What is a Voice Disorder?
Our voice is a large part of our identity; we use our voices as a tool to represent ourselves, to communicate, and to express ourselves through verbal means, whether that be talking, chanting, humming or singing. The use of this tool should feel natural and easy. Your voice should also feel like you - it should reflect your identity.
However, issues can arise with a person’s voice - in quality, pitch or loudness. When these issues arise, people may have difficulty with producing a natural and easy voice that reflects their identity, or meets their daily needs. The degree to which voice disorders impact a person’s daily life is dependent on numerous factors such as their line of work. For example, a professional singer with a mild voice disorder may experience a greater impact compared to a computer software engineer with a mild voice disorder who communicates mostly through emails.
How do I Know if I Have a Voice Disorder
Voice disorders may sound different from person to person. But, if your voice feels very effortful to produce, or sounds different from your baseline voice in quality, pitch and loudness, you may want to get assessed by a Speech-Language Pathologist or let your family physician know.
How Voice Works
There are three subsystems that are important for the production of voice.
Respiration – Breathing
The process of respiration involves our lungs, and many muscles, to generate enough breath support for voicing. Our muscles also provide breath control so that the air flow is coordinated and controlled when we need to produce speech. Compared to breathing quietly with no voice production, breathing to speak requires much more support and control so that sentences can be completed with adequate breath support and loudness.
Phonation - Source of Voice
Phonation involves the larynx (“voice box”) and the vocal folds (“vocal cords”). Multiple muscles in the larynx control and adjust the vocal folds for breathing and producing voice. When we are breathing in and quietly breathing out, the vocal folds are pulled apart so that the space between the vocal folds is open. When we produce voice, the laryngeal muscles bring the vocal folds together at the midline. Then, the air pressures from the respiratory subsystem cause the vocal folds to vibrate, thereby creating a buzzing sound quality - the source of the voice. The number of times the vocal folds vibrate per second is called the pitch, and is determined by the length and tension of the vocal folds, which can be modulated by the laryngeal muscles.
Resonance – Amplifier of Voice
The process of resonance occurs in the vocal tract, which consists of the throat, oral cavity and nasal cavity. Within the vocal tract, certain vibrations in the buzzing sound quality created by the vocal folds are selectively amplified, creating what we recognize as human voices.
Causes of Voice Disorders
There are many causes for voice disorders:
Neurological - resulting from damage with the central or peripheral nervous system (e.g. Parkinson's Disease, stroke, Multiple Sclerosis)
Lifestyle - habits or choices such as chronic stress, smoking and excessive alcohol consumption
Structural - changes to the vocal folds, such as nodules and polyps
Medications - resulting from medications taken that can impact vocal quality
Respiratory disorders - disorders that affect the production of voice
Digestive disorders - disorders that cause conditions where acidic stomach fluids backflow into the throat and vocal folds. This can cause irritation to the vocal folds
Psychogenic - loss of voice that appears to be related to psychological conditions (e.g. anxiety, depression, personality disorder)
What an Assessment Might Look Like
Based on whether a diagnosis has been made, and what healthcare setting you are in, a voice assessment may look different; however, these components may be part of a comprehensive assessment:
Case history – the clinician will go through the client’s medical history and relevant information
Interview – the clinician will conduct an informal interview with the client to discuss topics such as the client’s self-reported concerns with their voice. This may include quality of life questionnaires such as the Voice Handicap Index (VHI). The clinician will also get an understanding of lifestyle factors that contribute to a healthy voice such as stress levels, hydration and consumption of alcohol
Oral mechanism exam and speech/voice tasks – an oral mechanism exam is an assessment of the structures that are involved with overall speech production (e.g. lips, tongue, teeth, jaw, etc.). Voice tasks can be used to assess the three subsystems involved with voice production
Auditory perceptual assessments – the clinician will assess the client’s voice quality, pitch and loudness during an informal conversation using a rating scale. A common scale that is used by clinicians is the Consensus Auditory-Perceptual Evaluation of Voice (CAPE-V) tool
Instrumental assessments - some clinics have instrumental assessment tools that can provide more objective measures of the voice. This may include acoustic assessments that can give objective measures of pitch, loudness and quality of the voice. Some clinicians are trained to conduct a laryngoscopy, which is a procedure in which the vocal folds can be imaged using a scope
Treatment
Based on the assessment results, the clinician will discuss treatment options for you, or, if appropriate, refer you to a specialist. Treatment is often approached in a holistic way to:
Educate the client on how to maintain a healthy voice and best practices for voice production
Teach the client exercises and/or maneuvers to target the subsystems affecting the production of voice
We use our voice to express ourselves and as a way to represent our identity. If your voice is not reflecting your identity, or is not robust enough to meet your daily needs, please reach out to a Speech-Language Pathologist to seek more information.
CONTRIBUTED BY: Joyce C. Chan, Speech-Language Pathologist, MSc, R.SLP, S-LP(C) Provisional
References
Baker J. Psychogenic voice disorders and traumatic stress experience: a discussion paper with two case reports. J Voice. 2003 Sep;17(3):308-18. doi: 10.1067/s0892-1997(03)00015-8. PMID: 14513954.
Froedtert & the Medical College of Wisconsin. (2021). Speaking & Swallowing Issues & Parkinson's Disease. Retrieved on February 12, 2021, from https://www.froedtert.com/parkinsons-movement-disorders/symptoms/voice#:~:text=Most%20people%20with%20Parkinson's%20disease,A%20soft%20voice
Huntzinger, A. (2010). Guidelines for the Diagnosis and Management of Hoarseness. Am Fam Physician. 2010 May 15;81(10):1292-1296. https://www.aafp.org/afp/2010/0515/p1292.html
National Spasmodic Dysphonia Association. (2021). Respiratory Dystonia. Retrieved on February 12, 2021, from https://dysphonia.org/voice-conditions/respiratory-dystonia/#:~:text=Laryngeal%20dystonia%20is%20a%20neurological,manifestation%20is%20called%20respiratory%20dystonia.
University of Pittsburgh. (2021). Reflux laryngitis. Retrieved on Feb 12, 2021, from http://www.otolaryngology.pitt.edu/centers-excellence/voice-center/conditions-we-treat/reflux-laryngitis