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106 The Voice and Voice Therapy
Tibbetts and colleagues (2017) retrospectively analyzed the demographics, treatment
approaches, and outcomes for patients treated for vocal fold cysts over 5 years. The average patient
age was 41.9 years, with a majority being female. Most patients underwent microflap excision,
with some receiving perioperative voice therapy. A significant improvement in Voice Handicap
Index (VHI)-10 scores was observed post-treatment, indicating enhanced vocal function. The
majority of cysts were mucus retention types. Surgical excision was effective in reducing symptoms
and improving vocal fold vibration, with low recurrence rates. Perioperative voice therapy showed
no additional significant benefit.
The Endocrine System and Voice
Occasionally, patients’ voice problems are related to some kind of endocrine dysfunction. Endocrine disorders can have an impact on the physiology of voice production, leading to perceived
changes in pitch, loudness, quality, and endurance. It is important for the voice clinician to
understand the effect of sex hormones on voice production, as well to understand the effect of
endocrine-based conditions such as pituitary disorders, thyroid disorders, diabetes, and hormonal
contraceptives on voice (Hari Kumar et al., 2016). This knowledge helps in accurately diagnosing
voice changes and providing appropriate therapy, considering underlying endocrine factors that
may need medical management alongside voice therapy.
Sex hormones, particularly testosterone and estrogen, play a significant role in the development and changes of the human larynx and voice across the lifespan (Zamponi et al., 2021).
During puberty, an increase in testosterone in males leads to the enlargement of the larynx and
thickening of the vocal folds, resulting in a deeper voice. This is due to the growth and elongation of the vocal folds, which vibrate at a lower frequency (Markova et al., 2016). On the other
hand, females experience a slight increase in vocal pitch during puberty due to the influence of
estrogen, although the change is less dramatic than in males. In adulthood, hormonal fluctuations
in women, particularly during menstrual cycles and menopause, can lead to temporary changes
in voice quality and pitch (Narasimhan & Pooja, 2022). During menopause, reduced estrogen
levels may lead to vocal fold atrophy and a decrease in vocal pitch. In both sexes, aging can lead
to changes in the voice, often referred to as presbyphonia. These changes include a decrease in
vocal pitch, volume, and quality, and are influenced by a combination of hormonal changes,
muscle atrophy, and decreased lung capacity. Professional voice users, such as singers, may find
these changes especially impactful. Understanding these changes is crucial for voice clinicians
to diagnose and treat voice disorders across the lifespan. It is important to note that while these
patterns are generally observed, individual variations exist due to genetic, environmental, and lifestyle factors. Therefore, voice clinicians should consider these factors when assessing and treating
individuals with voice disorders.
Growth hormone imbalances can significantly affect the voice (Pedersen et al., 2020). Excess
growth hormone thickens laryngeal tissues, lowering voice pitch, and may lead to arytenoid cartilage dislocation, altering voice quality. Conversely, growth hormone deficiency leads to higher
pitch and maintains a prepubertal voice quality by affecting oral and pharyngeal cavity sizes. Additionally, growth hormone deficiency impacts voice perception, increases risk of laryngopharyngeal
CHAPTER 4 Organic Voice Disorders 107
reflux, and results in vocal challenges, emphasizing the intricate connection between endocrine
function and vocal characteristics (Hari Kumar et al., 2016).
Thyroid gland disorders can result in either insufficient or excessive secretion of thyroid
hormones, leading to conditions known as hypothyroidism and hyperthyroidism, respectively.
Hypothyroidism is a condition characterized by a deficiency of thyroid hormones, despite the
normal functioning of the hypothalamus and the pituitary gland. The most common cause of
hypothyroidism is Hashimoto’s disease. Clinical symptoms of hypothyroidism can manifest as
weight gain, chronic fatigue, cold intolerance, dry skin, hair loss, or menstrual cycle abnormalities
(Stogowska et al., 2022). Notably, voice changes, such as hoarseness, can also occur (Chaker et al.,
2017). The possible mechanism of these vocal symptoms might stem from vocal fold edema due to
the accumulation of mucopolysaccharides in the lamina propria, cricothyroid muscle edema and
weakness, vocal cord constriction by the enlarged thyroid gland, and vagus nerve edema (Altman
et al., 2003). Hyperthyroidism is a condition characterized by the overproduction of thyroid
hormones. The most common cause of hyperthyroidism is Graves’ disease. The clinical manifestation of hyperthyroidism comprises tachycardia, increased sweating, heat intolerance, nervousness,
or weight loss. Another often observed symptom is muscle weakness, which can potentially impair
the function of laryngeal muscles, thereby affecting voice parameters (Hamdan et al., 2012).
Diabetes mellitus is a disease of the endocrine system in which the body is incapable of regulating its blood glucose levels. As of 2018, 34.2 million Americans, or 10.5% of the population,
suffer from diabetes; of these, 7.3 million were undiagnosed and therefore untreated. This figure
was projected to double by 2040, with 90% of the cases classified as type 2 diabetes mellitus
(T2DM) (Boyle et al., 2001). Voice disorders occur in about 12.5% of individuals with diabetes, a
rate over twice that seen in people who do not have diabetes (Stogowska et al., 2022). Saghiri and
colleagues (2024) conducted a cross-sectional study investigating the potential of voice analysis as
a prescreening tool for T2DM by examining the differences in voice recordings between participants with and without T2DM. The study included 60 participants, 30 diagnosed as nondiabetic
and 30 with T2DM. They were matched according to their year of birth and placed into six
age categories. Seven acoustic features were extracted from voice recordings. The results showed
significant differences in fundamental frequency, jitter, shimmer, cepstral peak prominence (CPP),
and harmonic-to-noise ratio between the two groups, while there were no significant differences
in formant and voice onset time. Shimmer was identified as the most significant predictor of the
disease group. There was also a significant difference between diabetes status and age, in the case
of CPP. The authors suggested that voice analysis could potentially serve as a prescreening tool
for T2DM. Those with T2DM, particularly with uncontrolled blood sugar levels, often report
symptoms like hoarseness and difficulty in vocal exertion (Hamdan etal., 2013). Diabetes can
affect respiratory and muscle function, impacting the airflow necessary for speech (Zineldin etal.,
2015). Diabetic myopathy and neuropathy, affecting up to 40% of diabetic patients, can alter
voice quality by damaging muscles and nerves. Additionally, dry mouth, a common diabetic
symptom, leads to vocal cord changes, reducing life quality for those affected (Grinstein-Koren
et al., 2021). It should be noted, however that a recent literature review and analysis came to a
different conclusion about the relationship between T2DM and voice. Hamdan and colleagues
(2024) conducted a systematic review and meta-analysis to examine the effect of T2DM on
voice. The analysis included 321 patients with T2DM and 171 controls across five studies. Six
108 The Voice and Voice Therapy
parameters were examined: the presence/absence of voice complaints, fundamental frequency,
jitter, shimmer, noise-to-harmonic ratio, and maximum phonation time. The results showed no
significant difference in the prevalence of voice complaints (i.e., hoarseness) between diabetic
patients and control groups. There was also no significant difference in any of the acoustic and
aerodynamic measures between patients with T2DM and controls. The authors suggest that these
findings can be ascribed to the high resilience of the laryngeal muscles to the adverse effect of
systemic diseases.
Rodney and Sataloff (2016) reviewed the literature on the effects of hormonal contraception
on the voice, especially for singers and professional voice users. Articles from 1971 to 2015 were
included. Early studies suggested that oral contraceptives (OCPs) had negative effects on the voice,
such as hoarseness, loss of range, and voice virilization. However, these studies used high-dose,
first-generation OCPs that are no longer available. More recent studies using low-dose, combined
OCPs showed that they stabilize the voice, especially for singers, by reducing hormonal fluctuations during the menstrual cycle (Lã & Polo, 2020). However, this effect was mainly observed for
sustained vowel production, not for connected speech. Only combined OCPs have been studied;
other forms of hormonal contraception have not been evaluated. The study authors point out that
the literature had many inconsistencies and shortcomings, such as different methods, parameters,
phases of the cycle, and characteristics of the participants. There was also a lack of standardization, validity, and reliability of the acoustic and aerodynamic measures used to assess the voice.
The effects of auditory feedback, body composition, age, and other indications for hormonal
contraception on the voice were not adequately addressed. The study authors conclude that OCPs
currently used in the United States appear safe and beneficial for vocalists, as they tend to stabilize
the singing voice. However, more research is needed to understand the full scope of their effects
on the voice as well as the effects of other forms of hormonal contraception.
Laryngeal Hemangioma
Hemangiomas are benign vascular tumors commonly seen in the head and neck region. Laryngeal
hemangiomas are generally classified into two types: infantile and adult. The infantile type is more
common, more frequent in girls and mostly found in the subglottic area. The main signs in infants
are stridor (a high-pitched wheezing sound due to obstructed airflow) and respiratory distress.
Laryngeal hemangiomas in infants typically show a growth phase in the first year of life followed
by a spontaneous regression phase (Kunimoto et al., 2022).
The adult type is uncommon, more frequent in males, and usually found at the supraglottic
area. The main signs and symptoms are hoarseness, dysphonia, dysphagia, and shortness of breath
that may differ due to the site of the lesion. Laohakittikul and Srirompotong (2023) reported on
five cases of adults with laryngeal hemangioma and identified smoking, vocal abuse, and laryngeal
intubation trauma as etiological factors.
Laryngoscopic examination typically reveals a clearly defined, vascular lesion that can vary
in color from bright red to deep purple, depending on the depth and the type of blood vessels
involved. These growths are most commonly found on the vocal folds but can also occur on the
aryepiglottic folds, arytenoids, and other areas of the larynx. The size and location of these heman-
CHAPTER 4 Organic Voice Disorders 109
giomas can significantly affect vocal function, potentially leading to symptoms such as hoarseness,
breathiness, or even difficulty breathing if the airway is compromised. Early identification and
accurate assessment are crucial for determining the most appropriate management strategy to
preserve or restore voice quality and ensure airway safety.
The management of laryngeal hemangiomas involves a variety of treatment modalities tailored
to the specific characteristics of the hemangioma, the patient’s age, overall health, presence of
symptoms, and potential risks associated with each treatment. A multidisciplinary approach
is often beneficial. The treatment approaches for laryngeal hemangiomas include observation,
pharmacological treatments, laser therapy, radiotherapy, surgical excision, and other potential
treatments like embolization and the use of ultrasonic scalpel (Kunimoto et al., 2022). Laohakittikul and Srirompotong (2023) suggest that microlaryngoscopic carbon dioxide laser excision is
the treatment of choice in symptomatic adult vocal fold hemangioma.
Leukoplakia and Hyperkeratosis
Laryngeal leukoplakia refers to a condition characterized by the appearance of white patches or
plaques on the mucous membranes of the larynx, typically resulting from chronic irritation. These
patches are considered precancerous, as they may undergo malignant transformation in some
cases (Hellquist et al., 1982). The exact cause of leukoplakia is not always known, but risk factors
include smoking, alcohol use, and chronic laryngeal irritation (Isenberg et al., 2008). Tobacco
smoke contains a variety of carcinogens and irritants that can cause chronic irritation and damage
to the mucous membranes of the larynx. This chronic irritation can lead to the formation of white
patches or plaques characteristic of leukoplakia. The harmful substances in tobacco smoke can
also induce cellular changes that increase the risk of malignant transformation in these lesions.
Thus, smoking is a significant risk factor for both conditions, emphasizing the importance of
tobacco cessation in preventing laryngeal pathologies. Jabarin and colleagues (2018) showed that
smoking had a major impact on the risk of malignant transformation. In a study of 72 cases, Rutt
and colleagues (2021) reported that a significantly greater proportion of patients with leukoplakia
were current smokers.
Hyperkeratosis in the larynx is a histological finding characterized by the thickening of the
stratum corneum, the outermost layer of the epithelium. This thickening is often a response
to chronic irritation or trauma and can be associated with benign conditions as well as precancerous changes. Hyperkeratosis can occur in conjunction with leukoplakia, where it contributes
to the white appearance of the lesions observed during laryngoscopic examination. The signs and
symptoms of laryngeal leukoplakia and hyperkeratosis often manifest subtly, potentially going
unnoticed initially. Individuals may experience persistent or worsening hoarseness, a sensation
of irritation or discomfort within the throat, or difficulties in swallowing, sometimes feeling as
though something is lodged in their throat. It is not uncommon for these conditions to be asymptomatic, only being identified during routine examinations for unrelated health concerns. Given
the risk of progression to more severe conditions, including cancer, any enduring voice changes
or sensations of throat discomfort should prompt a consultation with a healthcare professional
for further evaluation.
110 The Voice and Voice Therapy
Laryngitis
Laryngitis describes inflammation of the larynx, and a variety of causes result in the presentation
of common symptoms. Laryngitis may be acute or chronic, infectious or inflammatory, an isolated
disorder, or part of systemic disease. Chronic laryngitis is defined by symptoms lasting 3 weeks
or more. Commonly, laryngitis is related to an upper respiratory tract infection and can have a
major impact on physical health, quality of life, and even psychological well-being and occupation
if symptoms persist (Cheung et al., 2009). Overall, laryngitis incorporates a cluster of nonspecific
laryngeal signs and symptoms that can also be caused by other diseases. Consequently, diagnosis
can be difficult and requires correlation of history, examination, and laryngoscopy. Acute laryngitis
is typically diagnosed and managed at the primary care level. In at-risk populations, or those with
persisting symptoms, referral to an otolaryngologist should be considered. Laryngitis presents with
symptoms such as persistent hoarseness, a sensation of a lump in the throat, painful swallowing,
and frequent throat clearing.
Acute laryngitis, marked by inflammation of the larynx, stems from infections (viral, bacterial,
fungal) or physical trauma, leading to vocal fold vibration impairment and symptoms like hoarseness. This inflammation can affect various laryngeal areas, triggered directly by inhaled substances
or indirectly through infection spread, lasting typically under 2 weeks with self-limiting symptoms.
Treatment focuses on supportive measures such as voice rest, hydration, and mucolytics.
Viral infections, especially from rhinovirus, adenovirus, and influenza, are the leading cause of
acute laryngitis. Bacterial laryngitis, challenging to distinguish from viral, may follow viral infections or present independently. Treatment of acute laryngitis with antibiotics is widely debated,
with frequent reports of inappropriate prescribing of antibiotics for upper respiratory tract
infections (Xu et al., 2013). A Cochrane systematic review of two trials involving a total of
206adults found no benefit in treating acute laryngitis with antibiotics, as measured by differences
in objective voice scores at 1 and 2 weeks follow-up (Reveiz & Cardona, 2013). The first included
study compared a 5-day course of penicillin with placebo and reported no difference in patientreported symptoms at 2 to 6 months’ follow-up. The second study compared erythromycin with
placebo and found a subjective reduction in voice disturbance at 1 week and a reduction in cough
at 2weeks in the erythromycin group. Signs and symptoms such as persistent fever (greater
than 48 hr), purulent sputum, membrane formation, or associated distant disease should prompt
consideration of antibiotic treatment.
A retrospective study by Cohen and colleagues (2014) found that three-quarters of patients
referred to an otolaryngologist with an initial diagnosis of acute laryngitis had a different final
laryngeal diagnosis. Importantly, nearly half the patients with laryngeal cancer had an initial
diagnosis by their primary care doctor of either acute laryngitis or nonspecific dysphonia. This
highlights the need for adequate laryngeal examination by an otolaryngologist in all patients with
persisting symptoms or in those who generate a high degree of suspicion, such as heavy smokers
(Wood et al., 2014).
There is debate as to how long dysphonia may be present before warranting laryngoscopy.
Many otolaryngologists would recommend laryngoscopy if dysphonia is present for more than
3weeks without an obvious cause, such as acute illness or intubation. Guidelines from the
American Academy of Otolaryngology-Head and Neck Surgery state that direct laryngeal exami-
CHAPTER 4 Organic Voice Disorders 111
nation is warranted for dysphonia that is present for up to 3 months, or sooner if there are concerns
(Schwartz et al., 2009). This recommendation is based on a cohort study that found that a delay
in diagnosis of laryngeal cancer greater than 3 months led to poorer survival outcomes (Schwartz
et al., 2009).
Phonotrauma, resulting from excessive or improper voice use, highlights the importance of
vocal care, especially in vocally demanding professions. Laryngeal inflammation from phonotrauma emphasizes the need for preventive vocal hygiene measures and appropriate use of
the voice to avoid persistent dysphonia. Vocal hygiene encompasses practices like voice rest,
staying hydrated, using humidifiers, and reducing caffeine consumption, all of which are
crucial for managing symptoms of laryngeal inflammation. Voice rest recommendations can
vary, suggesting a pause in vocal use until humming feels comfortable, indicating readiness for
gradual speech resumption. Hydration is particularly important for those prone to snoring or
mouth-breathing, achievable through methods like chewing sugar-free gum or increasing daily
fluid intake.
Chronic laryngitis is defined as laryngitis that persists beyond 3 weeks. It can be due to a
range of different disease processes. Common causes include allergies, LPRD, and autoimmune
disorders. By definition, chronic laryngitis implies persistent laryngeal problems, and the glottis
should be directly visualized in this situation.
Recurrent Respiratory Papillomatosis
Recurrent respiratory papillomatosis (RRP) is a disease of viral origin that is caused by human
papillomavirus types 6 and 11 (HPV6 and HPV11) in which wartlike growths repeatedly appear
in the respiratory tract. It is usually benign, although malignant transformation can occur. RRP
may have its clinical onset during either childhood or adulthood. Two distinct forms are generally recognized: a juvenile or aggressive form and an adult or less aggressive form. The childhood form is referred to as juvenile-onset RRP (JORRP). Children whose RRP was diagnosed
Video 4–2. Excessive loudness of voice is
most often not the primary reason driving a
voice problem, rather a secondary symptom.
Although the child in Video 4–2 does not
present with a history of recurrent respiratory
papillomatosis, he is still a candidate for
change of loudness intervention because of a
history of screaming and yelling. Grand Rounds:
Describes the changes that might occur to
a child’s larynx with surgical intervention to
remove papilloma. How might the changes
lead to the child’s perceived need to speak
more loudly?
112 The Voice and Voice Therapy
at younger ages (3 years and younger) have been found to be 3.6 times more likely to have more
than four surgeries per year and almost two times more likely to have two or more anatomical sites affected than children whose RRP was diagnosed at later ages (older than 3 years) (Li
et al., 2022).
JORRP is the most common benign laryngeal neoplasm in children and among the
most common causes of pediatric hoarseness (Ben-Harush Negari & Kahn, 2017). Amiling
and colleagues (2021) examined the birth records of 215 children under the age of 18 years
enrolled from 26 pediatric otolaryngology centers in 23 U.S. states from 2015 through 2020
and reported that children born with JORRP were commonly firstborn and delivered vaginally
to young mothers; most of the mothers reported no HPV vaccination before delivery. Further,
vaccine-preventable HPV was identified in all specimens with detectable HPV. In most series,
JORRP is diagnosed between 2 and 4 years of age with a delay in diagnosis from the time
of onset of symptoms averaging about 1 year (Mounts et al., 1982). Seventy-five percent of
children are typically diagnosed before their fifth birthday (Cohn et al., 1981). It is estimated
that between 1,500 and 2,500 new cases of JORRP occur in the United States each year. The
incidence among children in the United States is estimated at 4.3 per 100,000 children (Amiling
et al., 2021).
JORRP significantly affects children, as well as their families and caregivers, due to its
demanding treatment regimen and impact on daily life. Treatment primarily involves surgical
intervention to remove papillomas and secure the airway, with adjuvant therapies employed in
certain cases to enhance outcomes (Amiling et al., 2021). In severe instances, tracheotomy may
be necessary to manage the disease (Lawlor et al., 2020). Traditionally, the severity of JORRP is
evaluated based on factors such as the frequency of surgeries (both annually and over a lifetime),
the extent of papilloma spread, or a combination of these criteria (Doyle et al., 1994). A task force
on RRP (Derkay, 1995) reported that 33% of children needed more than 20 operations, with 7%
requiring more than 100 operations in their lifetime. A study of 30 cases of JORRP by Gandhi and
Jacob (2012) revealed that half the patients experienced remission, which was more likely in those
whose RRP onset was earlier in childhood rather than later. Although the majority of papillomas
stop recurring about the time of puberty, approximately 20% persist beyond puberty (Andrus &
Shapshay, 2006). The financial burden of JORRP is considerable, with the lifetime cost per case
in the United States in 2018 estimated at approximately $149,000, underscoring the significant
economic impact of this condition on healthcare resources (Chesson et al., 2019).
JORRP can represent a serious threat to the airway, limiting the needed flow of air through
the glottal opening. The majority of papillomas occur in children under the age of 6 years; for this
reason, hoarseness and shortness of breath in preschool children should be evaluated promptly.
Harris and colleagues (2012) write that in their clinical experience, patients with JORRP are
usually asymptomatic for the first 6 months of life. As the RRP develops, symptoms begin to
develop. These range from hoarseness to inspiratory stridor. The SLP is sometimes asked to see
a toddler or young child with obstructive RRP who has had to have a tracheostomy to permit
adequate respiration. Developing functional communication with such a child and fostering
normal language growth are the primary concerns of the clinician. Teaching the child to occlude
the trach tube with a finger, or fitting the child with a one-way valve that covers the valve (to
permit vocalization without finger occlusion), usually permits some voicing. In older children or
CHAPTER 4 Organic Voice Disorders 113
adults who are being treated surgically for RRP, helping them to develop the best voice possible
with the compromised laryngeal mechanisms is a realistic goal in voice therapy. Some work on
respiration control (such as voicing with larger lung volumes of air); some work on loudness and
pitch, which may improve vocal function.
Sulcus Vocalis
The term sulcus vocalis is used to describe a groove at the free edge of the vocal folds resulting in
an area of mucosal stiffness and giving the vocal folds a bowed aspect during phonation (Giovanni
etal., 2007). Commonly referred to as spindle-shaped glottis, this deformity causes dysphonia due
to glottic leakage as well as to mucosal stiffness. Sulcus vocalis may be either congenital or acquired
and is of unknown etiology, although vocal abuse and laryngopharyngeal reflux may play a role in
the acquired form (Belafsky, Postma, & Koufman, 2002; Rajasudhakar, 2016). Sulcus significantly
changes the physical properties of the vocal fold and alters the relationship between the body of the
fold and its cover and inhibits normal propagation of the mucosal wave (Giovanni et al., 2007).
Histologically, sulcus vocalis involves the superficial layers of the lamina propria (Reinke’s space)
on the free edge of the vocal fold. An increase in the density of collagen fibers is observed around
the sulcus (Hirano et al., 1990).
Phonotrauma is a key factor in the development of many benign vocal fold lesions, highlighting
the impact of vocal misuse or overuse. Additionally, functional voice disorders can precipitate the
formation of such lesions. Specifically, conditions like sulcus vocalis, characterized by a groove or
furrow in the vocal fold, impair glottic closure and diminish the quality of vocal fold vibrations,
exacerbating existing voice problems. This issue is particularly pronounced in patients with a
unilateral sulcus or asymmetrically located bilateral sulcus, where the imbalance in vocal fold
vibration can lead to further benign vocal fold lesions. This underscores the intricate relationship
between vocal function and the structural integrity of the vocal folds, emphasizing the need for
careful assessment and management in affected individuals.
The SLP today sees more patients with sulcus vocalis than in former years. With mirror
examination, many of these abnormalities were missed. However, videostroboscopy permits close
examination of vocal fold cover abnormalities. With sulcus vocalis, when the folds are abducted,
we can often identify the fold furrow; on adduction with phonation, we can see the compromised
mucosal wave produced by the stiff, compromised lamina propria and glottal incompetence, with
air leakage through the midline of the anterior two-thirds of the folds. Vocal quality reveals a
strained quality with little pitch change and low intensity with difficulty speaking loudly without
fatigue. Individuals may experience periods of aphonia and increased tension in the laryngeal
muscles (Giovanni et al., 2007).
Medical management of sulcus vocalis involves addressing underlying conditions that may
exacerbate the voice disorder, such as laryngopharyngeal reflux (LPRD) or allergies, with appropriate medications like PPIs for reflux or antihistamines for allergies. In some cases, surgery may
be considered to improve the glottic closure and vocal fold vibration. Techniques vary and can
include microflap surgery, fat injection, or other augmentation procedures to fill the sulcus and
create a smoother vocal fold edge. However, surgery is typically reserved for cases where conservative management has not yielded sufficient improvement.
114 The Voice and Voice Therapy
Management by the voice clinician is crucial, starting with a comprehensive assessment
after medical intervention to determine the need for voice therapy. Therapy is tailored to each
individual, aiming to correct maladaptive vocal habits and reduce vocal hyperfunction. Techniques
such as pitch shifts, loudness variations, lateral digital pressure, and exercises for firmer glottal
closure are employed. Additionally, auditory feedback through real-time amplification can aid in
reestablishing gentle phonation. This individualized approach in voice therapy plays a vital role
in rehabilitating patients with sulcus vocalis, emphasizing the SLP’s critical role in both diagnosis
and management of this complex voice disorder.
Laryngeal Web
Laryngeal webs are abnormal formations of tissue that span across the glottis, the space between
the vocal folds, leading to partial or complete obstruction of the airway and affecting voice production. These webs are classified into two primary categories: congenital and acquired.
Congenital laryngeal webs are less common and result from incomplete embryonic development of the larynx, leading to a failure of the vocal folds to separate fully. They typically present at
birth or early in life. Congenital webs are often found at the anterior glottis and may be associated
with other syndromes such as velocardiofacial syndrome. They are rare, accounting for a small
percentage of congenital laryngeal anomalies. Acquired laryngeal webs develop after birth, usually
due to trauma or surgery on the larynx, prolonged intubation, infection, or irradiation. They can
occur at any age, depending on the cause of the trauma or irritation. Acquired webs are more
common, but exact incidence rates vary based on the underlying causes and patient populations.
Laryngeal webs vary in thickness and length, appearing as thin membranes or thick fibrous
bands. Their location within the larynx can be anterior, extending posteriorly, and they may
cover a small portion or a significant part of the glottis. The appearance of the web can range
from translucent to opaque, depending on its composition. In 1985, Cohen published a review
of laryngeal webs and proposed a grading system for anterior webs that is now of common use.
Type 1 laryngeal webs are thin, are membranous, and involve less than 35% of the glottis. Type2
is a web with 35% to 50% glottic involvement. A type 3 web encompasses 50% to 75% of the
glottis and often extends to the anterior cricoid cartilage in the subglottis. Type 4 is a laryngeal
web involving up to 99% of the glottis. The symptoms of laryngeal webbing can range from an
incidental finding to mild hoarseness, weak cry, stridor, dyspnea, aphonia, and severe respiratory
distress at birth with potential death due to airway obstruction (Lawlor et al, 2020).
The treatment for laryngeal webs primarily involves surgical intervention to remove or cut
through the web to restore the airway and improve vocal function (Karle & Lott, 2023). In cases
of thin webs, procedures such as microlaryngoscopy with laser excision can be effective. For
thicker or more extensive webs, more complex surgery may be required, potentially including the
placement of a laryngeal keel (a small silicone or metal device) to prevent the reformation of the
web following surgery. Following surgery, patients may need voice rest, voice therapy, and in some
cases, temporary tracheostomy to ensure adequate breathing during the healing process. The goal
of voice therapy is to optimize vocal function and help the patient achieve the best possible voice
quality following treatment. Successful cases have been reported where patients regained normal
voice function after surgery and voice therapy, highlighting the importance of a comprehensive
and individualized treatment approach.
CHAPTER 4 Organic Voice Disorders 115
Lawlor and colleagues (2020) reported on a series of 37 patients. The etiology of acquired
webs included prior surgeries, papillomatosis, and prolonged intubations. Most patients presented
with vocal symptoms, although respiratory complaints were also significant, especially in severe
cases requiring tracheotomy. Surgical intervention was the primary treatment. Observation was an
option for some, while others required multiple surgeries. Recurrence was common, particularly
after endoscopic procedures, underscoring the complexity of managing laryngeal webs. Despite
improvements in respiratory and voice symptoms for many, recurrence and the challenge of
achieving decannulation in tracheotomy patients were significant hurdles. This comprehensive
review underscores the complexity of pediatric laryngeal web management, highlighting the need
for ongoing research to optimize surgical strategies and improve patient outcomes.
Summary
Organic voice disorders may result from various laryngeal conditions, such as papilloma, granuloma, webbing, and reflux. For each of the various organic voice disorders, we discussed medical
management and the role of the SLP in evaluation and therapy. It is the responsibility of the
SLP to be familiar with each voice disorder, its sequelae (e.g., signs and symptoms), and management. By being familiar with the pathology of the voice disorder, we can better counsel our clients
and provide efficacious behavioral intervention. In many cases, we are the first professional to
detect an organic-related voice disorder and the first professional to make the critical referral to
the ENT physician.
CLINICAL CONCEPTS
The following clinical concepts correspond with many of the objectives at the beginning of
this chapter:
1. Long ago, Van Riper and Irwin (1958) said that speech is defective if it interferes with
communication, draws undue attention to itself, or causes the speaker to be somehow
maladjusted. The same may be said for voice (see Chapter 1).
2. Hoarseness that persists longer than several days is often identified by the
laryngologist as a possible symptom of serious laryngeal disease, and it may be.
Reflux, laryngeal cancer, and recurrent respiratory papillomatosis are examples of
organic disease processes that require immediate attention and referral.
3. Contact granulomas (ulcers) are multifactorial in nature and are considered a chronic
inflammatory disease of the larynx. They seem to result from one of three causes or
a combination of these: hard glottal attack along with throat clearing and coughing,
laryngopharyngeal reflux, and endotracheal intubation. Behavioral voice therapy in
combination with medical intervention is a powerful approach (see Chapter 7).
4. Cysts may masquerade as space-occupying lesions of a functional nature, such as
vocal nodules or polyps, because they are associated with hoarseness and breathiness.