. In some cases these changes may also cause voice problems. Most complex voice disorders are caused by improperly functioning central nervous system (e.g., a brain disease); in these cases the voice disorders are usually secondary to other disorders.
Treatment for voice disorders can be pharmacological (for example, recommendation for specific medicines), surgical (such as surgical removal of abnormal growth), or behavioral (such as an exercise or training regimen for the voice). Often a combination of these approaches is necessary to treat a voice disorder. For example, some voice disorders are best treated by a pharmacological or surgical procedure followed by behavioral treatment. The treatment methods depend greatly on the cause of the disorder.
Pharmacological management is used whenever the changes causing the disorder are reversible. Examples of such medical conditions include: acute inflammation (irritation, e.g., due to a cold), chronic inflammation (irritation, e.g., due to allergy, acid reflux, etc.), hormonal changes, and so on.
Surgical management is used when there are structural changes in the throat or on the vocal folds that cannot be managed by medications or behavioral therapy alone. Examples of such conditions are large vocal nodules, polyps, cysts, papilloma, granulomas, vocal fold paralysis or cancer.
Behavioral voice therapy consists of behavioral techniques that teach the client how to analyze their own voice characteristics and how to optimize the use of their breath support, laryngeal muscle tension, vocal tract resonance, articulation and voice projection to attain the targeted voice that can support one's communication and professional needs.
The scientific literature has also shown that acupuncture is effective in treating certain types of benign vocal lesions. Other forms of alternative or complementary medicine are also available but their effect is still not clear.
Here are a few tips:
DO NOT UNDERESTIMATE HOARSENESS! Hoarseness indicates that your vocal folds (commonly known as vocal cords) are unwell and need care and treatment.
INJURED VOICES NEEDS TIME TO HEAL. Sudden occurrence of hoarseness and throat pain indicate injured vocal folds. Limit using your voice until the pain and hoarseness go away.
IN CASE OF PROLONGED HOARSENESS VISIT A CLINICIAN who is capable of examining your vocal folds. An early diagnosis of the cause of hoarseness, including cancer, can then be treated with minimal harm to your voice box.
DRY THROAT IS DAMAGING FOR VOICE. Avoid speaking heavily in dry environments. Protect your voice by drinking plenty of fluids, especially water. Spirits and caffeine, however, may dehydrate the mucosa and increase the danger of damaging your vocal folds.
DO NOT OVERLOAD YOUR VOICE. Heavy voice use can harm your vocal folds. Remember that vocal occupations such as teaching may involve heavy voice use, which may be risky, especially if you are unwell. (When needed, voice amplification may be used as a solution). Be careful with yelling at sport events. Beware of lengthy conversations in noisy bars and clubs!
AVOID SMOKING AND HEAVY ALCOHOL DRINKING. Excessive smoking and alcohol drinking together increase the risk of laryngeal cancer.
Keep a healthy and well-balanced life-style. Stress and inadequate rest can increase the risk of voice problems.
The following websites can offer more information:
- The Voice Problem Website: http://www.voiceproblem.org/
- Dysphonia: http://www.dysphonia.certec.lth.se/
- Disorders of the Larynx that May Cause a Voice Problem: http://www.nyee.edu/cfv-larynx-disorders.html#nodules
- National Center for Voice and Speech: http://www.ncvs.org/e-learning/health.html
- National Institute on Deafness and Other Communication Disorders: http://www.nidcd.nih.gov/
- The Voice Foundation: http://www.voicefoundation.org/index.php?option=com_content&view=article...
- The Voice Academy: http://www.uiowa.edu/~shcvoice/
Prepared by the Voice Committee of the International Association of Logopedics and Phoniatrics, July 2010