Voice disorders (Change of voice)

Voice is the sound made by air passing from lungs through larynx or voice box. In larynx there are vocal cords, two band like structures that vibrate to make sound. For most of us, our voices play a big part in who we are, what we do, and how we communicate. Like fingerprints, each person's voice is unique.

Many things we do can injure our vocal cords. Talking too much, screaming, constantly clearing throat, or smoking can make voice hoarse.
A disordered voice can be define as one that has one or more of the following characteristics
it is not audible, clear or stable in a wide range of acoustic settings;
it is not appropriate for the gender and age of the speaker;
it is not capable of fulfilling its linguistic and paralinguistic functions;
it fatigues easily;
it is associated with discomfort and pain on phonation.

Dysphonia: Any impairment of the voice or difficulty speaking
Dysarthria: Difficulty in articulating words, caused by impairment of the muscles used in speech.
Dysarthrophonia: Dysphonia in conjunction with dysarthria, for example after a cerbrovascular accident,head injury
Dysphasia: impairment of the comprehension of spoken or written language (sensory dysphasia)or impairment of the expression by speech or writing(expressive dysphasia),especially when associated with brain injury.

Hoarseness: A perceived rough harsh or breathy quality to the voice.

Treatment for voice disorders varies depending on the cause. Most voice problems can be successfully treated when diagnosed early.

Aetiology
Voice disorders are often multifactorial which includes four main stems,  out of which more than one condition contribute to voice disorder-
1. Inflammatory;
2. Structural or neoplastic;
3. Neuromuscular;
4 . Muscle tension imbalance.

List of voice disorders
   The most common voice disorders      Less frequently seen conditions include:

muscle tension dysphonia;
puberphonia
presbylaryngis
laryngitis/muscle tension dysphonia secondary to poor vocal hygiene,
dietary and lifestyle issues;

extraoesophageal reflux (laryngopharyngeal reflux);
vocal fold nodules;
vocal. fold polyps;
vocal fold cysts;
vocal fold palsy and paresis;
arytenoid granulomas.
sulci and mucosal bridges;
   spasmodic dysphonia;
   papillomatosis;
   microvascular lesions;
   laryngeal trauma, including post -surgical causes;
   other neuromuscular causes;
   hyperkeratosis, dysplasia and carcinoma;
  endocrine causes;
  amyloid;
  other laryngeal tumours.

Patient assessment
Patient should be assessed in a voice clinic where should be available following :
01.Voice laboratory
02.Laryngologist.
03. Voice therapist assessing-
    -voice production,
-breathing patterns,
-posture,
             -disorders of articulation,
-fluency
- communication
-psychologically related issues.

History
A detailed history is required to determine:
the nature and chronology of the voice problem;
exacerbating and relieving factors;
lifestyle, dietary and hydration issues;
contributing medical conditions or the effects of their treatment;
the patient's voice use and requirements;
the impact on their quality of life, social and psychological well-being;
their expectations for outcome of the consultation and treatment.
The patients' complaints are most frequently related to:
changes in voice quality (hoarseness, roughness and breathiness);
a pitch that is increased or decreased which is not appropriate for their age and sex;
an inability to control their voice as required (pitch breaks, voice cutting out);
an inability to raise the voice or make the voice heard in a noisy environment (reduced loudness);
an increased effort and/or reduced stamina of the voice or one that tires with use;
difficulties or restrictions in the use of their voice at different times of the day or related to specific daily, social or work-related tasks;
a reduced ability to communicate effectively;
difficulty in singing;
throat-related symptoms (soreness, discomfort, aching,dryness, mucus), particularly related to voice  use;
the consequent emotional, psychological effects caused by the above.

Many of the patient self-report questionnaires that have been developed to measure the impact of the voice problem on the quality of life are concerned with these areas of voice complaint .

Examination
Examination should include –
oral cavity,
oropharynx,
nasal cavity,
lower cranial nerves,
neck for
lymphadenopathy,
masses and
signs of increased muscle tension,
external laryngeal skeleton and position,
posture,
breathing pattern and
general affect.

Treatment overview
 Not all patients presenting with a voice disorder want treatment and some may be happy being given a diagnosis, an explanation of their voice problem and be reassured there is no serious underling condition present. If treatment is required, it will usually consist of one or more of the following options depending on the patient's symptoms, vocal requirements and clinical findings:

vocal hygiene, lifestyle and dietary advice;
voice (speech) therapy;
specialist therapy, for example singing therapy,
osteopathy;
medical treatment;
phonosurgery.
Vocal hygiene, lifestyle and dietary advice

 Depending on the relevance to the patient this may consist of a discussion or video presentation either in individual or group sessions. Additional material is usually given in patient information leaflets.

The areas covered may include:
an explanation of how the voice works;

the links between lifestyle, phonatory and nonphonatory vocal activities and stress on voice
disorders;

the potentially traumatic effects to the vocal folds of 'vocally abusive behaviors’ such as talking or singing too loudly, talking too fast, shouting, throat clearing and harsh coughing;

communicating effectively without raising or straining the voice, for example using a whistle in the school playground or using amplification devices where practical and conserving the voice where possible or in extreme situations discussing the possibility of changing jobs;

the importance of adequate hydration for vocal fold function, i.e. by drinking water, use of steam inhalations and avoiding excessive amounts of drinks containing caffeine, i.e. coffee, tea and colas;

smoking cessation, reducing alcohol and social drug consumption (particularly spirits, cannabis and cocaine) and avoiding exposure to fumes, dust and dry air;

diet and reflux reduction, for example avoiding eating late at night, large or fatty meals.
Voice therapy
This is the mainstay of treatment for muscle tension dysphonia (MTD) and may be delivered as an individual course of therapy or in groups., usually for no longer than eight sessions.

Aims
    to help the patient find a better voice quality which is stable, reliable and less effortful to produce;
    to make better use of vocal resonance and tonal quality;
    to increase the flexibility of the voice by improving the pitch range and loudness without undue      
       effort;
    to increase the stamina of the voice.

Techniques
    vocal exercises with the aim of tar getting and strengthening specific muscle groups and improving glottal closure and efficiency;
    increasing awareness of and reducing excessive tension in the muscles around the larynx, neck  
        and shoulders;
    advice on posture and improving breathing during  speech;
    laryngeal massage;
    general relaxation exercises and stress management;
    psychological counseling;
    remedial singing lessons.
    
Some techniques may need additional specialist input  from clinical psychologists, singing         teachers and osteopaths,

Medical treatment
This mainly includes treatment for
acid reflux  
upper respiratory tract infections
 allergies.
change medication for  asthma inhalers, diuretics and other antihypertensive medication.

Phonosurgery
Phonosurgery refers to any surgery designed primarily for the maintenance, restoration or enhancement of the voice .It encompasses the following-

Microlaryngoscopic surgery
The vocal folds or occasionally false cords are inspected and lesions removed using a microscope and endoscope.
The aim is usually to remove pathological tissue and attempt to restore the normal surface contour and layered structure of the vocal fold.

Laryngeal injection techniques
Various synthetic,biological and autologous materials are usually injected laterally into the muscle of deep layers with a view to augmenting the vocal fold.

Laryngeal framework surgery
Transcutaneous surgery performed on the cartilaginous skeleton of the larynx, for example, laryngoplasty (thyroplasty), arytenoid adduction and cricothyroid approximation with a view to improving glottic closure and body cover differential tone.

Nerve-muscle pedicle graft techniques
Nerve-muscle pedicle graft techniques are used for bulking out or restoring tone to the vocal fold.
Reinnervation and electrode pacing techniques
Reinnervation and electrode pacing techniques are used for restoring tone to the vocal fold or
stimulating contraction of specific muscles.(Reprint)

Voice disorders (Change of voice)

Voice is the sound made by air passing from lungs through larynx or voice box. In larynx there are vocal cords, two band like structures that vibrate to make sound. For most of us, our voices play a big part in who we are, what we do, and how we communicate. Like fingerprints, each persons voice is unique. Many things we do can injure our vocal cords. Talking too much, screaming, constantly clearing throat, or smoking can make voice hoarse. A disordered voice can be define as one that has one or more of the following characteristics it is not audible, clear or stable in a wide range of acoustic settings; it is not appropriate for the gender and age of the speaker; it is not capable of fulfilling its linguistic and paralinguistic functions; it fatigues easily; it is associated with discomfort and pain on phonation. Dysphonia: Any impairment of the voice or difficulty speaking Dysarthria: Difficulty in articulating words, caused by impairment of the muscles used in speech. Dysarthrophonia: Dysphonia in conjunction with dysarthria, for example after a cerbrovascular accident,head injury Dysphasia: impairment of the comprehension of spoken or written language (sensory dysphasia)or impairment of the expression by speech or writing(expressive dysphasia),especially when associated with brain injury. Hoarseness: A perceived rough harsh or breathy quality to the voice. Treatment for voice disorders varies depending on the cause. Most voice problems can be successfully treated when diagnosed early. Aetiology Voice disorders are often multifactorial which includes four main stems, out of which more than one condition contribute to voice disorder- 1. Inflammatory; 2. Structural or neoplastic; 3. Neuromuscular; 4 . Muscle tension imbalance. List of voice disorders The most common voice disorders Less frequently seen conditions include: muscle tension dysphonia; puberphonia presbylaryngis laryngitis/muscle tension dysphonia secondary to poor vocal hygiene, dietary and lifestyle issues; extraoesophageal reflux (laryngopharyngeal reflux); vocal fold nodules; vocal. fold polyps; vocal fold cysts; vocal fold palsy and paresis; arytenoid granulomas. sulci and mucosal bridges; spasmodic dysphonia; papillomatosis; microvascular lesions; laryngeal trauma, including post -surgical causes; other neuromuscular causes; hyperkeratosis, dysplasia and carcinoma; endocrine causes; amyloid; other laryngeal tumours. Patient assessment Patient should be assessed in a voice clinic where should be available following : 01.Voice laboratory 02.Laryngologist. 03. Voice therapist assessing- -voice production, -breathing patterns, -posture, -disorders of articulation, -fluency - communication -psychologically related issues. History A detailed history is required to determine: the nature and chronology of the voice problem; exacerbating and relieving factors; lifestyle, dietary and hydration issues; contributing medical conditions or the effects of their treatment; the patients voice use and requirements; the impact on their quality of life, social and psychological well-being; their expectations for outcome of the consultation and treatment. The patients complaints are most frequently related to: changes in voice quality (hoarseness, roughness and breathiness); a pitch that is increased or decreased which is not appropriate for their age and sex; an inability to control their voice as required (pitch breaks, voice cutting out); an inability to raise the voice or make the voice heard in a noisy environment (reduced loudness); an increased effort and/or reduced stamina of the voice or one that tires with use; difficulties or restrictions in the use of their voice at different times of the day or related to specific daily, social or work-related tasks; a reduced ability to communicate effectively; difficulty in singing; throat-related symptoms (soreness, discomfort, aching,dryness, mucus), particularly related to voice use; the consequent emotional, psychological effects caused by the above. Many of the patient self-report questionnaires that have been developed to measure the impact of the voice problem on the quality of life are concerned with these areas of voice complaint . Examination Examination should include oral cavity, oropharynx, nasal cavity, lower cranial nerves, neck for lymphadenopathy, masses and signs of increased muscle tension, external laryngeal skeleton and position, posture, breathing pattern and general affect. Treatment overview Not all patients presenting with a voice disorder want treatment and some may be happy being given a diagnosis, an explanation of their voice problem and be reassured there is no serious underling condition present. If treatment is required, it will usually consist of one or more of the following options depending on the patients symptoms, vocal requirements and clinical findings: vocal hygiene, lifestyle and dietary advice; voice (speech) therapy; specialist therapy, for example singing therapy, osteopathy; medical treatment; phonosurgery. Vocal hygiene, lifestyle and dietary advice Depending on the relevance to the patient this may consist of a discussion or video presentation either in individual or group sessions. Additional material is usually given in patient information leaflets. The areas covered may include: an explanation of how the voice works; the links between lifestyle, phonatory and nonphonatory vocal activities and stress on voice disorders; the potentially traumatic effects to the vocal folds of vocally abusive behaviors such as talking or singing too loudly, talking too fast, shouting, throat clearing and harsh coughing; communicating effectively without raising or straining the voice, for example using a whistle in the school playground or using amplification devices where practical and conserving the voice where possible or in extreme situations discussing the possibility of changing jobs; the importance of adequate hydration for vocal fold function, i.e. by drinking water, use of steam inhalations and avoiding excessive amounts of drinks containing caffeine, i.e. coffee, tea and colas; smoking cessation, reducing alcohol and social drug consumption (particularly spirits, cannabis and cocaine) and avoiding exposure to fumes, dust and dry air; diet and reflux reduction, for example avoiding eating late at night, large or fatty meals. Voice therapy This is the mainstay of treatment for muscle tension dysphonia (MTD) and may be delivered as an individual course of therapy or in groups., usually for no longer than eight sessions. Aims to help the patient find a better voice quality which is stable, reliable and less effortful to produce; to make better use of vocal resonance and tonal quality; to increase the flexibility of the voice by improving the pitch range and loudness without undue effort; to increase the stamina of the voice. Techniques vocal exercises with the aim of tar getting and strengthening specific muscle groups and improving glottal closure and efficiency; increasing awareness of and reducing excessive tension in the muscles around the larynx, neck and shoulders; advice on posture and improving breathing during speech; laryngeal massage; general relaxation exercises and stress management; psychological counseling; remedial singing lessons. Some techniques may need additional specialist input from clinical psychologists, singing teachers and osteopaths, Medical treatment This mainly includes treatment for acid reflux upper respiratory tract infections allergies. change medication for asthma inhalers, diuretics and other antihypertensive medication. Phonosurgery Phonosurgery refers to any surgery designed primarily for the maintenance, restoration or enhancement of the voice .It encompasses the following- Microlaryngoscopic surgery The vocal folds or occasionally false cords are inspected and lesions removed using a microscope and endoscope. The aim is usually to remove pathological tissue and attempt to restore the normal surface contour and layered structure of the vocal fold. Laryngeal injection techniques Various synthetic,biological and autologous materials are usually injected laterally into the muscle of deep layers with a view to augmenting the vocal fold. Laryngeal framework surgery Transcutaneous surgery performed on the cartilaginous skeleton of the larynx, for example, laryngoplasty (thyroplasty), arytenoid adduction and cricothyroid approximation with a view to improving glottic closure and body cover differential tone. Nerve-muscle pedicle graft techniques Nerve-muscle pedicle graft techniques are used for bulking out or restoring tone to the vocal fold. Reinnervation and electrode pacing techniques Reinnervation and electrode pacing techniques are used for restoring tone to the vocal fold or stimulating contraction of specific muscles.(Reprint)