Voice Disorders

By
Dr. Baseem N. Abdulhadi

Voice is the method by which humans predominantly

communicate.
Changes in our voice can alter
communicate or express ourselves.

the

way

we

Production of voice is not purely based around the

larynx !!
The vocal fold is a five-layered structure that allows
the mucosa to move over Reinkes space = Mucosal
wave
The vocal folds may vibrate 80-1000 times/second,
therefore if visualized with white light, the mucosal
wave can not be visualized.
Stroboscopic examination allows for assessment of

Approach to a patient with hoarseness:

1)History:
)

It is essential to listen carefully to the voice itself

Try to find out what the patient uses their voice for (both
occupation and hobbies)

Duration and progression of the hoarseness are important

Associated symptoms such as dysphagia, odynophagia,

neck mass or otalgia

Preceding symptoms such as URTI

A thorough medical and drug history (assess conditions that

may affect respiratory drive) e.g. ACEI may precipitate
coughing, anticholinergic side effect which dry the URT

2) Examination:
a. General ENT examination:
Oral cavity, oropharynx and nasal cavity
(articulators and resonators)
b. Laryngeal examination:
1) fiberoptic nasolaryngoscopy
2) rigid laryngoscopy
3) stroboscopic examination

Pathology:
Voice changes at the laryngeal level occur because of
the following changes:
1)Mass effect on the vocal fold
2)Incomplete closure of the vocal folds
3)Poor vibration or mucosal wave as a result of
pathology

Causes of
Hoarseness
Inammation
Acute
Chronic:
Specific
Non-specific
Neoplastic
Benign:
Papilloma
Haemangioma
Malignant:
Squamous
carcinoma

Neurological
Central:
Cerebrovascular accident
Multiple sclerosis
Peripheral:
Recurrent laryngeal
nerve palsy
Motor neuron disease
Mechanical
Singers nodules
Vocal polyp
Vocal cord cysts
Non-organic

Common voice conditions:

1)Reinkes oedema:
a. The patient has long standing deepening of the voice
b. Patients are often smokers, or have acid reflux
c. Pathologically: oedema occurs within the Reinkes space
in the vocal fold
Treatment:
1) Smoking cessation
2) Use of anti-reflux therapy (PPI)
3) In resistant cases: superior cordotomy on the non
vibratory surface of the vocal cord can be undertaken

2) Vocal fold nodules (Singers nodules)

Often affect actors or singers and teachers
The

larynx

typically,

but

not

always

bilateral nodules at the junction of

shows

the anterior

third and posterior two thirds of the vocal folds

(which will affect good closure of the vocal folds)
Treatment:
a. Speech and language therapy to educate the
patient on use of the voice and to help them
use their voice appropriately
b. Rarely, they require surgical intervention

3) Vocal fold palsy:

Patients present with a recent onset, breathy voice
which becomes tired with use.
sinister etiology should be excluded by imaging
including the skull base through the upper chest (for
left vocal cord palsy) and from skull base into the
root of the neck (for right vocal cord palsy) [CT scan
+/- MRI skull base].
Treatment:
a. For idiopathic vocal fold palsy: initially speech
therapy
b. In case of failure or malignant etiology:
a. Injection thyroplasty
b. Vocal cord medialization surgery

4) Hemorrhagic polyp:
This pathology is not infrequently seen following an
URTI
A

telangectatic

vessel

bleeds

causing

slight

irregularity on the vocal cord (usually unilateral)

It sometimes heals, but occasionally persists and
matures
Treatment:
In cases of persistent polyp, surgical resection with a
microlaryngoscopy with or without laser resection

5) Vocal cord cysts:

The patients present with a change in voice
It can be very variable in its severity and frequency
Some are superficial mucosal cysts and some are
deeper intracordal cysts
Treatment:
Speech and language therapy
In

resistant

cases,

surgical

microlaryngoscopy is required

resection

by

6) Vocal cord granuloma:

Patients typically have undergone recent surgery
requiring endotracheal intubation or have been on the
ICU with an endotracheal tube in situ for a few days.
The pathology forms typically on the posterior medial
aspect of the vocal cord over the vocal process of the
arytenoid cartilage.
The granuloma forms due to healing exposed
cartilage as a result of trauma from an endotracheal
tube.
Also it might develop as a result of LPR
Treatment:
a. Aggressive anti-reflux treatment over 6 weeks
b. If symptoms persist, surgical resection with microlaryngoscopic technique is undertaken

7) Functional dysphonia/muscle tension

dysphonia

Previously known as hysterical dysphonia.

The patient may present with a hoarse or weak voice
that tires easily, a high or abnormally pitched voice,
or even no voice
It might be attributed to laryngeal dysfunction
resulting from vocal strain, stress and psychological
or psychiatric problems
The patient may have experienced some form of
stress or major life event at the time of the onset of
their symptoms
Treatment: firm reassurance, speech therapy and
rarely psychiatric consultation

Thank you