What are the causes and treatments of vocal changes?

Causes and Treatments of Vocal Changes (Dysphonia)

Vocal changes (dysphonia) have numerous potential causes ranging from benign self-limited conditions to serious underlying diseases, and treatment should be directed at the specific cause with voice therapy being strongly recommended for conditions amenable to such therapy. 1

Common Causes of Vocal Changes

Acute Causes

• Upper respiratory tract infections - most common cause of acute dysphonia, typically resolving in 7-10 days 1
• Vocal abuse/overuse - common in professional voice users (>50% of teachers experience dysphonia) 1
• Laryngitis (infectious, allergic, or chemical) 1
• Vocal fold hemorrhage - can occur with anticoagulants, thrombolytics, phosphodiesterase-5 inhibitors 1
• Recent endotracheal intubation - can cause temporary or prolonged vocal changes 1

Chronic/Structural Causes

• Vocal fold nodules, polyps, and cysts 1, 2
• Vocal fold paralysis - may result from thyroid surgery, anterior cervical spine surgery, or other causes 1
• Laryngeal cancer - particularly concerning in smokers with persistent hoarseness 1, 3
• Spasmodic dysphonia and laryngeal dystonia 1
• Muscle tension dysphonia (MTD) - caused by increased tension of (para)laryngeal musculature 4
• Age-related changes - vocal fold atrophy/bowing is common in elderly patients 5

Systemic/Medical Causes

• Medication side effects 1:

  • Inhaled steroids (mucosal irritation, fungal laryngitis)
  • Antihistamines, diuretics, anticholinergics (mucosal drying)
  • ACE inhibitors (cough)
  • Bisphosphonates (chemical laryngitis)
  • Antipsychotics (laryngeal dystonia)
  • Sex hormone medications

• Neurological disorders 1:

  • Parkinson's disease
  • Stroke
  • Multiple sclerosis
  • Amyotrophic lateral sclerosis
  • Essential tremor

• Endocrine disorders 1:

  • Hypothyroidism
  • Menopause

• Other conditions 1:

  • Gastroesophageal reflux disease (GERD)/Laryngopharyngeal reflux (LPR)
  • Sjögren's syndrome
  • Chronic tobacco use
  • Alcohol abuse

Evaluation of Vocal Changes

When to Seek Prompt Evaluation

• Dysphonia persisting >4 weeks 1
• Professional voice users (due to occupational impact) 1
• History of tobacco use 1
• Recent neck/chest surgery or endotracheal intubation 1
• Presence of neck mass 1
• Respiratory distress or stridor 1

Diagnostic Approach

1. Laryngoscopy - recommended when dysphonia fails to resolve within 4 weeks or when serious underlying cause is suspected 1
2. Imaging - should not be obtained prior to laryngoscopy but may be indicated based on laryngoscopic findings 1
3. Voice assessment - may include perceptual evaluation and standardized voice measures 3

Treatment Options

Non-Pharmacological Approaches

• Voice therapy - strongly recommended for conditions amenable to therapy 1, 3

  • Proper vocal techniques
  • Breathing exercises
  • Vocal hygiene
  • Resonance therapy
  • Reduction of vocal strain

• Voice rest and hydration 3

  • Maintaining adequate hydration
  • Avoiding vocal abuse/misuse
  • Avoiding whispering (which can increase laryngeal strain)

• Lifestyle modifications 1, 3

  • Smoking cessation
  • Avoiding irritants
  • Proper vocal hygiene

Pharmacological Treatments

• Avoid empiric medication use 1
  • Antireflux medications should not be prescribed for isolated dysphonia without visualization of the larynx
  • Corticosteroids should not be routinely prescribed prior to laryngoscopy
  • Antibiotics should not be routinely prescribed for dysphonia

Surgical Interventions

• Surgery - recommended for 1:

  • Suspected malignancy
  • Symptomatic benign vocal fold lesions not responding to conservative management
  • Glottic insufficiency

• Botulinum toxin injections - recommended for spasmodic dysphonia and other types of laryngeal dystonia 1

• Specific procedures for vocal fold paralysis 1:

  • Injection laryngoplasty (temporary improvement)
  • Framework procedures (permanent improvement)
  • Reinnervation procedures (permanent improvement)

Special Considerations

Post-Surgical Voice Changes

• Thyroid surgery can cause recurrent laryngeal nerve damage in up to 2.1% of patients 1
• Anterior cervical spine surgery may cause hoarseness in up to 50% of patients immediately post-surgery 1
• Cardiac surgery may result in hoarseness in 17-31% of patients 1

Professional Voice Users

• Require early evaluation due to occupational impact 1, 2
• May experience significant psychological and economic ramifications from voice disorders 1
• Often have multiple concomitant factors contributing to voice problems 2

Follow-up and Monitoring

• Document resolution, improvement, or worsening of symptoms after treatment 1
• Educate patients about preventive measures 1
• Consider referral to specialists based on underlying cause 3