What are the causes and treatments of vocal changes?

Causes and Treatments of Vocal Changes (Dysphonia)

Voice changes (dysphonia) have numerous potential causes ranging from benign self-limited conditions to serious underlying pathologies, and treatment should be targeted to the specific cause with voice therapy as the cornerstone for most amenable conditions. 1

Common Causes of Dysphonia

Acute Causes

• Upper respiratory tract infections - most common cause of acute dysphonia, typically resolving within 7-10 days 1
• Vocal fold hemorrhage - can occur with anticoagulant medications, thrombolytics, or phosphodiesterase-5 inhibitors 1
• Acute laryngitis - infectious or chemical 1
• Recent endotracheal intubation - can cause laryngeal edema and vocal fold ulceration 1

Chronic Causes

Structural/Anatomical

• Vocal fold nodules and polyps - often from vocal abuse/overuse 1, 2
• Vocal fold paralysis - may follow thyroid surgery, anterior cervical spine surgery, or cardiac procedures 1
• Laryngeal cancer - particularly concerning in smokers with persistent hoarseness 1, 3
• Age-related changes - vocal fold atrophy/bowing in elderly patients 4

Neurological

• Spasmodic dysphonia - laryngeal dystonia 1
• Parkinson's disease and Parkinson-plus syndromes 1
• Essential tremor - causing voice tremor 4
• Multiple sclerosis, ALS, myasthenia gravis 1

Inflammatory/Irritative

• Laryngopharyngeal reflux (LPR) - though often over-diagnosed 5
• Allergic or chronic rhinitis 1
• Chronic tobacco use 1
• Inhaled steroids - dose-dependent mucosal irritation 1

Functional

• Muscle tension dysphonia (MTD) - excessive tension of (para)laryngeal musculature 6
• Vocal cord dysfunction (VCD) - paroxysmal glottic obstruction 7

Systemic Conditions

• Endocrinopathies - particularly hypothyroidism 1
• Sjögren's syndrome 1
• Post-tuberculosis hoarseness 3

Medication-Related

• Antihistamines, diuretics, anticholinergics - mucosal drying effects 1
• Angiotensin-converting enzyme inhibitors - cough 1
• Bisphosphonates - chemical laryngitis 1
• Antipsychotics - laryngeal dystonia 1

Evaluation Approach

1. History and physical examination - focusing on duration, associated symptoms, occupation (especially professional voice users), and risk factors 1

2. Laryngoscopy - indicated when:

   • Dysphonia persists >4 weeks
   • Serious underlying cause is suspected regardless of duration
   • Patient is a professional voice user
   • Recent neck surgery or intubation
   • Presence of neck mass
   • History of tobacco use 1, 3

3. Imaging - should NOT be obtained prior to laryngoscopy, but may be indicated based on laryngoscopic findings 1

Treatment Recommendations

General Principles

• Voice therapy - strongly recommended for conditions amenable to it 1, 3
• Laryngoscopy before therapy - essential for proper diagnosis and treatment planning 1

Specific Treatments Based on Cause

1. For acute infectious causes:

   • Supportive care
   • NOT antibiotics - strongly recommended against routine use 1

2. For reflux-related dysphonia:

   • NOT empiric antireflux medications - visualization of the larynx required before prescribing 1

3. For inflammatory causes:

   • NOT routine corticosteroids - recommended against prior to visualization 1
   • Proper vocal hygiene and hydration 3

4. For vocal fold paralysis:

   • Voice therapy for compensation techniques 1
   • Injection laryngoplasty (temporary) 1
   • Framework procedures (permanent) for persistent cases 1
   • Reinnervation procedures in select cases 1

5. For muscle tension dysphonia:

   • Voice therapy focusing on reducing muscular tension 6
   • Circumlaryngeal manual therapy 6
   • Address underlying psychological factors if present 6

6. For spasmodic dysphonia:

   • Botulinum toxin injections 1

7. For structural lesions (nodules, polyps):

   • Voice therapy as first-line treatment 1, 2
   • Surgery for lesions not responding to conservative management 1

8. For suspected malignancy:

   • Prompt biopsy and appropriate cancer workup 1, 3

Prevention and Education

• Avoid vocal abuse/misuse
• Maintain adequate hydration
• Avoid irritants (tobacco smoke)
• Proper use of inhaled medications
• Voice rest during acute episodes 1, 3

Important Caveats

1. Beware of over-diagnosis of LPR - many patients diagnosed with reflux-related dysphonia have other underlying causes 5

2. Professional voice users require special attention and earlier intervention due to occupational impact 1, 2

3. Post-surgical patients (thyroid, cervical spine, cardiac) should be evaluated promptly if voice changes occur 1

4. Smokers with persistent hoarseness require urgent evaluation regardless of duration 1, 3

5. Elderly patients commonly present with vocal fold bowing and unilateral vocal fold paralysis as causes of dysphonia 4