Voice disorders may be caused by many different factors, events, physical ailments and diseases. The majority of voice problems are caused by factors that are not life threatening and that are easily treatable. However, because there can be serious causes of voice disorders such as laryngeal cancer persistent voice problems should be evaluated by an otolaryngologist (ENT specialist).
The larynx houses the vocal cords. The larynx is vital in the body's production of sound. Almost every problem with the larynx, often called the voice box, may result in more than one symptom, and there is no single symptom associated with a specific disorder of the larynx. For example, hoarseness, limitations in pitch and loudness, shortness of breath or increased vocal effort may be a sign of any number of disorders of the larynx.
The severity of the voice symptoms does not necessarily correspond to the severity of the underlying disease. The only way to know what is causing your specific voice problem is to be evaluated by an otolaryngologist.
Some of the most common diseases to affect the larynx are caused by strain or injury to the vocal cords through excessive talking, throat clearing, coughing, smoking, screaming, singing, or speaking too loudly or too low. Eventually, frequent vocal abuse and misuse can cause permanent changes in vocal function and possibly the loss of voice. Disorders caused by abuse, misuse, or overuse include:
Laryngitis: An inflammation or swelling of the vocal cords.
Vocal cord nodules: Small, benign (non-cancerous) growths on the vocal cords. Nodules are among the most common vocal disorders. Professional singers and people who have a lot of vocal demands are often affected by nodules.
Vocal cord polyps: Similar to a vocal nodule, but softer and more blister-like. Heavy smokers often experience this condition and they are often caused by an injury to the vocal folds.
Vocal cord hemorrhage: A sudden loss of voice, usually due to screaming, shouting, or other strenuous vocal tasks. In a hemorrhage, one or more of the blood vessels on the surface of the vocal cord rupture and the soft tissues of the vocal cord fill with blood.
Other disorders include:
Spasmodic dysphonia: People with this condition experience involuntary movements of one or more muscles of the larynx. This can cause difficulty in speech, or make it sound as if the patient's voice is intermittently tight, strangled, or breathy.
Laryngeal papillomatosis: These wart-like tumors grow inside the larynx or vocal cords, or the respiratory tract leading from the nose into the lungs. The lesions, which are caused by the human papilloma virus (HPV), may grow very quickly and frequently recur despite careful treatment. This may cause breathing problems if the patient's airway is blocked or, more frequently, hoarseness if they are on the vocal folds. Laryngeal papillomatosis can affect adults, children, and infants.
Vocal cord paralysis: the vocal cords in the larynx do not open or close properly. In addition to affecting speech, vocal cord paralysis can cause coughing and difficulty swallowing, as food or liquids may slip into the trachea (windpipe) and lungs. Although the main symptom tends to be a breathy and weak voice, symptoms of vocal cord paralysis can be more significant. The disorder can be caused by head trauma, neurologic conditions such as Parkinson's disease, a stroke, neck injury, prior neck or chest surgery, cancer, or a viral infection.
Laryngopharyngeal reflux disease (LPR): also called heartburn, acid reflux disease, or gastro-esophageal reflux disease (GERD). Gastro-esophageal reflux is a burning sensation in the chest that may occur after eating, bending, stretching, exercising, and lying down. GERD occurs when the contents of the stomach travel back up into the esophagus. This can happen when the lower esophageal sphincter (LES) valve, which controls the passage of food from the esophagus to the stomach, fails to close correctly. Reflux can affect the larynx and cause symptoms such as coughing, hoarseness, inflammation, and sore throat. In such cases it is referred to as laryngopharyngeal reflux disease (LPR). LPR is possibly associated with laryngeal cancer due to the chronic irritation but more commonly may be associated with frequent coughing, throat clearing, excess mucus and phlegm, and the sensation of a lump in the throat.
Laryngeal cancer: Though many growths that affect the larynx are non-cancerous, cancerous tumors can also grow in the larynx. The inner walls of the larynx are lined with cells called squamous cells. Almost all laryngeal cancers begin in these cells and are called squamous cell carcinomas. If not caught early, laryngeal cancer can spread (metastasize) to nearby lymph nodes in the neck. Smokers are at higher risk than non-smokers for cancer of the larynx. The risk is even higher for smokers who drink alcohol. Fortunately, if caught early, laryngeal cancer is very treatable. Constant hoarseness while speaking is an early symptom of this type of cancer and hoarseness that lasts longer than three weeks should be evaluated by an ENT specialist (otolaryngologist).
Laryngeal stenosis: is a narrowing of the airway that can cause problems with breathing. It can be caused by infection, neck injury, or an intubation (placement of a breathing tube).
Dysphagia: People with this condition have difficulty with swallowing. Some people with dysphagia may be unable to swallow solid foods, liquids, or even saliva. Dysphagia is often seen in patients who have suffered strokes but can also occur following neck surgery or after radiation treatments for head and neck cancer. Other sources include reflux, muscular problems, benign (harmless) or cancerous growths, or scarring.
Flexible endoscopy of the larynx This test means having the back of your mouth and throat (including the larynx) examined with an endoscope which is a narrow, flexible medical device with a light attached that an ENT specialist uses to look at the back of your throat. There is a camera and light at one end, and an eyepiece at the other. Through the endoscope, your doctor can see the inside of your nose and throat very clearly. This is passed up your nose so the specialist can look at all your upper air passages, including the larynx from above. This may be a bit uncomfortable, but you can have an anesthetic spray to numb your throat first. If your specialist sees an abnormality in your throat they may they may recommend removal of a small sample of tissue (a biopsy) to be examined and tested. Video of your vocal cords This test is sometimes called a videostroboscopy or videolaryngoscopy with stroboscopy. It is a test to examine the larynx and vocal cords while you speak. It uses a thin flexible tube (endoscope) which has a camera and fiber optic strobe light on the end. The specialist will pass the tube either up your nose or down your throat. They can spray a local anesthetic to numb the area. They will ask you to talk. The test allows the specialist to see your vocal cords moving in slow motion and gives a clear picture of the area. If your doctor suspects a cancer of the larynx or hypopharynx, you will be referred to an ear, nose, and throat (ENT) doctor, also known as an otolaryngologist, who will do a thorough exam of the head and neck area. This will include an exam of the larynx and hypopharynx, known as laryngoscopy. Flexible laryngoscopy: For this exam, the doctor inserts a fiber-optic laryngoscope − a thin, flexible, lighted tube − through the mouth or nose to look at the larynx and nearby areas. This is a minor procedure done in the office with topical anesthetic. Patients with laryngeal or hypopharyngeal cancer also have a higher risk for other cancers in the head and neck region, so the nasopharynx (part of the throat behind the nose), mouth, tongue, and the neck are also carefully looked at and felt for any signs of cancer. If your doctor can feel a lump in your neck, you may have a fine needle aspiration (FNA). This means putting a very thin needle into the lump. The specialist will feel the lump first so that they know where to put the needle. Once the needle is in the lump, they draw out cells and fluid. They send the cells to the lab for examination to see if they are cancerous. In certain situations, ultrasound is used to help position the needle accurately. Gastroesophageal Reflux Disease Your doctor may be able to diagnose gastroesophageal reflux disease, or GERD, from your description of symptoms. The doctor may also suggest tests to rule out other possible causes of your symptoms, to monitor the degree of damage, or to determine the best treatment for you. An X-ray of your upper digestive system (sometimes called a barium swallow or upper GI series) involves drinking a chalky liquid that coats and fills the inside lining of your digestive tract. Then X-rays are taken of your upper digestive tract. The coating allows your doctor to see a silhouette of your esophagus, stomach and upper intestine (duodenum). Endoscopy is a way to visually examine the inside of your esophagus and stomach. During endoscopy, your doctor inserts a thin, flexible tube equipped with a light and camera (endoscope) down your throat. Oropharyngeal pH probe testing is a test where a small probe is worn for 24 hours to test the pH in the back of the throat to see if reflux is contributing to symptoms. Laryngopharyngeal Reflux Diagnosis is usually made based on the findings of irritation or swelling in the throat, more specifically in the back part of the voice box. Most of the time, no further testing is needed to make the diagnosis. If testing is needed, there are three commonly used tests. A barium swallow study allows the esophagus, stomach, and intestine to be viewed outlined on an x-ray. Another method used to diagnosis LPR is to pass a specific type of scope through the mouth and into the upper part of the throat. A third test determines the level of acid in the throat.
Treatment of laryngeal and voice disorders depends upon what is causing them. For example the treatment for laryngitis may be as simple as needing regular rest and fluids. Several medications are available for treating voice disorders. Depending on the cause of your voice disorder, you may need medication to reduce inflammation, treat gastroesophageal reflux , see a speech pathologist, or have a lesion removed. If your voice problem is the result of smoking, you may be referred to a smoking cessation program. Laryngeal and hypopharyngeal cancer can often be successfully treated, especially if they are found early. There are three main treatment options for laryngeal and hypopharyngeal cancer: radiation therapy, surgery, and chemotherapy. One these therapies or a combination of therapies may be used to treat the cancer. Surgery and radiation therapy are the most common treatments used for both laryngeal and hypopharyngeal cancer. Chemotherapy may be used in combination with radiation therapy to increase the chance of destroying cancer cells. In cancer care, different types of doctors and other specialists often work together to create a patient's overall treatment plan, combining different types of treatments. This is called a multidisciplinary team. An evaluation should be done by each specialist before any treatment begins. The team may include medical and radiation oncologists, surgeons, otolaryngologists (ear, nose, and throat doctors), maxillofacial prosthodontists (specialists who perform restorative surgery to the head and neck areas), dentists, physical therapists, speech pathologists and audiologists. Diagnostic radiologists and pathologists also are an integral part of the treatment team because they assist with diagnosis and staging (determining how advanced the cancer is).
Treatment for heartburn and other signs and symptoms of GERD usually begins with over-the-counter medications that control acid. If you don't experience relief within a few weeks, your doctor may recommend other treatments, including prescription medications. In severe cases and those that do not respond to medication, surgery may be recommended. If you have both GERD and asthma, managing your GERD may help control your asthma symptoms. Studies have shown that people with asthma and GERD saw a decrease in asthma symptoms (and asthma medication use) after successfully treating their reflux disease.
Most of the time, LPR is well controlled with medications. Occasionally, surgery is needed in severe cases or those that don't resolve with medications.