Causes and Management of Aphonia (Loss of Voice)
Aphonia is primarily caused by functional disorders, neurogenic conditions, psychogenic factors, or somatic disorders, and management should begin with laryngoscopy to identify the underlying cause, followed by targeted interventions such as voice therapy, which resolves most cases within the first day of treatment. 1
Causes of Aphonia
Organic Causes
- Laryngeal pathology:
- Vocal fold paralysis (unilateral or bilateral)
- Laryngeal inflammation/laryngitis
- Suspected malignancy
- Benign vocal fold lesions
- Glottic insufficiency 1
Neurogenic Causes
- Central dysphonias
- Spasmodic (spastic) dysphonia
- Myasthenia gravis
- Skull base syndromes
- Inferior or superior laryngeal nerve palsy 2
Psychogenic Causes
Other Causes
- Recent head/neck/chest surgery
- Recent endotracheal intubation
- Post-traumatic dysphonia
- Arthrogenic dysphonia
- Presbyphonia (age-related) 1, 2
Diagnostic Approach
Initial Evaluation
- Laryngoscopy is mandatory and should be performed:
- When voice disorders fail to resolve within 4 weeks
- Immediately if a serious underlying cause is suspected 1
Enhanced Visualization
- Stroboscopy can alter diagnosis in up to 47% of cases by revealing functional abnormalities not visible with standard laryngoscopy 1
Risk Factors Requiring Expedited Evaluation
- Recent head/neck/chest surgery
- Recent endotracheal intubation
- Presence of neck mass
- Respiratory distress or stridor
- History of tobacco use
- Professional voice user status 1
Management Strategies
Voice Therapy (First-Line Treatment)
- Voice therapy must be preceded by laryngoscopy to identify the underlying cause 1
- Specific techniques include:
Psychogenic Aphonia Management
- Direct symptom approach is highly effective
- Voice typically returns in 82% of patients during the first day of vocal exercises 4
- Even after lengthy periods of aphonia, complete recovery is possible in nearly all cases 3
- Some techniques include double cough with laryngoscopic feedback 5
Surgical Interventions
- Indicated for:
- Suspected malignancy
- Symptomatic benign vocal fold lesions not responding to conservative management
- Glottic insufficiency 1
- Specific procedures:
- Injection laryngoplasty (for temporary improvement)
- Framework procedures (for permanent restoration of vocal fold position)
- Botulinum toxin injections (for spasmodic dysphonia and laryngeal dystonia) 1
Pharmacological Management
- Avoid routine prescription of:
- Oral corticosteroids (potential adverse effects include lipodystrophy, hypertension)
- Anti-reflux medications without evidence of GERD
- Antibiotics 1
Follow-up and Prevention
Voice Conservation
- Proper vocal hygiene
- Adequate hydration
- Avoidance of vocal irritants, abuse, and misuse 1
Monitoring
- Regular follow-up with laryngoscopic examination to assess progress
- Documentation of resolution, improvement, or worsening of symptoms 1
Special Considerations
Professional Voice Users
- Require more urgent evaluation due to occupational impact
- More susceptible to microvascular lesions and vocal fold hemorrhage 1
Post-surgical Patients
- Those who have undergone thyroid or cervical spine surgery should have expedited evaluation between 2 weeks and 2 months following surgery 1
Adolescents
- Be alert to underlying mutational falsetto when confronted with an aphonic adolescent patient with no organic laryngeal pathology 6
Common Pitfalls to Avoid
- Treating without laryngoscopic examination
- Prescribing medications empirically without identifying the underlying cause
- Assuming aphonia is always psychogenic without proper evaluation
- Delaying treatment for psychogenic aphonia due to fear of fixation (evidence shows recovery is possible even after lengthy periods) 1, 3