Voice Disorders

Part 1: Background

What is a Voice Disorder? 

A voice disorder occurs when voice quality, pitch, and loudness differ or are inappropriate for an individual’s age, gender, cultural background, or geographic location. A voice disorder is present when an individual expresses concern about having an abnormal voice that does not meet daily needs—even if others do not perceive it as different or deviant.

Signs that a voice disorder is present: 

• Strained, hoarse, croaky, shaky or strangled voice quality 
• Breathy or hoarse voice quality that is difficult to be heard Tiredness (from increased effort) after speaking 
• A voice that doesn’t carry well over background noise 
• No speech production 
• A feeling that it is an effort to use voice 
• Frequent throat-clearing or coughing 
• A voice that does not have the usual variability in pitch range or variation

Any of the above symptoms can be seen as a result of the vocal folds not working properly

Voice Disorders that are common with Acquired Brain Injury: 

• Dysphonia 
  • Symptoms come from more than one source. Some people appear to have nervous system changes that produce an organic tremor of the vocal cords. In rare cases, people can have spasmodic dysphonia symptoms because of acute or chronic life stress.
• Vocal fold paralysis 
  • Everyone has two vocal cords in his or her larynx (voice box). The vocal cords vibrate during speech to produce voice. If one or both vocal cords are unable to move then the person will experience voice problems and possibly breathing and swallowing problems. There are different types of vocal cord paralysis.(2) Vocal fold paralysis.

Part II: Voice Evaluation

General Goal of Voice Therapy: To establish long-term vocal quality without recurrence of the voice disorder

Components of a Voice Evaluation:

• Medical History and Physical Examination 
• Voice related History 
• Patient ratings of vocal function and impact of the disorder 
• Videostroboscopy, perceptual, acoustic and laryngeal function studies 
• Evaluation of response to therapeutic Probes 

Step 1: Gather a Case History

• What is the patient’s age, occupation and social history? 
• Onset of the voice disorder: When? Sudden vs. gradual? 
• Patient’s perception of their voice (what bothers you, how much?) 
• What have you done about it? 
• Relevant medical history (illness, medication) 
• Relevant behavioral History 

Step 2: Reflux Symptom Index: 

Within the last MONTH, how did the following problems affect you?

0 = no problem

5 = severe problem

• Hoarseness or a problem with your voice
• Clearing your throat
• Excess throat mucous or postnasal drip      
• Difficulty swallowing food, liquids, or pills
• Coughing after you ate or after lying down    
• Breathing difficulties or choking episodes
• Troublesome or annoying cough
• Sensations of something sticking in your throat or a lump in your throat
• Heartburn, chest pain, indigestion, or stomach acid coming up

Step 3: Assess the impact of Voice on the Patient’s quality of life 

• Ask the patient questions about how much their voice disorder affects their activities of daily living

Step 4: Videostroboscopy and perceptual, acoustic and laryngeal function studies 

Step 5: Continuous evaluation of response to therapeutic probes 

Part III: Voice Treatment

What does the first therapy session look like? 

• Patient Education 
  • Diagnosis 
  • Pathophysiology (What is physiologically going on?_ 
  • Explain the Anatomy and Physiology of normal voice production 
• Goal Setting: 
  • What would the patient like to get out of voice therapy? 
  • Short and Long term? 
• Introduce the Therapy Program 
  • Hygiene Program 
  • Vocal Exercises 
• Provide Homework 

How do we change unhealthy voice behaviors? 

• Indirect Voice Therapy 
  • Education 
  • Vocal Hygiene Program 
  • Voice Rest 
  • Strategies to optimize vocal fold/laryngeal health 
• Direct Voice Therapy 
  • Exercises/Techniques to change voice production mechanics