Many voice disorders remain unidentified. Often, voice complaints are dismissed as "par for the course" for a cold, flu, or an allergy. Other times, voice complaints are not considered to be part of a voice disorder – especially if the complaints have been present for a long time or most of the patient's life. Even if a patient's voice has been hoarse since childhood, hoarseness – or any other voice complaint – should be evaluated by an otolaryngologist or laryngologist.
If voice symptoms persist for more than two or three weeks after a cold or flu has gone away – especially if the patient is a smoker – please consider a visit to an ear, nose, and throat physician specialist.
The anatomy of the voice box (larynx): Note the vocal cords move in and out in a V-shape and are covered by a line layer of moist mucous membrane. Also, the esophagus is located just behind the larynx. Problems with the esophagus can affect the larynx which is also the entrance to the lungs.
To vibrate efficiently vocal folds need to be able to move equally and completely come together. When one of the muscles that move the vocal folds together does not work properly or when a problem with the surface of the vocal fold prevents the edges from meeting, air will escape between the cords and result in breathy voice.
A view of the complex movement of the pink mucosal layer loosely over the tighter surface of the yellow vocal ligaments
Causes of a hoarse, raspy voice (laryngitis)
- a viral infection (common but only temporary form of laryngitis)
- poor voice use (long-lasting laryngitis) Bad habits in using our voice, such as long hours of talking, yelling or singing too loud or aggressively, will lead to swelling (vocal cord polyps) or small hard deposits of scar tissue on the vocal cords (vocal cord nodules) or a broken blood vessel on the vocal cord.
- acid reflux (raspiness changes throughout the day)
- benign vocal cord lesions (polyps, nodules, granulomas, cysts, scars, leukoplakia and other precancerous changes to the mucous membrane). The hoarseness remains more constant.
- yeast infections (caused by chronic use of steroid inhalers or impaired immune system)
- cancer. The mass interferes with movement of the vocal cords. The voice change is persistent and worsening.
- aging. The breathy quality of the voice is due to the inability for the vocal cords to come together. The cords are thinner and bow secondary to the loss of elasticity and water content of the tissue
- neurologic disorders (Parkinsonism, spasmodic dysphonia) which affects the muscles of the vocal cords
Vocal cord lesions
Cysts, granulomas, polyps and nodules are not dangerous. They are not cancer (uncontrolled growth). They are benign.
Vocal cord nodules (“singer’s nodules) are hard opposing scar tissues that form in one small area of the vocal cords where the force of vocal cord contact is most hard. This is almost always the result of poor voice use. They are similar to calluses. Persons who are often susceptible include exuberant children, cheerleaders, politicians, teachers, singers and drill instructors. Nodules are the most common vocal cord lesion.
Vocal cord polyps appear as soft, floppy swellings on the vocal folds. This swelling is inflammation of the delicate mucosa over the more rigid vocal cord ligaments. They cause a very persistent gravelly voice and some wheezing or airway distress. Swelling is usually the result of heavy cigarette smoking.
Vocal cord cyst is a swollen area on only one vocal cord. This is usually the result of a blocked gland in the mucous membrane and can be removed surgically.
Vocal cord granuloma is a lesion that appears on one vocal cord and is caused by an infection or chronic inflammation, such as acid reflux.
Another view of a granuloma
More dangerous changes of the vocal cords.
Often the result of years of heavy smoking, alcohol consumption and acid reflux.
Leukoplakia- white changes to the mucous membrane.
Vocal Cord Cancer
- Examination of the vocal cords with a mirror or fiberoptic laryngoscopy. After numbing the nose, a flexible thin cord is passed through the nose to the back of the throat to see the voice box. The advantage of fiberoptic laryngoscopy is that it allows examination of the voice box while a person speaks or sings.
- Videostroboscopy: a similar examination which visually slows down the movement of the vocal cords and allows more precise analysis of certain lesions
- Direct microlaryngoscopy with a sampling (biopsy) or complete removal of a lesion– see below
It is important to be cautious with your voice during an episode of laryngitis, because the swelling of the vocal cords increases the risk for serious injury such as blood in the vocal cords or formation of vocal cord nodules, polyp or cysts.
- common medicines include antacids and oral steroids
- treatment of allergies
- voice rest and voice therapy
- direct microlaryngoscopy. In an operating room, completely asleep under general anesthesia, a specialized tube placed through the mouth creates a view of the voice box. A microscope and small instruments are used to operate delicately on the vocal cords. The surgery requires less than an hour and most patients can return home in a few hours with little discomfort. The risks include damage or loss of a tooth, neck or throat pain, difficulty breathing or a change in the voice.
(surgical removal of vocal cord polyp) "The surgery was painless. The most difficult parts were that my neck was sore from being extended and that I had to avoid talking for two weeks, but the good part is that I have my normal voice back." - Mary Marsh (edited)
"From the time I walked in till the time I left, everything was smoothly and pleasantly arranged so that all my needs were anticipated and met with no difficulty or fuss. There was only momentary pain (minimal) for anesthesia. Otherwise the entire experience was pain-free.
The pain was quick to disappear. After 4 days of not using my voice I was able to resume talking (gently) after 2 weeks I felt completely restored.
I had never had outpatient surgery before, but I found the exceptional care of the staff totally alleviated an anxiety I had and I left completed satisfied and relieved." - Marc Gousie