Dysphonia

Dr. med. Fabian Sinowatz is a freelancer in the medical editorial team.

More about the experts All content is checked by medical journalists.

Dysphonia (voice disorder) is when the ability of the voice to function is impaired and its sound is changed. Dysphonia can have a variety of causes. Usually the reasons are harmless and the voice disorder goes away on its own. Sometimes, however, there may also be serious illnesses in the voice that make a doctor's visit advisable. With the help of voice therapy, the voice can often be significantly improved. Read everything you need to know about dysphonia here.

Dysphonia: description

With dysphonia (Greek: φωνή, phōné, "loud, tone" and δυς, dys "wrong, bad") the voice sounds weak and clearly changed. Dysphonia is not an independent disease, but a symptom that can have various causes. The voice disorder can be due to physical illnesses (organic causes) or disorders of the larynx function (functional causes). The most severe form of dysphonia is called voicelessness (aphonia). In order to track down the reasons for impaired voice training, it helps to know how and where the voice originates.

How the voice is created

In order for a person to be able to communicate with his environment, he is primarily dependent on his voice. At least three processes are involved in the creation of the voice:

1. The lungs produce the air flow (phonation flow) necessary for sound production.
2. The larynx with its muscles, cartilage and especially the vocal folds ("vocal cords") creates a primary sound.
3. The throat, mouth and nose (so-called extension tube) modulate the primary sound into speech sounds.

In principle, disorders in all three processes can lead to dysphonia.

Dysphonia: causes and possible diseases

Dysphonia can be caused by physical reasons (organic voice disorder) or functional disorders (functional voice disorder).

Organic voice disorder (organic dysphonia)

For normal voice formation, the vocal folds ("vocal cords") in the larynx must be able to vibrate freely. Various physical disorders can mean that this is no longer guaranteed - it leads to dysphonia. The organic causes of dysphonia often show characteristic changes or abnormalities in the larynx. A doctor can diagnose this with a laryngoscopy.

Voice overload: People who speak or sing a lot for work-related reasons often experience symptoms of overloading of the vocal cords. The result of permanent stress on the vocal folds are the so-called singer nodules. They sit on the vocal folds and are made of connective tissue. The nodules prevent the vocal folds from vibrating freely during voice formation - dysphonia occurs. Teachers, actors and singers are often affected. The main characteristic of this voice disorder is hoarseness.

Inflammation of the larynx: If the larynx or even the entire pharynx is inflamed, impaired voice production often occurs. Everyone knows this phenomenon with a cold, when viruses or bacteria trigger inflammation in the throat and thus lead to hoarseness. A backflow of acidic gastric juice into the windpipe can damage the larynx and throat and thus cause dysphonia.

Paralysis of the larynx muscles (larynx paralysis): Damage to the nerve tracts (Nn. Laryngei recurrentes) in the area of ​​the larynx can cause unilateral or bilateral paralysis of the vocal folds. The nerve tracts can be injured, for example, during operations on the thyroid gland. Nerve impulses are then no longer transmitted to the small muscles in the larynx. If only one of the two vocal folds is paralyzed (unilateral paralysis), the person affected can usually still speak almost normally.If, on the other hand, both vocal folds are affected (bilateral paralysis), there is shortness of breath and the most severe form of dysphonia - complete voicelessness (aphonia).

Benign tumors on the vocal folds: After injuries to the vocal folds (for example through the ventilation tube during long-term ventilation), an overgrowth can develop on the vocal folds (vocal fold granuloma, contact granuloma). These tumors can be unilateral or bilateral. The body reacts to the injury to the vocal folds from the ventilation tube. Benign tumors also include papillomas, cysts (spaces filled with fluid) and polyps (growths of the mucous membrane) that sit directly on or in the vocal folds. The free vibration and proper closing of the vocal folds are disturbed by these mechanical obstacles. Surgical removal (phonosurgery) is often necessary in order to correct the dysphonia caused by this.

In Reinke's edema, fluid (edema) collects in the edge of the vocal folds. The exact mechanism has not yet been clarified. What seems certain, however, is that there is a connection with chronic irritation from smoking and refluxing stomach acid. Women between the ages of 40 and 60 are particularly affected. The voice sounds rough and hoarse. Dysphonia can lead to complete voicelessness (aphonia).

A less common cause of dysphonia is cancer of the larynx (laryngeal cancer, larynx tumor). This type of cancer currently affects significantly more men than women. The main risk factor is smoking. However, as more and more women smoke, the incidence of the disease among women has increased in recent years. The main symptoms of throat cancer are persistent hoarseness and possibly shortness of breath. Alcohol and environmental toxins such as asbestos also appear to be involved in the development of throat cancer. If dysphonia persists for a long time, this is in any case an alarm signal.

Functional voice disorder (functional dysphonia)

In functional dysphonia, doctors differentiate between a hyperfunctional and hypofunctional variant. However, mixed forms are very common. In all cases there is an imbalance in the muscles involved in voice training. Functional dysphonia is presumably present if the voice is impaired, but the organic findings on a larynxoscopy are almost normal. Those affected report persistent hoarseness, increasing voice fatigue and sometimes a feeling of pressure or burning in the throat area.

Hyperfunctional dysphonia:
This form of dysphonia occurs when the muscles involved in voice training exert too much force. This tenses the muscles. Adjacent muscle groups in the face, neck and neck area can also be tense. The cause of this tension is usually a permanently excessive use of the voice. The vocal folds cannot vibrate freely in hyperfunctional dysphonia, which results in a pressed and creaky voice.

Hypofunctional dysphonia:
In this form of dysphonia, the muscles in the larynx are underactive. The vocal folds do not close completely, leaving a larger gap between them. Air escapes through this gap, which is perceived as a breathy sound in the voice. The causes for this are mostly illness or exhaustion with a general weakening of the body's performance. Psychological stress such as fear or grief can also lead to hypofunctional dysphonia. The escaping air creates an audible breath in the voice, which also usually sounds quiet and powerless.

Mixed forms of dysphonia:
In practice, pure hyperfunctional or hypofunctional dysphonia is rare. More often there is a mixed form of dysphonia, in which overactive muscle groups try to compensate for weakened muscles. This clearly shows that with a functional voice disorder there is an imbalance between the muscles involved in voice formation.

Dysphonia: when should you see a doctor?

If dysphonia only lasts a few days and has an obvious cause (for example, after a party or as part of a cold), there is usually no cause for concern. However, if the voice does not work repeatedly or for more than two weeks, you should consult a doctor. If you yourself notice that your voice sounds tight, creaky, or breathy, or if you have pain when speaking, a doctor may be advisable. After all, a strong, resilient voice is desirable in both professional and private life.

Dysphonia: what does the doctor do?

Phoniatrists specialize in voice disorders. Specialists in ear, nose and throat medicine (ENT) and general medicine are also possible contacts in the event of dysphonia. First, the doctor uses specific questions to get an overview of the causes and severity of the dysphonia. This is followed by the physical examination (especially the larynxoscopy) and any further examinations.

Medical history

The doctor will ask you various questions, for example:

• How long have you had this voice disorder?

• Was the voice strained before the dysphonia appeared?

• Are there any known diseases of the respiratory tract or the lungs?

• Did you have an operation, for example on the chest or neck area, shortly before the onset of the voice disorder?

• If so, was the operation performed under general anesthesia with artificial ventilation?

• Do you smoke? If so, how much and how long?

• Do you drink alcohol? When Yes, how much?

• Have you noticed any hardening, swelling or a feeling of pressure in the neck area?

• What medication are you currently taking?

Investigations:

There are various examinations to clarify dysphonia. It depends on the suspected cause which examination method is used.

• During the general physical examination, your doctor first gets an overview of the general health situation. This includes, for example, listening with a stethoscope (auscultation) and inspecting the throat with a flashlight and tongue depressor.

• In dysphonia, palpation of the larynx and neck is also important in order to feel any swelling or hardening.

• If you talk to the doctor, he or she will get clues as to how the voice disorder is showing up in you. You may need to repeat sentences or sounds so that he can better assess the function of your voice.

• A laryngoscopy allows a close look at the larynx. The doctor examines the neck directly with the help of a mirror or a special camera. This procedure is very helpful for dysphonia because the doctor gets a direct view of the vocal folds and larynx. You don't have to be afraid of a laryngoscopy. If you relax slightly, there are usually no problems whatsoever.

Further investigations

Sometimes dysphonia is followed by further examinations to determine the cause. They are used for a long-standing or very pronounced voice disorder. Even if additional symptoms such as shortness of breath, coughing up blood or difficulty swallowing occur, the following examinations can be useful:

• Measurement of acidity (pH) in the esophagus. If the vocal folds are suspected of being damaged by acidic gastric juice, a gastroscopy may also be necessary.

• Ultrasound (sonography) of the thyroid gland

• Chest x-ray (chest x-ray)

• Tissue removal (biopsies) from the lining of the larynx or the bronchi

• Computed tomography (CT) or magnetic resonance imaging (MRI) scan of the neck, chest, or brain

Therapies

Depending on the cause, individual voice therapy is used. Speech therapists, speech therapists or breathing / speech teachers usually carry out voice therapy.

Therapy for organic dysphonia
If you have larynx paralysis, you have to get a grip on harmful vocal habits. With the right technique, an efficient and less stressful use of the voice is often possible even with larynx paralysis.

A cold as the cause of dysphonia is treated symptomatically. Once the cold is over, the voice usually comes back quickly.

If gastric acid refluxes, so-called proton pump inhibitors may be used, which reduce gastric juice production.

Vocal cord granulomas, papillomas, cysts and polyps can be removed using phonosurgery techniques.

In the case of Reinke's edema, it is especially important that you stop smoking. Surgical ablation and voice therapy are also possible.

Therapy for functional dysphonia:
As part of voice therapy, voice exercises are developed which, with regular use, are intended to ensure better coordination of the individual muscle groups in the larynx. Usually these exercises start with single sounds. Later, an optimal volume regulation of the voice is practiced in a targeted manner.

A particular focus of voice therapy is on good breathing technique, as this is essential for efficient voice training. Therapy is complete when the person affected can reliably use their newly learned voice behavior in everyday life.

Dysphonia: you can do it yourself

With the help of the voice exercises learned in voice therapy, you will in most cases achieve a significant improvement in dysphonia. However, it is important that you do the vocal exercises at home consistently.

Also try to work on your body tension. Because the voice is also influenced by the overall posture. Loosening up and relaxation exercises can be helpful. In order to relax the muscles permanently, an interplay of regular exercise and relaxation is necessary.

If you have voice problems, don't try to hide them. Better to talk about it with friends or loved ones and find a solution together with the doctor and voice therapists. Because with the right therapy, success in the treatment of dysphonia is very likely.

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