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Voice disorders are frequently seen in the pediatric population. They can have significant impact on the patient. Voice disorders may result from aberrations in the speech mechanism. The salient features of four common voice disorders and their clinical relevance are discussed.
Voice disorders are commonly seen in general medical practice. In some cases voice disorders represent the presenting symptom for serious underlying disease. It is important for clinicians from internal medicine, pediatrics, and family practice to be able to identify those factors in the history or observed vocal symptoms which suggest need for referral for comprehensive voice evaluation as well as to understand the distinct but complementary roles of the specific disciplines (otolaryngology and speech-language pathology) involved in diagnosis and treatment of patients with voice disorders.
Voice disorders are common among children, estimated to range from 6% to 23% in school-aged children. The various causes of voice disorders are presented in this article in addition to a discussion of normal laryngeal voice and development. Also presented are the causes of abnormal voice and brief discussion of a framework for multidisciplinary assessment and treatment of pediatric voice disorder.
OBJECTIVES: Recently developed systems for ambulatory monitoring of voice use employ miniature accelerometers placed at the base of the anterior neck to sense phonation. As it is hoped that such systems will help improve the clinical assessment and management of voice disorders, this study was undertaken to determine the impact of dysphonia severity on the accuracy of accelerometer-based estimates of vocal function. METHODS: Simultaneous recordings were made of oral acoustic (microphone) and neck skin acceleration signals for 6 normal speakers and 18 patients with voice disorders (mild to severe dysphonia) as they performed several speech tasks. Measures of phonation time, fundamental frequency, and sound pressure level were extracted from the two types of signals and compared. RESULTS: It was generally demonstrated that accelerometer-based measures closely approximated corresponding measurements obtained from a microphone signal across all levels of dysphonia severity. Furthermore, there was evidence that in some cases the accelerometer may actually represent a more robust approach for estimating phonation parameters in disordered voices. CONCLUSIONS: The results generally support the recent application of accelerometers as phonation sensors in ambulatory voice monitoring systems that can be used in the clinical assessment and management of voice disorders.
Occupational voice disorders have been increasing for years. The aim of this study was to examine whether a constitutionally weak voice should be regarded as a risk factor for developing such voice disorders. In a prospective study, 15 female teacher students with a normal vocal constitution were compared with 18 students with constitutionally weak voices during teaching practice. There was a significant difference in the mean fundamental frequency of both groups after teaching for 30 min. Students with constitutionally weak voices tended to have increased values. Taking into consideration the physiological aspects of an increasing fundamental frequency as a sign of vocal fatigue, a constitutionally weak voice has to be regarded as a potential risk factor for developing a voice disorder in vocally intensive occupations. To prevent future vocal problems by appropriate prophylactic intervention (i.e. voice therapy, introduction to vocal hygiene), a phoniatric examination of vocal constitution and endurance is recommended at the beginning of a voice dependent professional career.
Functional voice disorders result from vocal misuse or abuse; they are more easily recognized than other psychosomatic disorders because the clinician is able to visualize the laryngeal structure and function. If those structures appear normal, then an aberration of voice quality can be assumed to be functional. Functional dysphonia with prolonged aberrant vocal usage may lead to development of secondary pathological lesions of the larynx, which, although true pathological entities, must be recognized as resulting from the underlying and preceding functional disorder. In this report, we present a classification of and an approach to the diagnosis and treatment of functional voice disorders. On the basis of our clinical experience with 52 patients, we distinguished five types of functional voice disorders: type 1, hysterical aphonia/dysphonia; type 2, habituated hoarseness; type 3, falsetto voice, type 4, vocal abuse; and type 5, postoperative dysphonia. Forty-eight of the 52 patients (92%) were followed for a median period of 16 months (range 2-51 months). Therapy yielded excellent results in patients with types 1, 2 and 3; good results with types 4 and 5.
Functional voice disorders (FVDs) are common. The diagnostic criteria for six types of FVD and the results of treatment in a large series of patients are reported. Voice therapy was effective in 69% of the patients. Failure of voice therapy usually correlated with continued tobacco use, noncompliance with therapy, or premature termination of therapy.
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The voice-related quality of life (V-RQOL) questionnaire was proposed as a disease specific measure of patients' subjective burden elicited by a voice disorder. The purpose of this study was to investigate the influence of gender and aetiology (benign organic versus functional) on V-RQOL results. Fifty-two German-speaking patients completed the questionnaire without prior information about their individual diagnosis. Results allow for the conclusion that women score lower indicating a poorer voice status. Differences between patients diagnosed with an organic or a functional voice disorder revealed no universal difference. This has to be investigated in future, especially against the degree of the voice disorder, the individual personality, health belief and social background.
Voice disorders can cause problems for patients emotionally, physically, economically and functionally. Neither subjective nor objective voice examinations are able to evaluate such factors adequately. For this study, a retrospective analysis of 79 dysphonic cases was conducted using the voice handicap index (VHI) to gather comprehensive data across a variety of voice disorders. Of the 79 cases, 41 involved glottic insufficiency, 26 involved vocal polyps or mass, and 12 involved functional voice disorders. Cases were assessed with the VHI using physical (P), functional (F), emotional (E) parameters and a total (T) of the three. P, F, E and T variables were entered into a statistical programme and analysed using one-way analysis of variance (ANOVA). Mean +/-SE values for P, F, E and T, respectively, in glottic insufficiency cases were 31.61 +/- 1.10, 26.49 +/- 1.43, 26.06 +/- 1.54, and 84.20 +/- 4.21. Mean +/-SE values for P, F, E and T, respectively, in vocal mass cases were 30.69 +/- 1.73, 25.23 +/- 1.90, 23.96 +/- 1.82, and 79.88 +/- 5.08. The mean +/-SE values of P, F, E and T, respectively, in functional voice disorders were 20.92 +/- 2.06, 18.33 +/- 1.82, 16.83 +/- 1.86, and 56.08 +/- 5.23. We found the mean glottic insufficiency was significantly greater than functional voice disorders for each measure. There were significant differences between vocal mass and functional voice disorders means for P and T. Glottic insufficiency and vocal mass means were not significantly different for any measure. Problems in the physical realm were identified as the most severe amongst all patients. Glottic insufficiency patients were found to suffer the most in every VHI value. Although VHI is a relatively new method by which to measure discomfort in voice-disordered patients, it provides a mechanism for patients to define their discomfort and for therapists to better target recovery programmes to patient's needs.
Outcome measurements of voice disorders is an important new area for both the evaluation of voice-disordered patients and evaluation of treatment efficacy. The Voice Handicap Index (VHI) measures the patient's perception of the impact of his or her voice-disorder. The VHI was used in this study to measure the changes of the patient's perception following treatment for four different voice disorders. The VHI showed a significant change following treatment for unilateral vocal fold paralysis, vocal cyst/polyp, and muscle tension dysphonia. Results of this paper indicate that the VHI is a useful instrument to monitor the treatment efficacy for voice disorders.
The study of voice disorders present some specific difficulties such as the aetiological variability of this kind of disorders or the heterogeneity and the poor data we have about the effectiveness of certain treatments used. Research has performed different types of questionnaires in this area to obtain data about the treatments used in clinical practice. These studies have shown lack or scarce of evaluation and control methods in the rehabilitation programs that the specialists commonly use. In this report, a screening questionnaire was sent to the Otorhinolaryngology Departments of the Spanish Hospitals to obtain information about evaluation and treatment resources in voice pathologies. The results show great variability in clinical voice disorders in Spain. However we can observe a full agreement in the need to systematize this evaluation and the collaboration of the speech-therapists in the treatment of the voice disorders.
OBJECTIVE: Occupational voice disorders in Poland account for over 25% of all occupational diseases. The aim of the study was to assess the prevalence of voice problems in the general population of Polish teachers, and identify risk factors for developing voice pathology. PATIENTS AND METHODS: The study group comprised 425 female full-time teachers (most of them primary and secondary school, age ranging from 23 to 61 years) and 83 non-teacher women (control) whose jobs did not involve vocal effort, matched for age to the study group. All participants were subjected to a survey using an extensive questionnaire, and to laryngological, phoniatric and videostroboscopic examinations. RESULTS: The overall lifetime vocal symptoms were more frequent in the teachers than in the non-teachers (69 vs. 36%), and in particular it related to permanent and recurrent hoarseness, and dryness in the throat. Mean number of the voice symptoms was 3.21 in teachers and 1.98 in controls (p < 0.001). Abnormal (non-euphonic) voice, neck muscle hypertension during phonation and incorrect resonator function were also significantly more frequent in the teachers. Mean maximum phonation time was shorter in teachers than in the controls (14.3 vs. 15.9 s, p < 0.01). Occupational voice disorders and hyperfunctional dysphonia (that is thought to predispose to such pathology) were found in 32.7% of teachers and 9.6% of control subjects. The probability of developing incomplete glottal closure (odds ratio 13.2x; 95% CI: 1.8-96.8) and hyperfunctional dysphonia (odds ratio 2.7; 95% CI: 1.14-6.44) were significantly higher in the teacher group versus non-teachers. A significant positive relationship was found in teachers between the prevalence of hyperfunctional dysphonia and strained phonation, neck muscle hypertension, instability of voice, self-assessed hyper-arousal, and lifetime vocal effort index (years of employment as a teacher x hours of professional activity/week). The prevalence of vocal nodules and incomplete glottal closure were correlated with incorrect phonation technique parameters, but not with psychological factors. No correlation was found with environmental variables, such as classroom temperature, humidity, airborne dust. CONCLUSION: The prevalence of self-reported symptoms and clinical signs of voice disorders is around 2-3 times more frequent in Polish female teachers than in non-teachers. Lifetime vocal effort, incorrect technique of phonation and psychological predisposition seem to constitute major risk factors for developing occupational voice disorders.
OBJECTIVES: To determine the efficacy of voice therapy techniques in 37 patients with functional dysphonia. PATIENTS AND METHODS: The patients were divided into three groups according to the type of functional voice disorder, including mutational falsetto (n=16), vocal nodule (n=17), and muscle-tension dysphonia (n=4). All the patients received voice therapy which varied according to the frequency of visits, time, and techniques for the type of functional voice disorder. Voices of the patients were evaluated subjectively by a questionnaire and the GRBAS scale, and objectively by videolaryngostroboscopy and computed voice analysis before and after the therapy. RESULTS: Fifteen patients with mutational falsetto (93%), eight patients with vocal nodules (47%), and all the patients with muscle-tension dysphonia were cured by voice therapy techniques. Vocal nodules were reduced in 35% of the patients and were stable in three patients (18%). CONCLUSION: Successful results can be obtained by voice therapy techniques in functional voice disorders, which are common in otolaryngology practice, causing difficulties in diagnosis and management.
Non-organic voice disorders are characterised by an impaired voice sound, and/or reduced vocal capacity, and/or laryngeal sensory disturbances, all in the absence of causal organic laryngeal pathology. Psychogenic causes, a "psychological disequilibrium", and an increased tension of the laryngeal muscles are presumed to be one end of the spectrum of possible factors leading to the development of the disorder. In making a diagnosis, perceptive and acoustic methods for voice analysis are used in addition to the ENT-examination and the laryngostroboscopy. An assessment of the degree to which the patient feels him/herself subjectively affected by the voice disorder also plays an important role. If the history reveals any indication of psychosocial stress or conflict, the patient is offered psychological consultations. These conflicts seem less often to be deep rooted psychopathological problems but rather daily anxieties, failures, injuries, annoyances, disappointments regarding the sufferer him/herself and others, the non-fulfillment of desires, feelings of inadequacy and of lack of self-confidence. The patients may find it difficult to speak about conflicts and feelings, and they follow social conventions to an excessive extent. In frustrating situations patients tend to react aggressively towards themselves rather than towards others and are too quick in seeking a solution to any problem that may arise. The role of the voice as a "barometer of emotion", where a disorder may be regarded as a sign of emotional stress, has to be taken into consideration before starting a therapy: If the non-organic voice disorder is obviously due to vocal misuse and muscle tension, a more symptom-orientated voice therapy may be favoured. If psychosocial stress seems to play a greater role, additional counseling may be necessary. Only by using this approach can the patient be offered a therapy which goes into the causes and thereby addresses the whole person.
Voice problems are common among schoolteachers. This prospective, randomized clinical trial used patient-based treatment outcomes measures combined with acoustic analysis to evaluate the effectiveness of two treatment programs. Forty-four voice-disordered teachers were randomly assigned to one of three groups: voice amplification using the ChatterVox portable amplifier (VA, n = 15), vocal hygiene (VH, n = 15), and a nontreatment control group (n = 14). Before and after a 6-week treatment phase, all teachers completed: (a) the Voice Handicap Index (VHI), an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders; (b) a voice severity self-rating scale; and (c) an audiorecording for later acoustic analysis. Based on pre- and posttreatment comparisons, only the amplification group experienced significant reductions on mean VHI scores (p = .045), voice severity self-ratings (p = .012), and the acoustic measures of percent jitter (p = .031) and shimmer (p = .008). The nontreatment control group reported a significant increase in level of vocal handicap as assessed by the VHI (p = .012). Although most pre- to posttreatment changes were in the desired direction, no significant improvements were observed within the VH group on any of the dependent measures. Between-group comparisons involving the three possible pairings of the groups revealed a pattern of results to suggest that: (a) compared to the control group, both treatment groups (i.e., VA and VH) experienced significantly more improvement on specific outcomes measures and (b) there were no significant differences between the VA and VH groups to indicate superiority of one treatment over another. Results, however, from a posttreatment questionnaire regarding the perceived benefits of treatment revealed that, compared to the VH group, the VA group reported more clarity of their speaking and singing voice (p = .061), greater ease of voice production (p = .001), and greater compliance with the treatment program (p = .045). These findings clearly support the clinical utility of voice amplification as an alternative for the treatment of voice problems in teachers.
Voice problems are a common occupational hazard of teaching school, yet few studies exist that have objectively evaluated treatment approaches aimed at rehabilitating these occupation-related voice disorders. This randomized clinical trial used patient-based treatment outcome measures to evaluate the effectiveness of three treatment programs. Sixty-four teachers with voice disorders were randomly assigned to 1 of 3 treatment groups: voice amplification using the ChatterVox portable amplifier (VA; n = 25), resonance therapy (RT; n = 19), and respiratory muscle training (RMT; n = 20). Before and after a 6-week treatment phase, all teachers completed (a) the Voice Handicap Index (VHI; B. H. Jacobson et al., 1997), an instrument designed to appraise the self-perceived psychosocial consequences of voice disorders, and (b) a voice severity self-rating scale. Both intention-to-treat and as-treated analyses revealed that only the VA and RT groups reported significant reductions in mean VHI scores and in voice severity self-ratings following treatment. Furthermore, results from a posttreatment questionnaire regarding the perceived benefits of treatment showed that compared to RT and RMT, teachers in the VA group reported significantly more overall voice improvement, greater vocal clarity, and greater ease of speaking and singing voice following treatment. These findings replicate previous results from an earlier clinical trial confirming the efficacy of VA and provide new evidence to support RT as an effective treatment alternative for voice problems in teachers. The results are discussed in the context of uneven levels of self-reported compliance and disparate dropout rates among the treatment groups.
The purpose of this article is to describe salient technologies available for assessing patients with disorders of voice. Measurements of jitter, shimmer, harmonic-to-noise ratio, fundamental frequency of the speaking voice, basal frequency, ceiling frequency, computation of pitch range, speaking intensity, intensity increase potential, vital capacity, laryngeal airflow during phonation, and laryngeal videoendoscopy-stroboscopy are covered. Some of the common instruments available to measure these voice components are described. Clinical case examples are provided to illustrate the importance of technology in the assessment of patients with voice disorder.