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96 The Voice and Voice Therapy
Somatization Dysphonia
In reviewing the clinical files of hospital and university voice clinics, we find rare clinical occurrences of voice patients who may be classified as having somatization dysphonia or who show
symptoms of Briquet’s dysphonia. In somatization dysphonia, the voice patient shows beyond
dysphonia an array of possible conversion symptoms, such as laryngeal pain, neck and shoulder
pain with stiffness, shortness of breath, depression, and extreme vocal fatigue (Verdolini et al.,
2006). Historically, these patients might have carried the diagnosis of Briquet’s syndrome but
in recent years would be classified in the International Classification of Diseases, Tenth Revision
(ICD-10) as a “Dissociative Motor Disorder” (F44.4), and in the Diagnostic and Statistical Manual
of Mental Disorders (Fourth Edition) under “Somatoform Disorders” as a “Conversion Disorder”
(300.11) (Kollbrunner et al., 2010). The SLP may be overwhelmed by the severity of patient
symptoms, soon realizing that the presenting dysphonia is but a small part of the patient’s overall
problem. Such a patient should be referred for an extensive medical workup and psychiatric evaluation/treatment (Misono et al., 2016).
The voice evaluation of such patients may typically reveal an elevated voice pitch, or increased
hoarseness with a reduced signal-to-noise ratio. Vegetative laryngeal functions (coughing, prevention of aspiration, etc.) may remain normal. The voice symptoms often begin in late adolescence
extending into young adulthood, and from the beginning are surrounded by many other symptoms.
The severity of these associated symptoms may present greater problems to the patient than the
presenting dysphonia. The prevalence of somatization dysphonia is much greater in women than
in men by a ratio estimated to be as high as 10 to 1 (Verdolini et al., 2006). Critical to the diagnosis
is the absence of any physical evidence that can support the cause of the dysphonia and the other
PluralPlus
Self-Check
3–5
related symptoms (Deary & Miller, 2011). Somatization dysphonia is a true conversion disorder,
and management appears possible only with successful identification and reduction of emotional
and psychological factors.
Summary
This chapter reviewed functional voice disorders — those that have no organic or neurological
cause. We described voice disorders due to excessive muscle tension and the benign laryngeal
pathology that may develop as a result. We also described voice disorders with a psycho-emotional
basis or overlay. We presented some evidence-based practice studies supporting the value of voice
facilitating approaches in treating most functional and psychogenic voice disorders.
CLINICAL CONCEPTS
The following clinical concepts correspond with many of the objectives at the beginning of
this chapter.
1. The majority of voice-disordered patients you see will be those with a functional
basis to their disorder. Most of these patients will exhibit excessive laryngeal muscle
CHAPTER 3 Functional Voice Disorders 97
tension, resulting in a voice that does not meet their daily communication needs.
Examples include a child who demonstrates repeated phonotrauma and develops
vocal fold nodules (see Chapter 8), a speaker who is an auctioneer and has a voice
that gives out before lunch each day, a speaker who has a weak or paralyzed vocal
fold and compensates by “pushing the voice out” (see Chapter 5), and a speaker with
glottic cancer who uses the false vocal folds to phonate (see Chapter 9).
2. Some voice-disordered patients will come to you because they have a strong psychoemotional basis for their voice disorder, or a strong psycho-emotional reaction to
their voice disorder. Examples include a postpubescent male who sounds like a little
boy or little girl (see Chapter 8), a patient who was put on short voice rest after
laryngeal surgery and whose voice did not “turn back on” easily after the period
of voice rest, an adult female in a verbally abusive marriage who “loses her voice”
in order to avoid angering her spouse and bringing on additional verbal abuse
(see Chapter 8), a patient who perceives himself as being stuck in a high-stress job
and who sees having a voice disorder as a way out of his job, and a patient who is
deprived of emotional attention and who experiences emotional gain by having a
voice disorder.
GUIDED READING
Read the following article:
Lee, J. M., Roy, N., Park, A., Muntz, H., Meier, J., Skirko, J., & Smith, M. (2021). Person-
ality in children with vocal nodules: A multitrait analysis. Journal of Speech, Language,
and Hearing Research, 64, 3472–3758.
Read the following article:
Van Houtte, E., Van Lierde, K., & Claeys, S. (2011). Pathophysiology and treatment of
muscle tension dysphonia: A review of the current knowledge. Journal of Voice, 25,
202–207.
Describe two ways in which the information reported in the article might influence your
clinical practice.
Read the following article:
Deary, V., & Miller, T. (2011). Reconsidering the role of psychosocial factors in functional
dysphonia. Current Opinion in Otolaryngology and Head and Neck Surgery, 19, 150–154.
Using the information reported in the article, identify the factors one should consider before
making a diagnosis of psychogenic voice disorder.
98 The Voice and Voice Therapy
PREPARING FOR THE PRAXIS
Directions: Please read the case study and answer the five questions that follow.
Miranda is a 34-year-old woman with a 3-month history of dysphonia, which began
after an upper respiratory infection. Her chief voice complaints are harsh and strained
voice quality, high speaking pitch, and vocal fatigue by the end of the day. She saw
an otolaryngologist (ENT), who diagnosed her with muscle tension dysphonia and
laryngopharyngeal reflux disease (LPRD). She has been prescribed proton pump
inhibitors. Miranda reports being depressed because of the changes in her social life due to
her dysphonia.
1. The ENT’s report of the stroboscopic laryngeal exam noted “moderate laryngeal
constriction.” Based on this information, which structures are most likely involved?
A. The petiole of the epiglottis
B. The arytenoids
C. The ventricular folds
D. All of the above
2. This type of dysphonia is known as:
A. Secondary-based muscle tension dysphonia
B. Primary-based muscle tension dysphonia
C. Puberphonia
D. Functional aphonia
3. Videolaryngostroboscopy also probably showed:
A. Swelling and redness of the vocal folds and arytenoid mucosa
B. Vocal fold atrophy
C. Polyps
D. Paresis
4. Which perceptual observations would be made about this patient’s voice on a
standardized voice protocol?
A. Her voice remains consistent across speaking tasks.
B. Her voice changes considerably across speaking tasks.
C. Her voice is normal for certain speaking tasks.
D. Her voice is hypernasal.
5. Which of the following treatment options would serve this patient well?
A. Pharmacological and behavioral
B. Voice rest
C. Whisper
D. Glottal stops
CHAPTER 4
ORGANIC VOICE
DISORDERS
LEARNING OUTCOMES
After reading this chapter, one should be able to:
●
Identify congenital abnormalities and discuss the medical, pharmacological, and
behavioral approaches to these disorders.
●
Describe acid reflux and the pathologies and voice changes typically associated
with this disorder. Describe the medical and pharmacological approaches to this
disorder. Describe how behavioral voice therapy intervention and lifestyle change
counseling can reduce the recurrence of this disorder.
●
Describe contact ulcers, cysts, endocrine changes, and hemangiomas and discuss
the medical and pharmacological approaches to these organic disorders. Describe
how behavioral voice therapy intervention and lifestyle change counseling can
reduce the recurrence of these disorders.
●
Describe hyperkeratosis, infectious laryngitis, leukoplakia, and recurrent respiratory
papillomatosis. Describe surgical and pharmacological approaches to these organic
disorders, and describe adjunct lifestyle and voice therapy approaches to these
disorders.
●
Describe pubertal changes, sulcus vocalis, and webbing. Explain the medical,
pharmacological, and behavioral approaches to the organic disorders of sulcus
vocalis and webbing.
99
100 The Voice and Voice Therapy
his chapter describes organic voice disorders. As noted in Chapter 1, organic voice disorders are related to structural deviations of the vocal tract (lungs, muscles of respiration,
T
Tolerance by the public or an indifference to voice problems makes the early identification of
voice pathologies difficult. Hoarseness that persists longer than several days is often identified
by the otolaryngologist (ear, nose, throat [ENT] physician) as a possible symptom of serious
laryngeal disease, and it may be. Hoarseness is certainly the acoustic correlate of improper vocal
fold functioning, with or without true laryngeal disease. The distinction between organic disease
of the larynx and functional misuse has been a prominent dichotomy in the classification of
voice disorders (as described in Chapter 1). It is important for ENT physicians, in their need
to rule out or identify true organic disease, to view the laryngeal mechanism by laryngoscopy in
order to make a judgment about functional versus organic versus neurological involvement. In
the absence of observable structural deviation or neurological involvement, the ENT physician
generally describes the voice disorder as functional. In addition to the examination by the ENT
physician, it is important for the voice clinician to view the larynx as part of the voice evaluation
and in designing the voice therapy. Indeed, the American Speech-Language-Hearing Association
(ASHA, 2004d) affirms the practice of visualization of the larynx by both ENT physicians and
speech-language pathologists (SLPs). It is an important milestone for SLPs to be able to count
laryngeal visualization and imaging as within their scope of practice.
larynx, pharynx, and oral cavity) or to diseases of specific structures of the vocal tract.
Congenital Abnormalities
Laryngomalacia
Laryngomalacia is a congenital anomaly of the larynx that is characterized by the collapse of supraglottic structures during inspiration. It is the most common cause of stridor in neonates and accounts
for 75% of all congenital anomalies of the larynx. Symptoms are usually evident at birth or within
the first few hours or days of life. The diagnosis is typically confirmed by an ENT physician using
direct laryngoscopy under general anesthesia or via flexible nasopharyngolaryngoscopy. Children
with laryngomalacia rarely present with acute airway compromise, and it is common for children to
outgrow the condition by 18 to 24 months. However, for those 5% of patients who require surgical
intervention for severe laryngomalacia, this occurs within 1 to 2 weeks of presentation.
Severe laryngomalacia is associated with the primary symptoms of inspiratory stridor, suprasternal retraction, substernal retraction, feeding difficulty, choking, postfeeding vomit, failure
to thrive, and cyanosis. The presence of concomitant gastroesophageal reflux disease (GERD)
or laryngopharyngeal reflux disease (LPRD) contributes to the feeding- and swallowingrelated symptoms. Supraglottoplasty is currently the preferred surgical intervention, replacing
tracheostomy. Supraglottoplasty eliminates inspiratory obstruction by widening the supraglottis and is a successful approach to correcting all anatomical abnormalities associated with
laryngomalacia.
CHAPTER 4 Organic Voice Disorders 101
Subglottic Stenosis
Subglottic stenosis is a medical condition characterized by the narrowing of the space below the
glottis and above the first tracheal ring. It is one of the most common causes of chronic upper
airway obstruction in infants and children, although it is rare. There are two types of subglottic
stenosis: congenital and acquired. Congenital subglottic stenosis is the second most common cause
of stridor in neonates, infants, and children, while acquired subglottic stenosis is the most common
acquired anomaly of the larynx in the pediatric age group and is the most common abnormality
necessitating tracheotomy in children below 1 year of age. The prognosis of acquired subglottic
stenosis in infants and children is significantly poorer than that of the congenital type.
Walner and colleagues (1999) introduced a grading system for subglottic stenosis that helps
determine levels of intervention by the ENT physician and SLP. For children with Grades I or
II subglottal stenosis — that is, stenosis corresponding to 0 to 50% and 51% to 70%, respectively — careful observation rather than intervention may be appropriate. Stenosis of Grades III
or IV, on the other hand — which correspond to 71% to 99%, and 100%, respectively — often
presents with either tracheal dependency or stridor and exercise intolerance. Children in these
latter categories may require endoscopic or surgical intervention, usually with voice intervention
to follow.
Esophageal Atresia and Tracheoesophageal Fistula
Congenital esophageal atresia (EA) represents a failure of the esophagus to develop as a continuous
passage. Instead, it ends as a blind pouch. Tracheoesophageal fistula (TEF) represents an abnormal
opening between the trachea and esophagus. EA and TEF can occur separately or together. EA and
TEF are diagnosed in the intensive care unit at birth and are treated immediately. The standard
intervention is surgery. However, surgery is not without risks, such as severe respiratory distress,
recurrent aspiration pneumonia, failure to thrive, and dysphagia. Any attempt at feeding could
cause aspiration pneumonia because the milk or other liquid collects in the blind pouch and
overflows into the trachea and lungs. A fistula between the lower esophagus and trachea may
allow stomach acid to flow into the lungs and cause damage. Because of these dangers, patients
should be treated as soon as possible after birth. Treatment by the SLP focuses primarily on
feeding and secondarily on voice. The clinician may suspect dysphagia and dysphonia because
unilateral vocal fold paralysis has been associated in a small percentage of patients treated surgically for EA or TEF. Recent advancements in surgical techniques have significantly improved the
prognosis for infants diagnosed with these conditions. Minimally invasive surgery, characterized by
reduced tissue trauma and quicker recovery times, has emerged as a viable alternative to traditional
open surgery. Nutritional support plays a pivotal role in the comprehensive care of patients with
EA/TEF. A study by Menzies and colleagues (2018) highlighted the importance of individualized nutritional plans to mitigate complications like failure to thrive and aspiration pneumonia.
Furthermore, ongoing research underscores the necessity for long-term follow-up care to address
chronic health issues arising from EA/TEF. Respiratory problems including tracheomalacia and
recurrent respiratory infections are common among survivors.
102 The Voice and Voice Therapy
Acid Reflux Disease
Gastroesophageal reflux disease (GERD) involves the passage of gastric contents from the stomach
into the esophagus, which can lead to complications such as esophagitis and dysphagia. In contrast,
laryngopharyngeal reflux disease (LPRD) occurs when these stomach contents reflux into the larynx
and pharynx, causing irritation that affects the voice and other laryngeal functions (Koufman,
1991). Many studies support a relationship between both conditions, and it is generally accepted
that 50% or less of patients with LPRD have GERD (Habermann et al., 2012; Nunes et al., 2016).
Barrett’s esophagus, a condition characterized by the replacement of normal esophageal squamous
cell epithelium with columnar metaplasia, affects approximately 5% of people in the United States
and approximately 1% worldwide (Sharma, 2022). Barrett’s esophagus affects approximately 2.3%
to 8.3% of people with gastroesophageal reflux disease (GERD) and approximately 1.2% to 5.6%
of people without GERD (Sharma, 2022).
There are few data on the prevalence of GERD in the United States. Delshad and colleagues
(2020) conducted a population-based study to determine the prevalence of GERD symptoms
and persistent GERD symptoms while on anti-reflux medications. They found GERD symptoms
to be common: two of five participants had GERD symptoms in the past, and one of three had
symptoms in the past week. They also found that half of anti-reflux medication users had persistent
symptoms. It has been reported that GERD is more prevalent in Western countries, likely due to
lifestyle and dietary factors (Boulton & Dettmar, 2022).
There is some uncertainty about the prevalence of LPRD, for a number of reasons. Controversies persist concerning epidemiology, clinical presentation, diagnosis, and treatment. No recent
epidemiological study exists regarding prevalence and incidence with the use of objective diagnostic tools. There is no survey that evaluates the prevalence of symptoms and signs on a large
number of patients with confirmed LPRD (Lechien et al., 2019). In laryngeal and voice clinic
patients, LPRD prevalence is estimated between 32% and 85% (Postma & Fritz, 2017). Notably,
many cases of LPRD may not exhibit overt symptoms, making diagnosis challenging.
Video 4–1. Counseling a client with acid
reflux disease. Rather than simply describe
the general symptoms of reflux, the clinician
in Video 4–1 uses time effectively by asking
the patient to reflect on her own signs and
symptoms of laryngopharyngeal reflux. See
Voice Facilitating Approaches 13 and 19 for
hierarchy analysis and pitch inflections. Not
mentioned in the interview is that the patient
has begun a regimen of proton pump inhibitors. Grand Rounds: Identify two additional
behavioral precautions that this patient
might initiate to reduce reflux and abusive
voice behaviors.
CHAPTER 4 Organic Voice Disorders 103
The most prevalent LPRD symptoms are globus sensation, throat clearing, hoarseness, excess
throat mucus, and postnasal drip (Lechien et al., 2019). However, reported prevalence of these
complaints varies among studies because of lack of uniformity in inclusion/exclusion criteria,
diagnostic approaches, and determination/definition of clinical symptoms. Additionally, the
prevalence of LPRD symptoms could significantly vary according to gender (Lechien et al., 2018),
with females reporting more severe dysphonia, and age (Gregory et al., 2016), with older adult
patients reporting less severe symptoms (Lechien et al., 2017).
Clinical tools used for diagnosis and treatment evaluation include patient-reported outcome
measures and instruments evaluating clinical findings. The Reflux Symptom Index (Belafsky etal.,
2002) and the Reflux Finding Score (Belafsky et al., 2001) are commonly utilized. However, there
are limitations and weaknesses in these tools, such as the nonspecific nature of symptoms and the
subjective evaluation of findings. There is a need for more precise diagnostic criteria and improved
instruments for evaluating LPRD.
There is no gold standard for diagnosing acid reflux disease (Figure 4–1). Multichannel intraluminal impedance–pH monitoring (MII-pH) is a diagnostic tool used to evaluate GERD and
LPRD (Hou et al., 2020). It measures both acid and nonacid reflux episodes by assessing changes in
impedance, which reflect the passage of liquid, gas, or mixed contents through the esophagus, alongside pH levels to determine the acidity of the regurgitated material. This comprehensive approach
allows for a more accurate diagnosis of reflux diseases, especially in cases where symptoms do not
align with acid reflux alone, making it valuable for tailoring treatment strategies (see Video 4–1).
The treatment for LPRD involves lifestyle modifications, dietary changes, and medical
management. However, the use of physician counseling for diet and lifestyle modification of
factors known to affect LPRD remains very low (Altman et al., 2005). Proton pump inhibitors
(PPIs) are commonly prescribed for a minimum of 3 months, with some evidence suggesting that
twice-daily dosing may be more effective than once daily (Talley & Zand Irani, 2021). It appears
that treatment with PPI therapy, alkaline water, and a Mediterranean-style diet is significantly
more effective than PPI therapy alone on laryngopharyngeal symptoms and voice quality (Lechien
et al., 2019; Zalvan et al., 2017). For cases that do not respond to conventional therapy, advanced
surgical laparoscopic techniques, such as transoral incisionless fundoplication, may be considered
(Testoni et al., 2021).
Vocal Fold Granulomas
As we explained in Chapter 2, the total length of the glottis can be divided into thirds: The anterior
two-thirds is muscular (vocalis portion of the thyroarytenoids) and covered by a membrane, and
the posterior third is cartilaginous (arytenoids) and covered by a membrane. Vocal fold (or vocal
process) granulomas are classically described as benign laryngeal lesions originating from the vocal
folds or adjacent to the vocal process (Devany et al., 2005). Other terms used to describe similar
lesions surrounding the area include laryngeal granulomas, contact granulomas, postintubation
granulomas, and arytenoid granulomas (Carroll and colleagues, 2010). In vocal fold granulomas,
trauma to the vocal folds results in injuries to the vocal fold and, in turn, stimulates the overgrowth
of tissue (Teng et al., 2023).
104 The Voice and Voice Therapy
FI GUR E 41. Acid reflux disease.
The etiologies of vocal fold granulomas include traumatic, neurological, and idiopathic
(unknown), with the majority being idiopathic (Jin et al., 2014). Trauma to the vocal folds, often
from intubation, is the most common direct cause, particularly in females due to anatomically
smaller larynxes (Martins et al., 2009). Other factors contributing to tissue formation include
excessive vocal abuse, laryngopharyngeal reflux, and certain laryngeal pathologies such as infections
(Teng et al., 2023). Vocal fold atrophy, paralysis, paresis, or scarring can also lead to glottal insufficiency, further increasing the risk of lesion development. Brunner and colleagues (2023) examined
CHAPTER 4 Organic Voice Disorders 105
the prevalence of benign vocal fold lesions from a single European institution and reported that
vocal fold granulomas were observed in 13% of patients, with males more likely to be affected.
The presence of vocal fold granulomas typically manifests through signs such as hoarseness,
vocal fatigue, throat pain, a sensation of a lump in the throat (globus), and difficulty swallowing.
These symptoms are rooted in the granuloma’s disruption of the vocal folds’ normal vibrations
and their ability to close properly. Such growths disturb the vocal folds’ smooth cover, leading
to inefficient voice production and discomfort. This not only affects the quality of the voice but
also introduces physical discomfort in the throat, significantly impacting vocal performance and
daily communication.
The treatment for vocal fold granulomas encompasses a wide array of nonpharmacological,
pharmacological, in-office, and surgical options, each with their strengths and limitations. No
single treatment has emerged as the definitive “gold standard,” but ongoing research is beginning
to highlight mainstay treatments (Teng et al., 2023). Voice therapy and hygiene (Leonard &
Kendall, 2005), steroids, anti-inflammatory drugs, proton pump inhibitors, injectables like botulinum toxin and steroids, laser treatments, and cold steel excision represent the diverse treatment
options. The effectiveness of these treatments varies based on the granuloma’s etiology, size, and
location, underscoring the need for personalized treatment plans.
Vocal Fold Cysts
Vocal fold cysts are benign lesions that can affect voice quality. They are classified as either mucus
retention cysts, resulting from blocked glandular ducts, or epidermoid cysts, which are filled with
keratin and arise from congenital or acquired conditions (Tibbetts et al., 2017). The etiology often
involves vocal misuse, overuse, or trauma leading to blockage or glandular issues. Brunner and
colleagues (2023) examined the prevalence of benign vocal fold lesions from a single European
institution and reported that vocal fold cysts were observed in 8% of patients, with no significant
gender differences.
Diagnosis of vocal fold cysts is typically through laryngoscopic examination, possibly complemented by stroboscopy to assess vibratory behavior. Examination typically reveals a well-defined,
translucent or white mass within the vocal fold layers. These cysts can be located on either one
or both vocal folds and may vary in size. Their presence can disrupt the normal vibratory pattern
of the vocal folds during phonation, which is often visible during stroboscopic examination. The
cysts might cause asymmetry or irregularities in the vocal fold’s surface, leading to changes in
voice quality.
Medical management involves careful monitoring. Depending on their size and location in the
larynx, their management often requires surgical excision. Courey and colleagues (1996) studied
41 benign laryngeal lesions (nodules, polyps, cysts, and corditis) and identified seven squamous
cysts and seven mucous cysts. All 14 cyst lesions were found on histological examination to be
benign. Depending on the site of the lesion, the patient may or may not experience dysphonia.
Young and Smith (2012), in a retrospective review, reported that all of a large cohort of patients
with saccular cysts reported dysphonia. Because cysts rarely resolve spontaneously, they should
be removed surgically using a small superficial incision along the superior edge of the vocal fold,
without disrupting the glottal margin.