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

Causes and Management of Aphonia (Loss of Voice)

Aphonia (complete loss of voice) requires prompt laryngoscopic evaluation within 4 weeks of onset to rule out serious underlying causes, followed by targeted treatment based on the identified etiology, with voice therapy being the first-line treatment for functional causes. 1

Causes of Aphonia

Aphonia (complete loss of voice) can result from various etiologies that can be categorized as follows:

Organic Causes

• Inflammatory conditions

  • Acute viral laryngitis (most common cause of acute aphonia) 2
  • Bacterial infections (e.g., epiglottitis) 2
  • Fungal laryngitis (often related to inhaled steroid use) 1

• Structural abnormalities

  • Vocal fold nodules, polyps, or cysts 1, 3
  • Laryngeal cancer (particularly concerning in smokers) 1
  • Vocal fold paralysis (unilateral or bilateral) 1

• Neurological disorders

  • Spasmodic dysphonia 1, 4
  • Parkinson's disease 1
  • Amyotrophic lateral sclerosis 1
  • Multiple sclerosis 1

• Traumatic causes

  • Post-intubation injury 1
  • Post-surgical injury (particularly after thyroid, anterior cervical spine, or cardiothoracic surgeries) 1
  • Laryngeal fracture or trauma 1
  • Inhalational injury 1

• Other medical conditions

  • Gastroesophageal reflux disease (GERD) and laryngopharyngeal reflux (LPR) 1
  • Autoimmune disorders (e.g., rheumatoid arthritis, Sjögren's syndrome) 1
  • Allergic conditions 1

• Medication-induced

  • Inhaled steroids 1
  • Anticholinergics 1
  • Antihistamines 1
  • Decongestants 1
  • Antihypertensives 1

Functional/Psychogenic Causes

• Muscle tension dysphonia (MTD) - accounts for 10-40% of cases in voice centers 1
• Psychogenic aphonia - involuntary whispering despite normal laryngeal structure 5
• Conversion disorder - psychological conflict manifesting as voice loss 6
• Mutational falsetto in adolescents - voice change issues 7

Diagnostic Approach

Red Flags Requiring Immediate Evaluation

Immediate laryngoscopic evaluation is necessary when aphonia is accompanied by:

• Hemoptysis
• Dysphagia or odynophagia
• Unexplained weight loss
• Neck mass
• History of tobacco or alcohol use
• Airway compromise or breathing difficulty
• Stridor
• Hoarseness in an immunocompromised patient
• Hoarseness following neck trauma
• Accompanying neurologic symptoms
• Persistent hoarseness after surgery 3

Diagnostic Algorithm

1. History and targeted examination

   • Duration of symptoms (acute vs. chronic)
   • Associated symptoms (cough, fever, weight loss)
   • Occupational voice demands
   • Smoking and alcohol history
   • Recent surgeries or intubation
   • Medication review 1

2. Laryngoscopy

   • Timing: Should be performed when:
     • Aphonia fails to resolve within 4 weeks
     • Serious underlying cause is suspected regardless of duration
     • Patient is a professional voice user with persistent symptoms
     • Red flags are present 1, 3

3. Additional testing (based on suspected etiology)

   • Stroboscopy for better visualization of vocal fold vibration
   • Imaging studies if neurological or structural causes are suspected
   • Swallowing assessment if aspiration is a concern 1

Management Approach

1. Acute Viral Laryngitis

• Voice rest
• Adequate hydration
• Avoid irritants (smoking, alcohol)
• Symptomatic treatment
• Usually self-limiting within 7-10 days 2

2. Functional/Psychogenic Aphonia

Voice therapy techniques:

• Relaxation and breathing exercises
• Gargle, chewing, and pushing techniques
• Inhalation phonation
• Masking
• Phonetic exercises 5

Specific techniques for psychogenic aphonia:

• Double cough technique (to facilitate vocal fold closure)
• Biofeedback approaches with direct laryngoscopic visualization
• Success rate: 82% voice return during first day of therapy 5, 6

3. Vocal Fold Nodules/Polyps

• Voice therapy as first-line treatment
• Address contributing factors:
  • Treat reflux
  • Manage allergies/asthma
  • Ensure hydration
• Surgery only if conservative management fails 3

4. Neurological Causes

• Referral to neurology for definitive management
• Specialized voice therapy based on specific condition
• Botulinum toxin injections for spasmodic dysphonia 1

5. Iatrogenic/Post-surgical Aphonia

• Early laryngoscopic evaluation
• Voice therapy
• Possible surgical intervention depending on findings 1

6. Medication-induced Aphonia

• Review and modify medication regimen if possible
• Treat fungal laryngitis if present
• Voice therapy for compensatory techniques 1

Special Considerations

Professional Voice Users

• Earlier evaluation (within 2-3 weeks of onset)
• More aggressive management approach
• May require specialized voice therapy
• Higher economic and quality of life impact 1

Pediatric Patients

• Neonatal aphonia requires immediate evaluation
• Children with persistent aphonia should be evaluated to rule out serious conditions like laryngeal papilloma
• Vocal nodules in children often resolve with conservative management 1, 3

Elderly Patients

• Higher prevalence of voice disorders (up to 29%)
• May have age-related laryngeal changes (presbylarynx)
• Requires evaluation to rule out malignancy 1

Quality of Life Impact

Voice disorders, including aphonia, can have substantial quality of life consequences:

• Social isolation
• Depression and anxiety
• Missed work and lost wages
• Lifestyle limitations
• Comparable QOL impact to conditions like asthma, coronary syndrome, and COPD 1

Early diagnosis and appropriate management are essential to minimize these impacts and prevent long-term voice problems.