This document defines and describes various voice and speech disorders. It discusses the anatomy and physiology of normal voice production. It then defines and describes various types of voice disorders like dysphonia, dysarthria, hoarseness, vocal register issues, and specific disorders like vocal nodules, vocal polyps, laryngeal paralysis, and functional disorders. Evaluation and treatment approaches for some common voice disorders are also mentioned.

1. VOICE & SPEECH DISORDERS
By Dr. M V HARIKA M.S ENT

2. Definition of voice
Voice is the product of the vibrating vocal folds,
combined with the resonation of the sound
throughout the vocal tract.

3. Phonatory system divided into 3 levels
• The voice activating air stream(the respiratory
system).
• The voice generator ( the larynx with its vocal
fold) which causes the air to vibrate and thus
produce the tone.
• The voice resonator (the pharyngeal and oral
cavity) which selectively transmits some
frequency bands (called formants) and weakens
others (antiresonances).

4. • Vocal folds have to be structurally and
functionally symetrical, at the same level and
close rapidly – clear vocal note.
• Insufficiency approximation of Vocal fold –air
wastage and production of breathy voice quality.
• Three parts of the oropharyngeal resonator are of
special interest:
– Laryngeal entrance immediately above the glottis
– Middle part with the velopharyngeal valve
– Outermost part between the lip

5. Vocal registers(characteristis of vocal fold adduction
and vibration)
• Registers have been regarded as the perceptually
distinct regions of vocal quality over certain ranges
of pitch and loudness.
• 3 main vocal register
– Loft register(or falsetto)
– Modal register
– Pulse register(or glottal fry or vocal fry or creaky
voice)

6. Register may include Equivalent
terms
Vocal folds Fo range(Hz)
Loft
register
Highest vocal frequency Falsetto Thin, tense,
lengethen,
minimal
vibration
275-1100
Modal
register
Range of fundamental
frequencies most
commonly used in
speaking and singing
Chest,
head,
middle,
heavy voice
Complete
adduction
100-300
Pulse
register
Lowest range of vocal
frequencies, laryngeal
output is perceived as
pulsatile
Vocal fry,
glottal fry,
creaky
voice
Long closed
phase
20-60

7. Definition of voice disorder
• Not audible, clear or stable in wide range .
• Not appropriate for gender and age.
• Not capable of fulfilling its linguistic and
paralinguistic functions.
• Fatigues easily.
• a/w discomfort and pain on phonations.

8. Key definitions
Dysphonia: Any impairment of voice or difficulty speaking
Dysarthria: Difficulty in articulating words, caused by
impairments of muscle used in speech
Dysarthrophonia: Dysphonia in conjunction with dysarthria
e.g MND,CVA
Dysphasia: Impairment of comprehension of spoken or
written language(sensory dysphasia) or impairment of the
expression by speech or writing(expressive dysphasia)
Hoarseness: perceived rough, harsh or breathy quality of the
voice.
Odynophonia: pain while talking

9. HOARSENESS
Hoarseness is defined as roughness of voice resulting from
variations of periodicity and/or intensity of consecutive
sound waves.
For production of normal voice, vocal cords should:
1. Be able to approximate properly with each other.
2. Have a proper size and stiffness.
3. Have an ability to vibrate regularly in response to air
column

10. Any condition that interferes with the above functions causes
hoarseness.
(a) Loss of approximation may be seen in vocal cord paralysis or
fixation or a tumour coming in between the vocal cords.
(b) Size of the cord may increase in oedema of the cord or a
tumour; there is a decrease in partial surgical excision or
fibrosis.
(c) Stiffness may decrease in paralysis, increase in spastic
dysphonia or fibrosis. Cords may not be able to vibrate properly
in the presence of congestion, submucosal haemorrhages,
nodule or a polyp.

11. AETIOLOGY
Hoarseness is a symptom and not a disease per se. The causes of hoarseness
are summarized below
1. Inflammation
Acute Acute viral laryngitis, diphtheria, whooping cough, noxious
gases
Chronic Chronic laryngitis (smoking, occupational gastro-oesophageal
reflux, steroid inhalations for asthma), tuberculosis, syphilis,
leprosy, fungal infections
2. Neoplasms
Benign-Papillomas (solitary or multiple), haemangioma, chondroma,
schwannoma, granular cell myoblastoma ,Premalignant -Leukoplakia
Malignant -Cancer, sarcoma
3. Non-neoplastic lesions- Vocal nodules, vocal polyp, contact ulcer, cyst,
laryngocoele, amyloid deposit
4. Trauma Forceful shouting (submucosal vocal cord haemorrhage), blunt and
sharp laryngeal trauma, foreign body, intubation

12. 5. Paralysis-Paralysis of recurrent, superior laryngeal or both the nerves
6. Fixation of cords- Arthritis or traumatic fixation of cricoarytenoid joints
7. Congenital -Laryngeal web, cyst, laryngocoele, paralysis, vocal sulcus
8. Systemic disorders- Hypothyroidism, sarcoidosis, Wegener’s
granulomatosis, amyloidosis, myasthenia gravis.

13. EVALUATION OF HOARSENESS
1. History. Mode of onset and duration of illness, patient’s occupation, habits
and associated complaints are important and would often help to elucidate
the cause. Any hoarseness persisting for more than 2 weeks deserves
examination of larynx. Malignancy should be excluded in patients above 40
years.
2. Indirect laryngoscopy. Many of the local laryngeal causes can be diagnosed.
3. Examination of neck, chest, cardiovascular and neurological system would
help to find cause for laryngeal paralysis.
4. Laboratory investigations and radiological examination should be done as per
dictates of the cause suspected on clinical examination.
5. Direct laryngoscopy and microlaryngoscopy help in detailed examination,
biopsy of the lesions and assessment of the mobility of cricoarytenoid joints.
6. Bronchoscopy and oesophagoscopy may be required in cases of paralytic
lesions of the cord to exclude malignancy.

14. DYSPHONIA PLICA VENTRICULARIS (VENTRICULAR
DYSPHONIA)
• Here voice is produced by ventricular folds (false cords) which have taken
over the function of true cords. Voice is rough, low-pitched and
unpleasant. Ventricular voice may be secondary to impaired function of
the true cord such as paralysis, fixation, surgical excision or tumours.
Ventricular bands in these situations try to compensate or assume
phonatory function of true cords.
• Functional type of ventricular dysphonia occurs in normal larynx. Here
cause is psychogenic. In this type, voice begins normally but soon becomes
rough when false cords usurp the function of true cords. Diagnosis is made
on indirect laryngoscopy; the false cords are seen to approximate partially
or completely and obscure the view of true cords on phonation.
Ventricular dysphonia secondary to laryngeal disorders is difficult to treat
but the functional type can be helped through voice therapy and
psychological counselling.

15. FUNCTIONAL APHONIA (HYSTERICAL
APHONIA)
It is a functional disorder mostly seen in emotionally labile females in the
age group of 15–30 years. Aphonia is usually sudden and unaccompanied
by other laryngeal symptoms. Patient communicates with whisper. On
examination, vocal cords are seen in abducted position and fail to adduct on
phonation; however, adduction of vocal cords can be seen on coughing,
indicating normal adductor function. Even though patient is aphonic, sound
of cough is good. Treatment given is to reassure the patient of normal
laryngeal function and psychotherapy.

16. PUBERPHONIA (MUTATIONAL FALSETTO VOICE)
• Normally, childhood voice has a higher pitch. When the larynx
matures at puberty, vocal cords lengthen and the voice changes to
one of lower pitch. This is a feature exclusive to males. Failure of
this change leads to persistence of childhood high-pitched voice
and is called puberphonia. It is seen in boys who are emotionally
immature, feel insecure and show excessive fixation to their
mother.
• Psychologically, they shun to assume male responsibilities though
their physical and sexual development is normal. Treatment is
training the body to produce low pitched voice. Pressing the thyroid
prominence in a backward and downward direction relaxes the
overstretched cords and low tone voice can be produced
(Gutzmann’s pressure test). The patient pressing on his larynx
learns to produce low tone voice and then trains himself to produce
syllables, words and numbers. Prognosis is good.

17. PHONASTHENIA
It is weakness of voice due to fatigue of phonatory muscles.
Thyroarytenoid and interarytenoids or both may be affected. It is
seen in abuse or misuse of voice or following laryngitis. Patient
complains of easy fatiguability of voice. Indirect laryngoscopy shows
three characteristic findings:
1. Elliptical space between the cords in weakness of thyroarytenoid.
2. Triangular gap near the posterior commissure in weakness of
interarytenoid.
3. Key-hole appearance of glottis when both thyroarytenoid and
interarytenoids are involved.
Treatment is voice rest and vocal hygiene, emphasizing on periods
of voice rest after excessive use of voice

18. DYSPHONIA
Dysphonia can be divided into three types:
1. adductor
2. abductor and
3. mixed.

19. ADDUCTOR DYSPHONIA
The adductor muscles of larynx go into spasm causing vocal cords to go into
adduction. Voice becomes strained or strangled, and phonation is
interrupted in between leading to voice breaks. Larynx is however
morphologically normal. Severity of the condition differs from mild and
intermittent symptoms to those with moderate or severe dysphonia. Flexible
fibreoptic laryngoscopy is useful during which patient’s speech, sustained
phonation and respiratory activities are studied. Patient may have tremors of
larynx, palate and pharynx.
Aetiology of the condition is uncertain but one should exclude neurological
conditions such as Parkinsonism, myoclonus, pseudobulbar palsy, multiple
sclerosis, cerebellar disorders, tardive dyskinesia and amyotrophic lateral
sclerosis. CT scan and MRI are not useful but help to rule out neurological
conditions

20. • Treatment consists of botulinum toxin injections in the thyroarytenoid
muscle on one or both sides to relieve spasm. Percutaneous
electromyography (EMG) guided route through cricothyroid space is
preferred. Dose of botulinum toxin depends on severity of the
condition. Toxin injections relieve voice breaks due to spasms and
improve airflow but the benefit lasts only up to 16 weeks or so when
repeat injection may be needed. Sometimes, if dose of toxin is not
regulated it may cause breathiness of voice and discomfort to swallow.
• Voice therapy is useful to improve voice and the duration of benefit.
Voice therapy alone without injection does not help much. Earlier
disease was considered to be psychological in origin but
psychotherapy was not found useful. Section of recurrent laryngeal to
paralyze the cord/cords has been used in the past but it interferes with
glottic closure leading to breathy and weak voice and swallowing
discomfort. This treatment is still used when injection treatment fails
and the spasms are severe.

21. ABDUCTOR DYSPHONIA
• It is due to spasms of posterior cricoarytenoid muscle (the only
abductor) and thus keeping the glottis open. Patient gets a breathy
voice or breathy breaks in voice. The condition is gradually
progressive and the symptoms get aggravated during periods of
stress or when patient uses telephone.
• Like adductor spasm dysphonia, cause of abductor spasmodic
dysphonia is not known.

22. • Treatment is injection of botulinum toxin in posterior cricoarytenoid
muscles. It can be done by percutaneous or endoscopic route. The
former being used with EMG guidance. Results of injection are not
as good as in adductor spasmodic dysphonia. Only about 50% of
patients improve and the duration of improvement is also less.
• Disadvantages of injection treatment are that it may compromise
vocal cord movements with respiration leading to airway
obstruction.
• Patients who do not respond to toxin injection can be treated by
thyroplasty type I or fat injection. A prior gelfoam injection can be
used to judge the effectiveness of the above procedure.
• Speech therapy should be combined with injection treatment as
speech therapy alone may not be effective.

23. MIXED DYSPHONIA
• It is more complex, both the adductor and
abductor function may be affected.

24. HYPONASALITY (RHINOLALIA CLAUSA)
• It is lack of nasal resonance for words which are resonated in the
nasal cavity, e.g. m, n, ng. It is due to blockage of the nose or
nasopharynx.
HYPERNASALITY (RHINOLALIA APERTA)
It is seen when certain words which have little nasal resonance
are resonated through nose. The defect is in failure of the
nasopharynx to cut off from oropharynx or abnormal
communication between the oral and nasal cavities.

25. STUTTERING
• It is a disorder of fluency of speech and consists of hesitation to
start, repetitions, prolongations or blocks in the flow of speech.
When well-established, a stutterer may develop secondary
mannerisms such as facial grimacing, eye blink and abnormal head
movements. Normally, most of the children have dysfluency of
speech between 2 and 4 years.
• If too much attention is given or child reprimanded by parents and
peers, this behaviour pattern may become fixed and child may
develop into an adult stutterer. Stuttering can be prevented by
proper education of the parents, not to overreact to child’s
dysfluency in early stages of speech development.
• Treatment of an established stutterer is speech therapy and
psychotherapy to improve his image as a speaker and reduce his
fear of dysfluency.

26. Treatment overview
Ideally patient should be assessed in a
multiprofesional voice clinic by a laryngologist
and voice therapist and a joint treatment plan
should be formulated.
1)Vocal hygiene, lifesyle and dietary advice
2)Voice therapy
3)Medical treatment
4)phonosurgery

27. Vocal hygiene, lifesyle and dietary
advice
• Patient are explain about how the voice work
• The links between lifestyle, phonatory and non
phonatory vocal activities and stress on voice
disorder.
• The traumatic effect to the vocal folds such as
talking or singing too loudly, talking too fast,
shouting, throat clearing and harsh coughing.
• Communicating effectively without raising or
straining the voice,e.g. using a whistle in the
school playground

28. • Importane of adequate hydration for vocal fold
function, i.e. by drinking water and use of steam
inhalation, and avoiding excessive amounts of
drinking caffeine
• 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, e.g avoid eating late at
night, large or fatty meals.

29. Voice therapy
• Mainstay of treatment for muscle tension
dysphonia (MTD).
• Individual course of therapy, usually for no longer
than 8 sessions or in group.

30. Aims
• To help the patient to 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 flexibilty of the voice by
improving the pitch range and loudness without
undue effort.
• To increase the stamina of the voice.

31. Various technique are:
• Vocal exercises with the aim of targeting and
strengthening specific muscle groups and improving
glottal closure and effiency.
• 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 counselling.

32. Medical treatment
• Treatment of acid reflux.
• Treatment of URTI.
• Treatment of allergies.

33. Phonosurgery
• Surgery designed primarily for the maintainance,
restoration or enhancement of the voice.
• It emcompasses :
– Phonomicrolaryngoscopy
– Injection laryngoplasty
– Laryngeal framework surgery
– Recurrent laryngeal nerve reinnervation
– Laryngeal pacing

34. Microlaryngeal surgery
• Examination of the larynx usually under GA to
further establish a diagnosis, but more
importantly to surgically treat a pathology with
the aim of improving voice.
• Done using a suitable sized rigid laryngoscope.

35. Advantages
• Binocular vision
• Magnification
• Better illumination
• The ability to use bimannual instrumentation
• The ability to use the carbon dioxide laser.

36. Conventional microlaryngeal surgery
Laser mircosurgery : CO2, KTP,diode
Laryngeal microdebrider

37. Injection laryngoplasty
• This procedure aims to medialize an adductor
cord is in a lateral
Vocal cord palsy where
position.
• Various material used are
• Teflon
• Fat
• Glycerine
• Collagen
• Silicone, Calcium hydroxyapatite

38. Laryngeal framework surgery
• First described by Isshiki in 1974.
• Procedure on the laryngeal cartilage to change the
position or tension on the vocal cords in order to
achieve the desired voice outcome.

39. • Isshiki’s functional classification of thyroplasty
– Type I – medialization
– Type II – lateralization
IIa – lateral approach
IIb – medial approach
- Type III – relaxation (shortening )
- Type IV – tensioning (Lengthening)
IVa – cricoid approximation
IVb – tensioning by lateral approach

40. Recurrent laryngeal nerve
reinnervation
• The paralyzed vocal cord can be reinnervated to
restore its function.
• Two techniques
– Non selective reinnervation
• indicated in hoarseness due to unilateral adductor vocal
paralysis.
• Under GA via ipsilateral neck incision at the level of the
cricoid cartilage
• Ansa cervicalis and recurrent laryngeal nerve are
identified and anastomosed using a 9/0 nylon suture.
– Selective reinnervation

41. Selective reinnervation
• Indicated in stridor due to bilateral abductor
vocal cord paralysis.
• Under GA via an extended anterior neck skin
incision at the level of the cricoid cartilage.
• C3 root of the phrenic nerve is identified on one
side and anastomosed with a cable graft
harvested from the great auricular nerve in a Y
shape which is then inserted into both posterior
cricoarytenoid muscle.

42. • Next step involves identification of the
descending branch of the ansa hypoglossi and
recurrent laryngeal nerve on both side of neck
and anastomoses carried out between these
nerve bilaterally.

43. Laryngeal pacing
• This technique still being evaluated in clinical
trials.
• Involves inserting
posterior cricoarytenoid
an electrode
muscle
into
which
each
then
causes automatic abduction and adduction
movement of the vocal cords.
• Electrode is connected to an external placing
device that is surgically fixed under the skin on
the chest wall.

44. Thank you