Voice Disorders

Your voice is the sound made by vibration of your vocal folds. This requires coordinating functions of the different parts of the vocal mechanism within the systems responsible for respiration, phonation, and resonation. Beginning with respiration, the diaphragm, lungs, and chest/abdominal muscles must work together to control the air pressure that moves up into the larynx, where it causes the vocal folds to vibrate. The larynx is the cavity that extends from the lungs to the base of the tongue. Within the larynx, our vocal folds are two strips of muscle that must vibrate, moving together and apart, to create phonation, or the sound that is shaped into our voice. When we are not speaking, the vocal folds are separated, allowing air to pass through the larynx unobstructed to our oral and nasal cavities. When we speak, the air coming from the lungs causes vocal fold vibrations, which create sound waves. This noise then moves up past the larynx to the cavities responsible for resonation, or shaping the sound into our recognizable voice. These cavities include the pharynx (throat), oral cavity (mouth), and nasal cavity (nose). Your specific voice (the pitch, quality, loudness) is created and changed based on the size, shape, and manner in which you use each of these mechanisms.

A change in the structure or function of any aspect of the vocal mechanism may lead to voice problems or a voice disorder. Vocal abuse and/or inadequate vocal hygiene habits may be the underlying cause of voice disorders characterized by a hoarse, raspy vocal quality. Many people have experienced voice problems due to an illness, allergies, singing, or period of long/loud talking or yelling (e.g., a sporting event or loud social event); however, extended abuse of the vocal mechanism may cause vocal nodules or vocal polyps. These growths on the vocal folds are similar to a callous or blister respectively, and are caused by repeated harsh or strained contact of the vocal folds. These growths not only impact the quality of your voice, but can also make it difficult to talk, requiring the speaker to strain to produce speech. Additionally, speaking at certain volumes or pitches, or phonating clearly enough to be heard may be difficult. These issues often impact quality of life as individuals can become frustrated by their inability to be heard or understood, or may avoid speaking situations due to the strain and effort involved in using their voice. While it may take effort to change something as automatic as voicing, with therapy and motivation on the part of the individual, nodules and polyps can go away over time.

Along with vocal abuse, vocal hygiene involves the behaviors and activities that keep our vocal mechanism working properly. Good vocal hygiene requires speaking at an appropriate volume and pitch to reduce strain on the vocal mechanism, as well as aspects such as hydration, sleep, and dietary considerations. The vocal mechanism may be impacted by gastroesophageal reflux (also known as acid reflux, heartburm, or GERD). Acid reflux may have various causes such as eating acidic foods or eating/drinking before bed. Acid reflux may cause inflammation of the vocal folds, resulting in symptoms similar to nodules or polyps.

Many jobs require individuals to use their voices extensively in their professional environment (e.g., teachers, lawyers, singers), putting them at greater risk for developing voice disorders. Additionally, children, who often have limited awareness of vocal hygiene and abusive vocal behaviors, tend to yell and/or use their voice in unnatural ways, such as creating unusual voices during play, which may also be the underlying cause of a voice disorder.

Individuals with voice disorders caused by vocal abuse or misuse often have hoarse, raspy, or breathy voices. They may also have limited pitch range, particularly with higher notes. These individuals may feel some level of pain or discomfort in their throat or notice strain or effort involved in talking.

In addition to voice problems being caused by abuse or misuse, common illnesses (e.g., common cold, bronchitis), allergies, laryngeal cancer, neurological disorders, or psychological disorders may also cause voice disorders. Various problems may occur depending on the etiology, such as vocal nodules, polyps, vocal fold paralysis, or spasmodic dysphonia. While nodules and polyps are often caused by vocal abuse and/or misuse, vocal fold paralysis occurs when neurological signals to the vocal folds are disrupted, causing limited movement of the vocal folds. Spasmodic dysphonia occurs due to involuntary spasms of the vocal folds, which may cause them to slam together tightly (adductor spasmodic dysphonia) or remain open (abductor spasmodic dysphonia), or a combination of the two. Individuals with spasmodic dysphonia may have a constricted, tense, or strained vocal quality. Depending on the underlying cause of insufficient vocal quality, a speech-language pathologist at Language & Learning will implement suitable techniques to enhance the functioning of the vocal mechanism. At times, this behavioral therapy is performed in conjunction with surgical or other medical treatments.

If a voice disorder is suspected, the first step is to visit an otolaryngologist (also known as an ENT), which is a doctor specializing in ear, nose, and throat disorders. This doctor can perform an examination to determine if there are structural or functional problems with the vocal mechanism. Following this appointment, the doctor may make a referral to a speech-language pathologist. A speech-language pathologist at Language & Learning will evaluate the vocal problem, taking into consideration the results of the otolaryngological evaluation and the individual’s concerns, in addition to performing a quantitative and qualitative voice evaluation. The speech-language pathologist will observe structures and functions of the vocal mechanism (such as determining if appropriate diaphragmatic breathing is being used), measure vocal parameters (such as pitch range), and assess elements of vocal quality both quantitatively and qualitatively (such as hoarseness, harshness, and breathiness). Following determination of areas of weakness and underlying causes, stimulability for enhanced vocal quality using a variety of techniques will be implemented. Those techniques that are most effective for the individual will continue to be implemented beginning in isolated phonatory contexts, and progressing to increasingly integrated contexts, ultimately resulting in improved vocal quality in spontaneous speech. Counseling and self-monitoring regarding vocal abuse and vocal hygiene is also often addressed in voice therapy.