FUNCTIONAL
VOICE
DISORDER
By Dr Nur Afiqah Jasmi
OBJECTIVE
• Explain the impact that functional voice disorders can have on
patients' quality of life.
• Identify the etiology of functional voice disorders.
• Outline the evaluation of functional voice disorders.
• Review the management options available for functional voice
disorders.
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INTRODUCTION
Vocalization means producing sound, preferably on an
emotional level
Phonation is sound production with the aim of
communicating by speech or singing
Voice production involves interaction between the
respiratory system, larynx, vocal tract, articulatory
organs, and cerebral coordination
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VOICE
• Every Human Voice is Unique
• Portrays our thoughts, emotions, joy and fear
Voice
originated from heart
VOICE
Voice is a critical medium of human communication and social
interaction;
Profound
Partial or total loss of voice
Implication
quality of life and safety,
functional &occupational
Affect
Communication
Personal &
Work
Relationship
Depression
Voice
Disorder
Low Self
Esteem
Anxiety
Impaired
Quality Of
Life
VOICE
The human voice is produced by the passage of exhaled air
from the lungs over the vibrating vocal folds; this
requires synchronization of diaphragmatic and laryngeal
function as well as the shaping of the sound by the tongue,
cheeks, and lips.
COMPONENTS OF PHONATORY APPARATUS
Activator (power
source)
Lungs And Respiratory Muscles
Generator ( of voice)
Vocal cords
Resonator
Vocal Tract( Supraglottic ,
Pharyngeal Passages)
Articulator
Palate , Tongue , Lips , Teeth
The coordination of
phonation originates in
two centers in the brain
The Limbic System And The
Primary Motor Area Of Cortex
VOICE
Organic abnormalities of the anatomy, such as nodules, scars,
cartilage subluxations, and nerve injuries, are likely to cause voice
anomalies.
A functional voice disorder should be suspected when vocal
quality is compromised without any identifiable anatomical or
neurological factors.
A functional voice disorder applies to an
alteration of voice quality where there is no
structural or neurological laryngeal pathology
or where the dysphonia is disproportionate to
the pathology detected.
• There is an overlap between ‘organic’ and ‘functional’ voice
disorders and that they do not represent dichotomous disorders.
• Benign vocal pathologies (e.g. vocal nodules, oedem of the
lamina propria, contact granulations) vocal hyperfunction,
voice misuse and poor voice technique.
• Aberrant phonatory physiology viewed on endoscopic
examination (e.g. bowing of the vocal folds, supraglottic
constriction) vocal hyperfunction and poor technique.
Most contemporary authors have accepted that functional
disorders of the voice might usefully be divided into two
different subcategories:
‘muscle tension’
dysphonia
‘psychogenic’
dysphonia
MUSCLE TENSION DYSPHONIA (MTD)
MTD is a clinical condition characterized by abnormal production of
voice and variable symptoms of voice disruption due to excessive
tension and incoordinated activity of intrinsic and extrinsic muscles of
the larynx.
MTD primarily the result of vocal misuse or poor vocal technique.
Psychological factors are considered negligible or secondary.
Morrison and Rammage describe different types of MTD (based on
endoscopic appearance) but with the understanding that they all arise
from laryngeal muscle tension during phonation.
MUSCLE TENSION DYSPHONIA
TYPE 1: THE LARYNGEAL ISOMETRIC.
• During healthy phonation, there is contraction of lateral cricoarytenoid
(LCA) and interarytenoid (IA) muscles with simultaneous relaxation of
posterior cricoarytenoid (PCA). In case of type 1 MTD, LCA and IA contract
normally during phonation; but PCA fails to relax during this process.
• Thyroarytenoid muscles contract with an attempt to close the posterior
glottal chink.
MUSCLE TENSION DYSPHONIA
TYPE 1: THE LARYNGEAL ISOMETRIC.
• This leads to convex reverse bowing of supraglottic
aperture
• Leads to secondary mucosal vocal fold
changes : nodules, chronic laryngitis of polypoidal
degeneration.
• Etiology: combination of poor vocal technique,
extensive and extraordinary voice use demands,
and anxiety
MUSCLE TENSION DYSPHONIA
TYPE 2: LATERAL CONTRACTION AND / OR
HYPERADDUCTION
• This dysfunctional pattern is a type of
tension fatigue syndrome in which
the larynx tends to be squeezed or
hyperadducted in a side to side
direction
MUSCLE TENSION DYSPHONIA
• Subtype:
• Glottic: During phonation, the vocal folds are tightly pressed . May be
triggered by an infection or chronic reflux. Voice usually becomes
effortful,harsh, and fatigable. In advanced cases, the pitch drops
toward the vocal fry register.
• Supra-glottic: supraglottic contraction forcing the ventricular bands to
approximate toward the midline during phonation. This pattern has
been earlier described as “plica ventricularis” . Vocal folds may or may
not be visible during scope. Tends to be strongly psychologically based.
MUSCLE TENSION DYSPHONIA
Vocal characteristics were suggestive of
A 59-year-old
woman with a history
asthma
severe
hyperfunctioning
of the of
supraglottic
was seen for voice evaluation due to a harsh,
and glottic musculature. She was placed on
strident voice with intermittent voice loss. The
a voice therapy program, which included
patient reported extreme familial stress and
progressive
relaxation
and lowering
pitch
the sole responsibility
of caring
for her elderly
parents. Her After
voice quality
reportedly
using biofeedback.
an intensive
2deteriorated
suddenly
after URTI.
Testing
month
voice therapy
program,
habitual
revealed a habitual pitch of approximately 280
pitch was reduced to 220 Hz and voice was
Hz, which is excessively high for a 59-year-old
functional.
female (norm is 200 Hz).
PLICA VENTRICULARIS
A 66-year-old patient experienced a right vocal
cord paralysis after undergoing carotid
endarterectomy. The patient subsequently
developed a compensating hyperfunctional voice
component and presented to the voice clinic for
evaluation.
Laryngoscopy and stroboscopic analysis
demonstrated severe anteroposterior and
mediolateral compression of the supraglottic
musculature with phonation produced by the false
vocal folds.
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PLICA VENTRICULARIS
Following 8 sessions of voice therapy that
focused on the reduction of supraglottic muscle
tension, the patient now demonstrates
improved glottic closure in the absence of false
vocal fold adduction.
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MUSCLE TENSION DYSPHONIA
TYPE 3 - ANTEROPOSTERIOR CONTRACTION OF THE
SUPRAGLOTTIC LARYNX.
• “Bogart- Bacall” syndrome in which patients exhibit a
tension-fatigue dysphonia with phonation at the very
bottom of their vocal dynamic ranges.
• A contraction pattern which results in reduced space
between the epiglottis and the arytenoid prominances in
the AP direction during phonation.
• Full length of the vocal folds can never be seen in flexible
laryngoscopy during connected speech or singing.
• Individuals using this posture complain of effortful voice
and rapid fatigue when speaking at a low pitch but are able
to talk more clearly and freely at a higher pitch
SPHINCTER LARYNX
• This is the most severe form of
supraglottic contraction where there is
complete closure of supraglottis, the
arytenoids touching the petiole of
epiglottis, during phonation
• The patients have an extremely strained
voice with severe odynophonia.At times,
these patients may present with
complete aphonia.
PSYCHOGENIC
• Psychogenic dysphonia is marked by loss of vocal control associated with
‘disturbed psychological processes’ (such as stressful life events at onset,
anxiety or depression and actual conversion).
• Some authors consider psychogenic dysphonia as an example of classical
(Freudian) conversion.
The term conversion disorder was coined by
Sigmund Freud, who hypothesized that the
occurrence of certain symptoms not explained by
organic diseases reflect unconscious conflict. The
word conversion refers to the substitution of a
somatic symptom for a repressed idea
In 1905, Freud published a case report that shock
the world. This was the start of the psychoanalytical movement.
A girl named Dora 18yo suffered from hysterical
aphonia, fainting spells, tussis, nervosa,
depression.
Dora lived with her parents, who had a loveless
marriage, but one which took place in close
relationship with another couple, Herr and Frau K.
Ida's hysteria is a manifestation of her jealousy
toward the relationship between Frau K and her
father, combined with the mixed feelings of Herr
K's sexual approach to her.
Ida Bauer (Dora) and her brother Otto
PSYCHOGENIC
• A study by Misono et al of adults clinically diagnosed with MTD indicated that voice
symptoms in these patients were exacerbated by psychological and emotional factors.
• Although in interviews, none of the patients reported their voice problem to have
arisen from a direct psychological cause, about half of them recounted that the
disorder was preceded by a significant life event, such as a health event (including
miscarriage), an interpersonal conflict, or the illness, injury, or death of a family
member.
• Adaptive emotional and behavioral responses by the patients seemed to aid symptom
improvement.
PSYCHOGENIC DYSPHONIA
Type 4. Conversion aphonia
• Involuntary whispering despite normal larynx.
• The vocal folds are held away from the midline during
phonation but function well for other duties such as cough.
• The vocal folds have full movement and can adduct
normally for cough or other types of vegetative phonation such
as laughter.
• But they stop short of sufficient adduction for voicing with an
attempt to speak.
PSYCHOGENIC
• Butcher et al detail three types of psychogenic conversion dysphonia:
• Type 1: Classical Hysterical Conversion Dysphonia
• Type 2: Cognitive Behavioural Conversion
• Type 3: ‘Habituated Conversion’, In Which The Suppressed Conflicts
Of A Cognitive Behavioural Conversion Have Been Largely Resolved,
But The Vocal Symptoms And Musculoskeletal Tension Persist As A
Matter Of Habit.
CONVERSION APHONIA
A 27-year-old woman presented to the voice
clinic with symptoms of loss of voice for a 4month period. Within 1 month of her return
home from the honeymoon, her mother had a
stroke, requiring placement in long-term care,
and her maternal grandmother died suddenly.
Following these events, the patient was
diagnosed with a dysphonia and a conversion
voice disorder. She was consequently placed on a
voice therapy program.
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CONVERSION APHONIA
Following therapy, her vocal
quality improved markedly.
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BURARI DEATH
• Lalit lost his voice for a year
after a psychological trauma
• Lalit losing his voice wasn't
organic and was just a
manifestation of internal
conflict
PSYCHOGENIC DYSPHONIA
TYPE 5. PSYCHOGENIC DYSPHONIA WITH BOWED
VOCAL CORDS
• In older patients, presbyphonia is associated with
loss of muscular bulk and tone, as well as
weakening and fragmentation of elastin and
collagen fibres.
• Hoarse, weak, breathy quality voice.
• Occasionally, patients who appear to have a
psychogenic functional dysphonia will present with
a bowed glottis but may resume normal phonation
and laryngoscopic appearance after voice and/or
psychotherapy.
PSYCHOGENIC DYSPHONIA
TYPE 6. ADOLESCENT TRANSITIONAL DYSPHONIA
• Puberphonia or Mutational Falsetto
• The normal adolescent voice change during puberty is
often accompanied by pitch breaks, register breaks
• Psychological factors may lead to inhibition of the
transitional event and establishment of perpetual falsetto
falsetto phonation.
• Laryngoscopy reveals a tense glottis and the cartilaginous
glottis may be hyperadducted, restricting phonation to
the anterior membranous vocal folds.
PUBERPHONIA
A 6'2" tall, 20-year-old man presented to the voice
clinic experiencing a harsh, hoarse voice that "cut
out" on him intermittently. Clinical evaluation
revealed a high, female pitch of approximately 196
Hz (average male pitch 120 Hz). The young man also
reported that he occasionally tries to speak with a
"lower voice," but uses it on a limited basis because
of negative feedback from his peers.
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PUBERPHONIA
Patient received voice therapy focusing on
counseling and biofeedback to help patient adjust to
use of his more appropriate male voice
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• The larynx is generally drawn up tightly into the hyoid bone or base of the tongue.
• Downward traction on the thyroid cartilages usually results in modal register
phonation at a pitch that is more representative of the adult male voice.
It is a common clinical experience to see a mixed picture
where some elements of both muscle tension and
psychogenic dysphonia combine to make a function voice
disorder which is complex to treat.
EPIDEMIOLOGY
Functional voice disorders may account for up to 40% of
the cases of dysphonia referred to a multidisciplinary voice
clinic.
FVD is commonest presentation to voice clinicians,
accounting for at least 50 000 new cases per year in the
UK.
Voice disorders have an estimated prevalence of 20 million
(0.98%) in the United States.
• Among adults, teachers represent the most atrisk population
• All the teachers were given a questionnaire to
fill out, followed by a complete head and neck
examination and videolaryngostroboscopy.
The study concluded that 57% of the
teachers suffered from voice disorders,
including vocal overstrain, which was the most
prevalent (18%).
ETIOLOGY
PERSONALITY
• Personality plays an important role in the development of
muscle tension.
• It has been established that introversion, neuroticism, anxiety,
and stress can contribute significantly to MTD.
• Peculiarities of personality like perfectionism, compulsive
attitudes, overambitious drive, and lack of social adaptability
can induce tension.
• Increased tension leads to nervous irritability, which in turn
leads to increased muscle tone, in excess of the actual
demands.
• Growing vocal demand both at profession and social life
compels some people to exert beyond the capability of their
phonatory apparatus.
VOCAL ABUSE/MISUSE
• Vocal abuse/misuse is definite contributory factor to the
development of MTD.
• Persons from all walk of life especially professional voice
users like teachers lawyers, politicians, and singers need to
exert themselves in order to meet their professional
demands.
• Undue use of extralaryngeal muscles of neck, tongue, and
jaw eventually leads to excessive tension in the
intralaryngeal muscle and cartilaginous framework.
• This results in faulty phonatory posture in the background
of a squeezed larynx, which eventually translates to MTD.
UNDERLYING PATHOLOGY
• Organic pathology of larynx such as laryngopharyngeal reflux (LPR),
vocal nodules, polyps, cysts and sulci, and Reinke’s edema and
incomplete glottic closure in cases of vocal fold palsy/paresis and
presbylaryngis can contribute to MTD.
• Up to 49% of patients of MTD have been found to have associated
LPR, suggesting LPR to be an important etiological factor in MTD.
• Compensatory phonatory behavior, usually untrained, results in
undue tension in laryngeal and paralaryngeal muscles, leading to
varying degree of dysphonia.
• It is difficult to determine in many situations, whether MTD caused
the mucosal lesion or muscle tension is a sequelae of the lesion.
1
HISTORY
HISTORY
• Most of the patients usually complain of change in
voice quality for a prolonged duration.
• Vocal fatigue, odynophonia, tightness, or pain in the
throat and strain are common symptoms in addition
to hoarseness.
• Globus sensation, aphonia, and frequent throat
clearing.
• Classically the voice problem gets worse with
prolonged voice use, usually toward the end of the
day.
HISTORY
• Professional voice users: Loss of pitch range and loss
of projection
• Thorough history of the duration and dimension of
voice usage is noted
• Vocation (ie, singing, athletic coaching) and
misuse of the voice
• Any trauma or acute respiratory illness
• TMJ disorders, cervical myalgia, or muscular fatigue
may be suggestive of a pattern of hyperfunction.
• Other medical disorders, including LPR must be
assessed.
HISTORY
• Psychosocial history is of utmost importance as a significant proportion
of these patients have a history of psychological conflict.
• Evaluate for exposure to irritants such as tobacco smoke, alcohol, and
occupational irritants.
• The patient's general health, including medications, should be
reviewed.
• Neurologic disorders such as generalized dystonia or myasthenia
gravis should be excluded.
10 questions to be used by the clinician for proper understanding of voice problem
VOICE
HANDICAP
INDEX
A VHI-10 score >11 should be considered
abnormal.
PHYSICAL
EXAMINATION
PHYSICAL EXAMINATION
• Before proceeding to detail physical examination, listening to the
voice provides valuable inputs for proper diagnosis.
• The typical MTD patient’s voice is rough with strained quality or
breathy strained quality.
INSPECTION
• Inspection of the neck during phonation can often provide valuable
information about the phonatory posture and pattern of breathing.
• MTD is one condition where external physical examination of the
neck, tongue, and jaws plays an equal role, if not greater than
endolaryngeal examination.
Palpation
• Palpation of the larynx and paralaryngeal architecture
both at rest and during phonation provides adequate
information about muscle tension and phonatory
posture.
• Three parameters are assessed during evaluation of
muscle tension:
• Extent of laryngeal elevation
• Pain in response to pressure in the region of larynx
• Extent of voice improvement after tension
reduction.
• Any asymmetry of the external bony and/or
cartilaginous framework at rest and during voicing is
also noted.
• Any deviation from normal position
Examination begins with
palpation of suprahyoid
area starting from body of
hyoid toward submental
area, looking for any tension
or tenderness
• Thyrohyoid and cricothyroid spaces are
palpated with the tip of index finger on the left
hand thumb on the right side of patient’s neck
• Moderately firm circumlaryngeal pressure over
thyrohyoid space can elicit discomfort and
tenderness, confirming tension of extra
laryngeal muscles.
ENDOLARYNGEAL EXAMINATION
• Information gathered from initial acoustic and tactile
inputs must be correlated with laryngoscopic
examination.
• This may be done with rigid or flexible laryngoscope
• Grasping the tongue for indirect or rigid laryngoscopy
tends to modify the laryngeal, particularly supraglottic
physiology to a great extent.
• Laryngoscopic features of each type of MTD have been
described earlier in this presentation.
• In addition to identification of the MTD features , the
examiner should also look for features of glottic
insufficiency or vocal fold lesions
Reflux Sign Assessment (RSA).
1. Coated tongue
2. Anterior pillar erythema (1, 2),
3. Diffuse laryngeal erythema (i.E.,
Ventricular bands, retrocricoid area,
posterior commissure)
4. pharyngeal sticky mucus (or pooling
in the left sinus piriform)
5. Severe tongue tonsil hypertrophy (in
this case, the vallecula were not
apparent when the tongue was
sticked)
6. Mild-to-moderate tongue tonsil
hypertrophy (in this case, the
vallecula are apparent when the
tongue was sticked)
7. Epiglottis erythema
8. Posterior commissure
9. Retrocricoid edema and granulation
of the posterior commissure
ENDOLARYNGEAL EXAMINATION
• Stroboscopy usually shows normal mucosal
waves, but asymmetric vibrations are commonly
seen in MTD.
• In cases of muscle tension and sphincteric
larynx, the view of the VF is obscured by
supraglottic tension.
• In these situations, the author prefers to
perform laryngostroboscopy after some degree
of manual relaxation therapy in the clinic.
LARYNGEAL ELECTROMYOGRAPHY
• The role of surface electromyography (sEMG) has been studied by Van
Houtte and colleagues and they could not demonstrate any significant
differences in paralaryngeal muscle tension between patients with MTD
and normal speakers.
• Sataloff et al. also concluded that laryngeal EMG was only useful for the
injection of botulinum toxin in the treatment of adductor spasmodic
dysphonia and there were no evidence-based data to support its use for
other laryngeal disorders.
• Therefore, EMG should not be considered as a diagnostic tool to
distinguish patients with and without MTD.
MANAGEMENT
MANAGEMENT
• Voice therapy by a specialist speech
and language therapist is a highly
effective treatment for functional
dysphonia.
• The objectives of voice therapy for this
condition are twofold:
• to return the patient’s voice to normal (or
best possible voice within their
anatomical and physiological capabilities)
• to satisfy the patient’s occupational, social
and emotional vocal needs.
MANAGEMENT
• Multimodality voice therapy is
the treatment of choice for
patients with MTD.
• Therapy may be either indirect
(non manual) or direct
(manual).
• In addition, improvement of
muscular tension and voice
quality with manual voice
therapy can serve as a
significant diagnostic tool in
cases with diagnostic dilemma.
Medical Therapy
• Role of medical therapy is limited in cases of MTD.
Associated LPR requires prolonged medical treatment with a
titrated dose of proton pump inhibitors and H receptor
antagonists.
• Life style modification also plays an integral role in managing
MTD.
• In rare cases, associated psychiatric disorders may require
medical attention.
2
Topical Lidocaine
• Topical lidocaine has been advocated by some
clinicians, which helps to reduce pain and tension in
specific perilaryngeal muscles, which not only
provides temporary relief but also helps setting the
environment for voice therapy.
• Improvement in voice quality has been demonstrated
within 15 minutes of transcricothyroid membrane
injection of lidocaine.
Botulinum Toxin
• In the recent years, botulinum toxin is being tried in
the treatment of MTD in cases who are refractory to
long-term voice therapy.
• Botulinum toxin is injected to the false vocal cords,
followed by voice therapy.
Surgical Treatment
• Role of surgery is limited in cases of MTD.
• Laser excision of hypertrophied ventricular
bands may be undertaken as an adjunct to
voice therapy in cases of secondary MTD
refractory to conventional voice therapy.
RELAXATION LARYNGOPLASTY OR
THYROPLASTY
• INDICATIONS: Puberphonia, which has not responded to at least 3
months of voice therapy.
• This is a surgery where tension at the vocal folds is reduced by anteriorposterior shortening of the thyroid ala. The reduced tension leads to
lowering of the speaking pitch.
• The advantage is that pitch is lowered without affecting the vibratory
pattern of the vocal cords.
• This surgery is also called relaxation thyroplasty by a medial approach
(anterior commissure retrusion) in the European Laryngological Society
classification system.
• Two vertical cuts are made on
either side, 5 mm lateral to the
midline.
• Final picture after suturing the
two lateral cut margins of thyroid
ala. Note retrusion of the middle
part of thyroid cartilage.
PROGNOSIS
Good prognostic indicators include acute onset of
symptoms, absence of underlying organic
pathology, ability to eliminate the trigger
(particularly if it is a life stressor), male gender,
young age, and good general health status.
Poor prognostic indicators include personality
disorders, poor perception of the patient's own
wellbeing, associated motor symptoms, and
psychogenic nonepileptic seizures.
• To optimize outcomes, it is essential to arrive at the correct
diagnosis through thorough evaluation and careful consideration.
• Unless the treatment is tailored to the underlying pathology, the
results will not be satisfactory for either the patient or the
clinician; voice therapy, for example, will not significantly help a
patient with a glottic mass that requires surgical excision.
• A multidisciplinary approach, typically involving an
otorhinolaryngologist or fellowship-trained laryngologist and an
SLP, is likely to be most effective at alleviating symptoms and
improving quality of life