Voice Disorders


Ironically, the voice box (larynx) is not actually designed for speech. Humans have learned to use it for speech, but that really isn’t its primary function; rather, it is there to separate the food tube from the breathing tube. However, for anyone with a voice or speech disorder, that primary function is of secondary importance.

The voice box consists of cartilage, muscle, the epiglottis (which helps protect the voice box during swallowing) and the vocal folds (vocal cords). Muscles control the movement of the vocal folds, which open to allow breathing and close to allow speech. Problems can occur anywhere within this area, leading to a variety of symptoms, diagnoses and treatments.

Types of Voice Disorders

There is a wide array of voice disorders that can be classified into various groups (e.g., inflammatory disorders, problems caused by overuse or misuse, vocal cord growths and neuromuscular disorders). At Lahey Hospital & Medical Center, we have the expertise and technology to diagnose and treat all of them, including rare and often misdiagnosed conditions. These are some of the more commonly seen types of voice problems:

  • Laryngitis is an inflammation or swelling of the vocal folds caused by excessive use of the voice, bacterial or viral infections, or irritants such as inhaled chemicals or stomach acid that has backed up into the throat.
  • Vocal cord paralysis (or paresis) is a voice disorder that occurs when one or both of the vocal cords do not open or close properly. Vocal cord paralysis is a common disorder, and symptoms range from mild to life threatening. Someone who has vocal cord paralysis often also has difficulty swallowing and coughing because food or liquids can slip into the trachea and lungs.
  • Spasmodic dysphonia is a voice disorder caused by involuntary movements of one or more muscles of the voice box, causing the voice to break or to have a strained or strangled quality.
  • Vocal nodules are small, benign (noncancerous) growths on the vocal cords, usually related to vocal abuse. Frequently seen among teachers and professional singers, vocal nodules are callus-like growths that form by repeated pressure at the juncture where the folds come together to vibrate. Vocal cord scarring can occur as a result of vocal nodules.
  • Vocal polyps are benign growths similar to vocal nodules but are softer and more like blisters than calluses. They most often form on only one vocal cord. A vocal polyp is often associated with long-term cigarette smoking but may also be linked to hypothyroidism (decreased activity of the thyroid gland), gastroesophageal reflux or chronic vocal misuse.

We also treat throat, laryngeal and thyroid cancers.

Symptoms of Voice Disorders

Common symptoms of a voice disorder include:

  • Hoarseness
  • Breathy vocal quality
  • Chronic cough or excessive throat clearing
  • Vocal strain or fatigue
  • Inability to speak loudly
  • Loss of voice
  • Reduced pitch range or sudden change in overall pitch
  • Sudden or gradual change in overall vocal quality
  • Tremulous quality in the voice
  • Diplophonic (double-toned) quality
  • Decreased breath support during speech

Hoarseness is the most common symptom of a voice disorder. Anyone who has had hoarseness for more than a week should see a doctor. In most cases, hoarseness and other voice problems are a result of vocal abuse and overuse. In some cases, however, hoarseness may be a symptom of vocal cord paralysis, neurologic disease, acid reflux, thyroid disorders or cancer. Other voice symptoms may be the result of infectious diseases, such as Lyme disease, syphilis or a fungal infection, or a symptom of previously undiagnosed asthma or lung disease.

Diagnosing & Treating Voice Disorders

Diagnosing Voice Disorders

At the Department of Speech Pathology, we provide a wide range of traditional and innovative diagnostic methods and technologies. Patients are often examined with a flexible telescope called a laryngoscope, which gives the physician a close look at the voice box. This tool enables the doctor to diagnose subtle disorders in the way the vocal folds move and to determine whether the patient is using his or her voice in a proper or improper manner.

Newer technology includes stroboscopy, a diagnostic exam that uses a tiny camera attached to a probe. The camera provides a magnified, high-resolution image to help physicians diagnose small vocal fold scars, for example. The physician can attach a microphone to the patient’s neck to pick up the frequency of the vocal cords’ vibration, which is far faster than the human eye can see. A computer interprets the vibration and flashes a strobe light to show a representation of the vocal fold vibration.

Utilization of acoustic analysis via computerized technology can also provide relevant information for diagnosis and treatment of voice disorders. The computer analyzes a recording of the patient’s voice in order to provide objective measures of how the voice is being used. The computer system can also be quite useful in treating voice disorders in adults and children, including trials of delayed auditory feedback for dysfluent patients and computerized voice games for children.

These technologies, combined with dynamic assessment (seeing and hearing the voice in action) and clinical observation help us to reach an accurate diagnosis and devise an appropriate treatment plan.

Treating Voice Disorders

At Lahey Hospital & Medical Center, we devise a treatment plan appropriate to each patient’s special needs. In some cases, a team approach may include–in addition to the otolaryngologist (ear, nose and throat specialist)–a speech pathologist, neurologist, psychologist, pulmonologist, primary care physician or pediatrician.

The type of treatment depends on the specific vocal condition and the patient’s other medical requirements. In all cases, however, we offer the latest proven therapies and technologies.

Most patients will be asked to go for a speech therapy evaluation and follow a treatment program before undergoing a surgical procedure, because properly directed vocal exercises can help or heal many patients’ voice problems. Depending on the underlying cause of the voice problem, therapy may be used to strengthen the muscles used to produce the voice, or to relax the structures and muscles that interfere with proper voicing.

Voice therapy can help patients learn to use their voices in a more efficient way. Computerized imaging and acoustic analysis of the patient’s vocal intensity, pitch and quality are used both as diagnostic measures and as biofeedback during treatment. The instrumentation actually allows patients to visualize the components of the voice, which often facilitates success.

Although many patients will improve or be cured by speech therapy and other non-surgical interventions, surgery is occasionally required to correct voice problems. For example, newer surgical treatments for vocal fold paralysis include hydroxyapatite injections and permanent implants to help the vocal folds return to a normal position. Many patients can receive vocal fold injections in our outpatient clinic, with only minimal discomfort. These injections are used to treat conditions such as glottic insufficiency, vocal fold paralysis and presbyphonia simply and easily.

Patients with vocal fold masses generally need to go to the operating room for their surgeries. During surgery, the vocal folds are magnified using a microscope, and a variety of equipment — including specialized knives, scissors, lasers and microdebriders — is used to remove the lesion.

Care of the Professional Voice

Singers are in a special category that makes them more susceptible to less common voice disorders. For them, minor problems can cause subtle changes in the voice that only they can notice. At Lahey Hospital & Medical Center, we’ve treated many singers who perform professionally and who produce and record their music.

The Department of Speech Pathology at Lahey Hospital & Medical Center has state-of-the-art equipment that can help professional and nonprofessional singers learn safer voicing and singing techniques. Our voice computers provide both visual and auditory feedback, which can be essential for singers seeking to improve and protect their voices.