Part II Vocal Health Medical Care of Voice Disorders

What is new in medical care?

Until the 1980s, most physicians caring for patients with voice disorders asked only a few basic questions such as: How long have you been hoarse? Do you smoke?. The physician's ear was the sole "instrument" used routinely to assess voice quality and function. Visualization of the vocal folds was limited to looking with a mirror placed inside the mouth using regular light, or to direct laryngoscopy (looking directly at the vocal folds through a metal pipe or endoscope) under anesthesia in the operating room. Treatment was generally limited to medicines for infection or inflammation, surgery for bumps or masses, and no treatment if the vocal folds looked "normal." Occasionally "voice therapy" was recommended, but the specific nature of therapy was not well controlled, and results were often disappointing. Since the early 1980s, the standard of care has changed dramatically.

What kind of questions are expected from one's doctor?

Correct medical diagnosis in all fields often hinges on asking the right questions and listening carefully to the answers. This process is known as "taking a history." Recently, medical care for voice problems has utilized a markedly expanded comprehensive history that recognizes that there is more to the voice than simply the vocal folds. Virtually any body system may be responsible for voice complaints. In fact, problems outside the larynx often cause voice dysfunction in people whose vocal folds appear fairly normal; these individuals would have received no effective medical care until just a few years ago. 

What is involved in a physical examination of a person with voice problems?

Physical examination of a person with voice complaints involves a complete ear, nose, and throat assessment and examination of other body systems, as appropriate. In 1854, a singing teacher named Manuel Garcia devised the technique of indirect laryngoscopy. He used the sun as a light source and a dental mirror placed in the mouth to look at the vocal folds of his students. This rapidly became a basic tool for physicians, and it is still in daily use, although we now use an electric light rather than the sun. This technique is valuable but has many shortcomings. Effective magnification and photographic documentation are difficult, and standard light does not permit assessment of the rapid and complex motion of the vibratory margin of the vocal folds. After 130 years, the 1980s finally saw technological advances that address these and other shortcomings.

In the last few years, the subjective examination has been supplemented by technological aids that improve our ability to "see" the vocal mechanism, and allow quantification of most aspects of its function. When singing the note middle C, for example, the vocal folds come together and separate approximately 250 times per second.  Strobovideolaryngoscopy (slow-motion visualization of the vocal folds) uses a laryngeal microphone to trigger a stroboscope which illuminates the vocal folds, allowing the examiner to assess them in slow motion. This technology allows detection of small masses, vibratory asymmetries, a-dynamic segments due to scar or early cancer, and other abnormalities that were simply missed in vocal folds that looked "normal" under continuous light (as opposed to stroboscopic, or pulsed, light). The instruments contained in a well-equipped clinical voice laboratory assess six categories of vocal function: vibratory, aerodynamic, phonatory, acoustic, electromyographic, and psychoacoustic. State-of-the-art analysis of vocal function is extremely helpful in diagnosis, therapy, and evaluation of progress during treatment of voice disorders. 

COMMON DIAGNOSES AND TREATMENTS

Following a thorough history, physical examination, and clinical voice laboratory analysis, it is usually possible to arrive at an accurate explanation for voice dysfunction. Treatment depends upon the etiology (cause), of course. Fortunately, as technology has improved voice medicine, the need for laryngeal surgery has diminished. In a great many cases, voice disorders result from respiratory, neurological, gastrointestinal, psychological, endocrine, or some other medical cause that can be treated. Many conditions require the prescription of drugs. However, medications must be used with caution because many of them have adverse side effects that alter voice function, as discussed above. Consequently, close collaboration is required among all specialists involved in the patient's care to be certain that treatment of one causal condition does not produce a secondary dysfunction that is also deleterious to the voice. When the underlying problem is corrected properly, the voice usually improves; but collaborative treatment by a team of specialists is most desirable to assure general and vocal health, and optimize voice function.

What is hoarseness?

Most people with voice problems complain of "hoarseness" or "laryngitis." A more accurate description of the problem is often helpful in identifying the cause. Hoarseness is a coarse, scratchy sound caused most commonly by abnormalities on the vibratory margin of the vocal fold. These may include swelling, roughness from inflammation, growths, scarring, or anything that interferes with symmetric, periodic vocal fold vibration. Such abnormalities produce turbulence which we perceive as hoarseness. Breathiness is caused by lesions (abnormalities) that keep the vocal folds from closing completely, including paralysis, muscle weakness, cricoarytenoid joint injury or arthritis, vocal fold masses, or atrophy of the vocal fold tissues. These abnormalities permit air to escape when the vocal folds are supposed to be tightly closed. We hear this air leak as breathiness. 

Fatigue of the voice is the inability to continue to phonate for extended periods without change in vocal quality. The voice may fatigue by becoming hoarse, losing range, changing timbre, breaking into different registers, or by other uncontrolled behavior. These problems are especially apparent in actors and singers. A well-trained singer should be able to sing for several hours without developing vocal fatigue. Fatigue is often caused by misuse of abdominal and neck musculature, or over-use (singing or speaking too loudly, too long). Vocal fatigue may be a sign of general tiredness or serious illnesses such as myasthenia gravis. 

Volume disturbance may present as an inability to speak or sing loudly or an inability to phonate softly. Each voice has its own dynamic range. Professional voice users acquire greater loudness through increased vocal efficiency. They learn to speak and sing more softly through years of laborious practice that involves muscle control, and the development of the ability to use the supraglottic resonators effectively. Most volume problems are secondary to intrinsic limitations of the voice or technical errors in voice production, although hormonal changes, aging, and neurological disease are other causes. Superior laryngeal nerve paralysis will impair the ability to speak loudly. This is a frequently unrecognized consequence of herpes infection (such as "cold sores") and may be precipitated by an upper respiratory tract infection. 

Even non-singers normally require only about ten to thirty minutes to warm-up the voice. Prolonged warm-up time, especially in the morning, is most often caused by reflux laryngitis, a condition in which stomach acid refluxes up the esophagus and ends up burning the throat. Tickling or choking during speech or singing is often associated with laryngitis or voice abuse. Often a symptom of the pathology of the vocal fold's leading-edge, this symptom requires that voice use be avoided until vocal fold examination has been accomplished. Pain while vocalizing can indicate vocal fold lesions, laryngeal joint arthritis, infection, or gastric (stomach) acid reflux irritation of the arytenoids; but it is much more commonly caused by voice abuse with excessive muscular activity in the neck rather than acute pathology on the leading edge of a vocal fold, and it does not usually require immediate cessation of phonation pending medical examination. 

Does age affect the voice?

Age affects the voice significantly, especially during childhood and older age. Children's voices are particularly fragile. Voice abuse during childhood may lead to problems that persist throughout a lifetime. It is extremely important for children to learn good vocal habits, and for them to avoid voice abuse. This is especially true among children who choose to participate in vocally taxing activities such as singing, acting, and cheerleading. Many promising careers and vocal avocations have been ruined by enthusiastic but untrained voice use. For children with vocal interests, age-appropriate training should be started early. Any child with unexplained or prolonged hoarseness should undergo prompt, expert medical evaluation performed by a laryngologist (ear, nose, and throat doctor) specializing in voice care.

In geriatric patients, vocal unsteadiness, loss of range and voice fatigue may be associated with typical physiologic aging changes such as vocal fold atrophy (wasting). In routine speech, such vocal changes allow a person to be identified as "old" even over the telephone. Among singers, they are typically associated with flat pitch and a "wobble" often heard in older amateur choir singers. However, recent evidence has shown that many of these acoustic phenomena are not caused by irreversible aging changes. Rather, they may be consequences of poor laryngeal respiratory and abdominal muscle conditions undermining the power source of the voice. The medical history usually reveals minimal aerobic exercise and shortness of breath climbing stairs. With appropriate conditioning of the body and voice, many of the characteristics associated with vocal aging can be eliminated, and a youthful sound can be restored. 

What are the effects of voice use and training?

The amount of voice use and training also affects voices. Inquiry into vocal habits frequently reveals correctable causes for voice difficulties. Extensive untrained speaking under adverse environmental circumstances is a common example. Such conditions occur, for example, among stock traders, salespeople, restaurant personnel, and people who speak over the telephone in noisy offices. The problems are aggravated by habits that impair the mechanics of voice production such as sitting with poor posture and bending the neck to hold a telephone against one shoulder. Subconscious efforts to overcome these impediments often produce enough voice abuse to cause vocal fatigue, hoarseness, and even nodules (callous-like growths, usually on both vocal folds). Recognizing and eliminating the causal factors usually results in the disappearance of the nodules and improved voice.

What about singers, actors, and other voice professionals?

It is also essential for the physician to know the extent to which any patient uses his or her voice professionally. Professional singers, actors, announcers, politicians, and others put "Olympic" demands on their voices. Interest in the diagnosis and treatment of special problems of professional voice users is responsible for the evolution of voice care as a subspecialty of otolaryngology. These patients are often best managed by subspecialists familiar with the latest concepts in professional voice care.

How about smoke and other things in the air?

Exposure to environmental irritants is a well-recognized cause of voice dysfunction. Smoke, dehydration, pollution, and allergens may produce hoarseness, frequent throat clearing, and voice fatigue. These problems can generally be eliminated by environmental modification, medication, or simply breathing through the nose rather than the mouth since the nose warms, humidifies, and filters incoming air.

The deleterious effects of tobacco smoke upon the vocal folds have been known for many years. Smoking not only causes chronic irritation but moreover can result in histologic (microscopic) alterations in the vocal fold epithelium. The epithelial cells change their appearance, becoming more and more different from normal epithelial cells. Eventually, they begin to pile up on each other, rather than lining up in an orderly fashion. Eventually, they escape normal homeostatic controls, growing rapidly without restraint and invading surrounding tissues. This drastic change is called squamous cell carcinoma, or cancer of the larynx.

Can foods or drugs affect the voice?

The use of various foods and drugs may affect the voice, too. Some medications may even permanently ruin a voice, especially androgenic (male) hormones such as those given to women with endometriosis, or with post-menopausal sexual dysfunction. Similar problems occur with anabolic steroids (also male hormones) used illicitly by bodybuilders. More common drugs also have deleterious vocal effects, usually temporary. Antihistamines cause dryness, increased throat clearing, and irritation, and often aggravate hoarseness. Aspirin contributes to vocal fold hemorrhages because of the same anticoagulant properties that make it a good drug for patients with vascular disease. The propellant in inhalers used to treat asthma often produces laryngitis.  Many neurological, psychological, and respiratory medications cause tremors that can be heard in the voice. Numerous other medications cause similar problems. Some foods may also be responsible for voice complaints in people with "normal" vocal folds. Milk products are particularly troublesome to some people because the casein they contain increases and thickens mucosal secretions.

How about other parts of the body?

The history must also assess the status of the respiratory (breathing), gastrointestinal (gut), endocrine (hormone), neurological and psychological systems. Disturbances in any of these areas may be responsible for voice complaints. Selected common examples are discussed or illustrated later in this booklet.

Problems anywhere in the body must be elicited during the medical history. Because voice function relies on such complex brain and other nervous system interactions, even slight neurological dysfunction may cause voice abnormalities; and voice impairment is sometimes the first symptom of serious neurological diseases such as myasthenia gravis, multiple sclerosis, and Parkinson's disease. 

A history of a sprained ankle may reveal the true cause of voice dysfunction, especially in a singer, actor, or speaker with great vocal demands. Proper posture is important to optimal function of the abdomen and chest. The imbalance created by standing with the weight over only one foot frequently impairs support enough to cause compensatory vocal strain, leading to hoarseness and voice fatigue. Similar imbalances may occur after other bodily injuries. These include not only injuries that involve support structures, but also problems in the head and neck, especially whiplash injuries. Naturally, a history of laryngeal trauma or surgery pre-dating voice dysfunction raises concerns about the anatomical integrity of the vocal fold; but a history of interference with the power source through abdominal or thoracic surgery may be just as important in understanding the cause and optimal treatment of vocal problems.     

Do stomach problems or hiatal hernias affect the voice?

Gastrointestinal disorders commonly cause voice complaints. The sphincter (a one-way valve) between the stomach and esophagus is notoriously weak. In gastroesophageal reflux laryngitis, stomach acid refluxes through this weak sphincter into the throat allowing droplets of the irritating gastric acid to come in contact with the vocal folds, and even to be aspirated into the lungs. Reflux may occur with or without a hiatal hernia. Common symptoms of reflux laryngitis are hoarseness especially in the morning, prolonged vocal warm-up time, bad breath, sensation of a lump in the throat, chronic sore throat, cough, and a dry or "coated" mouth. Typical heartburn is frequently absent. Over time, uncontrolled reflux may cause cancer of the esophagus and larynx. So, this condition should be treated aggressively and conscientiously.

Physical examination of the larynx usually reveals a bright red, often slightly swollen appearance of the arytenoid mucosa which helps establish the diagnosis. A barium esophagogram with water siphonage may provide additional information but is not needed routinely. In selected cases, 24 hour pH monitoring provides the best analysis and documentation of reflux. The mainstays of treatment are elevation of the head of the bed (not just sleeping on pillows), use of antacids, and avoidance of food for 3 or 4 hours before sleep. Avoidance of alcohol and coffee is also beneficial. Medications that block stomach acid secretion are also useful, including cimetidine (Tagamet), ranitidine (Zantac), famotidine (Pepcid), nizatidine (Axid), omeprazole (Prilosec), lansoprazole (Prevacid), and others. In some cases, surgery to repair the lower esophageal sphincter and cure the reflux may be more appropriate than life-long medical management. This option has become much more attractive since the development of laparoscopic surgery which has drastically decreased the morbidity associated with this operation.

Do lung problems cause voice disorders?

Respiratory problems are especially problematic to singers, other voice professionals, and wind instrumentalists, but they may cause voice problems in anyone. Support is essential to healthy voice production. The effects of severe respiratory infection are obvious and will not be enumerated. Restrictive lung disease such as that associated with obesity may impair support by decreasing lung volume and respiratory efficiency. However, obstructive pulmonary disease is the most common culprit. Even mild obstructive lung disease can impair support enough to cause increased neck and tongue muscle tension and abusive voice use capable of producing vocal nodules. This scenario occurs even with unrecognized asthma and may be difficult to diagnose unless suspected because many such cases of asthma are exercise-induced. The vocal performance is a form of exercise, whether the performance involves singing, giving speeches, sales, or other forms of intense voice use. Individuals with this problem will have normal pulmonary function clinically and may even have normal or nearly normal pulmonary function test findings at rest. However, as the voice is used intensively, pulmonary function decreases, effectively impairing support and resulting in compensatory abusive technique. When suspected, this entity can be confirmed through a methacholine challenge test performed by a pulmonary (lung) specialist.

Treatment of the underlying pulmonary disease to restore effective support is essential to resolving the vocal problem. Treating asthma is rendered more difficult in professional voice users because of the need in some patients to avoid not only inhalers but also drugs that produce even a mild tremor. The cooperation of a skilled pulmonologist specializing in asthma and sensitivity to problems of performing artists is invaluable.

What about hormones?

Hormones are complex, natural chemicals that affect a variety of bodily functions. Endocrine (hormone-producing organs) problems also have marked vocal effects, primarily by causing accumulation of fluid in the superficial layer of the lamina propria, altering the vibratory characteristics. Mild hypothyroidism typically causes a muffled sound, slight loss of range and vocal sluggishness. Similar findings may be seen in pregnancy, during the use of oral contraceptives (in about 5% of women), for a few days prior to menses, and at the time of ovulation. Premenstrual loss of vocal efficiency, endurance, and range is also accompanied by a propensity for vocal fold hemorrhage which may alter the voice permanently. The use of some medications with hormonal activity can also permanently injure a voice. This is particularly true of substances that contain androgens (male hormones) as discussed above.

Does anxiety have anything to do with the voice?

When the principal cause of vocal dysfunction is anxiety, the physician can often accomplish much by assuring the patient that no organic (physical) difficulty is present and by stating the diagnosis of anxiety reaction. The patient should be counseled that anxiety-related voice disturbances are common, and that recognition of anxiety as the principal problem frequently allows the disorder to be overcome. Tranquilizers and sedatives are rarely necessary and are undesirable because they may interfere with fine motor control, affecting voice adversely. Recently, Beta-adrenergic blocking agents such as propranolol hydrochloride (eg, Inderal) have achieved some popularity in the treatment of pre-performance anxiety in singers and instrumentalists. Beta-blockers should not be used routinely for voice disorders and pre-performance anxiety. They have significant effects on the cardiovascular system and many potential complications, including hypotension, thrombocytopenic purpura, mental depression, agranulocytosis, laryngospasm with respiratory distress, and bronchospasm. In addition, their efficacy is controversial. If anxiety or other psychological factors are an important cause of a voice disorder, their treatment by a psychologist or psychiatrist with special interest and training in voice problems is extremely helpful. This therapy should occur in conjunction with voice therapy.