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Voice Disorders

Voice disorders are also called vocal disorders. Voice is the sound made by air passing from your lungs through your larynx, or voice box. In your larynx are your vocal cords, two bands of muscle that vibrate to make sound. For most of us, our voices play a big part in who we are, what we do and how we communicate. Like fingerprints, each person's voice is unique.

Many things we do can injure our vocal cords. Talking too much, screaming, constantly clearing your throat or smoking can make you hoarse. These can also lead to problems such as nodules, polyps and sores on the vocal cords.

Other causes of voice disorders include infections, upward movement of stomach acids into the throat, growths due to a virus, cancer and diseases that paralyze the vocal cords. Treatment for voice disorders varies depending on the cause. Most voice problems can be successfully treated when diagnosed early.

VOICE CONDITIONS
Acute Non-Specific Laryngitis

Laryngitis is an inflammation of the vocal folds and larynx that may cause hoarseness, lowered pitch, or total voice loss. Acute laryngitis may be associated with viral infections, acid reflux, exposure to atmospheric pollutants, tobacco or drugs, or a vocal fold irritation, such as is caused by prolonged shouting.

Chronic Non-Specific Laryngitis

Chronic laryngitis is a result of long-term inflammation of the vocal folds, leading to persistent hoarseness and vocal fatigue. Vocal overuse and misuse is a leading cause of chronic laryngitis. Additional causes include smoking, dehydration including the use of dehydrating medications, acid reflux disease, abusive use of mouthwashes containing alcohol, or the repeated vomiting often associated with bulemia.

Approximately one-third of patients seen for hoarseness are diagnosed with a reflux disease, usually laryngopharyngeal reflux (LPR), which differs from the well-known gastroesophageal reflux disease (GERD). In GERD, the stomach acid refluxes up past the lower esophageal sphincter, usually when the patient is sitting back or lying down, causing heartburn. In LPR, the stomach acid goes all the way to the upper esophageal sphincter even when the patient is upright, bathing the vocal cords in acid and causing swelling that leads to hoarseness. These patients may not even have heartburn.

Using the TNE videolaryngoscopy, the physician can identify erosions and even a condition called Barrett’s esophagus, a sign of chronic acid exposure and a pre-cancerous condition. Treatment for GERD and LPR is the same: dietary restrictions and proton pump inhibitors.

VOCAL OVERUSE AND MISUSE
Vocal Fold Nodules

Vocal fold nodules are the most common non-cancerous vocal fold lesions, and are sometimes referred to as "singers nodes." They are usually bilateral and may vary significantly in size. Nodules may be acute or chronic; chronic nodules are similar to calluses within the vocal fold tissue. Vocal characteristics include hoarseness, breathiness, and lowered pitch.

Vocal Fold Polyps

A vocal fold polyp is a fluid-filled lesion that may occur on one or both vocal cords. They may vary in size and are most commonly attributed to vocal abuse or trauma, cigarette smoking, or vocal fold hemorrhage, but the exact cause is unknown. Vocal characteristics often include hoarseness, breathiness, diplophonia (audible perception of two distinct pitches), and stridor (noisy breathing).

Professional Voice

Singers, actors, teachers, ministers, salesmen, auctioneers, even cheerleaders depend on their voices and are very susceptible to overuse.

Vocal Fold Cysts

Vocal fold cysts are fluid-filled growths that may be congenital or acquired. They may appear on one or both of the vocal folds. Vocal quality consistent with a vocal cord cyst may include hoarseness, breathiness, and voice and pitch breaks.

Reinke's Edema

Reinke's Edema occurs when the membranous portion of the vocal folds become filled with fluid. It may be unilateral or bilateral, and when it becomes very severe, it is often referred to as Polypoid Degeneration. Risk factors include long-term smoking and chronic vocal overuse or misuse. Vocal characteristics consistent with Reinke's Edema include significantly lowered pitch and severe hoarseness.

Muscle Tension Dysphonia (MTD)

MTD is a general term describing excessive and unnecessary tension of laryngeal muscles during voice use. MTD is often thought to be a compensatory mechanism for an underlying laryngeal pathology. Symptoms may include a sensation of excessive laryngeal tension and strain, vocal fatigue, and hoarseness.

Presbylarynx

Normal aging of the larynx can result in loss of vocal fold tone and elasticity, creating hoarseness, breathiness, decreased loudness, and pitch instability. Upon examination, the vocal cords appear to be "bowed", due to vocal fold atrophy (muscle wasting). Voice therapy can increase strength/ tone of laryngeal mucles, improve vocal fold closure, and improve overall vocal quality.

VOICE DISORDERS RELATED TO NERVOUS SYSTEM DISTURBANCES
Vocal Fold Paresis/ Paralysis

Vocal fold paresis (weakness) or paralysis (complete absence of movement) may result from a viral infection, stroke, trauma to the head, recurrent laryngeal nerve damage following surgery to the head, neck, or chest region, or the cause may be unknown. A tumor may also cause immobility of the vocal fold(s). Vocal characteristics consistent with vocal fold paresis/ paralysis include breathiness, hoarseness, diplophonia (audible perception of two distinct pitches), decreased pitch range, and an inability to increase loudness.

Spasmodic Dysphonia

Spasmodic dysphonia describes a group of disorders characterized by involuntary spasms of the vocal folds. The two most common forms are abductor spasmodic dysphonia (increased closing of the vocal folds) or abductor spasmodic dysphonia (increased opening of the vocal folds). The exact cause of spasmodic dysphonia is unknown, but it is thought to have a neurological origin. Other neurological symptoms will sometimes be present, including tremor, facial ticks/ jerks, or other uncontrollable movements. Symptoms may include a strained/strangled voice, or in the case of abductor spasmodic dysphonia, a breathy voice, often with pitch breaks. Symptoms often disappear in whispered or sung speech.

The Voice and Swallowing Center sees more than 200 cases a year. The Center is one of the few practices in this area of the country that successfully uses Botox treatments to control it.

VOICE DISORDERS RELATED TO DISEASE OR TRAUMA
Hemorrhage

A hemorrhage of the vocal fold occurs when a blood vessel ruptures and bleeds into the submucosal layer of the vocal fold. A hemorrhage is usually one-sided, but can occur bilaterally, and is usually the result of a single episode of traumatic voice use. It may also result from a combination of overuse of the voice and taking anticoagulants (e.g., aspirin) or persistent usage of steroidal inhalants. Vocal characteristics include hoarseness, loss of pitch range, and vocal fatigue.

Varix

A varix is a long, defined blood vessel on the surface of the vocal fold, and is often seen in conjunction with a hemorrhagic episode. It is thought to be caused by vocal overuse or misuse and is usually the result of a single traumatic episode. Vocal quality may be hoarse.

Granuloma

Granulomas are vascular lesions that are most often the result of acid reflux into the larynx, laryngeal intubation during surgery, or voice misuse. Because granulomas often occur on the vocal process of the arytenoid cartilage and not on the actual vocal fold, vocal quality may not be affected; however, vocal symptoms may include hoarseness, breathiness, reduced pitch range, and vocal fatigue.

Papilloma

Papillomas are wart-like lesions attributed to viruses. Lesions can invade deep into vocal fold tissue, causing severe hoarseness and breathiness, and in some cases, respiratory problems. Papillomas can occur throughout the larynx and upper airway.

The Center has a high volume of referrals for treatment of adult papilloma. When the papillomas become large enough to interfere with speech or breathing, a laser planes off the growth that extends above the vocal cord. They do grow back, and subsequent treatments are always needed. Children do not seem to need as frequent treatment as adults with this condition.

Contact Ulcers

A contact ulcer is a small lesion that typically develops on the medial portion of the vocal folds. The ulcer may be unilateral or bilateral. Contact ulcers are most often caused by vocal overuse and misuse, acid reflux into the larynx, smoking, and excessive alcohol consumption. Vocal symptoms are often hoarseness, breathiness, lowered pitch, and decreased pitch range.

Carcinoma

Cancer may affect the oral, pharyngeal (throat), or laryngeal cavities. Most laryngeal cancers are of the squamous cell type, and are most often the result of chronic irritation due to cigarette smoke. Laryngeal cancer can be life-threatening, and can also cause devastating changes in voicing, breathing, and swallowing.

Patients who have had their larynx removed either due to trauma or cancer now have more options for regaining their voice, including leading edge surgery to reconstruct the voice box. (http://outlook.wustl.edu/fall2003/talking.html) This surgery is performed at the Washington University Medical Center.

Voice Disorders in Children

Children are often seen with hoarseness as a result of papilloma growths, or laryngeal palsy. (Note to Patty: These two link to the new page on children’s airway disorders)
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Copyright 2014 Washington University School of Medicine