Other Voice Disorders

With normal aging, the voice changes. In men, the pitch becomes higher, and in women the pitch drops. The volume and endurance of the voice decreases.  Similar to the loss of muscle mass throughout the rest of the body, the muscles of the vocal folds also shrink with age. This can cause thinning or "bowing" of the vocal folds decreasing the strength of closure of the vocal folds. Additionally, with age the mucus membranes become more dry and the cushioning layer over the muscles of the vocal folds thin. In general, maintaining overall body health can help improve voice health. Voice exercises under the direction of a speech language pathologist can help a person to regain strength of the voice. Procedures such as vocal fold injection augmentation and medialization thyroplasty can also help in refractory cases.

Chronic cough can be a difficult entity to diagnose and treat.  The source of the cough may be from above the voice box from sinus disease or postnasal drip.  It may be from below the voice box from asthma, chronic obstructive pulmonary disease (COPD), infection, inflammation or irritation in and around the lungs. Lastly the cough may come from laryngopharyngeal reflux, infection, inflammation, irritation or dysfunction of the larynx.  When all of these have been excluded the cause of the cough may be hypersensitivity of nerves to or from the larynx.  Several medications have been recommended in the treatment of this disorder that calm the nerves and help to diminish the coughing.

Laryngopharyngeal reflux (LPR), is the backflow of stomach contents to the throat which can then cause inflammation in the larynx and cause symptoms such as hoarseness, cough, globus sensation (feeling a lump in the throat), chronic throat clearing, and excess mucus or phlegm.  LPR can be diagnosed by patient history, specific laryngoscopic exam findings, and by pH probe testing.  Treatment of LPR is multifactorial involving both diet/lifestyle changes and medications such has H2 blockers and proton pump inhibitors.

Paradoxical Vocal Fold Motion (PVFM) occurs when the vocal folds paradoxically close instead of opening during inspiration (also referred to by pulmonologists as vocal cord dysfunction or VCD).  This results in difficulty breathing and even noisy breathing.  It is often confused with asthma and may require pulmonary function testing to determine the diagnosis.  Laryngospasm occurs when PVFM is so severe that the vocal folds close or spasm together entirely blocking off the airway.  Laryngospasm, though quite frightening is temporary and will stop on its own.  There are many potential triggers to PVFM/laryngospasm and they are thought to be related to laryngopharyngeal reflux (LPR).  In addition to treating LPR if present, PVFM and laryngospasm are treated with breathing recovery exercises taught by a speech language pathologist.

Spasmodic dysphonia, also called laryngeal dystonia, is a voice disorder characterized by involuntary spasms or movements in the muscles of the larynx, which causes the voice to break, and have a tight, strained, or strangled sound.  It most often affects women, particularly between the ages of 30 and 50.  The cause of spasmodic dysphonia is not known, but most cases are believed to be caused by a nervous system disorder and may occur with other movement disorders.

There are three types of spasmodic dysphonia:

Adductor spasmodic dysphonia: Characterized by sudden involuntary spasms that cause the vocal cords to slam together and stiffen. The spasms interfere with vibration of the vocal cords and production of sound is difficult. Stress can make spasms more severe.  Speech sounds are strained and full of effort. Spasms do not occur when whispering, laughing, singing, speaking at a high pitch, or speaking while breathing in.

Abductor spasmodic dysphonia: Characterized by sudden involuntary spasms that cause the vocal cords to open. Vibration cannot occur when cords are open so production of sound is difficult. Also, the open position allows air to escape during speech.  Speech sounds are weak, quiet, and whispery. Spasms do not occur when laughing or singing.

Mixed spasmodic dysphonia: Characterized by symptoms of both adductor and abductor spasmodic dysphonia.

Spasmodic dysphonia treatment is be determined by your physician based on a patient’s age, overall health, medical history, extent of the disease, tolerance for specific medications, procedures, or therapies, expectations for the course of the disease, and opinion or preference.  The goal of treatment is to reduce symptoms of the disorder. Periodic botulinum toxin injections to one or both vocal cords can often relieve symptoms. Some patients will be a candidate for surgical therapy - selective laryngeal nerve adductor denervation and reinnervation. This involves cutting the nerves to the vocal cords that are responsible for spasm and inserting new nerves that can allow for a normal voice.

Normally the vocal folds move symmetrically, opening or separating with inspiration and closing or coming together with talking or coughing. These movements are controlled by the recurrent laryngeal nerve on each side of the larynx.  Vocal fold paresis or paralysis is caused by damage or injury to the neurologic input to the larynx.

Unilateral: If one of the vocal folds does not move appropriately it can cause hoarseness with a breathy voice. This is when the vocal folds do not come all the way together to vibrate against each other resulting in a gap or space between the vocal folds.  This space between the vocal folds can be closed through both temporary and permanent treatment options including [vocal fold injection augmentation], [medialization thyroplasty], [laryngeal reinnervation], and [arytenoid repositioning surgeries].

Bilateral: If both of the vocal folds do not move appropriately, a patient may have difficulty breathing from the vocal folds not being open enough, or hoarseness if the vocal folds are not close enough together.  In some cases, patients require a tracheostomy to breathe comfortably.  While procedures can be done to both improve the voice or the airway in the setting of bilateral vocal fold paralysis, it is a balance between breathing and talking.  If breathing improves, generally the voice worsens, and the risk of difficulty swallowing increases.  If the voice improves, breathing may become more difficult.