You are in: eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > LARYNGOLOGY Functional Voice DisordersArticle Last Updated: Jun 28, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: John Werning, MD, DMD, FACS, Assistant Professor, Department of Otolaryngology-Head and Neck Surgery, University of Florida John Werning is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Head and Neck Society, and American Medical Association Coauthor(s): Linda McAllister, MA, CCC-SLP, Director of the Voice and Swallowing Center, Department of Otolaryngology-Head and Neck Surgery, Medical College of Ohio; Kim Antush, MEd, Consulting Staff, Department of Otolaryngology, Medical College of Ohio Editors: John Schweinfurth, MD, Associate Professor, Department of Otolaryngology, University of Mississippi Medical Center; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Stephen G Batuello, MD, Consulting Staff, Colorado ENT Specialists; Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders; Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine Author and Editor Disclosure Synonyms and related keywords: oropharynx, voice, larynx, dysphonia, conversion dysphonia, polyps, nodules, vocal cord nodules, Reinke edema, psychogenic voice disorder, vocal misuse, vocal abuse, falsetto, puberphonia, mutational falsetto, muscle tension dysphonia, tension-fatigue syndrome, dysphonia plicae ventricularis, false vocal fold phonation, ventricular dysphonia, spasmodic dysphonia, laryngeal dystonia, paradoxical vocal fold dysfunction, vocal cord dysfunction, factitious asthma, psychogenic asthma INTRODUCTIONSection 2 of 10
  Human voice production involves the synchronization of optimal glottic positioning and control of the airflow from the lungs to the oropharynx. Laryngeal function must be coordinated, efficient, and physiologically stable to produce a normal voice. Any imbalance in this delicate system affects vocal quality. When vocal quality deteriorates and both anatomic and neurologic etiologic factors are excluded, a functional voice disorder should be suspected. Functional voice disorders account for at least 10% of the cases of dysphonia referred to multidisciplinary voice clinics. They occur predominantly in women, are frequently transient, and commonly develop after an upper respiratory infection. Functional voice disorders can be misdiagnosed because they can have variable presentations and multiple causative factors. Psychosocial issues are frequently present in patients with functional voice disorders, and many patients have symptoms that fulfill the Diagnostic and Statistical Manual of Mental Disorder (DSM-IV) criteria for a mood disorder, an anxiety disorder, or an adjustment disorder. Patient response to these psychological stressors may result in a variety of voice disorders with different clinical manifestations. Furthermore, the role that psychogenic factors play in a particular voice disorder varies from patient to patient. This article provides an overview of the diagnosis and management of functional voice disorders. For excellent patient education resources, visit eMedicine's Ear, Nose, and Throat Center. Also, see eMedicine's patient education article Strep Throat. Classification Consensus is lacking regarding classification of functional voice disorders. Some authors classify polyps, nodules, and Reinke edema as functional voice disorders, while others classify them as anatomic or structural abnormalities secondary to vocal abuse. Furthermore, disagreement exists about the etiology of some functional voice disorders. Many voice disorders are recognized by different names, resulting in additional confusion. The authors have divided the functional voice disorders into 4 categories based on etiology:
CLINICAL EVALUATIONSection 3 of 10
History A complete history must be taken, including characterization of the patients' specific vocal complaints and any precipitating factors. A recent upper respiratory infection may serve as a catalyst that forces an already stressed vocal tract into a more severely imbalanced state. Vocation (eg, singing, athletic coaching) and use or misuse of the voice in this vocation must be assessed. The patient's general health, including medications, should be reviewed. Neurologic disorders such as generalized dystonia or myasthenia gravis should be excluded, and any history of laryngeal trauma or neural injury resulting from prior neck surgery or trauma should be obtained. A history of temporomandibular joint disorders, cervical myalgia, or muscular fatigue may be suggestive of hyperfunction. Other medical disorders, including gastroesophageal reflux and laryngopharyngeal reflux as well as endocrinopathies such as hypothyroidism, must be excluded. Any psychiatric history or recent history of psychosocial stressors should be elicited. A complete social history must be obtained to evaluate for exposure to irritants such as tobacco smoke, alcohol, caffeine, dairy products, chocolate, mints and occupational irritants. Clinical evaluation Initial assessment of vocal quality for the range ease, volume, and quality of the voice occurs during the patient interview. All patients must undergo a complete ear, nose, and throat examination to assess nasal airway patency, pharyngeal function, and velopharyngeal competency and evaluate for xerostomia and dental wear suggestive of bruxism. Hearing loss also may result in voice strain because the patient may speak with greater volume. Flexible fiberoptic laryngoscopy should be performed in addition to indirect laryngoscopy because it allows the examiner to observe the larynx in a more functional state. If a functional voice disorder is suspected, the patient is usually referred to a speech-language pathologist to obtain measurements of acoustic, aerodynamic, and perceptual voice parameters. Laryngeal videostroboscopic assessment also may be performed to more closely visualize the vocal folds' vibratory patterns during selective speech tasks. A functional voice disorder can be diagnosed only after a complete history, clinical examination, and voice assessment have been performed and no anatomic, neurologic, or other organic cause can be identified for the dysphonia. The diagnosis of a particular voice disorder is dependent on characterization of the patient's voice symptoms. PSYCHOGENIC VOICE DISORDERSSection 4 of 10
Psychogenic voice disorders are maladaptive responses that result at least partially from psychological stressors and conditions in the patient. Psychological assessments of patients with functional voice disorders have been performed using the Minnesota Multiphasic Personality Inventory. These patients demonstrated elevated levels of anxiety, somatic complaints, introversion, and poor levels of adaptive functioning. Conversion dysphonia The development of conversion dysphonia, also called functional dysphonia/aphonia, may result from a temporally related psychologically or emotionally traumatic event. Conversion disorder is a somatoform disorder in which the symptoms are not intentionally produced or feigned by the patient. The patient's vocal quality is usually hypofunctional, or aphonic. Fiberoptic laryngoscopy may demonstrate a lack of vocal cord adduction during attempted phonation. However, coughing and throat clearing demonstrate normal vocal cord adduction. Treatment is voice therapy. Patients also may require psychotherapy to address the underlying psychological trauma. Falsetto Patients experiencing falsetto (also called puberphonia or mutational falsetto) present with a disorder of pitch control. The typical patient is a young male of pubertal age who is suffering emotional stress resulting from the psychosocial changes of adolescence. The adolescent's voice fails to descend to a normal adult pitch level at puberty. Falsetto is typically responsive to voice therapy. Occasionally, psychological counseling may be beneficial. DISORDERS OF MISUSE OR ABUSESection 5 of 10
Patients with disorders of misuse or abuse typically manifest hyperlaryngeal function, which may be secondary to increased muscle tension or vocal abuse resulting from behaviors such as frequent throat clearing or professional singing. Psychogenic factors may also play a role in their development. Muscle tension dysphonia In muscle tension dysphonia, excessive tension of the laryngeal or extralaryngeal muscle or both results in altered phonatory function. Numerous factors may contribute to the development of this disorder, including gastroesophageal reflux, stress, and excessive voice use and loudness. Patients with muscle tension dysphonia (also called tension-fatigue syndrome) frequently demonstrate significant emotional stress and manifest other symptoms of muscle tension such as neck and shoulder strain. Extended periods of voice use result in vocal effort and fatigue that intensifies over time. Patient subgroups who are at increased risk for muscle tension dysphonia include singers and speakers with extraordinary voice demands and patients with learned adaptations following an upper respiratory tract infection. Treatment options include voice therapy and biofeedback that focus on muscle tension reduction. Such treatment modalities require identification of the reasons for hyperfunction. A technique known as manual laryngeal tension reduction, or circumlaryngeal massage, also may be beneficial in these patients. Dysphonia plicae ventricularis Typically, patients with dysphonia plicae ventricularis (also called false vocal fold phonation or ventricular dysphonia) demonstrate a low-pitched, coarse or rough, monotone voice. The voice may have a breathy quality. Usually, hyperadduction of both the true and false vocal folds is present. Because the ventricular folds have difficulty in making a good firm approximation along their entire length, severe hoarseness and breathiness often result. Vocal fold scarring may be mistaken for this disorder and must be ruled out. This disorder is frequently responsive to voice therapy that focuses on gestures such as gargling and sighing, which relax supraglottic muscles and isolate true vocal fold adduction from false vocal fold adduction. IDIOPATHIC DISORDERSSection 6 of 10
Spasmodic dysphonia A significant number of authorities purport that spasmodic dysphonia, or laryngeal dystonia, is a neurologic disorder described as a focal action dystonia in which volitional activation of speech results in involuntary adduction or abduction of the vocal cords, resulting in abnormal speech production. Other focal dystonias include blepharospasm, oromandibular dystonia, and torticollis. This disorder may be precipitated or exacerbated by an upper respiratory tract infection, excessive voice use, or psychological stress. However, dystonias are often incorrectly attributed to psychological causes, and the rate of psychopathology in patients who have spasmodic dysphonia is much lower than in those patients who have been diagnosed with other forms of functional dysphonia. Blitzer et al published a series of 901 patients with spasmodic dysphonia. Of these patients, 63% were female, and their average age of onset was 39 years. Adductor spasmodic dysphonia was diagnosed in 83% of the patients, while 17% were diagnosed with the abductor type. Adductor spasmodic dysphonia demonstrates hyperadduction of the vocal folds, producing an irregular, interrupted, effortful, strangled, strained, staccato voice. Abductor spasmodic dysphonia demonstrates a voice that is abruptly interrupted by a breathy hypophonic voice, causing aphonic or whispered segments of speech. In addition, a mixed adductor-abductor form of spasmodic dysphonia exists. The following 3 main treatment modalities exist:
Paradoxical vocal fold dysfunction The etiology of paradoxical vocal fold dysfunction may be psychogenic in some patients and associated with gastroesophageal reflux in others. Increasing evidence suggests that a relationship between chronic cough and paradoxical vocal fold dysfunction exists. This disorder is more common in females and teenagers. Paradoxical vocal fold dysfunction is also known as vocal cord dysfunction, factitious asthma, episodic laryngeal dyskinesia, and psychogenic stridor. Patients experiencing paradoxical vocal fold dysfunction present with sudden difficulty in breathing, which is often diagnosed as difficult to control asthma that is not responsive to treatment. Episodes may be exercise-induced. Laryngeal stridor may be present. Most patients have no dysphonia, but some are significantly dysphonic. The paradoxical nature of this disorder involves the adduction of vocal folds during inhalation when they should abduct, resulting in stridor. Laryngoscopy, however, demonstrates no laryngeal structural abnormalities. Paradoxical vocal fold dysfunction is usually responsive to voice therapy and, when indicated, psychological counseling. Significant dyspnea may require the use of botulinum toxin or anxiolytics. ORGANIC ABNORMALITIES RESULTING FROM MISUSE OR ABUSESection 7 of 10
Anatomic abnormalities such as vocal cord nodules, polyps, intracordal cysts, edema, laryngitis, and sulcus vocalis, as well as other abnormalities may result from a functional voice disorder (vocal misuse). However, poor vocal hygiene (abuse) is the most common cause of these organic findings. VOCAL REHABILITATIONSection 8 of 10
Vocal hygiene All voice rehabilitation should include the elimination of vocally abusive behaviors such as throat clearing, habitual yelling or screaming, habitual breath holding or improper glottic valving during exercise. In addition, caffeine and alcohol intake should be eliminated, and irritative inhalants such as tobacco and toxic chemicals should be avoided. Furthermore, medications with drying potential should be minimized, and gastroesophageal reflux should be controlled. Increased fluid intake to optimize laryngeal hydration is crucial to proper vocal hygiene. Voice therapy Stemple has classified the different treatment philosophies of voice therapy into the following 5 categories.
In reality, voice disorders are usually treated by combining a number of therapeutic modalities. A multimodal approach is frequently essential, since many of these voice disorders have psychogenic overlay. MULTIMEDIASection 9 of 10
REFERENCESSection 10 of 10
Functional Voice Disorders excerpt Article Last Updated: Jun 28, 2006 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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