Voice Disorders

Our voice is just like our fingerprints--each person’s is unique. For many of us, our voices play a major role in our identity and how we communicate with others.

A complex series of muscle movements takes place every time we use our voice. Each of us have a larynx (commonly called a voice box) that is located at the bottom of our throat. Within the larynx are our vocal folds (or vocal cords). Every time we use our voice, air travels from our lungs and through our vocal folds, which causes them to vibrate and create sound.

When this delicate balance of airflow and muscle movements is disturbed, we may develop a voice disorder. Many people don’t give much thought to their voice, or the incredible vocal anatomy that makes speech possible, until they experience a problem. However, the inability to effectively use our voice can have a major impact on our quality of life, affecting our interpersonal relationships, school or work performance, and overall confidence and self-esteem.

When it comes to voice disorders, educating yourself is the best way to make informed treatment decisions. For that reason, we’ve put together this informational guide to answer common questions about voice disorders, identify signs and symptoms, and explain how a voice disorder is evaluated, diagnosed, and treated.

1What is a voice disorder?

2What are common types of voice disorders?

3How common are voice disorders?

4What are the symptoms of a voice disorder?

5What causes a voice disorder?

6How are voice disorders diagnosed?

7How are voice disorders treated?

8How can voice therapy from a speech therapist help?

9How does Expressable assess and treat voice disorders?

10Tips to prevent voice problems

What is a voice disorder?

Voice disorders can occur when our vocal folds are unable to properly vibrate. This can happen when vocal folds become inflamed; develop nodules, polyps, or other growths; or are unable to move properly. A voice disorder can affect the pitch, volume, or quality of your voice.

What are common types of voice disorders?

While voice disorders are a fairly broad category covering a number of conditions, here are some of the most common ones:

• Spasmodic dysphonia: Spasmodic dysphonia is a chronic voice disorder caused by nerve problems. Instead of your vocal cords vibrating normally, they may spasm or tighten when you speak. As a result, your voice may be very inconsistent: sometimes you may not be able to produce any sounds, while other times your voice could sound completely normal. The voice of a person with spasmodic dysphonia might sound hoarse, jerky, or tight.

• Vocal nodules and polyps: Both vocal nodules and polyps are lesions that form on your vocal cords. Vocal nodules are benign growths and generally result from the repetitive overuse or misuse of your voice (for this reason, they’re sometimes referred to as singer’s nodules). When your voice is pushed to the limit, swelling may occur. Over time, this swelling can become callous and enlarged. Vocal polyps are often bigger than nodules and can take the form of a swollen bump or blister. While nodules generally develop over a period of time, polyps can happen after a single episode of vocal abuse (like screaming at a concert). Both nodules and polyps can cause similar symptoms, including hoarseness, a rough or scratchy voice, trouble breathing, and more.

• Vocal fold paralysis: Vocal fold paralysis can occur when one of your vocal folds, or in some cases both of them, are unable to move or vibrate properly. This can cause a variety of breathing and swallowing symptoms, including hoarseness, problems with voice pitch and volume, trouble with choking or coughing during eating, and more.

• Paradoxical vocal fold movement (PVFM): Every time you breathe, your vocal folds open, allowing air to travel through to your lungs. When children or adults have paradoxical vocal fold movement (PVFM), their vocal folds may close partway or fully. This can cause a series of breathing and voice problems, including coughing, breathing difficulties, throat tightness, loss of voice, or changes to your voice. It’s important to know that PVFM is often confused and misdiagnosed with asthma. While symptoms can be similar, these are different conditions. Proper diagnosis is important when considering treatment.

• Chronic coughing: While coughing occasionally is completely normal, and actually helps clear your throat and lungs to prevent infection, prolonged coughing can be highly disruptive and frustrating. Coughing is generally considered chronic if it lasts longer than 4 weeks in children and 8 weeks in adults. It can interrupt your sleep and day-to-day life, cause problems with your voice, and lead to headaches.

• Laryngitis: Laryngitis occurs when there is an inflammation of your larynx (or voice box). Typically, this is due to overuse, irritation, or infection of your vocal folds, which can cause them to swell and distort your sounds when air passes through them. Laryngitis can be short-lived or more chronic. While it’s often caused by a temporary viral infection, persistent hoarseness of the voice can sometimes signal a more serious medical condition.

How common are voice disorders?

Voice disorders are fairly common and affect a large part of the population. According to data compiled by the American Speech-Language-Hearing Association, an estimated 3% to 9% of the U.S. population may have a voice disorder. The prevalence of voice disorders breaks down into the following categories:

Age: While elderly adults are most likely to have a voice disorder, they can affect people of all ages.

• Prevalence is highest in older adults, with estimates ranging from approximately 5% to 29%.

• In children, the reported prevalence of voice disorders ranges from approximately 1.5% to 6.0%.

Gender: Males and females can both develop voice disorders. However, the prevalence of voice disorder in females increases with age.

• Adult females are 50% more likely than adult males to develop a voice disorder.

• When it comes to children, boys are significantly more likely to develop a voice disorder than girls.

Occupation: Certain types of voice-intensive occupations appear to increase a person’s risk of developing a voice disorder. This includes teachers, manufacturing/factory workers, salespeople, and singers.

What are the symptoms of a voice disorder?

Here are some common symptoms that could signal you have a voice disorder. It’s important to note that different types of voice disorders can have varying symptoms. However, if you notice any of these signs, it’s important to speak with a doctor or a speech therapist.

• Hoarse, rough, or raspy voice

• Weak or breathy voice

• Changes to your voice’s pitch or volume

• Raw or strained throat

• Tension or pain in your throat while speaking

• Difficulty talking or breathing

• Repeatedly clearing your throat

• The feeling of a lump in your throat when swallowing

• Pain when touching the outside of your throat

What causes a voice disorder?

Anything that prevents or disrupts your vocal fold movement can cause a voice disorder. There is a wide range of factors that can interfere with this normal function. Some causes of voice problems include:

• Vocal abuse: Vocal abuse is any type of behavior that can strain, harm, or injure your vocal folds. This can be caused by excessive talking or screaming, inhaling irritants, smoking, coughing, or clearing your throat. Vocal abuse can often lead to the development of nodules, polyps, or other growths on your vocal folds, which can change how your voice sounds. Frequently engaging in activities that cause vocal abuse and damage your vocal folds can have both temporary or permanent effects on your voice quality and vocal function.

• Abnormal growths: Some people may develop extra tissue on their vocal folds that can impact their function. These growths have a variety of causes, including injury, vocal abuse, cancer, or illness. These growths can take many forms, including nodules, polyps, cysts, papillomas, lesions, and more.

• Nerve problems: Your central nervous system controls your voice and swallowing abilities. There are several health conditions that can affect these nerves, including multiple sclerosis, Huntington's disease, Parkinson's disease, or amyotrophic lateral sclerosis (also referred to as ALS or Lou Gehrig’s disease).

• Inflammation and swelling: When your vocal cords become inflamed, they can affect your natural airflow. Inflammation and swelling of the vocal folds can be caused by surgery, respiratory illness, allergies, smoking, vocal abuse, substance abuse, and more.

• Hormones: Disorders that affect your hormones can cause voice disorders, including thyroid hormones and growth hormones.

How are voice disorders diagnosed?

Your doctor will often diagnose voice problems through a combination of learning your medical history and performing a series of examinations and diagnostic tests. In some cases, your doctor may refer you to an ear, nose, and throat specialist (sometimes referred to as an ENT or otolaryngologist).

Your doctor may start by asking you questions regarding your voice problems. This information will help them determine which tests to perform. These questions can include a description of your voice problems, when they were first noticed, how long they’ve lasted, how often problems occur, if they’re made worse by certain triggers, and other underlying factors such as whether you’re a smoker.

Your doctor may then perform a series of tests to examine your vocal folds and larynx. Voice disorders may have multiple causes, and identifying each one is necessary to ensure your care team can develop the right treatment plan. However, don’t let this scare you! Just because your doctor does several tests doesn’t mean your voice disorder is more severe.

Some common tests include:

• Laryngoscopy: This tool allows your doctor to examine your throat using a thin, lighted scope.

• Laryngeal electromyography, or EMG: This test measures the electrical activity in the muscles of the throat, which can help reveal any underlying nerve problems.

• Stroboscopy: This instrument uses a light and camera to visualize how your vocal folds move and vibrate when you speak.

• Imaging tests: X-rays and MRI can help doctors identify and locate certain growths, like nodules or polyps, that may be on your vocal folds.

• Acoustic analysis: This technique uses computer analysis to measure any irregularities in how your vocal folds produce sound.

How are voice disorders treated?

Treatment for voice disorders can involve a multidisciplinary team of specialists, including your doctor, an ENT, pulmonologist, psychologist, and speech-language pathologist, also known as a speech therapist. Your specific treatment will depend on the cause of your voice disorder, and the treatment may have several parts. Some examples include:

• Lifestyle changes: There may be certain changes you can make to your lifestyle and behaviors that can help you control your voice disorder or reduce its symptoms. Common changes include lowering the volume of your voice, reducing yelling or speaking loudly, and resting your voice at regular intervals. There are also certain exercises that can help relax or relieve the tension in your vocal folds.

• Medicines: Medication can sometimes help the root cause of your voice disorder. Talk with your doctor before taking any medicines.

• Injections: Your doctor may recommend injections if muscle spasms are causing your voice disorder. There are other types of injections that can help control your vocal folds.

• Surgery: In some circumstances, your doctor may recommend surgery to remove nodules, polyps, or other types of growth on your vocal folds.

• Voice therapy: In many cases, your doctor will recommend voice therapy from a licensed speech therapist. This can be used as your primary treatment, alongside other types of treatments, or as a precursor to medical treatments. We’ve provided more information on voice therapy below.

How can voice therapy from a speech therapist help?

As mentioned, many voice disorders require voice therapy from a speech-language pathologist. Speech therapists are communication experts, and many specialize in voice therapy to treat and manage voice disorders. Speech therapists are often involved during evaluation, diagnosis, and treatment of a variety of voice conditions:

• Spasmodic dysphonia: For people with spasmodic dysphonia, your speech therapist can teach you strategies to articulate sounds in certain ways that make it easier to speak. They may instruct you on methods to improve your airflow, reduce excess tension and strain when uttering sounds, or compensate for your voice disorder in more efficient ways. These voice techniques can help you take back a sense of control with your voice and ultimately improve your quality of life.

• Vocal nodules and polyps: Treatment often begins with voice therapy from a speech therapist. Voice therapy may focus on taking care of your voice (also called voice hygiene) by learning the signs of abuse and changing your behavior. Your speech therapist will help you find ways to feel relaxed, relieve stress, and change how your voice sounds.

• Vocal fold paralysis: When it comes to vocal fold paralysis, your doctor may recommend voice therapy before surgery or medical treatments. Your speech therapist will work with you to alter the pitch of your voice, and help increase airflow and breathing support to improve the volume of your voice.

• Paradoxical vocal fold movement (PVFM): Treatment for PVFM focuses on helping to ensure your vocal folds open normally, and continue to stay open, as you breathe. A speech therapist may help you practice different exercises and strategies to relax your throat during breathing. They may teach you methods for using your throat muscles to open your airways, suppress unnecessary coughing, and other ways to control and manage your PVFM. Additionally, they will help you become aware of certain triggers that can worsen PVFM and teach you strategies for avoiding these.

• Chronic coughing: Your speech therapist will teach you techniques for suppressing your urge to cough, strategies to keep your vocal folds healthy, and how to avoid triggers that contribute to your cough. They may make recommendations such as breathing through your nose rather than your mouth, or avoiding certain substances like alcohol or caffeine.

How does Expressable assess and treat voice disorders?

Expressable matches families and adults with a certified speech therapist trained to evaluate and treat a range of voice disorders using voice therapy. All therapy is delivered online via face-to-face video conferencing.

If your child is receiving therapy, their age and development will influence how your speech therapist interacts with them through these video sessions.

Ages 0-3: Caregivers work directly with their child's speech therapist to learn cues and at-home strategies. That way they can confidently practice with their child outside the session and improve their child's voice.

Ages 3-6: Caregivers attend video sessions alongside their child so they both learn valuable skills from their speech therapist. Reinforcing these lessons outside the session will continue to promote at-home skill building.

Ages 7 and up: Most children attend video sessions independently, but parents are kept in the loop with updates and tips during each session.

Adults: Adults attend sessions by themselves but are welcome to bring loved ones or family members as well.

All Expressable clients have access to our client portal, which features educational Learning Paths covering the strategies taught in therapy sessions. You can access examples, tips, demo videos, quizzes, and more. Plus, through the portal, you'll receive weekly home practice activities tailored to your needs. The more you practice voice therapy techniques at home, between sessions, the faster you'll make progress!

Tips to prevent voice problems

Each of these recommendations can help you maintain vocal hygiene and possibly prevent or manage a voice disorder:

• Stay hydrated by drinking six to eight glasses of water a day.

• Limit alcoholic and caffeinated drinks. These can cause you to become dehydrated, which may dry out your vocal folds and larynx.

• Use a humidifier in the winter or in dry climates.

• Common cold and allergy medications can dry out the vocal folds. Try to limit your intake when possible, and if you have voice problems, ask your doctor which medications are the safest to use.

• Avoid smoking, as this can irritate your vocal folds.

• Get plenty of rest, as fatigue can have a negative impact on your voice.

• Try not to overuse your voice when possible. Avoid speaking or singing excessively when your voice is tired or hoarse.

• Rest your voice when you are sick.

• Avoid using the extremes of your vocal range, such as screaming or whispering often.

• Practice good breathing techniques, including taking deep breaths from your chest.

• Avoid talking in noisy environments when you can, as this can put an unnecessary strain on your voice.

• Consider voice therapy to learn healthy tips and techniques to support good vocal quality.