Brief overview
- Description: Disturbance of voice formation due to organic or functional causes; in extreme cases, complete loss of voice (voicelessness).
- Causes: e.g. inflammations, injuries, paralysis, tumors on vocal folds or larynx, overloading of the voice, incorrect speaking technique, psychological reasons, medication, hormonal changes
- Diagnosis: Medical history; physical examination, laryngoscopy, further examinations (such as ultrasound) if necessary.
- Treatment: Depending on the cause – treatment of physical causes, voice therapy.
- Prevention: Against overload, among other things, warm-up exercises of the vocal apparatus; rest breaks; voice exercises.
What is dysphonia?
Dysphonia is not a disease in its own right, but a symptom with various underlying causes. Sometimes these are physical diseases (organic causes). In other cases, disorders of laryngeal function (functional causes) are the reason for dysphonia.
To understand how voice production can be disturbed, it helps to know how and where the voice originates in the first place.
How the voice develops
- The lungs produce the air stream (phonation stream) necessary for sound production.
- The larynx with its muscles, cartilages and especially the vocal folds (“vocal cords”) produces a primary sound.
- The pharynx, mouth and nasal cavity (so-called embouchure tube) modulate the primary sound to produce speech sounds.
In principle, disorders at all three levels can cause dysphonia.
Dysphonia: Causes and possible disorders
In addition, there is a “normal” form of dysphonia (such as during puberty or old age). In addition, voice production disorder can be the side effect of medication.
Organic voice disorder (organic dysphonia)
For “normal” voice production, the vocal folds (“vocal cords”) in the larynx must vibrate freely. Various physical disorders can impede this free vibration – dysphonia results.
Voice overload: People who speak or sing a lot for professional reasons often develop symptoms of overload on the vocal folds. The consequence of a permanent strain on the vocal folds are the so-called singer’s nodules (vocal fold granuloma due to overload, contact granuloma).
The main feature of this voice disorder is hoarseness. Because in ancient times preachers were often among those affected, this form of voice formation disorder also bears the name “Dysphonia clericorum” in older literature.
Dysphonia can also occur if acidic gastric juice frequently flows back into the trachea, damaging the mucous membrane of the larynx and pharynx (laryngitis gastrica).
Injuries to the larynx: Such injuries, such as those caused by intubation, accidents or surgery, often trigger dysphonia.
If only one of the two vocal folds is paralyzed (unilateral paralysis), the affected person can usually still speak almost normally. If, on the other hand, both vocal folds are affected (bilateral paralysis), there is shortness of breath and the most severe form of dysphonia – complete voicelessness (aphonia).
Spasmodic dysphonia (speech spasm, laryngeal spasm, laryngeal dystonia): In this case, the voice disorder results from involuntary, prolonged spasms of the muscles in the larynx. This is a neurological disorder that belongs to the dystonias (movement disorders).
Other benign tumors include papillomas, cysts (fluid-filled cavities) and polyps (mucosal growths), which are located directly on or in the vocal folds. As mechanical obstacles, they interfere with the free vibration and proper closure of the vocal folds – those affected suffer from dysphonia.
Reinke’s edema mainly affects women between the ages of 40 and 60. The voice sounds rough and hoarse. In extreme cases, the dysphonia leads to complete voicelessness (aphonia).
Laryngeal cancer (laryngeal carcinoma): A malignant laryngeal tumor is less often the cause of dysphonia. Its main symptoms are prolonged hoarseness and possibly shortness of breath.
Congenital malformations of the vocal folds or larynx: These are also a possible cause of a voice production disorder. As a rule, they are already noticeable in childhood.
If dysphonia persists for a long time, this is an alarm sign in any case. Then have the cause clarified by a doctor!
Functional voice disorder (functional dysphonia)
Those affected report persistent hoarseness, increasing vocal fatigue and sometimes a pressing or burning sensation in the throat area. However, the organic findings in a laryngoscopy are almost inconspicuous.
In functional dysphonia, physicians distinguish between a hyperfunctional and a hypofunctional variant. Very often, however, mixed forms are also found.
Adjacent muscle groups in the face, neck and throat area are also often tense.
Hyperfunctional dysphonia usually manifests itself in people who permanently use their voice excessively.
This is usually caused by states of illness or exhaustion with a general weakening of the body’s performance. Psychological stress such as anxiety or grief can also lead to hypofunctional dysphonia.
Habitual, ponogenic and psychogenic dysphonia.
Functional voice disorders can also be described more specifically depending on their cause. Thus, habitual dysphonia is present when voice-damaging speech habits are the reason for the voice formation disorder – for example, frequent shouting, incorrect technique when singing, constant pressed or over-accentuated speech.
In some people, psychological or psychosomatic causes manifest themselves in hypofunctional dysphonia (whispering, breathing, powerless voice). This is referred to as psychogenic dysphonia.
Other dysphonia
In addition, some medications cause dysphonia as an undesirable side effect. These include, for example, neuroleptics (antipsychotics, psychotropic drugs) and some asthma sprays.
Dysphonia: When to see a doctor?
Also, if you notice that your voice sounds pressed, creaky or breathy, or you experience pain when speaking, you should seek medical advice.
Specialists in voice disorders are specialists in phoniatrics. Specialists in ear, nose and throat medicine (ENT) and general medicine are also possible contacts for dysphonia.
Dysphonia: examinations and diagnosis
Medical history
To take your medical history, the doctor will ask you questions such as:
- How long have you had this voice disorder?
- Did you put a lot of strain on your voice before the onset of dysphonia?
- Do you have any known respiratory or pulmonary conditions?
- Did you undergo surgery, for example in the chest or neck area, shortly before the onset of the voice disorder?
- Do you smoke? If so, how much and for how long?
- Do you drink alcohol? If yes, how much?
- Have you noticed any hardening, swelling or a feeling of pressure in the neck area?
- What medications are you currently taking?
Physical examination
Several examinations help medical professionals clarify dysphonia.
- listening with the stethoscope (auscultation)
- inspection of the throat with a flashlight and tongue depressor
- palpation of the larynx and throat in search of possible swellings or indurations
Repeating sounds or sentences
Already during the anamnesis, the doctor pays attention to how your voice sounds – for example, powerless, very hoarse or pressed. This often provides clues to possible causes.
Laryngoscopy
Laryngoscopy allows a close look at the larynx. The doctor examines your throat with the help of a mirror or a special camera: this allows a direct view of the vocal folds and the larynx.
This procedure is very helpful in clarifying dysphonia. Although the idea of having your throat looked at so deeply is frightening for many people, the examination is harmless.
Sometimes further examinations are necessary to determine the cause of dysphonia. This is usually the case, for example, if the voice disorder has been present for a long time or is very pronounced. Also, if additional complaints such as shortness of breath, coughing up blood or swallowing difficulties occur, further examinations are often useful.
Such examinations can be:
- Ultrasound (sonography) of the thyroid gland
- X-ray of the chest (X-ray thorax)
- Tissue sampling (biopsies) from the mucous membrane of the larynx or bronchi
- Computed tomography (CT) or magnetic resonance imaging (MRI) of the neck, chest, or brain
Dysphonia: Treatment
The following is an example of how different types of dysphonia are treated:
A cold as the cause of organic dysphonia can be treated symptomatically, such as by drinking plenty of fluids (e.g., tea), inhaling, and taking it easy. Once the cold is over, the voice usually returns quickly.
In the case of laryngeal paralysis (vocal cord paralysis), doctors treat the cause of the nerve damage (e.g., Parkinson’s disease, ALS, stroke) if possible. In the case of unilateral vocal cord paralysis, voice exercises often help, in which the second, unparalyzed vocal fold is specifically trained.
In the case of Reinke’s edema, it is particularly important for smokers to refrain from smoking in the future. Other possible treatment options include surgical removal of the fluid accumulation and voice therapy.
Malignant tumors in the larynx are usually surgically removed by physicians. In many cases, however, voice production is still disturbed after surgery.
A special focus of voice therapy is on good breathing technique, as this is essential for efficient voice development. The therapy is completed when the affected person reliably uses his newly learned voice behavior in everyday life.
In the case of psychogenic dysphonia, psychotherapeutic treatment is usually advisable.
Dysphonia: Prevention
Also, try to work on your body tension. This is because the voice is influenced by the entire posture of the body. Loosening and relaxation exercises, for example, are helpful. To relax the muscles permanently, an interplay of regular movement and relaxation is necessary.
Rest periods for the voice and good moistening of the mucous membranes (e.g., through sufficient fluid intake and the right room climate) are further measures that can prevent dysphonia caused by overuse. The same applies to (largely) abstaining from smoking and alcohol.
