What are the causes and management options for aphonia (loss of voice)?

Causes and Management of Aphonia (Loss of Voice)

Aphonia (complete loss of voice) requires diagnostic laryngoscopy within 4 weeks of symptom onset, followed by targeted treatment based on the underlying cause, with voice therapy being the primary approach for most cases. 1

Causes of Aphonia

Aphonia can result from various underlying conditions that can be categorized into several groups:

1. Functional/Psychogenic Causes

• Psychogenic aphonia (involuntary whispering despite normal larynx) 2
• Conversion disorders related to psychological stress 3
• False mutation (particularly in adolescents) 4

2. Neurogenic Disorders

• Central dysphonias
• Spasmodic (spastic) dysphonia
• Myasthenia gravis
• Unilateral or bilateral palsy of the inferior laryngeal nerve
• Palsy of the superior laryngeal nerve 5

3. Somatic Disorders

• Vocal cord insufficiency
• Vocal cord edema
• Laryngitis
• Post-traumatic dysphonia
• Arthrogenic dysphonia
• Presbyphonia (age-related voice changes) 5

4. Other Causes

• Recent head/neck/chest surgery
• Recent endotracheal intubation
• Neck masses
• Malignancy 6, 1

Diagnostic Approach

Initial Assessment

• Evaluate voice quality, pitch, loudness, and vocal effort that impairs communication or reduces quality of life 6, 1
• Perform thorough history and physical examination to identify underlying causes 6

Key Diagnostic Tests

• Laryngoscopy: Should be performed when aphonia fails to resolve within 4 weeks or immediately if serious underlying cause is suspected 6, 1
• Enhanced visualization with stroboscopy: Can reveal functional abnormalities not visible with standard laryngoscopy, altering diagnosis in up to 47% of cases 1
• Standardized evaluation scales: GRBAS scale and CAPE-V (Consensus Auditory-Perceptual Evaluation of Voice) scale 1

Important Considerations

• Do not obtain CT or MRI prior to laryngoscopy 6, 1
• Expedite evaluation for high-risk patients (recent surgery, intubation, neck mass, respiratory distress, tobacco use, professional voice users) 1
• Audio recordings in a quiet environment can be useful for evaluation 1

Management Approaches

1. Voice Therapy (First-line for most causes)

• Must be preceded by laryngoscopy to identify underlying cause 6, 1
• Specific techniques include:
  • Relaxation and respiration exercises
  • Gargling with firm sounds
  • Chewing and pushing exercises
  • Inhalation phonation
  • Masking and phonetic exercises
  • Slow easy onset with prolonged speech sounds 1, 2

2. Psychological Interventions (for psychogenic aphonia)

• Short-term psychodynamic psychotherapeutic intervention 3
• Directive therapy with biofeedback aspects 7
• Combined approach of voice therapy with psychological support 2, 3

3. Medical Interventions

• Botulinum toxin injections: Recommended for spasmodic dysphonia and other types of laryngeal dystonia 6, 1
• Do not routinely prescribe:
  • Antibiotics for aphonia 6
  • Antireflux medications without evidence of GERD 6, 1
  • Corticosteroids prior to laryngoscopy 6, 1

4. Surgical Interventions

• Recommended for:
  • Suspected malignancy
  • Symptomatic benign vocal fold lesions not responding to conservative management
  • Glottic insufficiency 6, 1
• Specific procedures:
  • Injection laryngoplasty for temporary improvement in vocal fold position and bulk
  • Framework procedures for permanent restoration of vocal fold position 1

Follow-up and Prevention

Follow-up Care

• Document resolution, improvement, or worsening of symptoms after treatment 6
• Regular follow-up with laryngoscopic examination to assess progress 1
• Consider referral to a multidisciplinary team if needed 1

Preventive Measures

• Voice conservation techniques
• Proper vocal hygiene
• Adequate hydration
• Avoidance of vocal irritants, abuse, and misuse 6, 1

Special Considerations

• Professional voice users: Require more urgent evaluation due to occupational impact 1
• Post-surgical patients: Need expedited evaluation between 2 weeks and 2 months following surgery 1
• Neurological symptoms: Warrant prompt evaluation for conditions like ALS 1
• Smokers: Should be evaluated promptly to rule out malignancy 1

Treatment Prognosis

For psychogenic aphonia, even after lengthy periods without voice, complete recovery is possible in nearly all cases. Studies show that 82% of patients can recover their voice during the first day of vocal exercises, while others may require continued therapy 2, 3.