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AIISH | Project

V oice is the laryngeal modification of pulmonary air stream which is further modified by
the configuration of the vocal tract (Brackett, 1971). The voice conveys information about
the speaking individual, & the voice quality serves as a primary means by which speakers project
their physical, physiological & social characteristics to the world. The production of voice is
dependent on four primary factors; i) Pulmonary air pressure, ii) Vocal fold vibrations, iii)
Transfer function of vocal tract, and iv) Central nervous system. There are mainly three attributes
of voice; Pitch, Quality & Loudness.

A voice is termed "disordered" when the vocal quality of an individual is altered/changed

in such a way that it is thought to be abnormal to the listener. The onset and development of

these disorders can be "sudden" or "slow." Examples of characteristics of sudden onset may be:
trauma, infection, CVA, injurious inhalation, intubation, conversion reaction, or a severe allergic
reaction. Degenerative neurologic disease, musculo-skeletal tension, vocal abuse and misuse,
growths of folds, gastro-esophageal reflux, and chronic allergies may characterize slow onset.

Voice disorders are characterized by the abnormal production &/or absence of vocal
quality, pitch, loudness, resonance, &/or duration, given an individual’s age &/or sex (ASHA).
Voice disorders result from faulty structure or function somewhere in the vocal tract, in the
processes of respiration, phonation, or resonance. Also one or more aspects of voice (loudness,
pitch, quality, or resonance) are outside of normal range of age, gender, or geographical
background of the speaker.

Voice problems can be broadly classified into four main categories: structural/neoplastic,
inflammatory, neuromuscular, & muscle tension imbalance. Many patients will have evidence of
more than one of these conditions contributing to their voice condition & this may change at
different phases in the chronology of the condition. For e.g. a vocal fold polyp (structural
/neoplastic cause) may arise as a result of primary muscle tension imbalance as a result of voice
abuse (shouting when suffering from a viral upper respiratory tract infection/inflammation). The
presence of polyp can in turn cause secondary physical trauma to the vocal folds & a muscle
tension imbalance to compensate for the alteration in the biomechanical properties of vocal folds.
An important part of assessment of a patient is the determination of which of these four
conditions are present, which are primary & which are secondary, & which are actually
contributing to the patient’s voice complaint.

The common voice complaints / symptoms are:

 Change in voice quality (harshness, hoarseness & breathiness

 A deeper or higher pitched voice that is not appropriate for the age & sex
 Problems controlling the voice described as pitch breaks, squeaky voice or the voice
cutting out.
 Difficulty making oneself heard in a noisy environment or in raising the voice.
 Effort in producing voice.
 Reduced stamina of the voice or one that tires with use.
 Difficulties or restrictions in the use of voice at different times of the day or related to
specific daily, social or occupational related tasks.
 A reduced ability to communicate effectively.
 Difficulty in singing.
 Throat-related symptoms (soreness, discomfort, aching, dryness, mucus) particularly
related to voice use.
 The consequent emotional, psychological effects caused by the above.

Children: 3-6% of the population; Adults: 3-9% of the population

Classification of Voice Disorders

Based on Perceptual Signs
 Disorders of Pitch
 Disorders of Loudness
 Disorders of Quality
 Disorders of Non-phonatory behaviors
 Aphonia

Based on Etiology

 Functional
 Organic
 Psychological

Functional Voice Disorders

Functional disorders encompass all disorders that result in physical change, but do not have a
known cause. They are typically hyperfunctional voice disorders (e.g., abuse or misuse),
however we are also subcategorizing them as Voice Disorders Resulting from Abuse (i.e., other
than hyperfunctional), Psychogenic Voice Disorders, Voice Disorders with No Indication of
Pathology, and Manifestations of Voice Disorders.

1. Hyperfunctional Voice Disorders

i) Contact Ulcers:

Definition: A small ulceration that develops on the medial surface of the vocal processes
of the arytenoid cartilages. Laryngoscopically, a contact ulcer will be visible as a buildup
of pink or pinkish-white tissue on one of the vocal processes of the arytenoids.
Etiology: (1) predominantly in males average age of 50 who engage in a great deal of
aggressive speaking or so called type A personality. (2) constant throat clearing that is
secondary to irritation of mucosa due to gastroesophageal reflux or regurgitation of peptic
Symptoms: constant throat clearing, vocal fatigue, and breathy voice with some

hoarseness accompanied by discomfort or even stabbing pain

ii) Vocal Nodules:

Definition: localized benign growths on the vocal folds that are usually thought to be a
result of vocal abuse.
Etiology: due to vocal abuse when the tissues are under constant stress induced by
frequent, hard oppositional movement of vocal folds
Symptoms: soreness or pain in neck, sensation of something in throat, hoarseness, and

iii) Vocal Polyps:

Definition: soft fluid filled bulges located at the front region of the vocal fold
Etiology: vocal abuse
Symptoms: hoarseness, shortness of breath, audible inhalation

2. Voice Disorders Resulting from Abuse (i.e., other than hyperfunctional)

i) Hyperkeratosis:

Definition: a mass of accumulated keratin (a scleroproteinous pigmented spot or

covering) which may grow on the inner glottal margins which may occasionally develop
into malignancy
Etiology: smoking, alcohol use, environmental pollution and other factors
Symptoms: pronounced hoarseness

ii) Leukoplakia (Keratosis):

Definition: a disease characterized by a whitish patchy thickening of the epithelium of a

mucous membrane. A precancerous lesion develops on the tongue or the inside of the
cheek as a response to chronic irritation.

Etiology: Chronic smoking or tobacco use.

Symptoms: hoarseness, roughness

3. Psychogenic Voice Disorders

i) Functional Aphonia:

Definition: absence of voice

Etiology: (1) acute stress to vocal folds (2) laryngeal pathology or other disease
Symptoms: no voice present
4. Voice Disorders with No Indication of Pathology
i) Ventricular Dysphonia:

Definition: a condition in which the false vocal folds, the ventricular bands adduct
together over the true vocal folds below
Etiology: (1) pathology may be unknown (2) may occur due to true vocal fold disease
Symptoms: monotonous voice, low pitched

5. Manifestations of Voice Disorders

i) Phonation Breaks:

Definition: temporary but complete cessation of phonation

Etiology: occurs after prolonged hyperfunction

Symptoms: breaks in phonation; complains of vocal fatigue and need to increase vocal
effort to speak

ii) Pitch Breaks:

Definition: unexpected and uncontrolled sudden shifts of pitch in either an upward or

downward direction are readily perceived even by an untrained listener

Etiology: (1) frequently associated with the changing voice of the adolescent male, and is
usually a temporary stage that changes with time (2) may occur as a result of laryngeal
pathology or as an accompaniment to conditions that involve some loss of neural control
of phonation
Symptoms: inappropriate pitch level, pitch breaks, increased fundamental frequency,
restricted phonation range, reduced maximal phonation time

iii) Thickening of Vocal Folds:

Definition: a disorder that occurs when vocal folds become too thick or massive
Etiology: unknown; alcohol/smoking may contribute; GERD
Symptoms: abnormal vibratory patterns of vocal folds
Organic Voice Disorders

Organic voice disorders are those disorders that do have a known cause. We are
subcategorizing them into four categories: Neurological Voice Disorders, Viral / Bacterial /
Infectious Voice Disorders, Traumatic / Surgical Voice Disorders, and Other Voice Disorders
(i.e., those with no determined etiology).

1. Neurological Voice Disorders

i) Flaccid Dysarthria:

Definition: A perceptually distinguishable motor speech disorder produced by injury or

malfunction of one or more of the cranial or spinal nerves. It may be manifested in any or
all of the respiratory, phonatory, resonatory and articulatory components of speech and
reflects problems in the nuclei, axons, or neuromuscular junctions that make up the motor
units of the final common pathway

Etiology: (1) surgery (2) trauma from accidents (3) muscle disease (4) tumor (5) stroke
(6) infections (7) degenerative and demyelinating diseases (8) anatomic malformations
Symptoms: hypernasality, breathiness, nasal emissions, audible inspiration, short
phrases, imprecise consonants, monopitch, harsh vocal quality, monoloudness

ii) Hyperkinetic Dysarthria:

Definition: a motor speech disorder where involuntary movements and variable muscle
tone are present as a result of damage to basal ganglia
Etiology: (1) Huntington's Disease (2) vascular trauma (3) infections (4) neoplastic and

metabolic factors
Symptoms: inappropriate loudness, slow rate, inappropriate interruption of phonation,
voice tremor, strained voice, voice stoppage, vocal noise, harsh voice, hypernasality

iii) Hypokinetic Dysarthria:

Definition: a motor speech disorder caused by damage to the basal ganglia

Etiology: (1) degenerative diseases (Parkinson's, Alzheimer's, PICK's) (2) stroke (3)
trauma (4) inflammation (5) tumor (6) drug toxicity (7) normal pressure hydrocephalus
Symptoms: monopitch, monoloudness, harsh voice, breathy voice, low pitch, reduced
stress, variable rate, resonance disorders, mild hypernasality

iv) Ataxic Dysarthria:

Definition: a motor speech disorder caused by a widespread disturbances in timing,
synergy, speed, movement range, control of dysmetria, and coordinated and alternating
forcing functions of the muscles of the speech and respiratory mechanism

Etiology: (1) stroke (2) tumor (3) infection (4) ataxic cerebral palsy
Symptoms: hoarse breathy coarse voice with tremors, monopitch, monoloudness, and
explosive pitch outburst

v) Spastic Dysarthria:

Definition: a disorder resulting from disturbances in muscular control over the speech
mechanism due to damage of the central (brain) or peripheral (spinal cord) nervous

Etiology: (1) stroke (2) accident/trauma (3) tumor

Symptoms: harsh vocal quality, low pitch voice

vi) Vocal fold paralysis:

Definition: a unilateral or bilateral paralysis of the vocal folds occurs when conduction
of nerve impulses is temporary blocked, the axons of the nerve section, or the nerve
fibers are entirely cut which disturbs glottal closure due to lack of adduction of the

affected vocal fold.

Etiology: (1) peripheral lesions of Vagus nerve (2) neuritis (3) neoplasm's in neck,
bronchi, and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6)
birth trauma (7) central nervous system disease
Symptoms: breathiness, hoarseness, diplophonia, and aphonia

2. Viral, Bacterial and Infectious Voice Disorders

i) Laryngeal Webbing:

Definition: a band of tissue varying in size that extends across the glottis between the
two vocal folds. Congenital webs results as the glottal membrane fails to separate in the
embryonic development. Acquired web result from injury to the vocal folds.

Etiology: prolonged infection or trauma

Symptoms: varying degrees of breathing problems, diplophonia, and dysphonia

ii) Papilloma:

Definition: is a common benign tumor that starts in the epithelium that interfere with
glottal closure depending on the extent of the lesion which causes increased stiffness

Etiology: caused by a virus of the papovavirus group

Symptoms: low pitch level

iii) Traumatic Laryngitis:

Definition: a minor inflammation of the larynx and surrounding tissues causing

temporary hoarseness.

Etiology: (1) viruses (2) bacteria (3) Allergies (4) excessive use of voice (5) electrolyte
disturbances (6) tumors (7) changes in production of hormones by endocrine glands
Symptoms: hoarseness or loss of voice, sore throat, sensation of lump in throat, slight
fever, swallowing difficulty (rare), tiredness

3. Traumatic/Surgical Voice Disorders

i) Granuloma:

Definition: area of thickened irregular tissue on vocal folds caused by irritation

Etiology: (1) complication of intubation (2) contact (3) gastroesophageal reflux

Symptoms: breathiness, hoarseness, phonation breaks

ii) Vocal fold paralysis:

Definition: a unilateral or bilateral paralysis of the vocal folds occurs when conduction
of nerve impulses is temporary blocked, the axons of the nerve section, or the nerve
fibers are entirely cut which disturbs glottal closure due to lack of adduction of the
affected vocal fold.

Etiology: (1) peripheral lesions of Vagus nerve (2) neuritis (3) neoplasm's in neck,
bronchi, and chest (3) acute external trauma to neck (4) surgery (5) idiopathic causes (6)
birth trauma (7) central nervous system disease
Symptoms: breathiness, hoarseness, diplophonia, and aphonia

iii) Laryngeal Webbing:

Definition: a band of tissue varying in size that extends across the glottis between the
two vocal folds. Congenital webs results as the glottal membrane fails to separate in the
embryonic development. Acquired web result from injury to the vocal folds.

Etiology: prolonged infection or trauma

Symptoms: varying degrees of breathing problems, diplophonia, and dysphonia

4. Other Voice Disorders

i) Puberphonia:

Definition: a high-pitched adolescent voice that occurs passed the age of puberty in

Etiology: difficult to determine the physical or psychological factors

Symptoms: high pitch

ii) Spasmodic Dysphonia:


Definition: a disorder described as both functional/organic basis that is a rare condition

with a neurological basis

Etiology: (1) psychological influence (2) unknown cause

Symptoms: strained struggled effortful voice which is hoarse with tremors, jerky voice
onset, intermittent voice breaks, breathy spasms, hypernasality, and failure to maintain
iii) Thickening of Vocal Folds:

Definition: a disorder that occurs when vocal folds become too thick or massive

Etiology: unknown; alcohol/smoking may contribute; GERD

Symptoms: abnormal vibratory patterns of vocal folds

iv) Carcinoma:

Definition: cancer is a disease that may affect the structures of the oral cavity, pharynx,
and larynx. Most carcinomas of the vocal fold are squamous cell carcinomas. The lesion
begins unilateral, but can extend to the contralateral side. The vocal fold tissue is
asymmetrical and glottic closure is usually bothered. The mass and the stiffness of the
cover are increased.

Etiology: (1) smoking (2) environmental irritants (3) chemical or other contaminants (3)
metabolic disturbances (4) unknown causes
Symptoms: hoarseness, lump in neck, broadening of larynx, tenderness in neck

v) Hemangioma:

Definition: a blood sac that usually occurs in the head and neck region. It is the most
common benign tumor in infants

Etiology: unknown
Symptoms: inspiratory stridors, hoarseness, excessive coughing, and dysphagia

Assessment Procedures

Based on state of the art technology, assessment of voice disorders can be performed in a
non-intrusive way, and many treatment plans are successful.

Perceptual evaluation – Perceptual evaluation is the fundamental in assessing voice quality, the
relevance of defects & their impact on the subject’s ability to communicate. This evaluation
usually involves the rating scale. The Voice Profile Analysis Protocol, The GRABS scale, Voice
Assessment Protocol for Children & Adults, Buffalo Voice Profile, Consensus Auditory –
Perceptual Evaluation of Voice (CAPE-V) etc are some of the tools used for perceptually
evaluating the voice.

Qualitative Assessment - This usually involves analyzing the psycho-acoustic / perceptual

correlates of voice – pitch, quality & loudness.

- Assessment of Pitch - Assessment of pitch includes ascertaining pitch disturbances &

quantifying the disturbances using rating scales. Includes assessing Habitual Pitch, Total
Pitch Range, Pitch stability, Pitch breaks & Pitch tremors.
- Assessment of Loudness - Habitual loudness, Loudness range & Loudness variability are
- Assessment of Vocal Quality - Vocal quality is the perceptual correlate of harmonics,
resonance & symmetry of vocal fold vibrations. Characterization of voice quality is one
of the key facets of perceptual assessment & an integral part of any voice evaluation.
Breathy, harsh, & hoarse are the three main disorders of voice quality.

Quantitative Assessment / Acoustic Analysis - Acoustic analysis uses a computer to analyze

the patient's voice, to determine variation from established norms. Acoustic analysis involves the
extraction of a) fundamental frequency & related measures, b) amplitude / intensity & related
measures, c) perturbation measures of frequency & amplitude, and d) other measures such as
tremors & soft phonation index.

- Fundamental frequency & its related measures - includes Fundamental Frequency

(Average F0), Highest F0, Lowest F0, Frequency range in Phonation & Speech (in Hz),
standard deviation of F0, F0-tremor frequency (fftr - Hz).

- Amplitude / Intensity & its related measures - consist of Mean intensity (dB), Intensity

range (dB), Rise time (ms), Fall time (ms).

- Frequency Perturbation Measures – comprise of Absolute Jitter (µ sec), Jitter Percent

(%), Relative Average Perturbation (%), Pitch Period Perturbation Quotient (%),
Smoothed Pitch Period Perturbation Quotient (sPPQ %), Variation in F 0 (vF0 %),
Frequency Tremor Index (FTRI %), F0 Tremor Frequency (Fftr Hz), Extent of
Fluctuations in Fundamental Frequency (Hz), Speed of Fluctuation in Fundamental
Frequency (Hz/sec).
- Amplitude Perturbation measures - involves Shimmer (Sh dB), Shimmer Percent (%),
Amplitude Perturbation Quotient (APQ %), Smoothed Amplitude Perturbation Quotient
(sAPQ %), Coefficient of Amplitude Variation (vAm %), Amplitude Tremor Frequency
(ATRI %), Frequency of Amplitude Tremor (Fatr), Extent of Fluctuation in Intensity
(dB) Speed of Fluctuation of Intensity (dB/sec).

- Other perturbation measures – Normalized Noise Energy (NNE dB), Signal to Noise
Ratio (SNR), Harmonic to Noise Ratio (HNR), Noise to Harmonic Ratio (NHR), Voice
Turbulence Index (VTI), Soft Phonation Index (SPI), Degree of Voice Break (DVB %).

There are different tools / softwares which help in the acoustic analysis. For e.g. Dr.
Speech, Vaghmi, Visi Pitch, MDVP (Multi Dimensional Voice Program), Praat, etc. More than
33 different aspects of voice are analyzed from a single vocalization (in MDVP). Acoustic
analysis of the voice is one part of the complete examination of voice.

Electroglottography (EGG) - EGG is a non-invasive technique of drawing inferences about

certain aspects of vocal fold vibration & therefore is very helpful in assessing laryngeal function.
EGG basically demonstrates vocal fold contact area based on motion-induced changes in
electrical impedance. These changes in the electrical impedance when both the vocal folds
vibrate is obtained & graphically represented. Various functional vocal fold vibration parameters
such as closed & open durations, open & speed quotients, speed index, etc are derived. F 0 & its
deviations, & tremor measurements could also be derived from the electroglottogram at greater
accuracy than from microphone signal.

Videostroboscopy - Videostroboscopy is one of the most practical techniques for clinical

examination of the larynx and vocal folds. "Stroboscopy" refers to using flashes of light to
observe movement. Stroboscopy allows the examiner to observe the movement of the vocal folds

in a type of "slow motion." Stroboscopy can reveal laryngeal diseases early in their development.
In many cases, stroboscopy is necessary for correct diagnosis. Capturing the examination on
videotape allows the examiner and physician to review the film following completion of the
examination (videostroboscopy).

Phonatory Function Analysis - Measurement of aerodynamic function consists of

measurements of airflow, volume, airflow rate, peak airflow, subglottic pressure, and phonation
time. For e.g. Helios. The quantitative analysis of resonance include obtaining measures such as
TONAR (The Oral & Nasal Airflow Ratio), Nasalance etc. ‘Nasal view’ is a tool for obtaining
such measures.

Voice Training - Professional voice users learn techniques to help avoid problems. Baseline
measurements taken when the voice is healthy can pinpoint voice problems should they develop

Treatments and Therapies

Voice therapy – The specific goal of voice therapy will vary from patient to patient. However,
in general, the goal of voice therapy is to restore the best voice possible, a voice that will be
functional for purpose of employment and general communication. Voice therapy must by root
in and derived from an understanding of laryngeal anatomy and phonatory physiology. Accurate
diagnosis of voice disorders is critical to treatment planning. It is also important to recognize that
there are differing approaches implemented for various disorders based on their own individual
assumption concerning the disorder. The manner in which therapeutic techniques are used will
vary from clinician to clinician with the awareness that one particular treatment may possible
contribute to hyperfunctional problems. There are varieties of voice therapy techniques for which
each disorder has a specific therapy technique. It is important to remember that no one specific
therapy approach is facilitative for all the patients with the same voice problem.

- Methods of achieving correct F0 - there are so many techniques to raise or lower the
baseline F0: Confidential Voice Therapy, Resonant Voice Therapy, The Accent Method,
The Lee Silverman Voice Treatment Program (LSVT), Circumlaryngeal Massage,

vegetative & Reflexive Techniques, Respiration training, etc.

- Approaches To Elicit True Vocal Fold Vibrations - most of the voice disorders are related
to misusing the vocal mechanism, producing functional dysphonia. Such patients produce
their faulty voice in different ways such as poor breathing pattern, speaking with hard
glottal attack, inappropriate use of vocal fold & usage of false vocal folds. Hence, to
facilitate or to elicit true vocal fold vibration, many approaches are there like Inhalation
Phonation, Masking Approach, Open mouth approach, & Pushing, Pulling & Isometric

- Approaches to Decrease Laryngeal Tension - the life stress elevates general muscle
tension, including that of the laryngeal muscles, & can produce an array of voice defects:
aphonia, breathiness, hoarseness, or excessively high pitch. The most useful techniques in
reducing laryngeal tension are: Digital Laryngeal Manipulation, Head Positioning,
Yawn-Sigh & Half Swallow Boom Technique.

- Methods to Improve Voice Quality - includes Chant-Talk Method, Altered Tongue

Position, Whisper Phonation Method, Chewing Technique, etc.

Post-laryngectomy rehabilitation - When the larynx is removed, usually for extensive cancer,
rehabilitation of the voice is a main concern. A speech/language pathologist determines the most
appropriate method of voice rehabilitation through an evaluation. This may include training
esophageal speech, TEP (Tracheo-eosophageal Puncture) speech, or speech using artificial

Botoxin injections - Botoxin, or botox, is a toxin that is injected into specific muscles of the
larynx for spasmodic dysphonia which is characterized by a tight, strained, strangled voice. The
botoxin weakens the muscles of the larynx so that voice can be produced with much less effort.
The results last for 3-5 months on average. Repeat injections are usually needed.

Phonosurgery - Phonosurgery is designed to alter voice quality and the ability to produce voice.
A paralyzed vocal cord often will prevent closure of the vocal cords. Thyroplasty is a surgical
technique that moves the paralyzed vocal cord closer to the normal, more robust vocal cord.
Phonosurgery can raise or lower the pitch of a voice to a more desirable range.

Voice Care

To improve vocal hygiene:

 Drink lots of fluids - Drink 7-9 glasses of water per day; also good are herbal tea and
chicken soup.
 Try your best to maintain good general health - Exercise regularly.

 Avoid smoking cigarettes - They are bad for the heart, lungs and vocal tract.

 Eat a balanced diet - Include vegetables, fruits and whole grain foods.

 Avoid dry, artificial interior climates.

 Do not eat late at night - May have problems when stomach acid backs up on the vocal

 Use a humidifier to assist with hydration.

The medications how they can affect the voice:

 Avoid taking antihistamines, decongestants and antidepressants - They dry out the
membranes in the throat.

 Take antacid for acid reflux - If you eat a late meal and you have trouble with acid
reflux, raise the head of your bed, and take an antacid at bedtime.

 Reduce the caffeine and alcohol intake - Caffeinated and alcoholic drinks pull water
out of your system and deplete vocal cord hydration.

 Avoid use of local anesthetic over-the-counter medications for throats. Chloraseptic™

is one example.

 Medications that help liquefy thick mucus and increase the output of thin
respiratory tract secretions are helpful. Examples are Robitussin™ and Guaifenesin™.

 Question the use of progesterone dominant birth control pills. They may make the

female voice deeper.

How to use the voice:

 Learn to use your voice with as little effort and tension as is necessary.
 Less is more if we think of vocal longevity. Avoid speaking too much. Try taking vocal
naps, avoid lengthy telephone conversations and wisely use natural pausing in
conversation (avoid vocalized pauses).

 Before singing or using the voice in unusual ways, always do vocal warm-ups.

 Avoid shouting, screaming, loud laughter and heavy throat clearing.

 Use non-vocal sounds such as clapping, bells or other things to gain the listener's

 Move close to those with whom you are speaking. Face the person(s) with whom you are

 Take advantage of amplification devices, such as microphones, as needed.

 Be aware of noise in the environment and do not compete with it (parties, cars, airplanes).

 Avoid making strange vocal noises and sounds. Do not whisper - it is worse than
speaking because whispering strains the laryngeal muscles.

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