VOICE DISORDERS

 

You may have a voice disorder if you have a problem with pitch, volume, tone, and other qualities of your voice. These problems occur when your vocal cords don't vibrate normally.

Your voice is the sound that air makes when it is forced out of your lungs and passes over your vocal cords. Vocal cords are the 2 folds of tissue inside your larynx, also called the voice box. The vibration of those cords is what produces speech.

Examples of voice disorders include:

  • Laryngitis. Laryngitis is when your vocal cords swell. It makes the voice sound hoarse. Or you may not be able to speak at all. Acute laryngitis happens suddenly, often because of a virus in the upper respiratory tract. It often lasts just a few weeks. Treatment is to rest the voice and drink plenty of fluids. Chronic laryngitis is when the swelling lasts for a long time. Common causes include a chronic cough, using inhalers for asthma, and GERD. Treatment of chronic laryngitis depends on the cause.

  • Vocal cord paresis or paralysis. The vocal cords can be paralyzed, or partially paralyzed (paresis). This can be caused by a viral infection that affects your vocal cord nerves, an injury to a nerve during surgery, stroke, or cancer. If one or both of your vocal cords are paralyzed in a nearly closed position, you may have noisy or difficult breathing. If they are paralyzed in an open position, you may have a weak, breathy voice. Some people will get better over time. In other cases, the paralysis is permanent. Surgery and voice therapy may help improve the voice.

  • Spasmodic dysphonia. This is a nerve problem that causes the vocal cords to spasm. It can make the voice sound tight, quivery, or jerky, hoarse, or groaning. At times, the voice may sound normal. Other times, the person may not be able to speak. Treatment may include speech therapy and injections of botulinum toxin to the vocal cords.                                                                     

What causes voice disorders?

For normal speech, your vocal cords need to touch together smoothly inside your larynx. Anything that interferes with vocal cord movement or contact can cause a voice disorder. Many voice disorders can be cured with treatment when diagnosed early.

Voice disorders can be caused by many factors. In some cases, the cause of a voice disorder is not known. Possible causes can include:

  • Growths. In some cases, extra tissue may form on the vocal cords. This stops the cords from working normally. The growths can include fluid-filled sacs called cysts, wart-like lumps called papilloma, or callus-like bumps called nodules. There may be patches of damaged tissue called lesions, or areas of scar tissue. In some people, a band of tissue called a web can grow between the vocal cords. Other growths include a small area of chronic inflammation called a granuloma, and small blisters called polyps. Growths can have many causes, including illness, injury, cancer, and vocal abuse.

  • Inflammation and swelling. Many things can cause inflammation and swelling of the vocal cords. These include surgery, respiratory illness or allergies, GERD (acid reflux), some medicines, exposure to certain chemicals, smoking, alcohol abuse, and vocal abuse.

  • Nerve problems. Certain medical conditions can affect the nerves that control the vocal cords. These can include multiple sclerosis, myasthenia gravis, Parkinson's disease, Amyotrophic lateral sclerosis (ALS), and Huntington disease. Nerves can also be injured from surgery or chronic inflammation of the larynx (laryngitis).

  • Hormones. Disorders affecting thyroid hormone, female and male hormones, and growth hormones can cause voice disorders.

  • Misuse of the voice. The vocal cords can be stressed by using too much tension when speaking. This can cause problems in the muscles in the throat, and affect the voice. Vocal abuse can also cause a voice disorder. Vocal abuse is anything that strains or harms the vocal cords. Examples of vocal abuse include too much talking, shouting, or coughing. Smoking and constant clearing of the throat is also vocal abuse. Vocal abuse can cause the vocal cords to develop calluses or blisters called nodes and polyps. These change how the voice sounds. In some cases, a vocal cord can rupture from vocal abuse. This causes the cord to bleed (hemorrhage), and can cause loss of voice. Vocal cord hemorrhage needs to be treated right away.

What are the symptoms of a voice disorder?

If you have a voice disorder, your voice may:

  • Have a quivering sound

  • Sound rough or harsh (hoarseness)

  • Sound strained or choppy

  • Is weak, whispery, or breathy

  • Is too high or low or change in pitch

You may have tension or pain in your throat while speaking, or feel like your voice box is tired. You may feel a "lump" in your throat when swallowing, or feel pain when you touch the outside of your throat.

How are voice disorders diagnosed?

If you have a voice change that lasts for a few weeks, your healthcare provider may send you to see a throat specialist called an otolaryngologist (Ears, Nose, and Throat specialist or ENT). An otolaryngologist will ask you about your symptoms and how long you've had them. He or she may examine your vocal cords and your larynx using certain tests. These may include:

  • Laryngoscopy. This lets the doctor view the throat. With indirect laryngoscopy, the healthcare provider holds a small mirror at the back of the throat and shines a light on it. With fiberoptic laryngoscopy, a thin, lighted scope called a laryngoscope is used. The scope is put through your nose down into your throat, or directly down into your throat.  

  • Laryngeal electromyography, or EMG. This test measures electrical activity in the muscles of the throat. A thin needle is put into some of the neck muscles while electrodes send signals from the muscles to a computer. This can show nerve problems in the throat. 

  • Stroboscopy. This test uses a strobe light and a video camera to see how the vocal cords are vibrating during speech.

  • Imaging tests. X-rays and MRI can show growth or other tissue problems in the throat.

How are voice disorders treated?

Treatment for a voice disorder depends on what's causing it. Treatment may include:

  • Lifestyle changes. Some lifestyle changes may help reduce or stop symptoms. These can include not yelling or speaking loudly, and resting your voice regularly if you speak or sing a lot. Exercises to relax the vocal cords and muscles around them can help in some cases. Warm up the vocal cords before extensive periods of speaking. Stay hydrated.      

  • Speech therapy. Working with a speech-language pathologist can help with certain voice disorders. Therapy may include exercises and changes in speaking behaviors. Some of these may include maneuvers that time deep breaths to power vocalizations with adequate breathing.

  • Medicines. Some voice disorders are caused by a problem that can be treated with medicine. For example, antacid medicine may be used for GERD or hormone therapy for problems with thyroid or female hormones.

  • Injections. Your doctor can treat muscle spasms in the throat with an injection of botulinum toxin. In some cases, your doctor can inject fat or other fillers into the vocal cords. This can help them close better.

  • Surgery. Your doctor can remove some tissue growths. If cancer causes the growths, you may need other treatments, such as radiation therapy.

Key points

  • Voice disorders are caused by a variety of reasons and affect the ability to speak normally.

  • An otolaryngologist should evaluate changes in vocal quality.

  • There are many different treatment options and each depends on what is causing the voice disorder.

  • Don't abuse your vocal cords by yelling or speaking loudly for long periods of time.

  • Therapy is directed at exercises that improve vocal cord function and strength and also allows for adequate rest periods.

  • If your job relies on the ability to use your voice then keeping it healthy is an important long term goal.

  • Stay rested, drink plenty of water, use a microphone, warm up your vocal cords, don’t smoke, learn proper breath flow, and seek care when there are changes to the voice quality.

Next steps

Tips to help you get the most from a visit to your healthcare provider:

  • Know the reason for your visit and what you want to happen.

  • Before your visit, write down the questions you want to be answered.

  • Bring someone with you to help you ask questions and remember what your provider tells you.

  • Know why a test or procedure is recommended and what the results could mean.

  • Know what to expect if you do not take the medicine or have the test or procedure.

 

GERD (Gastroesophageal Reflux Disease)

There are a number of symptoms of gastro-oesophageal reflux (GOR), often just called reflux, with the most noticeable being heartburn. But there are symptoms in addition to heartburn that you may not realize are related to reflux. See our list of common reflux symptoms below.

Heartburn

Heartburn is a burning pain that is generally felt in the chest area behind the breastbone and sometimes also the middle of the top part of your abdomen. The burning pain moves upwards during an episode of reflux. It can sometimes be felt in the throat.

The pain of heartburn is usually provoked by eating or by bending over, lying down or straining.

Regurgitation

Regurgitation of acid, food or fluid into the mouth. You may not be aware of bringing up anything, just a bitter taste which appears in your mouth. Bad breath (halitosis) can result.

Waterbrash

Waterbrash is the sudden appearance of an excess of salty or tasteless fluid in the mouth. This fluid is caused by an excessive production of saliva.

Belching

Many people with reflux suffer from excessive belching or burping.

Chest pain

Chest pain that can be similar to the pain associated with a heart attack is another symptom of reflux that is generally caused by acid reflux from the stomach into the oesophagus.

Always remember that your doctor should check any chest pain, even if it is associated with a gastrointestinal disorder, to make sure that the pain is not caused by a heart condition.

Hoarseness

Hoarseness or change in voice can occur when stomach acid reaches the mouth and throat, causing laryngitis (inflammation of your larynx, or voice box).

You may sometimes wake up with a hoarse voice because you had reflux during the night and find that your voice gets better during the day.

Sore throat

A sore throat can also be due to reflux. This is caused by the acidic stomach contents irritating the throat.

Cough

Reflux can cause persistent coughing in some people. Night-time coughing or choking can happen when the stomach contents enter the windpipe and the lungs while you are sleeping. You may wake up suddenly feeling that you are choking.

Asthma and asthma-like symptoms

Some people with reflux experience symptoms of wheezing and shortness of breath, especially at night.

Also, some people with asthma find that reflux makes their asthma symptoms worse.

Complications of gastro-oesophageal reflux, Unlike the stomach lining, the lining of the esophagus is not designed to withstand acidic conditions. Complications of gastro-oesophageal reflux disease (GORD) are caused by inflammation and damage to the esophagus due to the regular reflux of acid from the stomach.

Symptoms that may be caused by complications of reflux include the following.

Problems with swallowing

In some cases of reflux, there may be difficulty in swallowing (called dysphagia).

There may be a feeling that food has got stuck in the esophagus. This feeling of blockage is sometimes due to narrowing (a stricture) of the esophagus and results from scar tissue forming in the esophagus.

Pain with swallowing (called odynophagia) may be caused by ulcers (open sores) in the esophagus brought about by it being exposed to acid over time. The pain is felt as the mouthful of food is swallowed and travels down the esophagus.

Laryngopharyngeal Reflux (LPR)

Laryngopharyngeal reflux is a condition in which acid that is made in the stomach travels up the esophagus (swallowing tube) and gets to the throat. Symptoms include sore throat and an irritated larynx (voice box). Treatments consist mostly of lifestyle changes.

What is laryngopharyngeal reflux?

Laryngopharyngeal reflux (LPR) is a condition in which acid that is made in the stomach travels up the esophagus (swallowing tube) and gets to the throat.

Who gets laryngopharyngeal reflux?

Anyone can get LPR, but it occurs more often as people age. People who are more likely to have LPR include those who:

  • Have certain dietary habits.

  • Consistently wear tight or binding clothing.

  • Are overweight.

  • Are overstressed

What causes laryngopharyngeal reflux?

LPR is caused by stomach acid that bubbles up into the throat. When you swallow, food passes down your throat and through your esophagus to your stomach. A muscle called the lower esophageal sphincter controls the opening between the esophagus and the stomach. The muscle remains tightly closed except when you swallow food.

When this muscle fails to close, the acid-containing contents of the stomach can travel back up into the esophagus. This backward movement is called reflux.

What are the symptoms of laryngopharyngeal reflux?

The symptoms of LPR are felt in the throat and include the following:

  • Sore throat

  • Mild hoarseness

  • Sensation of a lump in the throat

  • The need to clear the throat

  • The sensation of mucus sticking in the throat, and/or post-nasal drip

  • Chronic (long-term) cough

  • Difficulty swallowing

  • Red, swollen, or irritated larynx (voice box).

How is laryngopharyngeal reflux diagnosed?

LPR is usually diagnosed based on the patient’s symptoms of irritation or swelling in the throat and the back of the voice box. In many cases, no testing is needed to make the diagnosis.

If testing is needed, three commonly used tests are: a swallowing study; a direct look at the stomach and esophagus through an endoscope, and; an esophageal pH test:

  • In a swallowing study, the patient swallows a special liquid called barium, which coats the esophagus, stomach and intestine so they are outlined on an X-ray. This allows the doctor to see the movement of food as it passes from the mouth to the esophagus.

  • The doctor can also view the inside of the stomach and esophagus with an endoscope, a long thin tube with a camera on the end that the doctor passes through the mouth, down the esophagus and into the stomach.

  • The esophageal pH test measures and records the pH (level of acid) in the esophagus. A thin, small tube with a device on the tip that senses acid is gently passed through the nose, down the esophagus, and positioned about 2 inches above the lower esophageal sphincter. The tube is fastened to the side of the face with tape. The end of the tube that comes out of the nose is attached to a portable recorder that is worn on the belt or over the shoulder. The recorder has several buttons on it that the patient presses to mark certain events.

How is laryngopharyngeal reflux treated?

Most cases of LPR do not need medical care and can be managed with lifestyle changes, including the following:

  • Follow a bland diet (low acid levels, low in fat, not spicy).

  • Eat frequent, small meals.

  • Lose weight.

  • Avoid the use of alcohol, tobacco and caffeine.

  • Do not eat food less than 2 hours before bedtime.

  • Raise the head of your bed before sleeping. Place a strong, solid object (like a board) under the top portion of the mattress. This will help prop up your head and the upper portion of your body, which will help keep stomach acid from backing up into your throat.

  • Avoid clearing your throat.

  • Take over-the-counter medications, including antacids, such as Tums®, Maalox®, or Mylanta; stomach acid reducers, such as ranitidine (Tagamet® or Zantac®); or proton pump inhibitors, such as omeprazole (Prilosec®), pantoprazole (Protonix®), and esomeprazole (Nexium®). Be sure to take all medications as directed.

In very severe cases of LPR, surgery may be recommended as treatment.

What can happen if laryngopharyngeal reflux is not treated?

If it is not treated, LPR can lead to:

  • Sore throat

  • Chronic cough

  • Swelling of the vocal folds

  • Ulcers (open sores) on the vocal folds

  • Formation of granulomas (masses) in the throat

  • Worsening of asthmaemphysema, and bronchitis

Untreated LPR also may play a role in the development of cancer of the voice box.