Dysphonia voice disorder
What is dysphonia?Dysphonia is a descriptive medical term meaning disorder (dys ) of voice ( phonia). There are many causes of dysphonia. Fortunately more than half of people with voice complaints have a benign (non cancerous) cause.
How is voice normally produced? The generation of voice requires a sound producing (‘phonatory’) system, a control centre and a network connecting the two.
Phonatory system The larynx (voice box) has a framework of cartilage with muscles attached to different structures. It also has a pair of vocal cords which move apart on breathing in (inspiration) and come closer together on breathing out (expiration).
The vocal cords resemble two small blinds that can be drawn across from the side of the larynx in to the middle, thus causing a variable restriction in the amount of air that can pass through.
According to how tightly the muscles tense the edges of the vocal cords and how much breath pressure is applied, the frequency of vibration of the cords can be changed very rapidly, which generates the tone of the sound being produced. The pharynx (area at the back of the throat) and oral cavity act together as a sound resonator.
Understandable voice is produced by co ordinated movements of the tongue, lower jaw and soft palate the flexible part of the roof of the mouth. This process is called articulation. Clearly it is a complex system, depending for its success on sophisticated control.
Control centre The brain acts as a control centre which receives and sends out signals to different parts of the body including the diaphragm, muscles of the chest wall, abdomen, larynx, pharynx, oral cavity, tongue, soft palate and lower jaw and co ordinates their movements.
Connecting network The crucial nerves that carry the brain’s signals to the muscles of phonation are the laryngeal nerves, which are themselves branches of the 10th cranial nerve the ‘vagus’ nerve. As with the other cranial nerves, (which all exist in pairs) the vagus arises directly from the brain, rather than from the spinal cord, and travels through a specific opening in the skull to reach its location.
What symptoms do people with dysphonia have? People with dysphonia may present with hoarseness and a sore or dry throat. A singer may notice that he or she is no longer able to sing in the upper range. There may be other associated symptoms such as a continuous drip at the back of the throat (nasal catarrh) and heartburn.
When should a patient seek treatment? Any person who has been hoarse for four weeks or more should seek medical attention from their family doctor. They may require to be seen by an ear, nose and throat specialist for further examination including inspection of the larynx. This can be done quite easily (by the specialist!) using an angled mirror, or flexible fibre optic ‘telescope’.
Persistent hoarseness, difficulty in swallowing,
sore throat, choking when swallowing (especially fluids), persistent earache, coughing up blood, weight loss and loss of appetite may indicate a more serious condition and should always be taken seriously.
Causes of dysphoniaInflammation of the larynx (voice box) over a short (acute) or long (chronic) period of time. Lumps (nodules) on the vocal cords (eg singer’s nodules). Underactive thyroid gland hypothyroidism. Trauma any kind of trauma, including surgery, to the vocal cords will inevitably cause scarring and hence affect the vocal fold function. The risk of permanent voice change therefore needs to be discussed prior to surgery on the larynx. Vocal cord paralysis some other surgical operations including removal of the thyroid gland and heart or lung surgery can damage the nerves to the larynx causing either temporary or permanent vocal cord paralysis (palsy). Reinke’s oedema of the larynx. Psychological voice changes are not uncommon when people are under stress either at work or at home. The voice may be lost suddenly, usually overnight or following a cold. It is important to identify and remove the underlying stress.
How is dysphonia treated? Each condition has its own specific treatment, and the treatment should also be tailor made to each individual. The general principles of management are described below.
Conservative therapy Every attempt should be made to identify and eliminate causative factors such as stress, smoking, and alcohol. Drink plenty of clear fluid to avoid a dry throat. Rest the voice completely for two to three days. No talking or whispering is allowed. Communicate to others by writing everything down on a note pad.
Speech therapy The speech therapist plays an important role in the assessment and treatment of patients with voice disorders, eg Reinke’s oedema, vocal cord nodules and voice misuse. The therapy will take some weeks or months before any improvements are noticed and so the patient must be highly motivated.
Medical therapy Upper respiratory tract infections, eg acute laryngitis, are commonly caused by viral infections. Bed rest, regular paracetamol and saline or soluble aspirin gargles are often adequate.
Antibiotics are only indicated when there is bacterial infection. Nasal sprays such as Beconase are used to treat patients who suffer from chronic inflammation of the sinuses and nasal lining and who get catarrh dripping down the back of the throat. Medications to reduce acid secretion by the stomach are used to treat patients with gastro oesophageal reflux.
Surgery Surgery is indicated for diagnosis (eg tissue biopsies) and treatment (eg removal of tumours and laser surgery). The operation is performed with a fibre optic viewing ‘telescope’ (endoscope) under general anaesthesia.
The view of the larynx is magnified with a microscope so that delicate operations can be carried out. The procedure is known as ‘microlaryngoscopy’ or ‘endolaryngeal microsurgery’.
Surgical management of non cancerous causes of voice disorders is only indicated when all the other measures have failed.
Last updated 03.10.2005
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