Serious Problems
- Vocal Nodules: ( Pictures | Video )
Localized benign growths (callous formations) on the vocal folds that are usually thought to be a result of vocal abuse. They form at the area that receives the most pressure when the folds come together to vibrate. The nodules develop from damage caused by repeated pressure on the same area much like a callous forms on areas of a person's feet that are irritated by tight shoes. Over time, repeated misuse of the vocal folds results in soft, swollen spots on each vocal fold that develop into harder, callus-like growths. The nodules will become larger and more stiff the longer the vocal abuse continues. The voice of a person who has vocal nodules usually sounds hoarse, low-pitched, and slightly breathy. Treatment: After a close examination by your otolaryngologist, several options are available. Sometimes the doctor will prescribe total vocal rest for a period of days. Speech therapy is almost always suggested, so as to learn how to use the voice without abusing it. Surgical removal is also an option. - Vocal Fold Polyps: ( Pictures | Video )
Polyps are soft fluid filled bulges located at the front region of the vocal fold. It is a benign growth that is similar to a vocal nodule but is softer, more like a blister than a callous. It most often forms on only one vocal cord. A vocal polyp is often associated with long-term cigarette smoking, but may have other causes. People who develop a vocal polyp usually have a low-pitched, hoarse, breathy voice, similar to the voices of people who have vocal nodules. Treatment: These may respond to conservative medical therapy and intensive speech therapy. If the lesion fails to respond, meticulous microsurgery may be indicated. - Vocal Fold Paresis/Paralysis: ( Pictures | Video )
A voice disorder that occurs when one or both of the vocal cords (or vocal folds) do not open or close properly. Vocal cord paralysis is a common disorder, and symptoms can range from mild to life threatening. Partial (paresis) or complete loss (paralysis) of nerve function to voice box muscles results in abnormal vocal fold function, affects the ability to speak and sing and, in some cases, also breathe and swallow. Attempts to compensate for loss of muscle function, often leads to voice tiring after prolonged use (vocal fatigue). Interruption of the nerve input to voice box muscles may be temporary or permanent, partial or complete, and may affect one or more voice box muscles. Someone who has vocal cord paralysis often has difficulty swallowing and coughing because food or liquids slip into the trachea and lungs. This happens because the paralyzed cord or cords remain open, leaving the airway passage and the lungs unprotected. Treatment: Since there are many causes of vocal fold paresis and paralysis, the cause for each patient needs to be evaluated systematically. There are several methods for treating this condition, surgery and speech therapy being among them. Usually your doctor will want to wait at least one year before attempting surgery, because many cases of paralysis go away without treatment. During this one-year wait, speech therapy is suggested, so the patient can try exercises that aim to strengthen the vocal cords and control breathing during speech. There are a number of different surgical techniques that aim to improve this condition. All of them are geared toward moving the vocal cords closer together during talking and swallowing. Vocal cord injection is just one of the techniques used.
- Spasmodic dysphonia: (
Audio Samples of Both
Types of SD - Scroll to bottom )
A disabling disorder of the voice characterized primarily by involuntary disruptions of phonation. It may also be accompanied by hoarseness, tremor, and pitch breaks. Spasmodic dysphonia is a vocal dystonia. There are two types of this disorder: adductor and abductor. Adductor spasmodic dysphonia (ADSD) is characterized by a squeezed, strained-strangled, effortful phonation with voice stoppages and voice breaks. Abductor spasmodic dysphonia (ABSD) is characterized by an excess flow of air with intermittent lack of vocal fold closure. In some cases, patients have evidence of both types of this disorder. By far, the most common of these is the adductor type. The causes of spasmodic dysphonia is unknown.
In adductor spasmodic dysphonia, sudden involuntary muscle movements or spasms cause the vocal folds to slam together and stiffen. These spasms make it difficult for the vocal folds to vibrate and produce voice. Words are often cut off or difficult to start because of the muscle spasms. It may also sound just like a tightness or effortfulness without any obvious cutting out type symptoms. Surprisingly, the spasms are usually absent while whispering, laughing, singing, speaking at a high pitch or speaking while breathing in. Stress, however, often makes the muscle spasms more severe.
Treatment: About 15 years ago, a report was published that dealt with two patients who experienced significant improvement in vocal function after receiving injections of Botullinum Toxin A (Botox) into the vocal fold muscle. Following these initial reports, Botox became increasingly available and has now become the choice of treatment for patients with spasmodic dysphonia. For ADSD, botox is injected into the thyroarytenoid muscle by passing the needle between the cricoid and thyroid cartilages and into the vocal fold. For ABSD, the posterior cricoarytenoid muscle is usually injected. Botox injection leads to symptom relief for up to six months and occasionally longer with few or no long term side effects. However, the average voice improvement time is about four months.
Treatment of SD begins with an accurate diagnosis. The diagnostic work up generally consists of a thorough case history, including a neurological history. Although most patients have some difficulty in pinpointing the exact onset of the disorder, they generally describe a slow, progressing form of voice difficulty that consists of voice breaks, some degree of hoarseness, more difficulty speaking in noisy situations, and increased difficulty when attempting to use a loud voice. There is no specific definitive test one can take to confirm that he/she has SD. This disorder is identified by the symptoms present, as well as the absence of other disorders or diseases that could cause similar symptoms. These other disorders would include vocal fold atrophy, vocal fold paralysis, muscular tension disorders, and the presence of lesions on the vocal folds.
For the actual injection, a local anesthetic is applied to the neck area, and electrodes are attached to the patient to monitor needle placement. Then a small needle is inserted through the neck in the appropriate place and directed up to the vocal fold. The entire process takes about 15 minutes, and the patient is free to leave after the injection.
- Dystonia: (
Classifications of Dystonias )
Dystonia is a neurological movement disorder characterized by involuntary muscle contractions, which force certain parts of the body into abnormal, sometimes painful, movements or postures. Dystonia can affect any part of the body including the arms and legs, trunk, neck, eyelids, face, or vocal cords. If dystonia causes any type of impairment, it is because muscle contractions interfere with normal function. Features such as cognition, strength, and the senses, including vision and hearing are normal. While dystonia is not fatal, it is a chronic disorder and prognosis is difficult to predict. It is the third most common movement disorder after Parkinson's Disease and Tremor, affecting more than 300,000 people in North America. Dystonia does not discriminate - affecting all races and ethnic groups.
The most common type of dystonia is called a focal dystonia. This type of dystonia affects only one part of the body.
- Reflux laryngitis: ( Pictures - Scroll to bottom of page )
An inflammation of the larynx caused by gastric acid irritation, frequently results in decreased vocal performance. This backflow of gastric acid is called laryngopharyngeal reflux. The structures and tissues of the throat (pharynx, larynx, vocal folds) are much more sensitive to stomach acid and digestive enzymes than is the esophagus, so smaller amounts of reflux into this area can cause more damage. Symptoms include hoarseness, chronic cough, felling of "lump" in throat, bitter taste in mouth (esp. in mornings), frequent throat clearing, sore throat, and other symptoms. Surprisingly, patients often do not have any heartburn symptoms. Treatment: Much emphasis is given to diet. Patient should avoid spicy foods, fried foods, acidic foods, tomato-based products, caffeinated beverages, chocolate, and peppermint. (Search for Acid Reflux diet on google.com for more information.) Other treatment includes maintaining a healthy body weight, eating smaller, more frequent meals, elevating the head of your bed 4-6 inches, and in some cases prescription medication such as Nexium or Prevacid. - Contact ulcers: A less common disorder of vocal abuse. They are experienced by people who use too much force when bringing the vocal folds together for speech. This excessive force causes ulcerated sores or a wearing away of tissue on or near the cartilages of the larynx that move to bring the vocal folds together. These ulcers are also found in people who have gastroesophageal reflux. People with this type of voice disorder often complain of their voice tiring easily and may feel pain in the throat, especially while talking.
- Vocal fold bowing: ( Pictures )
A disorder commonly seen in older adults, can result in vocal weakness. It can result from neural, muscular, traumatic, congenital, or functional causes, with or without vocal fold atrophy, and can result in vocal weakness.
This problem exists when the vocal folds have lost muscle bulk due to injury,
aging or neuromuscular diseases. Bowed vocal folds fail to come together and
then result is usually a breathy voice sound and effortful phonation.
Bowing is often difficult to diagnose and treat. - Presbylaryngis: ( Pictures - Scroll or use Edit - Find - Presbylaryngis in your browser )
A condition that is caused by thinning of the vocal fold muscle and tissues with aging. The vocal folds have less bulk than a normal larynx and therefore do not meet in the midline. A patient with this condition has a hoarse, weak, or breathy voice. It can be corrected by injection of an appropriate substance into both vocal folds to achieve better closure. - Vocal fold cyst: ( Pictures | More Pictures )
A fluid-filled sac in the vocal folds. The cyst can be located near the surface of the vocal cord or deeper, near the ligament of the vocal cord. As with vocal cord polyps and nodules, the size and location of vocal cord cysts affect the degree of disruption of vocal cord vibration and subsequently the severity of hoarseness or other voice problem. Surgery followed by voice therapy is the most commonly recommended treatment for vocal cord cysts that significantly alter and/or limit voice. -
Granuloma: (
Pictures )
A benign growth that typically occurs in the posterior (back) part of the larynx, either directly on the vocal fold, or on one of the mucosal surfaces nearby. The growth may prevent glottic closure, causing vibration to be weak or non-existent. This could cause a weak or breathy voice, or frequent "breaks" in the voice. Or the lesion may interfere with vibration, causing a rough, irregular sound. The voice may fatigue easily and become worse sounding with continued use. A lesion that is not directly on the vocal fold may not interfere with voice quality, but can be very irritating and even painful. A large enough lesion may obstruct the airway. Treatment: The treatment can be quite frustrating, as opinions vary among doctors. Some doctors prefer to remove the lesion immediately, although recurrence is quite common. A more widely recommended treatment program includes a combination of anti-reflux medications (this prevents any burning and further irritation by acid reflux, a short course of steroids (to reduce inflammation), antibiotics (to cure any infection), and speech therapy. The above treatment program may be enough to cause the granuloma to resolve. The next step would be surgical options. Quick facts about this type of surgery are as follows; (a) performed under general anesthesia, (b) the inflamed area is often injected with steroids immediately after removal, (c) total voice rest after surgery for 3-5 days, (d) voice use is gradually undertaken over a course of 1-4 months.
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Paradoxical Vocal Fold Movement (PVFM)
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Video and Audio - Scroll to Bottom )
A voice disorder in which the vocal folds behave in a normal fashion almost all of the time, but, when an episode occurs, causes the vocal folds to close when they should open, such as when breathing. PVFM can be mistaken for asthma as it leads to wheezing and difficulty breathing, sometimes to the point of requiring hospitalization. PVFM episodes may be triggered by shouting, coughing, physical exercise, acid reflux, breathing cold air, irritants such as smoke or pollen, psychosocial issues, and neurological issues. Treatment: PVFM is treated both medically and behaviorally. Medical intervention addresses any physical and/or psychological factors, while behavioral intervention with a speech-language pathologist addresses vocal exercises, relaxation techniques, and proper respiratory support for speech. The goal of intervention is to make the individual aware of PVFM triggers so they can avoid them and to teach the individual how to handle an episode when it occurs.
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Reinke's Edema: (
Pictures )
Reinke's edema, also called polypid degeneration, is a buildup of fluid underneath the lining of your vocal cords. Frequently caused by laryngopharyngeal reflux disease , vocal abuse or smoking, Reinke's edema is characterized by a raspy, deep voice and vocal fatigue. This condition is most noticeable in women.
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Laryngeal papilloma: (
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These are wartlike growths on the larynx caused by a viral infection. Laryngeal papillomatosis involves numerous warty growths on the vocal cords, most commonly in young children between the ages of 1 and 4. Recurrences are, unfortunately, frequent. Remission may occur after several years. Treatment: Laryngeal papillomas are detected using a laryngoscope to view the voice box. Doctors perform a biopsy in which they take a sample of the papilloma to confirm the diagnosis. Surgery is the usual treatment. Drug treatment is available for papillomas that rapidly recur or spread beyond the larynx. Such drug treatments include chemotherapy and antibiotic therapy. Many children require numerous procedures through childhood to remove the tumors as they reappear. At puberty, some papillomas may disappear on their own.
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Vocal Fold Scarring
Vocal fold scarring is abnormal scar tissue in the vibrating layer of the vocal fold. Vocal fold scarring causes a number of voice disorders that are problematic to patients and is very challenging to diagnose and treat. Vocal cord scarring can be mild or severe, or anywhere in between. It can also occur in one spot, or span the entire length of the vocal cord. The more severe the scar, usually the more severe are the symptoms to the vocal cord in its ability to vibrate - which directly corresponds to the degree of the voice problem. When the vocal folds are altered by such scar tissue, the ability to vibrate is also altered. This can produce many different symptoms, such as hoarseness, breathy voice, and the sensation that it requires more effort to speak. Treatment: There is presently no treatment to remove scars from the vocal folds. That being said, professional voice users do well to carefully follow suggestions for good voice use, since prevention is the only cure. Several things can contribute to vocal fold scarring, including laryngopharyngeal reflux disease and allergies. Your doctor will need to anyalyze if either of these two conditions are making your problem worse, and treat them accordingly. There is no one single treatment option that works for all patients with vocal fold scars. Thus, preventing vocal fold scarring and attempting all non-surgical treatment options prior to surgery are crucial. Vocal fold augmentation can also result in noticeable voice improvement.
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Muscle Tension Dysphonia
( Video and Audio -
Scroll to Bottom )
Abnormal-sounding voice due to loss of normal muscle coordination or innappropriate muscle contraction. The voice usually sounds very strained and effortful. There is no diagnostic test that can differentiate spasmodic dysphonia from muscle tension dysphonia, which can sound the same but is caused by muscle tension. Whatever the underlying cause of vocal fold spasms, voice production patterns can become quickly habituated in the brain, and can be difficult to change. Your brain develops a "voice image" and faithfully tries to reproduce it.
Tip: Anyone who experiences vocal change or hoarseness for more than 2 weeks should be examined by a physician, preferably an otolaryngologist (a physician/surgeon who specializes in diseases of the ears, nose, throat, and head and neck).