voice disorder 2011.pdf

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249JMAJ, July/ August 2011 Vol. 54, No. 4

chological factors. Of these, 1) to 3) are abnor-malities in the shape and motility of the larynxand are the main causes of voice disorders. Whenexamining patients who are complaining of voicedisorders, first of all they are asked about theirmain complaints, medical history, degree and

quality of hoarseness, past history, occupation,and daily lifestyle habits and social backgroundrelated to phonation, and possible causes of thevoice disorder are estimated. A physician whois a voice specialist can estimate the patientscondition just by listening to their voice. Further-more, performing indirect laryngoscope or laryn-geal endoscopy enables the diagnosis of manylaryngeal disorders.

Initial responses to patients by general practi-tioners differ according to whether the disorderthey have is benign or malignant, acute or chronic.Although it is thought that patients with benign

disorders such as acute corditis vocalis with acommon cold are in many cases initially treatedat internal medicine clinics, in cases where thereis a high degree of hoarseness and the hoarsenesshas not improved in two weeks or more, thepatient is referred to a physician specializing inear, nose, and throat disorders. Loosely examin-ing a patient without looking at the larynx canresult in malignancies such as laryngeal cancerand thyroid cancer being overlooked. Of course,patients with acute epiglottitis or other airwaystenotic disorders should be referred to a spe-

cialist physician urgently.

Diagnosis of General Practitioners forVoice Disorders

Taking the patients medical history

With regard to the patients chief complaints,they are asked about how phonation has been

impaired. It is important to obtain a present ill-ness including the time since onset of the symp-toms and treatment at other hospitals. Withregard to contributory factors, the patient isasked about voice misuse, past operations on thelarynx, and past operations for which the patientwas under general anesthesia. If the patient hasexperienced symptoms of heartburn, acid reflux,or reflux esophagitis in the past, the possibilityof laryngeal granuloma can be considered.2 Ifthe patient complains of respiratory difficulties,there is the possibility of airway stenosis and thepatient is referred to a specialist.

With regard to occupation, all of the occupa-tions shown in Table 1misuse the voice and vocalcord nodules are easily formed in cases withvocal abuse. Dysphonia plicae ventricularis canbe observed amongst Buddhist monks. For res-taurant and service industry employees, smok-ing, drinking, and karaoke singing also exert aneffect, with vocal cord polyps and polypoid vocalcords occurring more commonly. Points for tak-ing medical histories are summarized in Table 1.

Inspection and palpation

With regard to inspection of the oral cavity and

Table 1 Points for taking medical histories

1) Chief complaints (hoarseness, abnormal voice pitch, abnormal voice strength,wavering voice, etc.)

2) Present illness (acute/chronic, time since onset of symptoms, treatment history, etc.)

3) Contributing factors (voice misuse, operations, external injuries, common cold,

hormone therapy, stress, etc.)

4) Complications (heartburn, acid reflux, laryngopharynx pain, respiratory difficulties,

misswallowing, etc.)

5) Past history (neurological disorders, psychological disorders, endocrine disorders,

etc.)

6) Occupation (teacher, singer, bus tour guide, announcer, sports instructor, nursery

teacher, Buddhist monk, restaurant employee, service industry employee, etc.) and/

or hobbies (yokyokuor karaokesinging)

7) Oral medication (psychotropic drugs, hormonal drugs, ACE inhibitory drugs)

8) Lifestyle habits (smoking history, drinking history, etc.)

9) Drug allergies

[Extracted and modified from the Japan Society of Logopedics and Phoniatrics (editor).1]

DIAGNOSIS OF VOICE DISORDERS


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oropharynx, the clinical features of acute inflam-mation, such as mucosal reddening or adhesionof purulent mucus, are observed. With regard topalpation of the neck, for acute disorders thepresence/absence and location of tenderness ischecked, and for cases in which a malignant dis-order is suspected, special attention is paid tocervical lymphadenopathy and thyroid tumors.

Maximum phonation time

For maximum phonation time (MPT), the maxi-mum length of time a patient can vocalize aftertaking a deep breath is measured. In general, 10seconds or less is abnormal, and 5 seconds or

less interferes with daily living. Disorders whichshorten MPT include recurrent nerve paralysisand vocal cord atrophy.

Auditory-perceptual evaluation of hoarseness

An auditory-perceptual evaluation method forhoarseness is the GRBAS scale of the JapanSociety of Logopedics and Phoniatrics, whichgives scores of 0, 1, 2, or 3 for the Grade ofhoarseness; Roughness, Breathiness, Asthenia,and Strain, where 0 is normal, 1 is a slight degree,2 is a medium degree, and 3 is a high degree.

Rough hoarseness is a rasping, rattling sound-ing voice that can be heard mainly in disorderssuch as vocal cord polyps, polypoid vocal cords,and laryngeal cancer. Breathy hoarseness is awhispery voice that can be heard in such dis-orders as recurrent nerve paralysis, vocal cordnodules, laryngeal cancer, acute corditis vocalis,and vocal cord atrophy. Asthenic hoarseness is asmall, weak voice which is heard in such disor-ders as psychosomatic aphonia and myastheniagravis. Strained hoarseness is produced with thethroat constricted; this condition occurs in suchdisorders as spasmodic voice disorders and laryn-

geal cancer.In addition, disorders in which the voice

becomes muffled include peritonsillar abscessand acute epiglottitis; these are potentially lethaldisorders which cause airway stenosis and mustnot be overlooked.

Specialist Otorhinolaryngological Testsand Diagnosis for Voice Disorder

1) Laryngeal endoscopy and indirectlaryngoscopy

Larlyngeal endoscopy and indirect laryngoscopy

are the most useful tests, and looking at the lar-ynx makes the diagnosis of many laryngeal disor-ders possible. Stroboscopy is an examination inwhich vocal cord vibrations are observed and isuseful in detecting minute pathological lesions invocal cords.2) Tests related to voice pitch and strength

Voice pitch measures speaking fundamentalfrequency (SFF) and vocal range. Voice strengthmeasures the sound pressure level at comfort-able phonation as well as at the maximum andminimum strengths of phonation.

Voice profile tests and other examinations areavailable.

3) Aerodynamic testsAerodynamic tests include measurement of MPT,average airflow rate during phonation, and lar-ynx efficiency.4) Acoustic analysis tests

These are tests which enable quantitative evalua-tion and include parameters such as pitch periodperturbation, amplitude perturbation, and laryn-geal noise components as well as spectrograms.5) Auditory-perceptual evaluation

The GRBAS scale is the main tool used inauditory-perceptual evaluation, which physicians

and speech pathologists use to subjectively assessthe degree and quality of hoarseness. There isalso a voice handicap index which patients use tosubjectively evaluate social and lifestyle limi-tations (functional aspects), voice and larynxcondition (physical aspects), and what the patientis feeling (emotional aspects).3

Conditions Which Cause Voice Disorders

Main diseases

The Japan Medical Association ContinuingMedical Education Curriculum 2009, lists the

chief complaints of hoarseness patients withregard to concrete responses to clinical problemsfor each symptom. The patient should be referredto a specialist physician, if the hoarseness doesnot improve in disorders (1) or (2) below, urgentlyin the case of disorder (3) and swiftly in the caseof disorders (4) or (5).(1) Vocal cord polyps

These are the most common organic disorders ofthe larynx which cause voice disorders. A com-mon site for polyps is from the front third to thecenter of the membranous portion of the vocal

cord, and in many cases the sides are asymmetri-

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cal, regardless if the polyp occurs on one side

or both sides of the vocal cords (Fig. 1A). Polypsare thought to be caused by submucosal bleedingof the vocal cords, and contributing factorsinclude voice misuse and smoking. With regardto hoarseness, in many cases the patient is foundto have rough hoarseness or breathy hoarseness.At our institution, the abovementioned special-ized tests are carried out and vocal sound beforeand after treatment is evaluated.4

(2) Acute corditis vocalis

The larynx becomes inflamed due to a commoncold, etc., causing the voice to become whisperyand hoarse, in some cases the patients voice

becomes aphonic. There is diffuse reddening andswelling of both vocal cords, and histologicallythis is regarded as being caused by inflammatorycell invasion of the superficial lamina propria,edema, and vasodilatation. Due to the rapid swell-ing of the vocal cords, the mucosa is extendedexcessively, reducing its mobility; mucosal wavesare diminished, with asymmetrical vocal cordvibrations.(3) Acute epiglottitis

Even when symptoms of acute inflammationsuch as pharyngeal pain or fever causing a

muffled voice are observed, examination of the

oral cavity may overlook the inflammation find-ing, making it extremely important that the lar-ynx also be examined. This is a potentially lethaldisorder that causes airway stenosis and must notbe overlooked (Fig. 1B).

This disorder is frequently observed in men inthe prime of their lives; it can easily cause medicaldisputes as the disease progresses quickly withthe patient dyspnea, resulting in hypoxic encepha-lopathy or death.(4) Recurrent nerve paralysis

After leaving the ambiguous nucleus of themedulla oblongata as the vagus nerve, the recur-rent nerve, which controls the movement of the

vocal cords, travels a long distance before reach-ing the larynx, and may become paralyzed dueto damage sustained along its various parts. Inmany cases this is caused by neck or chest dis-orders, and it may also be caused by tumors suchas thyroid cancer, esophageal cancer, and lungcancer; lymph node metastasis, aortic aneurysm,and complications of surgeries performed to curethese; infectious diseases such as viruses; andtracheal intubation. It may also be caused byidiopathic and intracranial/skull base diseases.Symptoms for unilateral recurrent nerve paraly-

sis include hoarseness and misswallowing, whilebilateral paralysis causes airway stenosis withrespiratory difficulties. The position in whichthe vocal cords are fixed determines the statusof glottal closure and the degree of hoarsenessalso changes depending on vocal cord position.(Fig. 1C). Although strictly speaking these differ,terms such as laryngeal paralysis, vocal cordparalysis, and vocal cord fixation are also used.(5) Laryngeal cancer

Laryngeal cancer is divided into supraglottic,glottic, and subglottic types. The glottic type is themost common, and when the cancer invades the

mucosal lamina propria and muscle layer of thevocal cords, it impairs vocal cord vibration, caus-ing hoarseness (Fig. 1D). In the supraglottic andsubglottic types, patients are slow to becomeaware of the hoarseness and detection of the can-cer is slower than that for the glottic type. Whenthe cancer invades the cricoarytenoid articula-tion, the vocal cord becomes fixed, developingincomplete glottal closure, causing air leak andbreathy hoarseness during vocalization.

Other disorders

Disorders (1) to (11) below should all be referred

Fig. 1 Main conditions which cause voice disorder

A: Right vocal cord polypB: Acute epiglottitisC: Left recurrent nerve paralysisD: Laryngeal cancer of the left glottis

[Extracted and modified from the Japan Society of Logopedics

and Phoniatrics (editor).1]



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to specialist physicians if the hoarseness does notimprove.(1) Vocal cord nodules

Nodules appear from the front third to the centerof the membranous portion of the vocal cords,usually on both sides. They are thought to becaused by mechanical stimulation, and while softin the early stages of growth, they grow increas-ingly hard, fibrous, and large if heavy voice usageor other voice misuse continues. This conditionoccurs commonly amongst school age boys andadult women, but often heals spontaneously inthe case of children.(2) Polypoid vocal cords (Reinkes edema)

In this condition, the superficial lamina propriaswells into polyps or an edematous state oververtically the entire membranous portion of thevocal cords, usually on both sides. These arethought to be caused by pathological lesionsgenerated by impaired absorption and leakageof serum components from blood vessels due toimpairment of blood circulation in the vocalcords mucosa. Smoking is a highly contributoryfactor and voice misuse is also thought to playa part in causing this condition, which is com-mon amongst middle-aged to elderly women

with a history of smoking. In serious cases, thecondition leads to airway stenosis with respira-tory difficulty.(3) Vocal cord atrophy

In vocal cord atrophy, the free edge of the vocalcord mutates into an arch shape as bowing, de-veloping incomplete glottal closure. Symptomsinclude breathy hoarseness, inability to produceloud sounds, vocalization quickly tires the patient.This condition is common amongst elderly men.(4) Sulcus vocalis

There is sulcus running front-to-back along ver-tically the entire membranous portion of the

vocal cords near the free edge of the vocal cord,and impairment of vocal cord vibration causesbreathy hoarseness. This condition commonlyoccurs on both vocal cords.(5) Laryngeal granuloma

This condition is a inflammatory granulation tis-sue that occurs commonly in the vocal process. Itis thought to be connected to tracheal intubation,coughing, and gastroesophageal reflux disease,and can be treated and improved with protonpump inhibitor (PPI) and digestive tract motor-activating drugs.2

(6) Functional aphonia

In many cases, this condition is psychosomatic;it is common amongst women aged betweenpuberty and age 40 and causes a high degree ofbreathy hoarseness, whispery voice, and aphoniaduring intentional vocalization, such as in conver-sations. Glottal closure is insufficient, and becauseaspirated air flows out of the glottal gap, the vocalcords do not vibrate. Although no voiced soundis produced during vocalization, a voiced soundis often produced when the patients cries, laughs,or coughs.(7) Spasmodic dysphonia

In this condition, the voice stops and starts inter-

mittently; it is thought to be a form of dystonia.Almost all cases are adducted and are thoughtto be caused by excessive contraction of the thy-roarytenoid muscle, making glottal closure toostrong and interfering normal vocalization.5

(8) Dysphonia plicae ventricularis

False vocal cords swell up for various reasons,covering the vocal cords and vibrate due to con-tact between both false vocal cords. The enlargedfalse vocal cords either come in contact with thevocal cords, interfering with their vibration, or donot come in contact with the vocal cords but raise

the supraglottal pressure, which also affects vocalcord vibration. This condition is observed com-monly amongst elderly men, and when it occurson only one side of the vocal cords is thoughtto be related to asymmetry of the thyroid carti-lage. With regard to occupation, this condition isobserved frequently amongst Buddhist monks.(9) Hypotonic voice disorders

These conditions produce a very weak, faintvoice. If the airflow rate decreases due to vocal-ization muscle fatigue caused by psychosomaticfactors, voice misuse, and/or respiratory organdisease, subglottal pressure does not rise, causing

asthenic hoarseness. These conditions occur inneurological/muscular disorders such as myas-thenia gravis and muscular dystrophy.(10) Mutational voice disorders

When the physiological voice-breaking processis impaired, a mutational voice disorder occurs.In the case of males, the voices pitch may be toohigh and a reverse voice change may occur.(11) Essential tremor

This is referred to as voice tremor and is charac-terized by the voices regular trembling (48times/second). It is observed in the regular open-

ing movement of the vocal cords, up-and-down

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movement of the larynx, and trembling of thediaphragm and rectus abdominis muscle.

Conclusion

This paper discussed the diagnosis of voice dis-orders. In summary, when patients come tothe hospital complaining of voice disorders, adescription is obtained of the patients chiefcomplaints, current medical history, degree andquality of hoarseness, past history, occupation,and voice-related life style habits or social back-ground. Useful in this are two simple-to-performtests which do not require special instruments:

the auditory-perceptual evaluation (the GRBASscale) and measurement of the MPT. The mainconditions which cause hoarseness are vocalcord polyps, vocal cord nodules, recurrent nerveparalysis, and laryngeal cancer. In cases wherethe degree of hoarseness is high or does notimprove in two or more weeks, the patient isreferred to a physician specializing in ear, nose,

and throat diseases. Many laryngeal diseases canbe easily diagnosed through observation of thelarynx using indirect laryngoscopy or laryngealendoscopy.

Cases which may easily cause medical disputesand call for particular care include hoarseness.The cases have been treated by a general practi-tioner but in actual fact the patient has recurrentnerve paralysis caused by thyroid cancer, andthose in which the patient has a high degree ofhoarseness and is being treated for bronchialasthma when in fact the patient has laryngealcancer.

Moreover, in the case that a patient has a

muffled voice and is complaining of a sore throatand respiratory discomfort, there is a possibilitythat the patient has an acute epiglottitis, a peri-tonsillar abscess, or another airway stenosis ands/he is referred urgently to a hospital wherethere are full-time physicians specializing in ear,nose, and throat diseases.

References

1. Omori K. Outline of voice disorders and examination methods.In: The Japan Society of Logopedics and Phoniatrics, ed. Voice

Examination Methods. New ed. Tokyo: Ishiyaku Publishers;2009:3654. (in Japanese)

2. Tada Y, Omori K. Treating disorders that are difficult to cure-

laryngeal granuloma. Otolaryngology-head and Neck Surgery.2005;77:10231027. (in Japanese)

3. Jacobson BH, Johnson A, Grywalski C, et al. The Voice Handi-

cap Index (VHI): Development and validation. Am J SpeechLang Pathol. 1997;6:6670.

4. Okano W, Tada Y, Omori K. laryngeal disordersThis is howI examine vocal cord polyps/nodes (1). JOHNS. 2009;25:535538. (in Japanese)

5. Kobayashi T (ed). Spasmodic Voice DisordersMechanismsand Current Situation Regarding Treatment. Tokyo: Jiku Pub-

lishers; 2000. (in Japanese)


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