Voice disorders is the general name for problems that affect the structure or movement of the vocal cords in the larynx, impairing the quality, strength and endurance of the voice. The most common symptom is hoarseness, which is often dismissed as a simple cold. In reality, different causes such as nodules, polyps, cysts or vocal cord paralysis each call for their own treatment approach.
What Are Voice Disorders?
Voice is produced when air from the lungs makes the two vocal cords in the larynx (voice box) vibrate. These structures, also called vocal folds, come together during speech and vibrate extremely fast. In adult men, the vocal cords vibrate roughly 100 to 150 times per second during speech, and in women about 180 to 250 times per second. In children, the rate is even higher.
The vocal cords have a layered structure. The outermost layer is a thin covering (epithelium); beneath it lies a soft, jelly-like flexible layer (Reinke’s space); and the vocal cord muscle forms the deepest layer. A healthy voice requires this surface to be smooth and flexible, with both sides moving symmetrically. Even a small swelling or stiff spot on the surface can disrupt vibration and change the voice.
Voice disorders can be divided into two main groups: organic and functional. In organic disorders, there is a visible structural change in the vocal cords or a nerve-related movement problem. In functional disorders, the vocal cords look structurally normal, but there is a problem with the way the voice is used. This article focuses mainly on organic voice disorders.
People who use their voice intensively, such as teachers, singers, lawyers, call center staff, religious officials, sales representatives and coaches, are at higher risk. Smokers, people with reflux and children who habitually use a loud, strained voice are also commonly affected.
Causes of Voice Disorders
Vocal cord disease usually develops from more than one factor working together. The most common causes are:
- Overuse and misuse of the voice: Talking loudly for long periods, shouting, straining the voice in noisy places and singing without proper technique cause friction and damage to the vocal cords.
- Smoking: It causes chronic irritation, swelling and cellular changes in the vocal cords and is a major risk factor for Reinke’s edema and laryngeal cancer.
- Reflux: Stomach contents reaching the larynx promote swelling and granuloma formation at the back of the vocal cords.
- Infections: Viral upper respiratory infections are the most common cause of acute laryngitis.
- Nerve damage: The nerves that move the vocal cords can be affected after thyroid, neck or chest surgery, by tumors, viral infections or stroke.
- Intubation: The breathing tube placed during general anesthesia can rarely leave a granuloma or damage on the vocal cords.
- Other factors: Allergies, low fluid intake, thyroid hormone disorders, some asthma inhalers and the HPV virus (laryngeal papillomatosis) can also affect the vocal cords.
Common Vocal Cord Conditions
- Vocal cord nodules: Callus-like thickenings that form opposite each other on the middle portion of both vocal cords. They are linked to vocal strain and are common in teachers, singers and children who shout a lot.
- Vocal cord polyp: Usually a one-sided, softer and raised lesion. It may develop after a sudden, forceful vocal strain or a small bleed within the vocal cord.
- Vocal cord cyst: A sac-like growth inside the vocal cord, filled with fluid or thicker material. It may be present from birth or result from a blocked mucus gland.
- Reinke’s edema: Diffuse swelling caused by fluid collecting in the superficial layer of the vocal cord. Almost all cases occur in long-term smokers, and it makes the voice noticeably deeper.
- Vocal cord paralysis: One or both vocal cords cannot move. With one-sided paralysis the voice sounds breathy and weak; with paralysis on both sides, shortness of breath may become the main problem.
- Laryngitis: Inflammation of the larynx. Acute laryngitis is usually viral and settles within a few days; chronic laryngitis, linked to smoking, reflux and voice overuse, can last for weeks.
- Vocal cord granuloma and papillomatosis: Benign growths that tend to recur. Granulomas are mostly associated with reflux and intubation, while papillomatosis is associated with HPV.
Symptoms of Voice Disorders
Problems affecting the vocal cords cause different complaints depending on the type and size of the lesion. Some symptoms appear only after heavy voice use, while others last all day. The main symptoms are:
- Hoarseness, roughness, a split or husky voice
- A voice that tires quickly and becomes increasingly hoarse toward the end of the day
- A change in pitch, with the voice becoming deeper or higher
- A breathy, weak voice close to a whisper
- Voice breaks while speaking or singing
- Inability to reach high notes, a narrower vocal range
- Pain, burning or a feeling of tension in the throat while speaking
- In vocal cord paralysis, liquids going down the wrong way and coughing when swallowing
- In advanced cases, noisy breathing or shortness of breath
The severity of symptoms does not always reflect how serious the disease is. A small cyst can cause marked voice problems, while an early-stage lesion may show up only as slight roughness. For this reason, any voice change that lasts should be examined.
How Are Voice Disorders Diagnosed?
Diagnosis begins with a detailed history. The doctor asks when and how the problem started, how much the voice is used for work or hobbies, and about smoking, reflux, previous surgery and intubation. The patient’s voice is also assessed during speaking and reading. Patients traveling from abroad are encouraged to bring previous examination reports, laryngoscopy recordings or imaging and a list of their current medications.
Endoscopic Examination and Stroboscopy
To view the vocal cords, a rigid endoscope is passed through the mouth or a flexible one through the nose. The examination takes a few minutes and can be done in the office. However, the vibration is too fast to see in detail under normal light.
Videolaryngostroboscopy was developed to overcome this. A strobe light flashes at intervals close to the vibration frequency of the vocal cords, making the vibration visible in slow motion. This allows assessment of the wave-like movement on the vocal cord surface (mucosal wave), the symmetry of the two sides and whether they close completely. It is especially valuable for telling apart lesions that look alike, such as nodules, cysts and scar tissue.
Additional Tests
- Acoustic voice analysis: Pitch, loudness and irregularity of the voice are measured by computer, allowing comparison before and after treatment.
- Voice Handicap Index: A questionnaire that assesses how the voice problem affects daily life.
- Laryngeal electromyography (EMG): Evaluates nerve and muscle function in vocal cord paralysis.
- Imaging: Neck and chest CT scans may be requested to look for the cause of paralysis.
- Biopsy: A tissue sample from a suspicious-looking lesion is examined by a pathologist.
Treatment of Voice Disorders
The treatment plan is tailored to the type and size of the lesion and to the patient’s voice needs and expectations. Some voice disorders improve with voice therapy and medication alone, while others require surgery.
Voice Therapy and Medication
Voice therapy is an exercise program led by a speech-language pathologist that aims to help the person use the voice more efficiently and with less strain. Voice therapy is usually the first treatment option for vocal cord nodules, and many nodules shrink this way. In patients who need surgery, voice therapy is also recommended before and after the operation to help prevent recurrence.
When reflux is involved, acid-reducing medication is recommended; for allergic causes, allergy treatment; and for acute laryngitis, voice rest, plenty of fluids and steam inhalation. In Reinke’s edema, quitting smoking is the essential first step of treatment.
Voice Microsurgery
Voice microsurgery (microlaryngoscopy) is used for polyps, cysts, significant Reinke’s edema and nodules that do not respond to voice therapy. The procedure is performed under general anesthesia. A special metal tube (laryngoscope) is placed through the mouth, the vocal cords are magnified under a microscope, and the lesion is removed with very fine instruments, or a laser when needed, while sparing as much healthy tissue as possible. No incision is made on the outside of the neck.
The operation is generally short, though its length depends on the lesion. Most patients go home the same day or the next day. To let the vocal cords heal, complete voice rest is usually advised for a few days to a week, followed by a controlled return to speaking. The exact period is set by the doctor according to the procedure performed.
Treatment of Vocal Cord Paralysis
In vocal cord paralysis, the cause is investigated first. Because the nerve may recover on its own, most patients are followed for several months up to a year while receiving voice therapy. If the voice remains inadequate or liquids clearly go down the wrong way when swallowing, a filler injection into the vocal cord (injection laryngoplasty) or a thyroplasty operation that moves the vocal cord toward the midline may be performed. In paralysis on both sides, keeping the airway open is the priority.
Possible Risks and Important Considerations
Voice microsurgery is a common procedure that usually goes smoothly in experienced hands, but like any surgery it carries some risks. Temporary sore throat, mild tongue numbness or taste changes due to the laryngoscope placed through the mouth, and rarely dental injury, may occur. Scar tissue forming on the vocal cord and recurrence of the lesion are also possible. Following the voice rest and voice therapy advice after surgery plays an important role in reducing these risks.
The following tips help protect the health of the vocal cords:
- Drink enough water during the day
- Avoid smoking and smoky environments
- Avoid shouting, long conversations in noisy places and frequent throat clearing
- Take a break when the voice feels tired
- Get treatment for reflux symptoms if present
Hoarseness lasting longer than three weeks, especially in smokers, should always be evaluated by an ear, nose and throat (ENT) specialist. If hoarseness comes with shortness of breath, difficulty swallowing, blood in the sputum, a lump in the neck or pain spreading to the ear, an examination should not be delayed.
Voice Disorders: Frequently Asked Questions
Do vocal cord nodules go away on their own?
New, soft nodules often shrink or disappear with correct voice use and voice therapy. For long-standing, hardened nodules that do not improve enough despite therapy, surgery may be considered.
When is hoarseness a cause for concern?
Hoarseness from a cold usually clears up within one to two weeks. Hoarseness that lasts longer than three weeks, keeps getting worse or comes with shortness of breath or difficulty swallowing should be taken seriously, and the larynx should be examined.
How long should I avoid talking after vocal cord surgery?
This depends on the procedure. Most patients are advised to rest the voice completely for a few days to a week, then return gradually with short, quiet conversations. A return to normal voice use is usually complete within a few weeks.
Is whispering good for a hoarse voice?
No. Whispering can strain the vocal cords and the muscles of the larynx. When hoarse, it is better to talk less, speak in a normal but soft voice when needed and drink plenty of water.
Can a vocal cord polyp be treated with medication?
Polyps usually do not go away with medication. Very small, newly formed polyps may be monitored with voice therapy and reflux treatment, but most polyps require voice microsurgery for lasting improvement.
Conclusion
Op. Dr. Tayfun Demirel, ENT specialist, examines patients with hoarseness and voice changes at the practice in Ataşehir, Istanbul, using endoscopic examination and stroboscopic evaluation. After identifying the type of vocal cord problem, voice therapy, medication or voice microsurgery options are discussed with the patient, and an individual treatment plan is created. Please contact the clinic to book an appointment. This article is for informational purposes only; an in-person examination is required for diagnosis and treatment.
